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Münchausen syndrome by proxy
Classification and external resources
DiseasesDB 33167
eMedicine med/3544 ped/2742
MeSH D016735

Münchausen syndrome by proxy (MSbP), referred to in the DSM-IV-TR as Factitious Disorder by Proxy, is a disorder in which a person deliberately causes injury or illness to another person (most often his or her child), usually to gain attention or some other benefit.[1][2] Münchausen by proxy has been described by some as a form of extended child abuse.[3][4] The motivation is to assume the sick role by proxy.[5] It involves physical abuse and medical neglect.[6]

The caregiver is usually a parent, guardian, or spouse, and the victim is usually a child or vulnerable adult. Most cases involve inducing physical illness; however, it is also possible for a perpetrator to simulate or fabricate conditions that appear to be psychiatric or genetic problems.

Contents

Initial description

Münchausen syndrome was first described in 1951 as when someone invents or exaggerates medical symptoms, sometimes engaging in self-harm, to gain attention or sympathy.

In 1977, pediatrician Roy Meadow, then professor of pediatrics at the University of Leeds, England, described the extraordinary behavior of two mothers. According to Meadow, one had poisoned her toddler with excessive quantities of salt. The other had introduced her own blood into her baby's urine sample. He referred to this behavior as Münchausen syndrome by proxy (MSbP).[7]

The medical community was initially skeptical of MSbP's existence, but it gradually gained acceptance as a recognized condition.

Indications

Caution is required in the diagnosis of fabricated or induced illness (FII). Many of the items below are also indications of a child with organic, but undiagnosed illness. An ethical diagnosis of MSbP must include an evaluation of the child, an evaluation of the parents and an evaluation of the family dynamics. Diagnoses based only on a review of the child's medical chart can be rejected in court. The adult care provider who is abusing the child often seems comfortable and not upset over the child's hospitalization. While the child is hospitalized, medical professionals need to monitor the caregiver's visits in order to prevent any attempt to worsen the condition of the child.[8] In addition, in most states, medical professionals have a duty to report such abuse to legal authorities.[9]Warning signs of the disorder include:[10]

  • A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling and unexplained.
  • Physical or laboratory findings that are highly unusual, discrepant with history, or physically or clinically impossible.
  • A parent who appears to be medically knowledgeable and/or fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients' problems.
  • A highly attentive parent who is reluctant to leave their child's side and who themselves seem to require constant attention.
  • A parent who appears to be unusually calm in the face of serious difficulties in their child's medical course while being highly supportive and encouraging of the physician or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to other, more sophisticated, facilities.
  • The suspected parent may work in the health care field themselves or profess interest in a health-related job.
  • The signs and symptoms of a child's illness do not occur in the parent's absence (hospitalization and careful monitoring may be necessary to establish this causal relationship).
  • A family history of similar or unexplained illness or death in a sibling.
  • A parent with symptoms similar to their child's own medical problems or an illness history that itself is puzzling and unusual.
  • A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with serious illness.
  • A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment.
  • A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgment of their abilities.

Prevalence by gender

One study showed that in over 90 percent of cases of MSbP, the mother is the abuser.[11] In other cases, the MSbP abuser is often another female caregiver. Fathers have been the perpetrators in a handful of professional reports. The female preponderance may be attributed to socialization patterns that encourage females to seek the sympathy and assistance of others. Neuropsychological testing of perpetrators has shown either normal results or nonspecific abnormalities.

MSbP may also be attributed to another prevalent socialization pattern, which places females in the primary care-taking role. For a psychodynamic model of this kind of maternal abuse, see Anna Motz's The Psychology of Female Violence: Crimes Against the Body (Routledge, 2001 ISBN 978-0415126755, 2nd ed. forthcoming 2008 ISBN 978-0415403870).

Controversy

During the 1990s and early 2000s, Meadow was an expert witness in several murder cases involving FII, some of which resulted in parents being wrongly convicted of murdering their children and imprisoned. In 2003, Lord Howe, the Opposition spokesman on health, accused the professor of inventing a "theory without science" and refusing to produce any real evidence to prove that Münchausen syndrome by proxy actually exists. It is important to distinguish between the act of harming a child, which can be easily verified (and there are plenty of cases to prove that it happens), and motive, which is much harder to verify and which MSbP tries to explain. For example, a caregiver may wish to harm a child simply out of malice, rather than in order to draw attention and sympathy.

