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Munchausen by Proxy: Understanding the Psychopathology of its Perpetrators

Bradley & Halder

Introduction

Munchausen by proxy is an eponymous syndrome that has caused much confusion, curiosity and controversy.

References have even been made in mainstream music lyrics, such as that by Eminem.

‘....going through public housing systems, victim of Munchausen's syndrome, my whole life I was made to believe I was sick when I wasn't 'til I grew up, now I blew up, it makes you sick to ya' stomach, doesn't it, wasn't it the reason you made that CD for me, ma, so you could try to justify the way you treated me, ma.......’
Eminem, “Cleanin’ out my Closet” (2002). Aftermath Records

The above example highlights how the term is confused with Munchausen’s syndrome, which is a different (but related) disorder. Munchausen syndrome (also known as Factitious disorder) is where sufferers intentionally falsify their history and fabricate signs and symptoms with the primary aim of obtaining medical attention and treatment (Semple & Smyth, 2009).

Munchausen syndrome by proxy, on the other hand, is often regarded as a serious form of child abuse. In more recent years it has been reported with increased frequency (Bools et al, 1994).

Although there is no clear underlying disorder or background that leads an individual to carry out such behaviours it is important to be aware of the current theories and try to identify possible cases. It is important for medical professionals to take a thorough detailed history and observe the interactions between the child and caregiver where a diagnosis of Munchausen syndrome by proxy is suspected.

There are currently no clear diagnostic criteria for Munchausen syndrome by proxy. In fact the DSM IV TR, 2000 from the American Psychiatric Association considered that there was insufficient information to warrant its inclusion as an official category or axis. Therefore DSM IV TR Research criteria were developed, as follows:

A) Intentional production or feigning of physical signs or symptoms in another person who is under the individual’s care.
B) The motivation for the perpertrator’s behaviour is to assume the sick role by proxy.
C) External incentives for the behaviour, such as economic gain, are absent.
D) The behaviour is not better accounted for by another mental disorder. (Meadow, 2000).

The aim for this article is to conduct a review of available English language literature on the topic of Munchausen by Proxy and the psychopathology of its perpetrators.

Methods

A literature search was conducted using the following databases; EMBASE, PubMed and PsycINFO. The following search terms were used; ‘Munchausen syndrome by Proxy’, ‘factitious disorder’, ‘psychopathology’, ‘perpertrators’, ’abnormal illness behaviour’, ‘Parental personality disorders’ and ‘psychodynamics’ to try to identify all relevant literature. Only articles in English were included in the selection.

Results

All articles obtained following the literature search were read, and the following themes emerged.

Prevalence and definition

Although exact data on the prevalence is not available, Munchausen syndrome by proxy is thought of as a rare psychiatric disorder (Marcus et al, 1995). It was first described by Meadow in 1977 as a form of abuse whereby the perpetrator (often the primary caregiver) induces somatic or mental symptoms of illness in the victim and then persistently presents the victim(s) for medical attention (Meadow, 1977).

The child may not only come to harm at the hands of the perpertrator (commonly the child’s mother) but may secondly be harmed as a consequence of a doctor carrying out unnecessary investigations or treatments, following the child’s presentation to medical services (Bools et al, 1994).

In 1987, Rosenberg defined Munchausen syndrome by proxy (MSP) as ‘Illness in a child which is simulated (faked) and/or produced by a parent or someone who is in loco parentis’ and a ‘Denial of knowledge by the perpetrator as to the aetiology of the child’s illness [at least before the deception is discovered]’. In the ICD-10 (though not itself explicitly cited in the classification) MSP may be placed under the category of ‘factitious disorders’ F68.1 (Rosenburg, 1987; WHO, 1983).

Rosenberg’s definition of MSP also states that the ‘Acute symptoms and signs of the child abate when the child is separated from the perpertrator’ (Rosenburg, 1987).

More recently the term ‘Munchausen Syndrome by proxy’ has been replaced by the now preferred term ‘Factitious illness by proxy’, which is felt to reflect the deceptive and self-induced aspect of this attention seeking behaviour (Adshead & Bluglass, 2005).

Understanding the psychopathology of the abuse

Despite increased attention being paid to this condition in recent years, the psychopathological basis for this behaviour remains unclear (Adshead & Bluglass, 2005). The issue of motive remains a major cause of debate (Bass & Adshead, 2007). Roy Meadow includes the motivation in the definition of Munchausen Syndrome by proxy, which is that ‘the perpetrator is considered to be acting out of a need to assume the sick role by proxy, or as another form of attention-seeking behaviour’, but realises that the inclusion of motivation in the definition has its disadvantages (Meadow, 2000).

The perpetrator’s motives for this behaviour may only become apparent long after the event and several theories for the development of such behaviours have been formulated. Meadow argues that by including motivation in the definition of the term Munchausen Syndrome by Proxy, it does prevent excessive and inappropriate use of the term (Meadow, 2000).

