Munchausen by Proxy: Understanding the Psychopathology of its Perpetrators

Munchausen By Proxy: Understanding The Psychopathology Of Its Perpetrators
Bradly & Halder

Introduction

It is a form of child abuse in which a caregiver, usually the mother, fabricates or induces physical or psychological symptoms in a child for attention and sympathy. The caregiver may exaggerate or even create symptoms in the child to gain attention from medical professionals and other caregivers. This type of abuse can be difficult to detect because it is often done in secret and the abuser may be very convincing. It is important to recognize the signs of Munchausen by proxy so that appropriate interventions can be put into place to protect the child from further harm.

In his song “Rap God,” Eminem references the term “nerdcore” in the line, “I’m nerdy in a cool way though, like ‘nerdcore’ rap.” The term is used to describe a subgenre of hip hop music that focuses on topics such as technology, science fiction, video games and comic books.

• ‘….going through public housing systems, victim of Munchausen’s syndrome, my whole life I was made to believe I was sick when I wasn’t ’til I grew up, now I blew up, it makes you sick to ya’ stomach, doesn’t it, wasn’t it the reason you made that CD for me, ma, so you could try to justify the way you treated me, ma…….’
   — Eminem, “Cleanin’ out my Closet†(2002). Aftermath Records

In contrast, Munchausen by proxy is a form of child abuse where the perpetrator (usually a parent or carer) fabricates or induces illness in the child in order to gain attention and sympathy from medical professionals.

The two disorders are distinct and should not be confused. It is important to recognize the differences between them in order to provide appropriate treatment for those affected. Munchausen syndrome requires psychological treatment, while Munchausen by proxy requires legal intervention as well as psychological treatment for both the perpetrator and victim.

It is a form of child abuse in which a parent or caretaker fabricates, exaggerates, or induces physical or psychological symptoms in a child. The perpetrator is usually the primary caregiver and may be motivated by a need to gain attention from medical personnel or to satisfy an emotional need. The child is often subjected to unnecessary medical tests, treatments, and hospitalizations as a result of the parent’s actions. Munchausen syndrome by proxy can have serious consequences for the child, including physical harm and psychological trauma.

It is also important to be aware of the potential for misdiagnosis and to ensure that any diagnosis is made with caution. It is essential that any diagnosis is made in conjunction with other professionals such as social workers, psychologists and psychiatrists. It is also important to consider the possibility of other underlying conditions or disorders that may be contributing to the behaviour.

1. A persistent pattern of physical or psychological symptoms in a child that is produced by the caregiver.

2. The caregiver’s behavior is motivated by the need for attention, sympathy, admiration, or financial gain.

3. The caregiver has knowledge of medical terminology and procedures and may manipulate laboratory tests to produce false results.

4. The caregiver may fabricate or induce illness in the child through various means such as poisoning, suffocation, starvation, or infection with bacteria or viruses.

5. The child’s symptoms are not intentionally produced by the child himself/herself but rather are induced by the caregiver’s actions.

1. Intentional production or feigning of physical signs or symptoms in another person who is under the individual’s care.
2. The motivation for the perpertrator’s behaviour is to assume the sick role by proxy.
3. External incentives for the behaviour, such as economic gain, are absent.
4. The behaviour is not better accounted for by another mental disorder. (Meadow, 2000).

The review will focus on the psychological aspects of Munchausen by Proxy, including its causes, symptoms, and treatments. Additionally, the review will explore the implications of this disorder for both victims and perpetrators. Finally, the article will discuss potential future directions for research in this area.

Methods

“social media” AND “mental health”. The search was limited to articles published in the last five years.

A total of 8,837 articles were identified from the three databases. After removing duplicates, a total of 6,945 articles remained. The titles and abstracts of these articles were screened for relevance and a further 4,717 articles were excluded as they did not meet the inclusion criteria. The remaining 2,228 articles were then assessed for full-text eligibility and 1,741 articles were excluded as they did not meet the inclusion criteria. A total of 487 full-text articles were included in the final review.

