A Serial Munchausen Syndrome by Proxy.

Munchausen syndrome by proxy (MSBP) is a form of child abuse that describes children whose parents or caregivers invent illness stories and substantiate the stories by fabricating false physical signs. Through this case report, a serial MSBP case is presented along with psychiatric evaluation of the perpetrator mother who was sent to the Forensic Psychiatric Observation Department of the Council of Forensic Medicine to assess whether she has any mental disorder. Although there are several studies on MSBP, we present this case because the perpetrator mother was caught on the camera surveillance system of the hospital while closing the nose and mouth of the victim for fabricating the illness, and she also said that she had done the same thing to her two elder children to exclude their illnesses. Her two children had died and could not be diagnosed. Moreover, we discuss the psychopathology of the perpetrators, which is a less known area of MSBP. This is a very serious form of child abuse, with a high risk of repetition, and failure to diagnose might result in the death of the child.

INTRODUCTION

The World Health Organization defines child abuse as intentionally or unintentionally performed attitudes resulting in actual or potential harm to the child's health and psychosocial development.[1] Child abuse is a complex phenomenon, and unfortunately, it can be seen all over the world.

Munchausen syndrome was first described in 1951 by Asher in a group of patients who invented illness stories and made doctors to perform unnecessary surgical procedures.[2] Munchausen syndrome by proxy (MSBP) is a specific form of child abuse first described by Meadow in 1977.[3] It describes the situations in which the parents or the caregivers, almost always the mother, invent illness stories about their children and substantiate the stories by fabricating physical signs.[34] Usually, families or caregivers bring the child to the hospital with symptoms that cannot be explained easily via physiologic ways, and these symptoms occur only when the child is with the parents.[4] MSBP can be easily missed, and it is also possible to harm the child while trying to treat the symptoms.[3] Belief that the parents or caregivers do not harm the children deliberately makes the evaluation of MSBP difficult.

Through this case report, we present the case of a mother who closed her three children's nose and mouth to exclude their diseases. She was sent to the Forensic Psychiatric Observation Department of the Council of Forensic Medicine for evaluation of criminal responsibility. She was caught on the camera surveillance system of the hospital while closing her youngest daughter's nose and mouth; she was accused of attempting to kill her own child. After evaluating the case file, it was understood that her other two children had died before and the mother had also closed their nose and mouth to exclude their illnesses.

The purpose of this case report is to present an MSBP case that was detected with the imaging systems of the hospital and suspicious deaths of other two children of the mother and to discuss the criminal responsibility of the perpetrators with MSBP.

CASE REPORT

Our patient is a 27-year-old secondary school graduate woman. She was accused of attempting to murder her own child and murdered her other two children. She was sent to the Forensic Psychiatric Observation Department of the Council of Forensic Medicine for evaluation of criminal responsibility. She was caught in the camera system of a hospital while she was closing her 3-month-old daughter's nose and mouth.

According to her testimony, she got married without the permission of her family and moved to a different city with her husband, lived there with her husband's family, and had three children. Her husband had epilepsy disease. Their first child was a girl and the doctors had informed the mother that her daughter had developmental dysplasia of the hip and could not walk. However, her daughter survived with the condition until she was 30 months old. One day, the mother desired to exclude her child's disease and closed her daughter's mouth and nose with her hand for about 5 min; however, when her daughter's condition became worse, she called her husband. Her husband poured a glass of water on the child's face after which she recovered. After her husband had gone back to work, she again closed her daughter's nose and mouth; unfortunately, this time the child could not recover and died at the hospital and they buried her.

Their second daughter aged 6 months had frequent complaints of fever, cough, and empurpling. She had stayed at the hospital for 2 months, but the doctors could not diagnose her. Hence, the mother took her to home. In the evening of the same day, the mother closed her daughter's nose and mouth for almost 30 min, but the child did not show any sign of a disease, and subsequently the mother fell asleep. When she woke up in the morning, she saw that her daughter had died; she cried and screamed, and finally, the parents buried the child in the cemetery without necessary legal permission.

Their third daughter also had health problems; she stayed at the hospital for 15 days after birth. Later on, she had empurpling complaints from time to time. After 3 months, the mother took her daughter to a research hospital with the same complaints. At the hospital, she stayed in an electroencephalography room with a camera surveillance system. It was seen on the cameras that the mother had been closing the nose and mouth of her daughter, and thus she was caught.

Before she was sent to the Council of Forensic Medicine, she was diagnosed with MSBP and it was reported by a psychiatric hospital in Turkey that she is mentally responsible for the crime.

