Marcy Rhodes

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Munchausens Syndrome by Proxy

• Marcy Rhodes
• Stephen F. Austin State University
• April 17, 2008

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What is factitious disorder?

• Diagnostic Criteria (DSM-IV-TR)
• Intentional production or feigning of physical or
  psychological signs and symptoms
• Motivation for the behavior is to assume the sick
  role
• External incentives for the behavior are absent

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Munchausens Syndrome

• Karl Friedrich Hieronymus,
• Baron Von Munchhausen
• (18th Century)
• Name given by Asher (1951)

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What is Factitious Disorder BY PROXY?

• By Proxy indirectly assumes sick role
• Listed in Appendix B in the DSM-IV-TR
• Research Criteria
• Intentional production or feigning of physical or
  psychological signs or symptoms in another person
  who is under the individuals care.
• The motivation for the perpetrators behavior is
  to assume the sick role by proxy
• External incentives for the behavior are absent
• The behavior is not better accounted for by
  another mental disorder

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Munchausens Syndrome By Proxy

• Coined by Roy Meadow, 1977
• Pediatrician in Leeds, England
• Became convinced that many apparent cot deaths
  were in fact the result of child abuse brought on
  by MSbP
• First to describe this
• disorder recognize
• it as a fatal form
• of child abuse.

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Overview of Munchausens Syndrome By Proxy (MSbP)

• Caretaker fabricates, exaggerates, or induces
  illness in a child, for which he or she seeks
  extensive medical testing and/or hospitalizations
• Perpetrator obtains psychological reward in the
  form of the attention she receives from others
• Victimization is often lengthy
• Perpetrator is usually the biological mother
  (98)
• Perpetrator presents as model parent
• Most victims are preschoolers

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Overview of Munchausens Syndrome By Proxy (MSbP)

• Prevalence has not been established considered
  uncommon
• Majority of cases involve the gastrointestinal,
  genitourinary or central nervous system.
• More than one child in the family may be abused
• In as many as 10 of cases, abuse leads to death

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Most common induced and simulated illnesses

• Persistent vomiting or diarrhea
• Respiratory arrest
• Asthma
• Central Nervous Systems dysfunctions (e.g.,
  seizures, loss of consciousness)
• Fever
• Infection Bacteriologically Battered Babies
• Bleeding
• Failure to thrive
• Hypoglycemia
• Electrolyte disturbances
• Rash

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Attachment Representations and MSbP

• Adshead Bluglass (2001)
• Assessed the attachment style of 26 mothers who
  had exhibited MSbP behaviors
• 88 exhibited an insecure attachment style
• Most common pattern dismissing (77)
• Adshead Bluglass (2005)
• Assessed attachment style of 67 mothers who had
  exhibited MSbP behaviors
• Only 18 exhibited a secure attachment style
• 85 rated as insecure
• Dismissing, 46

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Case Study Kathy Bush

• Diagnosed with MSbP
• Charged with aggravated child abuse and Medicaid
  fraud
• Jennifer Bush, daughter
• Between August 1993 and April 1995
• Taken to the hospital more than 130 times
• Underwent 40 surgeries
• Amassed over 3 million in medical bills

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Profile of MSbP Perpetrators

• Most often biological mothers
• Appear to be very knowledgeable about victims
  illness
• Past exposure experience with healthcare system
• Often have some previous (usually incomplete)
  training in nursing or medicine
• Remain uncharacteristically calm in view of
  victims perplexing medical symptoms

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Profile of MSbP Perpetrators

• Praise medical staff excessively
• Welcome medical tests, even those that are
  painful
• Increased incidence of Munchausen syndrome
• History of Abuse or at least reported history of
  abuse
• Fabrication of info about perpetrators life
• Poor relationship skills
• Poor coping skills

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Profile of MSbP Perpetrators

• Typically shelter victim from outside activities
• Maintain a high degree of attentiveness to the
  victim
• Often unresponsive to child when unaware of being
  observed
• Find emotional satisfaction when the child is
  hospitalized because of the staffs praise of
  their ability to be a superior, attentive
  caregiver.

