Munchausen Syndrome by Proxy: An Adult Dyad

Munchausen Syndrome by Proxy: An Adult Dyad

Psychosomatics 2012:53:294 –299 © 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved. Case Reports Munchause...

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Psychosomatics 2012:53:294 –299

© 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Case Reports Munchausen Syndrome by Proxy: An Adult Dyad George W. Deimel IV, M.D., M. Caroline Burton, M.D., Sania S. Raza, M.D., Julia S. Lehman, M.D., Maria I. Lapid, M.D., J. Michael Bostwick, M.D.

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unchausen syndrome by proxy (MSBP) is a form of abuse in which an individual deliberately produces or feigns clinical illness in a person under his or her care. Although well-documented in the child and adolescent literature, few case reports document MSBP with an adult proxy. We describe two patients: (1) Ms. A, a 21-year-old female, with recurrent episodes of polymicrobial bacteremia of unknown etiology, and (2) Ms. B, a 23-year-old female, with a history of a recurrent painful rash involving the pudenda. In the first case, medical staff found in the patient’s bed a syringe with an uncapped needle that contained a cloudy substance that grew the same organisms found in her blood. In the second case, the rash responded to topical treatment but dramatically worsened on the day of planned discharge. When the mother’s visitation was restricted and supervised, the rash immediately improved. Although typically reported in pediatric patients, MSBP should be considered in adult dyads when a patient’s medical problems do not respond as expected to therapy, and a caretaker appears overly involved or attention-seeking. Victims may suffer from “Stockholm syndrome,” holding the caretaker in high regard despite danger, even at risk of death. Munchausen syndrome by proxy (MSBP) is a mental illness characterized by a caregiver—the perpetrator— deliberately producing or feigning physical or psychological signs or symptoms in another person—the victim—who is under the perpetrator’s care.1 The perpetrator’s psychological needs are met through the attention he or she receives during medical evaluations of their charge, even as induced conditions and iatrogenic complications can cause victims significant morbidity and even mortality. While MSBP is well described in the pediatric literature,2 only seven cases have been reported with adult victims,3–9 and in three of these cases, the perpetrator was the same person. We believe that MSBP with an adult victim is underrecognized. We present two such cases with the objective 294

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of increasing awareness among medical professionals that MSBP can occur in adult dyads, with potentially devastating consequences.

Case Report 1

Ms. A, a 21-year-old female college student who lived at home was hospitalized with fever and persistent bacteremia despite appropriate antimicrobial therapy. She had in place a central intravenous catheter (Port-A-Cath) for administration of intravenous fluid boluses to treat postural orthostatic tachycardia syndrome (POTS). She also had a history of Arnold-Chiari malformation type-1 with multiple cervical decompression surgeries. Two months prior to admission, Ms. A had been admitted to a local hospital with a fever. Blood cultures showed growth of Enterobacter agglomerans and Curtobacterium, presumably from a contaminated Port-A-Cath, which was removed. Based on bacteria susceptibilities, she was administered vancomycin HCL and levofloxacin. A percutaneously inserted central catheter (PICC) was placed after blood cultures remained negative for 48 hours. Several days later she again became febrile. Blood cultures revealed growth of the same organisms. She was transferred to another facility where PICC cultures, CSF fluid analysis, and MRI of the brain and cervical spine were negative. After 4 weeks of antimicrobial therapy, the feReceived February 3, 2011; revised April 26, 2011; accepted April 27, 2011. From Department of Medicine, Mayo Clinic, Rochester, MN (GWD, MCB, SSR); Department of Dermatology, Mayo Clinic, Rochester, MN (JSL); Department of Psychiatry, Mayo Clinic, Rochester, MN (MIL, JMB). Send correspondence and reprint requests to M. Caroline Burton, M.D., Department of Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905; e-mail: [email protected] © 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

