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Laboring in the Shadow of the Media: Care and Perceptions of Care in the VA
Just over 2 years ago, I finished a psychiatry residency at the Mayo Clinic, turned down an offer to stay on staff, and topped it off by taking a position at the VA. Not one of my brighter moments—or so one of my friends thought. “Are you off your rocker? Don’t you know that the VA is terrible? Why would you go work there?” he jabbed incredulously. I cringed, knowing that I had passed up an opportunity to stay in arguably the best hospital system in the nation, possibly the world, to work at what some (maybe even a lot) view as a corpulent and recalcitrant bastion of ineptitude bound by the dictates of a fickle Congress.
In the wake of the Phoenix wait-time scandal (and no, it’s not like Disneyland), the suicide by self-immolation of Charles Richard Ingram III outside a VA facility in New Jersey, the new data on veteran suicide showing progress but continued significant concern, and the ongoing VA privatization discussion, the prevailing discourse about the VA is largely negative.1,2 And in a high-voltage election cycle where public outrage can serve as an efficient tool to garner support, the VA risks getting pummeled.
Add to this the shocking research that shows nearly half of VA psychiatrists are considering leaving the VA within the next 2 years, and it’s clear that dissatisfaction within and outside the VA is high.3 This does not bode well for veterans at a time when suicide and mental health care needs are so critically important. But while the bureaucracy of the VA is often the focus of negative press, it also filters down and unfortunately has the potential to directly affect VA practitioners and veterans. When we lose sight of what the VA does well, we risk being caught up in a vortex of negativity and a profound sense of inadequacy and helplessness. More attention to what is already being done well can help us as a nation more realistically chart a path forward rather than being fueled by negative rhetoric and rage.
Despite the challenges, the VA is currently succeeding in a number of areas that deserve recognition:
Medical school and resident education and collaboration with VA. In 2014, > 41,000 medical residents and nearly 23,000 medical students had some or all of their training in a VA setting. More than 95% of allopathic medical schools and nearly 90% of osteopathic medical schools had affiliation agreements with the VA in 2014.4 Suffice it to say, if the educational endeavors of the VA were curtailed, there would be an unholy scramble to provide well-trained physicians for our nation. (This does not include the dentists, psychologists, pharmacists, social workers, nurses, and other health care professionals whose training involves the VA in some capacity.) In addition, the VA often provides loan repayment assistance, which is very important given that many young professionals carry substantial school debt after completing training.
Mental health and primary care integration. Medical care overall is changing, and there is an increasing shift away from volume-based, fee-for-service care to integrated, team-based models. The VA is one of several successful leaders at a time when most U.S. health care providers are being scrutinized for their use of health care dollars and overall national health outcomes.5 In addition to primary care integration, the VA uses home-based primary care and mental health intensive case management teams for vulnerable veterans, adding flexibility, continuity, and access for many.
Overall excellent mental health care. A recent study by Watkins and colleagues found that when comparing quality measures for medication evaluation and management for schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, and substance use disorders, “In every case, VA performance was superior to that of the private sector by more than 30%.”6 This is not an aberration and not limited to mental health care. It is a consistent finding about which books have been written.7 However, the availability of evidence-based care may not be consistent across all VA facilities nationally, depending on demand and staffing.
Despite the rumors, VA has high customer satisfaction. According to the American Customer Satisfaction Index, the VA has consistently performed well in measures of customer satisfaction compared with those of the private sector health care providers.8 Let’s not ignore what veterans have actually said and continue to say about their care.
Once in, you’re in! I recently missed an initial appointment with a private sector pediatrician for one of my sons. I was tersely invited to find another doctor. This seemed scandalous since I have become accustomed in my role as a VA physician to reaching out, sometimes incessantly, to patients who do not come in for either a new or follow-up appointment. Yes, I call my patients; personally, directly, and often. In many clinics, patients receive reminder letters about upcoming appointments and then phone calls and sometimes letters when appointments are missed. My colleagues and I have jokingly referred to this practice as “benign stalking.”
Further, if a veteran is dissatisfied with care, there is a process to review and make adjustments if necessary, including transfer to a different doctor. Additionally, and sometimes alarmingly, veterans are not “fired” (and actually can’t be) for bad behavior (including direct threats to VA staff). Time, place, and manner of care can be tailored based on assessed risk, and VA police may be involved, but veterans continue to get care. I can assure you that if I made a threat to one of my doctors in private practice, I would very quickly be searching for a new doctor and answering some tough questions from law enforcement. Unlike many patients in private care, veterans have consistent access via phone (though admittedly not always user-friendly), walk-in appointments, after-hours availability in some locations, and secure messaging.
Electronic medical record and telehealth initiatives. The VA Computerized Patient Record System, has been around for some time and provides an excellent (although not perfect) system for documenting patient care. Each VA is linked to other VAs across the nation so patients don’t have to reinvent their story when they move and can actually get down to the business of being treated. Prior interventions, hospitalizations, medication trials, diagnostic impressions, imaging, lab work, etc, are all available at the touch of a button! And the VA’s telehealth initiative is all about access.
Veteran suicide prevention and opioid prescribing. Suicide is disproportionately high among veterans in the U.S. Recent data show that in 2014, an average of 20 veterans died by suicide per day.1 This accounted for 18% of all U.S. adult suicide deaths, even though veterans represent only 8.5% of the population. And while these recent statistics represent some improvement over prior research, prevention and care coordination remain major priorities in the VA. Veterans have access to same-day care (at least in Boise, Idaho) and a 24-hour crisis line that gives feedback to the patient’s local VA and can help coordinate follow-up care. The VA has specialized suicide prevention coordinators who attend to the needs of patients assessed to be at high risk for suicide and also disseminate training to providers in a variety of disciplines. All of this as the VA moves to ensure that suicide prevention remains a priority across disciplines and treatment sites.
Additionally, the VA is directly addressing the nationwide crisis of overprescription of opioids, beginning with education for both patients and staff and systemic encouragement of responsible prescribing via the national Opioid Safety Initiative and increased emphasis on providing at-risk veterans with naloxone kits.9
Research. VA research endeavors are wide ranging. The VA has been involved in pioneering clinical research in a substantial way since at least the 1920s and has contributed to important innovations in treatment, ranging from prosthetics to imaging, neuromodulation to medication intervention for a broad array of pathology.10
Drawing in professionals who want to work with veterans. The reason that many health care providers work at the VA is the veterans themselves. Veterans by and large represent a segment of our population who have demonstrated dedication, commitment to a shared goal, and the willingness to sacrifice their health or their lives for a greater good. The veteran identity and sacrifice has drawn many of us to want to serve them. My father’s and cousin’s service are truly inspirational on a personal level. I am not alone in this.
I recently had a veteran in my office who, once seated, pulled his chair closer to mine than I ordinarily prefer. He then gave me a penetrating stare, moved well within the comfort zone of even the closest of close-talkers, and began to scream about the wrongs he had heard about in the VA system. When he finished screaming (and once the other clinicians in the building realized that I wasn’t being physically attacked), he freely acknowledged that he had never actually experienced any of the VA shortcomings personally but, nonetheless, learned how reprehensible the VA is through the media. Our veterans deserve the best care that we as a nation can provide, and they also deserve to know the truth about the quality of VA care. But too often the negative media attention does not tell the whole story that directly impacts the well-being of our veterans.
I sit on the disruptive behavior committee at the Boise VAMC and see firsthand the stress that our veterans and staff are under. We review reports of veterans who disrupt the environment, sometimes by direct threats to shoot or in some way physically harm those taking care of them. Some of this is over pain medications or other specific health care issues. Some is due to frustration in trying to navigate an increasingly complex and nonintuitive system as the VA scrambles to implement congressional directives that sometimes clash with what is clinically appropriate and evidence-based. Some of the disruptive behavior, however, is fueled by the negative national discourse against the political establishment and its nearest representative—in this case, the VA. And again, this is often fueled, in my opinion, by incomplete media coverage.
The VA has problems. It would be delusional to argue otherwise. It is rightly open to public scrutiny as a tax-funded governmental agency, and lives are literally at stake as we grapple nationally with how best to deliver on Lincoln’s promise to “care for those who have borne the battle.”
As I reflect on my friend’s skepticism at my taking a VA position, I can answer that yes, the VA needs work. It has some major issues. But I no longer feel the need to cringe, because I now know firsthand the kind of care that is being delivered (at least to the veterans in Boise).
Wherever you stand on the quality of VA care, the movement to privatize, or the politicizing inevitable during an election year, to indiscriminately excoriate the VA is to risk marginalizing the superlative care that many currently receive by the thousands of physicians and other health care providers and administrators throughout the VA. Our veterans are a national treasure that deserve excellent care and real solutions to the problems that exist in the VA, not overwhelming negative rhetoric.
1. U.S. Department of Veterans Affairs, Office of Suicide Prevention. Suicide Among Veterans and Other Americans 2001-2014. http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf. Published August 3, 2016. Accessed August 10, 2016.
2. Longman P, Gordon S. A conversation about the commission on care and the future of the VA. Washington Monthly. http://washingtonmonthly.com/2016/07/14/a-conversation-about-the-commission-on-care-and-the-future-of-the-va/. Published July 14, 2016. Accessed August 4, 2016.
3. Garcia HA, McGeary CA, Finley EP, Ketchum NS, McGeary DD, Peterson AL. Burnout among psychiatrists in the Veterans Health Administration. Burnout Research. 2015;2(4):108-114.
4. U.S. Department of Veterans Affairs, Office of Academic Affiliations. Medical and dental education program. http://www.va.gov/oaa/GME_default.asp. Updated December 9, 2015. Accessed August 4, 2016.
5. Katzelnick DJ, Williams MD. Large-scale dissemination of collaborative care and implications for psychiatry. Psychiatr Serv. 2015;66(9):904-906.
