Munchausen by proxy

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

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Hurting for Love

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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. Scenario.1

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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. Scenario.1 (Cont.)

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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. Scenario.1 (Cont.)

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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 . Scenario.1 (Cont.)

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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 . Scenario.2

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During the next 9 months, MA experienced 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. Scenario.2 (Cont.)

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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 Scenario.2 (Cont.)

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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 Scenario.2 (Cont.)

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The hospital immediately informed child protection services and police 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 Scenario.2 (Cont.)

". . . a victim of Munchausen syndrome :

". . . a victim of Munchausen syndrome 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" A victim of MSBP

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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-fbi-case-study-munchausen-syndrome/#ixzz1shFu716Q Facts

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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 Facts (Cont.)

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People with MSP often express extreme love and attentiveness towards their child http://www.shvoong.com/social-sciences/psychology/171074-fbi-case-study-munchausen-syndrome/#ixzz1shGfE75Y Facts (Cont.)

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Extreme love

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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-fbi-case-study-munchausen-syndrome/#ixzz1shHpHjsS Facts (Cont.)

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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 Facts (Cont.)

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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. Facts (Cont.)

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

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

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Facts (Cont.)

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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

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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 .

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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. . [2] Asher R. Munchausen's syndrome. Lancet . Feb 10 1951;1(6):339-41.

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Criteria of MSBP include : 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 Criteria American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.

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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

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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 Subtypes (Cont.)

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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 Subtypes (Cont.)

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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 . [2] Warner JO, Hathaway MJ. Allergic form of Meadow's syndrome (Munchausen by proxy). Arch Dis Child . Feb 1984;59(2):151-6 . [3] McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child . Jul 1996;75(1):57-61.

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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

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Presentation (cont.) In 98% of cases, the perpetrator is the biological mother . [ 1] Characteristics of perpetrators include: * F emale * E xperiencing marital discord * H aving healthcare knowledge or training, * F riendly and cooperative with staff *Very a ttentive to the child *May have a h istory 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. . [2] Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30

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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. Presentation (cont.)

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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 . Presentation (cont.) Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30 .

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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

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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

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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. . [2] Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30

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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

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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/munchausen3.htm Note:

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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

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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

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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? Questions to be asked? (Cont.)

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

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

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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 Warning signs (Cont.)

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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. Warning signs (Cont.) Mason J, Poirier M. Munchausen syndrome by proxy. eMedicine, 2007. http://www.emedicine.com/emerg/topic830.htm

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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] .

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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] .

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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.

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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 Treatment (cont.)

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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. Prognosis

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Famous Cases Famous Cases

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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 1

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All nine of Marybeth Tinning 's children died between 1972 and 1985, most of them under 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." 2 Crime Library ]. Marybeth Tinning was convicted of murder in 1987 and was sentenced to 20 years in prison .

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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 3

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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.

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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 Summary (Cont.)

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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 Summary (Cont.)

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Why?

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Thank you

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