For medical professionals only
"Mom, am I really sick?"
In November 2020, a special child was admitted to the Department of Pediatrics of Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology[1].
A 4-year-old and 4-month-old girl who was admitted to the hospital for "retrosternal pain and abdominal pain for 1 month, aggravated with multi-organ pain for 20 days", reported that "retrosternal acid reflux, pain, teeth, esophagus, abdomen and other parts have pain." At a young age, how can there be so much pain in so many parts? Could it be a rare disease?
The results of the examination are even more bizarre: there are no obvious abnormalities in the physical examination of the children admitted to the hospital, and almost all the relevant laboratory tests and imaging tests are not abnormal.
The doctor tracked the child's medical history in detail and found that the mother and daughter had several characteristics:
(1) By July 2021, the child's mother and the child have only been hospitalized 4 times in Tongji Hospital affiliated to Huazhong University of Science and Technology, with up to 177 outpatient visits, and even visited two outpatient doctors in one day, or repeatedly visited the hospital for several consecutive days, most of them chose the chief physician or deputy chief physician, and there were more repeated examinations.
(2) The mother of the child likes to check the relevant knowledge of the disease through the mobile phone, search for some medical terms, and use this to question the doctor's diagnosis or ask for further examination. Many times to the doctor to show the mobile phone a large number of "proof of the child's condition" photos, but the doctor observed the child, did not see obvious physical discomfort, no positive signs on the examination.
(3) Through the child's grandfather, I learned that the child's mother worked outside the home when she was young, and when she earned money, she went to the hospital to see herself, and after giving birth to the child, she took the child everywhere to see a doctor, and the family's persuasion was ineffective.
The final diagnosis was: Munchausen syndrome by proxy (MSBP). The case is the first case of MSBP in children in mainland China and was published in the Chinese Journal of Practical Pediatrics in February 2022.
It turned out that it was not the child who was sick, but the mother of the child!!!
Physical illness is false, mental illness is true
Some children will have the experience of pretending to be sick to attract the attention of their parents or avoid going to school, which is a normal phenomenon in the child's growth process and can be gradually improved through parental guidance and communication. When the child constantly reports his illness to the people around him, imitates the symptoms of the disease, or deliberately causes a physical disease or deliberately exaggerates or aggravates his or her own pre-existing disease, this psychology has developed into a pathological degree. In 1951, The Lancet named this "fraudulent disease" "Monjosen syndrome".
The perpetrator of MSBP does not harm himself, but targets the person being cared for, and triggers unnecessary medical diagnosis and treatment by falsifying symptoms and other means to meet his own pathological psychological needs of "caring for the patient", at which time the caregiver is an MSBP patient. The person being cared for is a victim, mostly a child, but also an adult or an animal, and when the object is a child, MSBP is also known as medical child abuse.
The American drama "The Act" (Chinese titled "Evil Deeds") depicts a girl named Gypsy trying to escape from her mother who suffers from MSBP, Gypsy "suffers" from asthma, mental retardation, chromosomal defects, epilepsy, leukemia and other diseases, while her mother Titi takes good care of her by her side.
Movie stills. Source: Douban
However, the truth is that all this is falsified by Titi, Gypsy was fed muscle relaxants, injections of anesthetics, etc. to create the illusion of disease, Titi also taught herself medical and nursing knowledge, inducing doctors to diagnose...
What the situation,
Should clinicians be on high alert for MSBP?
Children with MSBP present with a variety of symptoms, most commonly abdominal pain, vomiting, diarrhea, weight loss, seizures, apnea, infection, fever, bleeding, intoxication, drowsiness, and rash.
These symptoms can be reported by the child or by the parent, but are often fictional, exaggerated, or precipitated, such as the provision of a sample of vomit or stool that does not come from the victim; the child has only a small amount of bleeding, which the caregiver exaggerated into a large amount of bleeding; and the use of emetics, laxatives, etc. to induce real diarrhea or vomiting [5].
Clinicians should note whether the child's clinical manifestations have the following features and should be highly vigilant against MSBP if they contain:
(1) After adequate evaluation and treatment attempt by medical staff, the signs or symptoms remain unexplained, persistent, or ineffective for interventions that "should" be effective.
(2) There is a serious discrepancy between the medical history, clinical manifestations and the general manifestations of the patient.
(3) After a very rare disease is clearly diagnosed, the child's condition is more serious.
(4) Signs and symptoms that appear only on a person or on a schedule (e.g., weekly, monthly).
(5) Nursing staff who insist on carrying records with them without sufficient reason.
(6) Nursing staff with prior medical or nursing experience, extensive medical history or history of human disorders.
(7) Families with similar problems to the patient's illness, but can not be fully explained.
(8) Caregivers who habitually exaggerate the symptoms and signs associated with themselves or others, or associate them with impossible events.
Doctors can also pay more attention to children and their families, and studies have shown that children who have suffered abuse from MSBP mostly have the following characteristics:
(1) Usually begins early in the patient's life, infants and young children are the most commonly the population to become MSBPs. According to the Rosenberg study, the median age of the child at the time of diagnosis of MSBP was 39.8 months[2]; mcClure et al. reported a median age of 20 months for the victim at the time of diagnosis [3].
(2) Siblings in a family may suffer the same abuse as children who visit the doctor, and the abuse often comes from the same parents.
(3) The vast majority of children who abuse children are mothers [4].
(4) Boys and girls are often abused without gender differences.
The perpetrator may have the following typical characteristics [8]:
(1) Biological mother.
(2) Those who have had past contact and experience with the health care system.
