Münchausen syndrome by proxy

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

Münchausen syndrome by proxy (MSbP) is a label for a pattern of behavior in which care-givers deliberately exaggerate, fabricate, and/or induce physical, psychological, behavioral, and/or mental health problems in others.^[1] Other experts classified MSbP as a mental illness. However, the term is not officially recognised in the latest Diagnostic and Statistical Manual, 4th Ed., published by the American Psychiatric Association.^[2][1][3] Münchausen by proxy has been described by some as a form of extended child abuse.^[4][5] The motivation is to assume the sick role by proxy.^[6] It involves physical abuse and medical neglect.^[7]

General information

In the Münchausen by Proxy syndrome, an adult care-giver makes a child sick by either fabricating symptoms or actually causing harm to the child, whereby convincing not only the child but others, including medical providers, that their child is sick.

Some conditions or symptoms that may be faked by the care-giver or parents include failure to thrive, allergies, asthma, vomiting, diarrhea, seizures and infections.^[8] These symptoms are easy to fake because when a child goes into the doctor’s office the adult can simply say that his or her child is experiencing these symptoms. This usually occurs during the preschool years.^[8]

Many experts^[who?] feel this form of ill treatment is driven not only by the attention that the child and parent/caregiver receive because of the diagnostic tests that must be run, but also by the satisfaction of being able to deceive individuals who the abuser feels are more important or powerful than he or she.^{[citation needed]}

Münchausen by Proxy can have many long-term effects on a child. In some cases, children themselves go on to develop Münchausen Syndrome, which is where they are likely to inflict injury upon themselves or fake illnesses.^{[citation needed]} One of the reasons for this is that they seek the attention they received when they were in poor health. They may also inflict injury or sickness upon themselves so that their caregiver/parent will not leave them.

Initial description

Named after the German nobleman Baron Münchhausen, Münchausen syndrome was first described by R. Asher in 1951^[9] as when someone invents or exaggerates medical symptoms, sometimes engaging in self-harm, to gain attention or sympathy.

The term "Münchausen syndrome by proxy" was first coined by John Money and June Faith Werlwas in a 1976 paper titled folie à deux^[10] in order to describe the abuse induced and neglect induced symptoms of the syndrome of abuse dwarfism. That same year, Sneed and Bell wrote an article titled The Dauphin of Münchausen: factitious passage of renal stones in a child.^[11]

According to other sources, the term Munchausen syndrome by proxy was created by the British pediatrician Roy Meadow in 1977.^[12][13][14] It is also known as Meadow's syndrome after him. In 1977 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).^[15] In 2005 British General Medical Council (GMC) struck off Meadow from the British Medical Register after he was found to have offered “erroneous” and “misleading” evidence in the Sally Clark case.^[16] Clark was a lawyer wrongly convicted in 1999 of the murder of her two baby sons, largely on the basis of Meadow's evidence. It emerged later that there was clear evidence of a staphylococcus aureus infection that had spread as far as Clark child’s cerebral spinal fluid.^[17] Mrs Clark was released in January 2003 after three judges quashed her convictions in the Court of Appeal in London.^[18][17] In 1977, Burman and Stevens coined the term "Polle syndrome"^[19] which was questioned by Meadow and Th. Lennert in 1984.^[20]

The medical community was initially skeptical of MSbP's existence, but it gradually gained acceptance as a recognized condition.^{[citation needed]}. Widely used, the term "Munchausen syndrome by proxy" has led to much confusion in the literature: initially referring to harmful medical care, the appellation "Munchausen syndrome by proxy" was then extended to cases in which the only harm arose from medical neglect or noncompliance or even educational interference.^[21]

In 1994, the DSM, Fourth Edition, labeled the condition under a new category called "factitious disorder by proxy." In 2002, the American Professional Society on the Abuse of Children suggested a new terminology: pediatric condition falsification (PCF) .

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.^[22] In addition, in most states, medical professionals have a duty to report such abuse to legal authorities.^[23] Warning signs of the disorder include:^[22]

• 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.^[24] 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. A psychodynamic model of this kind of maternal abuse exists.^[25]

These symptoms may be more prevalent in the parents of those with a learning difficulty or mental incapacity, and as such the apparent patient could in fact be a grown adult.

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.^[26] 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.^[27] 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^[28] and Angela Cannings.^[29] 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]}

In addition to the controversy surrounding expert witnesses, an article appeared in the forensic literature that detailed legal cases involving controversy surrounding the murder suspect.^[30] The Perri and Lichtenwald article provides a brief review of the research and criminal cases involving Münchausen Syndrome by Proxy in which psychopathic mothers and caregivers were the murderers. This article also briefly describes the importance of gathering behavioral data including observations of the parents who commit the criminal acts and references the 1997 work of Southall, Plunkett, Banks, Falkov, and Samuels.^[31]

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.^[32] The April 2007 issue of the journal Pediatrics specifically mentions Meadow as an individual who has been inappropriately maligned.

Münchausen syndrome by proxy involving pets

Medical literature describes a subset of MSbP care-givers, 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 care-givers in traditional MSbP presentations involving human proxies.^[33] 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 popular culture

The American movie Yes Man features a band called Münchausen by Proxy, featuring Zooey Deschanel's character as lead vocalist.

The novel Sickened: The Memoir of a Munchausen by Proxy Childhood by Julie Gregory details the life of a girl growing up with a Münchausen by Proxy mother, who took her to various doctors, coaching her to act sicker than she was and exaggerating her symptoms, and demanding increasingly invasive procedures to diagnose the girl's imaginary illnesses.

