munchausen syndrome: another point of view

+ MODEL

Pediatrics and Neonatology (2014) xx, 1e2

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http: / /www.pediatr -neonatol .com

REFLECTIONS: PEDIATRICS AND THE HUMANITIES

Munchausen Syndrome: Another Point ofView

Tzee-Chung Wu a,b

a Division of Gastroenterology, Hepatology, and Nutrition, Children’s Medical Center,Taipei Veterans General Hospital, Taipei, Taiwanb School of Medicine, National Yang-Ming University, Taipei, Taiwan

Received Oct 23, 2013; received in revised form Mar 14, 2014; accepted Mar 18, 2014

This was already the third upper gastroesophageal endos-copy we performed on the patient over the past year.Looking at the patient’s morbid expression and curled-upbody while she endured the pain caused by the procedure, Ihoped that we could finally find out what was going on torelieve her suffering. However, by day’s end, mild mucosalbreaks in the lower esophageal sphincter constituted theonly finding we could identify, and again we had failed tofind the cause of her symptoms.

Unlike most 13-year-old girls living a regular teenagelife, this girl had been dealing with medical admissions andinvasive medical procedures throughout her childhood. Shefirst came to my office because of severe abdominal pain 2years earlier. She described the pain as intermittent, per-iumbilical in location, and associated with vomiting andprogressive severity over the past few months. As a pedi-atric gastroenterologist, many diseases came to mind suchas reflux esophagitis, Helicobacter pylori gastroduodenitis,drug-induced gastritis, and superior mesenteric arterysyndrome, to name but a few. I tried to prove she had oneof those diseases, because those were the problems I couldsolve. Most results of the examinations and tests werewithin normal limits. Her pain would subside a few daysafter each admission. Nevertheless, she kept coming backevery month or two with the same complaints and waswilling to endure the many invasive and uncomfortablemedical procedures for more than 2 years.

I started to questionwhether her pain was of psychosocialorigin. I consulted an associate working as a pediatric

E-mail address: tcwu@vghtpe.gov.tw

Please cite this article in press as: Wu T-C, Munchausen Syndrome: Adx.doi.org/10.1016/j.pedneo.2014.03.003

http://dx.doi.org/10.1016/j.pedneo.2014.03.0031875-9572/Copyright ª 2014, Taiwan Pediatric Association. Published b

psychiatrist for assessment. After a fewpsychosocial therapysessions, he toldme her pain might be of psychosocial origin,but she still was not ready to reveal her true problems.

I tried to recall everything I knew about her. She lived inthe countryside with her parents and grandparents, hadseveral friends who occasionally came to visit during herhospital admissions, did well academically, and had parentswho cared about her. Her family was doing well financially.Her parents were both workers and her grandparents wereretired. Then something crept into my thoughts; I had onlymet her father a couple of times over the past years despiteher frequent hospital admissions. Although he did seemvery concerned about his daughter’s condition, it wasmostly her mother who accompanied her during her hos-pital stays. Her mother was a kind and unassuming womanwho took great care of her and they stood together like bestfriends. She cared very much about the physical well-beingof her daughter and seemed to be satisfied with my treat-ment despite her daughter’s recurrent abdominal pain ep-isodes and no clear diagnosis.

Just when I was about to give up, her symptoms ofabdominal pain dramatically improved. She began highschool in the city and moved to an apartment near herschool with her mother. They still visited my office, butmuch less frequently. They mostly came for the evaluationof minor symptoms and always thanked me for helpingthem. Being a confidant of hers for years, she finally toldme her secret but begged me not to tell her mother. Shestill felt abdominal pain occasionally and was really gettingbetter after seeing me, but that was not the main reasonfor all those hospital visits. The real reason was that herpaternal grandparents often mistreated her mother at

nother Point of View, Pediatrics and Neonatology (2014), http://

y Elsevier Taiwan LLC. All rights reserved.

2 T.-C. Wu

+ MODEL

home. She felt that she could help her mother escape thestressful environment by taking her along during thefrequent hospital admissions. At first, I was a little upsetafter hearing this. I had spent many hours over the past fewyears trying to come up with a plan to treat her complaints,only to be told that her condition was not serious. Ireconsidered: this was a girl who would do whatever ittook, even suffering from many invasive and uncomfortablemedical procedures only to make her mother happier. I wasstill convinced that her symptoms were real. I then realizedthat this was a case of Munchausen syndrome, not “by”proxy but “for” proxy instead. I had been too busy digginginto her medical complaints and forgot to step back andreally look at her as a whole person. Two years should havebeen more than enough time for a caring physician to sortout the pieces, but I had to wait for her disclosure to fully

Please cite this article in press as: Wu T-C, Munchausen Syndrome: Adx.doi.org/10.1016/j.pedneo.2014.03.003

understand the situation. I was grateful for the lesson shetaught me and was glad that I was able to provide assis-tance during her times of need.

Conflicts of interest

The author declares no conflicts of interest.

Acknowledgments

I thank Frank E. James, MD, and Po-Hon Chen, MD, forproviding valuable feedback in helping me shape mythoughts and preparing the manuscript.

nother Point of View, Pediatrics and Neonatology (2014), http://