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Deimel IV et al. vers persisted. Her mother requested transfer to our facility. Upon admission, the mother was extremely inquisitive about her daughter’s evaluation, stating that “nobody else could figure out what was wrong.” The mother, a medical secretary, described her own suffering from multiple medical problems and asked in her daughter’s presence to be alerted to all of her daughter’s test results. The daughter gave verbal consent to share all information about tests, procedures, and labs with her mother. Physical examination showed a well-nourished female appearing younger than her stated age. She wore Disney character pajamas, had with her in bed stuffed animals and a personal blanket, and with a childlike affect deferred all questions to her mother. Vital signs on admission were temperature 37.2 °C, blood pressure 79/55 mmHg, pulse 131 beats/minute, and respirations 12/minute with 98% oxygen saturation on room air. Physical examination was unremarkable except for the tachycardia and a PICC line in her right upper arm. CBC, electrolytes, and urinalysis were unremarkable. A CT-abdomen/pelvis was negative. A transesophageal echocardiogram revealed a superior vena cava sleeve thrombus at the PICC site. Ms. A and her mother initially refused PICC removal, insisting that the line was needed to administer fluids for treatment of POTS. They agreed to removal when assured it would be replaced. On hospital day 2, blood cultures returned positive for Enterobacter cloacae and Pantoe agglomerans. Vancomycin HCL and levofloxacin were started empirically and continued when the organism proved susceptible. Ms. A received hydromorphone via PCA for generalized pain. On hospital day 5, after blood cultures had been negative for 48 hours, a new PICC line was placed. On hospital day 6, a physician found a syringe containing cloudy fluid with an uncapped needle underneath Ms. A in her bed. The physician at first believed medical personnel had accidentally left the syringe and apologized. The mother became upset and demanded a prompt investigation; Ms. A remained silent. The medical team subsequently learned that this brand of syringe was not used at this facility. When Ms. A and her mother were informed of this discrepancy, the mother admitted that the syringe belonged to the daughter and contained ondansetron. Ms. A had been unable to dispose of the syringe in the hotel, she said, and it had fallen out of her daughter’s bag. Ms. A did not comment. As a potential MSBP scenario unfolded, the team increasingly questioned who was making the decisions for the patient Psychosomatics 53:3, May-June 2012

and whether the patient herself was equipped to negotiate on her own behalf. Because of its concerns, the medical team sought advice from legal counsel who recommended a full room search and psychiatric evaluation in the event that Ms. A attempted to leave against medical advice. The evaluating psychiatrist opined that she had the capacity to make medical decisions and showed no evidence of underlying psychiatric disorder. Within 4 hours of discovery of the syringe, the mother requested that her daughter be discharged, insisting that she had made follow-up arrangements with local physicians for her daughter to receive antibiotic therapy through outpatient infusion therapy. Approximately 24 hours after discovery of the syringe, toxicological analysis revealed the fluid in the syringe to be hydromorphone. Fluid cultures grew Enterobacter cloacae and Pantoe agglomerans. In arranging follow-up care, the primary team communicated to the patient’s local physician its suspicions about MSBP based on the hospital course, the behaviors of the patient and her mother, and toxicological and microbiological analysis of the fluid contained in the syringe. The medical team recommended that the PICC be removed after she completed antimicrobial therapy. Three weeks after discharge and 2 days before her scheduled follow-up with her physician for PICC line removal, Ms. A appeared at her local emergency department with fever and hypotension. Despite resuscitative efforts, she died from overwhelming sepsis. Ms. A’s local physician called the team and reported that her blood cultures showed growth of multiple organisms including those commonly found in “ear wax.”

