Munchausen by proxy (MBP)

Munchhausen syndrome by proxy (MBP/MBPS) is a serious form of child abuse. The person with this syndrome (often a mother) appears loving and concerned, regularly seeks intensive medical help for a child, but is the one who consciously makes the child ill. This is done by administering substances, inflicting injuries or infections. Munchausen by proxy can take very serious forms: approximately 10% of children die from the consequences of MBP.

Name Munchhausen by proxy
Munchausen syndrome by proxy
Origin of Munchausen concept by proxy
Signals Munchausen by proxy
Munchausen by proxy: bodily signals
Munchausen by proxy: Behavioral signals
Explanation of Munchausen syndrome by proxy
Perpetrators Munchausen by proxy
Approach and treatment at Munchausen by proxy
Problems in contact with perpetrators
Notification as a measure at Munchausen by proxy
Caution is advised
Information Munchausen syndrome by proxy

Name Munchhausen by proxy

Munchausen syndrome by proxy is also called:

MBP syndrome
MBPS

(Note: Münchausen (with umlaut) is the official spelling; here it is written as Munchausen).

Munchausen syndrome by proxy

Munchausen syndrome by proxy is a very serious and hidden form of child abuse. This syndrome can take on devastating proportions: approximately 10 percent of children exposed to it die from its consequences. The caregiver of an often young child (usually the mother, sometimes family members or professional caregivers) regularly seeks intensive, drastic medical help. This is done on the basis of incorrect or incomplete information about complaints, by:

administration of substances by the caregiver to the minor so that he or she appears seriously ill
the intentional infliction of injury or infection by the caregiver for the same purpose

Origin of Munchausen concept by proxy

The syndrome is named after a famous German noble army officer: Baron Munchausen, who became famous for his unbelievable, (too) strong stories about his experiences in the Russian military service and went down in history as a fantasist.

Around 1950, the term Munchhausen Syndrome was used for an individual with the morbid desire to repeatedly undergo drastic treatments without medical necessity.

Later, in 1977, Money and Meadow (psychiatrists) added Munchausen syndrome by proxy, to indicate that instead of the patient himself, others or the environment feigns the complaints.

Proxy – in English – means intermediary or go-between, which is thus a reference to the morbid attention that the intermediary (the other) demands. The syndrome is also described as factitious disorder by proxy.

The DSM-IV (Diagnostic Statistic Manual: the handbook for psychological/psychatric diagnostic criteria) gives the following description of Munchausen by proxy under factitious disorder by proxy’, i.e.: ‘factitious disorder. In some publications, by proxy is described as ‘approximate’.

Signals Munchausen by proxy

Below we indicate how Munchausen syndrome by proxy can be recognized. The signals mentioned should be read with caution, as they are guiding indications and not yet ‘official diagnostic criteria’.

Munchausen by proxy: bodily signals

Likely physical signals

Constant or recurring complaints or diseases for which no explanation can be found and/or which are unusual or unusual
Experienced doctors cannot classify the complaints in question under an unambiguous clinical denominator and often speak of a unique disease
The results of anamnestic (history), laboratory and physical examination show a significant discrepancy with the child’s overall health status
The symptoms do not occur when the caregiver is absent, or the symptoms occur only when the caregiver is alone with the child and cannot be observed by anyone else.

Possible physical signals

Vague complaints that require repeated hospital admissions or doctor visits (so-called ‘doctor shopping’)
The presenting complaints repeatedly do not respond to the therapy or treatment initiated
Certain forms of treatment are not tolerated: e.g. the infusion does not remain in place, local rash or inflammation, repeated vomiting with oral medication, etc.
A family history of ‘Sudden Infant Death Syndrome’ (SIDS) under ‘suspicious’ circumstances or the occurrence of unexplained failure to thrive in one of the children
The child’s caregiver had suffered from the same complaint or condition for the past five years
The caregiver suffered or suffers from Munchhausen Syndrome.

Munchausen by proxy: Behavioral signals

Likely behavioral signals

Although doctors find the symptoms alarming, the caregiver does not appear to be at all concerned about the child’s condition
The doctor/patient care provider relationship often takes on a different character and is exchanged for a more personal, almost collegial or family relationship
The caregiver appears to be full of devotion and attention to the child and refuses to leave the child alone for even short periods of time
The caregiver continues to cling to the fact that the child is (seriously) ill (even if it has been declared cured) and resists discharge from the hospital
Caregivers who tell others that the child is ‘very seriously’ ill or is in danger of dying, while the care providers indicate that the child is not (seriously) ill.