6. Watkins KE, Smith B, Akincigil A, et al. The quality of medication treatment for mental disorders in the Department of Veterans Affairs and in private-sector plans. Psychiatr Serv. 2016;67(4):391-396.
7. Longman P. Best Care Anywhere: Why VA Health Care Would Work Better for Everyone. 3rd ed. San Francisco, CA: Berrett-Koehler; 2012.
8. U.S. Department of Veterans Affairs, Veterans Health Administration. American customer satisfaction index 2013 customer satisfaction outpatient survey. http://www.va.gov/health/docs/VA2013OutpatientACSI.pdf. Published March 2014. Accessed August 10, 2016.
9. U.S. Department of Veterans Affairs. VHA pain management, Opioid Safety Initiative (OSI). http://www.va.gov/PAINMANAGEMENT/Opioid_Safety_Initiative_OSI.asp. Updated June 17, 2015. Accessed August 4, 2016.
10. U.S. Department of Veterans Affairs. Office of Research and Development. http://www.research.va.gov. Updated July 21, 2016. Accessed August 4, 2016.
Just over 2 years ago, I finished a psychiatry residency at the Mayo Clinic, turned down an offer to stay on staff, and topped it off by taking a position at the VA. Not one of my brighter moments—or so one of my friends thought. “Are you off your rocker? Don’t you know that the VA is terrible? Why would you go work there?” he jabbed incredulously. I cringed, knowing that I had passed up an opportunity to stay in arguably the best hospital system in the nation, possibly the world, to work at what some (maybe even a lot) view as a corpulent and recalcitrant bastion of ineptitude bound by the dictates of a fickle Congress.
In the wake of the Phoenix wait-time scandal (and no, it’s not like Disneyland), the suicide by self-immolation of Charles Richard Ingram III outside a VA facility in New Jersey, the new data on veteran suicide showing progress but continued significant concern, and the ongoing VA privatization discussion, the prevailing discourse about the VA is largely negative.1,2 And in a high-voltage election cycle where public outrage can serve as an efficient tool to garner support, the VA risks getting pummeled.
Add to this the shocking research that shows nearly half of VA psychiatrists are considering leaving the VA within the next 2 years, and it’s clear that dissatisfaction within and outside the VA is high.3 This does not bode well for veterans at a time when suicide and mental health care needs are so critically important. But while the bureaucracy of the VA is often the focus of negative press, it also filters down and unfortunately has the potential to directly affect VA practitioners and veterans. When we lose sight of what the VA does well, we risk being caught up in a vortex of negativity and a profound sense of inadequacy and helplessness. More attention to what is already being done well can help us as a nation more realistically chart a path forward rather than being fueled by negative rhetoric and rage.
Despite the challenges, the VA is currently succeeding in a number of areas that deserve recognition:
Medical school and resident education and collaboration with VA. In 2014, > 41,000 medical residents and nearly 23,000 medical students had some or all of their training in a VA setting. More than 95% of allopathic medical schools and nearly 90% of osteopathic medical schools had affiliation agreements with the VA in 2014.4 Suffice it to say, if the educational endeavors of the VA were curtailed, there would be an unholy scramble to provide well-trained physicians for our nation. (This does not include the dentists, psychologists, pharmacists, social workers, nurses, and other health care professionals whose training involves the VA in some capacity.) In addition, the VA often provides loan repayment assistance, which is very important given that many young professionals carry substantial school debt after completing training.
Mental health and primary care integration. Medical care overall is changing, and there is an increasing shift away from volume-based, fee-for-service care to integrated, team-based models. The VA is one of several successful leaders at a time when most U.S. health care providers are being scrutinized for their use of health care dollars and overall national health outcomes.5 In addition to primary care integration, the VA uses home-based primary care and mental health intensive case management teams for vulnerable veterans, adding flexibility, continuity, and access for many.
Overall excellent mental health care. A recent study by Watkins and colleagues found that when comparing quality measures for medication evaluation and management for schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, and substance use disorders, “In every case, VA performance was superior to that of the private sector by more than 30%.”6 This is not an aberration and not limited to mental health care. It is a consistent finding about which books have been written.7 However, the availability of evidence-based care may not be consistent across all VA facilities nationally, depending on demand and staffing.
Despite the rumors, VA has high customer satisfaction. According to the American Customer Satisfaction Index, the VA has consistently performed well in measures of customer satisfaction compared with those of the private sector health care providers.8 Let’s not ignore what veterans have actually said and continue to say about their care.
Once in, you’re in! I recently missed an initial appointment with a private sector pediatrician for one of my sons. I was tersely invited to find another doctor. This seemed scandalous since I have become accustomed in my role as a VA physician to reaching out, sometimes incessantly, to patients who do not come in for either a new or follow-up appointment. Yes, I call my patients; personally, directly, and often. In many clinics, patients receive reminder letters about upcoming appointments and then phone calls and sometimes letters when appointments are missed. My colleagues and I have jokingly referred to this practice as “benign stalking.”
Further, if a veteran is dissatisfied with care, there is a process to review and make adjustments if necessary, including transfer to a different doctor. Additionally, and sometimes alarmingly, veterans are not “fired” (and actually can’t be) for bad behavior (including direct threats to VA staff). Time, place, and manner of care can be tailored based on assessed risk, and VA police may be involved, but veterans continue to get care. I can assure you that if I made a threat to one of my doctors in private practice, I would very quickly be searching for a new doctor and answering some tough questions from law enforcement. Unlike many patients in private care, veterans have consistent access via phone (though admittedly not always user-friendly), walk-in appointments, after-hours availability in some locations, and secure messaging.
Electronic medical record and telehealth initiatives. The VA Computerized Patient Record System, has been around for some time and provides an excellent (although not perfect) system for documenting patient care. Each VA is linked to other VAs across the nation so patients don’t have to reinvent their story when they move and can actually get down to the business of being treated. Prior interventions, hospitalizations, medication trials, diagnostic impressions, imaging, lab work, etc, are all available at the touch of a button! And the VA’s telehealth initiative is all about access.
Veteran suicide prevention and opioid prescribing. Suicide is disproportionately high among veterans in the U.S. Recent data show that in 2014, an average of 20 veterans died by suicide per day.1 This accounted for 18% of all U.S. adult suicide deaths, even though veterans represent only 8.5% of the population. And while these recent statistics represent some improvement over prior research, prevention and care coordination remain major priorities in the VA. Veterans have access to same-day care (at least in Boise, Idaho) and a 24-hour crisis line that gives feedback to the patient’s local VA and can help coordinate follow-up care. The VA has specialized suicide prevention coordinators who attend to the needs of patients assessed to be at high risk for suicide and also disseminate training to providers in a variety of disciplines. All of this as the VA moves to ensure that suicide prevention remains a priority across disciplines and treatment sites.
Additionally, the VA is directly addressing the nationwide crisis of overprescription of opioids, beginning with education for both patients and staff and systemic encouragement of responsible prescribing via the national Opioid Safety Initiative and increased emphasis on providing at-risk veterans with naloxone kits.9
Research. VA research endeavors are wide ranging. The VA has been involved in pioneering clinical research in a substantial way since at least the 1920s and has contributed to important innovations in treatment, ranging from prosthetics to imaging, neuromodulation to medication intervention for a broad array of pathology.10
Drawing in professionals who want to work with veterans. The reason that many health care providers work at the VA is the veterans themselves. Veterans by and large represent a segment of our population who have demonstrated dedication, commitment to a shared goal, and the willingness to sacrifice their health or their lives for a greater good. The veteran identity and sacrifice has drawn many of us to want to serve them. My father’s and cousin’s service are truly inspirational on a personal level. I am not alone in this.
I recently had a veteran in my office who, once seated, pulled his chair closer to mine than I ordinarily prefer. He then gave me a penetrating stare, moved well within the comfort zone of even the closest of close-talkers, and began to scream about the wrongs he had heard about in the VA system. When he finished screaming (and once the other clinicians in the building realized that I wasn’t being physically attacked), he freely acknowledged that he had never actually experienced any of the VA shortcomings personally but, nonetheless, learned how reprehensible the VA is through the media. Our veterans deserve the best care that we as a nation can provide, and they also deserve to know the truth about the quality of VA care. But too often the negative media attention does not tell the whole story that directly impacts the well-being of our veterans.
I sit on the disruptive behavior committee at the Boise VAMC and see firsthand the stress that our veterans and staff are under. We review reports of veterans who disrupt the environment, sometimes by direct threats to shoot or in some way physically harm those taking care of them. Some of this is over pain medications or other specific health care issues. Some is due to frustration in trying to navigate an increasingly complex and nonintuitive system as the VA scrambles to implement congressional directives that sometimes clash with what is clinically appropriate and evidence-based. Some of the disruptive behavior, however, is fueled by the negative national discourse against the political establishment and its nearest representative—in this case, the VA. And again, this is often fueled, in my opinion, by incomplete media coverage.
The VA has problems. It would be delusional to argue otherwise. It is rightly open to public scrutiny as a tax-funded governmental agency, and lives are literally at stake as we grapple nationally with how best to deliver on Lincoln’s promise to “care for those who have borne the battle.”
As I reflect on my friend’s skepticism at my taking a VA position, I can answer that yes, the VA needs work. It has some major issues. But I no longer feel the need to cringe, because I now know firsthand the kind of care that is being delivered (at least to the veterans in Boise).
Wherever you stand on the quality of VA care, the movement to privatize, or the politicizing inevitable during an election year, to indiscriminately excoriate the VA is to risk marginalizing the superlative care that many currently receive by the thousands of physicians and other health care providers and administrators throughout the VA. Our veterans are a national treasure that deserve excellent care and real solutions to the problems that exist in the VA, not overwhelming negative rhetoric.
