Munchausen by proxy

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

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Munchausen by proxy

  1. 1. Hurting for Love Page 1
  2. 2. Scenario.1 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. Page 2
  3. 3. Scenario.1 (Cont.) A couple of days later the mother returned to the emergency department again with complaint of blood in her daughters 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. Page 3
  4. 4. Scenario.1 (Cont.) 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 physicians rounds and purchased donuts for the entire staff. The results returned within normal limits. Page 4
  5. 5. Scenario.1 (Cont.) 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. Page 5
  6. 6. Scenario.2 Victim MA, a 9-month-old boy, was repeatedly admitted to Childrens 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. Page 6
  7. 7. Scenario.2 During the next 9 months, MA experienced(Cont.) 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 MAs mother witnessed the actual events. Two episodes occurred in the hospital. Unfortunately, despite many tests and surgical procedures, MAs apnea persisted, and his growth slowed. Page 7
  8. 8. Scenario.2 (Cont.) 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 mothers presence. If she left the room, however, he would eat Page 8
  9. 9. Scenario.2 (Cont.) 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 Page 9
  10. 10. The hospital immediately informed childScenario.2 protection services and police(Cont.) 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 FBIs Law Enforcement Bulletin Page 10
  11. 11. ". . . a victim of MunchausenA victim syndromeof MSBPMy whole life I was made to believe I wassick when I wasn‘t til I grew up . . ." --rapper Eminem, in "Cleaning Out My Closet" Page 11
  12. 12. Facts Women are most often the perpetrators of the syndrome, and its victims the womans own child http://www.shvoong.com/social-sciences/psychology/171074- Page 12
  13. 13. Facts (Cont.) 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 Page 13
  14. 14. Facts (Cont.) People with MSP often express extreme love and attentiveness towards their child http://www.shvoong.com/social-sciences/psychology/17107 Page 14
  15. 15. Extreme love Page 15
  16. 16. Facts (Cont.) 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-f Page 16
  17. 17. Facts (Cont.) 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 cant be easily detected. http://www.shvoong.com/social-sciences/psychology/171074-fbi- case-study-munchausen-syndrome/#ixzz1shIhDXVg Page 17
  18. 18. Facts (Cont.) 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. Page 18
  19. 19. Facts (Cont.) The mother maintains a dynamic relationship with the physician, as the whole disorder is centered upon her need for attention from the doctor. Page 19
  20. 20. Facts (Cont.) The disorder was named after an 18th- century German dignitary named Baron von Munchausen. Who was known for telling “outlandish stories,” Page 20
  21. 21. Facts (Cont.) Las fabulosas aventuras del Baron de Munchausen - YouTube.flv Page 21
  22. 22. Pediatric MunchausenSyndrome by Proxy(MSBP) Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital ,Sharjah, UAE saadsalani@aol.com Page 22
  23. 23. 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 . Page 23
  24. 24. 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. . Asher R. Munchausens syndrome. Lancet. Feb 10 1951;1(6):339-41. [2] Page 24
  25. 25. Criteria of MSBP include:Criteria 1.Intentional production of or feigning of physical or psychological symptoms in a person under ones 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 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV- TR. Washington, DC: American Psychiatric Association; 2000. Page 25
  26. 26. 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 Page 26
  27. 27. Subtypes (Cont.) 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 Page 27
  28. 28. Subtypes (Cont.) 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 Page 28
  29. 29. 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 . Warner JO, Hathaway MJ. Allergic form of Meadows syndrome (Munchausen by proxy). Arch [2] Dis Child. Feb 1984;59(2):151-6 . McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by [3] proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child. Jul 1996;75(1):57-61. Page 29
  30. 30. 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 Page 30
  31. 31. Presentation (cont.) • In 98% of cases, the perpetrator is the biological mother.[1] •Characteristics of perpetrators include: *Female *Experiencing marital discord *Having healthcare knowledge or training, *Friendly and cooperative with staff *Very attentive to the child *May have a history 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. . Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30 [2] Page 31
  32. 32. Presentation (cont.) •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 childs illnesses through dramatic measures. Page 32
  33. 33. Presentation (cont.) • These parents are typically anxious, depressed, or paranoid. •And finally, some may be "doctor addicts" who are obsessed with getting treatment for their childrens nonexistent illnesses . Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30. Page 33
  34. 34. 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 caretakers own blood or red-colored substances to simulate bleeding Page 34
  35. 35. 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 Page 35
  36. 36. 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. . Cyr AM. What is Munchausen syndrome by proxy. Nursing. 2007;37:30 [2] Page 36
  37. 37. Diagnosis •Tends to be difficult •The diagnosis of MSBP cannot be made quickly •Victims 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 Page 37
  38. 38. Note: 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, its often hard for doctors to spot the problem before its too late. http://health.howstuffworks.com/mental-health/mental-disorders Page 38
  39. 39. 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 Page 39
  40. 40. 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 Page 40
  41. 41. Questions to be asked?(Cont.) 4.During clinical assessment, is the childs medical status consistent with the mothers description? 5.Does objective diagnostic evidence support the childs reported medical condition? 6.Has any staff member, including the pediatrician, witnessed the symptoms? Page 41
  42. 42. Questions to be asked?(Cont.) 7. Do negative test findings reassure the mother? 8.Is treatment being provided to the child primarily because of the mothers persistent demands? Siegel PT, Fischer H. Munchausen by proxy syndrome: barriers to detection, confirmation, and intervention. Child Serv Soc Policy Res Pract. 2001;4:31-50. Page 42
  43. 43. Warning signs • Illness that is multisystemic, prolonged, unusual, or rare • Symptoms that are inappropriate or incongruent • Multiple allergies • Symptoms that disappear when caretaker is absent Page 43
  44. 44. Warning signs (Cont.) 5.One parent, usually the father, absent during the childs 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 Page 44
  45. 45. Warning signs (Cont.) 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. Mason J, Poirier M. Munchausen syndrome by proxy. eMedicine, 2007. http://www.emedicine.com/emerg/topic830.htm Page 45
  46. 46. 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]. Page 46
  47. 47. 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]. Page 47
  48. 48. Treatment •Difficult to treat because people who have these conditions are unwilling to admit they have a problem •Doctors have to investigate the patients medical history and perform medical tests to confirm that the problem is psychological and not than physical. Page 48
  49. 49. Treatment (cont.) • 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 Page 49
  50. 50. Prognosis •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. Page 50
  51. 51. Famous Cases Famous Cases Page 51
  52. 52. 1 William McIlhoy made it into "Guinness World Records," but he didnt have many fans at Britains 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 Page 52
  53. 53. All nine of Marybeth Tinnings children died between 1972 and 1985, most of them under 2 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 hadnt 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 dont ask questions."Crime Library]. Marybeth Tinning was convicted of murder in 1987 and was sentenced to 20 years in prison. Page 53
  54. 54. 3 When five of Waneta Hoyts 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 Hoyts 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 Page 54
  55. 55. 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. Page 55
  56. 56. Summary (Cont.) •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 childs. •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 Page 56
  57. 57. Summary (Cont.) •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 Page 57
  58. 58. Why? Page 58
  59. 59. Thank you Page 59

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