Caregiving in disguise

Munchausen syndrome by proxy

Case: A 4.5-year-old male child was brought repetitively to a paediatrician in the emergency department of a government hospital; the hospital sent the family back each time, citing nothing was wrong with him medically. The mother worked as a daily wage labourer, and cited a variety of complaints — from the child passing blood in stools to not being able to swallow or eat properly, vomiting to even fainting. A series of tests were carried out, but no issues were found. On the repeated insistence of the mother, he was thoroughly re-assessed.

The child was admitted for a long stay with the mother and, on a chance observation of CCTV footage of the inpatient wards, it was noted that the mother was not giving the child his medications, and giving him something to drink every day, following which he would be vomiting, become sick and remain in bed the rest of the day.

The doctors insisted that the caregiver be changed and that the father accompany the child for the next few days, after which he became completely fit. The mother was then referred for a psychiatric consultation in view of Munchausen syndrome by proxy.

What is Munchausen by proxy?

Munchausen syndrome by proxy (MSBP) is a mental illness in which the caretaker of a child either makes up fake symptoms or causes actual symptoms physically or mentally to make it look like the child is sick. This counts as a form of child abuse.

Currently, this term is replaced by the term FDIA — Factitious Disorder Imposed on Another.

History

The term Munchausen syndrome is named after Baron von Munchausen — an 18th-century German cavalry officer. He was known for exaggerating his life experiences and later became famous due to a collection of his tales being published. He would tell elaborate colourful stories about his travels and experiences to get attention. "By proxy" indicates that a parent or other adult is making up or exaggerating symptoms in a child, not in himself or herself.

Can your caretaker/parent ever hurt you? Why does it occur?

Munchausen by proxy syndrome is a mental illness and requires treatment. A clear-cut cause and effect cannot be found for MSP. The causes can be multifactorial:

⁕ The caretaker themselves may have been abused as a child

⁕ Strained marriage with a partner

⁕ Unplanned child

⁕ Frustration against the medical system

⁕ Psychological roots: unmet needs of love and care

How common is it?

The exact prevalence of Munchausen syndrome by proxy is hard to examine owing to the difficulty in documenting the diagnosis. Munchausen by proxy syndrome is a relatively rare disorder. In general medicine, about one per cent meet the criteria for Munchausen by proxy.

How is it diagnosed? When to suspect?

No clear-cut symptom is diagnostic. A red flag must go up in a practitioner's mind if the parent is repetitively bringing a child in with multiple medical complaints, the tests are inconclusive and the problems don't respond to treatment or follow a puzzling course. The lab findings of such cases are highly unusual due to the tampering with samples and may be impossible to correlate clinically. Another red flag is when the parent isn't reassured by the good news that the results are normal and there is no issue with the child but insists on a diagnosis. A lot of doctor shopping, and multiple specialist consultations ensue. The symptoms tend to stop or improve when the victim is not with the parent inflicting FIDA.

Involvement of social services and child welfare services is required medicolegally.

What happens to these children? Do they have a normal future?

The prognosis for children with Munchausen syndrome by proxy is bleak. In some cases, there is a high mortality rate, and many children may suffer from Munchausen disease as adults themselves.

Isn't this just lying and malingering?

The Diagnostic and Statistical Manual of Mental Disorders notes that this disorder is different from malingering. In cases of malingering, individuals fake illness to benefit financially, to avoid legal trouble, or for other self-protective reasons. While FIDA is intentionally creating or exaggerating symptoms, it isn't aimed at making concrete benefits.

Must read and watch:

Sickened: The Memoir of a Munchausen by Proxy Childhood: In 2015, a woman named Dee Dee Blanchard was found stabbed to death in the Missouri home by her teenage daughter, Gypsy Rose. It was later revealed that the mother had falsely convinced Gypsy Rose and everyone they knew including the doctors that the daughter was seriously ill and needed to use a wheelchair for many years. Dee Dee in this case was posthumously diagnosed with FIDA

Book: Dying to be Ill: True Stories of Medical Deception

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