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Perpetrator Motivational Factors

• Crave attention from medical staff, doctors,
  family and friends
• Might receive gratification for being able to
  fool those who they perceive as having more
  power, status
• Some offenders may fear going home or adjusting
  to a normal daily routine without being the
  center of attention
• An offender who is praised as a hero for saving a
  child might elect to re-create that euphoria by
  fabricating subsequent incidents of abuse and
  revival of the victim.

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MSbP Warning Signs

• Unexplained, persistent, recurring illness
• Repeated hospitalizations and extensive medical
  tests that fail to produce a diagnosis
• Symptoms that do not make medical sense
• Lab results that are inconsistent with each other
  or recognized diseases
• Persistent failure of the victim to respond to
  therapy

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MSbP Warning Signs

• Signs and symptoms that occur ONLY in the
  presence of the caretaker
• Mother who is extremely attentive and always in
  the hospital
• Mothers who do not seem worried about their
  child's illness but are constantly at the child's
  side while in the hospital
• Mothers who have an unusually close relationship
  with the hospital's medical staff

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MSbP Warning Signs

• A family history of sudden infant death syndrome
• Mothers with previous medical or nursing
  experience or with an extensive history of
  illness
• A parent who welcomes medical testing of the
  child, even if painful
• May become angry and demand further procedures,
  second opinions, further intervention

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MSbP Warning Signs

• Attempts to convince the staff that the child is
  still ill when advised that the child will be
  released from the hospital
• A caregiver with a previous history of Munchausen
  Syndrome
• A caregiver who adamantly refuses to accept the
  suggestion that the diagnosis is nonmedical.
• Increasingly urgent visits to the same hospital
  or clinic.

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Difficult to Confirm MSbP

• Practitioners may be reluctant to diagnose
• Goes against the belief that a parent or
  caregiver would ever deliberately hurt his or her
  child.
• Legal consequences of inaccurate diagnosis
• Personal consequences of inaccurate diagnosis
• Sally Clark (1964 2007)

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M.A.M.A.

• Mothers Against Munchausens Allegations
• Mission To stop the assault on innocent parents
  from MSbP allegations and to reveal the ulterior
  motives of the accusers
• These mothers claim that they are falsely
  accused
• Doctor or institution can evade a medical
  malpractice lawsuit
• Doctors can rid themselves of a troublesome mom
  when frustrated and unable to diagnose a child's
  condition
• The false MSBP diagnosis can be gravely
  detrimental adding deep emotional stress of
  maternal deprivation to an ill child
• www.msbp.com

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If you do suspect MSbP

• Proceed with Multidisciplinary team
• CPS
• Law enforcement
• Psychologist or psychiatrist
• Prosecutor
• Hospital social worker
• Nurse practitioner
• Pediatrician (especially one specialized in MSbP)
• Other members of the childs medical team

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If you do suspect MSbP

• Review medical records
• Entries regarding child/parent interactions
• May establish temporal relationship between
  symptoms and parents presence
• Direct monitoring of childs hospital room
• Sitter
• Documents time of visits, especially of suspected
  perpetrator
• No food or drink allowed except for the provided
  by hospital staff
• Video surveillance (controversial)
• Completely restrict parents access (must be
  court-ordered)

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Treatment - Prepetrator

• Psychotherapy is often ineffective
• Successful treatment depends upon
• the patient's ability to break through denial and
  willingness to undergo therapy
• Changes in the family system
• Increased parental sensitivity and responsiveness
  to childs needs
• Plan to prevent relapse
• If the patient cannot overcome her issues,
  prognosis for recovery is poor.

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Treatment Child/Victim

• First, the child must be placed in a safe
  environment
• 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.

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Short Long-Term Implications

• Short term
• Pain
• Mothers actions
• Medical procedures
• Reduced social, educational, and emotional
  opportunities
• Long term
• Long term disability
• Increased likelihood of developing Munchuasens
  syndrome
• Libow (1995)
• PTSD
• Feelings of inadequacy
• Poor self-esteem
• Relationship problems