Just over 2 years ago, I finished a psychiatry residency at the Mayo Clinic, turned down an offer to stay on staff, and topped it off by taking a position at the VA. Not one of my brighter moments—or so one of my friends thought. “Are you off your rocker? Don’t you know that the VA is terrible? Why would you go work there?” he jabbed incredulously. I cringed, knowing that I had passed up an opportunity to stay in arguably the best hospital system in the nation, possibly the world, to work at what some (maybe even a lot) view as a corpulent and recalcitrant bastion of ineptitude bound by the dictates of a fickle Congress.
In the wake of the Phoenix wait-time scandal (and no, it’s not like Disneyland), the suicide by self-immolation of Charles Richard Ingram III outside a VA facility in New Jersey, the new data on veteran suicide showing progress but continued significant concern, and the ongoing VA privatization discussion, the prevailing discourse about the VA is largely negative.1,2 And in a high-voltage election cycle where public outrage can serve as an efficient tool to garner support, the VA risks getting pummeled.
Add to this the shocking research that shows nearly half of VA psychiatrists are considering leaving the VA within the next 2 years, and it’s clear that dissatisfaction within and outside the VA is high.3 This does not bode well for veterans at a time when suicide and mental health care needs are so critically important. But while the bureaucracy of the VA is often the focus of negative press, it also filters down and unfortunately has the potential to directly affect VA practitioners and veterans. When we lose sight of what the VA does well, we risk being caught up in a vortex of negativity and a profound sense of inadequacy and helplessness. More attention to what is already being done well can help us as a nation more realistically chart a path forward rather than being fueled by negative rhetoric and rage.
Despite the challenges, the VA is currently succeeding in a number of areas that deserve recognition:
Medical school and resident education and collaboration with VA. In 2014, > 41,000 medical residents and nearly 23,000 medical students had some or all of their training in a VA setting. More than 95% of allopathic medical schools and nearly 90% of osteopathic medical schools had affiliation agreements with the VA in 2014.4 Suffice it to say, if the educational endeavors of the VA were curtailed, there would be an unholy scramble to provide well-trained physicians for our nation. (This does not include the dentists, psychologists, pharmacists, social workers, nurses, and other health care professionals whose training involves the VA in some capacity.) In addition, the VA often provides loan repayment assistance, which is very important given that many young professionals carry substantial school debt after completing training.
Mental health and primary care integration. Medical care overall is changing, and there is an increasing shift away from volume-based, fee-for-service care to integrated, team-based models. The VA is one of several successful leaders at a time when most U.S. health care providers are being scrutinized for their use of health care dollars and overall national health outcomes.5 In addition to primary care integration, the VA uses home-based primary care and mental health intensive case management teams for vulnerable veterans, adding flexibility, continuity, and access for many.
Overall excellent mental health care. A recent study by Watkins and colleagues found that when comparing quality measures for medication evaluation and management for schizophrenia, bipolar disorder, posttraumatic stress disorder, depression, and substance use disorders, “In every case, VA performance was superior to that of the private sector by more than 30%.”6 This is not an aberration and not limited to mental health care. It is a consistent finding about which books have been written.7 However, the availability of evidence-based care may not be consistent across all VA facilities nationally, depending on demand and staffing.
Despite the rumors, VA has high customer satisfaction. According to the American Customer Satisfaction Index, the VA has consistently performed well in measures of customer satisfaction compared with those of the private sector health care providers.8 Let’s not ignore what veterans have actually said and continue to say about their care.
Once in, you’re in! I recently missed an initial appointment with a private sector pediatrician for one of my sons. I was tersely invited to find another doctor. This seemed scandalous since I have become accustomed in my role as a VA physician to reaching out, sometimes incessantly, to patients who do not come in for either a new or follow-up appointment. Yes, I call my patients; personally, directly, and often. In many clinics, patients receive reminder letters about upcoming appointments and then phone calls and sometimes letters when appointments are missed. My colleagues and I have jokingly referred to this practice as “benign stalking.”
Further, if a veteran is dissatisfied with care, there is a process to review and make adjustments if necessary, including transfer to a different doctor. Additionally, and sometimes alarmingly, veterans are not “fired” (and actually can’t be) for bad behavior (including direct threats to VA staff). Time, place, and manner of care can be tailored based on assessed risk, and VA police may be involved, but veterans continue to get care. I can assure you that if I made a threat to one of my doctors in private practice, I would very quickly be searching for a new doctor and answering some tough questions from law enforcement. Unlike many patients in private care, veterans have consistent access via phone (though admittedly not always user-friendly), walk-in appointments, after-hours availability in some locations, and secure messaging.
Electronic medical record and telehealth initiatives. The VA Computerized Patient Record System, has been around for some time and provides an excellent (although not perfect) system for documenting patient care. Each VA is linked to other VAs across the nation so patients don’t have to reinvent their story when they move and can actually get down to the business of being treated. Prior interventions, hospitalizations, medication trials, diagnostic impressions, imaging, lab work, etc, are all available at the touch of a button! And the VA’s telehealth initiative is all about access.
Veteran suicide prevention and opioid prescribing. Suicide is disproportionately high among veterans in the U.S. Recent data show that in 2014, an average of 20 veterans died by suicide per day.1 This accounted for 18% of all U.S. adult suicide deaths, even though veterans represent only 8.5% of the population. And while these recent statistics represent some improvement over prior research, prevention and care coordination remain major priorities in the VA. Veterans have access to same-day care (at least in Boise, Idaho) and a 24-hour crisis line that gives feedback to the patient’s local VA and can help coordinate follow-up care. The VA has specialized suicide prevention coordinators who attend to the needs of patients assessed to be at high risk for suicide and also disseminate training to providers in a variety of disciplines. All of this as the VA moves to ensure that suicide prevention remains a priority across disciplines and treatment sites.
Additionally, the VA is directly addressing the nationwide crisis of overprescription of opioids, beginning with education for both patients and staff and systemic encouragement of responsible prescribing via the national Opioid Safety Initiative and increased emphasis on providing at-risk veterans with naloxone kits.9
Research. VA research endeavors are wide ranging. The VA has been involved in pioneering clinical research in a substantial way since at least the 1920s and has contributed to important innovations in treatment, ranging from prosthetics to imaging, neuromodulation to medication intervention for a broad array of pathology.10
Drawing in professionals who want to work with veterans. The reason that many health care providers work at the VA is the veterans themselves. Veterans by and large represent a segment of our population who have demonstrated dedication, commitment to a shared goal, and the willingness to sacrifice their health or their lives for a greater good. The veteran identity and sacrifice has drawn many of us to want to serve them. My father’s and cousin’s service are truly inspirational on a personal level. I am not alone in this.
I recently had a veteran in my office who, once seated, pulled his chair closer to mine than I ordinarily prefer. He then gave me a penetrating stare, moved well within the comfort zone of even the closest of close-talkers, and began to scream about the wrongs he had heard about in the VA system. When he finished screaming (and once the other clinicians in the building realized that I wasn’t being physically attacked), he freely acknowledged that he had never actually experienced any of the VA shortcomings personally but, nonetheless, learned how reprehensible the VA is through the media. Our veterans deserve the best care that we as a nation can provide, and they also deserve to know the truth about the quality of VA care. But too often the negative media attention does not tell the whole story that directly impacts the well-being of our veterans.
I sit on the disruptive behavior committee at the Boise VAMC and see firsthand the stress that our veterans and staff are under. We review reports of veterans who disrupt the environment, sometimes by direct threats to shoot or in some way physically harm those taking care of them. Some of this is over pain medications or other specific health care issues. Some is due to frustration in trying to navigate an increasingly complex and nonintuitive system as the VA scrambles to implement congressional directives that sometimes clash with what is clinically appropriate and evidence-based. Some of the disruptive behavior, however, is fueled by the negative national discourse against the political establishment and its nearest representative—in this case, the VA. And again, this is often fueled, in my opinion, by incomplete media coverage.
The VA has problems. It would be delusional to argue otherwise. It is rightly open to public scrutiny as a tax-funded governmental agency, and lives are literally at stake as we grapple nationally with how best to deliver on Lincoln’s promise to “care for those who have borne the battle.”
As I reflect on my friend’s skepticism at my taking a VA position, I can answer that yes, the VA needs work. It has some major issues. But I no longer feel the need to cringe, because I now know firsthand the kind of care that is being delivered (at least to the veterans in Boise).
Wherever you stand on the quality of VA care, the movement to privatize, or the politicizing inevitable during an election year, to indiscriminately excoriate the VA is to risk marginalizing the superlative care that many currently receive by the thousands of physicians and other health care providers and administrators throughout the VA. Our veterans are a national treasure that deserve excellent care and real solutions to the problems that exist in the VA, not overwhelming negative rhetoric.
1. U.S. Department of Veterans Affairs, Office of Suicide Prevention. Suicide Among Veterans and Other Americans 2001-2014. http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf. Published August 3, 2016. Accessed August 10, 2016.
2. Longman P, Gordon S. A conversation about the commission on care and the future of the VA. Washington Monthly. http://washingtonmonthly.com/2016/07/14/a-conversation-about-the-commission-on-care-and-the-future-of-the-va/. Published July 14, 2016. Accessed August 4, 2016.
3. Garcia HA, McGeary CA, Finley EP, Ketchum NS, McGeary DD, Peterson AL. Burnout among psychiatrists in the Veterans Health Administration. Burnout Research. 2015;2(4):108-114.
4. U.S. Department of Veterans Affairs, Office of Academic Affiliations. Medical and dental education program. http://www.va.gov/oaa/GME_default.asp. Updated December 9, 2015. Accessed August 4, 2016.
