Definition ,types , warning signs, features,diagnosis , treatment , morbidity and mortality

1. Hurting for Love
Page 1

2. Scenario.1
A 2-year-old female was brought to the
emergency department for blood in her diaper.
The physician performed a complete history and
physical examination, including laboratory
studies. After results came back normal, the little
girl was discharged home with her mother.
Page 2

3. Scenario.1 (Cont.)
A couple of days later the mother returned to
the emergency department again with
complaint of blood in her daughter's diapers.
The mother, a registered nurse, brought the
bloody diaper and gave a complete medical
history, including all medications used in
pregnancy and Apgar scores.
Page 3

4. Scenario.1 (Cont.)
The daughter was admitted to the pediatric
floor for observation. The mother appeared
anxious but was very helpful with the staff.
Every morning she was present for the
attending physician's rounds and purchased
donuts for the entire staff. The results returned
within normal limits.
Page 4

5. Scenario.1 (Cont.)
The results returned within normal limits.
The mother became agitated and insisted on a
second opinion. The attending physician
agreed. The next morning the nursing staff
paged the physician to report that the mother
took the patient and left the hospital in the
middle of the night.
Page 5

6. Scenario.2
Victim MA, a 9-month-old boy, was
repeatedly admitted to Children's Hospital
because of recurrent life-threatening apnea.
At 7 weeks of age, he experienced his first
apneic event, and his mother administered
mouth-to-mouth ventilation. Spontaneous
respiration returned, and MA was
hospitalized, treated, and discharged with a
home monitor.
Page 6

7. Scenario.2 During the next 9 months, MA experienced
(Cont.) 10 similar events and 7 more
hospitalizations. Eight of the events
required mouth-to-mouth ventilation. All of
these episodes occurred while mother and
child were alone, and only MA's mother
witnessed the actual events. Two episodes
occurred in the hospital.
Unfortunately, despite many tests and
surgical procedures, MA's apnea persisted,
and his growth slowed.
Page 7

8. Scenario.2 (Cont.)
Because of his persistent apnea and failure
to thrive, MA received home nursing care.
During these home visits, several nurses
observed that MA would refuse to eat in his
mother's presence. If she left the room,
however, he would eat
Page 8

9. Scenario.2 (Cont.)
To better observe mother-child interaction,
MA was moved to a hospital room equipped
for covert audio-visual surveillance.
On the sixth day, the video clearly recorded
Mrs. A bringing on the apnea by forcing the
child into her chest, which caused him to lose
consciousness. MA became limp and
experienced a falling heart rate. Mrs. A then
placed the baby back on the bed, called for
help, and began mouth-to-mouth resuscitation
Page 9

10. The hospital immediately informed child
Scenario.2 protection services and police
(Cont.)
authorities, who reviewed the recording.
Shortly thereafter, a team consisting of a
physician, nurse, social worker, and
police officer confronted the parents. At
first, Mrs. A expressed disbelief at the
suggestion that she smothered MA, but
when she was informed of the video, she
made no comment. She was then
arrested.
This article is reprinted from the June, 1992 issue of the FBI's Law Enforcement Bulletin
Page 10

11. ". . . a victim of Munchausen
A victim
syndrome
of MSBP
My whole life I was made to believe I was
sick when I wasn‘t 'til I grew up . . ."
--rapper Eminem,
in "Cleaning Out My Closet"
Page 11

12. Facts
Women are most often the
perpetrators of the syndrome,
and its victims the woman's own
child
http://www.shvoong.com/social-sciences/psychology/171074-
Page 12

13. Facts (Cont.)
In 95% of cases the mother is the
one abusing the child this way; in
other cases, the father,
grandparent, or even babysitter
may be the abuser.
Abdulhamid, I. & Siegal, P. (2002). Munchausen syndrome by proxy. eMedicine.com
Page 13

14. Facts (Cont.)
People with MSP often express
extreme love and attentiveness
towards their child
http://www.shvoong.com/social-sciences/psychology/17107
Page 14

15. Extreme love
Page 15

16. Facts (Cont.)
The major trademark of the disorder
is causing just enough harm to the
victim so as to garner sympathy
and attention from physicians, law
enforcement, family, etc.
http://www.shvoong.com/social-sciences/psychology/171074-f
Page 16

17. Facts (Cont.)
They must injure their children over and
over again to get that all consuming high.
They are very thoughtful in choosing their
modus operandi. i.e., injecting air or fluid
into an IV. They must be careful to harm
in a way that can't be easily detected.
http://www.shvoong.com/social-sciences/psychology/171074-fbi-
case-study-munchausen-syndrome/#ixzz1shIhDXVg
Page 17

