Munchausen by Proxy-The Deadly Game
Schreier, Herbert A., Libow, Judith A., The Saturday Evening Post
The national spotlight is focused on the little-known Munchausen by proxy syndrome, where the protective role of motherhood conceals a bizarre portrait of child abuse.
After 22 months of unsuccessful diagnostic procedures in a hospital setting in England to determine the cause of a baby's breathing problem, staff concealed a video camera in the baby's hospital room, and a policewoman and a nurse jointly monitored the scene. The following events occurred:
Sixteen hours after the onset of video monitoring, the child was asleep in his cubicle with only his mother in attendance. She moved the chair away from the cot and lowered the cot sides. She then placed a soft garment (a T-shirt) on the bedding close to the child's face. Five minutes later she placed the garment over his nose and mouth and forced his head onto the mattress. He awoke immediately and struggled violently. After ten seconds the policewoman alerted the nurses who went into the cubicle. . . . In this first episode the woman police officer had intervened prematurely [by legal standards] because of her own distress at what she had seen. She decided to continue surveillance. Twenty minutes later, when the child was asleep on his side and the mother was again alone in the cubicle, she placed him in a supine position with his face upright and tucked his arms under the bedding. Ten minutes later she again applied the garment to his nose and mouth and forced his head onto the mattress. The child struggled violently. Forty-two seconds later the nursing staff were alerted by the police and went into the cubicle. . . . The mother claimed that he had woken screaming and that she was comforting him.
What Is Munchausen by Proxy Syndrome?
This case is a classic example of Munchausen by proxy syndrome (MBPS). These patients, usually mothers, systematically fabricate information about their children's health or intentionally make their children gravely ill. The children usually require extensive medical attention, often entailing serious and dangerous invasive medical procedures, surgeries, intravenous medicines, or multiple x-rays. Well versed in medical conditions, MBPS parents will seemingly stop at nothing to gain access to doctors and the inner circle of care in hospitals. Often they seek more general recognition of, or public adulation for, their devoted caretaking of a sick child. Sometimes the MBPS parent's interventions or the medical responses prompted by her fabrications result in the death of the child. We know, based on parents' own admissions as well as observations of some of these incidents taped by hidden cameras, that the mother's behavior is calculated and is performed calmly and carefully. These mothers are generally not psychotic and not in a dissociative state when they harm their children. When confronted by physicians who suspect they are inducing illness, or even when confronted by documented proof of their abuse, MBPS mothers tend to deny vigorously and persistently their role in harming the child. Some mothers even deny abuse years after conviction in court, and others only gradually come to acknowledge their role over the course of many years.
The name Munchausen by proxy syndrome was coined from the adult "Munchausen syndrome" because it seemed to mimic the adult disorder of illness fabrication but involved the use of a child as a type of proxy, or substitute, for the adult's own body. Unfortunately, the similarity in names of the two disorders has engendered considerable confusion about the relationship between the adult factitious disorder and the "by-proxy" syndrome. The name "Munchausen syndrome by proxy," still widely in use, makes the unwarranted assumption that the proxy syndrome is simply a variant of the adult disorder. We have chosen to use the term "Munchausen by proxy syndrome" to clearly distinguish it as a separate entity from Munchausen syndrome. While some patients share symptoms of both disorders, in fact there seem to be distinct differences in behavior for the two syndromes. What they share most clearly is the "Munchausen" name.
Origins of the Syndrome Name
The 18th-century baron Hieronymus Karl Friedrich Freiherr von Munchausen was a military mercenary known for his skills as a raconteur who told fantastical stories of his exploits. The term "Munchausen syndrome" was first used by Dr. Richard Asher in 1951 to describe self-induced or fabricated illness by an adult in order gain medical attention.
The first clinical description of "Munchausen by proxy" behavior as we know it today was published in 1977 by the British pediatrician Roy Meadow. He described several cases of children who were repeatedly and unnecessarily examined, hospitalized, tested, and treated for a variety of medical problems ultimately found to be fabricated by their mothers.
Since 1977, approximately 200 professional papers have been published describing several hundred of the more unusual and life-threatening manifestations of this syndrome, running the gamut from the fabrication of fevers and seizures to the poisoning and asphyxiation of children. And it is clear that for every published case, there are many more that are dealt with less publicly in doctors' offices, hospitals, and courtrooms around the world. This phenomenon is strikingly more common in mothers than fathers, though fathers often play a role of passive collusion in this form of abuse of their children.