5. Katzelnick DJ, Williams MD. Large-scale dissemination of collaborative care and implications for psychiatry. Psychiatr Serv. 2015;66(9):904-906.
6. Watkins KE, Smith B, Akincigil A, et al. The quality of medication treatment for mental disorders in the Department of Veterans Affairs and in private-sector plans. Psychiatr Serv. 2016;67(4):391-396.
7. Longman P. Best Care Anywhere: Why VA Health Care Would Work Better for Everyone. 3rd ed. San Francisco, CA: Berrett-Koehler; 2012.
8. U.S. Department of Veterans Affairs, Veterans Health Administration. American customer satisfaction index 2013 customer satisfaction outpatient survey. http://www.va.gov/health/docs/VA2013OutpatientACSI.pdf. Published March 2014. Accessed August 10, 2016.
9. U.S. Department of Veterans Affairs. VHA pain management, Opioid Safety Initiative (OSI). http://www.va.gov/PAINMANAGEMENT/Opioid_Safety_Initiative_OSI.asp. Updated June 17, 2015. Accessed August 4, 2016.
10. U.S. Department of Veterans Affairs. Office of Research and Development. http://www.research.va.gov. Updated July 21, 2016. Accessed August 4, 2016.
1. U.S. Department of Veterans Affairs, Office of Suicide Prevention. Suicide Among Veterans and Other Americans 2001-2014. http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf. Published August 3, 2016. Accessed August 10, 2016.
2. Longman P, Gordon S. A conversation about the commission on care and the future of the VA. Washington Monthly. http://washingtonmonthly.com/2016/07/14/a-conversation-about-the-commission-on-care-and-the-future-of-the-va/. Published July 14, 2016. Accessed August 4, 2016.
3. Garcia HA, McGeary CA, Finley EP, Ketchum NS, McGeary DD, Peterson AL. Burnout among psychiatrists in the Veterans Health Administration. Burnout Research. 2015;2(4):108-114.
4. U.S. Department of Veterans Affairs, Office of Academic Affiliations. Medical and dental education program. http://www.va.gov/oaa/GME_default.asp. Updated December 9, 2015. Accessed August 4, 2016.
5. Katzelnick DJ, Williams MD. Large-scale dissemination of collaborative care and implications for psychiatry. Psychiatr Serv. 2015;66(9):904-906.
6. Watkins KE, Smith B, Akincigil A, et al. The quality of medication treatment for mental disorders in the Department of Veterans Affairs and in private-sector plans. Psychiatr Serv. 2016;67(4):391-396.
7. Longman P. Best Care Anywhere: Why VA Health Care Would Work Better for Everyone. 3rd ed. San Francisco, CA: Berrett-Koehler; 2012.
8. U.S. Department of Veterans Affairs, Veterans Health Administration. American customer satisfaction index 2013 customer satisfaction outpatient survey. http://www.va.gov/health/docs/VA2013OutpatientACSI.pdf. Published March 2014. Accessed August 10, 2016.
9. U.S. Department of Veterans Affairs. VHA pain management, Opioid Safety Initiative (OSI). http://www.va.gov/PAINMANAGEMENT/Opioid_Safety_Initiative_OSI.asp. Updated June 17, 2015. Accessed August 4, 2016.
10. U.S. Department of Veterans Affairs. Office of Research and Development. http://www.research.va.gov. Updated July 21, 2016. Accessed August 4, 2016.
Munchausen Syndrome by Adult Proxy
Asher first described Munchausen syndrome by proxy over 60 years ago. Like the famous Baron von Munchausen, the persons affected have always traveled widely; and their stories like those attributed to him, are both dramatic and untruthful.[1] Munchausen syndrome is a psychiatric disorder in which a patient intentionally induces or feigns symptoms of physical or psychiatric illness to assume the sick role. In 1977, Meadow described the first case in which a caregiverperpetrator deliberately produced physical symptoms in a child for proxy gratification.[2] Unlike malingering, in which external incentives drive conscious symptom falsification, Munchausen syndrome by proxy (MSBP) is associated with fulfillment of the abuser's own psychological need for garnering praise from medical staff for devoted care given a sick child.[3, 4]
MSBP was once considered vanishingly rare. Many experts now believe it is more common, with a reported annual incidence of 0.4/100,000 in children younger than 16 years, and 2/100,000 in children younger than 1 year.[5] It is a disorder in which a parent, often the mother (94%99%)[6] and often with training or interest in the medical field,[5] is the perpetrator. The medical team caring for her child often views her as unusually helpful, and she is frequently psychiatrically ill with disorders such as depression, personality disorder, or prior personal history of somatoform or factitious disorder.[7, 8] The perpetrator typically inflicts physical harm, although occasionally she may simply lie about symptoms or tamper with laboratory samples.[5] The most common methods of inflicting harm are poisoning and suffocation. Overall mortality is 6% to 9%.[6, 9]
Although a large body of literature addresses pediatric cases, there is little to guide clinicians when victims are adults. An obvious reason may be that MSBP with adult proxies (MSB‐AP) has been reported so rarely, although we believe it is under‐recognized and more common than thought. The primary objective of this review was to identify all published cases of MSB‐AP, and synthesize them to characterize victims and perpetrators, modes of deceit, and relationships between victims and perpetrators so that clinicians will be better equipped to recognize such cases or at least include MSB‐AP in the differential of possibilities when symptoms and history are inconsistent.
METHODS
The Mayo Clinic Rochester Institutional Review Board approved this study. The databases of Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Knowledge, and PsychINFO were searched from inception through April 2014 to identify all published cases of Munchausen by proxy in patients 18 years or older. The following search terms were used: Munchausen syndrome by proxy, factitious disorder by proxy, Munchausen syndrome, and factitious disorder. Reports were included when they described single or multiple cases of MSBP with victims aged at least 18 years. The search was not limited to articles published in English. Bibliographies of selected articles were reviewed for reports identifying additional cases.
RESULTS
We found 10 reports describing 11 cases of MSB‐AP and 1 report describing 2 unique cases of MSB‐AP (Tables 1 and 2). Two case reports were published in French[10, 11] and 1 in Polish.[12] Sigal et al.[13] describes 2 different victims with a common perpetrator, and another report[14] describes the same perpetrator with a third victim. One case, though cited as MSB‐AP in the literature was excluded because it did not meet the criteria for the disorder. In this case, the wife of a 28‐year‐old alcoholic male poured acid on him while he was inebriated, ostensibly to vent frustration and coerce him into sobriety.[15, 16]
| Author | Gender | Age, y | Presenting Features | Occupation/Education | Outcome |
|---|---|---|---|---|---|
| |||||
| Sigal M et al. (1986)[13] | F | 20s | Abscesses (skin) | NP | Death |
| F | 21 | Abscesses (skin) | Child care | Paraplegia | |
| Sigal MD et al. (1991)[14] | M | NP | Rash | NP | Abuse stopped |
| Smith NJ et al. (1989)[19] | M | 69 | None | Retired businessman | Continued fabrication |
| Krebs MO et al. (1996)[10] | M | 40s | Coma | Businessman | Abuse stopped |
| Ben‐Chetrit E et al. (1998)[20] | F | 73 | Coma | NP | Abuse stopped |
| Feldman KW et al. (1998)[8] | F | 21 | NP | Developmental delay | NP |
| Chodorowsk Z et al. (2003)[12] | F | 80 | Syncope | NP | Abuse stopped |
| Strubel D et al. (2003)[11] | F | 82 | None | NP | NP |
| Granot R et al. (2004)[21] | M | 71 | Coma | NP | Abuse stopped |
| Deimel GW et al. (2012)[17] | F | 23 | Rash | High school graduate | Continued abuse |
| F | 21 | Recurrent bacteremia | College student | Death | |
| Singh A et al. (2013)[22] | F | 79 | Fluid overload/false symptom history | Retired | Continued |
| Author | Gender | Age, y | Relationship | Occupation | Mode of Abuse | Outcome When Confronted |
|---|---|---|---|---|---|---|
| ||||||
| Sigal M et al. (1986)[13] | M | 26 | Husbanda | Businessman | Poisoningb followed by subcutaneous gasoline injection | Confession and incarceration |
| M | 29 | Boyfrienda | Businessman | Poisoningb followed by subcutaneous gasoline injection | Confession and incarceration | |
| Sigal MD et al. (1991)[14] | M | 34 | Cellmatea | Worked in medical clinic where incarcerated | Poisoningc followed by subcutaneous turpentine injection | Confession and attempted murder conviction |
| Smith NJ et al. (1989)[19] | F | 55 | Companion | Nurse | False history of hematuria, weakness, headaches | Denial |
| Krebs MO et al. (1996)[10] | F | 47 | Wife | Nurse | Tranquilizer injections | Confession and placed on probation |
| Ben‐Chetrit E et al. (1998)[20] | F | NP | Daughter | Nurse | Insulin injections | Denial |
| Feldman KW et al. (1998)[8] | F | NP | Mother | Business woman | False history of Batten's disease | NP |
| Chodorowsk Z et al. (2003)[12] | F | NP | Granddaughter | NP | Poisoningb | Denial |
| Strubel D et al. (2003)[11] | M | NP | Son | NP | False history of memory loss | NP |
| Granot R et al. (2004)[21] | F | NP | Wife | Hospital employee | Poisoningb | Confession |
| Deimel GW et al. (2012)[17] | F | NP | Mother | Unemployed chronic medical problems | Toxin application to skin | Denial |
| F | NP | Mother | Medical office receptionist | Intravenous injection unknown substance | Denial | |
| Singh A et al. (2013)[22] | M | NP | Son | NP | Fluid administration in context of fluid restriction/erratic medication administration/falsifying severity of symptoms | Denial |
Of the 13 victims, 9 (69%) were women and 4 (31%) were men. Of the ages reported, the median age was 69 years and the mean age was 51 (range, 2182 years). Exact age was not reported in 3 cases. Lying about signs and symptoms, but not actually inducing injury, occurred in 3 cases (23%), whereas in 10 cases (77%), the victims presented with physical findings, including coma (3), rash (2), skin abscesses (2), syncope (1), recurrent bacteremia (1), and fluid overload (1). Seven (54%) of the victims were poisoned, 2 via drug injection and 5 by beverage/food contamination. A perpetrator sedated 3 victims and subsequently injected them, 2 with gasoline and another with turpentine. Two of the victims were involved in business, 1 worked in childcare, 1 attended beauty school after graduating from high school, 1 attended college, and 1 was developmentally delayed. Victim education or occupation was not reported in 7 cases.
