Munchausen Syndrome by Proxy: Integration of Classic and Contemporary Types

Deirdre Conway Rand^*

ABSTRACT: The current article elaborates on the concept that a contemporary manifestation of Munchausen syndrome by proxy (MSP) has emerged in which a parent or other adult caretaker fabricates or induces the idea that a child has been abused and presents the child to professionals as a victim (Rand, 1989).  The evolution of the diagnosis of MSP is described since its introduction into the literature by Meadow in 1977.  The three major roles in the MSP triangle of professional — mother/care taker — child are discussed, with emphasis on issues that may be problematic for the professional when sex abuse is alleged.  A list of warning signs is provided for both classic and contemporary-type MSP.  Evaluation procedures should include checking the details of the personal, social, and family history that the mother/caretaker has given and contacting other family members.  It is important to look for the motive for the behavior and, in the case of contemporary MSP, to uncover the context in which allegations were made.  When the disorder is treatable, case management, rather than traditional psychotherapy, appears to be the treatment of choice.
  

Recently, a contemporary manifestation of Munchausen syndrome by proxy (MSP) has emerged in which a parent or other adult caretaker fabricates or induces the idea that a child has been abused and then gains recognition from professionals as the protector of an abused child (Rand, 1989).  Munchausen syndrome by proxy is a specialized form of child abuse in which a physical or mental disorder of the child is either fabricated or induced by a parent or other adult caretaker.  Fabricated and induced symptoms in classical cases have led doctors to diagnose and treat children as suffering from a wide variety of medical conditions, including diabetes, epilepsy, nephritis, cystic fibrosis, recto-vesical fistula, ulcerative colitis, etc. in classical cases, the child or "proxy" often undergoes painful tests, unnecessary and/or harmful treatments and surgeries, as well as frequent and/or lengthy hospitalizations.  It is estimated that the child dies in ten to twenty-two percent of classical cases.
  

Evolution of Munchausen Syndrome by Proxy as a Diagnosis

Munchausen syndrome by proxy derives from adult Munchausen syndrome, which was first described in the literature in 1951 by Asher.  In adult Munchausen syndrome, the patient fabricates and/or induces his own symptoms and presents himself for treatment.  The description of Munchausen syndrome by proxy was first made in 1977, after British pediatrician Roy Meadow recognized that mothers of two children in his practice were engaging in dissimulations that put their children in the patient role, using the children as proxies.  Subsequently, Meadow has collected and presented a number of cases, noting from the outset that is was often the doctors who harmed the child most through their unnecessary tests and treatments.

Originally, Meadow observed the mother of the child as perpetrator and the child as a simple victim, stating in 1982 that only children up to age six were used as proxies because a child older than that would likely reveal the deception.  After two more years of study, however, he reported in 1984 that an older child could act as a confederate of the mother, with the two involved in a sort of folie â deux, a pattern that might be perpetuated even after the child reached adulthood.  Thus, Meadow began to describe the complex psychological nature of MSP.

Today, our understanding of the perpetrator role has expanded as well.  For example, MSP has been found to be practiced with children not the perpetrator's own (Elkind, 1983; United States vs. Woods, 1973).  Sigal, Carmel, AItmark, and Silfen (1988) described a male perpetrator abusing two female adults, while Sinanan and Haughton (1986) cited the bizarre case of a female perpetrator who manipulated nurses and their families into the proxy role, seeing to it that they received about 100 unnecessary injections, from which one of the nurses became very ill.

It wasn't until the 1980 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) that Munchausen syndrome was officially incorporated, classed under the generic name of factitious disorder.  In addition to production of factitious physical symptoms, factitious psychological symptoms were recognized.  Factitious psychological symptoms have been found to include factitious post-traumatic stress disorder, factitious psychosis, factitious depression, factitious rape, and factitious bereavement.

According to Sinanan and Haughton "the probable range of variations in the presentation of Munchausen syndrome is likely to develop in parallel with the evolution of medical and social services" (1986, p. 465).  Thus, it is to be expected that the proliferation of services available to sex abuse victims will be accompanied by a parallel increase in factitious "adult molested as child" presentations (factitious disorder with psychological symptoms) as well as factitious claims by an adult that a child has been molested (Munchausen syndrome by proxy, contemporary-type).

