Munchausen Syndrome by Proxy (MSBP) is the deliberate production or feigning

of physical or psychological symptoms in another person who is under that individual’s

care, or “disease forgery.” It is the most severe and chronic form of Factitious Disorders.

The motive for the perpetrator’s behavior is thought to be a psychological need to assume

the sick role by proxy – “through a substitute” and to accrue emotional satisfaction.

People with MSBP simulate the illness in the victim and then take the victim for medical

care denying any knowledge about the cause of the problem. A person with MSBP will:

exaggerate (deliberately embellish a genuine problem), fabricate (deliberately make up a

problem story or make it look as if a problem exists), or induce (deliberately cause a

problem to exist). External drives for the behaviors are not to achieve a concrete benefit

such as financial gain, and the behavior is not better accounted for by another mental

disorder. The caregiver is almost always a mother and her child is usually the victim,

however, cases have been reported of adult victims. Because children are victims,

Munchausen Syndrome by Proxy is considered to be a form of child abuse, which is a

criminal offense. MSBP is considered a form of maltreatment, rather than a mental

disorder.

A person with Munchausen Syndrome by Proxy commonly has knowledge in

health related areas and may thrive in a medical environment. People with MSBP have

an internal need for the victim to be seen as ill or injured, and may they suffer from

Munchausen Syndrome. The perpetrator may demonstrate pathological lying in

describing daily events when presenting the victim for medical care, and is usually very

good at fooling the doctors. They are willing to have their child or other patient undergo

painful or risky tests and operations in order to get the sympathy and special attention
given to those who are truly ill and their families (1995-2005). He or she always seems

devoted to the child, but is often unresponsive to the child when unaware of being

observed. The perpetrator is usually the mother, who, feels important and in control of

events when she gains respect, sympathy, and attention from health professionals and

those concerned about the child, including the spouse. Sometimes, the perpetrator may

be the father of husband and may collaborate with the mother or act alone.

The caregiver gains emotional fulfillment from the many hospitalizations that

help develop close relationships with the health professionals involved in her child’s care.

A person with MSBP also uses the victim’s illness as a way to earn praise from others for

her devotion to the child’s care and do not seem to perceive their behavior as harmful.

The caregiver may falsely claim a child has experienced a seizure, contaminate test

results, or physically harm the child, seeking the hero role when the child is cured. Some

perpetrators become angry with the health professionals and seek further medical care

from other providers. When confronted with the consequences of their behavior, the

person with MSBP may become depressed and suicidal. The perpetrator may receive

criminal charges ranging from abuse to murder.

Underneath this satisfaction of the caregiver, much hostility is shown toward the

victim. In Munchausen Syndrome by Proxy, a mother may abuse more than one of her

children at different times (2007). The victim is usually a preschool child, but older

children may be used as victims too. Older victims may be convinced that they really do

have an illness, and may collaborate with the perpetrator in deceiving health

professionals. Victims of MSBP may undergo needless and painful medical tests and

surgeries. Usually the caregiver focuses on one victim at a time who may become
seriously ill or injured, which may lead to death. As the victim matures, he or she may

develop Munchausen Syndrome or MSBP themselves when they learn to associate

getting attention to being sick.

Because so many cases go undetected and lack of reliable statistics, it is difficult

to say how common this disorder is. It is estimated that close to 1,000 of the 2.5 million

cases of child abuse reported annually are related to MSBP. The type and severity of

signs and symptoms of MSBP are limited only by the medical sophistication and

opportunities of the perpetrator (American Psychiatric Association, 2002). The most

common inflictions result in persistent vomiting, diarrhea, respiratory arrest, asthma,

central nervous system dysfunction, fever, infection, bleeding, failure to thrive,

hypoglycemia, electrolyte disturbances, and rash. The caregiver usually reports a

worsening of the child’s symptoms, which are not seen by a health professional, and the

child’s reported condition does not match the results of the diagnostic tests. The child

usually has a history of many hospital visits, and there may be more that one illness of

death of children in the same family. The victim’s condition seems to improve in the

hospital, but upon returning home, the conditions recur. The blood of the child may not

match the lab samples, and there may be traces of chemicals in his or her urine, stool, or

blood. The other parent is often absent and uninvolved in the care of the child. The

caregiver often switches doctors, providing each with wrong information about previous

testing and treatment. The parent usually is not satisfied with normal test results and is

calm or elated when the child’s condition is at its worst. The perpetrator may also make a

real effort to become close with the healthcare staff.

