Forensic Nurses

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Understanding Munchausen Syndrome by Proxy
 By Lisa Barry , RNC, MSW
 On The Edge - Winter 2008

Munchausen Syndrome by Proxy
Munchausen Syndrome by Proxy is listed as Factitious Disorder by Proxy in the DSM-IV(American Psychiatric Association, 2000) MSBP is defined as a highly documented variant of factitious disorder in which a parent fabricates or induces illness in a dependent that can result in unnecessary medical evaluation and treatment (Lynch,2006).  Prolonged or repeated contact with the healthcare system usually ensues as a result of this dangerous form of child abuse.  In a study of 117 cases of MSBP, Rosenberg found that 98% of the perpetrators were biological mothers (Lynch, 2006).  The most common methods of assault found in these cases included suffocation, poisonings with ipecac or laxatives, and induced seizures (Lynch, 2006).  This paper will address Munchausen Syndrome as segue into MSBP.

Munchausen Syndrome - A Historical Perspective
The nosology of Factitious Disorder dates back to the first half of the 19th century as is evident in the 1843 publications of the British physician Hector Gavin (Gregory & Jindal, 2006).  According to Gregory & Jindal (2006), Gavin differentiated individuals who simulated illness to obtain some compensation from those who feigned their illnesses for no apparent reason other than to assume the sick role.  Although Karl Menninger had reviewed Factitious Disorders in a paper in 1934 entitled Polysurgery and Polysurgical Addiction, Munchausen’s Syndrome was not formally recognized until 1951 by Richard A. J. Asher (Turner & Reid, 2002).  According to Turner & Reid (2002), it was Asher’s three case reports and his historical reference to the fabled raconteur Baron von Munchhausen (the anglicized spelling of the name is different from the German version) that sparked the interest and publications now associated with this disorder.

Karl Friedrich Hieronymous Baron von Munchhausen, also known as the Baron of Lies, was a German cavalry captain serving in a Russian regiment in campaigns against the Ottomans in the 18th century (Turner & Reid, 2002).  According to Turner and Reid (2002), little is known of this German cavalry captain other than his renown for fabulous anecdotes about his life and adventures.  There was much criticism regarding Asher’s use of Munchhausen’s name in view of the absence of similarity between the Baron and the syndrome (Turner & Reid, 2006).  According to Turner & Reid (2002), although alternative names such as hospital hoboes, peregrinating problem patients, and hospital addiction syndrome have been used to describe this group of patients, none have persisted as Asher’s paper on Munchausen Syndrome, which remains the key reference.

Munchausen Syndrome characterizes 10% of patients with factitious disorders and first entered the scientific nomenclature through the third edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-III) as a diagnostic category (Gregory & Jindal, 2006).  According to Gregory and Jindal (2006), more recent descriptions of Munchausen’s Syndrome include a triad of symptoms involving wandering from hospital to hospital seeking medical treatment, elaborate falsified storytelling (pseudologia fantastica) and bizarre and dramatic presentations of feigned illnesses.  The revised edition of the DSM-III, according to Gregory & Jindal (2006), expanded the definition to include psychological symptoms in addition to the original emphasis on a chronic course and physical symptoms.  The fourth edition and its text revision delineated three subtypes based on whether the symptoms are physical, psychological or both (Gregory & Jindal, 2006). According to the American Psychiatric Association (2003), the DSM-IV-TR requires the following diagnostic criteria be met for the diagnosis of Factitious Disorder to apply:

1.  Intentional production or feigning of physical or psychological signs or symptoms.
2. The motivation for the behavior is to assume the sick role.
3. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well being, as in Malingering) are absent.

Differential Diagnosis and Comorbidity
Factitious Disorder or Munchausen Syndrome can be confused with other disorders such as Malingering, Hypochondriasis and Hysterical Illness (Amodeo, 1987).  Definitions to clarify these three disorders are as follows (Amodeo, 1987):

1. Malingering-characterized by the voluntary production of false or grossly exaggerated physical or psychological symptoms.  It differs from conversion and other somatoform disorders in that the person voluntarily causes his/her symptoms.  Unlike factitious disorder, malingering is done to achieve a recognizable goal such as avoiding work.
2. Hypochondriasis-involves an extreme preoccupation with personal health.  A person suffering from Hypochondriasis unrealistically interprets physical sensations as abnormal and worries excessively about being ill.
3. Hysterical Illness-also known as somatization disorder is a polysymptomatic disorder chiefly affecting women.  It’s characterized by recurrent, multiple, somatic complaints often dramatically described.  Complaints include pain, anxiety, gastrointestinal disturbances and conversion symptoms.  Most symptoms are related to psychological causes.

