Beyond MSBP or, Why I Hate Munchausen Syndrome by Proxy

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Beyond MSBPor, Why I Hate Munchausen Syndrome by
Proxy

• John Stirling, MD
• Santa Clara Valley Medical Center
• San Jose CA
• Stanford University

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Beyond MSBPor, 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

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The standard medical talk

• Pathophysiology
• Symptoms
• Diagnosis
• Treatment
• Polite applause

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The trouble with Munchausen Syndrome by Proxy

• Its an eponym
• Its not really a syndrome
• Its not really a disease
• Its not really a diagnosis
• Its medical and psychiatric and social
• Its very hard to treat
• Its hard to spell

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Primum non nocere
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The trouble with Munchausen Syndrome by Proxy

• What to call it?
• Who can diagnose?
• Wheres the threshold?
• When to involve the authorities?

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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

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Beyond Munchausen Syndrome by ProxyIdentificatio
n and Treatment of Child Abuse in a Medical
SettingPediatrics 20071191026-1030

• A clinical report from the Committee on Child
  Abuse and Neglect of the American Academy of
  Pediatrics

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Why Another Report?

• To remind pediatricians
• Children are injured by factitious illness
• Harm often requires physicians complicity
• We cant usually diagnose it alone (much less
  treat it), but
• Medical input is essential to diagnosis
• Our focus is on harm to the child

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Background
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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

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Diagnosis
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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

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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)

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Definition

• Jenny (2008),Medical Child Abuse
• A child receiving unnecessary and harmful or
  potentially harmful medical care at the
  instigation of the caretaker.

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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.

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Presentations

• Spectrum
• Exaggeration of symptoms
• Fabrication of symptoms
• Induction of symptoms
• resulting in harm to child,
• through actions of caregiver,
• in a medical setting

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Presentations

• Top ten
• Apnea/cyanosis
• Feeding problems/anorexia
• Seizures
• Behaviors
• Asthma/allergy
• Fever/pain
• No common presentation!

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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

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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

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Warning!

• Caveats
• Literature review isnt random
• Diagnoses not equally certain
• Series often span years
• Inconsistent approaches

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Typology Victims

• 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

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Typology Perpetrators

• Female gtgt Male
• Mothers heavily represented
• Medical background 14-27
• Munchausen features in caregiver 29
• Psych diagnosis 23
• Depression, personality disorders, somatization

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Terminology/Definition

• Pediatric or Psychiatric diagnosis?
• MSBP or MBPS?
• Pediatric focus identify and mitigate harm to
  the child
• Primum non nocere

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Terminology/Definition

• APSAC PCF FDP M(S)BP
• Pediatric Condition Falsification, plus
• Factitious Disorder by Proxy, equals
• Munchausen by Proxy

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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

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a rose by any other name
MSBPA?
MSBP?
MBPS?
PCF FDP?
Child Abuse!
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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!
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Diagnosis

• Whats a diagnosis?
• Differential diagnosis
• Degrees of certainty
• Diagnostic criteria
• Inclusion vs exclusion

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Diagnosis

• How important is the caretakers motive?
• How useful is a profile?

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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

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Diagnosis

• Whats proof?
• Confessions?
• Improvement out of home?
• Covert video surveillance?
• Lab findings?

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Treatment

• Childs safety is the first priority
• Use least restrictive option
• Close observation
• In-home dependency
• Foster care
• Criminal prosecution

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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

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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

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john.stirling_at_hhs.sccgov.org
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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 doesnt adhere to Moms special diet

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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

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Case 3

• 6yo boy with asthma sx per mom
• meds dont 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

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Other Cases?