Portuguese Version

Year:  2001  Vol. 67   Ed. 5 - (20º)

Relato de Casos

Pages: 733 to 736

Factitious disorders by proxy. Discussion of one case

Author(s): Nelson Caldas 1,
Silvio Caldas Neto 2,
Clístenes R. Oliveira 3,
Mariana C. Leal 4,
Silvana Moraes 5

Keywords: factitious diseases, factitious disorders, Münchausen's syndrome

Abstract:
The authors presented a case of Münchausen's syndrome by proxy (factitious disorders), described by Meadow in 1977. We discussed the various aspects of the syndrome and its diagnostic difficulties, requiring deep suspicion and serenity from the physician.

INTRODUCTION

In 1951, Ascher1 described the syndrome named by him Münchausen's syndrome. The Baron of Münchausen, Karl Friedech Hieronymus, was a German military man who fought against the Turkish in 1740. He became famous for his exaggerated and factious stories about his time in the war and his hunting activities. Up to the present, hunters are known for tending to tell lies when reporting their adventures, all due to the Baron's stories.

The syndrome comprises malingers or those who self-induce the disease owing to different reasons, ranging from gaining advantages to pure psychopathology.

After the first publication, the medical services became more attentive to this kind of event, which had been reported since the Middle Ages. In 1977, Meadows described the same syndrome but not self-induced, but rather inflicted on somebody else, reason why it was named "by proxy". This is the origin of Münchausen's syndrome by proxy (MSP).

They are usually difficult to diagnose and rare cases. It becomes easy, though, if we are highly suspicious and match suspicion reports to a risk group for further evaluation, as described by Caldas Neto et al.3, in 1992.

In our opinion, the publication of the cases should be mandatory, so that we could define its real incidence. By doing so, we will be able to reduce physician's stress, prevent the disease from turning into a tragedy and the malinger into a criminal, maybe even a murderer.

Bibliographic review

After the publication by Meadow5, a number of other reports were published. Bourchier2 reported a case of auricular hemorrhage and Rosenberg7, in 1987, revised the literature giving a very good overview of very frequent cases of bleeding simulation by mothers of patients, who used their own blood, raw meat or dyes.

The MSP described by Meadows was indexed as a factious disorder by proxy in Table 19-3 of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), referred by Jones4 in 1999. Therefore, it was classified as a psychopathology.

DiBiase6 described a dramatic case of MSP in one of his patients, who presented an operated cholesteatoma and had a narrow escape from a fatal outcome, leading the surgeon, to great anxiety and the readers to movie suspicion moments. The author emphasized the importance of separating the patient from his or her accompanying person in case of MSP suspicion, which is, according to Jones4, the mother in about 95% of the cases, followed by the father and the nanny.

Differential diagnosis

Differential diagnosis should be made with the disease that the patient intends to simulate. It depends on the level of suspicion of the physician and the performance of the malinger. Jones4 pointed to the fact that the clinical history is always fantastic and dramatic, full of exaggerated details that are sometimes obviously untrue. It is the socalled "fantastic pseudology". Sometimes the malinger includes truths in the history so as not be caught. If the suspected person is put away from the patient and he or she experiences improvement or remission of symptoms, the diagnosis of MSP becomes very likely. It is not always easy to accomplish that, especially because mother and infant are the main characters of the drama.

CASE REPORT

WWSB, 2 years and 5 months male patient. The parents brought the patient to Hospital da Aeronautica with history of bilateral otorrhagia, gingival hemorrhage and fever for four days. Upon the physical examination, the pediatrician detected oral monoliasis, but did not manage to perform a good otoscopy because there was wax and blood clots in the external auditory canals. Based on the suspected diagnosis of acute otitis media, the patient was hospitalized and medicated with oral cefalexine and topical nistadine.

During the three-week hospital stay, the mother stayed with the son, reporting alternated otorrhagia on the right and left ears, followed by vomiting, always at night, witnessed by her constant watch. It is important to point out that the mother used to dress only her underwear during the nights, despite the fact that she was staying in the hospital, which attracted the attention of physicians and allied staff as an awkward behavior. The otoscopy presented blood clots in the external auditory canal, which showed normal canal after aspiration. Coagulation test, temporal bone CT scan, and angiographic magnetic resonance were normal. Therefore, the patient was discharged to carry on outpatient follow-up.

The morning before the hospital discharge, the mother showed a large quantity of blood found on the sheets of the child's bed, an amount larger than any spontaneous otorrhagia could ever produce, except for cases of tumor.

The patient was referred to Hospital das Clínicas UFPE with suspicion of MSP.

The patient was hospitalized for microscopic otoscopy under general anesthesia. In the pre-surgical room, the mother called the attention of the medical staff to show bilateral auricular bleeding in the patient. Both pinna were full of dark clots.

After anesthetic inhalation with open mask and under microscopy, debris of recent and old clots were aspirated and washed from the right ear. The external auditory canal was intact. The tympanic membrane seemed to be bowed by the anesthetic insuflation. Exploratory myringotomy showed tympanic cavity with normal mucosa and fluid. A ventilation tube reel type Shepard was inserted. The same findings and the same procedures were followed on the other side.

