Munchausen syndrome and Munchausen syndrome by proxy: a narrative review / Síndrome de Munchausen e síndrome de Munchausen por procuração: uma revisão narrativa

ABSTRACT The Munchausen syndrome and Munchausen syndrome by proxy are factitious disorders characterized by fabrication or induction of signs or symptoms of a disease, as well as alteration of laboratory tests. People with this syndrome pretend that they are sick and tend to seek treatment, without secondary gains, at different care facilities. Both syndromes are well-recognized conditions described in the literature since 1951. They are frequently observed by health teams in clinics, hospital wards and emergency rooms. We performed a narrative, nonsystematic review of the literature, including case reports, case series, and review articles indexed in MEDLINE/PubMed from 1951 to 2015. Each study was reviewed by two psychiatry specialists, who selected, by consensus, the studies to be included in the review. Although Munchausen syndrome was first described more than 60 years ago, most of studies in the literature about it are case reports and literature reviews. Literature lacks more consistent studies about this syndrome epidemiology, therapeutic management and prognosis. Undoubtedly, these conditions generate high costs and unnecessary procedures in health care facilities, and their underdiagnose might be for lack of health professional's knowledge about them, and to the high incidence of countertransference to these patients and to others, who are exposed to high morbidity and mortality, is due to symptoms imposed on self or on others.

RESUMO A síndrome de Munchausen e a síndrome de Munchausen por procuração são condições caracterizadas pela invenção ou pela produção intencional de sinais ou sintomas de doenças, bem como alterações de exames laboratoriais. Indivíduos com esta síndrome fingem que estão doentes e tendem a procurar tratamento, sem ganho secundário, em diferentes serviços de saúde. Ambas as síndromes são condições bem descritas na literatura desde 1951. Elas são frequentemente observadas pelas equipes de saúde em clínicas, enfermarias hospitalares e prontos-socorros. Conduziu-se revisão narrativa, não sistemática da literatura, incluindo relatos de caso, séries de relatos de caso, artigos de revisão indexados no MEDLINE/PubMed de 1951 a 2015. Cada estudo foi revisado por dois especialistas em psiquiatria que, por meio de consenso, escolheram quais estudos seriam incluídos nesta revisão. Apesar da síndrome de Munchausen ter sido descrita pela primeira vez há mais de 60 anos, a maioria dos estudos conduzidos sobre esta condição são relatos de caso e revisões da literatura. A literatura é carente de estudos mais consistentes sobre epidemiologia, manejo terapêutico e prognóstico da síndrome. Sem dúvida, tais condições geram altos custos e procedimentos desnecessários nos serviços de saúde. Seu subdiagnóstico pode se dar pela falta de conhecimento das síndromes por parte dos profissionais de saúde, e à alta incidência de contratransferência aos pacientes e a outros que são expostos à alta morbidade e à mortalidade é justificada pelos sintomas impostos em si mesmo ou em terceiros.

Munchausen syndrome and Munchausen syndrome by proxy: a narrative review.

The Munchausen syndrome and Munchausen syndrome by proxy are factitious disorders characterized by fabrication or induction of signs or symptoms of a disease, as well as alteration of laboratory tests. People with this syndrome pretend that they are sick and tend to seek treatment, without secondary gains, at different care facilities. Both syndromes are well-recognized conditions described in the literature since 1951. They are frequently observed by health teams in clinics, hospital wards and emergency rooms. We performed a narrative, nonsystematic review of the literature, including case reports, case series, and review articles indexed in MEDLINE/PubMed from 1951 to 2015. Each study was reviewed by two psychiatry specialists, who selected, by consensus, the studies to be included in the review. Although Munchausen syndrome was first described more than 60 years ago, most of studies in the literature about it are case reports and literature reviews. Literature lacks more consistent studies about this syndrome epidemiology, therapeutic management and prognosis. Undoubtedly, these conditions generate high costs and unnecessary procedures in health care facilities, and their underdiagnose might be for lack of health professional's knowledge about them, and to the high incidence of countertransference to these patients and to others, who are exposed to high morbidity and mortality, is due to symptoms imposed on self or on others.

Attempted Serial Neonaticides: Case Report and a Brief Review of the Literature.

