The Deceit Continues an Updated Literature Review of Munchausen Syndrome by Proxy

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Child Abuse & Neglect

Abstract

Objective: This article presents an updated review of the literature of Munchausen Syndrome by Proxy (Factitious Disorder by Proxy, MBP).

Method: Four hundred fifty-one cases of MBP were analyzed from 154 medical and psychosocial journal articles.

Results: Typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of MBP. Mothers were perpetrators in 76.5% of cases, but as knowledge of MBP grows a wider range of perpetrators is identified. In a small number of cases, MBP was found to co-exist with secondary gain or other inflicted injury.

Conclusion: Although published cases form a non-random sample, they add to knowledge about MBP and validate claims that it occurs. More knowledge about non-medical aspects of MBP, and more pooling of data, is desirable.

Résumé

Objectif: Cet article présente une mise à jour de la littérature sur le syndrome de Munchausen par procuration (désordre factice par procuration, DFP).

Méthode: Les auteurs ont analysé 451 cas du DFP tirés d'articles parus dans des revues médicales et psychosociales.

Résultats: Les victimes typiques appartiennent aux deux sexes et sont habituellement âgées de 4 ans ou moins. Du début des symptômes jusqu'au moment du diagnostic, il s'écoule en moyenne 21.8 mois. Parmi les victimes, 6% sont décédées et 7.3% ont souffert de blessures permanentes ou de longue durée. Vingt-cinq pour cent des frères et sœurs des victimes sont décédés et 61.3% de ce groupe souffrent de maladies semblables à celles des victimes ou bien ont été soupçonnés d'être victimes de DFP. Dans 76.5% des cas, les mères sont les auteurs, cependant, à mesure que nous en apprenons plus longuement sur ce syndrome, la gamme des auteurs s'élargit. Dans un petit nombre de cas, on a noté que le syndrome existe de pair avec des gains secondaires ou autres blessures.

Conclusions: Bien que les cas étudiés ne soient pas un échantillon aléatoire, ils nous informent néanmoins sur le syndrome de Munchausen par procuration et confirment nos soupçons à savoir son existence. Il serait bon d'en connaı̂tre plus long sur les aspects non médicaux du syndrome et d'avoir un plus vaste bassin de données.

Resumen

Objetivo: Este artı́culo presenta una revisión actualizada de la literatura sobre el Sı́ndrome de Munchausen por poderes (Trastorno Facticio por Poderes, TFP).

Método: Se analizaron 451 casos de TFP de 154 artı́culos de revistas médicas y psicosociales.

Resultados: Las vı́ctimas tı́picas pueden ser tanto varones como mujeres, habitualmente de 4 años de edad o menos. Se tardó una media de 21.8 meses entre la aparición de los sı́ntomas y el diagnóstico. El 6% de las vı́ctimas murieron y en el 7.3% se juzgó que habı́an sufrido un daño permanente o de largo plazo. Un 25% de los hermanos conocidos de las vı́ctimas habı́an muerto y un 61.3% de los hermanos tuvieron enfermedades similares a las de las vı́ctimas o que generaron sospechas de TFP. Las madres fueron las perpetradoras en el 76.5% de los casos, pero a medida que aumenta el conocimiento del TFP se van identificando un rango más amplio de perpetradores. En un pequeño grupo de casos, se observó que el TFP coexiste con ganancias secundarias u otro tipo de lesiones.

Conclusiones: A pesar de que los casos publicados forman una muestra no aleatoria, añaden conocimiento acerca del TFP y validan las consideraciones de que ocurre. Es deseable disponer de más conjuntos de datos y de más conocimiento acerca de aspectos no médicos del TFP.

Introduction

In 1987, Rosenberg published the first and, to date, only comprehensive journal article review of the literature of Munchausen Syndrome by Proxy (MBP). This review analyzed cases from medical journal articles, compiling demographic information about the victims and their symptoms. Information about perpetrators and victims' siblings was also included. Rosenberg cited 98 articles in her review, which yielded 117 cases.

Since 1987, many articles have been published about MBP. Many of these include case examples. Although published cases cannot be considered a statistically representative sample of MBP, in the aggregate they do represent the best knowledge currently available. The Stockholm conference sponsored by the National Institutes of Mental Health in 1998 provided an appropriate opportunity for a new review of the literature and compilation of cases. This has now been updated to include articles available through early 2000.

Rosenberg (1987) defined MBP as:

•: Illness in a child which is simulated (faked) and/or produced by a parent or someone who is in loco parentis;
•: Presentation of the child for medical assessment and care, usually persistently, often resulting in multiple medical procedures;
•: Denial of knowledge by the perpetrator as to the etiology of the child's illness [at least before the deception is discovered]; and
•: Acute symptoms and signs of the child abate when the child is separated from the perpetrator.

The definition specifically excludes physical abuse only, sexual abuse only, and nonorganic failure to thrive only (pp. 548–549).

Although there has been considerable discussion of definitions within the MBP community, especially as perpetrators' motive(s) affect criteria, this definition remains pertinent and clear. It also focuses on the child maltreatment behavior of MBP. Thus, in the opinion of this author, it is more useful for the study of maltreatment than the research category of Factitious Disorder by Proxy in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition: DSM IV (American Psychiatric Association, 1994).

Section snippets

Method

A comprehensive bibliography prepared for Levin and Sheridan's (1995) Munchausen Syndrome by Proxy was used as the starting point for case retrieval and review. This was supplemented by computerized searches of the health care and social science literature using the search terms "Munchausen Syndrome by Proxy" and "Factitious Disorder by Proxy" and the databases MedLine, Internet Grateful Med, CINAHL, and Psychlit. All journal articles that could be located and retrieved locally or via

Gender

Of the 415 children whose gender was indicated, 214 (52%) were males and 201 (48%) were females. Rosenberg found 46% males, 45% females, and 9% unidentified in her 117 cases, so these results are comparable, and suggest that there is no strong overall gender preponderance in MBP cases. However, in the specific case of the father as perpetrator (N=28), targets of abuse are more commonly boys than girls (21:7) (summarized in Table 3).

Race

Rosenberg did not consider this variable. Information on race

Conclusions

1.: With a greater number of cases in the literature, the professional community has become aware of more diverse presentations and situations. Although a review such as this yields interesting and valuable data, these cases constitute a non-random sample that reflects the interests of authors and editors. Thus we still cannot draw firm conclusions, for example on the many issues related to epidemiology. This is the next step in the study of MBP, and it is an important one.
2.: The majority of published

Acknowledgements

The author is grateful to the following for their help: Lydia Widyarta and the librarians at Meader Library, Hawaii Pacific University, for their assistance in obtaining the articles for review; Jeffrie Wagner for assistance with checking of data and with the bibliography.

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The Deceit Continues an Updated Literature Review of Munchausen Syndrome by Proxy