Goodwin (1982) was one of the first to write that Munchausen syndrome by proxy appeared to be operating in some sex abuse cases.  She described mothers who became obsessed with the idea that their young child had been molested, taking the child for repeated pelvic exams that the mother observed.  Libow and Schreier (1986) report a case consistent with this pattern.  According to Goodwin, some of these mothers repeated the pelvic exam again at home, perpetuating the abuse.  In a case reported by Wakefield and Underwager (1988), a divorced mother admitted to examining the children herself for sex abuse after visits with the father, as well as taking them for post-visit medical exams.  Eventually, she was suspected of using a tampax to dilate the youngest child's vaginal opening and produce "physical evidence" of the alleged abuse.

Schuman (1986) has suggested that Munchausen syndrome by proxy may be operating in some divorce-related false allegation cases.  Ferguson (1988) gives a fictionalized account of a true, post-divorce drama that was eventually diagnosed as Munchausen syndrome by proxy.  The two teenage children, living with their biological mother, began making sex allegations against relatives and were taken by their mother to several therapists in search of one who would confirm abuse.  The accusations became so numerous, however, that the court removed the children from the biological mother's home, an action that mother and children perceived as punishment.  The investigation that followed concluded that the biological mother had induced the idea of molestation through the use of formal brainwashing techniques.  The children were allowed to return home on the condition that the family receive therapy to learn healthier ways of relating, but instead they obtained further treatment for the original sex allegations.  Subsequently, these therapists left the agency and the mother and children sought treatment from new therapists for new allegations against relatives.  The fact that several sets of professionals were drawn into providing this inappropriate treatment demonstrates some the problems that professionals have with MSP.
  

MSP and Its Professional Participants

Meadow (1982) observed that the doctor's tendency to react in a stereotyped manner resulted in his doing the most harm to the child with his tests and treatments.  He attributed the doctor's reflexive reaction to the fear of missing an organic cause for a complaint.  Analogously, in the sex abuse arena, the stereotyped response of many professionals has been, "Children don't lie" and "Believe the child."  A quick and zealous reaction to suspected abuse reports is deemed necessary to prevent even the possibility of abuse.  However, premature commitment to the idea that abuse has occurred will make it difficult, if not impossible, to correctly diagnose MSP.

Zitelli, Seltman and Shannon (1987) go a step further and identify, "Physicians and legal and protective service agencies" (p. 1099) as unwitting participants in the MSP when they fail to recognize the MSP and treat the true disorder.  It is not surprising that professionals should find themselves in this position, for the mother or other adult caretaker in MSP is, by definition, manipulating and exploiting the professionals' response.  Goodwin makes a similar point in describing, "Nineteenth century cases in which fathers and physicians collaborated to devise inspections and punishments to prevent children from masturbating.  (This) probably represents another instance of the cooperation of the professional in the perpetration of sexual abuse" (p.164).

According to Meadow (1982) and others, it is common in classical MSP for the perpetrator to be in a medical or quasi-medical field.  In fact, the knowledge gained by being in the profession can help the perpetrator to fabricate or induce convincing symptoms.  It is only a matter of time before it is recognized that contemporary-type MSP may occasionally be perpetrated by some mental health professionals, social workers, and prosecutors who induce the idea that a child has been abused (Underwager & Wakefield, 1989).
  

Pathology of the MSP Perpetrator

Whether the MSP is classical or contemporary in its manifestation, the adult perpetrator gratifies his or her own needs at the expense of a child or other dependent/enmeshed individual.  Thus, it is not surprising that the DSM-III and the literature on Munchausen syndrome are clear on the presence of a severe underlying personality disorder.  Folks and Freeman (1985) observe that histrionic, schizotypal, borderline, antisocial, and masochistic personality disorders have all been observed to coexist in cases of Munchausen syndrome.  Spiro (1968) mentions several cases in which psychosis was present.  Psychotic features were identified in several reports of contemporary-type MSP as well (Ferguson, 1988; Goodwin, 1982; Wakefield & Underwager, 1988).  Mothers with MSP have also been noted, in some cases, to fabricate or induce symptoms in themselves, an expression of adult Munchausen syndrome.

