Tuesday, November 14, 2006

Nursing Munchausen Syndrome by Proxy

NSG 3320: Nursing and Mental Health

Nursing Munchausen Syndrome by Proxy

March 21, 2005

Nursing Munchausen Syndrome by Proxy

Imagine meeting a young family wherein the child has suffered from many painful medical treatments and procedures as a result of many illnesses. The mother is intelligent, attentive and always involved in the care of her child. This child is a survivor, beating the odds and goeing through painful procedures, testing and surviving multiple surgeries. Appropriately your heart goes out to this family. You hope for the best and as a nurse provide professional care for the child and family. The mother is always helpful and attentive with the care of her child. You develop a therapeutic relationship with her. Now how would you feel if you were discovering that this mother was inducing the ailments onto her child? This child is perfectly healthy. But has undergone multiple procedures and surgeries because of induced or feigned symptoms. Unfortunately this is a profile that has been proven to be reality. This is an illustration of Munchausen Syndrome by Proxy.

There have been highly publicized cases of MSBP. “Hillary Rodham Clinton chose Jennifer Bush to represent her campaign for health care reform” (Dowdell & Foster, 2005). Afterwards Jennifer’s mother was charged with inducing medical problems on her that could not otherwise be explained. As a result of her mothers actions Jennifer was subjected to more than 200 hospitalisations and 40 surgeries (Dowdell & Foster, 2005). MSBP is now recognised to be “an unusual and potentially lethal form of child abuse” (Dowel & Foster, 2005). The victim is the child. In Jennifer’s case she suffered physical consequences needlessly and now lives without her gallbladder, appendix and part of her intestines as they were surgically removed.

First identified in 1951, Munchausen syndrome was named for Baron van Munchausen, an eighteenth century German aristocrat infamous for his tall tails (Smith-Alnimer & Papas-Kavalis, 2003). The syndrome was named for its characteristic lies. Individuals with Munchausen syndrome induce or invent elaborate and contradictory symptoms and demand medical treatment for themselves (Yonge & Haas, 2004). Closely related is Munchausen syndrome by Proxy (MSBP). Roy Meadow first described MSBP in 1977 (Schreier, 2002). MSBP is catalogued in the American Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a fictitious disorder. However MSBP “has yet to be recognized as an official separate category in the DSM-IV” (eMedicine, 2002). It is recognised in section 300.19; Factitious Disorder not otherwise specified.

There are four specific criteria for the diagnosis of MSBP. MSBP involves the fabrication or induction of an illness in one person by another (US National Library of Medicine, 2004). The motivation for the behaviour is to assume the sick role by proxy. All external incentives, such as economic gain are absent and the behaviour is not otherwise accounted for by another mental disorder (eMedicine, 2002). As with most mental disorders the pathophysiology is unclear. There is no test that indicates a positive diagnosis of MSBP; a diagnosis is reliant on many accumulated factors or evidence.

Individuals diagnosed with MSBP are found in all socio-economic classes and ninety five percent of the time the mother is the perpetrator. The majority of the families with an MSBP diagnosis are dysfunctional but have a tendency to be intact. A family history of Munchausen syndrome or MSBP is also a risk factor of MSBP (Dowel & Foster, 2005). The perpetrator may have Munchausen Syndrome herself and have a complicated health history. Cases usually start in infancy and up to six years of age. If it continues as the child ages, the child may accommodate to the deceptions. Older children are more likely to reveal the truth about their symptoms as they are out of the home for school (Dowel & Foster, 2005). Considering all of these characteristics the nurse caring for a child suspected of being affected by MSBP should be mindful of such signs and document any findings objectively.

The subtle characteristics of this disorder make it difficult to diagnose. “Nurses play a vital role in the observation and confirmation of the profile of MSBP” (Dowdell & Foster, 2005). A diagnosis is based on the observations of the signs and symptoms, as there is no known pathophysiology. Signs and symptoms leading to the diagnosis of MSBP are not easily recognised. MSBP “frequently goes undiagnosed-the true incidence is not known” (Thomas, 2003). This is a direct result of the unfamiliarity of the syndrome as well as the failure to consider the diagnosis. A “better knowledge of the disorder and analysis of large number of homogeneously and detailed reported cases” (Szoke, 2000) is needed. Health care professionals especially nurses need to keep updated on current literature. Knowing about the possibility is the first step in achieving a diagnosis and getting help for the victim.

Diagnosis alone may take months or years. “The average length of time to the diagnosis of MSBP generally exceeds six months” (Dowdell & Foster, 2005). With time the perpetrator becomes more convincing and practised at being deceitful. This also impacts the process of detection and proving an MSBP diagnosis. Increasing the difficulty of catching the perpetrator in the act of deceit or inflicting harm.

One apparent sign of MSBP is the fact that the child is ill with the perpetrator but when separated the child’s condition improves. As noted by Huynh, the acute signs and symptoms decrease when the child is separated from the parent. Given this fact observation and documentation of such characteristics by the nurse is key. Another sign is a family history, including death of a sibling. “There is a high incidence of unexplained sibling mortality” (PhycNet-UK, 2003). In most instances the death of a sibling is what triggers the investigation to a MSBP diagnosis. The perpetrator uses the excuse that the symptoms “run in the family”. A detailed and accurate family history is important, as is communication amongst the health care team. Since deception is a characteristic of MSBP it is likely that a history taken from the perpetrator will not be accurate (Huynh, 1998). A detailed medical history from the parents in this case is rendered invalid. Discrepancies between clinical findings and the parents’ history should raise suspicion and warrants documentation. The nurse needs to pay special attention to conflicting detail and discuss concerns with the multidisciplinary team. A combined effort and high suspicion is required to make the diagnosis of MSBP.

