番茄社区

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, , said at the annual meeting of the .

Munchausen syndrome was 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 , 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 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 番茄社区 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.

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