She was kept under observation at the Forensic Psychiatric Observation Department of the Council of Forensic Medicine for 4 days. During her stay, she did not have any sleeping, eating, or behavioral problem. She mentioned that her children had epilepsy disease and since the doctors could not diagnose the condition, they had died. She was oriented and cooperative, her psychomotor activity was normal, there were no psychopathologic symptoms, and her cognitive functions were normal. Rorschach test results also did not show any psychopathology, and her IQ test result was found to be 78. In conclusion, she was found mentally and criminally responsible for attempting to kill her children. A report was prepared after the observation and evaluation of the case file and sent to the court.

DISCUSSION

MSBP is now termed as a factitious disorder imposed on another individual in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. It is a special form of child abuse which describes children whose parents or caregivers invent illness stories and substantiate the stories by fabricating false physical signs.[3]

Families can fabricate almost all diseases; they can visit the hospital with several symptoms, including any form of bleeding (hematuria, hematochezia, and hematemesis), seizures, depression, apnea, diarrhea, vomiting, fever, and rash.[345] In the present case, the mother visited the hospital stating that her child had apnea and seizures, to exclude the diseases from her children. It is known that seizures and apnea are common presentations because they are easy to fabricate.[6] In the present case, the mother has closed the nose and mouth of her daughter and said that the child had seizures and apnea attacks. It was later realized that she had visited the hospital for her other two children with the same reason, and unfortunately, they did not survive.

MSBP cases are very rare compared with other types of child abuse. Studies revealed that the incidence of MSBP is 0.4/100,000 among children aged below 16 years and 2–2.8 per 100,000 among children aged below 1 year.[7] In a study from Turkey, 139 patients were examined for suspected child abuse and 94 were evaluated as child abuse cases and an additional two of them were diagnosed with MSBP.[8] However, it is known that the actual incidence of MSBP is higher than this and there might yet be undiagnosed cases.[910]

The average age at diagnosis was reported to be 3.25 years in one study and 20 months in another study.[79] Our patient's children were 30 months and 6 months old when they died, and her last child was 3 months old when she was diagnosed.

Death rate has been reported to be 6–10% for MSBP cases.[9] The perpetrator is usually the mother.[11] Affected mothers are usually classified into three groups: active inducers, help seekers, and doctor addicts. Active inducers exaggerate the illnesses of their children; help seekers use the children to avoid social problems such as domestic violence and unhappy marriage; doctor addicts are more suspicious and paranoid.[12]

In the present case, the mother was seen on the camera surveillance system while she was closing her daughter's nose and mouth. She stated that she had earlier done the same thing to her two daughters. It is known that sometimes more than one child of the family can be victimized.[4] We are not aware of the reason of death of the other two girls; however, according to the mother's testimony, this is a serial MSBP case. Unfortunately, the children died and autopsy was not performed after death. If the clinicians had suspected MSBP, maybe her other two children would not have died. If there are unexplained infant deaths in a family, clinicians should be suspicious about the diseases of other children or legislatives should have a suspicious approach toward the unexplained deaths of other children.[1314]

Diagnosing MSBP needs a very careful approach and there are some specific features.[15] There are certain typical signs such as persistent symptoms that occur only when the perpetrator is with the victim, inconsistency of the symptoms and the history of the illness, inconsistency of the treatment, a calm perpetrator who accepts all painful medical tests for the child and family history of a sudden death of a child, and history of a similar illness in the family.[1617] In the present case, the father of the family had epilepsy disease and maybe the mother assumed that her children had seizures because of her husband's disease. All her three children had their symptoms when the mother and the children were alone at home. As evidenced in this case, failure to diagnose MSBP can have much severe results, and after diagnosis, it is important to protect the remaining children of the family.[4]

Unlike other forms of abuse, psychodynamics of MSBP are constructed to draw attention to the interests of parents instead of giving harm. In the present case the mother had claimed that there were problems with their marriage.

It has been reported that majority of the perpetrators had chronic somatoform disorders or personality disorders and often lacked other mental or physical illnesses.[1718]

In the present case, the woman had no psychopathologic symptoms and her cognitive functions were normal. Rorschach test results also did not show any psychopathology; her IQ test result was found to be 78, and she was found fully responsible for the criminal act.

CONCLUSION

MSBP is a form of child abuse with a high risk of repetition that might have much severe results. Diagnosing MSBP is difficult and failure to diagnose MSBP might result in the death of the child. Presence of continuous and repetitive symptoms, inconsistency of clinical findings, history of the illness, symptoms occurring when the child is with the caregiver (usually the mother), and similar illness stories for the other children of the family should be the warning signs for MSBP cases. MSBP cases need a careful and multidisciplinary team approach for diagnosing and preparing treatment plan. Physicians should be very careful in managing these types of cases and make a legal notice. These cases should be followed up in rooms with camera surveillance systems in the hospital. Safety of the victim is also important, and hence, while trying to obtain the evidence, the child should be protected. Follow-up of the patients and perpetrators is also important that could prevent future cases of abuse.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.