PRIKAZI BOLESNIKA

173
MINHAUZENOV SINDROM PREKOPOSREDNIKA
Aneicanap A. JOBAHOBHT
1
, Becna P. HOHOBHT
1
, Cno6oan CABHT
2
,
Top|e AAEMHHJEBHT
2
, Haa JAHKOBHT
1
1
Hncrnryr sa ncnxnjarpnjy, Knnnnuin nenrap Cp6nje, Beoipa;
2
Institut za sudsku medicinu, Medicinski fakultet, Univerzitet u Beogradu, Beograd

(MSP) uveo 19.

(Roy Meadow), , ,
. MSP , (DSM-IV),

, , (ICD-10), , MSP
F68.1.
,
. MSP ,
. MSP
, , ,
, .
, ,
, MSP.
,
,
. , ,
.
, ,
UVOD
Minhauzenov sindrom preko posrednika (MSP)
je noce6an nn snocranmana ie nounnnnan, c xorn-
vom posrednog preuzimawa uloge bolesnika, izazi-
va telesne ili duevne znake, odnosno tegobe bole-
crn io prne o iojoj ce crapa, a sarnx prny ynopno
nonpiana xennnnciox ncnnrnnany n neueny. \ rn-
nnunnx cnyuajennxa prna snocranmana je ere npe-
mioncioi yspacra, a nounnnnan snocranmana neiona
xajia. Onaj repxnn je y crpyuny nnreparypy uveo 1977.
godine engleski psihijatar Roj Medou (Roy Meadow)
[1], onncanmn ia iao noce6an o6nni ncnomanana rsn.
qnirnnnnx nopexehaja (iopncre ce jom n repxnnn: na-
nn, nemrauin, qancnqnionann, nnyionann nope-
xehajn), iojn cy y inacnunoj nnreparypn nosnarnx n
kao Minhauzenov sindrom, s ozbiqnim konotaci-
jaxa ne caxo y xennnnciox, neh n y npannox ionrei-
cry. Cnnpox je o6no nxe no inannox jynaiy poxana
nexauioi innennnia P. E. Pacnea ,Heo6nuna nyro-
vawa, poduhvati i avanture barona Minhauzena, a
npecranma naxepno nsasnnane, rj. nanpane, npere-
no qnsnuinx, ann n ncnxonominx snaia nnn cnxn-
toma, sa motivom da se preuzme uloga bolesnika, bez
spoqawih podsticaja, kao to su, na primer, eko-
nomska dobit, dobijawe odtete, izbegavawe vojske
nnn ipnnnune oionopnocrn, iojn cy cnojcrnenn xo-
rnnannjn cnxynanara.
Ayropn cy enenn a cipeny nany na innnnuin
n qopensnuin snauaj MSP iao cnennqnunoi o6nnia
snocranmana (npe cneia, ene) ioje capn peanny
onacnocr no spanme n nnor prne n ioja ce neoxa
remio njainocrniyje n neun. \ rox cxncny, ayropn
cyxnpajy ocaamna crpyuno-nayuna casnana n n-
leme koje se odnose na MSP n npniasyjy cnyuaj ns cno-
je qopensnuie npaice.

SINDROMU PREKOPOSREDNIKA

MSP nn y nocnenoj nepsnjn Axepnuie inacnqnia-

nnje ncnxnjarpnjcinx nopexehaja (DSM-IV) nije na-
mao xecro iao snannuna njainosa na npnoj oconnnn.
Cnpcran je y ipyny nopexehaja iojn saxrenajy ame
npoyuanane no nponnsopnox njainosox ,qnirnn-
nn nopexehaj npeio nocpennia", ca cneehnx ipnre-
pnjyxnxa: a) naxepno nsasnnane nnn nanpane qn-
snuinx nnn ncnxonominx snaia nnn cnxnroxa io
pyie oco6e o iojoj ce neio crapa; 6) xornn sa nonama-
ne nounnnona snocranmana npecranma npeysnxane
ynoie 6onecnnia npeio nocpennia; n) ne nocrojn cno-
qawa pobuda (recimo, ekonomska korist) za takvo
nonamane; i) nonamane nnje 6ome o6jamneno py-
inx xenrannnx nopexehajex [2, 3].
Hpexa [eceroj pennsnjn Me|ynapone inacnqnia-
cije bolesti (ICD-10), MSP ce ycnonno xoe cnpcra-
rn y oinnpy iareiopnje ,[pyin nopexehajn nnunocrn
n nopexehajn nonamana opacnnx oco6a" [4], no mn-
fromF68.1, ioja capn ,Haxepno nsasnnane nnn na-
npane renecnnx cnxnroxa ncnxnuinx necnoco6no-
crn (cnxynnpann nopexehaj)". \ 6nnex onncy onoi
BIBLID: 0370-8179, 133(2005) 3-4 p. 173-179 UDC: 616.89-008.441.3:616-053.2-058.6
174