The distinction is often crucial in criminal proceedings, in which the prosecutor must prove both the act and the mental element constituting a crime to establish guilt. In most legal jurisdictions, a doctor can give expert witness testimony as to whether a child was being harmed but cannot speculate regarding the motive of the caregiver. FII merely refers to the fact that illness is induced or fabricated and does not specifically limit the motives of such acts to a caregiver's need for attention and/or sympathy. There are now more than 2,000 case reports of FII in the professional literature. Reports come from developing countries that include, but are not limited to, Sri Lanka, Nigeria, and Oman. Dr. Meadow was knighted for his work for child protection, though later, his reputation, and consequently the credibility of MSbP, became severely damaged when several convictions of child killing, in which he acted as an expert witness, were overturned.[12] In 2003, a number of high-profile acquittals brought Meadow's ideas into serious disrepute. Around 250 cases resulting in conviction in which Meadow was an expert witness were reviewed, with few changes. Meadow was investigated by the British General Medical Council over evidence he gave as an expert witness for the prosecution in the Sally Clark trial, where he asserted that the odds of there being two unexplained infant deaths in one family were one in 73 million. That figure was crucial in sending her to jail but was hotly disputed by the Royal Statistical Society, who wrote to the Lord Chancellor to complain. It was subsequently shown that the true odds were much lower, i. e., there was a much higher possibility of two deaths happening as a chance occurrence. In July 2005, the GMC declared Meadow guilty of "serious professional misconduct", and he was struck off the register for giving "misleading" evidence in the Sally Clark case.[13] At appeal, High Court judge Mr. Justice Collins described this as "irrational" and set it aside. Meadow was involved as a prosecution witness in two other high-profile cases resulting in mothers being imprisoned and subsequently cleared of wrongdoing — those of Trupti Patel[14] and Angela Cannings.[15] Collins's judgment raises important points concerning the liability of expert witnesses — his view is that referral to the GMC by the losing side is an unacceptable threat and that only the Court should decide whether its witnesses are seriously deficient and refer them to their professional bodies.[citation needed]

Legal status in Australia and the UK

In most legal jurisdictions, doctors are only allowed to give evidence in regard to whether the child is being harmed. They are not allowed to give evidence in regard to the motive. Australia and the UK have established the legal precedent that MSbP does not exist as a medico-legal entity.

In a June 2004 appeal hearing, the Supreme Court of Queensland, Australia, stated:

In some person's opinions, the term factitious disorder (Münchausen syndrome by proxy) is merely descriptive of a behavior, not a psychiatrically identifiable illness or condition. American experts mostly disagree, however, and perpetrators' legal actions in the U.S. to quash descriptions and use of Münchausen syndrome by proxy have almost always failed. [R v LM [2004] QCA 192.].

The Queensland Supreme Court further ruled that the determination of whether or not a defendant had caused intentional harm to a child was a matter for the jury to decide and not for the determination by expert witnesses:

The diagnosis of Doctors Pincus, Withers, and O'Loughlin that the appellant intentionally caused her children to receive unnecessary treatment through her own acts and the false reporting of symptoms of factitious disorder (Münchausen Syndrome) by proxy is not a diagnosis of a recognised medical condition, disorder, or syndrome. It is simply placing her within the medical term used for the category of people exhibiting such behavior. In that sense, their opinions were not expert evidence because they related to matters able to be decided on the evidence by ordinary jurors. The essential issue as to whether the appellant reported or fabricated false symptoms or did acts to intentionally cause unnecessary medical procedures to injure her children was a matter for the jury's determination. The evidence of Doctors Pincus, Withers, and O'Loughlin that the appellant was exhibiting the behavior of factitious disorder (Münchausen syndrome by proxy) should have been excluded.