Case Report 2

Ms. B, a 23-year-old female student presented to her local emergency department with disorientation that medical personnel believed resulted from a recent increase in her pregabalin dosage to control pain associated with a rash involving her pudenda. The disorientation resolved without intervention, but she was found to be hypoxic and was admitted. The following day, her mother requested transfer to our facility for further evaluation of the rash. The admitting physician found Ms. B sitting in her hospital bed in the lithotomy position, undressed and uncovered below the waist. While she wept, her mother massaged her shoulders and exposed legs. According to the mother, the rash had begun 4 years earlier in her www.psychosomaticsjournal.org

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Case Reports daughter’s vaginal area and had been initially diagnosed as a yeast infection. Treatment with intravaginal miconazole “made the rash worse,” she said. Her pain continued, and they consulted numerous healthcare providers, including a homeopath, who performed chelation therapy with EDTA. Ms. B underwent a cystoscopic examination that was negative and had trigger point injections that failed to alleviate her pain. Interviewed alone, Ms. B reported that she still lived at home with her “very religious” parents, had had a wonderful childhood, and was close to her mother whom she admired because she “suffers bravely with back pain” that had resulted from a car accident. Her father cofounded a nondenominational church in which she was active until she became ill. She insisted that her parents did not cause her medical problems. She denied physical, verbal, or sexual abuse. She said she was not sexually active. Her admission medication consisted of numerous topical agents, including benzocaine 5% compounded cream and spray as well as silver sulfadiazine 1% cream applied to her pudenda, and parenteral morphine sulfate and pregabalin. Vital signs included a temperature of 36.7 °C, respiratory rate of 20 breaths/minute, blood pressure of 118/66 mm Hg, and a pulse of 118 beats/minute. She appeared younger than her stated age, an effect enhanced by the stuffed animals in her bed and her Tweety Bird pillowcase. Blue discoloration of her lips and nail beds was evident. Skin examination showed a well-demarcated, erythematous and edematous rash with superficial erosion involving the pudenda and medial thighs (Figure 1). No other mucocutaneous lesions were noted. Cardiac, lung, and abdominal exams were unremarkable. An arterial blood gas showed a pH of 7.43, a PO2 of 118 mm Hg, a PCO2 of 45 mm Hg, a HCO3 of 29 mm Hg, a measured O2 saturation of 78%, and a MetHb of 15% (0%–1.5%). Because of methemoglobinemia Ms. B was treated with intravenous methylene blue. Her cyanosis resolved, and subsequent blood gas showed a measured O2 saturation of 90% and MetHb of 4%. Other significant laboratory findings included a lidocaine level of 2.9 ug/mL (2–5 ug/mL), Hb 9.1 g/dL (13.5– 17.5 g/dl), and haptoglobin ⬍ 14 mg/dL (20 –200 mg/dL). Heavy metal screen was significant for an elevated serum silver level of 20 mg/mL (0 –14 mg/mL). Peripheral blood smear showed acanthocytes, bite cells, and helmet cells. Outside records indicated Ms. B had had methemoglobinemia 4 months earlier believed to stem from the lidocaine in her topical anesthetic agents. Records indi296

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FIGURE 1.

Rash with Superficial Erosion.

cated that the physician had instructed the patient and her mother to discontinue these medications. Dermatology believed the rash represented an irritant contact dermatitis. Hematology believed the patient’s hemolytic anemia resulted from the silver in one of her topical ointments. She was told to stop using all home topical skin-care products. She received wet dressings, initially with sterile saline and a bland emollient and later, with dilute Sweitzer’s solution and hydrocortisone 2.5% cream. Even though nursing staff customarily does dressing changes and the patient was capable of doing them herself, the mother insisted on performing the dressing changes. Ms. B’s mother never left the hospital room. During rounds she animatedly answered all questions the team asked the patient. On hospital day 3, the unit secretary received an anonymous call in which the caller stated, “keep the family away from [the patient].” On hospital day 4, with the rash significantly improved, Ms. B and her mother were told that she would be discharged the next day. The following morning, however, the patient was distressed, crying, and complaining of pain from the rash. Her mother was at the bedside massaging Psychosomatics 53:3, May-June 2012

