Munchausen Syndrome by Proxy (MSBP)

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

Munchausen syndrome by proxy facts

  • Munchausen syndrome by proxy (MSBP) is now classified as a somatic symptom and related disorder. It is referred to as factitious disorder that is imposed by one individual on another or factitious disorder by proxy.
  • MSBP is characterized by feigning or intentionally producing physical or emotional symptoms in another person in order to place that person in the sick role.
  • This disorder is named after Baron Karl Friedrich von Munchausen, who was known to invent fantastic stories of his adventures, including his riding cannonballs and traveling to the moon.
  • MSBP specifically involves a caretaker describing nonexistent symptoms or inducing symptoms in a third person, usually a child they care for.
  • How often MSBP occurs is likely very much underestimated, as evidenced by it often taking years to be discovered, even being completely missed in siblings of the victim that is eventually identified.
  • Males are victims of MSBP as often as females. Women are perpetrators of this disorder the vast majority of the time, theoretically because women remain the primary caretakers of children.
  • Perpetrators of MSBP are vulnerable to also suffering from depression, anxiety, and some personality disorders.
  • While there is no specific cause for MSBP, perpetrators tend to have trouble forming a healthy attachment to their children, difficulty managing their anger and frustration, as well as having an ability to overcome the more natural tendency for caretakers to protect the children they care for.
  • Perpetrators are also more likely to have a history of either losing a parent or being abused or neglected as a child.
  • While the symptoms the victim of MSBP presents with are highly variable, they may consist of symptoms that are more easily faked or induced, like suffocation, seizure, bleeding or nausea, vomiting, or diarrhea that can be the result of poisoning.
  • Theories about what perpetrators gain from assuming the sick role through their child include seeking help, inducing symptoms, and being "addicted" to interactions with medical professionals.
  • MSBP is usually diagnosed through intensive communication between medical, mental-health, and child-protection professionals, as well as review of all available medical records and interviewing family members, school personnel, and other pertinent community members.
  • Sometimes, covertly videotaping the suspected abuser when with the child can be a useful additional diagnostic tool.
  • The treatment of MSBP involves close collaboration with professionals, family, and community members, intensive psychotherapy for the victim and the perpetrator, as well as protecting the child by either intensive supervision of the perpetrator, temporary or permanent removal of the child from the care of the abuser, and sometimes includes prosecution and incarceration of the perpetrator.
  • If left untreated, MSBP can result in the child's death or growing up emotionally and/or medically disabled.

What is Munchausen syndrome by proxy?

Munchausen syndrome by proxy (MSBP) features a caretaker covertly abusing a child by faking or causing symptoms in the victim. MSBP is also called Munchausen by proxy (MBP), factitious disorder that is imposed by one individual on another, or factitious disorder, by proxy induced illness, or fabricated illness and is a mental disorder that belongs to the group of mental illnesses called somatic symptom and related disorders. It is characterized by a feigning or intentional production of physical or mental-health symptoms in another person for the sole purpose of placing the other person in the sick role. While the reported frequency with which MSBP occurs seems low at one to three in 100,000, it is likely that the actual number of undiscovered MSBP cases is much higher. International statistics indicate that this condition is being increasingly assessed when it is severe, and as many as 1% of children with asthma have experienced MSBP at least once. MSBP tends to affect males as victims as often as females. Affected individuals are usually 4 years old or younger and mothers are typically the perpetrators most of the time. The tendency toward maternal perpetrators may be more a result of women continuing to be the primary caregiver role than any gender-based predisposition to the disorder. MSBP can take two years or more from the beginning or onset of symptoms to when it is diagnosed. Victims of MSBP are ominously found to have a sibling who is either deceased or to have had medical problems very similar to the current victim of the disorder.

This disorder was named for Baron Karl Friedrich von Munchausen. He lived from 1720-1797, was born in Germany, joined the Russian military, and was known to tell fantastic tales about the battles he participated in against the Ottoman Turks. For example, he apparently told stories about riding cannonballs and traveling to the moon. As opposed to MSBP (factitious disorder imposed on another person), factitious disorder imposed on self is a mental illness in which what are initially thought to be symptoms of illness in the sufferer are in reality a fabrication of the illness by the sufferer rather than fabrication of illness by a third person. The motivation for factitious disorder imposed on self also tends to be an attempt by the sufferer to be seen as sick (assuming the sick or patient role). Emotional problems that tend to co-occur in people with MSBP include depression, anxiety, and some personality disorders like borderline personality disorder and sociopathy.

What causes Munchausen syndrome by proxy? What are MSBP risk factors?