Principles of law and implications for legal processes that may be deduced from these findings are that:

  1. Any matters brought before a Court of Law should be determined by the facts, not by suppositions attached to a label describing a behavior, i.e., MSBP/FII/FDBP;
  2. MSBP/FII/FDBP is not a mental disorder (i.e., not defined as such in DSM IV), and the evidence of a psychiatrist should not therefore be admissible;
  3. MSBP/FII/FDBP has been stated to be a behavior describing a form of child abuse and not a medical diagnosis of either a parent or a child. A medical practitioner cannot therefore state that a person "suffers" from MSBP/FII/FDBP, and such evidence should also therefore be inadmissible. The evidence of a medical practitioner should be confined to what they observed and heard and what forensic information was found by recognized medical investigative procedures;
  4. A label used to describe a behavior is not helpful in determining guilt and is prejudicial. By applying an ambiguous label of MSBP/FII to a woman is implying guilt without factual supportive and corroborative evidence;
  5. The assertion that other people may behave in this way, i.e., fabricate and/or induce illness in children to gain attention for themselves (FII/MSBP/FDBY), contained within the label is not factual evidence that this individual has behaved in this way. Again therefore, the application of the label is prejudicial to fairness and a finding based on fact.

The Queensland Judgment was adopted into English law in the High Courts of Justice in Case No. WR03C00142 [A County Council v A Mother and A Father and X,Y,Z children] on 18 January 2005 by Mr. Justice Ryder. In his final conclusions regarding Factitious Disorder, Ryder states that:

I have considered and respectfully adopt the dicta of the Supreme Court of Queensland in R v. LM [2004] QCA 192 at paragraph 62 and 66. I take full account of the criminal law and foreign jurisdictional contexts of that decision but I am persuaded by the following argument upon its face that it is valid to the English law of evidence as applied to children proceedings.

The terms "Münchausen syndrome by proxy" and "factitious (and induced) illness (by proxy)" are child protection labels that are merely descriptions of a range of behaviors, not a pediatric, psychiatric or psychological disease that is identifiable. The terms do not relate to an organized or universally recognized body of knowledge or experience that has identified a medical disease (i.e. an illness or condition) and there are no internationally accepted medical criteria for the use of either label.

In reality, the use of the label is intended to connote that in the individual case there are materials susceptible of analysis by pediatricians and of findings of fact by a court concerning fabrication, exaggeration, minimization or omission in the reporting of symptoms and evidence of harm by act, omission or suggestion (induction). Where such facts exist the context and assessments can provide an insight into the degree of risk that a child may face and the court is likely to be assisted as to that aspect by psychiatric and/or psychological expert evidence.

All of the above ought to be self evident and has in any event been the established teaching of leading pediatricians, psychiatrists and psychologists for some while. That is not to minimize the nature and extent of professional debate about this issue which remains significant, nor to minimize the extreme nature of the risk that is identified in a small number of cases.

In these circumstances, evidence as to the existence of MSBP or FII in any individual case is as likely to be evidence of mere propensity which would be inadmissible at the fact finding stage (see Re CB and JB supra). For my part, I would consign the label MSBP to the history books and however useful FII may apparently be to the child protection practitioner I would caution against its use other than as a factual description of a series of incidents or behaviors that should then be accurately set out (and even then only in the hands of the pediatrician or psychiatrist/psychologist). I cannot emphasis too strongly that my conclusion cannot be used as a reason to re-open the many cases where facts have been found against a carer and the label MSBP or FII has been attached to that carer's behavior. What I seek to caution against is the use of the label as a substitute for factual analysis and risk assessment.

In his book Playing Sick (2004), Marc Feldman notes that such findings have been in the minority among U.S. and even Australian courts. Pediatricians and other physicians have banded together to oppose limitations on child-abuse professionals whose work includes FII detection.[16] The April 2007 issue of the journal Pediatrics specifically mentions Meadow as an individual who has been inappropriately maligned.

Münchausen syndrome by proxy: pet

Medical literature describes a subset of MSbP caretakers, where the proxy is a pet rather than another person. These cases are labeled Münchausen syndrome by proxy: pet (MSbP:P). In these cases, pet owners correspond to caretakers in traditional MSbP presentations involving human proxies.[17] No extensive survey has yet been made of the extant literature, and there has been no speculation as to how closely MSbP:P tracks with human MSbP.