Factitious Disorder needs to be differentiated from Malingering, both of which involve intentional production of false or grossly exaggerated physical or psychological symptoms (Gregory & Tindal, 2006).  According to Gregory and Jindal (2006), there is a conscious motivation in Malingering driven by external incentives such as avoiding military duty or work, obtaining financial compensation, evading criminal prosecution or obtaining drugs.  The motivation is usually unconscious in Factitious Disorder driven by a need to assume a sick role (Gregory and Jindal, 2006).  A combination of internal and external incentives may exist which contribute to the challenge of diagnosing Factitious Disorders. According to Swanson (1981), Barker, who attempted to study the syndrome, reported that individuals with Munchausen Syndrome exhibit features common to several personality types such as hysterical and antisocial personality disorders.  The former differs from Munchausen in that the individual seeks a cure for the symptoms, does not willingly leave the hospital and does not consciously synthesize illness (Swanson, 1981).  According to Swanson (1981), simulating and feigning are also features of the antisocial personality, the latter of which is a label often applied to the patient with Munchausen Syndrome.  Parents who are perpetrators of MSBP have also been diagnosed with other personality disorders such as Narcissistic or Borderline Personality Disorder.  According to Kahan and Yorker (1991), the literature on adults with Munchausen Syndrome reveals that some individuals with severe personality disorders use simulation of disease as their primary mechanism for expressing rage, as well as for obtaining emotional support and nurturance.  The reason for the choice of disease simulation lies in some aspect of personal history such as a mother from an emotionally deprived background who may have experienced the hospital as a place of nurturance during childhood and later in life causes her child to be hospitalized in order to meet her own emotional needs (Kahan and Yorker, 1991).

An Axis I diagnosis of schizophrenia has also been used to categorize several patients with Munchausen’s Syndrome (Swanson, 1981).  According to Swanson (1981), Bursten has found no impairment of affect or thought processes in several patients and therefore concluded that although the Munchausen life pattern might be bizarre, it is certainly not schizophrenic.  Substance use and depressive disorders were the most common comorbid Axis I conditions in 6 out of a 100 patients admitted to the psychiatry ward at University Hospital in New York (Gregory & Jindal, 2006).  Personality disorders or traits were documented in these 6 cases, with Borderline Personality Disorder being the most prevalent (Gregory & Jindal, 2006).

Munchausen Syndrome
Munchausen Syndrome, listed as Factitious Disorder in the DSM-IV, is a behavior complex in which individuals feign a presentation of illness to such a plausible degree that they are able to obtain and sustain multiple hospitalizations (Swanson, 1981).  According to Beavers (1987), individuals with Munchausen Syndrome present with complaints of acute abdominal pain, dramatic displays of hemoptysis or hematemesis, seizures or fainting spells and dermatologic conditions.  These individuals undergo a plethora of treatments and diagnostic testing during these hospitalizations.  According to unknown author (nd), the unnecessary tests and waste of other medical resources caused by Munchausen’s Syndrome cost the United States $40 million per year.

This syndrome can start during adolescence or childhood, although it usually begins in early adult life.  As the syndrome progresses, the individual acquires knowledge regarding medicine and hospitals, and the typical individual with Munchausen is described as a single woman who is a health care professional (Amodeo, 1987).  Some authorities dispute this, claiming the disorder mostly occurs in men, while others report it as occurring equally among men and women.  Munchausen Syndrome characterizes 10% of patients with Factitious Disorder (Gregory & Jindal, 2006).

According to Swanson (1981), Bursten considers three criteria, with a fourth added, as essential to diagnosing Munchausen Syndrome:

1.  Presentations are always dramatic, puzzling and the patients eagerly submit to painful procedures.
2.  They show pseudologia fantastica and travel widely for attention (wandering).
3.  Their inconsistent stories and bizarre interactions with staff who react with anger, inevitably lead to discovery and their disappearance against medical advice.
4.  Restricts the diagnosis to individuals displaying the behavior without overt, concrete gain.

