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Pathophysiology Symptoms Diagnosis
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tarix | 06.05.2017 | ölçüsü | 7,41 Mb. |
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Pathophysiology Symptoms Diagnosis Treatment Polite applause
It’s an eponym It’s an eponym It’s not really a disease It’s not really a diagnosis It’s medical… and psychiatric… and social It’s very hard to treat It’s hard to spell
What to call it? What to call it? Who can diagnose? Where’s the threshold? When to involve the authorities?
Not a single condition, but a variety of presentations along a spectrum of severity Not a single condition, but a variety of presentations along a spectrum of severity Evaluations have to be exhaustive …and involve physicians
To remind pediatricians: To remind pediatricians: Children are injured by factitious illness Harm often requires physician’s complicity We can’t usually diagnose it alone (much less treat it), but Medical input is essential to diagnosis Our focus is on harm to the child
Asher, 1951: “Munchausen Syndrome” Asher, 1951: “Munchausen Syndrome” Kempe, 1975: “Uncommon manifestations of Battered Child Syndrome” Meadow, 1977: “Munchausen Syndrome by Proxy: The hinterland of child abuse” Rosenberg, 1987: “The web of deceit”
Rosenberg (1987): Rosenberg (1987): Illness in a child which is simulated and/or produced by someone in loco parentis Presentation of the child for medical assessment and care, usually persistently, often resulting in multiple medical procedures Denial of knowledge by the perpetrator Acute symptoms abate with separation
DSM-IV (1994) “Factitious Disorder by Proxy”: DSM-IV (1994) “Factitious Disorder by Proxy”: (A) Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care. (B) The motivation for the perpetrator's behavior is to assume the sick role by proxy. (C) External incentives for the behavior (such as economic gain) are absent. (D) The behavior is not better accounted for by another mental disorder. (p. 727)
Jenny (2008),“Medical Child Abuse”: Jenny (2008),“Medical Child Abuse”: A child receiving unnecessary and harmful or potentially harmful medical care at the instigation of the caretaker.
Factitious Disorder Imposed on Another (previously, Factitious Disorder By Proxy) Factitious Disorder Imposed on Another (previously, Factitious Disorder By Proxy) To make this diagnosis, all 4 criteria must be met. Note that the perpetrator, not the victim, receives this diagnosis. 1. A pattern of falsification of physical or psychological signs or symptoms in another, associated with identified deception. 2. A pattern of presenting another (victim) to others as ill or impaired. 3. The behavior is evident even in the absence of obvious external rewards. 4. The behavior is not better accounted for by another mental disorder such as delusional belief system or acute psychosis.
Spectrum: Spectrum: Exaggeration of symptoms Fabrication of symptoms Induction of symptoms resulting in harm to child, through actions of caregiver,
Top ten: Top ten: - Apnea/cyanosis
- Feeding problems/anorexia
- Seizures
- Behaviors
- Asthma/allergy
- Fever/pain…
- No common presentation!
Symptoms actively produced in 57% Symptoms actively produced in 57% - Suffocation, drugs, poisons, etc.
- Half while child was in the hospital!
Many had unrelated injuries, neglect, FTT Average of 3.25 medical conditions
Web of deceit: a literature review of Munchausen Syndrome by Proxy Rosenberg, Donna A., Child Abuse & Neglect, 1987 The deceit continues: an updated literature review of Munchausen Syndrome by Proxy Sheridan, Mary S., Child Abuse & Neglect, 2003
Caveats: Caveats: Literature review isn’t random Diagnoses not equally certain Series often span years Inconsistent approaches
Male = Female Male = Female Average age: 48 months Time to diagnosis: 22 months Outcomes: long-term disability in 7-8%, death in 6-9% Siblings: 25% of sibs dead, half under “suspicious circumstances”
Female >> Male Female >> Male Mothers heavily represented Medical background: 14-27% Munchausen features in caregiver: 29% Psych diagnosis: 23% - Depression, personality disorders, somatization
Pediatric or Psychiatric diagnosis? Pediatric or Psychiatric diagnosis? MSBP or MBPS? “Primum non nocere”
APSAC: PCF + FDP = M(S)BP APSAC: PCF + FDP = M(S)BP Pediatric Condition Falsification, plus Factitious Disorder by Proxy, equals Munchausen by Proxy
FDP is not a mental disorder FDP is not a mental disorder PCF and FDP can occur independently Examples: - PCF without FDP
- Harm to the child without PCF or FDP
- “Lookalikes”
What’s a diagnosis? What’s a diagnosis? - “Differential diagnosis”
- Degrees of certainty
Diagnostic criteria
How important is the caretaker’s motive? How important is the caretaker’s motive? How useful is a profile?
Difficult because: Difficult because: Medical personnel are involved in harm Multiple institutions, scattered records Failure to consider the diagnosis Failure to involve other professionals
What’s proof?: What’s proof?: Confessions? Improvement out of home? Covert video surveillance? Lab findings?
Child’s safety is the first priority Child’s safety is the first priority Use least restrictive option - Close observation
- In-home dependency
- Foster care
- Criminal prosecution
Consult child abuse pediatrician Gather and review all medical records Work as multidisciplinary team Involve state Child Protection agency prn Involve whole family in treatment
Not a single condition, but a variety of presentations along a spectrum of severity Not a single condition, but a variety of presentations along a spectrum of severity MBP is a dyadic diagnosis; PCF/FDP are individual diagnoses Child abuse is child abuse, whatever the context Evaluations have to be exhaustive …and involve physicians
3yo boy 3yo boy 14 visits to PCP in past year, 3 to ED, usually after visitation Parents share custody Allegations of poor care: constipation, abdominal pain, possible sexual abuse Father doesn’t adhere to Mom’s special diet
8yo twin girls Mother describes allergic reactions to aero-allergens, behavioral symptoms Naturopath supports her Children missed 30 days of school last yr Sleep on wooden panels, in mylar blankets, wear masks outside
6yo boy with asthma sx per mom 6yo boy with asthma sx per mom “meds don’t help” Peak flow decreased in office, but improves w/ albuterol neb Mom asks for steroids Wants disability papers filled out
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