AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

malingering, psychiatric disorder, pseudosickness, pseudologues, mental disorder, child abuse emergency, physical child abuse, tampering, infection of unknown origin, unexplained death, feigned illness, faked illness, hospital hobo, pathomimicry disease forgery, doctor addicts, hospital addicts, hospital hoppers, professional patients, false patients, operation addicts, peregrinating problem patients, dissociative pseudologia fantastica, hypochondriasis, hypochondriacs, black-hole patients, fabricated symptoms, invented symptoms, personality disorders, somatoform disorder, sudden infant death syndrome

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Roy Meadow, MD, coined the term Munchausen syndrome by proxy in 1977 after observing 2 cases of mothers causing their children to be ill.

The cardinal feature of Munchausen syndrome by proxy is the production or feigning of physical or psychological symptoms in another person, usually a child or adult under the care of another. Secondary or external factors are not present. The person often lacks other mental or physical illnesses.

The caretaker simulates or induces symptoms of an illness and then takes the child or other person to seek medical attention, disavowing knowledge of the source of the problem. The deception may arise from anger or a desire for attention, which is satisfied by having a relationship with a physician.

Most symptoms are physical complaints, whereas feigning of mental symptoms occurs to a lesser extent. Physical presentations include vomiting, diarrhea, respiratory arrest, asthma, seizure, recurrent conjunctivitis, clumsiness, syncope, fever, infection, bleeding, failure to thrive, or electrolytic disturbance. For example, polymicrobial sepsis in a central line is extremely rare and should elicit consideration of the possibility of tampering. Another example is finding carbamazepine in the blood of a patient to whom the drug was not prescribed or finding a high level in a patient in whom it was discontinued.

Physicians are trained to elicit the history of a sick child from his or her parents. A parent with Munchausen syndrome by proxy, usually the biologic mother, recounts serious but vague symptoms. This information may result in the performance of many laboratory tests and other procedures, including surgery. The child does not contradict the information because of fear. The outcome for the child could be serious injury or even death.

Although Munchausen syndrome by proxy is not formally listed as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),¹ it can be found as factitious disorder not otherwise specified.

Many authorities consider Munchausen syndrome by proxy a lethal form of child abuse in which the action is voluntary (not impulsive) and potentially harmful to normal development.

Pathophysiology

Most cases of Munchausen syndrome by proxy are reported in the pediatric literature. Although the exact pathophysiology is unknown, a number of theories have been postulated.

Most people turn to the psychodynamic literature, which emphasizes a reaction to loss or a way to obtain attention and nurturing, a way to feel powerful, or a way of just acting out as possible explanations for this syndrome.

Some investigators offer unspecified brain dysfunction as an explanation. In this theory, the mother may have experienced abuse as a child, or she may be simply rejecting her childhood for some unknown reason.

Munchausen syndrome by proxy may be explained as a parent's pathologic relationship with a child. The mother may receive a psychological reward in the form of attention she receives from medical staff.

Frequency

United States

Frequency is unknown.²

International

Although the true prevalence is unknown, Munchausen syndrome by proxy is increasingly recognized and reported worldwide.

Mortality/Morbidity

A wide variety of morbidity, ranging from infection of unknown origin to unexplained death, is noted. The mortality rate is approximately 6%.³

Race

A racial or ethnic predilection for this condition has not been determined, but most mothers are Caucasian.

Sex

Approximately 98% of persons with Munchausen syndrome by proxy are women.⁴

Age

Whether a certain age group is more likely to have the condition remains unknown.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Factitious disorder by proxy

The DSM-IV-TR includes the following research criteria for factitious disorder by proxy:

• The perpetrator intentionally produces or feigns physical or psychological signs or symptoms in another person who is under his or her care.
• The motivation for the perpetrator's behavior is to assume the sick role by proxy.
• External incentives for the behavior (eg, economic gain) are absent.
• Another mental disorder does not account for the behavior.

Factitious disorder not otherwise specified

The category of factitious disorder not otherwise specified includes disorders with contrived symptoms that do not meet the criteria for a factitious disorder, such as factitious disorder by proxy (ie, the intentional production or feigning of physical or psychological signs or symptoms in another person for the purpose of indirectly assuming the sick role).