Neonaticide is an infant murder occurring on the day of birth. The case reports found in the literature are often focused on the mother as the agent in the context of pregnancy denial, dissociative symptoms, or psychosis. However, this report describes a rare case of attempted serial neonaticides, in which the acts were committed by a nurse at the nursery of a referral hospital in Brazil. The authors describe a forensic psychiatric evaluation for criminal responsibility and correlate the information from this particular case with relevant forensic themes, namely neonaticide, Munchausen by proxy syndrome, and serial healthcare killers.

Munchausen syndrome by proxy in Mexican children: medical, social, psychological and legal aspects.

INTRODUCTION: The Munchausen Syndrome by Proxy (MSP), is considered as an unusual less frequent variety of child abuse (CA). In this type of abuse the perpetrators purposely provide factitious information, tamper with specimens or actually induce an illness in a child. Nowadays, it is a clinical entity described in pediatrics as more frequently than before. Despite the fact of its presence worldwide, there are still problems in order to get an appropriate diagnostic. It is also difficult to handle both the clinical and legal aspects in various countries. OBJECTIVE: Make our academic fellows aware of various pediatric, psychological, social and legal aspects of a series of cases attended at the Clínica de Atención Integral al Niño Maltratado from Instituto Nacional de Pediatría (CAINM-INP), Mexico [Integral Clinic of Attention for Abused Children, at National Institute of Pediatrics, Mexico]. MATERIAL AND METHODS: From a series of 25 cases, 18 minors of age were considered with this syndrome since we found that they shared medical, psychological, social and legal characteristics. RESULTS: 18 minors of age belonged to 14 families. 4 of those families had two affected children each one. These affected children were girls 13/18, predominant in children under six years in 10/18. Syndrome expression was distributed as follows: fever from a non determined origin, seizures, chronic diarrhea, hematuria, and probable sexual abuse. 14 children were hospitalized. In all cases, the aggressor was the mother. The psychological evaluation of six perpetrators revealed psychotic, histrionic, and compulsive-obsessive traits. The socio-economic condition was low in 50% of the cases. A legal demand was posed for seven patients in which all the children remained under the custody of the mother. CONCLUSIONS: In Mexico, reports of CA have increased within the last years according to experience. Some complex forms as MSP require the participation of an interdisciplinary team for both diagnosis and integral attention.

Síndrome de Munchausen por poderes / Munchausen syndrome by proxy

El síndrome de Munchausen por poderes corresponde a una forma grave de abuso infantil, potencialmente mortal, caracterizado por la presencia de síntomas y signos no clasificables en ninguna enfermedad, y que no corresponden a medidas habituales; la sintomatología es inducida o simulada por un perpetrador, frecuentemente la madre que busca adoptar el rol de enfermo y lograr la atención del equipo de salud. Un enfoque multidisciplinario es necesario para lograr el diagnóstico y proteger al paciente. El manejo psiquiátrico del perpetrador y del niño es necesario a largo plazo para evitar las secuelas. Es necesario que médicos, enfermeras, psicólogos y trabajadores sociales conozcan esta patología para lograr un diagnóstico y manejo precoz.

O encontro da violência com a mentira: síndrome de Münchausen por Procuração / The encounter of violence with lie: Münchausen Syndrome by proxy

Este estudo focaliza a Síndrome de Münchausen por Procuração (SMP), um transtorno factício, no qual a mãe simula ou provoca sintomas em seu filho. O objetivo da pesquisa, de cunho qualitativo, foi saber como os profissionais da saúde atuam para identificar, manejar, tratar e delimitar um possível prognóstico nesses casos. Pediatra, psiquiatra, psicólogo e assistente social participaram de uma entrevista, que foi analisada através do método de análise de conteúdo. Os resultados indicam que a identificação da SMP requer cuidadoso exame das características da mãe, da criança e das questões ligadas à transgeracionalidade; além disso requer que haja questionamento dentro da equipe e conscientização do pouco conhecimento que ainda há a esse respeito. Quanto ao manejo, é necessário tomar providências em relação à criança, à mãe e nos âmbitos institucional e social. O tratamento é direcionado para a criança, a mãe e a família. Quanto ao prognóstico, há unanimidade a respeito de que a síndrome deixa seqüelas permanentes na criança (AU)

O encontro da violência com a mentira: síndrome de Münchausen por Procuração / The encounter of violence with lie: Münchausen Syndrome by proxy