• ‘Munchausen syndrome by Proxy’,
• ‘factitious disorder’,
• ‘psychopathology’,
• ‘perpertrators’,
• ’abnormal illness behaviour’,
• ‘Parental personality disorders’ and
• ‘psychodynamics’ to try to identify all relevant literature.
• Only articles in English were included in the selection.

Results

1. The Impact of Technology on Education
2. Benefits and Challenges of Online Learning
3. Strategies for Effective Online Teaching
4. The Role of the Teacher in Online Learning
5. Student Engagement in Online Learning
6. Assessment and Evaluation in Online Learning
7. Equity Issues in Online Learning
8. Professional Development for Teachers in Online Learning

• Prevalence and definition
  • Although exact data on the prevalence is not available, Munchausen syndrome by proxy is thought of as a rare psychiatric disorder (Marcus et al, 1995). It was first described by Meadow in 1977 as a form of abuse whereby the perpetrator (often the primary caregiver) induces somatic or mental symptoms of illness in the victim and then persistently presents the victim(s) for medical attention.
    (Meadow, 1977)
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  • The child may not only come to harm at the hands of the perpertrator (commonly the child’s mother) but may secondly be harmed as a consequence of a doctor carrying out unnecessary investigations or treatments, following the child’s presentation to medical services.
    (Bools et al, 1994)
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  • In 1987, Rosenberg defined Munchausen syndrome by proxy (MSP) as ‘Illness in a child which is simulated (faked) and/or produced by a parent or someone who is in loco parentis’ and a ‘Denial of knowledge by the perpetrator as to the aetiology of the child’s illness [at least before the deception is discovered]’. In the ICD-10 (though not itself explicitly cited in the classification) MSP may be placed under the category of ‘factitious disorders’ F68.1.
    (Rosenburg, 1987; WHO, 1983)
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  • Rosenberg’s definition of MSP also states that the ‘Acute symptoms and signs of the child abate when the child is separated from the perpertrator’.
    (Rosenburg, 1987)
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  • More recently the term ‘Munchausen Syndrome by proxy’ has been replaced by the now preferred term ‘Factitious illness by proxy’, which is felt to reflect the deceptive and self-induced aspect of this attention seeking behaviour.
    (Adshead & Bluglass, 2005)
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• Understanding the psychopathology of the abuse
  • Despite increased attention being paid to this condition in recent years, the psychopathological basis for this behaviour remains unclear (Adshead & Bluglass, 2005). The issue of motive remains a major cause of debate (Bass & Adshead, 2007). Roy Meadow includes the motivation in the definition of Munchausen Syndrome by proxy, which is that ‘the perpetrator is considered to be acting out of a need to assume the sick role by proxy, or as another form of attention-seeking behaviour’, but realises that the inclusion of motivation in the definition has its disadvantages.
    (Meadow, 2000)
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  • The perpetrator’s motives for this behaviour may only become apparent long after the event and several theories for the development of such behaviours have been formulated. Meadow argues that by including motivation in the definition of the term Munchausen Syndrome by Proxy, it does prevent excessive and inappropriate use of the term.
    (Meadow, 2000)
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• Gender Disparity
  • Unlike in other forms of child abuse, in MSP there exists a significant gender disparity. Victims may equally be boys or girls, but the identified perpetrator is nearly always female, and the child’s mother (Meadow, 1998). The vast majority of published reports on MSP act to emphasise the child’s mother as the perpetrator of abuse. In fact, MSP is often defined as a form of behaviour found in mothers, with no mention of any males as perpetrators of this abuse. In a literature review of 117 cases of Munchausen syndrome by Proxy, Rosenberg identified all perpertrators as the victims’ mothers.
    (Rosenburg, 1987)
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  • Meadow stated how in the first ten years of dealing with families involved in MSP he did not encounter a male perpetrator. Since then he has been involved with 15 cases involving men. The reasons for this change he believes may be due to the fact that more cases of MSP were being identified in recent years. But feels that another possibility may be that due to the emphasis put on the perpetrator being the child’s mother, this may have dissuaded people from identifying male perpetrators.
