Transcript Munchausen Syndrome by Proxy

Munchausen Syndrome by
Proxy
Kristen K. Marciel, M.S.
James H. Johnson, Ph.D
Who was Munchhausen?
• Baron von Munchhausen (1720 – 1797)
• German, retired officer of Russian cavalry
• Fond of recounting exploits from war
• Age 74, married 17-year-old
– Wedding night spent alone
– Wife gave birth to a baby
– Infant died at 1 year under “suspicious circumstances”
Munchausen Syndrome
• 1877 Charcot’s “mania operativa passiva”
– Treatment for self-inflicted or falsified injuries
• 1951 Dr. Richard Asher’s “Munchausen
Syndrome”
– Fabricated illness, traveled from doctor to doctor
– Complex medical investigations/procedures
Definition of MSBP
• First highlighted by British Pediatrician, Roy
Meadow, and described in a number of
publications (1977,1982, 1985)
• A condition in which a parent or other
caretaker persistently fabricates symptoms on
behalf of another, causing that person to be
regarded as ill (Meadow, 1985)
• Considered a type of abuse as the behaviors of
the perpetrator (usually the mother) can result
in the child having to undergo invasive medical
tests and receive treatments that may be
harmful
The Nature of the Problem
• The nature of the problem can be best
highlighted by considering characteristics of 19
cases initially described by Meadow (1982)
• 10 boys, 9 girls
• Mean age 3 years, 2 months
• Children displayed wide range of symptoms,
typically suggestive of a “multisystem disorder”
Case Characteristics:
Summary
• False symptoms had persisted on average 13
months prior to diagnosis
• Most had been seen by numerous doctors, had
been referred from hospital to hospital – one
had been examined by 28 consultants
• In each case the mother was the source of the
fraudulent history and the fabricator of false
symptoms
Case Characteristics:
Summary
• False histories provided by mothers were
“impressive in medical detail and fabricated
symptoms were often quite realistic”
• Meadow notes that “the methods used
combined cunning, dexterity, and, quite often,
medical knowledge”
• It is noteworthy that the perpetrators were, not
infrequently, individuals with some medical
knowledge
Case Characteristics:
Summary
• Bleeding – generally the result of mother
adding her own blood to the child’s vomit,
urine, and feces
– (Have seen one case here where mother put her own blood in
child’s feces)
– In one instance feces were mixed with the child’s vomit to
cause abnormal findings
• Fevers – often produced by rubbing
thermometer or immersing it in hot liquids
• Biochemical Chaos – often resulted from
diluting or adding chemicals, such as salt, to
blood specimens
Case Characteristics:
Summary
• Rashes – fabricated by rubbing the skin, by
adding caustic solutions to skin, or by painting
the skin with some sort of dye
• Neurological Symptoms – generally the result
of the mother giving the child drugs (sedatives
or tranquilizers) that had been prescribed for
herself
• Fabricated symptoms led to a range of
unnecessary procedures including many
medical procedures and long and expensive
hospital stays
Symptom Categories
1.
Exaggerations
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2.
Claim migraines when child has headaches
False reports
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3.
Falsely claim child has seizures
Falsification of signs
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4.
Parent alters child’s urine sample
Simulations of signs/symptoms
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5.
Child taught to fake seizures
Dissimulations
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6.
Allow real illness to progress
Aggravations
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7.