Spiro and others suggest that production of factitious symptoms and the attention received thereby may actually help to stave off further psychotic decompensation.  If this effort is successful, the presence of psychosis may be difficult to detect, especially if the professional accepts the factitious symptoms at face value.  This is particularly true in contemporary-type MSP where the perpetrator's obsession with the idea that abuse has occurred may be impossible to disprove. Ravenscroft and Hochheiser (1980) have characterized the MSP parent's thinking as "quasi-delusional," hypothesizing that the parent may come to believe, at least intermittently, that the child's problem is real and not fabricated.

Certainly, in order for the mother to maintain the deception as the child grows older, it serves her purpose to make the child believe that he or she is ill, disabled, or abused, as the case might be.  Meadow (1985) notes the example of a 22-year-old confined to a wheelchair because he was brought up to believe he had spinal bifida and couldn't walk — medical examination showed his back and legs to be normal.  This manipulation of the child's belief seems to occur in contemporary-type MSP as well, where a non-abused child is induced, sometimes with the help of professional participants, to believe that he or she was abused.

The DSM-III states that in factitious disorder the production of symptoms is voluntary and conscious, but this fails to take into account the "quasi-delusional" aspect.  A mother who adds blood to the child's urine specimen or who tells a child directly to say that daddy did something sexual is clearly acting voluntarily, displaying anti-social features.  However, where the mother's underlying pathology is histrionic or psychotic, the distinction between conscious and unconscious fabrications may be blurred.

Despite the severe underlying pathology, in classical cases, the mother is often described as making a good impression on staff by being attentive to the child, helpful to staff and appreciative of their efforts.  In fact, Meadow (1985) stated that, as a rule, mothers appeared normal on psychological tests, with no disorder apparent to the psychiatrist.  He adds that the psychologist and psychiatrist often write that they do not believe the mother could be practicing the kinds of deception that have been discovered.  This suggests that interpretation of test results may have been biased by professional disbelief or lack of understanding of perpetrator dynamics.  Rosen et al. (1983) describe a case where the mother's MMPI fell within normal limits and her Rorschach and TAT also showed no signs of psychosis or of psychopathic tendencies.  However, a seemingly psychodynamic interpretation of the test data resulted in a diagnosis of narcissistic personality disorder, with the mother filling her sense of emptiness by adopting the role of a dedicated mother to children with rare, undiagnosed illnesses.  As understanding of MSP continues to evolve, perhaps practitioners will be better able to draw useful information from psychological tests and interviews.

It is often difficult for professionals to reconcile the incongruity between how caring the MSP mother may seem to be and what she is really doing, for example scratching the child's skin to induce a rash, overdosing the child on medications to make the child ill, or suffocating the child to induce seizures, etc.  Professionals may have further trouble accepting the fact that, if the adult caretaker in classical MSP can induce symptoms, then it is to be expected that this will occur in some contemporary-type MSP cases as well, like the divorced mother mentioned by Wakefield and Underwager and cited earlier.

The motivations for MSP appear to be varied.  While staving off of psychotic decompensation may be a factor in some cases, Meadow (1985) recommends looking for the individual reinforcers in each case such as increased social status, improved family relationships, direct or indirect financial benefit, to name only a few.  Sigal et al. (1988) remark on the acting out of sadistic impulses in MSP, while another commonly mentioned motivation is the attention the adult caretaker gains by presenting the child in the "sick" role, or, in contemporary-type MSP, the "victim" role.  Additionally, the adult's dependency needs may be met through the symbiotic bond with the child that is reinforced by the production of factitious symptoms.

