Munchausen Syndrome by Proxy
Munchausen Syndrome by Proxy (MSbP) is the name that has been given to a situation in which one person fabricates an illness in a second person and presents the second person to a doctor. The term was first used in the title of an article by Roy Meadow, a professor of pediatrics (Meadow 1977). MSbP has usually been used to refer to a situation involving a mother and child. Other adults, occasionally the father, have been reported to fabricate illnesses in a child under their care.
There has been controversy about MSbP, including usage of the term. MSbP refers to a situation comprising behaviors and psychological states of the fabricator, a victim, and a medical professional in a triadic interaction. MSbP is not a psychiatric diagnosis applicable to the fabricator, although many reports indicate consistent findings regarding the psychology of fabricators.
Recognition of fabrication is usually made by the doctor following bewilderment at the medical presentation, which may be one of a series of similar presentations. Following strong suspicion or confirmation of MSbP, multidisciplinary action under local child protection procedures is usually appropriate, with the paramount task being to ensure the health and safety of the child.
A psychiatrist or a clinical psychologist will usually carry out a detailed assessment of the fabricator. The importance of consulting the health records of the fabricator (as well as the victim and siblings) and meeting with reliable relatives or friends of the fabricator who will act as informants cannot be over-emphasized.
The fabricator psychopathology (abnormal psychology) has been found to range in type and severity across a spectrum. Usually there will have been a history of presentations of physical symptoms, which are the result of a somatizing process (a tendency to experience emotional problems as physical symptoms detached from the emotional aspect of the problem). This may be extreme as in chronic factitious disorder (sometimes known as Munchausen's Syndrome, as described by Richard Asher in 1951) in which the adult lives a life centered around the fabrication of illness and gaining access to hospitals. In some cases the fabricator has been found to have a history of criminal behavior (especially involving deception, such as fraud), repeated self-harm, or misuse of medications or alcohol (Bools et al. 1994). The diagnosis made by a psychiatrist will often be of a personality disorder.
The child victim of MSbP may come to serious physical harm if, as part of the fabrication, physical signs of illness are actually caused in the child. Many methods of such illness induction have been reported: smothering to produce fits, poisoning to produce drowsiness or diarrhea, and abrading skin. Clearly such action constitutes physical child abuse. In situations in which illness is fabricated in the child without direct physical harm, the child may undergo medical investigations and procedures, such as surgery or toxic medications, so that in the end some physical harm results. In the absence of physical harm the child is likely to suffer psychological harm, including the effect of substantial school nonattendance (Bools et al. 1993). The relationship between the mother and child is usually highly pathological with the attachment needs of the child not being met, resulting in emotional and behavioral disturbance as well as the risk of abnormal personality development. The actions of the mother are likely to constitute some degree of emotional (psychological) child abuse.
Teresa Parnell (1998) noted that the majority of the fabricators gave histories consistent with emotional, physical, or sexual abuse in their own childhoods, which, together with constitutional factors, are likely to be important in the development of the abnormal relationship with the child and the eventual fabrication. Moreover, the husbands/partners of fabricating mothers typically reported minimal involvement in family life. The distance between the partners may be emotional, physical, or both, and when the mother is over-involved with the child, the father becomes peripheral in the family system. This situation allows the mother to develop the fabricated illness in the child with little challenge—or even knowledge—of the father. Therefore, using a family systems perspective, treatment will require therapeutic work with both parents, later including the child victim, to complement the individual treatments. One aspect of the treatment is likely to include work to bring the father and child(ren) closer, improve the emotional environment for the child, and increase the protective role of the father.
In a number of cases, psychiatric treatment of fabricators has been successful enough to allow the rehabilitation of the fabricator as a caregiver of the child (Berg and Jones 1999). Important aspects in the assessment in this respect are the acknowledgement of the fabricating behavior and its impact on the child victim, and a capacity to tolerate an intensive psychotherapeutic treatment regime. Unfortunately, in many cases treatment was not found to be possible.
Most reports of MSbP have come from English-speaking countries; however, reports from non-English-speaking countries are growing in number (Brown and Feldman 2001). An estimate of incidence of MSbP in the United Kingdom—based on an epidemiological study—was at least 0.5 per 100,000 of children under sixteen years of age, and at least 2.8 per 100,000 of children ages under one year (McClure et al. 1996). There are no epidemiological data available from other countries.
Asher, R. (1951). Munchausen's Syndrome. The Lancet 1:339–341.
Berg, B., and Jones, D. P. H. (1999). "Outcome of Psychiatric Intervention in Factitious Illness by Proxy (Munchausen's Syndrome by Proxy)." Archives of Disease in Childhood 81:465–472.
Bools, C. N. (1993). "Follow up of Victims of Fabricated Illness (Munchausen Syndrome by Proxy)." Archives of Disease in Childhood 69:625–630.
Bools, C. N.; Neale, B. A.; and Meadow, S. R. (1994). "Munchausen Syndrome by Proxy: A Study of Psychopathology." Child Abuse and Neglect 18:773–788
Brown, R., and Feldman, M. (2001). "International Perspectives on Munchausen Syndrome by Proxy." In Munchausen's Syndrome by Proxy: Current Issues in Assessment, Treatment and Research, ed. G. Adshead and D. Brooke. London: Imperial College Press.
Meadow, S. R. (1977). "Munchausen Syndrome by Proxy: The Hinterland of Child Abuse." Lancet 2:343–345
McClure, L. J.; Davis, P. M.; Meadow, S. R.; and Sibert, J. R. (1996). "Epidemiology of Munchausen Syndrome by Proxy, Non-Accidental Poisoning and Non-Accidental Suffocation." Archives of Disease in Childhood 75:57–61.
Parnell, T. F. (1998). "Guidelines for Identifying Cases." In Munchausen by Proxy Syndrome: Misunderstood Child Abuse, ed. T. F. Parnell and D. O. Day. Thousand Oaks, CA: Sage Publications.
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