1. Munchausen Syndrome - 1 -
Munchausen Syndrome by Proxy
The Role of a Medical Social Worker in the Diagnosis and Treatment of
Munchausen Syndrome by Proxy
David R. Julian, MSW, LSW
Rutgers University
August 2011
Professor Carol Pepe

2. Munchausen Syndrome - 2 -
Abstract
This paper will be a historical view of Munchausen Syndrome by Proxy and the correlating
role of the medical social worker in the diagnosis, and treatment of the patient and
perpetrator. It is important to note that even though most often considered an incident of
child abuse, Munchausen Syndrome by Proxy is first and foremost a medical concern and
most often a psychiatric condition of the perpetrator.

3. Munchausen Syndrome - 3 -
History of the Disorder
Munchausen Syndrome by Proxy (MSP) has been classified as a factitious disorder of
mental illness. It is common for MSP to be referred to as Factitious illness by proxy. In
almost all cases, the parent presenting with the child and reporting the symptoms and concern
is the mother. “The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV) refers to Munchausen syndrome as factitious disorder (300.19), and motivations for
this bizarre behavior continue to puzzle both medical and mental health professionals,
(Stirling, 2007).” Unfortunately, MSP is not a new phenomenon or condition. “In 1951, Dr.
Richard Asher originally used the term Munchausen Syndrome to describe adults who
fabricated illnesses to get medical attention, with no secondary gain except to adopt the role
of illness through unnecessary medical procedures and treatments, (Abdulhamid, 2008).”
Munchausen Syndrome has been used in reference to Baron von Munchhausen who
was widely known for factious tales relating to his travels. Interestingly though, a literature
review reveals no mention of Baron von Munchhausen ever fabricating an illness.
“According to the stories, as retold by others, the Baron’s astounding feats included riding
cannonballs, travelling to the moon, and escaping from a swamp by pulling himself up by his
own hair, (www.wikipedia.com).”
In instances of Munchausen Syndrome by Proxy, the apparent medical symptoms are
projected onto a dependent child as the parent fabricates signs and symptoms of often
nonexistent illnesses. Munchausen Syndrome by proxy was first described in 1977 by Roy
Meadow.
“In 1977, Roy Meadow coined the term Munchausen Syndrome by
proxy to describe 2 mothers who fabricated, lied, and induced
symptoms in their 2 children. One of the children had a history of

4. Munchausen Syndrome - 4 -
prolonged and recurrent passing of purulent bloody urine, and the other
had a history of recurrent hypernatremia, (Abdulhamid, 2008).”
The actual cause of MSP remains unknown to this day. “Although not precisely
known, incidence and prevalence of Munchausen syndrome by proxy are almost certainly
more common than once estimated, (Abdulhamid, 2008).”
Medical Concerns
Although often considered a form of severe child abuse, Munchausen Syndrome by
proxy presents by caregivers either fabricating or actually causing medical conditions for
their young child. In most cases of MSP, the child is preschool age and is not able to report
nor confirm or deny symptoms themselves. These concerns can often times be falsified,
imagined or in extreme cases be intentionally inflicted upon the child on the part of the
caregiver. Unfortunately, there is no typical presentation for the condition of Munchausen
Syndrome by Proxy. “Conditions faked by parents or caregivers include: failure to thrive,
allergies, asthma, vomiting, diarrhea, seizures, and infections, (Gault,
www.qualityhealth.com).”
“Munchausen syndrome by proxy refers to a pattern of behaviors in which a parent
fabricates an illness in his or her child, either by lying about symptoms the child is
experiencing or physically inducing the symptoms, (Rocha, 2004).”
Because of the complexity of the disorder, and the amount of time and documentation
necessary to make a diagnosis of Munchausen Syndrome by Proxy, often times MSP goes
undiagnosed and unreported. In many cases, since the parent is familiar with the medical
community she is even seen as helpful and well liked by the medical staff she interacts with.
“The parent is usually very helpful in the hospital setting and is often
appreciated by the nursing staff for the care she gives her child. She is often

5. Munchausen Syndrome - 5 -
seen as devoted and self-sacrificing, which can make medical professionals
unlikely to suspect the diagnosis of Munchausen syndrome by proxy,
(http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002522/, 2011).”
In fact, in some situations the medical community is even fearful of making a
diagnosis of Munchausen Syndrome by Proxy. They either fear the parent and how they will
react, or they fear damaging their reputation for having been fooled into thinking a patient
was sick and ordering tests and medications when in fact, there was nothing wrong with the
patient.
“There are no reliable statistics regarding the number of people in the
United States who suffer from MSP, and it is difficult to assess how
common the disorder is because many cases go undetected. However,
estimates suggest that about 1,000 of the 2.5 million cases of child abuse
reported annually are related to MSP, (http://my.clevelandclinic.org).”
Social Work Role
“Munchausen syndrome by proxy (MSBP) is a controversial topic, but one of which
all social workers, child welfare professionals, and mental health practitioners should be
aware, (Rocha, 2004).” There continues to be a debate amongst the social work, medical,
legal, and law enforcement professions about what this term should encompass. According to
Rocha, “Munchausen syndrome by proxy is not a universally accepted term, (Rocha, 2004).”
The medical social worker plays an integral role in the diagnosis of Munchausen
Syndrome by Proxy. When attempting to diagnosis MSP, it is important for the treating
physician to have a complete social work assessment of the patient and the family, this
includes any documented mental illness in the parents or extended maternal or paternal
family.
The social worker will be the integral link in obtaining the necessary background
information, interviewing the parent(s), child if old enough, and any available family