In divorce, a powerful motivation for developing the idea that a child has been abused is to gain custody and to sever the child's emotional relationship with the other parent.  According to the definition of contemporary-type MSP offered here, these cases, described as Parental Alienation Syndrome by Gardner (1987), appear to be a sub-type of MSP.  Gardner's experience with severe cases of Parental Alienation Syndrome is that the underlying pathology of the falsely accusing parent (usually the mother but sometimes the father) is of a rigid, often paranoid type.  In order for professionals to recognize the pathology, however, they need to be able to differentiate between fabricated and genuine child abuse, best accomplished through a thorough evaluation that follows guidelines such as Gardner provides.

Munchausen syndrome by proxy in its extreme, classical form may appear to be a discrete entity, and probably is relatively rare, though most believe that it is less rare than previously thought.  But MSP can also be viewed on a continuum, which is what Nadelson (1979) does in going from the idea of imagining illness occasionally, to diseases that are totally imagined, and finally to disease that is totally induced or fabricated.  The DSM-III describes a continuum from single episodes or just a few mild episodes, on the one hand, to the production of serious symptoms as an ongoing way of life, on the other.  Libow and Schreier (1986) divide MSP into three types, with the least severe manifestation a "Cry for Help," while much more significant pathology is present in the "Active Inducer" and the "Doctor Addict."  Certainly the expansion of concepts relating to MSP suggests that it is not so much rare as it is still in the process of being detected and understood.
  

The Mother-Child Dyad

The boundary between mother and child is often blurred in MSP, as seen in the common occurrence of the mother "donating" her symptoms to the child (Meadow, 1982).  This may take the form of the mother borrowing from her medical history and asserting that the child has the same condition. Or the mother may actually reenact her symptoms through the child, as in the case reported by Feldman, Christopher, and Opheim (1989).  In this instance, a bulimic mother induced vomiting and failure to thrive in her infant through illicit doses of ipecac, apparently administered to make the child conform to her ideals of thinness.  Similarly, in contemporary-type MSP cases, the mother or other adult caretaker may give a history of herself as an abused or molested child.

The mother-child relationship in MSP is variously described as enmeshed, symbiotic, and mutually anxious and overprotective.  The mother relies on the child to meet her needs, and typical of the role reversal noted in other forms of child abuse, "The children in these cases in some way help their parents deal with their own psychological and medical concerns" (Waller, 1983, p. 82).  Ravenscroft and Hochheiser (1980) describe a mother who was distressed over her deteriorating marriage, and through her symbiotic bond with the child was able to express her sense of being "sick" by making the child sick.  Her own depression lifted as a result.

Once past infancy, the child may actually participate with the mother in the production of symptoms.  A very young child may do this by being aware of what the mother is doing but not volunteering that information to anyone.  According to Meadow (1982), not only is there more complicity between the child and the mother as the child gets older, but the deception may be initiated by either one, with the other helping to perpetuate it.

This highlights the need for more investigation into what aspects of the child's own personality (dependency needs, need for attention, manipulativeness) can predispose him/her to involvement in Munchausen syndrome by proxy.  Similarly, the relationship between the mother/caretaker and one child in a group of siblings may be a predisposing factor.  In some cases, only one child in the family is known to be a victim of MSP, while in others, several siblings are involved.  With respect to siblings, this author received the following anecdotal report after a presentation to colleagues on MSP: An adult in therapy gave a history suggesting that she had been victim of Munchausen syndrome by proxy until age six, at which time she refused to go along any further with the mother's deception.  The patient reported that her sister, however, continued, over a number of years, to participate with the mother in MSP fabrications.  In a different scenario, the interaction between siblings can promote the development and maintenance of factitious symptoms (Ferguson, 1988; Gardner, 1989).

There are two reports in the literature of what appear to be manifestations of Munchausen syndrome in a child, where the child is not acting in a proxy role, but independently.  Sneed and Bell (1976) report the case of a ten-year-old-boy who inserted small stones into his urethra to simulate passage of renal stones.  Goodwin, Cauthorne, and Rada (1980) report on three girls, ages nine and ten, each adopted, who exhibited the "Cinderella syndrome," in which they simulated neglect.  According to Goodwin et al. underlying the false allegations of abuse were histories that included early loss of a mother or mother figure, abuse in a previous placement, and emotional abuse in the adoptive home.  They emphasize the importance of not dismissing the child's fabrications as merely manipulative but rather understanding and addressing the real family problems of which such fabrications are a symptom.
  