Deimel IV et al. her arms and legs. Skin examination showed worsening of the rash. Cutaneous biopsy from a new area of suprapubic edematous erythema showed chronic dermatitis with mixed dermal and pannicular granulomatous inflammation with eosinophils, consistent with irritant contact dermatitis. Because the team suspected MSBP, it ordered one-toone nursing. The mother’s visits were restricted to 30 minutes three times a day, and only nursing staff members were allowed to apply topical treatment to the rash. The mother became distraught. She complained of poor medical care and requested a different physician. Her husband arrived and similarly complained. Psychiatry found no evidence of psychiatric disorder and determined that Ms. B had capacity should she decide to leave. The team consulted county officials about its obligation to report Ms. B as a vulnerable adult but was told that individuals with capacity by definition could not be considered vulnerable adults. She continued to deny that her mother had harmed her or worsened her rash, and she cooperated with continued therapy. She again experienced rapid improvement in the skin eruption and was discharged 2 days later. She reportedly continued to seek care at other area care providers for a recurrent rash.

Discussion

Our objective is to raise awareness of MSBP in adults. Although well documented in the pediatric and adolescent literatures, our two cases represent the first reports of MSBP in which the dyads perpetuating the deception consist of a parent and an adult child with presumably normal intelligence. There are a few reported cases of recurring unexplained illness in elderly patients believed to represent MSBP which emphasize the need to identify elderly abuse.5–9 Our cases of MSBP involving adult victims present a different relationship dynamic with the perpetrator than those referenced in pediatric or elder cases. Our cases also exemplify diagnostic challenges that result, particularly when the spectrum of factitious disorders is not included, in the differential diagnosis for this population. There are a unique set of difficulties when two adult individuals are collaborating in deception of the healthcare system or if the victim does not regard the abuse as harm. Other potential pitfalls in the successful recognition of this disease is the manipulative nature of the perpetrator, a general lack of awareness among healthcare Psychosomatics 53:3, May-June 2012

staff, and the potentially harsh repercussions for the victim, who on the one hand risks the loss of the symbiotic relationship with the parent and on the other hand faces potential permanent disability or even death at the behest of that same parent. While we encourage increased vigilance for this disorder, we also recommend a comprehensive medical evaluation as there are devastating repercussions associated with incorrectly identifying MSBP. There are other explanations and conclusions that could be drawn from the series of events outlined in our cases, which highlight the difficulties of management, let alone diagnosis, that these cases present to the clinician. First, it is possible that the syringe Ms. A was using for injection was contaminated by her blood prior to or during the hospitalization and not vice versa. However, the circumstances surrounding the syringe are highly suspicious for self-injection during the hospitalization. Ms. A’s mother insisted that the syringe contained odansetron. It did not. It contained hydromorphone. Ms. A was receiving hydromorphone via continuous intravenous infusion. We suspect that this was the likely source of the medication as there was no history of intravenous hydromorphone use as an outpatient and an uncapped needle was attached to the syringe, which would allow for easy access to the infusion through a port. Secondly, her mother said the syringe could not be disposed of at the hotel. We contacted the hotel, a facility well-equipped for caring for medical patients, and learned that sharps containers were readily available for syringe disposal. Third, even if Ms. A was injecting odansetron, which she denied, there was no reason for her to do so. The admitting physician ordered the medication on an as-need basis. We believe the key point is that Ms. A was most likely surreptitiously accessing her IV line. In the second case, we suspect that the cause of the irritant contact dermatitis was one or several of the numerous topical preparations being applied to the area by her mother. The initial source of the dermatitis could not be identified but we believe that the mother caused the rash since she performed all wound care. Given the deception at the core of factitious illness, medical teams can rarely be absolutely certain about the diagnosis. Nevertheless, we tallied the circumstantial and objective evidence, and argue that these two cases fit criteria for MSBP. Several alternative conclusions can certainly be drawn from these cases and should be considered. First, the patients could have been willing participants absent coercion, force, or brainwashing in their mothers’ plans. We believe this is unlikely because www.psychosomaticsjournal.org