The range of MBPS cases that have been described in the pediatric literature is quite remarkable. The youngest case of a MBPS mother that we know of involved a teenager who had her first child when she was 13 and a second baby by age 16. Each was seen repeatedly for "apnea," though no episode was ever witnessed by anybody but the mother. Both died of unexplained respiratory arrests between the ages of 3 months and 20 months.
The Public Presentation Versus the Private Reality
Almost everyone who initially comes into contact with MBPS experiences some resistance to believing that mothers could intentionally harm their children in this horrifying way. The disbelief is in part engendered by the very dramatic discrepancies between the public presentations and private realities of these families.
While MBPS mothers appear very caring in front of others, they may show little interest when alone with their children. Covert videotaping has demonstrated that long periods can pass in which the mother scarcely communicates with her infant. Adding to the disbelief are the extraordinary lengths to which some parents will go in order to establish a medical problem in their children. One mother gathered names of patients from the Cystic Fibrosis Foundation under false pretenses and then called patients by phone in order to collect sputum for "research." She tried to use one of these samples to convince doctors that her child was ill with this serious disease. These vignettes seem too bizarre to believe, yet the existence of countless cases like these eventually help us to see this as an integral part of this disorder.
While this disorder can manifest itself in hundreds of different medical symptoms, modes of abuse, and victim and parent characteristics, the critical dynamic for comprehending this clinical picture is the mother's intense need to be in a relationship with doctors and/or hospitals. The child is used to gain and maintain this contact.
The Medical Presentation
The illnesses that have been presented in MBPS cover a remarkable range of organ systems and physical complaints, including abdominal pain, apnea, bleeding, diabetes, diarrhea, eczema, fevers, infections, lethargy, rashes, renal failure, seizures, shock, tachycardia, vomiting, and weight loss. And the list is expanding all the time, as new cases are seen and described in medical journals. Unfortunately, since these "illnesses" are nonexistent or induced by other substances or manipulations, they generally fail to respond to the physician's usual treatments, or they show an unusual and unexpected course of recurrence or intensification. The medical picture tends to get progressively more complicated by the addition of new medications and invasive interventions as the physicians search for ever-more powerful treatments for these persistent "illnesses."
Sometimes a pattern of unexpected symptoms in an illness can give clues that something is amiss in a puzzling medical picture. For example, frequent bouts of apparent apnea prior to a sudden infant death syndrome (SIDS) death occur less than 10 percent of the time in true SIDS, but up to 90 percent of the time in active suffocation. In our experience, a dramatic example of a MBPS symptom that raised suspicion because it did not fit the usual pattern of a known disorder was physiologically impossible amounts of outflow from a mild stomach condition being monitored by a gastric drainage tube. In that case a mother was surreptitiously adding fluids to the collection bag. Another symptom sometimes seen in these cases is enteric pathogens causing a sepsis (blood infection), unusual without bowel disease. This symptom is usually caused by contamination of an IV line, which can be done in a variety of ways by an enterprising parent determined to convince the caregiver that her child is ill.
Unfortunately, a hallmark of MBPS cases is that, for a variety of complex reasons, suspicion by the physician usually takes a long time to develop.
Few Visits from Husbands
A number of typical behaviors are often associated with MBPS cases. While these behaviors do not by themselves define the syndrome, they help alert us to the possibility of the diagnosis and also give important clues in our attempts at understanding the dynamics of the phenomenon.
By almost all accounts, these mothers appear totally devoted to their child.
They appear intensely interested in their child's medical problems, persistently pursue tests and procedures, are actively involved in caring for the child, and usually are reluctant to leave the child or the hospital for any reason. They often develop first-name relationships with nurses, physicians, and ward staff. Yet a closer examination often reveals that these mothers are not devoting themselves solely to their child during the hospital stay. They can often be found far from their children having coffee with, or offering solace and emotional caretaking to, other mothers. Mothers with the syndrome appear to enjoy belonging to a social circle whose common bond is caring for sick children. Only rarely do they have outside visitors, including, most notably, their husbands. And they appear to have few friends outside of hospital personnel and other parents.
These mothers often are very knowledgeable about medical issues and questions, offering highly elaborated, technically proficient medical histories that reveal a medical sophistication beyond their general fund of knowledge. Indeed, many parents involved are connected to the field of medicine, working as nurses, orderlies, medical transcriptionists, and nurse's aides.
Their knowledge of medical matters would suggest an intellectually sophisticated and generally well-educated person. And yet paradoxically they often appear shallow in other interactions, have limited interpersonal skills outside of medical issues or general knowledge, and exhibit poor judgment.