Munchausen Syndrome by Proxy Warning Signs

The first list below gives classical MSP symptoms in bold face type (Jones et al., 1986), with contemporary-type extrapolations of these symptoms in italics.  This is followed by additional warning signs of contemporary-type MSP.

1. Persistent or recurrent illnesses for which a cause cannot be found; child continues to be presented in victim role through "add on" and newly "remembered" allegations or "add on" details.

2. Discrepancies between history and clinical findings; history given of abuse that should produce physical findings, e.g. repeated anal intercourse, yet medical exam negative; history includes episodes of abuse that are factually contradicted e.g. in underground tunnels that can't be found by police.

3. Symptoms and signs that do not occur when a child is away from the mother; child answers negatively about abuse away from mother/accuser.

4. Unusual symptoms, signs or hospital course that do not make clinical sense; abuse allegations that are bizarre or improbable; child appeared well-adjusted during the period that abuse was supposed to have occurred.

5. A differential diagnosis consisting of disorders less common than Munchausen syndrome by proxy; e.g. allegations of multiple family members involved in incest, including grandparents.

6. Persistent failure of a child to tolerate or respond to medical therapy without clear cause; child does not recover from abuse through therapy.

7. A parent less concerned than the physician, some times comforting the medical staff; child recites allegations in a rote manner or eager to tell story.

8. Repeated hospitalizations and vigorous medical evaluations of mother or child without definitive diagnoses; mother/accuser has child repeatedly evaluated for abuse and is dissatisfied with negative or equivocal results.

9. A parent who is constantly at the child's bedside, excessively praises the staff, becomes overly attached to the staff, or becomes highly involved in the care of other patients; symbiotic, enmeshed relationship between mother and child, e.g. mother insists on staying in room for child's therapy interview.

10. A parent who welcomes medical tests of her child, even when painful; mother/accuser seems to welcome repeated sexual assault exams and interrogations of child.

11. Frequent comparisons of the child's medical problems to those of the parents; mother/accuser gives a history of having been molested as child.
  

Additional warning signs of contemporary-type MSP may include:

1. The accusing adult seems to know more about what allegedly happened than does the child.

2. Either mother/accuser or child distorts the truth, manipulates information by omission, or fabrications of any kind, e.g. school, employment, medical, history.

3. The accuser is more interested in building a case than in helping child deal with abuse and moving on.

4. There is a united front between mother and child, especially when the child is inappropriately alienated from the other parent, who is the accused.

5. The accuser gives a history of herself having been molested as a child which is inconsistent with view of the family held by the majority of its members and with the family history as constructed by interviews with different family members.
  

Evaluation Procedures for Munchausen Syndrome by Proxy

Meadow (1985) offers guidelines for the evaluation of classical MSP that include:

1. Studying the history to decide which events are likely fabricated and which ones are real.

2. Looking at the temporal relationship between illness events and the presence of the mother.

3. Checking the details of the personal, social, and family history that the mother has given.

4. Making contact with other family members.

5. Looking for the motive for the behavior.

With respect to contemporary-type MSP, the evaluator must make as accurate a determination as possible as to whether or not a child has been abused.  A good resource is the Guidelines for the Clinical Evaluation of Child and Adolescent Sexual Abuse position statement of the American Academy of Child and Adolescent Psychiatry (1988).  The broader context in which the allegation was made must be determined and investigated.  The evaluator should insist on access to all persons and records that will enable the checking of the history given by the mother or other adult accuser.  In some instances, the person accused of abusing the child is a relative stranger and though it may be desirable to evaluate that individual, it may not be possible.  When abuse allegations occur in a divorce context, however, Gardner (1987) feels that a single evaluator should evaluate everyone, including the accused:

On a number of occasions I have been asked to see a child in order to ascertain whether or not he or she has been sexually abused.  Frequently I am told that I will not be permitted to interview the alleged perpetrator.  I will, however, be permitted to interview the accuser.  I have never accepted such an invitation. ... I cannot emphasize strongly enough that examiners who involve themselves in these cases should insist upon being given the freedom to see all concerned parties: the allegedly abused child, the adult accuser, and the alleged perpetrator.  In addition, it is crucial that the examiner have the opportunity to interview these parties individually and in any combination that is warranted.  To do otherwise is to conduct what can only be described as a seriously compromised, if not completely inadequate, evaluation (p. 107).