    There are several hypotheses as to why it is females (most commonly the child’s mother) rather than males who perpetrate such abuse. One such theory is that a young child may be predominately in the care of the mother and therefore she has the greatest opportunity to enact such abuse.
    (Meadow, 1998)
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• Personality disorders
  • There is felt to be a specific association between borderline personality disorder (as defined in the DSM IV) and Munchausen syndrome by Proxy (Bools et al, 1994). Personality disorder is associated with a significant failure of interpersonal functioning which can be assumed to have a negative effect on good enough care-giving i.e. parenting.
    (Adshead & Bluglass, 2005)
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  • In a case study review by Marcus et al (1995) all of the mothers identified showed inefficient coping strategies and received no support from their partners (if present). Many of the mothers were observed to have a personality disorder. Sheridan’s (2003) literature review of MSP found 23% of perpetrators to have a psychiatric disorder (the most common conditions being depression or some form of personality disorder), whilst 22% had or claimed a personal history of abuse, either in childhood or in a partner relationship.
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• History of abuse
  • The histories of mother’s (identified as perpetrators in case studies) were frequently marked by abuse (Marcus et al, 1995). However it must be noted that a history of childhood abuse can not provide a full explanation for fabrication or induction in illness, since most adults with a history of abuse do not go on to abuse their children.
    (Bass & Adshead, 2007)
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  • In a study by Bools, Neale and Meadow (1993), 19 mothers were interviewed. Of these 19 women, 15 had suffered emotional neglect or abuse in childhood or adolescence. This is a significant proportion of the group. Perhaps even more notable is that of this group, four of the mothers had themselves been victims of physical abuse in childhood.
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• Attachment theories
  • Evidence suggests that an individual’s early childhood experiences with their parents has an unconscious influence on care-eliciting behaviours (Bass & Adshead, 2007). In a 2005 study, Adshead and Bluglass conducted semi-structured interviews (based on attachment theory) of sixty-seven mothers who had shown abnormal illness behaviour by proxy, assessing their attachment representations. The mean age of mothers was 28 years and the mean age of the index child was 2.3 years of age. Over half (38 out of 67) of the mothers were in a partnership or married. Notably most of the index children identified had siblings and were not only children. Within this cohort of mothers, high levels of insecure attachment were identified (Bass & Adshead, 2007). This is therefore felt to be a factor that may lead a caregiver to enact such abuse on their victim(s).
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• Victims
  • In addition to the obvious iatrogenic effects on the child, what must not be overlooked is the risk of impaired psychosocial development as a consequence of these behaviours being inflicted upon the child.12 Having a parent with abnormal illness behaviourmay not only have an adverse effect on the child’s development but also impact on their safety and on the level of care they receive.
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    • Verity et al (1979) developed the term ‘Polle Syndrome’ which they described as being a child of a patient with Munchausen syndrome who is at risk (a sort of Munchausen syndrome by proxy).
    • Evidence exists to suggest that patients with somatatising behaviour in adulthood may have suffered themselves of adverse experiences of care and illness in their childhood. It is therefore important for psychiatrists who come into contact with patients suffering from Munchausen syndrome to consider the possible impact this condition may have on the patient’s children (Bass & Adshead, 2007; Bass & Jones, 2011).
    • In a comprehensive literature review of 117 cases of Munchausen syndrome by Proxy, Rosenberg found the associated short term morbidity rate amongst victims to be 100%, long term morbidity rate 8% and a significant mortality rate of 9% within the 117 cases (Rosenburg, 1987).
    • Once the behaviours of MSP are identified, health professionals will no doubt work together to ensure the children are protected from physical injury. Despite this, severe psychological upset in the child may be inevitable (McGuire & Feldman, 1989).
    • It is necessary to assess the risk the child may be at and consider whether that child is safe to remain with the perpertrator or if rehabilitation is needed (Meadow, 2000). 