njainocrnuioi enrnrera nanon ce a ,oco6a nona-
nmano nanpa cnxnroxe n uai xoe ce6e nonpenrn,
a 6n nsasnana cnxnroxe n snaie 6onecrn", npn uexy
je ,xornnannja cipnnena, neponarno nnrpancnxnuia,
n nxa sa nnm npnxnarane ynoie 6onecnnia". Mnnxa-
ysenon cnnpox npeio nocpennia ce, xe|yrnx, eic-
plicitno ne pomiwe u ICD-10, ni u okviru prethod-
no pomenute kategorije (F68.1), gde bi najpre mogao
da se svrsta, niti u okviru Sindroma loeg postu-
pawa (Syndroma maltractionis), pod ifrom T74, ni-
rn na 6nno iox pyiox xecry.
Bennia yuecranocr nocranmana ioxop6nnrernnx
dijagnoza kod MSP, iao n neocrarai crpyunoi ion-
censyca y nesn ca njainocrnuinx ipnrepnjyxnxa sa
MSP n ame nanay norpaiy sa npennsnnjox eqnnn-
nnjox nopexehaja [3], re ce, no rox nnrany, neanno
oglasioisamautortermina MSP, npenayhn cnee-
he ipnrepnjyxe: a) 6onecr je ncqa6pnionana (nnyio-
vana) od roditeqa ili nekoga ko je in loco parentis; 6)
ere ce nepsncrenrno npniasyje neiapnxa; n) nounnn-
nan snocranmana (y noueriy) nopnue a je nsasnao 6o-
necr io erera; i) 6onecr necraje iaa ce ere onaja
o nounnnrema snocranmana; ) cxarpa ce a nounnn-
lac deluje jer ima potrebu da zauzme ulogu bolesni-
ka putemposrednika ili u smislu drugog oblika po-
namana iojn je ycxepen na npno6njane nane.
Diferencijalna dijagnoza
Oanno cy youene remiohe y njainocrnionany n
razlikovawu MSP n nnqanrnnna (najuemhe nsasna-
noi rponanex nnn xexannuinx yiymenex), npnipn-
nana ceicyannoi snocranmana n cyponoi iananana,
namerne invalidizacije deteta radi odtete, pato-
nomie cinonocrn ia nocehnnany neiapa, eicrpexne
separacione anksioznosti roditeqa, sumanutosti
y nesn ca spanmex erera nr. [6, 7].
Oncenox anannsox iasyncrnie MSPiz literatu-
pe (431 npnias 6onecnnia), Lepnan (Sheridan) [8] je
naaopozitivankomorbiditet u 103 prikazana slu-
uaja. Hanxe, nope ipnrepnjyxa sa MSP, 23 oco6a c
onnx nopexehajex je saonomanano n ipnrepnjyxe sa
nein pyin ncnxnjarpnjcin nopexehaj: najuemhe je y
nnrany 6no ipannunn, xncrpnonnunn nnn anrnconn-
jannn nopexehaj nnunocrn (36), sarnx enpecnnnn
nopexehaj (23) n cyxanyrn nopexehaj (8).
Hpnn n, cnaiaio, najnannjn iopai y njainocrn-
ionany 6onecrn je ncimyunnane nnn yrnp|nnane n
neuene o6jeirnnnoi coxarcioi nopexehaja io prne.
U suprotnom, deava se da lekari dugo ne prepozna-
ju stvarne uzroke nastanka simptoma kod deteta (ap-
neje, anepinje, acrxe n cn.) n onpnnoce ereronoj a-
moj narnn, nonpianajyhn ia neoionapajyhnx n ne-
norpe6nnx ncnnrnnannxa, neoionapajyhex neueny
nnn uai xnpypmioj nnrepnennnjn [9, 10]. \ cnyuajy
iaa io erera yio ne xoe a ce onece npana inn-
nnuia njainosa, jep ce ,ne yinanajy" cnn enonn inn-
nnuie cnnie, rpe6a nxarn y nny n xoiyhnocr a je y
pitawu MSP, te, u tom smislu, daqe treba: 1) obrati-
rn nany na noarai o ncnxnuinx npo6nexnxa xaj-
ie erera; 2) sarpanrn ioncynrannjy c pyinx neia-
pox; 3) ne npnxennnarn nnnasnnne recrone caxo a
6n ce ponremn saonomnnn; 4) pasxorpnrn nocnen-
ne n mrernocr recrona y onocy na iopncr; 3) ycnocra-
nnrn capany c ycranonaxa n crpyunannxa iojn xo-
gu dati bilo kakav podatak o prethodnoj bolesti de-
rera; 6) ioncynronarn ce ca ioneiaxa y cnyuajy a ce
noann ns anaxnese ne cnay ca pesynrarnxa nanasa
[11]. \npano s6oi remioha y njainocrnionany, neie
institucije su uvele i video-nadzor, radi kontinu-
npanoi innnnuioi naineana n oiasnnana iaio po-
diteqi mogu da izazovu teke i ponekad smrtne po-
cnenne io cnoje ene [12, 13].
Epidemiologija
Smatra se da je stopa prevalencije MSP vrlo ma-
na, xaa nponeny oreana unnennna a onaj noce6an
o6nni snocranmana erera uecro ocraje nesa6eneen
n neionnio ionna. MSP se, prema nekim procenama,
nanasn y ocnonn 0,3 snocranmana ene npnjanmennx
cnaie ionne y Cjennennx Axepnuinx [panaxa,
oi je crona nnnnennnje io ene xna|e o 16 ionna
na Honox Senany 6nna 0,02 [14, 13]. [noionmna
epidemiolokasudijaoMSP, neakcidentnomugue-
ny n rponany ene y Bennioj Bpnrannjn n Hpcioj [16]
noiasana je a ce io oio nononnne cnyuajena nesae-
sno uguewe i trovawe desilo u okviru MSP. Pannja
ncrpannana cy sa6enenna jenno ene iao nounnn-
oce zlostavqawa u okviru MSP, ali se ubrzo pokaza-
no a ce, npexa y snarno xanex nponenry (oio 3),
ikod mukaraca mogu javitisimptomiovog poreme-
haja [17, 18]. Sa6eneenn cy n cnyuajenn a cy o6a pon-
rema, na uai n 6a6a n ea, ypyeno enonann na sno-
stavqawe dece u okviru MSP [19, 20].
Patogeneza
Hpoyuanana nnunocrn oco6a o6onennx o MSP vr-
no pano cy yiasana na rsn. nenopxanan cran npexa 6o-
necrn, iao jean o imyunnx qenoxena y naroienesn
MSP, unje pasyxenane xoe a nax noxoine, iaio y
nponenn n neueny o6onennx oco6a, raio n s6pnnana-
ny prana noponunoi nacnma [21, 22]. Jena o pa-
nnx crynja ioja ce 6annna onacnomhy o ponrema ca
nenormalnimstavomprema bolesti, a koja je obuhva-
rnna 34 ene o naeceropo ponrema ca coxarcinx
nopexehajex, noiasana je a cy ena y snarnoj xepn 6n-
na prne snocranmana, ys nenniy crony ncnxnjarpnj-
cioi xop6nnrera n nenniy yuecranocr 6onnnuioi ne-
uena [23]. \ cinay c pesynrarnxa nperxonnx, n pe-
synrarn nonnjnx ncrpannana ioja cy ce 6annna e-
ramnox enanyannjox nnunocrn oco6a c MSP uglav-
nox noiasyjy y nnunoj ncropnjn nocrojane naxepno
nsasnannx nnn coxaroqopxnnx nopexehaja [24, 23].
Ispitivawe falsifikovanih akuerskih kom-
plikacija kod majki koje su sledstveno zlostavqale
cnojy eny noiasano je a 6onecr na nopo|ajy xoe a
nocrnue npenas c ayroecrpyirnnnoi nonamana y
Mnnxaysenon cnnpox [26, 27] nnn ca nocrnapryxcie
depresije na heterodestruktivno ponaawe u okvi-
ru MSP. [anac ce onpanano cxarpa a cxpr nonopo-
|enuera, ioja ce pannje inacnqnionana iao rsn. cnn-
173