Individuals with Munchausen are described as lonely, restless individuals that seem locked in a blurred play in which reality and fantasy are indistinguishable (Swanson, 1981).  According to Swanson (1981), individuals with Munchausen Syndrome also have difficulty separating elaboration from invention and conscious from unconscious motivation.  A quote from Jaspers in Swanson (1981) claims that “once the game of fancy has started, it frequently leads to self-deception…[and] self-surrender to a fictitious existence, which has arisen from an urge to get away from reality”, resulting in a transformation from fantasy to pseudologia (page 440).

According to Patenaude, Zitsch & Hirschi (2006), individuals with Munchausen’s Syndrome are between the ages of 20 and 30 years at presentation.  These individuals are usually intelligent and their deception is sophisticated.  Many individuals with Munchausen’s Syndrome have serious personality disorders with borderline or sociopathic features and frequently claim that they or a close relative has medical training (Patenaude et al., 2006).  Although uncommon, there are discrepancies in the literature regarding the true incidence of Munchausen Syndrome.  Some of the literature indicates that the syndrome is over-reported because a single patient is often diagnosed by several different physicians while other literature reveals that the syndrome is under-reported because so much deception is involved (Patenaude et al., 2006).  Despite this controversy, it is apparent that the diagnosis and management of Munchausen Syndrome continues to create a challenge for medical personnel who become involved in the care of the patient with this mystical syndrome.

Prognosis and Treatment
The prognosis for Munchausen Syndrome is poor with statistics for recurrent episodes and successful suicides ranging between 30% and 70% (unknown author, nd).  According to Turner and Reid (2002), although there have been no treatment studies on the management of Munchausen’s Syndrome, the first goal of treatment is reduction of potentially harmful investigations and procedures.  A therapeutic approach should always be adopted and confrontation of the patient should take place in a sympathetic and non-punitive way (Turner & Reid, 2002).  The latter can be a challenge for medical personnel caring for patients with Munchausen Syndrome due to the behaviors exhibited by the patient and the nature of the disorder. Therefore, it is essential for health care providers to obtain consistent supervision with another professional to process one’s feelings in order to provide the necessary care for individuals with this syndrome.

Consulting a psychiatrist can increase staff understanding regarding the dynamics of this disorder. According to Patenaude et al. (2006), the psychiatry literature recommends that patients not be directly confronted with proof of their deception because this approach usually provokes patients into engaging in even more theatrics that sometimes culminate in self-harm.  Denial is a common defense mechanism employed by individuals with Munchausen Syndrome.  The recommended approach is that clinicians attempt to phrase their discussion in a way that provides the patient with a way to concoct a face-saving explanation (Patenaude et al., 2006).

According to Gregory and Jindal, the four essential components of successful management of Munchausen Syndrome are, making the diagnosis, cognitive and behavioral framing, team communication and avoidance of iatrogenic harm.  The forensic nurse can provide education and support for medical personnel regarding these components and can be instrumental in facilitating an investigation process when Munchausen Syndrome is suspected.  Nurses and other medical personnel, who have been consumed by this perplexing situation in which the patient is not making progress, may be experiencing a plethora of emotions such as anger and frustration. The forensic nurse, who has not been providing direct care, can provide an objective approach in caring for and meeting the needs of patient and staff.  A forensic nurse could also prove useful in stressing the need for accurate documentation and communication among the multidisciplinary team to track frequent visits to emergency rooms for various medical concerns. The literature indicates there is much unfamiliarity with Munchausen Syndrome and Munchausen Syndrome by Proxy, which reiterates the significance of education by a forensic nurse who has expertise in this arena.

Munchausen Syndrome by Proxy
MSBP, unlike Munchausen Syndrome, is a crime of child abuse and requires utilization of an integrated practice model which incorporates an accomplished clinician cross-trained in the principles and philosophies of nursing science, forensic science and criminal justice (Lynch, 2006).  The importance of utilizing an integrated practice model and multidisciplinary approach when attempting to solve a forensic case will become apparent in the discussion of MSBP.  The unfamiliarity, together with the seemingly bizarre nature of this type of child abuse, can lead to serious problems in identification and management of this syndrome (Kahan & Yorker, 2006). The multidisciplinary team,  manifested by each individual’s  experience and knowledge,  should be utilized to educate staff who lack familiarity in dealing with individuals with MSBP.