When we left the operating room, the mother surprised us with the complaint of left ear bleeding, probably because of an old assault she had suffered from her husband, as informed by her. We immediately took the patient, who resisted our approach, to the operating room and found recent blood in the external acoustic canal and normal meatus and tympanic membrane.

We informed the mother that we had inserted "devices" into the boy's ears to identify the origin of the bleeding and asked the patient to come again one week later. However, they only showed up four months later. In fact, the mother got confused about us using the term "device" and though there were microcameras that would disclose her malingering, which has probably prevented her from coming to the hospital before.

DISCUSSION

Jones4 explained the behavior of the malinger by' proxy, also called perpetrator, by the psychological need to take the place of the patient in a indirect way. A number of needs motivate them.

Psychiatric studies showed that the perpetrator has a profile of intelligence and tenderness towards the patient. However, in some occasions, other motivations, such as financial issues, may be present, characterizing a picture different from the genuine psychotic syndrome, as described by Table 19-3 of DSM-IV4.

In our case, the suspect presented financial difficulties and seemed to be interested in having the child at the hospital, together with her as an accompanying person. One of the characteristics of the perpetrators is that of hiding its role in the simulation process. They rarely confess and if catch in the act, they may commit suicide, especially if belonging to the genuine psychosis group, with no material interests.

It was definitely not the characteristic of our perpetrator. She did not act intelligently and exaggerated the simulation of bleedings in a very suspicion way. She used to stay half-naked in the ward and had a vulgar approach with the staff. She did not have the "ideological" profile of psycho patients. She would never commit suicide if caught in the act, which happened in fact when we examined the child's ears and her own and did not find anything. We believed that it was a mixed disorder, combining psychopathology and another factor.

Another characteristic of the perpetrator is to remain all the time close to the patient. Thus, the actions are easily and well performed and the person is able to see the medical measures taken, monitoring his or her own.

These characteristics are useful to diagnose MSP because if the suspected person is taken away from the patient, the symptoms disappear. It was not possible to separate the mother from the child in the first hospital they visited because the mother refused to do so.

FINAL REMARKS

The classic Münchausen's syndrome described by Ascher1 normally affects adults older than 20 years and the physician should be alert to this fact. Suspects should be treated with intelligence and common sense so that they do not realize they have been included in the risk group and do not improve their simulation. In MSP, everything should be performed as is, but the emotional factor may interfere negatively. It is normally a child that is used or maltreated by the mother directly or through induction to unnecessary tests, which may be invasive sometimes, such as CT scans, endoscopies or exploratory surgeries. When the diagnostic suspicion of MSP is considered, the aspect of cruelty with the child is revolting and the concept of psychopathology is sometimes overcome by rage.

The indignation of the professionals involved in the treatment of the child may hinder the remaining investigation, causing the evasion of the suspect and the patient. And if the perpetrator has been trained by the experience, he or she will not make the same mistake twice, but will look for another doctor. They usually leave name and address as untrue as the disease. The suspect should be treated with cordiality and respect as all psycho patients, not only because of the ethical issue but also because it is easier to come up with the diagnosis without scaring the perpetrator or convicting him or her prematurely. The physician has to be creative and prudent, a real detectives are. One eye in the suspect, another in the child. Both eyes, though, should be wide open to the possibility of false negative diagnosis, comprising the child, or false positive diagnosis, complicating the life of the physician because he or she will then become the suspect.

REFERENCES

1. ASCHER, R. - Münchausen's syndrome. Lancet, 1:339, 1951.
2. BOURCHIER, D. - Bleeding ears: case report of Münchausen syndrome by proxy. Aust. Paediatr J. 19:256-7, 1983.
3. CALDAS NETO, S.; DUPRAT, A.C.; ALMEIRA, R.R. a CALDAS, N. Doenças fictícias em otorrinolaringologia. Caderno de ORL a Cirurgia de Cabeça a Pescoço. Folha Médica, 104 (5):177, 1992.
4. JONES, R.M. - Transtornos Factícios. In: KAPLAN, H J. & SADOCK. B. J. - Tratado de Psiquiatria 6ª Ed. Vol. 2, Porto Alegre, 1382-90, 1999.
5. MEADOW, R. - Münchausen by proxy: the hinterland of child abuse. Lancet, 2.343, 1977.
6. P. DiBIASE, P.; TIMMIS, H.; BONILLA, A.J.; SZERMETA, W. & POST, C. - Münchausen syndrome by proxy complicating ear surgery. Arch. Otolaryngol. Head and Neck Surg. 122:1377-80, 1996.
7. ROSENBERG, D. - Web of deceit: a literature review of Münchausen syndrome by proxy. Child. Abuse Negl. 11:547-63, 1987.

1 Faculty Professor of Otorhinolaryngology, UFPE.
2 Joint Professor of Otorhinolaryngology, UFPE.
3 Resident Physician (R3) of Otorhinolaryngology, HC/UFPE.
4 Resident Physician (R2) of Otorhinolaryngology, HC/UFPE.
5 Second Lieutenant - Physician with the Air Force - PE.

Discipline of Otorhinolaryngology, Department of Surgery, UFPE.
Address correspondence to: Nelson Caldas - Avenida Boa Viagem, 2514 - Apt° 1202 - Boa Viagem - 51020-000 Recife /PE - Tel/Fax: (55 81) 3326-5746.
Article submitted on February 13, 2001. Article accepted on February 22, 2001.

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