(3) It seems that the victim is well cared for when observed, but in some cases the victim is less concerned with meeting their own needs.
(4) Inappropriate emotions when discussing the victim's problem.
(5) Impose a medical history of a possible anthropogenic disorder on yourself.
(6) The abuser may have prior knowledge of health care and is often fascinated by the medical field. (In one study, 80 percent of the recorded abusers were mothers, who worked or had worked in health care or childcare facilities.) ）
(7) In the face of the confusing illness that the victim is experiencing, the abuser often behaves unexpectedly calmly. She tends to insist on seeking additional diagnostic and treatment options, regardless of whether they will cause pain and discomfort to the victim, and almost always resists discharge orders and negative diagnostic results. If medical staff are suspicious or unwilling to continue the assessment, she may take the victim elsewhere.
(8) A large percentage of abusers themselves induce symptoms, or have done so in the past. (For example, the mother of the case, when she was young, kept seeing herself.) Severe mental illnesses, such as schizophrenia, are rare, but the presence of one or more personality disorders is common.
(9) Abusers may have a history of excessive attention-seeking, even from childhood. Family history may reveal various types of abuse, unusual diseases in multiple family members.
How is the disease diagnosed?
Diagnostic evaluation of MSBP must be based on specific investigations and findings. Laboratory tests, imaging, other tests, and multidisciplinary consultations are necessary. According to the Fifth Edition (DSM-5) of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders and the American Academy of Pediatrics, diagnostic criteria [6]:
(1) Fabricating physical or psychological signs or symptoms, or inducing injury or illness to another person, in connection with an identified act of deception.
(2) The individual shows the victim that he or she is sick, injured, or injured.
(3) Even without obvious external encouragement, deceptive behavior is obvious.
(4) This behavior cannot be better explained by another mental disorder, such as delusional disorder or another psychosis.
It is important to note that the diagnosis of the disease is sometimes difficult to detect and diagnose in a timely manner, as most pediatricians lack an understanding of the disease [7] and fail to take the disease into account in the differential diagnosis.
Sometimes doctors also have difficulty distinguishing between the anxiety of normal parents and the pathological anxiety of parents of children with this disease, and most of the parents of MSBP have certain medical knowledge, can provide a very convincing and convincing medical history, and even accompany fake information, making the diagnosis of this disease more difficult.
Relevant prognosis
▌For MSBP mothers, the prognosis depends on their characteristics[9]:
(1) Mothers with these characteristics who can understand, acknowledge, and take responsibility for their actions, who can improve coping skills, and who can put the victim's needs above themselves, may have a good prognosis.
(2) Mothers with personality disorders who show a high degree of denial, non-cooperation or non-compliance with treatment by medical staff may have a poor prognosis.
▌ Prognosis for abused children:
The differences in morbidity and mortality rates reported are wide, with victims sometimes being seriously injured or even dying. Children with MSBP will not only develop induced physical disorders, but also fabricated psychological symptoms. These children may have long-term emotional, psychological/behavioral, and educational disorders.
What is even more unfortunate is that because these children lack a good parental model when they are young, they may treat their children as if they were their parents, creating a vicious circle. Older children often endure parental abuse and even cooperate with them, self-abuse and make up their own illness.
brief summary
Clinicians, especially pediatricians, need to increase their understanding of the disease, not only need to pay attention to the child himself, but also need to pay attention to the child's caregiver, such as encountering multiple times with the child alone, the child's medical history and clinical symptoms are seriously inconsistent with the characteristics, should pay attention to the early experience of the child's caregiver, or through the child's other family members to understand the situation.
Patients with suspected MSBP should have a complete mental status, physical, and neurologic examination to assist in assessing, treating any problems that exist, and ruling out other disorders.
Diagnosis of the disease is relatively difficult because it is difficult for the average person to believe that parents would hurt their children in this way, and people who abuse in this way are described as loving and attentive people. Therefore, pediatricians should be reminded to increase their interaction with the child during the consultation, and then make a diagnosis cautiously.
bibliography:
Zhu Huijie,Liu Xinglou,Zou Biao. Et al. Chinese mainland first case of Surrogate Munchausen syndrome. Chinese Clinical Journal of Practical Pediatrics,2022,37(3):222-224.
[2] Rosenberg DA. Web of deceit: a literature review of Munchausen syndrome by proxy. Child Abuse Negl. 1987. 11(4):547-63.
[3] McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child. 1996 Jul. 75(1):57-61.
[4] Yates G, Bass C. The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) - A systematic review of 796 cases. Child Abuse Negl. 2017 Oct. 72:45-53.
[5] Carter KE, Izsak E, Marlow J. Munchausen syndrome by proxy caused by ipecac poisoning. Pediatr Emerg Care. 2006 Sep. 22(9):655-6.
[6] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. 324-326.
[7] Kaufman KL, Coury D, Pickrel E, McCleery J. Munchausen syndrome by proxy: a survey of professionals' knowledge. Child Abuse Negl. 1989. 13(1):141-7.
[8] Libow JA, Schreier HA. Three forms of factitious illness in children: when is it Munchausen syndrome by proxy?. Am J Orthopsychiatry. 1986 Oct. 56 (4):602-611.
[9] Sanders MJ, Bursch B. Psychological Treatment of Factitious Disorder Imposed on Another/Munchausen by Proxy Abuse. J Clin Psychol Med Settings. 2020 Mar. 27 (1):139-149.
This article was first published: Pediatrics Channel of the Medical Professions
Author: Zhang Guangcheng, Yuzu
Editor-in-Charge: CiCi
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