Although elderly people can be victims of MSPB, the focus in this section is biological mothers and their children. Anecdotal evidence also now suggests that using a dependent or helpless child as a “proxy” for fabricated or induced illness can also occur in professional settings and is not isolated to familiar caregivers (Lynch, 2006).  Nurses and other healthcare providers in a hospital setting may be seen as heroes by the mothers of children who they have saved.  Unbeknownst to these mothers, this very hero is also the perpetrator of their child’s trauma.  According to Lynch (2006), Dr. Roy Meadow, a famous British physician and leading expert on MSBP, suggested that having a previous history of feigning or inducing one’s own illness, as indicated with Munchausen Syndrome, is a risk factor in individuals who later develop MSBP.

According to Kahan & Yorker (1991), MSBP is an unusual form of child abuse in which a parent, usually the mother, presents for medical attention with a child who has symptoms that have either been falsified or directly induced by the parent, resulting in the child being subjected to an unnecessary and potentially harmful medical investigation.  These children are also victims of unnecessary procedures, diagnostic testing and surgeries that can be painful, costly and sometimes fatal.

Mothers who have the diagnosis of MSBP harm their children to draw attention to themselves and gain sympathy from others.  It is a common occurrence for the abuse to continue by the perpetrator during periods of hospitalization.  Schrier found that mothers who actively induce symptoms versus those who fabricate them display key clinical features such as pathological lying, causing repeated serious harm to the infant, manifesting a compulsive need to repeat the behavior, taking unnecessary risks and displaying a kind of gleeful excitement just at the moment when the infant’s life hangs in the balance (Lynch, 2006). Another common characteristic of mothers with MSBP is that they often have some medical training or work in a medical area.  These women are usually portrayed by investigators, friends, family and neighbors as very caring and loving parents who try to do everything they can for children afflicted with devastating illnesses (Chiczewski & Kelly, 2003).

According to the American Psychiatric Association (2000), the DSM-IV-TR requires that the following criteria be met for the category of Factitious Disorder by Proxy to apply:

1. Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care.
2. The motivation for the perpetrator’s behavior is to assume the sick role by proxy.
3. External incentives for the behavior (such as economic gain) are absent.
4. The behavior is not better accounted for by another mental disorder.

Child Victims of Munchausen Syndrome by Proxy
According to Kahan and Yorker (1991), child victims are equally divided between males and females and average around four or five years old at the time of diagnosis, but can also include many school age children.  Evidence indicates that the child victims begin to actively participate in the parental deception, as they become older (Kahan & Yorker, 1991). A case example cited in Kahan & Yorker (1991) described a four year old boy who feigned epileptic seizures under direction from his mother.  The literature also attests that siblings can also become victims of MSBP.

Children who are victims of their mother’s behaviors from an early age can show detrimental effects on their physical and emotional well being.  According to Precey (1998), it is estimated that nearly 10% of mothers who deliberately induce illness in their children ultimately kill them.  Therefore, a good assessment of the mother is essential in making decisions about the child’s safety (Precey, 1998).  Hospital and child protective social workers are an important part of the multidisciplinary team.  They can assist nurses and other personnel in understanding that although the safety of the child is of utmost importance, it is also crucial to consider the impact on the child of removing them from their home, as children have a tendency to idealize their parents.  A forensic nurse can be instrumental in developing designated protocols that will enhance the safety of the child victims and the ability of the health care providers to involve and collaborate with community agencies (Pasqualone & Fitzgerald, 1999).

Prognosis and Treatment
Ensuring safety and providing appropriate medical treatment for the child who is a victim of MSBP is crucial.  Years of psychiatric counseling for the perpetrators of the abuse is recommended, however, very little is known about the effectiveness of treatment for this rare but serious disorder. More research is needed by medical personnel and family members who have professional and/or personal familiarity with MSBP.