Of the 11 perpetrators, 8 (73%) were women, and 3 (27%) were men (note that the same male perpetrator had 3 victims). Median age was 34 years (range, 2655 years), although exact age was not reported in 4 cases. The perpetrator was the victim's mother in 3 cases, wife in 2 cases, son in 2 cases, and daughter, granddaughter, husband, companion, boyfriend, or prison cellmate in 1 case each. Five (38%) worked in healthcare.
All of the perpetrators were highly involved, even overly involved, in the care of their victims, frequently present, sometimes hovering, in hospital settings, and were viewed as generally helpful, if not overintrusive, by hospital staff. When confronted, 3 perpetrators confessed, 3 denied abuse that then ceased, and 4 more denied abuse that continued, culminating in death in 1 case. In 1 case, the outcome was not reported.[8] At least 3 victims remained with their perpetrators. Two perpetrators were criminally charged, 1 receiving probation and the other incarceration. The latter began abusing his cellmate, behavior that did not stop until he was confronted in prison.
CONCLUSION/DISCUSSION
Our primary objective was to locate and review all published cases of MSB‐AP. Our secondary aim was to describe salient characteristics of perpetrators, victims, and fabricated diseases in hopes of helping clinicians better recognize this disorder.
Our review shows that perpetrators were exclusively the victims' caregivers, including mothers, wives, husbands, daughters, granddaughters, or companions. These perpetrators, many with healthcare backgrounds, were attentive, helpful, and excessively present. In the majority of cases, hidden physical abuse yielded visible disease. Less commonly, perpetrators lied about symptoms rather than actually creating signs of disease. The most common mode of disease instigation involved poisoning through beverage/food contamination or subcutaneous injection. Geriatric and developmentally delayed persons appeared particularly vulnerable to victimization. Of the 13 victims, 5 were geriatric and 1 was developmentally delayed.
The adult cases we report are similar to child cases in that the perpetrators are caregivers; however, the caregivers of the adults are a more diverse group. Other similarities between adult and child cases are that physical signs occur more often than simply falsifying information, and poisoning is the most common method of disease fabrication. Suffocation, although common in child cases, has not been reported in adults. Though present in only a minority of cases, another feature distinguishing these cases from those reported in the pediatric literature is the presence of collusion between the perpetrator and victim. When MSBP was first described, Meadow believed that victims would reach an age at which the disorder would cease because they would fight back or report the abuse.[2] In 7 of the adult cases, the victims were unknowingly poisoned; however, in 2 cases,[17] the victims knew what their mothers were doing to them and yet denied that they were harming them. To explain this collusion, Deimel et al. proposed Stockholm syndrome, a condition in which a victim holds a perpetrator in high regard, despite experiencing at their hands what others might consider brainwashing and torture.
The data from the individual cases are sometimes frustratingly incomplete, with inconsistent reporting of dyad demographics and outcomes across the 13 cases, which compromises efforts to compare and contrast them. However, because no published studies have thoroughly reviewed all existing cases of MSB‐AP, we believe our review provides important insights into this condition by consolidating available information. It is our hope that by characterizing perpetrators, victims, and common presentations, we will raise awareness about this condition among healthcare providers so that it may be included in the differential diagnosis when they encounter this dyad: a patient's medical problems do not respond as expected to therapy and a caregivers appears overly involved or attention seeking.
The diagnosis of a factitious disorder often presents an immense clinical challenge and generally involves a multidisciplinary approach.[18] In addition to the incomplete data for existing cases in the literature, we recognize the ongoing difficulties in precise diagnosis of this disorder. Because a hallmark of pathology is secrecy at the outset and often denial, and even abrupt transition of care, upon confrontation, it is often very difficult, especially early on, to uncover patterns of perpetration, let alone posit a motive. We recognize that there may be some perpetrators who are motivated by something other than purely psychological end points, such as financial reward or even sexual victimization. And when alternate care venues are sought, clinicians are often left wondering. Further, the damage that may come to a therapeutic relationship by prematurely diagnosing MSB‐AP is important to keep in mind. Hospitalists who suspect MSB‐AP should consult psychiatry. Although MSB‐AP is a diagnosis of exclusion and often based on circumstantial evidence, psychiatry can assist in diagnosing this disorder and, in the event of a confession, provide immediate therapeutic intervention. Social services can aid in a vulnerable adult investigation for patients who do not have capacity.
When Meadow first described MSBP, he ended his article by asking Is this degree of falsification rare or is it under‐recognized? Time has answered Meadow's question. Now we ask the same question with regard to MSB‐AP, is it rare or under‐recognized? We must remain vigilant for this disorder. Early recognition can prevent healthcare providers from unknowingly perpetuating victimization by treating caregiver‐induced pathology as if legitimate, thereby satisfying the perpetrator's psychological needs. Despite Meadow's assertion that proxies outgrow their victimization, our review warns that advanced age does not preclude vulnerability and in some cases, may actually increase it. In the future, the incidence and prevalence of MSB‐AP is likely to increase as medical technology allows greater survival of cognitively impaired populations who are dependent on others for care. The elderly and developmentally delayed may be especially at risk.
ACKNOWLEDGMENTS
Disclosures: M.C.B., M.B.W., and M.I.L. report no conflicts of interest. J.M.B. receives payment for lectures, including service on speakers bureaus, from nonprofit continuing medical education organizations and universities for occasional lectures; however, this funding is not relevant to this review.
- . Munchausen syndrome. Lancet. 1951(1):339–341.
- . Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 1977;2(8033):343–345.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. 4th ed. Washington, DC: American Psychiatric Press; 2000.
- , , , et al. Position paper: definitional issues in Munchausen by proxy. Child Maltreat. 2002;7(2):105–111.
- , , , . Epidemiology of Munchausen syndrome by proxy, non‐accidental poisoning, and non‐accidental suffocation. Arch Dis Child. 1996;75(1):57–61.
- . Web of deceit: a literature review of Munchausen syndrome by proxy. Child Abuse Negl. 1987;11(4):547–563.
- , . Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011;199(2):113–118.
- , . The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy. J Pediatr Surg. 1998;33(4):623–627.
- , . Munchausen syndrome by proxy: diagnosis and prevalence. Am J Orthopsychiatry. 1993;63(2):318–321.
- , , , . Munchhausen syndrome by proxy between two adults [in French]. Presse Med. 1996;25(12):583–586.
- , , . Munchhausen syndrome by proxy in an old woman [in French]. Revue Geriatr. 2003;28:425–428.
- , , , . Consciousness disturbances: a case report of Munchausen by proxy syndrome in an elderly patient [in Polish]. Przegl Lek. 2003;60(4):307–308.
- , , . Munchausen syndrome by adult proxy: a perpetrator abusing two adults. J Nerv Ment Dis. 1986;174(11):696–698.
- , , . Munchausen syndrome by adult proxy revisited. Isr J Psychiatry Relat Sci. 1991;28(1):33–36.
- , , , , , . Otolaryngology fantastica: the ear, nose, and throat manifestations of Munchausen's syndrome. Laryngoscope. 2012;122(1):51–57.
- . Witchcraft's syndrome: Munchausen's syndrome by proxy. Int J Dermatol. 1998;37(3):229–230.
- , , , , , . Munchausen syndrome by proxy: an adult dyad. Psychosomatics. 2012;53(3):294–299.
- , . Factitious disorders and malingering: challenges for clinical assessment and management. Lancet. 2014;383(9926):1422–1432.
- , . More in sickness than in health: a case study of Munchausen by proxy in the elderly. J Fam Ther. 1989;11(4):321–334.
- , . Recurrent hypoglycaemia in multiple myeloma: a case of Munchausen syndrome by proxy in an elderly patient. J Intern Med. 1998;244(2):175–178.
- , , , , . Idiopathic recurrent stupor: a warning. J Neurol Neurosurg Psychiatry. 2004;75(3):368–369.
- , , . Munchausen by proxy in older adults: A case report. Maced J Med Sci. 2013;6(2):178–181.
Asher first described Munchausen syndrome by proxy over 60 years ago. Like the famous Baron von Munchausen, the persons affected have always traveled widely; and their stories like those attributed to him, are both dramatic and untruthful.[1] Munchausen syndrome is a psychiatric disorder in which a patient intentionally induces or feigns symptoms of physical or psychiatric illness to assume the sick role. In 1977, Meadow described the first case in which a caregiverperpetrator deliberately produced physical symptoms in a child for proxy gratification.[2] Unlike malingering, in which external incentives drive conscious symptom falsification, Munchausen syndrome by proxy (MSBP) is associated with fulfillment of the abuser's own psychological need for garnering praise from medical staff for devoted care given a sick child.[3, 4]
MSBP was once considered vanishingly rare. Many experts now believe it is more common, with a reported annual incidence of 0.4/100,000 in children younger than 16 years, and 2/100,000 in children younger than 1 year.[5] It is a disorder in which a parent, often the mother (94%99%)[6] and often with training or interest in the medical field,[5] is the perpetrator. The medical team caring for her child often views her as unusually helpful, and she is frequently psychiatrically ill with disorders such as depression, personality disorder, or prior personal history of somatoform or factitious disorder.[7, 8] The perpetrator typically inflicts physical harm, although occasionally she may simply lie about symptoms or tamper with laboratory samples.[5] The most common methods of inflicting harm are poisoning and suffocation. Overall mortality is 6% to 9%.[6, 9]
Although a large body of literature addresses pediatric cases, there is little to guide clinicians when victims are adults. An obvious reason may be that MSBP with adult proxies (MSB‐AP) has been reported so rarely, although we believe it is under‐recognized and more common than thought. The primary objective of this review was to identify all published cases of MSB‐AP, and synthesize them to characterize victims and perpetrators, modes of deceit, and relationships between victims and perpetrators so that clinicians will be better equipped to recognize such cases or at least include MSB‐AP in the differential of possibilities when symptoms and history are inconsistent.
