Taking on the parent to save a child: Munchausen syndrome by proxy

DR. MALATACK is professor of pediatrics at Jefferson Medical College in Philadelphia, Pa., and director of the Diagnostic Referral Division at Alfred I duPont Hospital for Children, Wilmington, Del.

DRS. CONSOLINI and MANN are assistant professors of pediatrics at Jefferson Medical College and staff clinicians in the Diagnostic Referral Division at Alfred I duPont Hospital for Children.

DR RAAB is clinical instructor at Jefferson Medical College and a staff clinician in the Diagnostic Referral Division at Alfred I duPont Hospital for Children.

The term Munchausen syndrome was first used by Asher in 1951 to describe "patients who give dramatic but untruthful medical histories and feign signs in an apparent attempt to secure hospitalization and medical care."¹ In 1977, Meadow applied the term Munchausen syndrome by proxy (MSBP) to a troubling, newly recognized entity created by "parents who by falsification caused their children innumerable harmful hospital procedures."² Defining features of MSPB include:

Debate continues whether the two conditions-Munchausen syndrome and Munchausen syndrome by proxy-are bound only by nomenclature, or whether a psychodynamic kinship also exists. To recognize the latter syndrome, we must first take a close look at Munchausen syndrome.

Hallmarks of Munchausen syndrome

The most important characteristic of Munchausen syndrome is uncontrollable lying "in a manner intriguing to the listener." Scars-often caused by previous medical treatment-are explained with fantastic tales told with dramatic flair. The patient's description of the medical history is, however, often vague and inconsistent.

A second classic feature of Munchausen syndrome is medical wandering-evidenced by a long trail of hospital stays and treatment by other physicians. A third feature is the patient's medical sophistication. A fourth relates to the patient's behavior in the hospital-alternatively disruptive and excessively compliant. The patient often expresses anger at the physician's inability to make a diagnosis, even as he or she adjusts the signs, symptoms, and even system involved. Absence of visitors is another hallmark.

Asher described three common clinical presentations of Munchausen syndrome: acute abdomen, bleeding, and neurologic symptoms. Since Asher's description, however, hundreds of cases reported in the medical literature suggest that the clinical presentation is limited only by the perpetrator's medical sophistication.^3-5 In a typical case, the Munchausen syndrome patient presents to the emergency department (ED) during off-peak hours, when less experienced physicians are likely to be on duty. The medical condition that presumably led to the ED presentation is both dramatic and acute. The supporting history and past medical history, although vague, plausibly relate to the presenting signs and symptoms. The patient is admitted and typically undergoes a variety of diagnostic studies that rule out the initially considered diagnoses. During hospitalization, the patient varies or adjusts the signs and symptoms, which leads to further diagnostic studies. The patient typically leaves the hospital against medical advice just as the physician recognizes the factitious nature of the illness, but before the patient can be confronted. She (or he) is off to renew the charade at another medical institution.

Although the psychology of the Munchausen syndrome patient may provide some insight into the motivations of MSBP perpetrators, the former remains poorly understood, despite more than 50 years of research since Asher's description. For example, the hypothesis that the Munchausen syndrome patient's behavior is protection against disintegration and schizophrenia has been rejected.⁶ An alternative hypothesis-that the patient projects a parent who was ambivalent, unloving, or insensitive on to the physician so that the patient can at last gain attention and control of the parent/physician-is rarely supported by family history. More recent research suggests that Munchausen syndrome is a manifestation of borderline personality disorder. Our inability to understand the Munchausen syndrome patient's motivation arises, in part, from our inability to get these patients into-and to continue-psychotherapy.