Abnormal illness behaviour

Illness behaviour is a term referring to the way an individual experiences, perceives and responds to an illness. Such behaviours are felt to be influenced by individual, cultural and social experiences. Munchausen Syndrome by Proxy involves three forms of abnormal illness behavior: 1) False accounts of symptoms 2) Fabricated symptoms and 3) Induction of symptoms (Adshead & Bluglass, 2005).

Whilst the motivation for such pathological behaviour continues to be questioned, it is often considered to be the unconscious need for the perpetrator to assume the sick role by proxy (Meadow, 1998). It is widely thought to be as a result of the parent’s own psychopathology and a form of attention seeking behaviour by the perpetrator (Meadow, 2000).

Perpetrators

The majority of reported cases throughout the literature appear to involve females. Only few reported cases highlight males as the perpetrators (Meadow, 1998). However as knowledge of MSP increases, a wider range of perpertrators are being identified (Sheridan, 2003).

Within the group of perpetrators there has been found to be a high incidence of abnormal illness behaviours (Meadow, 2000). One of the first systematic studies of a group of perpetrators found that 34 of the 47 perpetrating mothers had some form of somatising disorder (Bools et al, 1994). In a study looking at 15 fathers who had perpetrated MSP, six were identified as having a somatising disorder and five others with Munchausen syndrome; only four of the 15 were found as having neither (Meadow, 1998).

These studies highlight the high proportion of perpetrators of MSP with abnormal illness behaviours, with over 70% having either a somatising disorder of Munchausen syndrome themselves (Meadow, 2000).

Gender Disparity

Unlike in other forms of child abuse, in MSP there exists a significant gender disparity. Victims may equally be boys or girls, but the identified perpetrator is nearly always female, and the child’s mother (Meadow, 1998). The vast majority of published reports on MSP act to emphasise the child’s mother as the perpetrator of abuse. In fact, MSP is often defined as a form of behaviour found in mothers, with no mention of any males as perpetrators of this abuse. In a literature review of 117 cases of Munchausen syndrome by Proxy, Rosenberg identified all perpertrators as the victims’ mothers (Rosenburg, 1987).
Meadow stated how in the first ten years of dealing with families involved in MSP he did not encounter a male perpetrator (Meadow, 1998). Since then he has been involved with 15 cases involving men. The reasons for this change he believes may be due to the fact that more cases of MSP were being identified in recent years. But feels that another possibility may be that due to the emphasis put on the perpetrator being the child’s mother, this may have dissuaded people from identifying male perpetrators.

There are several hypotheses as to why it is females (most commonly the child’s mother) rather than males who perpetrate such abuse. One such theory is that a young child may be predominately in the care of the mother and therefore she has the greatest opportunity to enact such abuse (Meadow, 1998).

Personality disorders

There is felt to be a specific association between borderline personality disorder (as defined in the DSM IV) and Munchausen syndrome by Proxy (Bools et al, 1994). Personality disorder is associated with a significant failure of interpersonal functioning which can be assumed to have a negative effect on good enough care-giving i.e. parenting (Adshead & Bluglass, 2005).

In a case study review by Marcus et al (1995) all of the mothers identified showed inefficient coping strategies and received no support from their partners (if present). Many of the mothers were observed to have a personality disorder. Sheridan’s (2003) literature review of MSP found 23% of perpetrators to have a psychiatric disorder (the most common conditions being depression or some form of personality disorder), whilst 22% had or claimed a personal history of abuse, either in childhood or in a partner relationship.

History of abuse

The histories of mother’s (identified as perpetrators in case studies) were frequently marked by abuse (Marcus et al, 1995). However it must be noted that a history of childhood abuse can not provide a full explanation for fabrication or induction in illness, since most adults with a history of abuse do not go on to abuse their children (Bass & Adshead, 2007).

In a study by Bools, Neale and Meadow (1993), 19 mothers were interviewed. Of these 19 women, 15 had suffered emotional neglect or abuse in childhood or adolescence. This is a significant proportion of the group. Perhaps even more notable is that of this group, four of the mothers had themselves been victims of physical abuse in childhood.

Attachment theories

Evidence suggests that an individual’s early childhood experiences with their parents has an unconscious influence on care-eliciting behaviours (Bass & Adshead, 2007). In a 2005 study, Adshead and Bluglass conducted semi-structured interviews (based on attachment theory) of sixty-seven mothers who had shown abnormal illness behaviour by proxy, assessing their attachment representations. The mean age of mothers was 28 years and the mean age of the index child was 2.3 years of age. Over half (38 out of 67) of the mothers were in a partnership or married. Notably most of the index children identified had siblings and were not only children. Within this cohort of mothers, high levels of insecure attachment were identified (Bass & Adshead, 2007). This is therefore felt to be a factor that may lead a caregiver to enact such abuse on their victim(s).

Victims

In addition to the obvious iatrogenic effects on the child, what must not be overlooked is the risk of impaired psychosocial development as a consequence of these behaviours being inflicted upon the child.12 Having a parent with abnormal illness behaviour may not only have an adverse effect on the child’s development but also impact on their safety and on the level of care they receive.