• Characteristics of the mother
• • Past exposure and experience with the healthcare system
  • Past training or work as a nurse or medical receptionist
  • Biologic mother (95% of known cases)
  • Excellent interactions with all medical staff
  • More concerned with appearance than with substance
  • Seemingly excellent care of the child in the hospital (Eg, She never leaves the hospital and never leaves the child's side.); yet, in some cases, less concern for the child or loved one than for herself
  • Inappropriate affect when discussing the child's illness
  • Lack of emotion
  • Possible history of Munchausen syndrome in the past (found in about 25% of patients)
  • Past abuse or at least a reported story of abuse
  • Possible reporting of falsehoods about their lives (eg, earning of a law degree)
  • Poor relationship skills
  • Poor coping skills
• Characteristics of the father
• • Dependent
  • High denial
  • Very supportive of the spouse
  • Little involvement - May never visit the hospital
• Warning signs of Munchausen syndrome by proxy
• • Unexplainable, persistent, or recurrent illnesses
  • Discrepancies among the history, clinical findings, and child's general health
  • Working diagnosis of a rare disorder
  • Symptoms and signs occurring only in the mother's presence
  • Mother who is extremely attentive and always in the hospital
  • Child who is frequently intolerant of treatment
  • Mother who appears less worried about her child's illness than about the medical staff
  • Seizures that do not respond to appropriate therapy
  • Families in which unexplained sudden infant death occurs
  • Mother with previous medical or nursing experience or with an extensive history of illness

Physical

Obtain a complete history and perform complete mental status, physical, and neurologic examinations to assist with the evaluation and to exclude other disease processes.

Causes

Research does not yet show a single cause for Munchausen syndrome by proxy.

• Major causes are thought to include the following:
• • Maternal history of abuse or reported abuse
  • Rejection of the child
  • Use of the child to maintain control
  • Pathologic relationship with the child
  • Psychological reward received from the medical community because of the sick child
• The following psychiatric comorbidities may be present:
• • Munchausen syndrome
  • Narcissistic and borderline personality disorder
  • Somatoform disorder
  • Factitious disorder
  • Dissociative pseudologia phantastica
  • Sudden infant death syndrome
  • Pediatric condition falsification

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

Standard medical workup for Munchausen syndrome by proxy is unlikely to provide useful information, other than findings that exclude medical conditions that could account for psychiatric pathology in the parent.

Laboratory tests may include these:

• Sequential multiple analysis
• Determination of the CBC count
• Assays for rapid plasma reagent, thyroid-stimulating hormone, and thyroid function

Toxicologic tests and DNA typing might also be indicated.

Imaging Studies

Perform CT scanning or MRI if intracranial pathology is likely or if findings from neurologic examination are abnormal.

Other Tests

• Psychological testing may be performed to help clarify the diagnosis.
• A separation test removes the mother from her child for the purpose of observation. In Munchausen syndrome by proxy, the child's medical condition typically improves in the parent's absence, or the child may develop new abnormal findings or worsen after a visit with the parent.
• If indicated, obtain an electroencephalogram.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Indications for inpatient treatment include suicidal or homicidal ideations and grave disability (ie, patients who are dangerous to themselves or others or who cannot care for themselves).

Treatment of Munchausen syndrome by proxy involves treating the child (victim), the patient, and the family.

The literature provides little information regarding psychotherapy for Munchausen syndrome by proxy.

Treatment for the child

Treatment for the child comprises several areas, as follows:

• First, the child must be placed in a safe environment where physicians can monitor his or her symptoms in the absence of the patient with Munchausen syndrome by proxy. There, the child can receive appropriate therapies.
• Treatment may involve play therapy and/or individual therapy depending on his or her age.
• Another important aspect is clarifying the child's health status.
• A single physician who is familiar with the case should be responsible for monitoring and treating the child.
• Depending on local laws, child welfare and/or protective services may need to be notified.

Treatment for the patient with Munchausen syndrome by proxy

Treatment of the person with Munchausen syndrome by proxy involves thorough evaluation, individual therapy, and parenting classes, among other facets. Without treatment, the relapse rate is high. It is important not to overlook any medical and other psychiatric illnesses.

• Clinical investigations are conducted to determine if other problems that require treatment are present. Studies include the following:
• • Physical examination
  • Laboratory evaluation
  • Psychiatric and/or psychological evaluations
• Individual therapy is aimed at decreasing anxiety, stressors, and other problems that perpetuate the illness.
• • Identified problems must be appropriately managed.
  • Successful treatment is predicated on the patient's ability to break through denial and willingness to undergo therapy.
  • If the patient cannot overcome the issues found, his or her prognosis for recovery is poor.
• Parenting classes are also needed to teach the patient how to parent effectively while meeting his or her needs.

Hospitalization

Hospitalization of the patient and/or child may be necessary to ensure that both the patient and the child are in safe but separate environments. The physician must be able to understand the patient's condition without becoming judgmental toward him or her, as this attitude can hamper therapy.

Family therapy

Family therapy starts with education regarding Munchausen syndrome by proxy and discussions about whether reunification of the patient and child might be possible.