In media

In the novel Keeping Faith by Jodi Picoult, the protagonist (Faith)'s mother is accused of inflicting wounds on her child, symptoms associated with the psychiatric condition Münchausen syndrome by proxy.

Darin Strauss's novel More Than It Hurts You tracks the fictional lives of a Long Island family after the mother is accused of inflicting injuries on their infant son, therefore showing signs of Münchausen syndrome by proxy.

In the novel Devil's Waltz by Jonathan Kellerman, the protagonist, a child psychologist named Dr. Alex Delaware, is faced with a sickly child that may be suffering from injuries committed by her mother, who may be suffering from MSbP.

The novel Sickened: The Memoir of a Munchausen by Proxy Childhood is an autobiographical account of the Münchausen syndrome by proxy abuse that author Julie Gregory suffered throughout her childhood.

In the second-season episode of the television series The X-Files entitled "The Calusari", Scully suspects a grandmother of MSbP.

In the 1994 made-for-TV movie A Child's Cry for Help starring Pam Dawber, a doctor follows the case of allegations against a mother who slowly poisons her son.

In the 1999 film The Sixth Sense, a young boy is able to converse with the dead. In one segment of the film, the boy aids the ghost of a young girl who was slowly poisoned to death by her mother, who exhibits symptoms of Münchausen syndrome by proxy. On the event of the girl's death, the mother is seen embracing the attention given to her at the girl's funeral reception. The mother is even wearing a bright red dress for the occasion. It is mentioned that the girl's younger sister is now beginning to fall ill. Comments from other funeral attendees (easier read, when subtitles are enabled, than heard) indicate that this is not the first such wasting death that has occurred in the family.

In the 2003 movie Chakushin Ari, a murderous spirit is suspected to draw its strength from its death as a victim of a mother suffering from MSbP.

Episode 11 of the courtroom TV drama Judging Amy, entitled "Presumed Innocent", has as part of its plot the juvenile court judge's decision in the case of a mother who, as an ex-nurse, is suspected of causing the mysterious (and recurring) strokes, fits and fevers of her daughter. In the episode, it turns out it is true (by the daughter accidentally betraying her mother), and the term Münchausen syndrome by proxy is in fact mentioned during one of the pleas.

In the third season of the TV Series Supernatural, the fifth episode, entitled "Bedtime Stories", talks about the spirit of a girl who is vengeful, as her stepmother had poisoned her with bleach and her father was unaware of that.

In the episode of the 2008 Televisa drama La Rosa de Guadalupe entitled "Saber Amar" ("Knowing How to Love"), a mother poisons her child with arsenic in an attempt to gain attention from her separated husband.

In the 2008 film Yes Man, the fictional band fronted by Zooey Deschanel is called Munchausen By Proxy.

American rapper Eminem reports that his mother suffered from this disease.

In the Mystery Science Theater 3000 episode "Jack Frost", one of the film viewers quips that the evil stepmother's treatment of her own daughter is an example of MSbP.

In the film The Good Mother (2006), two siblings lose their parents in a tragic accident. They are adopted by a couple. Shortly after, the youngest child becomes deathly ill, and his sister soon realizes her foster mother is poisoning him and has done the same to several foster children before him. She does research online and discovers her foster mother has MSbP.

In the fifth season of the TV series Wire in the Blood, the first episode, entitled "The Colour of Amber", involves the death of a young child. Initially, the child is thought to be the victim of a child molester, but the murderer is eventually revealed to be her attention-seeking mother, who has been poisoning her daughter with salt and food served long after its sell-by date. Ironically, the murder was accidental and was caused by a physical blow and not from the sickening caused by MSbP.

In the third season of the TV series Drawn Together, in the fourth episode, entitled "Unrestrainable Trainable", Clara keeps Wooldoor Sockbat sick by feeding him poison and harming him physically. One of the poison bottles reads, "Not to be used for Munchausen by Proxy."

In the Stephen King novel It, the character Eddie Kaspbrak has a mother with Munchausen syndrome by proxy.