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Case Reports the harm was more severe and painful than a reasonable person would allow. Secondly, the cases could simply represent Munchausen syndrome. This may represent the most logical alternative explanation although unlikely given how passive and deferential the patients were to their mothers. Third, it is possible that the patients and mothers participated equally with the malfeasance; however the relationship dynamic in each case, a domineering mother and a passive daughter, supports dual but certainly not equal participation. Because of our high degree of diagnostic certainty in both cases, legal counsel advised us to clearly document our concerns in the patients’ records, and we listed Munchausen syndrome by proxy as a discharge diagnosis in each case. With regard to victim participation, we propose an explanation that our victims suffer from “Stockholm syndrome,” a condition in which a victim holds a perpetrator in high regard despite what others might consider brainwashing and torture. Stockholm syndrome is a psychological phenomenon without clear diagnostic criteria and is not recognized formally as a mental disorder. Stockholm syndrome is used to describe a psychological response whereby victims form a bond and a seemingly positive identification with their captors.10 The circumstances that initiate the syndrome typically involve the captor threatening the survival of the victim through either fear or deception, creating a sense of helplessness where the victim feels there is no escape, isolating the victim so the perpetrator can manipulate the environment to create a false reality, and fostering a sense of dependence in which the victim relies on the perpetrator for all basic needs.11 We contend that it is possible that a person with Stockholm syndrome may demonstrate decision-making ability but lack the capacity to act in his or her best interest. The psychological defect is the victims’ loyalty to and apparent collusion with those who perpetrate harm, as in the cases of the Stockholm bank employees (1973), Patty Hearst (1974), the passengers of TWA Flight 847 (1985), and Jaycee Lee Dugard (2009). If Stockholm syndrome were formally recognized as a mental disorder, we believe we would have had grounds to proceed with police involvement or protective custody just as we would with a patient who has decision-making capacity and yet is suicidal or homicidal. In our two cases, when separated from their mothers, both victims repeatedly denied being abused, whether due to an inability to recognize their respective situations as potentially dangerous or through conscious efforts to protect the perpetrators. This is in contrast to previously published cases of MSBP with adult proxies where the same 298

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adult perpetrator produced illnesses in three different adult victims without their knowledge, a wife, girlfriend, and prison cellmate.3,4 The other cases involved a developmentally delayed 21-year-old adult whose mother was fabricating illness12 and unexplained recurring illness in elders under the care of another person.5–9 In our two cases, consistent with simple factitious disorder, both dyads fled when confronted, and sought treatment elsewhere with new medical providers who were presumably unaware of the deceptive behaviors. Moreover, psychiatrists judged both victims—to our surprise—to possess capacity, the ability to understand relevant medical information, and to appreciate in a reasonable manner the potential consequences of a decision. Our efforts to seek county intervention under vulnerable adult statutes were then stymied when we were told that individuals with capacity could not legally be considered vulnerable adults. In the end, we were left hoping that our expressions of concern to the patient–mother dyads would help deter future harmful acts and lay the foundations for the victims to seek help in the future. Unfortunately, this will never happen in the first case, as the patient died of sepsis shortly after dismissal from our hospital. To date it has not happened in the second case as she and her mother, consistent with a factitious disorder diagnosis, have continued to seek care at other area hospitals.

Conclusion

These two cases illustrate the importance of physicians including MSBP in the differential diagnosis of adult patients presenting with (1) a complex constellation of symptoms, (2) with no unifying etiology, and (3) an overly involved caretaker who appears to be receiving secondary gain from the patient’s treatment. Recognition is critical so that affected patients can be identified early before healthcare providers unknowingly perpetuate further victimization through treatments that satisfy the perpetrator’s psychological needs at the expense of the patient. While patients may need treatment for induced pathology, as both patients in these two cases did, the key is in the medical providers recognizing the factitious nature of the pathology. The stakes are high. Victims can die as a consequence of caregiver-inflicted illness, as the patient in our first case did. Furthermore, healthcare providers need to be Psychosomatics 53:3, May-June 2012

Deimel IV et al. able to seek consultation to formulate effective medical, psychiatric, and legal strategies when caring for adult dyads with this catastrophic disorder.

Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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