If other children live in the patient's home, their health status should be evaluated, and appropriate treatment given. All members of the family should receive therapy; they include parents, siblings, and the affected child.

If the family is reunited, supervision is mandatory to ensure the child's safety.

Consultations

Consultations with the following individuals may be indicated:

• Attorney
• Law enforcement personnel - To conduct covert video surveillance
• Family court personnel - To terminate parental rights
• Child welfare authorities - To arrange for foster care

Activity

Restrict activity if patients are a danger to themselves or others or if they are gravely disabled.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

No information is available regarding the use of medications in the treatment of Munchausen syndrome by proxy.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

Patients may require further inpatient care if they are a danger to themselves or others or if they are gravely disabled.

Further Outpatient Care

The literature provides little information regarding psychotherapy for Munchausen syndrome by proxy.

In/Out Patient Meds

No information is available.

Transfer

If patients are charged with a crime or if they have been arrested, they may be incarcerated.

Deterrence/Prevention

Deterrence and/or prevention may encompass these aspects:

• Education
• Legal ramifications

Complications

Complications of Munchausen syndrome by proxy and its management include the following:

• Noncompliance with therapy
• Difficulty in proving the syndrome

Prognosis

Patients with a good prognosis have the following characteristics:

• They are able to assume responsibility for their behavior.
• They can improve their coping skills.
• They can place child's needs above their own.

Patients with a poor prognosis may exhibit the following signs:

• They demonstrate a high degree of denial.
• They are uncooperative with therapy.
• They may have a personality disorder.

Patient Education

Educating the patient, family, and medical staff about Munchausen syndrome by proxy is important.

• Patient education is directed at increasing the patient's coping and stress-management skills, among other areas.
• Family education regarding patterns of this disorder in previous generations of the family is needed to effectively treat patients.
• • If other children are present in the home, they should be evaluated for possible abuse.
  • A helpful endeavor is instructing the patient in techniques to reduce stress and anxiety in the home to improve his or her prognosis.
  • The family should also be educated about healthy ways for the patient to express anger. The family members should allow the patient to appropriately express anger and not consider it a hindrance to the recovery process.

For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Munchausen Syndrome.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to be familiar with local laws
• Failure to maintain or appropriately break patient confidentiality (eg, failure to report patients to the proper authorities)