METHODS
The Mayo Clinic Rochester Institutional Review Board approved this study. The databases of Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Knowledge, and PsychINFO were searched from inception through April 2014 to identify all published cases of Munchausen by proxy in patients 18 years or older. The following search terms were used: Munchausen syndrome by proxy, factitious disorder by proxy, Munchausen syndrome, and factitious disorder. Reports were included when they described single or multiple cases of MSBP with victims aged at least 18 years. The search was not limited to articles published in English. Bibliographies of selected articles were reviewed for reports identifying additional cases.
RESULTS
We found 10 reports describing 11 cases of MSB‐AP and 1 report describing 2 unique cases of MSB‐AP (Tables 1 and 2). Two case reports were published in French[10, 11] and 1 in Polish.[12] Sigal et al.[13] describes 2 different victims with a common perpetrator, and another report[14] describes the same perpetrator with a third victim. One case, though cited as MSB‐AP in the literature was excluded because it did not meet the criteria for the disorder. In this case, the wife of a 28‐year‐old alcoholic male poured acid on him while he was inebriated, ostensibly to vent frustration and coerce him into sobriety.[15, 16]
| Author | Gender | Age, y | Presenting Features | Occupation/Education | Outcome |
|---|---|---|---|---|---|
| |||||
| Sigal M et al. (1986)[13] | F | 20s | Abscesses (skin) | NP | Death |
| F | 21 | Abscesses (skin) | Child care | Paraplegia | |
| Sigal MD et al. (1991)[14] | M | NP | Rash | NP | Abuse stopped |
| Smith NJ et al. (1989)[19] | M | 69 | None | Retired businessman | Continued fabrication |
| Krebs MO et al. (1996)[10] | M | 40s | Coma | Businessman | Abuse stopped |
| Ben‐Chetrit E et al. (1998)[20] | F | 73 | Coma | NP | Abuse stopped |
| Feldman KW et al. (1998)[8] | F | 21 | NP | Developmental delay | NP |
| Chodorowsk Z et al. (2003)[12] | F | 80 | Syncope | NP | Abuse stopped |
| Strubel D et al. (2003)[11] | F | 82 | None | NP | NP |
| Granot R et al. (2004)[21] | M | 71 | Coma | NP | Abuse stopped |
| Deimel GW et al. (2012)[17] | F | 23 | Rash | High school graduate | Continued abuse |
| F | 21 | Recurrent bacteremia | College student | Death | |
| Singh A et al. (2013)[22] | F | 79 | Fluid overload/false symptom history | Retired | Continued |
| Author | Gender | Age, y | Relationship | Occupation | Mode of Abuse | Outcome When Confronted |
|---|---|---|---|---|---|---|
| ||||||
| Sigal M et al. (1986)[13] | M | 26 | Husbanda | Businessman | Poisoningb followed by subcutaneous gasoline injection | Confession and incarceration |
| M | 29 | Boyfrienda | Businessman | Poisoningb followed by subcutaneous gasoline injection | Confession and incarceration | |
| Sigal MD et al. (1991)[14] | M | 34 | Cellmatea | Worked in medical clinic where incarcerated | Poisoningc followed by subcutaneous turpentine injection | Confession and attempted murder conviction |
| Smith NJ et al. (1989)[19] | F | 55 | Companion | Nurse | False history of hematuria, weakness, headaches | Denial |
| Krebs MO et al. (1996)[10] | F | 47 | Wife | Nurse | Tranquilizer injections | Confession and placed on probation |
| Ben‐Chetrit E et al. (1998)[20] | F | NP | Daughter | Nurse | Insulin injections | Denial |
| Feldman KW et al. (1998)[8] | F | NP | Mother | Business woman | False history of Batten's disease | NP |
| Chodorowsk Z et al. (2003)[12] | F | NP | Granddaughter | NP | Poisoningb | Denial |
| Strubel D et al. (2003)[11] | M | NP | Son | NP | False history of memory loss | NP |
| Granot R et al. (2004)[21] | F | NP | Wife | Hospital employee | Poisoningb | Confession |
| Deimel GW et al. (2012)[17] | F | NP | Mother | Unemployed chronic medical problems | Toxin application to skin | Denial |
| F | NP | Mother | Medical office receptionist | Intravenous injection unknown substance | Denial | |
| Singh A et al. (2013)[22] | M | NP | Son | NP | Fluid administration in context of fluid restriction/erratic medication administration/falsifying severity of symptoms | Denial |
Of the 13 victims, 9 (69%) were women and 4 (31%) were men. Of the ages reported, the median age was 69 years and the mean age was 51 (range, 2182 years). Exact age was not reported in 3 cases. Lying about signs and symptoms, but not actually inducing injury, occurred in 3 cases (23%), whereas in 10 cases (77%), the victims presented with physical findings, including coma (3), rash (2), skin abscesses (2), syncope (1), recurrent bacteremia (1), and fluid overload (1). Seven (54%) of the victims were poisoned, 2 via drug injection and 5 by beverage/food contamination. A perpetrator sedated 3 victims and subsequently injected them, 2 with gasoline and another with turpentine. Two of the victims were involved in business, 1 worked in childcare, 1 attended beauty school after graduating from high school, 1 attended college, and 1 was developmentally delayed. Victim education or occupation was not reported in 7 cases.
Of the 11 perpetrators, 8 (73%) were women, and 3 (27%) were men (note that the same male perpetrator had 3 victims). Median age was 34 years (range, 2655 years), although exact age was not reported in 4 cases. The perpetrator was the victim's mother in 3 cases, wife in 2 cases, son in 2 cases, and daughter, granddaughter, husband, companion, boyfriend, or prison cellmate in 1 case each. Five (38%) worked in healthcare.
All of the perpetrators were highly involved, even overly involved, in the care of their victims, frequently present, sometimes hovering, in hospital settings, and were viewed as generally helpful, if not overintrusive, by hospital staff. When confronted, 3 perpetrators confessed, 3 denied abuse that then ceased, and 4 more denied abuse that continued, culminating in death in 1 case. In 1 case, the outcome was not reported.[8] At least 3 victims remained with their perpetrators. Two perpetrators were criminally charged, 1 receiving probation and the other incarceration. The latter began abusing his cellmate, behavior that did not stop until he was confronted in prison.
CONCLUSION/DISCUSSION
Our primary objective was to locate and review all published cases of MSB‐AP. Our secondary aim was to describe salient characteristics of perpetrators, victims, and fabricated diseases in hopes of helping clinicians better recognize this disorder.
Our review shows that perpetrators were exclusively the victims' caregivers, including mothers, wives, husbands, daughters, granddaughters, or companions. These perpetrators, many with healthcare backgrounds, were attentive, helpful, and excessively present. In the majority of cases, hidden physical abuse yielded visible disease. Less commonly, perpetrators lied about symptoms rather than actually creating signs of disease. The most common mode of disease instigation involved poisoning through beverage/food contamination or subcutaneous injection. Geriatric and developmentally delayed persons appeared particularly vulnerable to victimization. Of the 13 victims, 5 were geriatric and 1 was developmentally delayed.
The adult cases we report are similar to child cases in that the perpetrators are caregivers; however, the caregivers of the adults are a more diverse group. Other similarities between adult and child cases are that physical signs occur more often than simply falsifying information, and poisoning is the most common method of disease fabrication. Suffocation, although common in child cases, has not been reported in adults. Though present in only a minority of cases, another feature distinguishing these cases from those reported in the pediatric literature is the presence of collusion between the perpetrator and victim. When MSBP was first described, Meadow believed that victims would reach an age at which the disorder would cease because they would fight back or report the abuse.[2] In 7 of the adult cases, the victims were unknowingly poisoned; however, in 2 cases,[17] the victims knew what their mothers were doing to them and yet denied that they were harming them. To explain this collusion, Deimel et al. proposed Stockholm syndrome, a condition in which a victim holds a perpetrator in high regard, despite experiencing at their hands what others might consider brainwashing and torture.
The data from the individual cases are sometimes frustratingly incomplete, with inconsistent reporting of dyad demographics and outcomes across the 13 cases, which compromises efforts to compare and contrast them. However, because no published studies have thoroughly reviewed all existing cases of MSB‐AP, we believe our review provides important insights into this condition by consolidating available information. It is our hope that by characterizing perpetrators, victims, and common presentations, we will raise awareness about this condition among healthcare providers so that it may be included in the differential diagnosis when they encounter this dyad: a patient's medical problems do not respond as expected to therapy and a caregivers appears overly involved or attention seeking.