The 1999 film The Sixth Sense portrays Münchausen syndrome by proxy during a scene in which a mother is caught on video adding floor cleaner to her ill daughter's food.

The plot of the 2003 Japanese J-horror film One Missed Call (着信アリ Chakushin ari) revolves around a mother with a case of Münchausen syndrome by proxy.

In "The Calusari" episode of The X-Files, Agent Scully initially believes that one of the characters is inducing illness in her grandson and makes reference to Münchausen syndrome by proxy.

See also

• Beverley Allitt
• Sally Clark
• Julie Gregory
• Waneta Hoyt
• Wendi Scott
• David Southall
• Marybeth Tinning
• Münchausen by Internet
• Münchausen syndrome
• Mythomania
• Psychosomatic illness
• Victim playing

References

1. ^ ^{a b} "MBP Overview & Definitions". http://www.mbpexpert.com/definition.html. 
2. ^ "Is the DSM-IV-TR available online?". http://www.psych.org/MainMenu/Research/DSMIV/FAQs/IstheDSMIVTRavailableonline.aspx. 
3. ^ "The Münchhausen of Munchausen Syndrome". http://archfami.ama-assn.org/cgi/content/summary/2/2/141. 
4. ^ 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.
5. ^ 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. 
6. ^ S Elwyn, Todd. "Factitious Disorder: eMedicine Psychiatry". emedicine.medscape.com. http://emedicine.medscape.com/article/291304-overview. Retrieved 2009-09-14. 
7. ^ 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. 
8. ^ ^{a b} Sheslow, D.V. & Gavin-Devitt, L.A. (2008). "Munchausen by proxy syndrome". KidsHealth from Nemours. http://kidshealth.org/parent/general/sick/munchausen.html. Retrieved 8/27/10. 
9. ^ Asher R. Munchausen's syndrome. Lancet. Feb 10 1951;1(6):339-41
10. ^ Money, J., & Werlwas, J. (1976). Folie a deux in the parents of psychosocial dwarfs: Two cases.Bulletin of the American Academy of Psychiatry and the Law, 4, 351-362 see Munchausen's Syndrome by Proxy: Update1
11. ^ pediatrics.aappublications.org
12. ^ "PEDIATRICS Vol. 74 No. 4 October 1984, pp. 554-556". http://pediatrics.aappublications.org/cgi/content/abstract/74/4/554. 
13. ^ "Definition of Munchausen syndrome by proxy". http://www.medterms.com/script/main/art.asp?articlekey=38327. 
14. ^ "Profile: Sir Roy Meadow". BBC News. 2006-02-17. http://news.bbc.co.uk/2/hi/health/4432273.stm. 
15. ^ 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 
16. ^ "BBC:Sir Roy Meadow struck off by GMC". BBC News. 2005-07-15. http://news.bbc.co.uk/2/hi/health/4685511.stm. 
17. ^ ^{a b} Shaikh, Thair. "Sally Clark, mother wrongly convicted of killing her sons, found dead at home", The Guardian, March 17, 2007.
18. ^ "Clark, R v [2003 EWCA Crim 1020 (11 April 2003)"]. http://www.bailii.org/ew/cases/EWCA/Crim/2003/1020.html. 
19. ^ D. Burman, D. Stevens:Munchausen family. The Lancet, London, 1977, 2: 456. cf Polle syndrome:children of Munchausen
20. ^ Munchausen by Proxy or Polle Syndrome: Which Term Is Correct?
21. ^ John Stirling ,Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting PEDIATRICS Vol. 119 No. 5 May 2007, pp. 1026-1030 (doi:10.1542/peds.2007-0563)
22. ^ ^{a b} Schreier, Herbert A..; Judith A. Libow (1993). Hurting for Love: Muchausen by Proxy Syndrome. The Guilford Press. ISBN 0-89862-121-6. 
23. ^ 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.
24. ^ 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. 
25. ^ See Anna Motz's The Psychology of Female Violence: Crimes Against the Body (Routledge, 2001 ISBN 978-0-415-12675-5, 2nd ed. forthcoming 2008 ISBN 978-0-415-40387-0).
26. ^ BBC (2003-12-10). "Profile: Sir Roy Meadow". BBC News. http://news.bbc.co.uk/1/hi/health/3307427.stm. Retrieved 2007-02-01. 
27. ^ 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. 
28. ^ Payne, Stewart (2003-06-12). "Joy for mother cleared of baby deaths". The Telegraph (London). http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2003/06/12/nmum12.xml. Retrieved 2007-02-01. 
29. ^ 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. 
30. ^ Perri, Frank S. and Lichtenwald, Terrance G. (2010). “The Last Frontier: Myths & The Female Psychopathic Killer,” ‘’Forensic Examiner’’, 19:2, 50-67.
31. ^ Southall, D.P., Plunkett, M.C., Blanks, M.W., Falkov, A.F. & Samuels, M.P. (1997). Covert video recordings of life-threatening child abuse; lessons for child protection. Pediatrics, 100(5):735-760.
32. ^ 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. 
33. ^ Tucker HS, Finlay F, Guiton S (2002). "Munchausen syndrome involving pets by proxies". Arch. Dis. Child. 87 (3): 263. doi:10.1136/adc.87.3.263. PMC 1719226. PMID 12193455. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1719226.