Rub dirt in child’s laceration
Self-induced signs/symptoms
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Parent injects child with bacteria
Case Characteristics:
Summary
• Seven of the 19 mothers had a history of
Munchausen’s syndrome themselves
• In two families, a sibling was also involved in
the mothers fabricating of symptoms
• Most carried no diagnostic label and were seen
by medical staff as caring and loving of their
children
Medical Procedures Incurred
• Six year old boy – Missed 13 months of school,
1 month of IV fluids, and a range of other
procedures such as lumbar puncture, EEG, and
brain scans
• Also had bone, kidney, and skin biopsies as well
as being prescribed a range of drugs including
antibiotics, steroids and ~ 20 other medications
Hints of Potential Contributors
• Meadow notes “It would be naïve to seek a single
cause for the harmful behaviors for these mothers”
• For some, the child’s illness brought about a closer
relationship with the husband, while for others, it
seemed to provide a welcome distraction from
personal and home difficulties
• Several mothers thrived on the children’s wards They seemed to love it, bustling around helping other
mothers, helping the nurses, and forming close
relationships with junior medical staff
• They made the medical staff feel that the pediatric
service was really good
Hints of Potential Contributors
• For some it seemed to be a bizarre game in
which they matched themselves against the best
specialists and the best hospitals the could find
• Several of these mothers were individuals with
prior training in nursing
• Based on observations made in working with
these cases, Meadow has presented a number of
tentative “warning signs” that may be helpful in
making an earlier diagnosis than would
otherwise be possible
Possible Warning Signs
• An illness that is unexplained, prolonged, and so
extraordinary that it prompts experienced colleagues
to state that “they have never seen anything like it
before”
• Symptoms and signs are inappropriate or incongruous
• Symptoms only when the mother is present
• Treatments that are ineffective or poorly tolerated
• Children who are alleged to be allergic to a great
variety of foods and drugs
• Mothers who are not as worried by the child’s illness
as are nurses and doctors
Possible Warning Signs
• Mothers are constantly with their ill child and will not
leave the ward, for even brief periods of time
• Families where sudden unexplained infant deaths
have occurred and families with many members who
are alleged to have serous medical disorders
• Symptoms of a very rare disorder (although children
can have rare disorders)
• Seizures that do not respond to carefully administered
anticonvulsants
• Note that these are simply “signs” that warrant being
more watchful as they many of them may also be
associated with other health related factors
Facts About MSBP
From Lasher and Feldman (2001)
• MSBP is dangerous
– It has been estimated that 6 to 10 percent of MBP
victims die
• MSBP is a recognized kind of maltreatment
(abuse/neglect)
• MSBP perpetrators deliberately engage in MSBP
behavior
• Cases that appear to involve only false reports or
simulation of symptoms should be considered as
dangerous as those in which induction of illness
has been suspected or confirmed
Epidemiology (From Huynh, 1998)
• Determining the incidence and prevalence of MSBP
is difficult for a variety of reasons
• No population-based studies have been conducted
• The true incidence of MSBP is hard to assess
because many cases go undetected
• Often, there are case suspicions, but insufficient
evidence exists or is gathered, so these cases are
never officially reported or investigated
• Furthermore, the diagnosis of MSBP takes time;
average time for diagnosis ranges from 6 to 15
months (Parnell, Day, 1997)
Epidemiology: Some Tentative
Findings
• Estimated 2-4 cases per million in the general
population (Alexander et al., 1990)
• Of the 2.5 million cases of child abuse reported
annually, 1000 are related to MSBP (Volz, 1995)
• Fatality rate for MSBP is approximately 10%
– 6% died, 25% siblings (Sheridan, 2003)
• Physical morbidity rate of 75%; possibly even
higher psychological morbidity rate (Rosenberg,
1987)
Epidemiology: Some Tentative
Findings
• Boys and girls are equally affected, and all
socioeconomic classes are represented
– 52% males, 48% females
• 79% Caucasian
• Average age of onset 48 months
• 6% dead, 7% long-term injury
– Most common symptom of dead victims – apnea
(Sheridan, 2003)
• 25% to 35% of the time, MSBP is perpetrated
serially on siblings (Alexander et al., 1990)
Epidemiology: Some Tentative
Findings
• Most perpetrators assume the “mother” role;
77-90% are biological mothers
• 5-6% include the father, babysitter, nanny, or
grandmother (Meadow, 1985)
• Characteristics
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29% symptoms of Munchausen Syndrome
22% history of childhood abuse
27% history of working in healthcare
23% psychological disorders, such as Personality
D/O, NOS; Depression; Borderline PD, Paranoia
(Sheridan, 2003)
MSBP Outcome:
Some Tentative Findings
(From Huynh, 1998)
• Currently, there is limited data available on child
victims of MSBP despite increased awareness
(Bools et al, 1993); very few follow-up studies
• As many as 10% may die as a result of induction
of illness or from diagnostic interventions
• May develop chronic invalidism
• Can experience permanent disfigurement from
medical procedures
MSBP Outcome: Some
Tentative Findings (From Huynh, 1998)
• Develop permanent impairment of bodily
function from the medical procedures
• Child may show academic delays from “chronic
absenteeism,” and problems with concentration,
emotions, and behaviors (Libow, 1994)
• Child may show delays in social development
from lack of age-appropriate interaction with
peers and adults
• Risk of perpetration of MSBP on their own
child(ren) as an adult