18. Facts (Cont.)
Symptoms of the syndrome are hard
to identify but are most prevalent
when the child only becomes sick in
the presence of his or her mother.
Page 18

19. Facts (Cont.)
The mother maintains a dynamic
relationship with the physician, as the
whole disorder is centered upon her
need for attention from the doctor.
Page 19

20. Facts (Cont.)
The disorder was named after an 18th-
century German dignitary named
Baron von Munchausen. Who was
known for telling “outlandish stories,”
Page 20

21. Facts (Cont.)
Las fabulosas aventuras del Baron de Munchausen - YouTube.flv
Page 21

22. Pediatric Munchausen
Syndrome by Proxy(MSBP)
Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital ,Sharjah, UAE
saadsalani@aol.com
Page 22

23. Definition
Munchausen by Proxy Syndrome, also called
Factitious Disorder by Proxy, is a
psychological disorder characterized by a
pattern of behavior in which someone,
usually a mother, induces physical ailments
upon another person, usually her child .
Page 23

24. History
In 1977, Englishman Roy Meadow
published the first report of a new form of
child abuse.[1] He coined the term
Munchausen syndrome by proxy (MSBP)
after the syndrome that first had been
reported by Asher in 1951 .[2]
.[1] Meadow R. Mun2hausen syndrome by proxy. The hinterland of child abuse. Lancet. Aug 13
1977;2(8033):343-5.
. Asher R. Munchausen's syndrome. Lancet. Feb 10 1951;1(6):339-41.
[2]
Page 24

25. Criteria of MSBP include:
Criteria 1.Intentional production of or feigning of
physical or psychological symptoms in a
person under one's care
2.Perpetrator motivated by assuming the sick
role by proxy
3.External incentives (such as monetary gain)
are absent
4.Behavior is not better accounted for by
another disorder
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-
TR. Washington, DC: American Psychiatric Association; 2000.
Page 25

26. Subtypes
Three subtypes of MSBP were described:
1.Episodic Munchausen by proxy occurs in spurts.
There are intervals when the person experiences
symptoms of MSBP and intervals where the
person lives a normal life.
Schreier H, Libow J. Hurting For Love: Munchausen by Proxy Syndrome. New
York, NY; The Guilford Press, 1993
Page 26

27. Subtypes (Cont.)
2. Mild Munchausen by proxy, affected individuals
fabricate medical histories for their children and
lie about their children being sick rather than
actively causing sickness. Their motivation is
the
emotional gratification they receive from
medical attention.
Schreier H, Libow J. Hurting For Love: Munchausen by Proxy Syndrome. New
York, NY; The Guilford Press, 1993
Page 27

28. Subtypes (Cont.)
3. Intense Munchausen syndrome by proxy, the
person resorts to measures such as inducing
vomiting, poisoning, removing blood from the
child, and suffocation. The individual is able
to induce severe illness in his or her own
child, yet remain cooperative, concerned, and
compassionate in the presence of healthcare
providers
Schreier H, Libow J. Hurting For Love: Munchausen by Proxy Syndrome. New
York, NY; The Guilford Press, 1993
Page 28

29. Incidence and Prevalence
•One % of children with asthma had been subjected
to Munchausen syndrome by proxy.[1]
•In another report of children with food allergies, 16
of 301 children (5%) had been subjected to
Munchausen syndrome by proxy.[2]
•An incidence of 2.8 cases per 100,000 children
younger than 1 year and 0.5 cases per 100,000
children younger than 16 years.[3]
[1]
Godding V, Kruth M. Compliance with treatment in asthma and Munchausen syndrome by
proxy. Arch Dis Child. Aug 1991;66(8):956-60
. Warner JO, Hathaway MJ. Allergic form of Meadow's syndrome (Munchausen by proxy). Arch
[2]
Dis Child. Feb 1984;59(2):151-6
. McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by
[3]
proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child. Jul
1996;75(1):57-61.
Page 29

30. Presentation
•There is no single, typical presentation of MSBP
• Victims are equally divided between male
and female
•Children most at risk are those aged 15months to 72
months
•Victims frequently have baffling symptoms and see
multiple healthcare providers before a diagnosis of
MSBP is made
Lieder HS, Irving SY, Mauricio R, Graf JM. Munchausen syndrome by proxy: a case
report. AACN Clin Issues. 2005;16:178-184
Page 30

