Cases That Test Your Skills

When a mother’s love hurts

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Ms. J’s life revolves around caring for her sickly 4-year-old daughter. A hospital videotape, however, exposes the mother’s impulsive, abusive actions toward her child. Is it Munchausen’s or child abuse? You decide.


 

References

INITIAL PRESENTATION: A sickly child

Ms. J, age 35, was referred to a psychiatrist after she was observed endangering her daughter. The child’s pediatrician provided the following history.

The 4-year-old has frequently required medical attention. As a baby, she wore a breathing monitor at home for almost 1 year after her mother expressed fear that she would die of apnea. Throughout her early years, the child was treated for asthma and abdominal pain and for bruises her parents said were caused when she fell out of her crib.

Recently, the child has suffered with recurring skin infections over her arm and shoulders. Her mother treated those with prescribed topical and oral antibiotics and dressings. The wounds would heal briefly, then become inflamed again.

The pediatrician consulted with a child psychiatrist, who suggested that the girl be hospitalized for a day so that doctors could examine the wound. Despite the mother’s protests, her daughter was hospitalized.

That day, Ms. J visited her daughter, unaware that the hospital room was equipped with a concealed video camera. As she was leaving late that evening, she lifted her daughter’s bandages as if to check them, then applied irritants to the wounds.

When the staff confronted her about this destructive behavior toward her daughter, Ms. J denied it had occurred. Upon seeing the videotape, however, she wept profusely, exclaiming, “I didn’t mean any harm.”

Ms. J does not fit the profile of a child abuser. Aside from part-time clerical work at home, she is a full-time mother who is intensely involved in every aspect of her daughter’s life. Before the videotaped incident, her pediatrician’s office staff had described her as caring and loving, and she had brought them thank-you gifts.

On psychiatric evaluation, Ms. J’s speech is coherent and logical, and she has no delusions or hallucinations. In describing her childhood, she recalls her parents arguing constantly. Her father, with whom she had little contact, traveled extensively on business. At home, her mother ruled with an iron fist. Any show of rebellion by Ms. J or her siblings led to a sharp slap on the shoulders.

Ms. J had few friends in grade school. In college, she earned good grades but often visited the infirmary with nonspecific complaints. She was hospitalized twice without a conclusive diagnosis. She twice saw a psychiatrist to address her medical symptoms and feelings of emptiness.

Table

Defining symptoms, features of Munchausen’s syndrome

Major symptoms
  • Simulated illness, usually recurrent
  • Pathological lying (pseudologia fantastica)
  • Peregrination (wandering, often with name and identity changes)
Secondary features
  • Medical knowledge or training
  • Multiple doctor visits or hospitalizations
  • Several scars (usually abdominal)
  • Unusual willingness to undergo diagnostic or treatment procedures
  • History of rejection or abuse during childhood, with feeling of comfort while receiving medical care
  • Borderline or antisocial personality
  • Ostentatious presentation at emergency room or doctor’s office

After college, Ms. J worked as a teacher’s aide. At age 30 she married a teacher, and their daughter was born 1 year later. The marriage ended in divorce after 3 years. After divorce the husband tried to visit the daughter but Ms. J interfered, insisting, “I’m enough.”

Ms. J told the psychiatrist that her ex-husband at times accused her of being “too clingy.” If he went to a sporting event, she would repeatedly ask what time he would come home. If she had to go shopping and he was home, she would ask him to drop everything and accompany her.

Does Ms. J’s behavior suggest a straightforward personality disorder, or would you consider a factitious disorder?

Dr. Messer’s observations

Ms. J recalled a childhood fraught with rejection and abuse. This finding, plus the deliberate injury to her daughter, points to a diagnosis of Munchausen’s syndrome by proxy.

Although not listed in DSM-IV-TR, Munchausen’s is the most severe form of factitious disorder (Table). First described in 1951, the disorder is named for Baron Karl von Munchausen, an 18th-century German nobleman known for telling tall tales about his life and exploits.1

In 1977, British pediatrician Roy Meadow described Munchausen’s syndrome by proxy, in which parents induce symptoms in their children—such as by injuring them with drugs or bacterial contaminants—then have doctors treat them.2 Because persons with Munchausen’s tend to frequently change their names and locales, the incidence of Munchausen’s and Munchausen’s by proxy has never been accurately gauged.

Munchausen’s occurs in both sexes, although men tend to exhibit more-dramatic symptoms such as self-induced fevers, bleeding, and seizures. Antisocial behavior is common among men with Munchausen’s, and many are jailed at some point. One man flying from New York to London feigned a heart attack so convincingly that he forced an emergency landing in Halifax, Nova Scotia, where he was hospitalized and released with a referral to his cardiologist.

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