Verity et al (1979) developed the term ‘Polle Syndrome’ which they described as being a child of a patient with Munchausen syndrome who is at risk (a sort of Munchausen syndrome by proxy).

Evidence exists to suggest that patients with somatatising behaviour in adulthood may have suffered themselves of adverse experiences of care and illness in their childhood. It is therefore important for psychiatrists who come into contact with patients suffering from Munchausen syndrome to consider the possible impact this condition may have on the patient’s children (Bass & Adshead, 2007; Bass & Jones, 2011).

In a comprehensive literature review of 117 cases of Munchausen syndrome by Proxy, Rosenberg found the associated short term morbidity rate amongst victims to be 100%, long term morbidity rate 8% and a significant mortality rate of 9% within the 117 cases (Rosenburg, 1987).

Once the behaviours of MSP are identified, health professionals will no doubt work together to ensure the children are protected from physical injury. Despite this, severe psychological upset in the child may be inevitable (McGuire & Feldman, 1989).

It is necessary to assess the risk the child may be at and consider whether that child is safe to remain with the perpertrator or if rehabilitation is needed (Meadow, 2000).

Conclusion

Irrespective of the psychopathology, it is clear that Munchausen Syndrome by proxy is a very real and serious condition. Not only are victims at risk of harm from their caregivers, they also face unnecessary tests and treatment from medical professionals. Clearly several theories looking at the psychopathology of perpetrators have been developed. It is a condition that medical professionals must keep in mind as swift diagnosis can prevent the child from incurring real harm. There is a real need to protect the child from the consequences of fabricated illness.

Munchausen Syndrome by Proxy only started to be described in the late 1970’s and information on and an understanding of the condition still remains limited. Continued research on this topic is needed. In order for cases of Munchausen syndrome by Proxy to be more readily identified it is important to think about the psychopathology and important signs to look out for. Behaviours such as a caregiver who welcomes medical investigations on their child (even if painful), a caregiver who themselves suffer from Munchausen syndrome and a parent who shows little concern are among a number of symptoms that may make a diagnosis of the condition more likely (Marcus et al, 1995).

Conflict of interests

None

Authors

Dr Verity Bradley, Foundation Year 1 Doctor, Buckinghamshire Hospitals NHS Trust
Dr Neel Halder, Consultant Psychiatrist, Alpha Hospital, Bury & Honorary Senior Lecturer, Manchester University

References

1. Semple D, Smyth R. (2009). Munchausen’s Syndrome (Factitious Disorder) in Oxford Handbook of Psychiatry. Chapter 19. Oxford University Press.

2. Bools C, Neale B, Meadow R. (1994). Munchausen Syndrome By Proxy: A Study Of Psychopatholgy. Child Abuse and Neglect, Vol 18, No. 9, 773-788

3. Marcus A, Ammermann C, Klein M, Schmidt M H. (1995). Munchausen Syndrome by Proxy and Factitious Illness: Symptomatology, Parent-Child Interaction, and Psychopathology of the Parents. European Child and Adolescent Psychiatry, Vol 4., Issue 4, 229-236

4. Meadow R. (1977). Munchausen Syndrome by Proxy. The hinterland of child abuse. Lancet, 2, 343-345

5. Rosenberg, D. (1987). Web of deceit: a literature review of Munchausen syndrome by proxy. 1987 Child Abuse Neglect, 11, 547-563

6. Adshead G, Bluglass K. (2005) Attachment representations in mothers with abnormal illness behavior by proxy. British Journal of Psychiatry, 187, 328-333

7. Bass C, Adshead G. (2007) Fabrication and induction of illness in children: the psychopathology of abuse. Advances in Psychiatric Treatment, 13, 169-177

8. Meadow R. (2000). The Dangerousness of Parents Who Have Abnormal Illness Behaviour. Child Abuse Review, 9, 62-67

9. Meadow R. (1998). Munchausen syndrome by proxy abuse perpertrated by men. Arch Dis Child, 78, 210-216

10. Sheridan, M. (2003). The deceit continues: an updated literature review of Munchausen syndrome by proxy. Child Abuse and Neglect,27, 431-451

11. World Health Organisation. (1983). The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. WHO

12. Bools C N, Neale B A, Meadow S R. (1993). Follow up of victims of fabricated illness (Munchausen syndrome by proxy). Archives of Disease in Childhood, 69, 625-630

13. Verity, C M, Winckworth C, Burman D, Stevens D, White R J. (1979). Polle Syndrome: children of Munchausen. British Medical Journal, 2, 422-423

14. Bass C, Jones D. (2011). Psychopathology of perpetrators of fabricated or induced illness in children: case series. British Journal of Psychiatry, 2, 113-8.

15. McGuire T L, Feldman K W. (1989). Psychological Morbidity of Children Subjected to Munchausen Syndrome by Proxy. Pediatrics, 83, 289-92

First Published March 2012

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