Factitious illness by proxy. Munchausen syndrome by proxy

Malingering in the medical setting

Malingering of mental illness has been studied extensively; however, malingered medical illness has been examined much less avidly. While in theory any ailment can be fabricated or self-induced, pain--including lower back pain, cervical pain, and fibromyalgia--and cognitive deficits associated with mild head trauma or toxic exposure are feigned most frequently, especially in situations where there are financial incentives to malinger. Structured assessments have been developed to help detect both types of malingering; however, in daily practice, the physician should generally suspect malingering when there are tangible incentives and when reported symptoms do not match the physical examination or no organic basis for the physical complaints is found.

Attachment representations in mothers with abnormal illness behaviour by proxy

BACKGROUND

Abnormal illness behaviour by proxy (also known as factitious illness by proxy or Munchhausen syndrome by proxy) is a type of child maltreatment, the origins of which are poorly understood.

AIMS

To describe attachment representations in a cohort of mothers demonstrating abnormal illness behaviour by proxy.

METHOD

Sixty-seven mothers who had shown this behaviour took part in a semistructured interview assessing their attachment representations.

RESULTS

Only 12 mothers (18%) were rated secure in terms of their own childhood attachments. There was evidence of unresolved trauma or loss reactions in 40 mothers (60%). Eighteen mothers (27%) gave unusually disorganised and incoherent accounts of attachment relationships in their own childhoods. The frequency of these attachment categories is higher than in normal non-clinical samples.

CONCLUSIONS

Insecure attachment is a risk factor for this type of child maltreatment. Therapeutic interventions could be offered in relation to unresolved traumatic stress or bereavement responses. Further study of similar groups, such as mothers with sick children or mothers with histories of traumatic experience, would be a useful next step.

Suffocation and poisoning?the hard-hitting side of Munchausen syndrome by proxy

Munchausen syndrome by proxy (MSBP) is a severe and difficult to diagnose form of child abuse characterised by the simulation, aggravation or production of symptoms of illness in a child by an adult. MSBP often leads to multiple hospitalisations and has a high mortality and long-term morbidity. This study describes the cases of 5 families with 8 children affected who presented with unexplained neurological or gastrointestinal symptoms or even loss of consciousness. All were victims of poisoning or suffocation by their mothers. Two of those children died and were initially diagnosed as SIDS or natural death, respectively. They were only recognised as MSBP victims after another sibling had fallen ill with similar symptoms. The cases are discussed in consideration of the relevant literature. In addition warning signs of this forensically relevant syndrome and a strategy for the management of suspected MSBP cases are described.

Munchausen Syndrome by Proxy: two case reports and an update of the literature

OBJECTIVES AND METHODS

Munchausen Syndrome by Proxy (MSP) may significantly hamper the normal development of children. Our aim was to describe the first two Israeli children who fit this diagnosis.

RESULTS

Case #1 was diagnosed at the age of seven months with failure to thrive, severe recurrent vomiting, and recurrent unexplained fever. Medical tests performed were normal. No improvement was noted following prolonged treatment, which included several surgical interventions. Case #2 was hospitalized at the age of four years because of recurrent convulsive episodes. Medical examinations performed were normal, and there was no improvement in the reported seizure disorder despite continuous treatment. In both cases, MSP was suspected because of a persistent illness that could not be explained by adequate medical basis, and because the symptoms and signs occurred only in the mother's presence. A confrontation was made, leading to rapid deterioration of the hitherto devoted relationship of the mother of case #1 with her child, and of the previous cooperative relationship of both mothers with the medical staff. Removal of both children from their families ensued, with considerable improvement within a brief period, which continued in a one- to two-year follow-up period.

CONCLUSIONS

The study reviews the required diagnostic criteria for MSP and possible treatment options.

Munchausen Syndrome by Proxy: medical diagnostic criteria

Medical diagnostic criteria for Munchausen Syndrome by Proxy are presented. The strength of the known facts may vary from case to case, and thus there may be different degrees of diagnostic conviction. Therefore, diagnostic criteria for a definitive diagnosis, and a possible diagnosis of Munchausen Syndrome by Proxy are provided. Because the gathering of evidence in a case may, ultimately, diminish or exclude the diagnosis of Munchausen Syndrome by Proxy, diagnostic criteria for the inconclusive determination and the definitely excluded diagnosis are also enunciated.

