Beyond MSBP
or, Why I Hate Munchausen
Syndrome by Proxy
John Stirling, MD
Santa Clara Valley Medical Center
San Jose CA
Stanford University
Beyond MSBP
or, Why I Hate Munchausen
Syndrome by Proxy
John Stirling, MD
Santa Clara Valley Medical Center
San Jose CA
Stanford University
Bea Yorker, RN, JD
University of California, Los Angeles
The standard medical talk…
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Pathophysiology
Symptoms
Diagnosis
Treatment
Polite applause
The trouble with “Munchausen
Syndrome by Proxy”
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It’s an eponym
It’s not really a syndrome
It’s not really a disease
It’s not really a diagnosis
It’s medical… and psychiatric… and social
It’s very hard to treat
It’s hard to spell
“Primum non nocere”
The trouble with “Munchausen
Syndrome by Proxy”
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What to call it?
Who can diagnose?
Where’s the threshold?
When to involve the authorities?
Take Home Points
• Not a single condition, but a variety of
presentations along a spectrum of severity
• MBP is a dyadic diagnosis; PCF/FDP are
individual diagnoses
• Child abuse is child abuse, whatever the
context
• Evaluations have to be exhaustive
• …and involve physicians
Beyond Munchausen Syndrome by Proxy:
Identification and Treatment of Child Abuse in
a Medical Setting
Pediatrics 2007;119;1026-1030
A clinical report from the Committee on
Child Abuse and Neglect of the
American Academy of Pediatrics
Why Another Report?
To remind pediatricians:
• Children are injured by factitious illness
• Harm often requires physician’s complicity
• We can’t usually diagnose it alone (much
less treat it), but
• Medical input is essential to diagnosis
• Our focus is on harm to the child
Background
Background
• Asher, 1951: “Munchausen Syndrome”
• Kempe, 1975: “Uncommon manifestations
of Battered Child Syndrome”
• Meadow, 1977: “Munchausen Syndrome
by Proxy: The hinterland of child abuse”
• Rosenberg, 1987: “The web of deceit”
Diagnosis
Definition
Rosenberg (1987):
• Illness in a child which is simulated and/or
produced by someone in loco parentis
• Presentation of the child for medical
assessment and care, usually persistently,
often resulting in multiple medical
procedures
• Denial of knowledge by the perpetrator
• Acute symptoms abate with separation
Definition
DSM-IV (1994) “Factitious Disorder by
Proxy”:
(A) Intentional production or feigning of physical or
psychological signs or symptoms in another
person who is under the individual's care.
(B) The motivation for the perpetrator's behavior is
to assume the sick role by proxy.
(C) External incentives for the behavior (such as
economic gain) are absent.
(D) The behavior is not better accounted for by
another mental disorder. (p. 727)
Definition
Jenny (2008),“Medical Child Abuse”:
A child receiving unnecessary and
harmful or potentially harmful medical
care at the instigation of the caretaker.
DSM – V (proposed)
Factitious Disorder Imposed on Another (previously,
Factitious Disorder By Proxy)
• To make this diagnosis, all 4 criteria must be met. Note
that the perpetrator, not the victim, receives this
diagnosis.
• 1. A pattern of falsification of physical or psychological
signs or symptoms in another, associated with identified
deception.
• 2. A pattern of presenting another (victim) to others as
ill or impaired.
• 3. The behavior is evident even in the absence of
obvious external rewards.
• 4. The behavior is not better accounted for by another
mental disorder such as delusional belief system or
acute psychosis.
Presentations
Spectrum:
• Exaggeration of symptoms
• Fabrication of symptoms
• Induction of symptoms
resulting in harm to child,
through actions of caregiver,
in a medical setting
Presentations:
Top ten:
– Apnea/cyanosis
– Feeding problems/anorexia
– Seizures
– Behaviors
– Asthma/allergy
– Fever/pain…
No common presentation!
Presentations:
• Symptoms actively produced in 57%
– Suffocation, drugs, poisons, etc.
– Half while child was in the hospital!
• Many had unrelated injuries, neglect, FTT
• Average of 3.25 medical conditions
What do we know?
