What is Munchausen syndrome by proxy? The disorder that turns caregivers into executioners.

A few weeks ago, a new case of child abuse came to light that shocked public opinion in our country. Print and digital media, as well as social media, reported on the rescue of three children between the ages of 8 and 10, who had been locked in their own home in Oviedo for over three years. Their parents kept them at home, living among excrement and without schooling.

A neighbor's complaint alerted authorities, and police arrived during the blackout on April 29. From that moment on, the terrible situation the children experienced began to be revealed.

Parents made their children believe they were sick, gave them medicines purchased on the black market, and put them in diapers even though, at 8 and 10 years old, they no longer needed them.

Pending a full analysis and evaluation, there are indications that this couple, consisting of a 53-year-old German man and a 48-year-old woman with dual German and American nationality, may suffer from Munchausen syndrome by proxy.

Serious side effects

Because it is “a rare and underdiagnosed condition, the true incidence of Munchausen syndrome by proxy is difficult to establish,” says Dr. Iria Rodríguez, a child and adolescent psychiatrist at HM Puerta del Sur University Hospital, who points out that “some estimates suggest a prevalence of 0.5 to 2 cases per 100,000 children.”

It is a severe form of child abuse in which a primary caregiver exaggerates or fabricates symptoms in a child or dependent person.

The problem is that, since it is a covert behavior, " many situations are likely never to be properly diagnosed ." However, the limited knowledge of cases does not diminish the importance of this strange psychopathology, which the expert defines thus: "Munchausen syndrome by proxy (also known as factitious disorder imposed on another ) is a severe form of child abuse in which a primary caregiver induces, exaggerates, or fabricates medical symptoms in a child or dependent person."

Furthermore, he emphasizes that "the ultimate goal is to attract medical, emotional, or social attention for themselves, making the child a victim of unnecessary medical procedures, hospitalizations, and misdiagnoses."

Whenever one of these cases comes to light, we often wonder how someone could be capable of committing the acts described against vulnerable people , whether they be children, as in the recently discovered Oviedo case, or elderly people, who are also a very common type of victim in this condition. The professional response to this question is that "they generally involve people who have had mental health issues at some point in their lives due to their need for care and validation from others," Rodríguez clarifies.

Furthermore, "they often have complex personal histories, and it is not uncommon to find a history of abuse or neglect in their biographies," the expert adds, adding that "in some cases, they may have jobs or knowledge in the healthcare field , and in the most seriously ill patients, the associated psychopathology may be a delusional disorder or even psychosis ."

Therefore, if we look for the causes, we must investigate various areas. According to Rodríguez, "patients often experience childhood traumas, such as abuse or neglect, personality disorders , a pathological need for attention, and, in some cases, life or professional frustration. Dysfunctional family dynamics and insecure attachment patterns may also play a role."

Beyond the causes stemming from a person's life history, events like the COVID-19 pandemic can act as catalysts . " Social isolation , increased stress, and more limited access to support networks can exacerbate underlying disorders," the expert says.

Furthermore, in the case of delusional pathologies , or in the field of psychosis, "the fact that there was a need for isolation, with multiple 'conspiracy' theories, may have influenced the onset or worsening of distrust of the outside world and worsened a complex clinical situation," he suggests.

Dr. Jaime Adán, a psychiatrist at Ruber Internacional Medical Center in Havana , expresses a similar opinion. He believes that "stressful situations or those that provoke an increase in social anxiety, such as the COVID-19 pandemic, could act as precipitants for pre-existing psychological disorders , including Munchausen syndrome by proxy." He adds: "Social isolation and growing health concerns could have facilitated a context in which predisposed people could develop pathological behaviors related to seeking medical attention or recognizing third parties."

With this breeding ground simmering under circumstances such as the pandemic, certain behaviors can become warning signs. "Recurring, unexplained, or unclear illnesses in a child or dependent person ; symptoms that disappear when the patient is separated from the suspected caregiver ; a caregiver who seems overly involved, very controlling, and seemingly indifferent to the sick person's real suffering; symptoms that don't match clinical findings; or a history of numerous medical consultations, interventions, or aggressive treatments without a clear justification," are some of the most obvious symptoms pointed out by Dr. Adán.

An increase in social anxiety, such as the pandemic, could act as a precipitant for pre-existing psychological disorders.

On the other hand, it has been observed that these people " do not usually go to a single hospital , that is, their appointments are spread across several health centers, even in several towns, as they try to avoid the same health professional being involved in multiple medical care sessions, thus avoiding detection," explains Dr. Rodríguez.

For all these reasons, it's understandable that people with Munchausen syndrome by proxy don't seek medical advice on their own initiative. "Access often occurs after suspicions on the part of healthcare personnel , social workers , or schools," the expert points out.

What typically happens is that " a discrepancy is detected between the child's symptoms and clinical tests . At that point, a multidisciplinary protocol is activated, which may lead to the intervention of mental health services ."

Holistic approach

Due to the unique nature of this disorder, which affects the health, social, and legal spheres, "treatment requires urgent multidisciplinary intervention: protection of the child, psychiatric care for the caregiver, and judicial follow-up, if appropriate," Rodríguez points out.

Furthermore, "all interventions must be accompanied by family support and institutional monitoring to ensure the safety and well-being of the minors /dependents involved," Rodríguez points out.

For his part, Dr. Adán explains how the priority at the beginning of this treatment is to protect the victim from potential harm, "which usually requires immediate intervention by social services and legal authorities (it is often essential to separate the child from the caregiver)."

At the psychiatric level, treatment for the abuser "is fundamentally based on psychotherapy (individual and, in some cases, family therapy)," the doctor points out. In addition, "it may include specific pharmacological approaches for depressive or anxiety symptoms."

On the other hand, " complete remission is rare , but with appropriate treatment, an improvement in awareness of the disorder and behavior can be achieved. The key is early intervention, a comprehensive approach, and environmental control to prevent relapse," says Dr. Iria Rodríguez.

In agreement with the doctor, psychiatrist Jaime Adán asserts that " the prognosis is often complicated if intensive intervention is not undertaken, although if intervention is early and the patient shows good adherence and motivation for treatment, recovery is possible."

The case of the children of Oviedo

Considering the symptoms of Munchausen syndrome by proxy and the information gathered in the case of the children in the Principality , Dr. Rodríguez believes that " it does not fully fit the case of Munchausen syndrome by proxy, because the responsible adults did not seek the children's care. Quite the opposite. These children were isolated and did not attend routine medical checkups ."

"Isolation seems to be the result of a lack of trust in external security and has also resulted in children lacking contact with their peers and lacking formal academic training," the expert argues.

On the other hand, although "they appear to be physically well, having been isolated for so long can obviously produce psychological consequences such as attachment disorders, anxiety , distrust of adults, post-traumatic stress disorder, and even difficulties identifying their own emotions or needs."

For all these reasons, the doctor believes that "we must be very vigilant in peer relationships and in the emotional regulation capacity of these minors who have been subjected to continuous isolation from the outside world. They will require specialized therapeutic support, a safe and stable environment, and ongoing monitoring."

Similarly, Dr. Adán believes that "it's possible for these children to recover, although they will likely require prolonged psychological treatment and specialized support for a significant period."