Munchausen syndrome by proxy (MSP) by Tariq Rehman

 Munchausen syndrome by proxy (MSP) by Tariq Rehman, an Educationist & Psychotherapist affiliated with Child Surgical Foundation.

 Munchausen syndrome is a psychological disorder where people seek out excessive medical attention, often going from city to city to get a new diagnosis and a new surgical procedure.

Aleem and Ajarim (1995) presented the case study of a 22-year-old female who had a painful swelling above her right breast. After many tests an infection was diagnosed and treatment began. Despite treatment, the infection got worse and spread to the left breast area. A nurse found needles and a syringe full of fecal material, which the girl had been injecting into herself. Munchausen syndrome was diagnosed.

 Munchausen syndrome by proxy (MSP) — or Munchausen by proxy — is a psychological but relatively rare disorder marked by attention-seeking behavior. MSP affects a primary caretaker, often the mother. The person with MSP gains attention by seeking medical help for exaggerated or made-up symptoms of a child in their care. As healthcare providers strive to identify what’s causing the child’s symptoms, the deliberate actions of the parent or caretaker can often make the symptoms worse.

The person with MSP does not seem to be motivated by a desire for any type of material gain. While healthcare providers are often unable to identify the specific cause of the child’s illness, they may not suspect the parent or caretaker of doing anything to harm the child. In fact, the caregiver often appears to be very loving and caring and extremely distraught over their child’s illness.

Here we describe a case pertaining to pseudo-bleeding from multiple sites.

A 15 months old boy suffering from acute exacerbation of asthma precipitated by lobar pneumonia was admitted to the P-ICU of Liaquat National Hospital (LNH). On the second day of admission, the child’s mother reported him bleeding from his mouth, nose, and ears. She drew the doctor’s attention by presenting blood-soaked cotton balls and showing the child’s blood-stained ears and nose. During the next 2 – 3 days of hospital stay, there were multiple episodes of bleeding from the child’s mouth, nose, and ears. The child’s physical examination was unremarkable and he was found to be conscious, active, alert, and hemodynamically stable after every bleeding episode. Laboratory investigation revealed normal blood counts, coagulation profile, and bleeding time.

During the hospital stay, it was noticed by a nurse that the mother was spreading blood over the baby’s nose, which was investigated by the on-call duty doctor. It was found that the mother had two sharp fresh cuts with oozing blood on her left ring finger. In addition to this, there were multiple sharp cuts on the mother’s little fingers of both hands of approximately 24 – 48 hours duration. The child was then separated from the mother, after which there was no further bleeding episode and the child was found to be very playful with his father. On inquiring, the mother totally denied doing any wrong with the child and told that these cuts had spontaneously appeared on her hand a long-time ago and stated that she was also suffering from having blood in tears. She was advised for psychological counselling which she refused.

During the case investigation, it was found that the mother is a known case of hepatitis C diagnosed 6 months back, and about a fortnight ago, the mother had incidentally discovered her husband’s second marriage which led to great emotional trauma to her. In order to draw her husband’s attention, she began to fabricate her child’s illness and in this process, she did not even hesitate to let her child undergo unnecessary, invasive procedures. The diagnosis of MSBP was put forward by a multi-disciplinary team as there was no underlying organic pathology in the bleeding patient.

Some authors classify such mothers into three groups; active inducers, help seekers, and doctor addicts.6 The mother in this case can be classified as a help seeker taking into consideration the trauma she faced on learning about the second marriage of her husband.

The exact cause of MSP is not known, but researchers are looking at the roles of biological and psychological factors in its development. Some theories suggest that a history of abuse or neglect as a child, or the early loss of a parent may be factors in its development. Some evidence suggests that major stress, such as marital problems, can trigger MSP.

Once the diagnosis is considered, it is crucial to take steps to protect not only the index patient but also siblings who may also be the recipients of this potentially life-threatening form of child abuse. The offending parents also need mental health care and psychological counseling.

Disclaimer: The following article is based on research and information published an article on https://www.jcpsp.pk/archive/2014/May2014/22.pdf While I have used their work as a reference the content presented here is my own editing of the topic discussed.