Special Concerns

• Munchausen syndrome by proxy is difficult to prove. Patients are typically not caught, and cases are usually based on circumstantial evidence.
• Physicians must have a high index of suspicion to be able to detect Munchausen syndrome by proxy, eg, on the basis of the level of dishonesty a patient exhibits. One considers a diagnosis of Munchausen syndrome by proxy only after physical illnesses in the child are ruled out.
• Review the child's medical history and the family history to look for a history of Munchausen syndrome in the patient. The adult—and not the child—is the patient in whom Munchausen syndrome by proxy is diagnosed.
• Video surveillance may assist in confirming the diagnosis.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision. Washington, DC: American Psychiatric Association; 200:517, 781-3.
2. Forsyth B. Munchausen syndrome by proxy. In: Melvin Lewis, ed. Child and Adolescent Psychiatry: A comprehensive textbook. 2^nd ed. Baltimore, MD: Williams & Wilkins; 1996:1048-1054.
3. Sheridan MS. The deceit continues: an updated literature review of Munchausen Syndrome by Proxy. Child Abuse Negl. Apr 2003;27(4):431-51. [Medline].
4. The Nemours Foundation. Munchausen by proxy syndrome. 2007;5 Nov:Accessed Jan 4, 2008. Available at www.kidshealth.org/parent/general/sick/munchausen.html.
5. Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry. Oct 2005;187:328-33. [Medline].
6. Ayoub CC, Schreier HA, Keller C. Munchausen by proxy: presentations in special education. Child Maltreat. May 2002;7(2):149-59. [Medline].
7. Bartsch C, Risse M, Schütz H, Weigand N, Weiler G. Munchausen syndrome by proxy (MSBP): an extreme form of child abuse with a special forensic challenge. Forensic Sci Int. Nov 26 2003;137(2-3):147-51. [Medline].
8. Baskin DE, Stein F, Coats DK, Paysse EA. Recurrent conjunctivitis as a presentation of munchausen syndrome by proxy. Ophthalmology. Aug 2003;110(8):1582-4. [Medline].
9. Bauer KA. Covert video surveillance of parents suspected of child abuse: the British experience and alternative approaches. Theor Med Bioeth. 2004;25(4):311-27. [Medline].
10. Bools C. Factitious illness by proxy. Munchausen syndrome by proxy. Br J Psychiatry. Sep 1996;169(3):268-75. [Medline].
11. Bools C, Neale B, Meadow R. Munchausen syndrome by proxy: a study of psychopathology. Child Abuse Negl. Sep 1994;18(9):773-88. [Medline].
12. Bornemann MA, Mahowald MW, Schenck CH. Parasomnias: clinical features and forensic implications. Chest. Aug 2006;130(2):605-10. [Medline].
13. Boros SJ, Ophoven JP, Andersen R, Brubaker LC. Munchausen syndrome by proxy: a profile for medical child abuse. Aust Fam Physician. May 1995;24(5):768-9, 772-3. [Medline].
14. Donald T, Jureidini J. Munchausen syndrome by proxy. Child abuse in the medical system. Arch Pediatr Adolesc Med. Jul 1996;150(7):753-8. [Medline].
15. Feldman MD, Brown RM. Munchausen by Proxy in an international context. Child Abuse Negl. May 2002;26(5):509-24. [Medline].
16. Folks DG. Munchausen's syndrome and other factitious disorders. Neurol Clin. May 1995;13(2):267-81. [Medline].
17. Forsyth BWC. Munchausen syndrome by proxy. In: Lewis M, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook. 2^nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1996:1048-54.
18. Lesaca TG. At mother's mercy: the nightmare of Munchausen syndrome by proxy. W V Med J. Nov-Dec 1995;91(7):318-9. [Medline].
19. Marcus A, Ammermann C, Klein M, Schmidt MH. Munchausen syndrome by proxy and factitious illness: symptomatology, parent-child interaction, and psychopathology of the parents. Eur Child Adolesc Psychiatry. Oct 1995;4(4):229-36. [Medline].
20. Maxmen JS, Ward NG. Factitious disorders. In: Essential Psychopathology and Its Treatment. 2^nd ed. New York, NY: W.W. Norton & Company; 1995:304-9.
21. Meadow R. Munchausen syndrome by proxy. Arch Dis Child. Feb 1982;57(2):92-8. [Medline].
22. Moldavsky M, Stein D. Munchausen Syndrome by Proxy: two case reports and an update of the literature. Int J Psychiatry Med. 2003;33(4):411-23. [Medline].
23. Murray JB. Munchausen syndrome/Munchausen syndrome by proxy. J Psychol. May 1997;131(3):343-52. [Medline].
24. Pankratz L. Persistent problems with the Munchausen syndrome by proxy label. J Am Acad Psychiatry Law. 2006;34(1):90-5. [Medline].
25. Rand DC, Feldman MD. An explanatory model for Munchausen by proxy abuse. Int J Psychiatry Med. 2001;31(2):113-26. [Medline].
26. Repper J. Munchausen syndrome by proxy in health care workers. J Adv Nurs. Feb 1995;21(2):299-304. [Medline].
27. Rogers R. Diagnostic, expanatory, and detection models of Munchausen by proxy: extrapolations from malingering and deception. Child Abuse Negl. Feb 2004;28(2):225-38. [Medline].
28. Rosenberg DA. Munchausen Syndrome by Proxy: medical diagnostic criteria. Child Abuse Negl. Apr 2003;27(4):421-30. [Medline].
29. Sahin F, Kuruoglu A, Isik AF, Karacan E, Beyazova U. Munchausen syndrome by proxy: a case report. Turk J Pediatr. Oct-Dec 2002;44(4):334-8. [Medline].
30. Schreier HA, Libow JA. Munchausen syndrome by proxy: diagnosis and prevalence. Am J Orthopsychiatry. Apr 1993;63(2):318-21. [Medline].
31. Skau K, Mouridsen SE. Munchausen syndrome by proxy: a review. Acta Paediatr. Sep 1995;84(9):977-82. [Medline].
32. Thomas K. Munchausen syndrome by proxy: identification and diagnosis. J Pediatr Nurs. Jun 2003;18(3):174-80. [Medline].
33. Truman TL, Ayoub CC. Considering suffocatory abuse and Munchausen by proxy in the evaluation of children experiencing apparent life-threatening events and sudden infant death syndrome. Child Maltreat. May 2002;7(2):138-48. [Medline].
34. Ulinski T, Lhopital C, Cloppet H, Feït JP, Bourlon I, Morin D. Munchausen syndrome by proxy with massive proteinuria and gastrointestinal hemorrhage. Pediatr Nephrol. Jul 2004;19(7):798-800. [Medline].
35. Von Burg MM, Hibbard RA. Munchausen syndrome by proxy: a different kind of child abuse. Indiana Med. Sep-Oct 1995;88(5):378-82. [Medline].
36. Wenk RE. Molecular evidence of Munchausen syndrome by proxy. Arch Pathol Lab Med. Jan 2003;127(1):e36-7. [Medline].

Article Last Updated: Jan 17, 2008