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Overview and Introduction

The first cases of Munchausen syndrome by proxy were reported in the late 1970s. In 1977, the British pediatrician and scientist Roy Meadow described 2 cases of mothers with this condition. One of them poisoned her baby with salt until it died at the age of 15 months, while the other mixed her urine with that of her child in order to obtain false test results and to force a further diagnosis.

In contrast to Munchausen syndrome in which those affected feign symptoms, in Munchausen syndrome by proxy, a second person assumes this role. ‘By proxy’ means as much as ‘deputy’, which is why the disorder can also be called ‘Munchhausen syndrome deputy’. However, the term is to be used with caution, since the victims almost always have a passive role and the disorder does not have to do with them.

The forms of abuse are manifold. Some mothers break their children’s bones, while others feed them with poisonous food or medicines, or press their faces into the pillow so that respiratory arrest occurs. Mothers may infect wounds intentionally with dirt or inject fluids, causing eruptions and edemas.

Signs and Symptoms

Women with this syndrome usually have contrasting personalities, appearing to be caring but being actually dangerous. Often, the mothers quickly get in touch with doctors and nurses and show care about the recovery of the child. They sacrifice themselves, are constantly in the hospital and are strongly involved in the treatment process. In doing so, they enjoy the attention they have probably been missing.

This is also the main reason the affected mothers inflict such suffering on their children. They usually live separately from the child’s father and are socially isolated. It is difficult for them to establish stable relationships with other people and to obtain the necessary confirmation. This can be seen as a secondary gain.

Often, the perpetrators have medical knowledge, so about one-third of those affected work in the medical field. This combination of a strong need for attention and the necessary knowledge is the dangerous basis for the disorder, which, according to the World Health Organization, counts as one of the artificial disorders. Often, the perpetrators have already experienced abuse in the past or have been very often in the hospital.

It is crucial to sensitize people to the syndrome so that society is aware of this abuse. There are certain signs that suggest Munchausen syndrome by proxy:

  • Unstable medical history, which is told differently by different care receivers.
  • Symptoms that occur only in the presence of one parent.
  • The health status improves in the absence of the mother.
  • Parents are calm despite the severity of the disease.
  • Parents are perfectly informed about the disorder.
  • Parents observe the staff and are often present above-average.
  • Parents have a history of abuse or an eating disorder.

Types of Mothers with Munchausen Syndrome by Proxy

There are 3 types of patient characters involved in this form of abuse (Libow and Schreier, 1986):  help seekers, doctor addicts, and active inducers.

The help seekers are often anxious-depressive personality types that flee from a violent situation or excessive demands. If they receive help, they usually refrain from abuse, as they are primarily concerned with receiving care and attention.

The doctor addicts usually go with their older children from one doctor to another. They invent symptoms and break off treatments frequently, especially psychiatric measures.

The active inducers provoke symptoms in their child and then resist treatments.

Epidemiology

Since it is a rare disease, there are also few studies on this. In an elaborate study, a professor of Psychiatry from Würzburg, Martin Krupinski and his team interviewed 379 clinics in Germany and about half of the clinics participated.

During an observation period of 11 years, 190 cases were documented, which were suspected to be Munchhausen syndrome by proxy. Half of these cases were verified.

The number of unreported cases is probably high for many reasons. On the one hand, the mothers always choose relatively non-specific symptoms, which can match those of many diseases; thus, complicating the diagnosis. Since they are often extraordinarily well-versed in the medical field or work in this sector, the story is often plausible and difficult to check. With the free doctor choice in Germany, the treatment can be interrupted as soon as the perpetrators suspect that they will get caught.

On the other hand, there is uncertainty on the part of the medical staff in the diagnosis. There are symptoms similar to those of other mental disorders such as somatoform and hypochondriacal disorders. Often, it is accepted also a not yet recognized or atypical symptom.

Management

If there is a suspicion of the presence of Munchausen syndrome by proxy, a careful procedure is required. Without a trusting relationship, it is very difficult to persuade the mother to undergo treatment, so that ultimately no interventions are possible because she changes the doctor or even moves out. However, damage to the child must also be prevented.

The most secure proof is probably a video recording. This idea was conceived almost 20 years ago by the Londoner pediatrician Christian Poets and proved to some mothers.

While surveillance cameras in hospitals in the USA and the UK are now becoming more common, Germany is still lacking in this regard. It is necessary to install information signs in the corridor, in order not to violate people’s rights; however, the perpetrators would already be warned.

Ultimately, an intervention must be done in close consultation with authorities, ranging from psychiatric care, temporary separation of perpetrators and victims, to the government taking custody of the child.

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