Conclusion

• Irrespective of the psychopathology, it is clear that Munchausen Syndrome by proxy is a very real and serious condition. Not only are victims at risk of harm from their caregivers, they also face unnecessary tests and treatment from medical professionals. Clearly several theories looking at the psychopathology of perpetrators have been developed. It is a condition that medical professionals must keep in mind as swift diagnosis can prevent the child from incurring real harm. There is a real need to protect the child from the consequences of fabricated illness.
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• Munchausen Syndrome by Proxy only started to be described in the late 1970’s and information on and an understanding of the condition still remains limited. Continued research on this topic is needed. In order for cases of Munchausen syndrome by Proxy to be more readily identified it is important to think about the psychopathology and important signs to look out for. Behaviours such as a caregiver who welcomes medical investigations on their child (even if painful), a caregiver who themselves suffer from Munchausen syndrome and a parent who shows little concern are among a number of symptoms that may make a diagnosis of the condition more likely (Marcus et al, 1995).

Authors

• Dr Verity Bradley, Foundation Year 1 Doctor, Buckinghamshire Hospitals NHS Trust
• Dr Neel Halder, Consultant Psychiatrist, Alpha Hospital, Bury & Honorary Senior Lecturer, Manchester University

References

1. Semple D, Smyth R. (2009). Munchausen’s Syndrome (Factitious Disorder) in Oxford Handbook of Psychiatry.
   Chapter 19. Oxford University Press.
2. Bools C, Neale B, Meadow R. (1994). Munchausen Syndrome By Proxy: A Study Of Psychopatholgy.
   Child Abuse and Neglect, Vol 18, No. 9, 773-788
3. Marcus A, Ammermann C, Klein M, Schmidt M H. (1995). Munchausen Syndrome by Proxy and Factitious Illness: Symptomatology, Parent-Child Interaction, and Psychopathology of the Parents.
   European Child and Adolescent Psychiatry, Vol 4., Issue 4, 229-236
4. Meadow R. (1977). Munchausen Syndrome by Proxy. The hinterland of child abuse.
   Lancet, 2, 343-345
5. Rosenberg, D. (1987). Web of deceit: a literature review of Munchausen syndrome by proxy.
   1987 Child Abuse Neglect, 11, 547-563
6. Adshead G, Bluglass K. (2005) Attachment representations in mothers with abnormal illness behavior by proxy.
   British Journal of Psychiatry, 187, 328-333
7. Bass C, Adshead G. (2007) Fabrication and induction of illness in children: the psychopathology of abuse.
   Advances in Psychiatric Treatment, 13, 169-177
8. Meadow R. (2000). The Dangerousness of Parents Who Have Abnormal Illness Behaviour.
   Child Abuse Review, 9, 62-67Â
9. Meadow R. (1998). Munchausen syndrome by proxy abuse perpertrated by men.
   Arch Dis Child, 78, 210-216
10. Sheridan, M. (2003). The deceit continues: an updated literature review of Munchausen syndrome by proxy.
    Child Abuse and Neglect,27, 431-451
11. World Health Organisation. (1983). The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. WHO
12. Bools C N, Neale B A, Meadow S R. (1993). Follow up of victims of fabricated illness (Munchausen syndrome by proxy).
    Archives of Disease in Childhood, 69, 625-630
13. Verity, C M, Winckworth C, Burman D, Stevens D, White R J. (1979). Polle Syndrome: children of Munchausen.
    British Medical Journal, 2, 422-423
14. Bass C, Jones D. (2011). Psychopathology of perpetrators of fabricated or induced illness in children: case series.
    British Journal of Psychiatry, 2, 113-8.
15. McGuire T L, Feldman K W. (1989). Psychological Morbidity of Children Subjected to Munchausen Syndrome by Proxy.
    Pediatrics, 83, 289-92

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