munchausen syndrome by proxy paper

Munchausen Syndrome - 1 -

Munchausen Syndrome by Proxy

The Role of a Medical Social Worker in the Diagnosis and Treatment ofMunchausen Syndrome by Proxy

David R. Julian, MSW, LSWRutgers University

August 2011Professor Carol Pepe


Abstract

This paper will be a historical view of Munchausen Syndrome by Proxy and the correlating role of the medical social worker in the diagnosis, and treatment of the patient and perpetrator. It is important to note that even though most often considered an incident of child abuse, Munchausen Syndrome by Proxy is first and foremost a medical concern and most often a psychiatric condition of the perpetrator.


History of the Disorder

Munchausen Syndrome by Proxy (MSP) has been classified as a factitious disorder of

mental illness. It is common for MSP to be referred to as Factitious illness by proxy. In

almost all cases, the parent presenting with the child and reporting the symptoms and concern

is the mother. “The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

(DSM-IV) refers to Munchausen syndrome as factitious disorder (300.19), and motivations for

this bizarre behavior continue to puzzle both medical and mental health professionals,

(Stirling, 2007).” Unfortunately, MSP is not a new phenomenon or condition. “In 1951, Dr.

Richard Asher originally used the term Munchausen Syndrome to describe adults who

fabricated illnesses to get medical attention, with no secondary gain except to adopt the role

of illness through unnecessary medical procedures and treatments, (Abdulhamid, 2008).”

Munchausen Syndrome has been used in reference to Baron von Munchhausen who

was widely known for factious tales relating to his travels. Interestingly though, a literature

review reveals no mention of Baron von Munchhausen ever fabricating an illness.

“According to the stories, as retold by others, the Baron’s astounding feats included riding

cannonballs, travelling to the moon, and escaping from a swamp by pulling himself up by his

own hair, (www.wikipedia.com).”

In instances of Munchausen Syndrome by Proxy, the apparent medical symptoms are

projected onto a dependent child as the parent fabricates signs and symptoms of often

nonexistent illnesses. Munchausen Syndrome by proxy was first described in 1977 by Roy

Meadow.

“In 1977, Roy Meadow coined the term Munchausen Syndrome by proxy to describe 2 mothers who fabricated, lied, and induced symptoms in their 2 children. One of the children had a history of


prolonged and recurrent passing of purulent bloody urine, and the other had a history of recurrent hypernatremia, (Abdulhamid, 2008).”

The actual cause of MSP remains unknown to this day. “Although not precisely

known, incidence and prevalence of Munchausen syndrome by proxy are almost certainly

more common than once estimated, (Abdulhamid, 2008).”

Medical Concerns

Although often considered a form of severe child abuse, Munchausen Syndrome by

proxy presents by caregivers either fabricating or actually causing medical conditions for their

young child. In most cases of MSP, the child is preschool age and is not able to report nor

confirm or deny symptoms themselves. These concerns can often times be falsified,

imagined or in extreme cases be intentionally inflicted upon the child on the part of the

caregiver. Unfortunately, there is no typical presentation for the condition of Munchausen

Syndrome by Proxy. “Conditions faked by parents or caregivers include: failure to thrive,

allergies, asthma, vomiting, diarrhea, seizures, and infections, (Gault,

www.qualityhealth.com).”

“Munchausen syndrome by proxy refers to a pattern of behaviors in which a parent

fabricates an illness in his or her child, either by lying about symptoms the child is

experiencing or physically inducing the symptoms, (Rocha, 2004).”

Because of the complexity of the disorder, and the amount of time and documentation

necessary to make a diagnosis of Munchausen Syndrome by Proxy, often times MSP goes

undiagnosed and unreported. In many cases, since the parent is familiar with the medical

community she is even seen as helpful and well liked by the medical staff she interacts with.

“The parent is usually very helpful in the hospital setting and is often appreciated by the nursing staff for the care she gives her child. She is often


seen as devoted and self-sacrificing, which can make medical professionals unlikely to suspect the diagnosis of Munchausen syndrome by proxy, (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002522/, 2011).”

In fact, in some situations the medical community is even fearful of making a

diagnosis of Munchausen Syndrome by Proxy. They either fear the parent and how they will

react, or they fear damaging their reputation for having been fooled into thinking a patient

was sick and ordering tests and medications when in fact, there was nothing wrong with the

patient.

“There are no reliable statistics regarding the number of people in the United States who suffer from MSP, and it is difficult to assess how common the disorder is because many cases go undetected. However, estimates suggest that about 1,000 of the 2.5 million cases of child abuse reported annually are related to MSP, (http://my.clevelandclinic.org).”

Social Work Role

“Munchausen syndrome by proxy (MSBP) is a controversial topic, but one of which

all social workers, child welfare professionals, and mental health practitioners should be

aware, (Rocha, 2004).” There continues to be a debate amongst the social work, medical,

legal, and law enforcement professions about what this term should encompass. According to

Rocha, “Munchausen syndrome by proxy is not a universally accepted term, (Rocha, 2004).”

The medical social worker plays an integral role in the diagnosis of Munchausen

Syndrome by Proxy. When attempting to diagnosis MSP, it is important for the treating

physician to have a complete social work assessment of the patient and the family, this

includes any documented mental illness in the parents or extended maternal or paternal

family.

