OldPsychDoc said:
Interesting case--first time I've had one where the perpetrator was my identified patient. Probably manipulating meds of her handicapped son to keep him dependent and avoid having him "abandon" her. Anyone have any tips on helping her to increase her insight into what she's doing and possibly why? Seems like the prognosis is pretty poor here.
I saw a few Munchausen's by proxy cases on the c/l service. I wasn't engaged in a therapeutic relationship with the 'perpetrator' as you put it, but we did discuss the ramifications of these cases in our rounds.
I would think that the direction of therapy would be directed at an sympathetic but firm approach as to why the behavior is occurring - giving her a full chance to explain her behavior, and listening for cues, without passing judgement, as hard as it may be.
Extreme behaviors are motivated by extreme desires, or even, extreme pathology. If it's the latter, the prognosis is indeed poor. If the Munchausen's is a direct result of a thought disorder or poor reality testing, then medications with some insight-oriented approaches may be best.
Of course, the most common cases like these involve a mother using the identified child as the proxy. Often with medications or infectious substances keeping the child in the sick role. What does this provide for the mother? Usually attention, sympathy, sometimes money, of often an excuse for an otherwise unacceptable behavior ("She's going through such a hard time"). "Simpler" reasons such as attention and sympathy can be explored and fettered out. i.e. was there active or passive neglect of her herself as a child, or a sibling? What was the response, and the current thoughts about this?
I treated a grown child who was a victim of Munchausen's, who was naturally very bitter about what had happened to her. This is also another avenue of exploration - asking what the mother hopes to gain from these behaviors. It seems more often than not a combination of the above with an intense fear of the child becoming independent (explore why). It may have to do with being alone, feeling of abandonment, or feeling devalued (bearing and raising a child makes her important).
Let us know how you fare.