Although there is no specific cause for MSBP, like most other mental disorders, it is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model). Little is known about the specific biological vulnerabilities of individuals with MSBP. Psychologically, MSBP perpetrators tend to have trouble forming a healthy bond (attachment) with their children. Personality traits of individuals who have a history of inducing symptoms in the children they care for include trouble managing anger or frustration. Socially, those who feign or induce symptoms in others tend to have suffered from some sort of major negative event (trauma) during their own upbringing, including the death of a parent or other caretaker or having been themselves the victim of child abuse or neglect.

What are Munchausen syndrome by proxy symptoms and signs?

In the diagnostic manual that is recognized by most mental-health professionals, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, MSBP is classified as a somatic symptom and related disorder and is referred to as factitious disorder that is imposed by one individual on another.

Symptoms of MSBP include the sufferer being induced to experience physical or psychological symptoms or to have symptoms fabricated by another person, usually a caretaker. Specific symptoms in the victim are nearly as varied as the number of victims and perpetrators, with perhaps more emphasis on symptoms that are more feasibly manufactured or induced or are more difficult to measure objectively through laboratory tests (for example, stomach upset, other body aches and pains, and trouble breathing or sleeping). Some more common symptoms presented by victims of MSBP include suffocation, induced seizures, bleeding, or poisoning that presents as vomiting or diarrhea. The abusive parent may describe symptoms in their child that do not exist. The symptoms may get worse only when the suspected caretaker is present or recently visited and may improve when the perpetrator is absent. Theories on what motivates the adult who assumes the sick role by causing a child to be sick might fall into one of three categories of motivation: help seeking, active induction of symptoms, and "addiction" to interactions with doctors. The help seeker is thought to be motivated to fabricate or cause their child's symptoms as a way of getting help for him or herself, assuming the sick role through their association with the supposedly sick child. This may be due to their feeling overwhelmed by their adult relationship, parenthood, or their own physical or emotional problems. The parent who actively induces symptoms of MSBP in the victim is thought to be seeking control of the medical professionals, as well as wanting recognition as an excellent parent by the professionals. Perpetrators who seem to be addicted to doctors are thought to be motivated to be seen as knowing better than the doctors.

How do health-care professionals diagnose Munchausen syndrome by proxy? What types of specialists treat MSBP?

As MSBP involves the caretaker covertly abusing a child by faking or causing symptoms in the child victim, a pediatrician who has experience and training in assessing and treating child abuse is often consulted and may be the primary professional working with the family. That professional will usually work with other professionals to review all medical records that have been kept and to communicate regularly about parents who are thought to seek excessive care since the abusive parent involved may have visited many different practitioners, even using different names in some cases, in an attempt to avoid the scrutiny that is likely harder to avoid if working with one medical practice, since one practitioner has more of an opportunity to get to know the perpetrator and the victim of MSBP over time. Covertly videotaping the interactions of a child with the suspected caretaker/abuser can be useful even when the victim is in a highly monitored setting like an intensive-care unit. While videotaping the child in the hospital may help in confirming or refuting the suspicion that the parent is engaged in harming the child, it is appropriately not seen as a substitute for the hard work of close monitoring, collaboration between all medical professionals, child protective services, mental-health professionals, and community members (for example, teachers, school counselors, clergy, and concerned extended family members) involved.

As with other mental-health issues, there is no specific definitive test, such as a blood test, that can accurately assess that a person has MSBP. Therefore, practitioners conduct a mental-health interview that looks for the presence of the symptoms previously described. As with any mental-health assessment, the professional will usually work toward ruling out other mental and physical disorders and ensuring that the individual is not suffering from a primary medical problem or from medical issues that may have symptoms that cause emotional symptoms. He or she will therefore often inquire about when the child has most recently had a physical examination, comprehensive blood work, and any other tests that a medical professional deems necessary to ensure that he or she is not suffering from a true medical condition instead of or in addition to a caretaker potentially manufacturing symptoms in the child. Also of significant importance is the practitioner reviewing any available previous medical records and talking to other people who may be in the child's life (such as the other parent, if available, teachers, and counselors) in order to explore the possibility of a pattern of the caretaker in question making illness up before in this child or in a sibling or other child in their care.

Due to the use of a mental-health interview in making the diagnosis, the potentially dire consequences to missing the diagnosis of MSBP or falsely assigning the diagnosis, as well as the fact that this disorder can be quite resistant to treatment, it is of great importance that the practitioner know to conduct a thorough assessment. It is equally important that the medical and mental-health professionals work together very closely and do not make assumptions about how much medical knowledge a parent should have or how they should behave in a situation involving the illness of their child. As only 50% of people with MSBP ever come to the attention of a psychiatrist, the importance of vigilant assessment and insisting on treatment when possible seems all the more important.

What is the treatment for Munchausen syndrome by proxy?