See also

References

  1. ^ Practical Aspects of Münchausen by Proxy and Münchausen Syndrome Investigation [1]
  2. ^ Health Care Fraud & Abuse
  3. ^ Sterling J Jr. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics. 2007 May;119(5):1026-30.
  4. ^ Vennemann B, Bajanowski T, Karger B, Pfeiffer H, Köhler H, Brinkmann B (March 2005). "Suffocation and poisoning--the hard-hitting side of Munchausen syndrome by proxy". Int. J. Legal Med. 119 (2): 98–102. doi:10.1007/s00414-004-0496-6. PMID 15578197. http://dx.doi.org/10.1007/s00414-004-0496-6. 
  5. ^ S Elwyn, Todd. "Factitious Disorder: eMedicine Psychiatry". emedicine.medscape.com. http://emedicine.medscape.com/article/291304-overview. Retrieved 2009-09-14. 
  6. ^ Stirling J (May 2007). "Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting". Pediatrics 119 (5): 1026–30. doi:10.1542/peds.2007-0563. PMID 17473106. http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=17473106. 
  7. ^ Meadow, Roy (1977), "Munchausen Syndrome by Proxy: the Hinterlands of Child Abuse", The Lancet 310: 343–5, doi:10.1016/S0140-6736(77)91497-0, http://web.tiscali.it/humanrights/articles/meadow77.html 
  8. ^ Schreier, Herbert A..; Judith A. Libow (1993). Hurting for Love: Muchausen by Proxy Syndrome. The Guilford Press. ISBN 0-89862-121-6. 
  9. ^ Elder W, Coletsos IC, Bursztajn HJ. Factitious Disorder/Munchhausen Syndrome. The 5-Minute Clinical Consult. 18th Edition. 2010. Editor: Domino F.J. Wolters Kluwer/Lippencott. Philadelphia.
  10. ^ Schreier, Herbert A..; Judith A. Libow (1993). Hurting for Love: Muchausen by Proxy Syndrome. The Guilford Press. ISBN 0-89862-121-6. 
  11. ^ Vennemann B, Perdekamp MG, Weinmann W, Faller-Marquardt M, Pollak S, Brandis M (2006). "A case of Munchausen syndrome by proxy with subsequent suicide of the mother". Forensic Sci. Int. 158 (2-3): 195–9. doi:10.1016/j.forsciint.2005.07.014. PMID 16169176. http://www.sciencedirect.com/science?_ob=ArticleURL&_aset=V-WA-A-W-A-MsSAYWA-UUW-U-AABVUDYAWY-AABAZCYEWY-VZAEVYCCC-A-U&_rdoc=1&_fmt=summary&_udi=B6T6W-4H87GDS-1&_coverDate=10%2F05%2F2005&_cdi=5041&_orig=search&_st=13&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=32f6b98ee793542f6cd9d66d103940b0. 
  12. ^ BBC (2003-12-10). "Profile: Sir Roy Meadow". BBC News. http://news.bbc.co.uk/1/hi/health/3307427.stm. Retrieved 2007-02-01. 
  13. ^ BBC (2005-07-15). "Sir Roy Meadow struck off by GMC". BBC News. http://news.bbc.co.uk/1/hi/health/4685511.stm. Retrieved 2007-02-01. 
  14. ^ Payne, Stewart (2003-06-12). "Joy for mother cleared of baby deaths". The Telegraph. http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2003/06/12/nmum12.xml. Retrieved 2007-02-01. 
  15. ^ BBC (2003-12-10). "Mother cleared of killing sons". BBC News. http://news.bbc.co.uk/1/hi/england/wiltshire/3306271.stm. Retrieved 2007-02-01. 
  16. ^ Feldman, Marc (2004). Playing sick?: untangling the web of Munchausen syndrome, Munchausen by proxy, malingering & factitious disorder. Philadelphia: Brunner-Routledge. ISBN 0-415-94934-3. 
  17. ^ Tucker HS, Finlay F, Guiton S (2002). "Munchausen syndrome involving pets by proxies". Arch. Dis. Child. 87 (3): 263. PMID 12193455. 

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