Munchausen Syndrome by Proxy (MSBP)

Mary E. Muscari, PhD, CPNP, APRN-BC at Medscape…

…usually describes the deliberate production, or feigning, of physical or psychological symptoms in another person who is under the individual’s care. …usually involves a mother and young child; however, there have been cases of MSBP involving illness produced or feigned in other adults and even in pets

Research criteria include:

• Intentional production of or feigning of physical or psychological symptoms in a person under one’s care;
• Perpetrator motivated by assuming the sick role by proxy;
• External incentives (such as monetary gain) are absent; and
• Behavior is not better accounted for by another disorder.[3]

Subtypes
Chronic Munchausen by proxy is characterized by the constant pursuit of attention by inducing symptoms in another person. Individuals displaying chronic MSBP are compulsive, and the behavior consumes most of their lives.

Episodic Munchausen by proxy occurs in spurts. There are intervals when the person experiences symptoms of MSBP and intervals where the person lives a normal life.

In mild Munchausen by proxy, affected individuals fabricate medical histories for their children and lie about their children being sick rather than actively causing sickness. Their motivation is the emotional gratification they receive from medical attention.

In intense Munchausen syndrome by proxy, the person resorts to measures such as inducing vomiting, poisoning, removing blood from the child, and suffocation. The individual is able to induce severe illness in his or her own child, yet remain cooperative, concerned, and compassionate in the presence of healthcare providers

Presentation
Victims are equally divided between male and female, and children most at risk are those aged 15 months to 72 months. Victims frequently have baffling symptoms and see multiple healthcare providers before a diagnosis of MSBP is made. In 98% of cases, the perpetrator is the biological mother.[6] Characteristics of perpetrators include female, white, experiencing marital discord, having healthcare knowledge or training, friendly and cooperative with staff, very attentive to the child, and may have a history of abuse and/or psychiatric disorders.[7]

Ways that MSBP can present include[6,7]:

• Complex pattern of illness and recurrent infection without physiologic explanation;
• Seizure activity that does not respond to medication and that is only witnessed by the caretaker;
• Bleeding from anticoagulants and poisons; use of caretaker’s own blood or red-colored substances to simulate bleeding;
• Vomiting precipitated by ipecac administration;
• Diarrhea induced by laxatives or salt administration;
• Hypoglycemia from administration of insulin or hypoglycemic agents;
• Rashes from caustic substances applied to the skin;
• Hematuria or rectal bleeding from trauma;
• Recurrent apparent life-threatening events (ALTE) from purposeful suffocation; and
• Central nervous system depression (usually from drug administration).

Mason and Poirier[6] recommend looking for these warning signs:

• Illness that is multisystemic, prolonged, unusual, or rare;
• Symptoms that are inappropriate or incongruent;
• Multiple allergies;
• Symptoms that disappear when caretaker is absent;
• One parent, usually the father, absent during the child’s hospitalization;
• History of sudden infant death syndrome (SIDS) in siblings;
• Parent who is overly attached to the patient;
• Parent who has medical knowledge/background;
• Child who has poor tolerance of treatment;
• Parent who encourages medical staff to perform numerous tests and studies; and
• Parent who shows inordinate concern for feelings of the medical staff.

When should I suspect Munchausen syndrome by proxy in a patient? [Medscape Med Students]