Este estudo focaliza a Síndrome de Münchausen por Procuração (SMP), um transtorno factício, no qual a mãe simula ou provoca sintomas em seu filho. O objetivo da pesquisa, de cunho qualitativo, foi saber como os profissionais da saúde atuam para identificar, manejar, tratar e delimitar um possível prognóstico nesses casos. Pediatra, psiquiatra, psicólogo e assistente social participaram de uma entrevista, que foi analisada através do método de análise de conteúdo. Os resultados indicam que a identificação da SMP requer cuidadoso exame das características da mãe, da criança e das questões ligadas à transgeracionalidade; além disso requer que haja questionamento dentro da equipe e conscientização do pouco conhecimento que ainda há a esse respeito. Quanto ao manejo, é necessário tomar providências em relação à criança, à mãe e nos âmbitos institucional e social. O tratamento é direcionado para a criança, a mãe e a família. Quanto ao prognóstico, há unanimidade a respeito de que a síndrome deixa seqüelas permanentes na criança

[Munchausen syndrome by proxy, an unusual presentation]. / Síndrome de Münchausen por poder, una presentación inusual.

We report a 12 year old girl that first consulted for fever with bilateral knee arthralgias. A neurological workout was started due to a progressive gait disturbance, but all results were incongruent with nerve or nerve root lesions, leading to the diagnosis of a functional paralysis. The patient worsened to the point of prostration. Due to the suspicion that the mother was inducing the symptoms, the patient was admitted to the hospital, where she improved notably. She was discharged walking. The improvement during hospital stay confirmed the diagnosis of a Münchausen by proxy syndrome, mimicking a disabling neurological condition.

Síndrome de Münchausen por poder: una presentación inusual / Münchausen by proxy syndrome: report of case

We report a 12 year old girl that first consulted for fever with bilateral knee arthralgias. A neurological workout was started due to a progressive gait disturbance, but all results were incongruent with nerve or nerve root lesions, leading to the diagnosis of a functional paralysis. The patient worsened to the point of prostration. Due to the suspicion that the mother was inducing the symptoms, the patient was admitted to the hospital, where she improved notably. She was discharged walking. The improvement during hospital stay confirmed the diagnosis of a Münchausen by proxy syndrome, mimicking a disabling neurological condition

Sindrome de Munchausen by proxy: descriçäo de um caso / Munchausen by proxy syndrome: case report

Os autores relatam um caso da Sindrome de Munchausen by proxy (SMBP), enfatizando a importancia do seguimento de criancas como o meio mais eficiente para se prevenir consequencias desastrosas. Essas criancas, acompanhadas por maes aparentemente cuidadosas, apresentam aspectos clinicos desafiadores e intrigantes.

[Factitious gastrointestinal hemorrhage in 3 school-age girls]. / Hemorragia digestiva facticia en 3 niñas en edad escolar.

Three female patients aged 9, 13 and 14 years, respectively, seen by the authors over a 1-year period presented with the complaint of recurrent hematemesis (2 patients) or melena (1 patient). The (presumed) bleeding episodes had only been seen by the respective patient and one parent (the mother in two cases and the father in one). In two cases, the other parent was antagonistic with the reported situation. A clear symbiosis had been forged between the index case and the allied parent. Two patients had previously been seen in several hospitals and had undergone various diagnostic tests, including esophagogastroduodenoscopies, all of which had proved normal. Two girls had attempted suicide. Two of the mothers had a depressive disorder. Re-evaluation of the patients by the authors again ruled out any cause for the presumed bleeding or any sequelae originating from it. The patients and their parents were referred to a psychiatric service but this was only complied by one family; the other two repeatedly avoided attending the psychiatric clinic. Awareness of this pattern of presentation and of the psychiatric profiles of the patients and their families is critical for practitioners in order to recognize factitious illness whenever a patient with a history of gastrointestinal bleeding presents with incongruous or illogical medical history and clinical findings.

Munchausen by proxy syndrome: a modern pediatric challenge.

Munchausen by proxy syndrome is a condition in which a mother pretends her infant or child is ill or causes the infant or child to be ill in order to engage in an intensely ambivalent but often destructive relationships with a physician. Despite appearances to the contrary, evidence indicates that the infant serves as little more than an object to regulate this relationship. The harming of the child takes place in a fully conscious nonpsychotic state and is a by-product of the dynamics of this relationship. We see the mother's actions as an example of imposturing good mothering. Physicians are susceptible to these mothers in ways that lead them to delays in uncovering these dynamics that can have disastrous consequences for the infant. Social and interpersonal forces that contribute to the unfolding of this syndrome are worthy of our study.