The involvement of a comprehensive child-protective-services team is of paramount importance in the treatment of MSBP. As with any other child abuse, achieving and maintaining the safety of the child in the least restrictive setting is a key focus. If professionals, family members other than the perpetrator, and community support systems can successfully maintain the safety of the victim and any other child in the home, refraining from removing children from the home may be encouraged. However, if keeping the child in the same home is thought to put him or her at continued risk of harm, steps will likely be taken to move the victim and/or other children to a safer placement. With effective treatment progress by the victim and the abuser, professionals may consider slowly reintroducing the child to the home while closely monitoring the child's safety. In the event that such reintegration is not possible, the child might be permanently placed outside the home of the perpetrator. In severe cases, professionals may seek the prosecution and incarceration of the perpetrator and permanently prevent the abuser's access to the victim.

In working with the child, therapists often teach the victim techniques for changing dysfunctional ways of behaving while helping the child understand the underlying feelings and motivations for those behaviors. While psychiatric medications like antidepressant, anti-anxiety, mood stabilizer, and antipsychotic medications may be used to alleviate specific symptoms for the perpetrator or victim, medication by no means cures the illness completely.

Individual psychotherapy for both the perpetrator of MSBP and the victim, as well as family therapy for members of the household involved are often incorporated into the treatment program. At the same time, the ongoing use of medical services is closely monitored by medical, mental-health, and child-protection professionals. Sometimes, the primary-care doctor (for example, pediatrician) will be notified by the insurance company of future use of medical services by the MSBP victim or the victim's siblings. The professional might also be notified when the child is absent from school. Access to such information is either granted through child protective services or by a parent. School officials may agree not to excuse an absence unless approved by the primary-care physician.

What are the complications of Munchausen syndrome by proxy? What is the prognosis of MSBP?

If left untreated, the prognosis of MSBP can be quite ominous. It can result in child victims who grow up to be medically, emotionally, or otherwise functionally disabled adults. Research shows that people who were the victim of MSBP as children are more likely to develop weight problems (including anorexia or obesity) and chronic pain as adults. Emotional complications can include depression, anxiety, anger problems, posttraumatic stress disorder (PTSD), and mood swings. People with this disorder are prone to having trouble completing their education and either avoiding or excessively visiting medical practitioners. It can even be fatal in more than 5% of cases, and more than 7% may have long-term or permanent injury as a result. Survivors of this disorder are sadly at higher risk of becoming perpetrators of this and other forms of child abuse as adults.

Is it possible to prevent Munchausen syndrome by proxy?

Prevention strategies for MSBP currently tend to focus on avoiding continued abuse once MSBP is identified. Given the low frequency with which this disorder is diagnosed, some researchers propose that studies of this disorder would be better focused on its early identification and treatment rather than on prevention.

Where can one get more information on Munchausen syndrome by proxy?

Child Welfare Information Gateway
Children's Bureau
1250 Maryland Avenue, SW, Eighth Floor
Washington, D.C. 20024
1-800-394-3366
703-385-3206
http://www.childwelfare.gov

National Child Abuse Hotline
1-800-4-A-CHILD

National Indian Welfare Association (NICWA)
5100 SW Macadam Avenue, Suite 300
Portland, OR 97239
Phone: 503-222-4044
Fax: 503-222-4007
http://www.nicwa.org

Prevent Child Abuse America
500 North Michigan Avenue Suite 200
Chicago, Ill. 60611
312-663-3520
http://www.preventchildabuse.org

American Psychiatric Association
1000 Wilson Blvd. Suite 1825
Arlington, Va. 22209
http://www.psych.org

American Psychological Association
750 First Street, N.E.
Washington, D.C. 20002- 4242
http://www.apa.org

National Alliance for the Mentally Ill (NAMI)
Colonial Place Three
2107 Wilson Blvd. Suite 300
Arlington, Va. 22201-3042
http://www.nami.org

National Institute of Mental Health (NIMH)
Office of Communications
6001 Executive Blvd. Room 8184
MSC 9663
Bethesda, Md. 20892-9663
http://www.nimh.gov

REFERENCES:

Adshead, G., Bluglass, K. "Attachment Representations in Mothers with Abnormal Illness Behavior by Proxy." The British Journal of Psychiatry 187 (2005): 328-333.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Publishing, 2013.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision. Washington, D.C.: American Psychiatric Publishing, Inc., 2000.

David, T.J. Child abuse and paediatrics. Journal of the Royal Society of Medicine 2005; 98: 229-231.

De Ridder, L., Hoekstra, J.H. Manifestations of Munchausen Syndrome by proxy in pediatric gastroenterology. Journal of Pediatric Gastroenterology and Nutrition 2000 August; 31(2): 208-211.