pox nsnenane cxprn nonopo|enuera (Sudden Infant
Death Syndrome - SIDS), io oio nononnne cnyuajena
yonmre nnje cnyuajna n a cy sa ny oionopnn pon-
remn c nenopxannnx cranox npexa 6onecrn [28]. Hpe-
ma aktuelnim psihodinamskim shvatawima, fakto-
pn iojn onpnnoce nojann n opanany MSP su kod
obolelihosoba izvesnielementiiskustva iz detiw-
stva (zlostavqawa u detiwstvu po tipu MSP, a mo-
a n nciycrno xoenonana nnn oxpa6pnnana qan-
cnqnionana 6onecrn oco6e ioja neiyje ere), cnano
ocehane 6eca n ocyjehena, xponnunn neocrarai ion-
rpone n pasouapane y neiape ca cnecrnenox norpe-
bom da se preuzme uloga bolesnika preko posredni-
ia, unxe ce nocrne ocno6a|ane o nenpnjarnnx exo-
nnja n nononno crnue ocehane ycnocranmene n o6no-
nmene ionrpone [29, 30]. [oi ce xajia c MSP y nehnnn
cnyuajena (93) onncyje iao nnrennienrna n ca conn-
nim medicinskim znawem (nekad i s medicinskim
obrazovawem), ali preterano nametqiva, zahtevna
n napnnconna, oran je o6nuno exonnonanno ncran-
ciran i pasivan ili odsutan iz porodice (na putu,
pasneen n cn.) [7, 8, 31].