 The dishonesty of this disorder makes if very difficult to diagnose MSBP. Since

the perpetrator is very helpful in the hospital setting and appears to be devoted to her

child, it is very difficult for health professionals to diagnose this illness. If it is suspected,

doctors must make sure that the victim is not possibly experiencing any physical illness

as the cause of the child’s symptoms. To do this, doctors often use a variety of diagnostic

tests and procedures and all health professionals involved in the child’s care carefully

observe, document, and chart, all symptoms, laboratory test results, and the caregiver’s

behavior. This process helps to make sure that the diagnosis of MSBP is unanimous and

that there is no further need for testing. Diagnosis of MSBP leads to police intervention

and no further investigation is needed. Legal authorities then begin to develop a plan for

the caregiver as well as the victim.

Medical professionals don’t entirely understand what causes a caregiver to create

or falsify and illness in a child (2007). Researchers believe that both biological and

psychological factors play a role in the development of this disorder, although the exact

cause is not known. The caregiver receives attention from having a sick child, and

sometimes the wanted attention is a result of having an illness as a child, abuse or neglect

as a child, or the early loss of a parent. The perpetrator may have grown up feeling

unwanted or unloved, and has poor self-esteem as a result. The perpetrator may have also

grown up in a family where being sick was a way to get love. The abuser often is unable

to manage stress and want to feel in control as they never felt in childhood. As a child,

the caregiver may have experienced several hospitalizations themselves, but as an adult,

do not have the same support from friends and family as they did at an earlier age.
 Other theories say that Munchausen by Proxy Syndrome is a cry for help on the

part of the parent or caregiver, who may be experiencing anxiety or depression or have

feelings of inadequacy as a parent or caregiver of a young child (Gavin-Devitt, 2005).

Some parents may get attention from doctors, nurses, and others in their community in

which they feel they have achieved a social reward. Sometimes, a monetary award is

given to people whose children are sick, and they may receive meals and help with their

chores as well. Evidence suggests that life stressors, such as chronic family dysfunction

and marital problems may trigger an MSBP episode.

The first concern and highest priority for treatment of Munchausen Syndrome by

Proxy is to ensure the safety and protection of the victim. The victim, as well as other

children in the family, must be put in custody away from the perpetrator and is protected

by the care of another such as medical staff, protective service workers, or police. Once

the child is removed from the caregiver, it is expected that symptoms will stop, and the

child is assigned to an individual physician.

Treatment of the person with MSBP is often difficult because the person denies

that they have a problem. It is usually coordinated through the legal system, and the

success of the treatment depends on whether the person is willing to tell the truth or not.

They often resist treatment and experience extreme denial. MSBP has a high rate of

recurrence and the abuser requires continuous monitoring and counseling. Psychotherapy

is used to establish and maintain a relationship with the patient, as well as give the

perpetrator a chance to express her need for support. Family therapy focuses on helping

the caregiver develop empathy and understand the effect of her behavior on the victim.

Therapy is useful because it helps the perpetrator to develop relationships that aren’t
associated with being ill. Medication is not used unless MSBP is accompanied by

another diagnosed condition. Most of the time, Munchausen Syndrome by Proxy is

extremely difficult to treat, and requires extensive therapy and support.

American Psychiatric Association, (2002). Diagnostic and Statistical Manual of Mental

Disorders Text Revision. Washington D.C.: American Psychiatric Association.

Gavin-Devitt, L (March 2005). Munchausen by Proxy Syndrome. Retrieved March 9,

2008, from Kids Health Web site:

http://www.kidshealth.org/parent/general/sick/munchausen.html

(July 27, 2007). Munchausen Syndrome by Proxy. Retrieved March 9, 2008, from Web

MD Web site: http://www.webmd.com/mental-health/tc/munchausen-syndrome-

by-proxy-topic-overview

(1995-2005). Munchausen Syndrome by Proxy. Retrieved March 9, 2008, from The

Cleveland Clinic Health and Information Center Web site:

http://www.clevelandclinic.org/health/heatlh-

info/docs/2800/2822.asp?index=9834