31. Presentation (cont.)
• In 98% of cases, the perpetrator is the
biological mother.[1]
•Characteristics of perpetrators include:
*Female
*Experiencing marital discord
*Having healthcare knowledge or training,
*Friendly and cooperative with staff
*Very attentive to the child
*May have a history of abuse and/or psychiatric
disorders.[2]
.[1] Lieder HS, Irving SY, Mauricio R, Graf JM. Munchausen syndrome by proxy: a case report.
AACN Clin Issues. 2005;16:178-184.
. Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30
[2]
Page 31

32. Presentation (cont.)
•Perpetrators of MSBP may be help-seekers
who
search for medical attention for their children
to communicate their own exhaustion, anxiety,
or depression.
•Others may be active inducers who create their
child's illnesses through dramatic measures.
Page 32

33. Presentation (cont.)
• These parents are typically anxious, depressed,
or paranoid.
•And finally, some may be "doctor addicts" who
are obsessed with getting treatment for their
children's nonexistent illnesses .
Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30.
Page 33

34. Presentation (cont.)
Ways that MSBP can present include:
•Complex pattern of illness and recurrent
infection without physiologic explanation
•Seizure activity that does not respond to
medication and that is only witnessed by the
caretaker
•Bleeding from anticoagulants and poisons; use of
caretaker's own blood or red-colored substances
to simulate bleeding
Page 34

35. Presentation (cont.)
4.Vomiting precipitated by ipecac administration
5.Diarrhea induced by laxatives or salt
administration
6.Hypoglycemia from administration of insulin
or
hypoglycemic agents
7.Rashes from caustic substances applied to the
skin
Page 35

36. Presentation (cont.)
8.Hematuria or rectal bleeding from trauma;
9.Recurrent apparent life-threatening events
(ALTE) from purposeful suffocation
10.Central nervous system depression (usually
from drug administration).
.[1] Lieder HS, Irving SY, Mauricio R, Graf JM. Munchausen syndrome by proxy: a case report.
AACN Clin Issues. 2005;16:178-184.
. Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30
[2]
Page 36

37. Diagnosis
•Tends to be difficult
•The diagnosis of MSBP cannot be made quickly
•Victim's signs and symptoms are undetectable
or inconsistent
•Confusing signs and symptoms lead to order
diagnostic tests
Stirling J and the Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy:
identification and treatment of child abuse in a medical setting. Pediatrics. 2007;119:1026-1030
Page 37

38. Note:
Victims of Munchausen syndrome by proxy
have to go through unnecessary tests and
treatments that can be painful or even
dangerous. Because the caregiver seems so
genuinely concerned, it's often hard for doctors
to spot the problem before it's too late.
http://health.howstuffworks.com/mental-health/mental-disorders
Page 38

39. Investigations
Tests that emergency physicians may consider
include the following:
•Urine toxicology screening
•Chemistry panels
•Electrocardiography (ECG)
•Drug levels for suspected poisoning agents
(e.g., aspirin, acetaminophen, anticonvulsants)
•Cultures
•Coagulation tests
•Head CT scan
Page 39

40. Questions to be asked?
• Are the history and signs and symptoms of
disease believable?
• Is the child receiving unnecessary, harmful,
or potentially dangerous testing and medical
care?
• If so, who is prompting the evaluations and
treatment?
Stirling J and the Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy:
identification and treatment of child abuse in a medical setting. Pediatrics. 2007;119:1026-1030
Page 40

41. Questions to be asked?(Cont.)
4.During clinical assessment, is the child's
medical status consistent with the mother's
description?
5.Does objective diagnostic evidence support
the child's reported medical condition?
6.Has any staff member, including the
pediatrician, witnessed the symptoms?
Page 41

42. Questions to be asked?(Cont.)
7. Do negative test findings reassure the
mother?
8.Is treatment being provided to the child
primarily because of the mother's
persistent demands?
Siegel PT, Fischer H. Munchausen by proxy syndrome: barriers to detection, confirmation,
and intervention. Child Serv Soc Policy Res Pract. 2001;4:31-50.
Page 42

43. Warning signs
• Illness that is multisystemic, prolonged,
unusual, or rare
• Symptoms that are inappropriate or
incongruent
• Multiple allergies
• Symptoms that disappear when caretaker is
absent
Page 43

44. Warning signs (Cont.)
5.One parent, usually the father, absent during the
child's hospitalization
6.History of sudden infant death syndrome (SIDS)
in siblings
7.Parent who is overly attached to the patient
8.Parent who has medical knowledge/background
Page 44

45. Warning signs (Cont.)
9.Child who has poor tolerance of treatment
10.Parent who encourages medical staff to
perform numerous tests and studies
11.Parent who shows inordinate concern for
feelings of the medical staff.
Mason J, Poirier M. Munchausen syndrome by proxy. eMedicine, 2007.
http://www.emedicine.com/emerg/topic830.htm
Page 45