Legal Issues
A crucial role of the forensic nurse examiner in a hospital setting would be to monitor and document the abuse through observation and surveillance with video cameras.  The use of a video camera has become controversial and creates an ethical dilemma as legal issues have arisen in regard to the Fourth Amendment, which guards against unreasonable search and seizure.  Is the use of a video camera unreasonable when child abuse is in question?  Confidentiality rules don’t apply if a person is disclosing that he/she is suicidal, homicidal or being abused, so should there be a clause in the Fourth Amendment that allows for video surveillance when the crime of child abuse is suspected?  Subsequently, visual evidence is often required to convince the courts that mothers are capable of fabricating illness or inducing harm to their children resulting in physical and emotional effects, which could be fatal.  According to Kahan & Yorker (1991), a general rule of criminal procedure is that evidence obtained in violation of a person’s Fourth Amendment rights will be excluded from any subsequent trial.  However, an exception to the exclusionary rule, which could apply in a MSBP case, is that evidence obtained illegally by a “private party”, the latter of which could include doctors, nurses and hospital administrators, is admissible (Kahan & Yorker, 1991).

According to Morrision, Libow, .a pre-eminent scholar on MSBP, suggests obtaining consent by adding “videotaping” to the consent form that parents must sign on admission to the hospital to permit medical treatment for their child. The legal implications related to camera use continue to prevail and the complexity of this issue reiterates the importance clarity and consistency regarding protocol and procedures.

Summary
MSBP is a complex and devastating syndrome that can result in life-damaging consequences for the victim and the perpetrator.  The forensic nurse’s expertise creates a heightened awareness and index of suspicion, which involves noticing cues in the environment and when conversing with parents, children and health care providers. Communication with the multidisciplinary team and documentation of these cues are a crucial component in the assessment process and should become a permanent part of the medical record.  For the professional’s protection documentation in the medical record must be accurate and consistent, only what the staff member sees or hear, factual without feelings.  It is also important to clarify doctor’s orders as needed and note details when giving medications.  Due to their expertise in identifying different types and patterns of wounds, the forensic nurse can also be a resource to staff who may suspect child abuse.

Although a multidisciplinary approach is most effective, often various professionals are drawn into the case in a disjointed response during the crises that occur when these cases are suspected and the perpetrators confronted (Pasqualone & Fitzgerald, 1999).  Strong emotions are elicited by staff due to the manipulation and deception by the perpetrator that has ensued over the course of their treatment.  A differing of perspectives by professionals can result in divisions of staff and compromise good working relationships (Pasqualone & Fitzgerald, 1999).   This division of staff presents as an obstacle in the treatment of MSBP since effective and consistent communication is essential component of the integrated practice model.  The availability of supervision for staff by a forensic nurse is essential in understanding the dynamics and resuming healthy working relationships.

The multidisciplinary team may include an emergency room nurse, a staff nurse, a forensic nurse, a physician(s), an x-ray technician, a volunteer who witnesses and reports suspicious behavior, DHHS, and the police and/or a school nurse or social worker. The forensic nurse can be an asset to all hospital personnel by providing the necessary education needed for those who are involved with patient care, in order to acquire a heightened awareness and index of suspicion.  A reminder of the importance of confidentiality should also be addressed with all staff involved.

MSBP is an intriguing, complex and devastating syndrome that requires the concept of an integrated practice model.  This model demonstrates attention to the concepts of person, health, nursing, environment, internal issues (clarification, expectation and behavior) and external components (sociology and criminology, social, cultural and political factors and education) (Lynch, 2006).

The integrated practice model employs a holistic approach that incorporates nursing science, forensic science and criminal justice.  Patients and the multidisciplinary team can benefit from the forensic nurse who provides knowledge regarding the importance of utilizing a holistic approach, which includes a biopsychosocial component when investigating suspected crimes such as MSBP.  Nurses in every specialty can embark on a journey toward a collaborative effort to mend the fragmentation in healthcare related to forensic nursing.

References

Lisa Barry RNC-BC, MSW, PMH-NP Intern has worked in different areas at Southern Maine Medical Center for the past 24 years, including medical-surgical, inpatient psychiatric and outpatient Partial Hospital Services. For the past 8 months has worked in EDAP (Emergency Department Acute Psychiatric) at Southern Maine Medical Center as a charge nurse. In August of 2009, will be graduating from the University of Southern Maine's Psychiatric Nurse Practitioner Program. bearie58@hotmail.com.


 

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