Forensic assessment of illness falsification, Munchausen by proxy, and factitious disorder, NOS

The purpose of this article is to propose guidelines for the evaluation of possible Munchausen by proxy child abuse for the court systems. These assessments require the evaluator to have an understanding of the complexity involved when this type of abuse is alleged. The evaluator should have an appreciation of how falsification of illness may or may not occur, recognize the need for careful analysis of medical records, and understand the problems associated with the use of a profile in determining the validity of an abuse allegation. This article presents guidelines for gathering pertinent data, analyzing records, and evaluating psychological testing for forensic evaluations when the questions for the evaluation are the following: (a) Is there evidence that child abuse did occur? (b) Does the alleged perpetrator meet criteria forfactitious disorder, NOS (or factitious disorder by proxy)? and (c) What management and treatment recommendations should be made?

Different interpretations of Munchausen Syndrome by Proxy

The definition of Munchausen Syndrome by Proxy is reviewed and considered in the context of the overlap with other harmful behaviors of parents. The high incidence of personal abnormal illness behavior in the perpetrators is leading to increasing concern about the safety of children who are cared for by parents who have abnormal illness behavior.

A vicious circle: transgenerational attachment representations in a case of factitious illness by proxy

Attachment theory offers a robust way to investigate transgenerational child maltreatment; first because there is a coherent theoretical hypothesis of how this might be mediated by the development of insecure working models of relationships, and second, because there is existing evidence from prospective studies that transgenerational attachment patterns can be predicted. Specifically, attachment theory may be particularly useful in cases of Fictitious Illness by Proxy (FIP), where the maltreating behavior is characterized bv disordered illness behavior and care-eliciting. We present a case history, using the Adult Attachment Interview (AAI), which examines attachment and child maltreatment in three generations. A single case history allows for hypothesis generation about the genesis of FIP behavior.

Maternal behaviors associated with smothering: a preliminary descriptive study

OBJECTIVES

To describe maternal behavior in 15 women identified as having smothered their children.

DESIGN

A descriptive study of maternal behavior and interaction with her child, using videotapes of mother and child together. These were obtained by covert video surveillance in a hospital setting. Maternal behavior was rated using an assessment schedule designed to be used with video.

RESULTS

The mothers showed a range of behaviors. Three groups emerged; one whose interaction with the child resembled normal maternal behavior, a second who interacted in a hostile way, and a third who showed a paucity of interaction.

CONCLUSION

These preliminary data suggest that smothering may reflect more than one type of abnormal maternal relationship or attitude towards children. This may have implications for treatment and prognosis.

Fatal child abuse by forced water intoxication

BACKGROUND

Although water intoxication leading to brain damage is common in children, fatal child abuse by forced water intoxication is virtually unknown.

METHODS

During the prosecution of the homicide of an abused child by forced water intoxication, we reviewed all similar cases in the United States where the perpetrators were found guilty of homicide. In 3 children punished by forced water intoxication who died, we evaluated: the types of child abuse, clinical presentation, electrolytes, blood gases, autopsy findings, and the fate of the perpetrators.

FINDINGS

Three children were forced to drink copious amounts of water (over 6 L). All had seizures, emesis, and coma, presenting to hospitals with hypoxemia (PO2 = 44 +/- 8 mm Hg) and hyponatremia (plasma Na = 112 +/- 2 mmol/L). Although all showed evidence of extensive physical abuse, the history of forced water intoxication was not revealed to medical personnel, thus none of the 3 children were treated for their hyponatremia. All 3 patients died and at autopsy had cerebral edema and aspiration pneumonia. The perpetrators of all three deaths by forced water intoxication were eventually tried and convicted.

INTERPRETATION

Forced water intoxication is a new generally fatal syndrome of child abuse that occurs in children previously subjected to other types of physical abuse. Patients present with coma, hyponatraemia, and hypoxemia of unknown etiology. If health providers were made aware of the association, the hyponatremia is potentially treatable.