Dubowitz, H., and W.G. Lane. "Factitious disorder by proxy (Munchausen syndrome by proxy)." In: Kliegman, R.M., et al, eds. Nelson Textbook of Pediatrics, 19th Edition. Philadelphia, PA: Saunders Elsevier, 2011.

Ehrlich, S., Pfeiffer, E., Salbach, H., Lenz, K., Lehmkuhl, U. Factitious disorder in children and adolescents: a retrospective study. Psychosomatics 2008 September-October; 49: 392-398.

Eminson, M., and J. Jureidini. "Concerns about research and prevention strategies in Munchausen syndrome by proxy (MSBP) abuse." Child Abuse and Neglect 27.4 Apr. 2003: 413-420.

Fanu, J.L. "Wrongful diagnosis of child abuse-a master theory." Journal of the Royal Society of Medicine 2005; 98: 249-254.

Glazier, K. "Effects of Munchausen syndrome by proxy on the victim." Graduate Student Journal of Psychology 11 (2009): 70-74.

Goodwin, J. Munchausen's Syndrome as a dissociative disorder. Dissociation 1988 March; 1:1.

Kamerling, L.B., Black, X.A., Fiser, R.T. Munchausen syndrome by proxy in the pediatric intensive care unit: an unusual mechanism. Pediatric Critical Care Medicine 2002 July; 3(3): 305-307.

Karlin, N.J. Munchausen syndrome by proxy. Dartmouth Medical School 1996.

Meadow, R. Mothering to death. Archives of Disease in Childhood 1999; 80: 359-362.

Rand, D., Feldman, M. An explanatory model for Munchausen by proxy abuse. International Journal of Psychiatry in Medicine 2001; 31(2): 113-126.

Sheridan, M.S. The deceit continues: an updated literature review of Munchausen Syndrome by Proxy. Child Abuse and Neglect 2003 April; 27(4): 431-451.

Stirling, J. Beyond Munchausen syndrome by proxy: Identification and treatment of child abuse in a medical setting. Pediatrics 2007 May; 119(5): 1026-1030.

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Reviewed on 10/19/2016
References
REFERENCES:

Adshead, G., Bluglass, K. "Attachment Representations in Mothers with Abnormal Illness Behavior by Proxy." The British Journal of Psychiatry 187 (2005): 328-333.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Publishing, 2013.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision. Washington, D.C.: American Psychiatric Publishing, Inc., 2000.

David, T.J. Child abuse and paediatrics. Journal of the Royal Society of Medicine 2005; 98: 229-231.

De Ridder, L., Hoekstra, J.H. Manifestations of Munchausen Syndrome by proxy in pediatric gastroenterology. Journal of Pediatric Gastroenterology and Nutrition 2000 August; 31(2): 208-211.

Dubowitz, H., and W.G. Lane. "Factitious disorder by proxy (Munchausen syndrome by proxy)." In: Kliegman, R.M., et al, eds. Nelson Textbook of Pediatrics, 19th Edition. Philadelphia, PA: Saunders Elsevier, 2011.

Ehrlich, S., Pfeiffer, E., Salbach, H., Lenz, K., Lehmkuhl, U. Factitious disorder in children and adolescents: a retrospective study. Psychosomatics 2008 September-October; 49: 392-398.

Eminson, M., and J. Jureidini. "Concerns about research and prevention strategies in Munchausen syndrome by proxy (MSBP) abuse." Child Abuse and Neglect 27.4 Apr. 2003: 413-420.

Fanu, J.L. "Wrongful diagnosis of child abuse-a master theory." Journal of the Royal Society of Medicine 2005; 98: 249-254.

Glazier, K. "Effects of Munchausen syndrome by proxy on the victim." Graduate Student Journal of Psychology 11 (2009): 70-74.

Goodwin, J. Munchausen's Syndrome as a dissociative disorder. Dissociation 1988 March; 1:1.

Kamerling, L.B., Black, X.A., Fiser, R.T. Munchausen syndrome by proxy in the pediatric intensive care unit: an unusual mechanism. Pediatric Critical Care Medicine 2002 July; 3(3): 305-307.

Karlin, N.J. Munchausen syndrome by proxy. Dartmouth Medical School 1996.

Meadow, R. Mothering to death. Archives of Disease in Childhood 1999; 80: 359-362.

Rand, D., Feldman, M. An explanatory model for Munchausen by proxy abuse. International Journal of Psychiatry in Medicine 2001; 31(2): 113-126.

Sheridan, M.S. The deceit continues: an updated literature review of Munchausen Syndrome by Proxy. Child Abuse and Neglect 2003 April; 27(4): 431-451.

Stirling, J. Beyond Munchausen syndrome by proxy: Identification and treatment of child abuse in a medical setting. Pediatrics 2007 May; 119(5): 1026-1030.

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