Initially, at least, these mothers are very supportive of doctors and staff, despite the fact that their child's health is deteriorating under these professionals' care. Often aggressive about demanding new procedures and interventions for their child, they can get very angry when they do not get their way. We know of one mother who is believed to have convinced physicians to unnecessarily implant Broviac catheters (surgically placed intravenous tubing through which food and medicines are injected) or nasogastric feeding tubes in children who had no need for them. When thwarted, she searched for a doctor who would listen to her.
In our experience, when a mother's claims are disbelieved by her physician, this disbelief can lead to disastrous consequences for her infant, even to death. She may act rashly in a desperate attempt to convince the physician. We also suspect that she lashes out at the physician through her child, injuring the child as a way of taking revenge on the doctor for having doubted her.
When giving a family history to the doctor evaluating a child for hospital admission, the mother often volunteers elaborate medical histories consistent with "somatization disorder" or adult Munchausen syndrome. She also may relate fantastical personal histories about herself or other family members. Typical is a mother of a five-year-old who brought him to his pediatrician with symptoms of seizures, vomiting, nasal congestion, wheezing, croup, pneumonia, ear infections, and knee dislocation. She claimed that her father suffered from epilepsy, and that her older brother had been killed in an equestrian accident. She reported that he took Dilantin, even though he had not been known to have epilepsy.
When their child is in the throes of a serious crisis, these parents often behave dramatically and draw attention to themselves; alternately they may be calm. While in general these mothers do not seem unusual to doctors, staff, or neighbors, sometimes they claim that bizarre and unverifled incidents have happened to their families when they are in the hospital, including reports of fires and burglaries. Sometimes anonymous phone calls that suggest that these mothers are hurting their children or having affairs with doctors, are received by the police or the hospital. It seems apparent that they themselves are making these phone calls. Their need to have the spotlight trained on them is seen in their use of the media and is sometimes manifested at their children's elaborate funerals, during which they often appear more concerned about relating to the hospital staff than mourning their dead child.
Tragic Costs of MBPS
MBPS can take a dramatic toll on its victims: deaths of innocent children, long-term psychological morbidity, severe family dysfunction, and turmoil for physicians, attorneys, therapists, and protective services workers who become involved. These cases also take a serious toll in medical costs to society, given the repeated medical visits, costly laboratory tests, extended hospitalizations, surgical procedures, specialist consultations, and equipment costs that these induced and fabricated illnesses extract from our healthcare system. One case we consulted on cost a local hospital close to $1 million in unnecessary procedures involving multiple long admissions, surgeries, and so on. While many pediatricians are aware of individual Munchausen by proxy cases that went undiscovered for years and generated many hundreds of thousands of dollars in unnecessary costs, few have studied the cost factor in any systematic way.
In summary, MBPS is a disorder that can cause enormous physical and emotional suffering to the children involved, as well as result in deaths, abuse of our healthcare system, and turmoil for our physicians and other guardians of childrens' well-being. Even when these cases are detected and proven, they pose major difficulties in management for the staffs of hospitals and the courts. Though the physician is generally the one to raise suspicions, it is usually only after a long period of exasperating and exhausting medical detective work. Complex psychological and societal forces are at play in the very challenging task of unmasking each unique case, even before the issue of treatment is confronted.
A mother induces a seizure by suffocating her baby, then calls hospital staff. Dr. Roy Meadow reported on a U.K. study of 76 children affected by MBPS in which by far the most common false symptom was 'seizures'; for 32 of the children, the primary diagnosis was epilepsy until the parents' deception was uncovered. Mothers have been detected creating seizures by asphyxiation and by injecting insulin.
Reprinted from Hurting for Love by Schreier, H.A., & Libow, J.A. with permission from Guilford Press, New York.
Other books on MBPS include: Patient or Pretender: Inside the Strange World of Factitious Disorders by Marc D. Feldman, M.D., & Charles V. Ford, M.D. and Non-Epileptic Seizures, edited by DeMoss.…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Munchausen by Proxy-The Deadly Game. Contributors: Schreier, Herbert A. - Author, Libow, Judith A. - Author. Magazine title: The Saturday Evening Post. Volume: 268. Issue: 4 Publication date: July/August 1996. Page number: 40+. © Benjamin Franklin Literary and Medical Society Jan/Feb 2007. Provided by ProQuest LLC. All Rights Reserved.
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