MSBP Outcome: Some
Tentative Findings (From Huynh, 1998)
• Child may develop disturbed understanding of
proper mother-child relationship
• The child may develop significant adjustment
problems
• In general, it seems that the prognosis is likely
to be quite poor
• Although many children return to the family
and survive, there is no convincing case in the
professional literature demonstrating
successful treatment
DSM Criteria
•
Munchausen’s Syndrome by Proxy
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Located in Appendix B of DSM-IV-TR
Criteria sets/axes provided for further study
Factitious Disorder by Proxy
A. Intention production or feigning of physical or
psychological signs or symptoms in another person
who is under the individual’s care
B. The motivation to assume sick role by proxy
C. External incentives (e.g., economic gain) are absent
D. Behavior not better accounted for by other mental
disorder
Differential Diagnoses
• Factitious Disorder by Proxy
• Malingering by Proxy
– Abuse to accrue tangible benefits, such as financial
compensation
• Munchausen Syndrome
• Factitious Disorder
– Both of these ARE mental disorders
– Disorders involving fabricated/simulated diseases
– Motivation is psychological payoff nurturance, no
apparent external incentive
– MS more severe form of FD
Sexual Abuse Allegations as
Munchausen by Proxy
• Given the sexual abuse allegations made by this
parent, note that professionals have highlighted the
fact that this can be a contemporary variation on
Munchausen Syndrome by Proxy
• Goodwin (1982) and Wakefield and Underwager
(1988) have cited examples of this type of MSBP
(e.g., use of tampons to create physical findings)
• Lasher and Feldman (2001) have authored an
article having to do specifically with this variation
http://childabuse.gactr.uga.edu/both/lasherfeldman/lasherfeldman1.phtml
Sexual Abuse Allegations as
Munchausen by Proxy
• It should be noted that, this variation on
Muchausen by Proxy can in fact represent
sexual abuse itself in some instances
• In cases where there are repeated allegations,
the repeated physical evaluations resulting
from these claims may represent a type of
abuse by proxy
• One also wonders about the contribution of this
type of MSBP to “false memories”
Enhancing Detection
• Positive separation test
• Analysis of previous medical course
– Temporal relationship between mother and illness
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Overt / Covert video monitoring
Station nurse near hospital room
Perform specialized testing
Ask the child
Psychological consultation!
Dr. Johnson’s case example
Psychology Clinic Case:
An Interdisciplinary Team Approach
• Specially called health care meeting
attended by total of 12 professionals
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Private practice pediatricians
Shands Pediatricians (Continuity of Care)
Child Protection Team members
Psychologist (that would be me!)
Social Workers
Staff from the Nurturing Program
Reasons the Meeting
• Meeting was prompted by a referral from ENT
• Related to a recent hospitalization of a 15-month-old
male who had tubes placed in ears and an
adenoidectomy
• Was sent home when deemed appropriate, with mom
being very upset – thought it was too early for him to
be discharged, was put on extra fluids
• Mom called indicating that he would not take fluids,
was dehydrated, was having seizures, and DEMANDED
that he be hospitalized
• No evidence of either dehydration or seizures was
found…
Data Suggestive of MSBP
• Call from mother indicating that was child
running, fell and head head – Mother reports that
child had a subdural hematoma
• No medical evidence was found
• Call from mother indicating that child fell and hit
head – Call was made 4 hours after presumed fall
with mother indicating that child had fluid
draining from ears
• Child was air lifted to Shands – No evidence of
fluid or any serious injury
• Alleged that child swallowed Christmas tree bulb –
No bulb was found
Data Suggestive of MSBP
• Mother took child for immunization – Child bite
marks found – Nurse practitioner finds bruising in
the area of the genitals and questions mother – Later
mother ends up at ER stating that child was bitten by
Brown Recluse spider
• Child’s 5 year old sister repeatedly taken to physician
with claims that she had been sexually abused by her
father, the mothers ex-husband, when child had gone
to visit
• Allegations resulted in child undergo multiple
examinations with no physical findings being noted
and mother continuing to allow visits
Other Data Suggestive
of MSBP
• By age 15 months the younger child had
experienced:
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4 hospitalizations at 2 different hospitals
9 emergency room visits
52 total medical visits
81 call slips were documented by one private
practice pediatrician
– Child had also been seen by Shands pediatrics after
original pediatrician told mom they would not
continue to see child unless mother became involved
in counseling
Team Meeting Conclusions
• It was determine that strong support existed
for Munchausen’s by Proxy
• It was concluded that the mother fabricated
physical symptoms for the 15 month old boy
• Both children were removed from the home
• Mother had also fabricated allegations of
sexual abuse for her 5-year-old daughter
Kristen’s case example
Case description
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14-year-old Caucasian female
Presented with severe hypoglycemia
Refused to show legs and abdomen
Family history of diabetes
– Grandparent – insulin dependent
– Mother taught her to check blood sugar
• Chaotic home environment
Case example
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Adolescent dropped off at hospital
No hypoglycemic episodes
Mother allegedly brought insulin to hospital
Hypoglycemic episode occurred
Overt video monitoring
Observation of self-induced symptoms
Questions??