The diagnosis of a factitious disorder often presents an immense clinical challenge and generally involves a multidisciplinary approach.[18] In addition to the incomplete data for existing cases in the literature, we recognize the ongoing difficulties in precise diagnosis of this disorder. Because a hallmark of pathology is secrecy at the outset and often denial, and even abrupt transition of care, upon confrontation, it is often very difficult, especially early on, to uncover patterns of perpetration, let alone posit a motive. We recognize that there may be some perpetrators who are motivated by something other than purely psychological end points, such as financial reward or even sexual victimization. And when alternate care venues are sought, clinicians are often left wondering. Further, the damage that may come to a therapeutic relationship by prematurely diagnosing MSB‐AP is important to keep in mind. Hospitalists who suspect MSB‐AP should consult psychiatry. Although MSB‐AP is a diagnosis of exclusion and often based on circumstantial evidence, psychiatry can assist in diagnosing this disorder and, in the event of a confession, provide immediate therapeutic intervention. Social services can aid in a vulnerable adult investigation for patients who do not have capacity.
When Meadow first described MSBP, he ended his article by asking Is this degree of falsification rare or is it under‐recognized? Time has answered Meadow's question. Now we ask the same question with regard to MSB‐AP, is it rare or under‐recognized? We must remain vigilant for this disorder. Early recognition can prevent healthcare providers from unknowingly perpetuating victimization by treating caregiver‐induced pathology as if legitimate, thereby satisfying the perpetrator's psychological needs. Despite Meadow's assertion that proxies outgrow their victimization, our review warns that advanced age does not preclude vulnerability and in some cases, may actually increase it. In the future, the incidence and prevalence of MSB‐AP is likely to increase as medical technology allows greater survival of cognitively impaired populations who are dependent on others for care. The elderly and developmentally delayed may be especially at risk.
ACKNOWLEDGMENTS
Disclosures: M.C.B., M.B.W., and M.I.L. report no conflicts of interest. J.M.B. receives payment for lectures, including service on speakers bureaus, from nonprofit continuing medical education organizations and universities for occasional lectures; however, this funding is not relevant to this review.
Asher first described Munchausen syndrome by proxy over 60 years ago. Like the famous Baron von Munchausen, the persons affected have always traveled widely; and their stories like those attributed to him, are both dramatic and untruthful.[1] Munchausen syndrome is a psychiatric disorder in which a patient intentionally induces or feigns symptoms of physical or psychiatric illness to assume the sick role. In 1977, Meadow described the first case in which a caregiverperpetrator deliberately produced physical symptoms in a child for proxy gratification.[2] Unlike malingering, in which external incentives drive conscious symptom falsification, Munchausen syndrome by proxy (MSBP) is associated with fulfillment of the abuser's own psychological need for garnering praise from medical staff for devoted care given a sick child.[3, 4]
MSBP was once considered vanishingly rare. Many experts now believe it is more common, with a reported annual incidence of 0.4/100,000 in children younger than 16 years, and 2/100,000 in children younger than 1 year.[5] It is a disorder in which a parent, often the mother (94%99%)[6] and often with training or interest in the medical field,[5] is the perpetrator. The medical team caring for her child often views her as unusually helpful, and she is frequently psychiatrically ill with disorders such as depression, personality disorder, or prior personal history of somatoform or factitious disorder.[7, 8] The perpetrator typically inflicts physical harm, although occasionally she may simply lie about symptoms or tamper with laboratory samples.[5] The most common methods of inflicting harm are poisoning and suffocation. Overall mortality is 6% to 9%.[6, 9]
Although a large body of literature addresses pediatric cases, there is little to guide clinicians when victims are adults. An obvious reason may be that MSBP with adult proxies (MSB‐AP) has been reported so rarely, although we believe it is under‐recognized and more common than thought. The primary objective of this review was to identify all published cases of MSB‐AP, and synthesize them to characterize victims and perpetrators, modes of deceit, and relationships between victims and perpetrators so that clinicians will be better equipped to recognize such cases or at least include MSB‐AP in the differential of possibilities when symptoms and history are inconsistent.
METHODS
The Mayo Clinic Rochester Institutional Review Board approved this study. The databases of Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Knowledge, and PsychINFO were searched from inception through April 2014 to identify all published cases of Munchausen by proxy in patients 18 years or older. The following search terms were used: Munchausen syndrome by proxy, factitious disorder by proxy, Munchausen syndrome, and factitious disorder. Reports were included when they described single or multiple cases of MSBP with victims aged at least 18 years. The search was not limited to articles published in English. Bibliographies of selected articles were reviewed for reports identifying additional cases.
RESULTS
We found 10 reports describing 11 cases of MSB‐AP and 1 report describing 2 unique cases of MSB‐AP (Tables 1 and 2). Two case reports were published in French[10, 11] and 1 in Polish.[12] Sigal et al.[13] describes 2 different victims with a common perpetrator, and another report[14] describes the same perpetrator with a third victim. One case, though cited as MSB‐AP in the literature was excluded because it did not meet the criteria for the disorder. In this case, the wife of a 28‐year‐old alcoholic male poured acid on him while he was inebriated, ostensibly to vent frustration and coerce him into sobriety.[15, 16]
| Author | Gender | Age, y | Presenting Features | Occupation/Education | Outcome |
|---|---|---|---|---|---|
| |||||
| Sigal M et al. (1986)[13] | F | 20s | Abscesses (skin) | NP | Death |
| F | 21 | Abscesses (skin) | Child care | Paraplegia | |
| Sigal MD et al. (1991)[14] | M | NP | Rash | NP | Abuse stopped |
| Smith NJ et al. (1989)[19] | M | 69 | None | Retired businessman | Continued fabrication |
| Krebs MO et al. (1996)[10] | M | 40s | Coma | Businessman | Abuse stopped |
| Ben‐Chetrit E et al. (1998)[20] | F | 73 | Coma | NP | Abuse stopped |
| Feldman KW et al. (1998)[8] | F | 21 | NP | Developmental delay | NP |
| Chodorowsk Z et al. (2003)[12] | F | 80 | Syncope | NP | Abuse stopped |
| Strubel D et al. (2003)[11] | F | 82 | None | NP | NP |
| Granot R et al. (2004)[21] | M | 71 | Coma | NP | Abuse stopped |
| Deimel GW et al. (2012)[17] | F | 23 | Rash | High school graduate | Continued abuse |
| F | 21 | Recurrent bacteremia | College student | Death | |
| Singh A et al. (2013)[22] | F | 79 | Fluid overload/false symptom history | Retired | Continued |
| Author | Gender | Age, y | Relationship | Occupation | Mode of Abuse | Outcome When Confronted |
|---|---|---|---|---|---|---|
| ||||||
| Sigal M et al. (1986)[13] | M | 26 | Husbanda | Businessman | Poisoningb followed by subcutaneous gasoline injection | Confession and incarceration |
| M | 29 | Boyfrienda | Businessman | Poisoningb followed by subcutaneous gasoline injection | Confession and incarceration | |
| Sigal MD et al. (1991)[14] | M | 34 | Cellmatea | Worked in medical clinic where incarcerated | Poisoningc followed by subcutaneous turpentine injection | Confession and attempted murder conviction |
| Smith NJ et al. (1989)[19] | F | 55 | Companion | Nurse | False history of hematuria, weakness, headaches | Denial |
| Krebs MO et al. (1996)[10] | F | 47 | Wife | Nurse | Tranquilizer injections | Confession and placed on probation |
| Ben‐Chetrit E et al. (1998)[20] | F | NP | Daughter | Nurse | Insulin injections | Denial |
| Feldman KW et al. (1998)[8] | F | NP | Mother | Business woman | False history of Batten's disease | NP |
| Chodorowsk Z et al. (2003)[12] | F | NP | Granddaughter | NP | Poisoningb | Denial |
| Strubel D et al. (2003)[11] | M | NP | Son | NP | False history of memory loss | NP |
| Granot R et al. (2004)[21] | F | NP | Wife | Hospital employee | Poisoningb | Confession |
| Deimel GW et al. (2012)[17] | F | NP | Mother | Unemployed chronic medical problems | Toxin application to skin | Denial |
| F | NP | Mother | Medical office receptionist | Intravenous injection unknown substance | Denial | |
| Singh A et al. (2013)[22] | M | NP | Son | NP | Fluid administration in context of fluid restriction/erratic medication administration/falsifying severity of symptoms | Denial |
Of the 13 victims, 9 (69%) were women and 4 (31%) were men. Of the ages reported, the median age was 69 years and the mean age was 51 (range, 2182 years). Exact age was not reported in 3 cases. Lying about signs and symptoms, but not actually inducing injury, occurred in 3 cases (23%), whereas in 10 cases (77%), the victims presented with physical findings, including coma (3), rash (2), skin abscesses (2), syncope (1), recurrent bacteremia (1), and fluid overload (1). Seven (54%) of the victims were poisoned, 2 via drug injection and 5 by beverage/food contamination. A perpetrator sedated 3 victims and subsequently injected them, 2 with gasoline and another with turpentine. Two of the victims were involved in business, 1 worked in childcare, 1 attended beauty school after graduating from high school, 1 attended college, and 1 was developmentally delayed. Victim education or occupation was not reported in 7 cases.
Of the 11 perpetrators, 8 (73%) were women, and 3 (27%) were men (note that the same male perpetrator had 3 victims). Median age was 34 years (range, 2655 years), although exact age was not reported in 4 cases. The perpetrator was the victim's mother in 3 cases, wife in 2 cases, son in 2 cases, and daughter, granddaughter, husband, companion, boyfriend, or prison cellmate in 1 case each. Five (38%) worked in healthcare.
All of the perpetrators were highly involved, even overly involved, in the care of their victims, frequently present, sometimes hovering, in hospital settings, and were viewed as generally helpful, if not overintrusive, by hospital staff. When confronted, 3 perpetrators confessed, 3 denied abuse that then ceased, and 4 more denied abuse that continued, culminating in death in 1 case. In 1 case, the outcome was not reported.[8] At least 3 victims remained with their perpetrators. Two perpetrators were criminally charged, 1 receiving probation and the other incarceration. The latter began abusing his cellmate, behavior that did not stop until he was confronted in prison.
