From: logical23x@gmail.com   
      
   Medpage Today   
   Psychiatry > General Psychiatry   
      
   Munchausen by Proxy: A Case Study of Abuse   
      
      
   This patient saw doctors in five different states.   
       
      
       
   by Joyce Frieden, News Editor, MedPage Today   
   October 29, 2014   
   Action Points   
   CHICAGO -- If you do an extensive workup on a patient with a very attentive   
   parent and can't find anything wrong, Munchausen syndrome by proxy might be at   
   play, Archana Kathpal, MD, said at the annual meeting of the American Academy   
   of Psychiatry and the    
   Law.   
   Munchausen syndrome was first described by British physician Richard Asher in   
   The Lancet in 1951 as ""when someone invents or exaggerates medical symptoms,   
   sometimes engaging in self-harm, to gain attention or sympathy," Kathpal, a   
   psychiatry fellow at    
   Rutgers University in New Brunswick, N.J., and colleagues noted in a poster   
   presented on Saturday at the meeting. It was named after Baron von   
   Münchhausen, a German military officer known for telling very exaggerated   
   stories about his life and    
   adventures.   
      
   But it wasn't until several decades later, in 1977, that British pediatrician   
   Roy Meadow coined the term "Munchausen by proxy," describing it as "a   
   condition in which a parent or other caretaker persistently fabricates   
   symptoms on behalf of another,    
   causing that person to be regarded as ill," the researchers noted. He was also   
   the first one to consider it as a type of abuse.   
   In the U.S., the disorder is known not as Munchausen by proxy but as   
   "factitious disorder by proxy," the researchers noted. In the DSM-5, it is   
   termed "factitious disorder imposed on another."   
   According to the literature, boys and girls are equally victimized, and 77% to   
   90% of the time, the perpetrator is the patient's biological mother. In   
   addition, 29% of perpetrators have symptoms of Munchausen syndrome themselves.   
   The investigators described the case of a 14-year-old African-American girl   
   (some information has been changed to protect the patient's identity) who   
   presented with diarrhea, constipation, and generalized abdominal pain.   
   During her hospital stay, the patient, who became bedridden, received consults   
   from the neurology, rheumatology, infectious disease, hematology/oncology,   
   ophthalmology, and physical therapy/occupational therapy departments, as well   
   as a consult from a    
   pain specialist. All the results of an extensive diagnostic workup were   
   negative, the authors noted.   
      
   "At this point, a psychiatry team was brought in to see if there were any   
   psychiatric symptoms," Kathpal told MedPage Today in a phone interview. "All   
   the other medical teams felt that there may not be a medical cause -- that it   
   may be psychiatric," with    
   some team members suggesting conversion disorder as a possibility since the   
   patient had neurological symptoms.   
   "But the mother was reluctant to see any psychiatric services, and also was   
   not very cooperative with the other medical teams," she said. "Also, the   
   hospital legal team got involved and felt that there might be a case of   
   medical neglect" due to the    
   mother's reluctance to consider a psychiatric diagnosis. "They wanted the   
   patient transferred to an inpatient psychiatric unit."   
   At the same time, the medical team received outside information indicating   
   that the mother had taken her daughter to five different states over the last   
   few months with similar presentations.   
   "It was interesting that we thought it was conversion disorder, but once you   
   get collateral information, you realize this is something more than   
   conversion, and how the mother could have a part in child's symptomatology,"   
   Kathpal said.   
   In such cases, separating the parent from the child is one way to figure out   
   if Munchausen's by proxy is what's happening. "If [that] child starts   
   improving over the next few hours or days, that also shows symptoms were   
   intentionally or unintentionally    
   produced," poster co-author Tarun Kumar, MD, also a psychiatry fellow at   
   Rutgers, said in a phone interview. In this particular case that proved   
   impossible to do because "the mother was not leaving the child's bedside," he   
   added.   
      
   Eventually, the mother signed the patient out of the hospital against medical   
   advice. Hospital officials considered calling Child Protective Services, but   
   because the mother had lined up another team of providers -- a neurologist and   
   psychiatrist -- in    
   another state, there were no grounds to consider medical neglect, and no   
   further action was taken, the authors explained.   
   They highlighted several management strategies, including using a   
   multidisciplinary team approach involving the medical, psychiatry, social   
   services, administrative and legal teams. Also, because Munchausen’s by   
   proxy is often perpetrated serially in    
   siblings, it is crucial to screen all the children in the household for any   
   form of abuse, they noted.   
   If safety is an issue, the child should be removed from the perpetrator’s   
   custody, and the appropriate state agencies should be informed so they can   
   initiate a formal legal investigation, the researchers said. In addition, even   
   though the literature    
   shows that perpetrators do not respond well to psychotherapy, it has been   
   found to be very effective for the victims.   
   As for preventing these cases, the authors listed several ideas that have been   
   discussed in the medical community, but noted that some — such as installing   
   video cameras in hospital rooms where the disorder is suspected — are   
   fraught with potential    
   ethical and legal difficulties, “including exposure of the child to further   
   abuse and a breach of trust between carer, child, and the professional. Is it   
   justified just based on the doubts? Isn’t this intrusion of privacy without   
   consent? And what if    
   the case turns out to be negative; can the physicians and the hospital be   
   sued?”   
   Other prevention ideas that have been suggested in the literature include   
   developing an electronic registry of parents who perpetrate the disorder and   
   mandating schoolteachers to identify children with a significant number of   
   absences due to “unknown    
   reasons” and report that information to the child’s primary care   
   physician, the researchers said.   
   Primary Source   
   American Academy of Psychiatry and the Law   
   Source Reference: Kathpal A, et al "Munchausen syndrome by proxy: Medical and   
   legal complications" AAPL 2014.   
   Next: Risk Calculator Promising for Predicting Bipolar Disorder in Kids   
      
      
   https://www.medpagetoday.com/psychiatry/generalpsychiatry/48311   
      
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