The social worker will be the integral link in obtaining the necessary background

information, interviewing the parent(s), child if old enough, and any available family


members. “A detailed social history can be helpful in identifying dysfunctional family

dynamics, and involvement of a multidisciplinary treatment team can be instrumental in

further assessing the situation and initiating any necessary legal action, (Zylstra, R. et al

2000).” This history would include medical concerns as well as mental health concerns of

the parent as well as the patient. If the patient is old enough to answer questions, the social

worker would also meet with the child to obtain information about home and the medical

symptoms that the parent says they are presenting with.

During this time the social worker should be focusing on building a rapport with the

family, needing to form an alliance in order to garnish as much background information as

possible. The social worker will be especially interested in forming this alliance with the

presenting parent, as a way of assisting the medical team in confirming or ruling out a

possible diagnosis of Munchausen Syndrome by Proxy. The social worker is the member of

the team who will spend the most time with the family and help the overall family in

understanding what is happening.

“Cabot viewed social workers as translators of medical information to patients and families in a way that they could understand. He said, ‘the social worker…can reassure patients as to the kind of things that are being done and are going to be done with them’, (Gehlert, S. and Browne, T., 2006.)”

“Because of the difficulty in diagnosing and addressing this syndrome, a supportive

team approach taken by medical, psychiatric, nursing, and social work personnel is essential,

(Rocha, 2004).”

“Although multidisciplinary input can be very helpful in diagnosis and essential in

treatment, psychologists, social workers, and others are not in a position to make or confirm

this diagnosis, Stirling, 2007).” Only a treating physician or team of physicians can make a


diagnosis of Munchausen syndrome by proxy as it is first and foremost a medical diagnosis.

However, it would be the role of the social worker to coordinate meetings of the team of

doctors treating the child to discuss the case, the medical conditions being reported and in

most cases, even the possibility of Munchausen Syndrome by Proxy on the part of the parent.

The social worker would also be responsible for discharge planning after any hospital

admission as well as making the necessary referrals for community based follow-up. These

referrals could include but are not limited to: Child Protection Officials, Visiting Nurse,

Community Mental Health Clinic, and psychologists and psychiatrists in private practice.

“The medical social worker in cases where notification to the child protective services is

necessary, would serve as the liaison between the medical community and the child abuse

social workers and law enforcement officials, (Personal Communication, J.R. former Director

Psychiatric Emergency Screening Services, Ocean County, 2008).”

In some cases, the medical social worker, may even be involved in educating the

medical team about the seriousness of child protection from incidents of Munchausen

Syndrome by Proxy. “Complicating the process, hospital doctors and general practitioners

are notoriously difficult to engage in the child protection process, as they are untrusting of

social workers or the police in cases such as MSBP-type abuse (Horwarth, 1999), (Cullen,

www.uic.edu).”

Conclusion

Munchausen Syndrome by Proxy is a serious medical concern with roots in child

abuse. However, “to think of this solely as a form of child abuse would be to discount the

unique manner in which perpetrators use the medical profession to carry out at least some of

the abuse, (Rocha, 2004).” The medical social worker must be educated and familiar with the


signs and symptoms of Munchausen Syndrome by Proxy, especially when working with

families and young children in an effort assist the multidisciplinary medical team in making a

diagnosis when it becomes apparent that Munchausen Syndrome by Proxy exists. “Children

who are victims of MSBP can have lifelong physical and emotional problems and may have

Munchausen syndrome as adults. This is a disorder in which a person causes or reports his or

her own symptoms, (www.webmd.com).”

It is imperative that a medical social worker be assigned to work with the medical

team in reviewing all available information when arriving at a diagnosis of MSP. Although a

social worker should be assigned to the multidisciplinary team in reviewing suspicions of

Munchausen syndrome by proxy, a social worker by nature of their training is not qualified to

make such a diagnosis.

“Sadly, Munchausen syndrome by proxy can be extremely difficult to detect, and even in cases where it is suspected, it can sometimes prove nearly impossible to substantiate. As healthcare professionals, much of what we treat, particularly in the pediatric setting, is based on the reporting of symptoms. For children, the most reliable reporter of those symptoms is usually thought to be the parents. Most physicians, nurses, social workers, and other healthcare personnel charged with the care of the sick children will balk at accusing a parent of deliberately causing their child harm under potentially ambiguous circumstances. Often there is nothing more than a nontraditional path followed by the parents of a sick child or a gut feeling by a healthcare provider to suggest Munchausen syndrome by proxy,” (Cauldwell, 2011).


References

Abdulhamid, I. Munchausen Syndrome by Proxy. Medscape Reference, March 2008

Cauldwell, K. Misdiagnosis of Munchausen Syndrome by Proxy: Disagreement or Disorder? Associated Content 2000

Cullen, M. Munchausen Syndrome by Proxy. www.uic.edu.

Gault, A. What’s Behind Munchausen Syndrome by Proxy? www.qualityhealth.com

Gehlert, T. and Browne, T. Handbook of Health Social Work, John Wiley & Sons, Inc. 2006.

Munchausen Syndrome by Proxy, Cleveland Clinic, http://www.clevelandclinic.org

Rocha, D. The Phenomena of Phantom Illness: A Discussion of Munchausen Syndrome by Proxy. Praxis. Vol. 4 p. 52-58. 2004.

Stirling Jr., John and the Committee on Child Abuse and Neglect, Pediatrics 2007; 119; 1026 DOI 10.1542/peds.2007-0563

Zylstra, R., Miller, K. and Stephens, W.: Munchausen Syndrome by Proxy: A Clinical Vignette. Primary Care Companion J. Clin Psychiatry 2:2 April 2000.

Websites

www.wikipedia.com

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002522/

http://my.clevelandclinic.org

munchausen syndrome by proxy paper

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