Psychiatrist: Munchausen Syndrome by Proxy is almost impossible to diagnose and cannot be treated

Leading expert says it can't be treated at all, but patients are aware of wrongdoing.

By JUDY SIEGEL-ITZKOVICH
A veteran Israeli psychiatrist who has treated three or four cases of Munchausen Syndrome by Proxy (MSP) against children syndrome and diagnosed the world's first case of such abuse against adults maintains the extremely rare condition cannot be treated. The only thing that can be done is to supervise the abuser and her family very carefully for years, to protect the children from abuse until they are old enough to defend themselves, Prof. Mircea Sigal, former director of the Lev Hasharon-Pardessiya Psychiatric Hospital, told The Jerusalem Post on Tuesday. Sigal has read in the media about the Toldot Aharon hassidic woman in the capital who is suspected of starving and abusing her three-and-a-half-year-old son, but does not have privileged information about the case. But he has studied the syndrome for decades and believes it combines both child abuse and the self-controllable urges to get appreciation and to stay close to medical professionals. In most cases, he declares, the person with MSP wanted to become a doctor or nurse but did not achieve this desire, Sigal said. Sometimes the parent (or rarely, another caregiver) just tries to make the child sick; in others, the parent actually makes him ill. An Orthodox Jerusalem psychiatrist, Dr. Ya'acov Weill, met the woman in this case for an hour late Monday night and said he needed several more sessions with her before he could make a recommendation. He would not given any details because of privacy rules. The police have claimed that she not only starved her child at home over a period of two years but also disconnected his feeding tubes at Hadassah University Hospital until they reached the conclusion that she had MSP. In 1984, Sigal described the case of an Israeli man who secretly injected gasoline into the backsides of his wife and mistress, causing one of them to die and the other to become paralyzed. The man, however, demonstrated great concern and love for the women, which tricked the doctors and law enforcers who were involved in the cases. The first case of ordinary Munchausen Syndrome, in which the usually masochistic person secretly causes harm to himself and constantly seeks medical care, was diagnosed by British physician Richard Asher in 1951. The world's first case of MSP, in which the perpetrator has a "sadistic and narcissistic nature" and secretly harms another person, was diagnosed by pediatrics Prof. Roy Meadow of Leeds, England, in 1977. The patient, unusually, was sentenced to 35 years in prison. Meadow discovered that one MSP mother took her own menstrual blood and mixed it with her child's urine to make him look sick; another case involved a child poisoned with table salt by his mother. Only 2,000 cases of MSP have been diagnosed and recorded in the world since the first case, said Sigal. It is almost always mothers who are involved, as "mothers regard their child as a part of themselves - as an ovary - and feel they have the right to hurt them," he said. Psychiatrists have also discovered Munchausen by proxy cases in which owners of a dog or cat torture their pets and obsessively take them to a veterinarian after doing them harm, Sigal reported. It has been extremely rare for MSP patients to be jailed, he continued, as it is very difficult to prove except with film or other tangible evidence that the person in fact harmed the child intentionally. There have been other cases, like the one in Jerusalem, in which friends or relatives protested against a hospital that claimed the patient suffered from MSP. The syndrome, said Sigal, is named for Baron Karl Munchausen, an Austrian soldier in the 18th century who wrote a book in which he described a military officer who told a lot of lies. He was ejected from the military and wandered. "In fact, Munchausen by proxy patients often wander and look for new places," said Sigal. What unites all Munchausen patients, both by proxy and against themselves, is that they want to be respected and admired and also want close contact with medical institutions and professionals. For decades, there has been an argument among psychiatrists whether MSP is a psychiatric disorder that can be diagnosed by examination of the patient, or a behavioral disorder like child abuse for the sake of hurting others but not a mental disorder. Sigal supports the first theory. "But I don't think it can be diagnosed by psychiatric examination, not after an hour or several hours of it," Sigal declared. "Determining what should be done has been according to whether the child will benefit or suffer from being reunited with the abusive parent," he continues. "But the parent is able to distinguish between good and evil and knows she is causing harm to her child, thus legally she is responsible for her actions and is liable to prosecution." Since Sigal last checked 25 years ago, not a single Munchausen by proxy patient has been jailed, except for the 1977 case. He said that he is sure that six months ago, the Hadassah pediatricians and nurses who took care of the hassidic toddler "thought the woman was an excellent mother, and that even today, her husband thinks the same. They did not realize then what she was doing. This child is gaining weight and improving, and he will probably recover physically - but recovering mentally is not simple. He could easily bear the scars." In some cases, Munchausen by proxy patients focus on a single child; in some where the parent has a large family, they pick on two or even three, according to medical literature studied by Sigal. Prof. Eliezer Witztum - a psychiatrist and faculty member at Ben-Gurion University's School of Health Sciences and director of psychotherapy supervision at the Beersheba Mental Health Center, as well as senior psychiatrist at Herzog Hospital's Community Mental Health Center in Jerusalem - has a different view. He thinks that written and/or computerized tests can help diagnose Munchausen by proxy, yet evidence in the form of photographs and films really determine whether the suspect suffers from the syndrome. "I regard it as a personality disorder, a factitious disorder with physical signs - not a psychosis. It cannot be diagnosed after an hour's examination by a psychiatrist. One can learn something, but diagnosis takes days. The initial psychiatrist can recommend whether the parent should be sent for psychiatric observation." Witztum, an expert in in cultural psychiatry, trauma and bereavement and dynamic psychotherapy who says he has treated a few cases in the past 30 years, conducted an epidemiological study of Munchausen by proxy and found that 90 percent involved mothers, 5% were fathers and the rest other caregivers. "It is difficult to diagnose, however, and mostly by eliminating other suspected causes. Having documentation is the main factor." He thinks patients do benefit from "psychotherapy and psychoeducation." But the problem is that doctors who treat victims of the syndrome in hospitals "have to become detectives. That is not good, because doctors are naturally trained to believe their patients. One should not suspect a specific community or any parent who brings in a child with unusual symptoms, but one must be alert." Dr. Alexander Grinshpoon, director of the Sha'ar Menashe Mental Health Center in Hadera and formerly the Health Ministry's director of mental health services, said the origin of Munchausen by proxy is "displacement - they worry about their own health and transfer it to heir children. They want to be close to medical facilities. It is not a psychosis but a developmental and personality disorder." Grinshpoon believes that cognitive behavioral therapy can be beneficial in the short term and dynamic psychotherapy in the long term. "The urge in patients to harm children or to make them look ill is not subconscious; it may be preconscious." He suggested that psychiatric observation would not help much in diagnosis; rather, collecting information about the suspect's childhood behavior "will help." He admitted that this would be extremely difficult in a closed, anti-Zionist sect such as Toldot Aharon hassidim, but hopes some of its rabbis would allow such testimony "for everyone's benefit." In any case, he concludes, "the family must be under close supervision to prevent further harm to the children."