A multidisciplinary team, that meets regularly, is important for maintaining continuity. A team consisting of nursing staff, physicians and any other professionals that are directly involved in the care of the child need to have good communication channels. Congruent care is important. MSBP is abuse and therefore matters of law are linked with the health care. The multidisciplinary team should therefore also include members from legal professions such as law enforcement and Children’s Aid Society (CAS) when the suspicion of MSBP begins. The safety of the child or children is of utmost importance.

The use of video surveillance is useful in diagnosing MSBP. A multidisciplinary team must agree that covert surveillance is needed prior to beginning the procedure in most facilities. Covert monitoring was determined to be a necessity for diagnosing MSBP over half of the studied cases by Hall et al. The use of video surveillance causes conflict with patient privacy and confidentiality (Smith-Alnimer & Papas-Kavalis, 2003). In addition Smith-Alnimer & Papas-Kavalis described how the act of abuse was not to be intervened by the nurse as to obtain evidence for legal matters. This is a direct conflict between nursing care and obtaining legal evidence to try the case. Watching someone inflict harm on a child would be difficult for anyone. The question of how much evidence is enough to take to a court of law as abuse. Is it right to let the harm be inflicted in order to have sufficient evidence for a jury? Overall the nurse often finds his or herself with ethical and legal dilemmas when dealing with MSBP. “Great distress among nurses when nurses’ sincere efforts to support and comfort the sick are exploited” (Yong & Haas, 2004) is felt. Above all the nurse must maintain a neutral status. The perpetrator has the legal right to obtain non-judgmental health care just as any other parent. Being suspected of or diagnosed with MSBP does not give the right to the nurse to treat the parent any different. As professionals, nurses must be aware of but not feed into personal biases. These persons are suffering from an illness and are deserving of compassion.

When using covert monitoring and suspecting illegal activities, the fear of litigation may be an issue for nurses. Clinical and legal standards change over time and can be difficult to be aware of. It is most important to keep focused on the patient in attempts “to provide best clinical care to guide practise, not fear of litigation” (Barloon, 2003). Sound clinical judgement is the most important characteristic to have. Barloon also states that keeping up with current literature and continuing education are crucial assets pertaining to safe and acceptable clinical psychiatric nursing practice. From a legal point of view documentation is most important. For the safety of the child a sound legal case is important. The onus is mainly on the nurse to document key findings and use sound judgement to intervene.

The perpetrator tends to have medical knowledge often from previous education and or experience in a health care field. In the study by Hall et al fifty five percent of the perpetrators had previous health care training or work and interestingly twenty five percent worked in a day care if they did not have previous health care experience. Individuals with this condition are attracted to helping professions such as nursing (Dowdell & Foster, 2005). An article written by Young and Haas describes a case in which a nursing student presented with Munchausn syndrome and the students’ daughter was a victim of MSBP. The main focus of this article was the fact that most faculties are not prepared for the possibility of encountering Munchausen syndrome in students. The knowledge of this disorder is beneficial for the detection as well as the outcome. Being a nurse in such a situation as to help a student do harm to a child is very difficult. The faculty who helped this perpetrator felt hostility after learning of the deceit and feeling exploited. Some felt guilt for teaching the perpetrator medical knowledge that potentially aided in the harm done to the child.

Treatment of this disorder typically does not have very favourable outcomes. Emphasis is put on managing rather than curing. The first step is confronting the perpetrator. Admission to the deceit may occur but more often denial is the result. The purpose is to stop the abuse and protect the child. The next step theoretically is developing a stable therapeutic relationship. With a stable relationship working, the focus of care goes to the management of the disorder including orientation to avoid unnecessary hospitalizations and medical acts (PhycNet-UK, 2003). There are no known cases of successful treatment of MSBP (Huynh, 1998). In most cases the fictitious disorders are more convincing than real cases of psychosis. The use of pharmacotherapies for MSBP is not well known. There has been some use of antipsychotic drugs with some indication of benefit (PhycNet-UK, 2003). Since “psychiatric disorders are common, in particular, personality disorders and depression” (Huynh, 1998) treatment of these disorders is the primary focus. As for psychotherapy and counselling, analytical and cognitive-behavioral approaches have been used with patients that accept and engage in treatment.

The role of the nurse in relation to MSBP is important in many ways. Close observations and documentation leads to the recognition of suspicious findings. In combination with knowledge of MSBP recognition of the signs and symptoms may lead to a diagnosis. Nurses may be the only persons to whom a mother makes statements that can be incriminating. The close professional relationship resulting from the care and ‘being there’ creates a bond between nurse and mother that no other member of the multidisciplinary team tends to develop. This trust sometimes allows for the mother to say suspicious things to the nurse. The nurse is the one who provides direct care for the child and is a fundamental member of the health care team. In a situation of caring for a child victim to MSBP the nurse must be vigilant and only intervene based on professional judgment and fact, not the demands of the parent. Support for the nurse is important. The use of a multidisciplinary team helps to support the nurse. Having others aware of the situation able to discuss details otherwise confined by confidentiality privileges is important. Nursing is a caring profession. Working with a case of suspected or diagnosed MSBP is very trying for nursing staff.

A diagnosis of MSBP is child abuse. MSBP is not a form of child abuse that is well known nor is it easily detected. Overall further research and study is needed in this area of mental health disorders. The nursing role related to the assessment, diagnosis, and treatment of MSBP is important throughout the process of detection to treatment. The most important thing is to be able to recognise and diagnose MSBP. This is accomplished firstly with increased awareness, especially nurses that care for children. With a heightened awareness nurses may be able to help the young victims from further abuse associated with MSBP. There are many ethical dilemmas and legal difficulties when gathering evidence to determine a diagnosis. The demands on nursing staff are high therefore they need strong support systems.


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