Web of deceit: a literature review of Munchausen
Syndrome by Proxy
- Rosenberg, Donna A., Child Abuse & Neglect, 1987
The deceit continues: an updated literature review
of Munchausen Syndrome by Proxy
- Sheridan, Mary S., Child Abuse & Neglect, 2003
Warning!
Caveats:
• Literature review isn’t random
• Diagnoses not equally certain
• Series often span years
• Inconsistent approaches
Typology: Victims
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Male = Female
Average age: 48 months
Time to diagnosis: 22 months
Outcomes: long-term disability in 7-8%,
death in 6-9%
• Siblings: 25% of sibs dead, half under
“suspicious circumstances”
Typology: Perpetrators
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Female >> Male
Mothers heavily represented
Medical background: 14-27%
Munchausen features in caregiver: 29%
Psych diagnosis: 23%
– Depression, personality disorders, somatization
Terminology/Definition
• Pediatric or Psychiatric diagnosis?
• MSBP or MBPS?
• Pediatric focus: identify and mitigate harm
to the child
“Primum non nocere”
Terminology/Definition
• APSAC: PCF + FDP = M(S)BP
• Pediatric Condition Falsification, plus
• Factitious Disorder by Proxy, equals
• Munchausen by Proxy
Terminology/Definition
• FDP is not a mental disorder
• PCF and FDP can occur independently
• Examples:
– PCF without FDP
– Harm to the child without PCF or FDP
– “Lookalikes”
“…a rose by any other name…”
MSBPA?
MSBP?
MBPS?
PCF + FDP?
=
Child Abuse!
Special Note: … if a physician has real evidence to
suspect child abuse, regardless of the motive of the
perpetrator, it must be investigated and the perpetrators
brought to swift and effective justice!
In contrast, often the agenda behind Munchausen
Syndrome by Proxy is to be able to make an accusation
without evidence, but by the Munchausen Syndrome By
Proxy profile . If it is in fact a crime has been committed,
call it by it's real name...suffocation, poisoning,
tampering with urine sample, etc....offer evidence! You
don't need fancy labels or self-proclaimed experts to
line their pockets pretending to be the only ones who
know how to diagnose a crime.
Backlash!
Diagnosis
• What’s a diagnosis?
– “Differential diagnosis”
– Degrees of certainty
• Diagnostic criteria
– Inclusion vs exclusion
Diagnosis
• How important is the caretaker’s motive?
• How useful is a profile?
Diagnosis
Difficult because:
• Presentations vary greatly
• Medical personnel are involved in harm
• Multiple institutions, scattered records
• Failure to consider the diagnosis
• Failure to involve other professionals
Diagnosis
What’s proof?:
• Confessions?
• Improvement out of home?
• Covert video surveillance?
• Lab findings?
Treatment
• Child’s safety is the first priority
• Use least restrictive option
– Close observation
– In-home dependency
– Foster care
– Criminal prosecution
Clinical Advice
• Consult child abuse pediatrician
• Gather and review all medical records
• Work as multidisciplinary team
• Involve state Child Protection agency prn
• Involve whole family in treatment
Take Home Points
• Not a single condition, but a variety of
presentations along a spectrum of severity
• MBP is a dyadic diagnosis; PCF/FDP are
individual diagnoses
• Child abuse is child abuse, whatever the
context
• Evaluations have to be exhaustive
• …and involve physicians
john.stirling@hhs.sccgov.org
Case 1
• 3yo boy
• 14 visits to PCP in past year, 3 to ED,
usually after visitation
• Parents share custody
• Allegations of poor care: constipation,
abdominal pain, possible sexual abuse
• Father doesn’t adhere to Mom’s special
diet
Case 2
• 8yo twin girls
• Mother describes allergic reactions to
aero-allergens, behavioral symptoms
• Naturopath supports her
• Children missed 30 days of school last yr
• Sleep on wooden panels, in mylar
blankets, wear masks outside
Case 3
• 6yo boy with asthma sx per mom
• “meds don’t help”
• Peak flow decreased in office, but
improves w/ albuterol neb
• Improvements not sustained at home
• Mom asks for steroids
• Wants disability papers filled out
Other Cases?