46. Morbidity and Mortality
•The incidence of death not precisely known
•Mortality rates are 9-31% among index cases,
with most investigators reporting a mortality
rate of 9-10%.
Sheridan MS. The deceit continues: an updated literature review of Munchausen
Syndrome by Proxy. Child Abuse Negl. Apr 2003;27(4):431-51. [Medline].
Page 46

47. Morbidity and Mortality (cont.)
• Morbidity can be the direct result of the abuse or
a consequence of multiple diagnostic and
therapeutic interventions performed by unwitting
physician facilitators.
• Of the 128 children
* 119 (93%) received unnecessary invasive
interventions
* 45 had major medical illnesses
* 31 had minor physical ailments
* 8 died
Light MJ, Sheridan MS. Munchausen syndrome by proxy and apnea (MBPA). A survey of
apnea programs.Clin Pediatr (Phila). Mar 1990;29(3):162-8. [Medline].
Page 47

48. Treatment
•Difficult to treat because people who have these
conditions are unwilling to admit they have a
problem
•Doctors have to investigate the patient's medical
history and perform medical tests to confirm that
the problem is psychological and not than
physical.
Page 48

49. Treatment (cont.)
• Treatment for Munchausen syndrome usually
involves psychiatric counseling to change the
thoughts and behaviors that are causing the
condition
•Get the child away from the caregiver before any
further harm is done.
•The child may need treatment both for the physical
complications of having undergone unnecessary
tests and procedures, and for the psychological
scars of abuse
Page 49

50. Prognosis
•About 10 percent of children who have been
victims of Munchausen syndrome by proxy
will die.
•Others could go on to develop Munchausen
syndrome when they grow up.
Page 50

51. Famous Cases
Famous Cases
Page 51

52. 1 William McIlhoy made it into "Guinness World
Records," but he didn't have many fans at
Britain's National Hospital Service. After 400
operations in 100 different hospitals, McIlhoy
ran up $4 million worth of medical bills. The
famous Munchausen syndrome sufferer died in a
retirement home in 1983.
http://health.howstuffworks.com/mental-health/mental-disorders/munchausen4.htm
Page 52

53. All nine of Marybeth Tinning's children died
between 1972 and 1985, most of them under
2 mysterious circumstances. Each time, she
faithfully played the role of the distraught
mother and basked in the sympathy. When she
was finally arrested in 1986, Tinning admitted
to having smothered her children with a pillow.
As is often the case with spouses of
Munchausen by proxy parents, her husband
hadn't interceded, despite his suspicions. When
interviewed, he said, "you have to trust your
wife. She has her things to do, and as long as
she gets them done, you don't ask questions."
Crime Library]. Marybeth Tinning was convicted of murder in 1987 and was sentenced to 20 years in prison.
Page 53

54. 3 When five of Waneta Hoyt's six children died
between 1965 and 1971, doctors suspected
sudden infant death syndrome (SIDS). The case
was even featured in prominent medical
journals. But when New York State Prosecutor
William Fitzpatrick read about the case, he grew
suspicious. His investigation led to Hoyt's arrest
in 1994. When she was interrogated, Hoyt broke
down and admitted that she had killed her
children in an attempt to quiet them. She was
sent to prison for life.
http://health.howstuffworks.com/mental-health/mental-disorders/munchausen4.htm
Page 54

55. Summary
•Munchausen syndrome by proxy is a covert
and serious form of child abuse
•In most cases, the mother is the perpetrator.
•The child may have a combination of symptoms and
signs that does not conform to any known disease
and that does not respond to routine treatments.
•Thorough evaluation of the child and verification of
pertinent medical and social histories are required.
Page 55

56. Summary (Cont.)
•Obtaining medical records from previous
hospitalizations and medical evaluations is
important in identifying this disorder.
• Body fluids, including blood, should be tested to
ensure any questionable specimens are the child's.
•A multidisciplinary team approach is mandatory
to
confirm the diagnosis and protect the child.
•Long-term psychiatric follow-up treatment of both
the child and the perpetrator is needed
Page 56

57. Summary (Cont.)
•Educating physicians, social workers, and other
healthcare workers about Munchausen syndrome
by proxy and establishing local task forces may
facilitate timely diagnosis and management of
the disorder.
•Investigating and reporting MSBP can be both
challenging and risky to caregivers.
•Physicians and healthcare institutions may be
tried or scrutinized in the public arena, and their
judgments and decisions may be challenged
Page 57

58. Why?
Page 58

59. Thank you
Page 59