Possible behavioral signals

The caregiver has medical or nursing training, aspires to do so or has never been able to successfully complete it
A manipulative and/or dominant attitude to gain control over the medical treatment or to determine it to a large extent
A caregiver who ‘welcomes’ major diagnostics and interventions, despite the fact that these are painful and burdensome for the child
An attitude of the caregiver that is aimed at (socially) isolating the child and the family
Information about previous medical treatments is difficult to obtain, because those involved do not give consent or because the information hardly yields anything essential
Caregivers who continue to speak for the child, while the child itself is addressed in a targeted and specific manner
Caregivers who speak about their own child’s illness as if it were their own condition
Intensive networking with action groups around the theme of Munchausen by proxy or with so-called ‘fellow sufferers’.

Explanation of Munchausen syndrome by proxy

From now on, the term ‘perpetrator’ will be used, where the term ‘carer’ was used above. In the literature the word ‘indicator’ is usually used instead of perpetrator.

The DSM IV places strong emphasis on the fact that the perpetrator tries to take on the role of a sick person as a kind of stand-in. This is a derivative of Munchausen syndrome, which concerns the individual himself. The addition by proxy indicates – as mentioned – that it concerns someone else. The perpetrator could therefore shift his problem to someone else, by making someone else ill instead of paying attention to his own illnesses or making himself sick.

It is difficult to give an overall picture of possible explanations, as some authors do not comment at all or others only speculate about the etiology. Below are a number of aspects that emerge from the literature, which could possibly provide an explanation.

Secondary gain MBP

The child’s illness can benefit the caregiver:

The behavior can act as a way of seeking attention from the caregiver to gain affection, recognition, and care. Munchausen by proxy then has a vicarious function, which, for example, combats feelings of loneliness and insufficiency
The self-induced complaints serve to reduce tension in the family. In many cases there appears to be marital and relationship problems. Caring for a ‘sick child’ then functions as a means to prevent the breakdown of the relationship or family
The behavior functions as a means to avoid responsibilities, such as caring for multiples

Stress as a (partial) cause of MBP

Sometimes the cause seems to lie in ineffective handling of tension or stress. This would then concern a sometimes very limited, but sometimes a relatively healthy, functioning caregiver.
Under the influence of stress as a result of a traumatic event, the personality can disintegrate, causing a loss of control over negative and aggressive impulses. This may be related to ‘psychotic filicide’ (filicide is infanticide), in which a caretaker, under the influence of delusions, abuses a child so that it dies.

Aggressive components MBP

The perpetrator’s behavior can sometimes also be seen as an expression of more or less unconscious feelings of aggressiveness. For example, a child can be punished by the mother out of feelings of revenge against the father. Due to lack of attention, competitiveness or (impending) divorce. In the literature, this form of spouse revenge is usually referred to as the Medeia complex. (Greek mythology: Medeia, a sorceress who fled with her lover, was abandoned by him and killed their shared children in revenge).
In some cases of stalking, Munchausen by proxy may play a role. Out of a combination of feelings of revenge towards a divorced partner and an (ultimate) attempt to commit the latter to them, women then cause serious complaints in their child.
Sometimes there also seems to be aggression towards medical science and/or doctors. This aggression is said to be in the sphere of competition and competence, due to the perpetrator’s failed (para)medical training. Through the child’s untreatable complaints, the perpetrator would then ‘demonstrate’ the ineffectiveness of the medical circuit to process their own traumas in this way.

Perpetrators Munchausen by proxy

One can still empathize somewhat with a desperate parent who, in pure anger, beats up his child with possibly (unintended) serious consequences (without approving this, by the way). It is much more difficult, if not impossible, when a mother deliberately, knowingly puts her young child in a life-threatening situation in order to get the attention of doctors or to take revenge on her partner or doctors. This unimaginable behavior of the perpetrators also hinders a clear view of their personalities. This probably has to do with the fact that little research has been done into the MBP syndrome from the forensic behavioral sciences.

Profile of MBP perpetrators

Most perpetrators suffer from serious personality problems with a clear narcissistic and/or borderline character (borderline is, in short: an image between neurosis and psychosis).
Sometimes they suffer from somatization disorder (converting psychological problems into physical ones)
For some, the problems only start during pregnancy. Pregnancy may play a role in the disintegration of people who already had a poorly integrated or unstable personality before pregnancy
According to other authors, there are no direct indications that the abuse is committed during a psychosis or a reduced level of consciousness.

Approach and treatment at Munchausen by proxy

Approach and treatment regarding Munchausen by proxy are complicated.