CONCLUSION/DISCUSSION
Our primary objective was to locate and review all published cases of MSB‐AP. Our secondary aim was to describe salient characteristics of perpetrators, victims, and fabricated diseases in hopes of helping clinicians better recognize this disorder.
Our review shows that perpetrators were exclusively the victims' caregivers, including mothers, wives, husbands, daughters, granddaughters, or companions. These perpetrators, many with healthcare backgrounds, were attentive, helpful, and excessively present. In the majority of cases, hidden physical abuse yielded visible disease. Less commonly, perpetrators lied about symptoms rather than actually creating signs of disease. The most common mode of disease instigation involved poisoning through beverage/food contamination or subcutaneous injection. Geriatric and developmentally delayed persons appeared particularly vulnerable to victimization. Of the 13 victims, 5 were geriatric and 1 was developmentally delayed.
The adult cases we report are similar to child cases in that the perpetrators are caregivers; however, the caregivers of the adults are a more diverse group. Other similarities between adult and child cases are that physical signs occur more often than simply falsifying information, and poisoning is the most common method of disease fabrication. Suffocation, although common in child cases, has not been reported in adults. Though present in only a minority of cases, another feature distinguishing these cases from those reported in the pediatric literature is the presence of collusion between the perpetrator and victim. When MSBP was first described, Meadow believed that victims would reach an age at which the disorder would cease because they would fight back or report the abuse.[2] In 7 of the adult cases, the victims were unknowingly poisoned; however, in 2 cases,[17] the victims knew what their mothers were doing to them and yet denied that they were harming them. To explain this collusion, Deimel et al. proposed Stockholm syndrome, a condition in which a victim holds a perpetrator in high regard, despite experiencing at their hands what others might consider brainwashing and torture.
The data from the individual cases are sometimes frustratingly incomplete, with inconsistent reporting of dyad demographics and outcomes across the 13 cases, which compromises efforts to compare and contrast them. However, because no published studies have thoroughly reviewed all existing cases of MSB‐AP, we believe our review provides important insights into this condition by consolidating available information. It is our hope that by characterizing perpetrators, victims, and common presentations, we will raise awareness about this condition among healthcare providers so that it may be included in the differential diagnosis when they encounter this dyad: a patient's medical problems do not respond as expected to therapy and a caregivers appears overly involved or attention seeking.
The diagnosis of a factitious disorder often presents an immense clinical challenge and generally involves a multidisciplinary approach.[18] In addition to the incomplete data for existing cases in the literature, we recognize the ongoing difficulties in precise diagnosis of this disorder. Because a hallmark of pathology is secrecy at the outset and often denial, and even abrupt transition of care, upon confrontation, it is often very difficult, especially early on, to uncover patterns of perpetration, let alone posit a motive. We recognize that there may be some perpetrators who are motivated by something other than purely psychological end points, such as financial reward or even sexual victimization. And when alternate care venues are sought, clinicians are often left wondering. Further, the damage that may come to a therapeutic relationship by prematurely diagnosing MSB‐AP is important to keep in mind. Hospitalists who suspect MSB‐AP should consult psychiatry. Although MSB‐AP is a diagnosis of exclusion and often based on circumstantial evidence, psychiatry can assist in diagnosing this disorder and, in the event of a confession, provide immediate therapeutic intervention. Social services can aid in a vulnerable adult investigation for patients who do not have capacity.
When Meadow first described MSBP, he ended his article by asking Is this degree of falsification rare or is it under‐recognized? Time has answered Meadow's question. Now we ask the same question with regard to MSB‐AP, is it rare or under‐recognized? We must remain vigilant for this disorder. Early recognition can prevent healthcare providers from unknowingly perpetuating victimization by treating caregiver‐induced pathology as if legitimate, thereby satisfying the perpetrator's psychological needs. Despite Meadow's assertion that proxies outgrow their victimization, our review warns that advanced age does not preclude vulnerability and in some cases, may actually increase it. In the future, the incidence and prevalence of MSB‐AP is likely to increase as medical technology allows greater survival of cognitively impaired populations who are dependent on others for care. The elderly and developmentally delayed may be especially at risk.
ACKNOWLEDGMENTS
Disclosures: M.C.B., M.B.W., and M.I.L. report no conflicts of interest. J.M.B. receives payment for lectures, including service on speakers bureaus, from nonprofit continuing medical education organizations and universities for occasional lectures; however, this funding is not relevant to this review.
- . Munchausen syndrome. Lancet. 1951(1):339–341.
- . Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 1977;2(8033):343–345.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. 4th ed. Washington, DC: American Psychiatric Press; 2000.
- , , , et al. Position paper: definitional issues in Munchausen by proxy. Child Maltreat. 2002;7(2):105–111.
- , , , . Epidemiology of Munchausen syndrome by proxy, non‐accidental poisoning, and non‐accidental suffocation. Arch Dis Child. 1996;75(1):57–61.
- . Web of deceit: a literature review of Munchausen syndrome by proxy. Child Abuse Negl. 1987;11(4):547–563.
- , . Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011;199(2):113–118.
- , . The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy. J Pediatr Surg. 1998;33(4):623–627.
- , . Munchausen syndrome by proxy: diagnosis and prevalence. Am J Orthopsychiatry. 1993;63(2):318–321.
- , , , . Munchhausen syndrome by proxy between two adults [in French]. Presse Med. 1996;25(12):583–586.
- , , . Munchhausen syndrome by proxy in an old woman [in French]. Revue Geriatr. 2003;28:425–428.
- , , , . Consciousness disturbances: a case report of Munchausen by proxy syndrome in an elderly patient [in Polish]. Przegl Lek. 2003;60(4):307–308.
- , , . Munchausen syndrome by adult proxy: a perpetrator abusing two adults. J Nerv Ment Dis. 1986;174(11):696–698.
- , , . Munchausen syndrome by adult proxy revisited. Isr J Psychiatry Relat Sci. 1991;28(1):33–36.
- , , , , , . Otolaryngology fantastica: the ear, nose, and throat manifestations of Munchausen's syndrome. Laryngoscope. 2012;122(1):51–57.
- . Witchcraft's syndrome: Munchausen's syndrome by proxy. Int J Dermatol. 1998;37(3):229–230.
- , , , , , . Munchausen syndrome by proxy: an adult dyad. Psychosomatics. 2012;53(3):294–299.
- , . Factitious disorders and malingering: challenges for clinical assessment and management. Lancet. 2014;383(9926):1422–1432.
- , . More in sickness than in health: a case study of Munchausen by proxy in the elderly. J Fam Ther. 1989;11(4):321–334.
- , . Recurrent hypoglycaemia in multiple myeloma: a case of Munchausen syndrome by proxy in an elderly patient. J Intern Med. 1998;244(2):175–178.
- , , , , . Idiopathic recurrent stupor: a warning. J Neurol Neurosurg Psychiatry. 2004;75(3):368–369.
- , , . Munchausen by proxy in older adults: A case report. Maced J Med Sci. 2013;6(2):178–181.
- . Munchausen syndrome. Lancet. 1951(1):339–341.
- . Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 1977;2(8033):343–345.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. 4th ed. Washington, DC: American Psychiatric Press; 2000.
- , , , et al. Position paper: definitional issues in Munchausen by proxy. Child Maltreat. 2002;7(2):105–111.
- , , , . Epidemiology of Munchausen syndrome by proxy, non‐accidental poisoning, and non‐accidental suffocation. Arch Dis Child. 1996;75(1):57–61.
- . Web of deceit: a literature review of Munchausen syndrome by proxy. Child Abuse Negl. 1987;11(4):547–563.
- , . Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011;199(2):113–118.
- , . The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy. J Pediatr Surg. 1998;33(4):623–627.
- , . Munchausen syndrome by proxy: diagnosis and prevalence. Am J Orthopsychiatry. 1993;63(2):318–321.
- , , , . Munchhausen syndrome by proxy between two adults [in French]. Presse Med. 1996;25(12):583–586.
- , , . Munchhausen syndrome by proxy in an old woman [in French]. Revue Geriatr. 2003;28:425–428.
- , , , . Consciousness disturbances: a case report of Munchausen by proxy syndrome in an elderly patient [in Polish]. Przegl Lek. 2003;60(4):307–308.
- , , . Munchausen syndrome by adult proxy: a perpetrator abusing two adults. J Nerv Ment Dis. 1986;174(11):696–698.
- , , . Munchausen syndrome by adult proxy revisited. Isr J Psychiatry Relat Sci. 1991;28(1):33–36.
- , , , , , . Otolaryngology fantastica: the ear, nose, and throat manifestations of Munchausen's syndrome. Laryngoscope. 2012;122(1):51–57.
- . Witchcraft's syndrome: Munchausen's syndrome by proxy. Int J Dermatol. 1998;37(3):229–230.
- , , , , , . Munchausen syndrome by proxy: an adult dyad. Psychosomatics. 2012;53(3):294–299.
- , . Factitious disorders and malingering: challenges for clinical assessment and management. Lancet. 2014;383(9926):1422–1432.
- , . More in sickness than in health: a case study of Munchausen by proxy in the elderly. J Fam Ther. 1989;11(4):321–334.
- , . Recurrent hypoglycaemia in multiple myeloma: a case of Munchausen syndrome by proxy in an elderly patient. J Intern Med. 1998;244(2):175–178.
- , , , , . Idiopathic recurrent stupor: a warning. J Neurol Neurosurg Psychiatry. 2004;75(3):368–369.
- , , . Munchausen by proxy in older adults: A case report. Maced J Med Sci. 2013;6(2):178–181.
© 2014 Society of Hospital Medicine