An unusual case of Munchausen syndrome by proxy

Sir,

Munchausen syndrome is a well-known syndrome in adults, but Munchausen syndrome by proxy is a poorly understood entity where a parent fabricates an illness in his child. We present a case for its unusual presentation and discuss the related nosological issues.

A 12-year-old girl was referred to psychiatric services by the department of otolaryngology after removing the dead houseflies from the child's ear on multiple occasions. The child was admitted to the psychiatry unit with her parents. Child's ears were plugged with cotton wool. However, the mother had removed the plugs and dead flies continued to appear in child's ear. Computed tomographic scan of temporal bone was normal. Tympanic membranes of both ears were intact. ENT specialists were of the opinion that the flies were introduced ‘deliberately’.

Mother appeared to be overconcerned and never allowed the child to be alone. The specialists suspected mother's involvement in the act, and therefore she was sent home. From the next day itself, no flies were found in the ear. But when the child was sent home on leave, she again came back with flies in her ear. During the rest of her stay, no further incident took place. Father could see the association between child going home and flies in the ear. A family meeting was called. Mother attended the meeting reluctantly and demanded immediate discharge. When pacified, she was able to understand the concerns and confessed to covert introduction of dead flies into child's ear.

The child had borderline intellectual functioning (IQ 80). Mother had received treatment for generalized anxiety disorder and also for dissociative disorder in the past.

Meadow was the first to describe children presenting with symptoms of an organic disorder, which resulted from manipulations initiated by their caretakers (usually the mother) and introduced the term ‘Munchausen syndrome by proxy’ (MSP).[1]

The perpetrator denies knowledge of the origin of illness, resulting in multiple investigations and treatments. Meadow[2] suggests that the presence of unexplained persistent or puzzling symptoms should alert for the diagnosis of MSP.

What motivates mothers remains unanswered. The parental investment theory by Saad[3] suggests that the same mechanism that predicts that women should be the ones to provide greater investment to their children can at times ‘misfire’ by having psychiatrically damaged women create conditions that signal to the world their attentive and laudable parental care.

The Royal College of Pediatrics and Child Health[4] suggests a new nomenclature, i.e., fabricated or induced illness by careers, shifting the focus to child abuse that happens in medical setting, to minimize harm to the child regardless of the motivation of the perpetrator.[5]

The management of MSP is not that easy. Ruling out the organic nature of presenting symptoms is important. Harm reduction remains to be the main aim. Child protection services and legal services may be involved depending on the severity of MSP.

In our case, we made use of the familial support system and the child could safely be placed back with the family.

This case further makes us think that MSP often considered a problem of developed societies is no longer considered so. It is likely that MSP remains unrecognized in this part of the world and we need to be more aware of such presentations.