The diagnosis is complicated. The caregiver’s incorrect information is characterized by great detail, while the self-induced symptoms are very realistic. Various authors express great amazement at the dexterity, cunning and sometimes thorough medical knowledge that some perpetrators have to create syndromes with a high degree of reality.
In a number of cases, the child has become really ill by simulating a disorder (poisoning). There is a very good chance that the child is in real danger in these circumstances. The approach must therefore be tailored to this, even though there are various snags (see below).
It can be difficult to convince third parties (therapists, nurses, doctors) that this is a case of factitious disorder and serious child abuse. This is even more true if the perpetrator has managed to build a clear/good bond with them (which is often the case).
Problems may arise when initiating an approach or treatment process, especially if the perpetrator/caregiver reacts with denial and hostility, engages action groups and tries to publicly discredit the doctor/care provider involved on the basis of incorrect and incriminating information. to bring.

Problems in contact with perpetrators

A major problem in contact with Munchausen by proxy perpetrators is that they lie pathologically. They may persist in this even when shown video recordings of their own behavior
They often refuse permission to take a history and/or request information from other doctors and/or care providers
It is difficult to obtain a good or reliable anamnesis, as the perpetrators (besides the illness of their child) also incorrectly or distorted life events.
In contacts with perpetrators, manipulation, exaggeration, distortion, concealment and lying are often in the foreground, while at the same time the perpetrators subtly want to give the impression that they are loving caretakers. This often makes admission, medication or drastic treatment unavoidable
The immediate environment or even partners generally know nothing about this problem. Sometimes this seems to be related to the partner’s absence within the family (e.g. due to busy work or marital problems). It cannot be said with certainty whether this position of the partner is a risk factor for the occurrence of Munchausen by proxy or whether it is a consequence of it.

Approach and treatment concern the following areas:

Medical treatment of the child
Separation of caregiver and child, for example by hospitalization and the introduction of safety measures
Collecting as much information as possible about the family, the caregiver/offender and the child
An action plan with a determination by whom and how the perpetrator/guardian(s) will be informed in the event of a suspicion or possibly demonstrable Munchausen by proxy problem
An assessment of whether there is an indication for legal measures by Child Protection, such as (provisional) supervision or release from parental authority
View options for adequate care of the child, such as placement within a foster family, (semi) residential setting, outpatient care, etc.
Consideration of whether criminal proceedings are necessary or possible
Treatment options for the perpetrator, whether or not forced (criminally).

about treatment options for a Muncha use by proxy perpetrator, but some general aspects can be mentioned.

Treatment aspects of perpetrators of MBP

Treatment options appear to be very difficult if the perpetrator has serious psychiatric or personality problems
If there is an emerging insight on the part of the perpetrator and in case of Munchausen by proxy as a result of compulsiveness, the treatment options seem more favorable. Sometimes the perpetrators are happy that the problem is discovered and that they are stopped
When the child is discharged from a hospital, thorough action must be taken to not only advise but also indicate treatment or therapy for the perpetrator/caregiver(s), as the risk of recidivism is very high.

Therapy

The treatments or forms of therapy below are mentioned in various publications.

Long-term intensive psychotherapy, in which recognition of reality and the perpetrator’s experience of regret, remorse and remorse are given a central place. And also treatment of a probable depressive attitude, the processing of negative experiences in the past and often low self-esteem.
Psychotherapeutic treatment of the (older) child aimed at ‘recoding’ one’s own thoughts about illness and health, clarifying the role of the perpetrator/caregiver(s) and positive support.

Notification as a measure at Munchausen by proxy

If there are suspicions or indications of Munchausen by proxy, there are various options for reporting and measures. Such as an (anonymous) report to the Confidential Doctor Office, the Child Protection Council or the criminal justice circuit: Police, Public Prosecution Service.

The best option seems to be the Child Protection Council. While taking these steps, it remains difficult to demonstrate or prove Munchausen by proxy. This can also be a problem in legal proceedings or before the judge itself, as it concerns an perpetrator who apparently takes good care of a child, but at the same time abuses it. The above-mentioned aspects (such as little file and correct anamnesis data, etc.) also complicate this process.

Caution is advised

Suspicions or indications of Munchausen by proxy must be treated with caution, no matter how important it is to intervene if this syndrome is actually present. This is because of course not every concerned or overprotective (overhanging) parent has Munchausen by proxy. The risk is that a parent will be wrongly given this label. There are cases where (innocent) parents of a child with, for example, cot death were considered guilty/perpetrators. Abroad, this fact has already led to the establishment of the action group Mothers Against Munchausen Allegations – MAMA. It is important, if not necessary, to involve multiple disciplines and experts in the reporting process and taking concrete steps to this end.

Information Munchausen syndrome by proxy

The Medical Forensic Society (MFG) is a national multidisciplinary committee for information about and development of guidelines for dealing with Munchausen by proxy. This committee consists of physicians (pediatrician, child psychiatrist, confidential physician), members of the judiciary (children’s judge, public prosecutor), a judicial forensic psychologist, a representative of the Child Protection Councils and the police (members of the criminal investigation department and cri).

Child abuse signs