6. Munchausen Syndrome - 6 -
members. “A detailed social history can be helpful in identifying dysfunctional family
dynamics, and involvement of a multidisciplinary treatment team can be instrumental in
further assessing the situation and initiating any necessary legal action, (Zylstra, R. et al
2000).” This history would include medical concerns as well as mental health concerns of
the parent as well as the patient. If the patient is old enough to answer questions, the social
worker would also meet with the child to obtain information about home and the medical
symptoms that the parent says they are presenting with.
During this time the social worker should be focusing on building a rapport with the
family, needing to form an alliance in order to garnish as much background information as
possible. The social worker will be especially interested in forming this alliance with the
presenting parent, as a way of assisting the medical team in confirming or ruling out a
possible diagnosis of Munchausen Syndrome by Proxy. The social worker is the member of
the team who will spend the most time with the family and help the overall family in
understanding what is happening.
“Cabot viewed social workers as translators of medical information to
patients and families in a way that they could understand. He said, ‘the
social worker…can reassure patients as to the kind of things that are
being done and are going to be done with them’, (Gehlert, S. and
Browne, T., 2006.)”
“Because of the difficulty in diagnosing and addressing this syndrome, a supportive
team approach taken by medical, psychiatric, nursing, and social work personnel is essential,
(Rocha, 2004).”
“Although multidisciplinary input can be very helpful in diagnosis and essential in
treatment, psychologists, social workers, and others are not in a position to make or confirm
this diagnosis, Stirling, 2007).” Only a treating physician or team of physicians can make a

7. Munchausen Syndrome - 7 -
diagnosis of Munchausen syndrome by proxy as it is first and foremost a medical diagnosis.
However, it would be the role of the social worker to coordinate meetings of the team of
doctors treating the child to discuss the case, the medical conditions being reported and in
most cases, even the possibility of Munchausen Syndrome by Proxy on the part of the parent.
The social worker would also be responsible for discharge planning after any hospital
admission as well as making the necessary referrals for community based follow-up. These
referrals could include but are not limited to: Child Protection Officials, Visiting Nurse,
Community Mental Health Clinic, and psychologists and psychiatrists in private practice.
“The medical social worker in cases where notification to the child protective services is
necessary, would serve as the liaison between the medical community and the child abuse
social workers and law enforcement officials, (Personal Communication, J.R. former Director
Psychiatric Emergency Screening Services, Ocean County, 2008).”
In some cases, the medical social worker, may even be involved in educating the
medical team about the seriousness of child protection from incidents of Munchausen
Syndrome by Proxy. “Complicating the process, hospital doctors and general practitioners
are notoriously difficult to engage in the child protection process, as they are untrusting of
social workers or the police in cases such as MSBP-type abuse (Horwarth, 1999), (Cullen,
www.uic.edu).”
Conclusion
Munchausen Syndrome by Proxy is a serious medical concern with roots in child
abuse. However, “to think of this solely as a form of child abuse would be to discount the
unique manner in which perpetrators use the medical profession to carry out at least some of
the abuse, (Rocha, 2004).” The medical social worker must be educated and familiar with the

8. Munchausen Syndrome - 8 -
signs and symptoms of Munchausen Syndrome by Proxy, especially when working with
families and young children in an effort assist the multidisciplinary medical team in making a
diagnosis when it becomes apparent that Munchausen Syndrome by Proxy exists. “Children
who are victims of MSBP can have lifelong physical and emotional problems and may have
Munchausen syndrome as adults. This is a disorder in which a person causes or reports his or
her own symptoms, (www.webmd.com).”
It is imperative that a medical social worker be assigned to work with the medical
team in reviewing all available information when arriving at a diagnosis of MSP. Although a
social worker should be assigned to the multidisciplinary team in reviewing suspicions of
Munchausen syndrome by proxy, a social worker by nature of their training is not qualified to
make such a diagnosis.
“Sadly, Munchausen syndrome by proxy can be extremely difficult to
detect, and even in cases where it is suspected, it can sometimes prove
nearly impossible to substantiate. As healthcare professionals, much of
what we treat, particularly in the pediatric setting, is based on the
reporting of symptoms. For children, the most reliable reporter of those
symptoms is usually thought to be the parents. Most physicians, nurses,
social workers, and other healthcare personnel charged with the care of
the sick children will balk at accusing a parent of deliberately causing
their child harm under potentially ambiguous circumstances. Often there
is nothing more than a nontraditional path followed by the parents of a
sick child or a gut feeling by a healthcare provider to suggest
Munchausen syndrome by proxy,” (Cauldwell, 2011).

9. Munchausen Syndrome - 9 -
References
Abdulhamid, I. Munchausen Syndrome by Proxy. Medscape Reference, March 2008
Cauldwell, K. Misdiagnosis of Munchausen Syndrome by Proxy: Disagreement or Disorder?
Associated Content 2000
Cullen, M. Munchausen Syndrome by Proxy. www.uic.edu.
Gault, A. What’s Behind Munchausen Syndrome by Proxy? www.qualityhealth.com
Gehlert, T. and Browne, T. Handbook of Health Social Work, John Wiley & Sons, Inc. 2006.
Munchausen Syndrome by Proxy, Cleveland Clinic, http://www.clevelandclinic.org
Rocha, D. The Phenomena of Phantom Illness: A Discussion of Munchausen Syndrome by
Proxy. Praxis. Vol. 4 p. 52-58. 2004.
Stirling Jr., John and the Committee on Child Abuse and Neglect, Pediatrics 2007; 119; 1026
DOI 10.1542/peds.2007-0563
Zylstra, R., Miller, K. and Stephens, W.: Munchausen Syndrome by Proxy: A Clinical
Vignette. Primary Care Companion J. Clin Psychiatry 2:2 April 2000.
Websites
www.wikipedia.com
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002522/
http://my.clevelandclinic.org