The evaluator must be clear about his or her role.  For example, the therapist turned evaluator and vice versa will blur objectivity.  By the same token, a professional who takes or makes a report of suspected abuse should not confuse that function with the role of evaluator.  The evaluator should be familiar with MSP and with other processes by which false accusations of child abuse come about, as well as with established guidelines for making determinations about the occurrence of abuse.  Obviously, an evaluation of the type required is often costly in terms of time and money, but short-cuts may result in harm to the child and innocent adults.

In criminal cases, where an adult is charged with child sexual abuse, there is often heavy reliance on statements made by the child, with information about the mother/child dyad, context of the allegation, and other historical material not permitted into evidence.  The argument is that an allegedly molested child should be treated like an adult rape victim.  An understanding of Munchausen syndrome by proxy should make it apparent that such an approach is ill advised.
  

Case Management is the Treatment of Choice

It is beyond the scope of this paper to provide a comprehensive review of treatment of Munchausen syndrome by proxy.  The titles of two major papers on the subject are informative, however, referring as they do to "obstacles to treatment" and "management of Munchausen syndrome by proxy" (Meadow, 1985; Waller, 1983;).  There seems to be agreement that once the diagnosis of MSP has been proven, the next step is to protect the child from the perpetrator's influence and to set limits on the perpetrator's behavior.  This may involve making the child a dependent of the court, placing the child with someone else, and/or designation by the court of a case manager to minimize the perpetrator's manipulations.  Wailer strongly recommends that the person who successfully diagnosed the MSP remain actively involved in the case.  Meadow discusses confronting the mother in mother/child cases, with pointers on how to do so therapeutically.

The approach taken in contemporary-type MSP will depend on the relationship between the parties, e.g. if the perpetrator is the child's mother and the alleged abuser is the child's father, or if the perpetrator is someone other than the mother and the alleged abuser is a relative stranger.  If it is a divorce situation and the MSP is severe, it may be appropriate to place the child with the accused (usually the father), according to guidelines set forth by Gardner (1989).  These would be cases where the father has been a good parent who has been significantly involved with the children.  In order to make this work, judicial support, supervision and enforcement is needed, with specific limitations on the mother's contact with the children.

At the most severe level, when sex abuse has been alleged, Gardner is of the opinion that a therapist who does not believe the mother's delusions will be seen by her as an ally of the former husband and thus no therapeutic alliance can be formed.  He further makes the point that ordering people into treatment is not likely to be productive.  In severe cases, therapy for the children while they are still living in the mother's home is often not possible, either.

Traditional individual psychotherapy has, by and large, been found to be ineffective in the treatment of MSP, although Meadow (1985) believes that a child psychiatrist may be a source of discussion and moral support to the pediatrician.  In theory, at least, enlightened therapy of less severe cases may be helpful if the mother is motivated, if she exhibits minimal anti-social tendencies, and the therapy is part of a holistic, well-supervised case plan monitored by the court or Child Protective Services.  If it is a divorce situation and therapy is indicated, there should probably be only one therapist, minimizing the MSP perpetrator's opportunities for manipulation.  The problem with "monitoring and supervision" is that the court system and caseworkers are often overloaded as it is, plus there may be frequent changes in personnel.  Thus, a program that depends on monitoring and supervision should only be attempted when these tasks can be conscientiously carried out.

Discussion of "treatment" tends to put the focus on the perpetrator, while the concept of case management provides caregivers with an alternative to being a professional participant in the syndrome.  When all is said and done, however, these families remain, as Meadow so simply and eloquently states, "exceedingly difficult and stressful to manage."

(Author's Note: I continue to be interested in learning more about other people's cases and invite people to contact me.)
  

References

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