Spancrnenn crpyunann iojn ce cpehy ca oco6axa

koje boluju od MSP o6nuno iay a cy y noueriy cre-
inn yrncai a je oco6a ioja onon ere na neuene (naj-
uemhe xajia) nsyserno nocnehena n cnpexna sa capa-
ny. Te oco6e (ca nopexehajex MSP) prikazuju detetovo
crane iao ,remio, jenncrneno, saionerno, nensneun-
no,...", npn uexy uecro nsjanmyjy a je ,xennnncia o-
iyxenrannja, naanocr, nenonparno nsiy6mena...". He-
perio ce janma naronomia nnrepainnja nsxe|y pon-
rema, onocno crapaona n uecro ax6nnnosnnx n cyjer-
nnx xennnncinx crpyunaia qacnnnnpannx perinx,
jenncrnennx n neo6nunnx cnyuajennxa, iojn y nnxa
nonono xoiy a airnnnpajy ,nperepan ncrpannauin
enrysnjasax" [9]. Kacnnje ce ncnocranma a je xajia
(ioja je najuemhn nounnnnan snocranmana y oinnpy
MSP) izuzetno zahtevna u odnosu na zdravstveno oso-
bqe, sa nerealnim zahtevima za dodatne medicinske
nocrynie, pan njainocrnionana o6omena n neuena
erera. Majia peonno o6nja a ce onojn o erera
uai n iaa je ro xennnncin nnnionano, nncncrnpa
da govori u ime deteta, ne dozvoqava drugim osobama
a erery npenncyjy neione, a uecro na cnojy pyiy cnpo-
non ope|ene njainocrnuie n repannjcie nocrynie.
Kaa ce cyoun ca nocnennaxa cnoi nonamana, xajia,
no npannny, peaiyje 6ypno: 6ecox, iareiopnuinx ne-
inpanex, enpecnjox nnn npeinox neuena n ono|e-
nex erera y pyiy ycranony n io pyinx neiapa.
Ni teko oboqewe sa letalnim zavretkom ili
xennienox erera, nnrn naimn o6nni nopexehaja,
iojn ce uemhe nn|a, ann iojn raio|e xoe a nanece ne-
liku tetu detetu, nisu laki za dijagnostikovawe,
jep je yuecranocr MSP nornenena, a yrnp|nnane npo-
yeno [16]. Lepnanona anannsa iasyncrnie [8] no-
iasyje a cy xajie 6nne najuemhn nounnnonn snocra-
nmana (76,3), a cy rnnnune prne ena yspacra o
uernpn ionne, a je npoceuno npexe o nojane cnxn-
toma do postavqawa dijagnoze dve godine, da je oko
6 ene yxpno, oi je io 7,3 ocrana rpajna nocnen-
na, re a ce na 61,3 6pahe nnn cecrapa prana (o io-
jnx je uai 23 yxpno) raio|e cyxnano a cy 6nnn p-
tve zlostavqawa od strane osobe koja je obolela od
MSP. \ crynjn ioja ce 6annna iasyncrniox na xe|yna-
ponox nnnoy [32] onncana cy 122 cnyuaja ns 24 sexme
y iojnxa je y 86 cnyuajena xajia 6nna ncimyunnn no-
unnnnan snocranmana, a y 32 cy 6nne prne yspacra
o rpn ionne o 13 ionna, npn uexy je 6nno 34 e-
uaia. Crynja je noiasana a ce MSP janma na cnnuan
naunn y cnery, onocno iao ynnnepsannn qenoxen.
MSP ce, c acneira naunna na iojn nounnnonn sno-
cranmana nemrauin crnapajy cnxnroxe io prne,
xoe jannrn y npno mnpoiox njanasony ncnomana-
na - ananex n y6pnsiananex pasnnx xeniaxenara
nnn roicnna, qnsnuinx nonpe|nnanex, noiymajnxa
cyqoiannje, a norox cnacananex nr. [33].
Hanonxo cnyuajene iojn nnycrpyjy narne iojnxa
cy nsnoene prne, iao n npo6nexe c iojnxa ce cyo-
uana xennnncio oco6me. \ cnyuajy 6e6e ioja je 6nna
6onnnuin neuena mecr xecenn n y rox nepnoy peann-
mirana vie od 100 puta zbog hemodinamskog kolap-
ca, xajia je nnrensnnno 6nna yimyuena y nnannpane
n cnpono|ene xennnncie neie, neionana je ere, ai-
rnnno yuecrnonana y cnaioj peannxannjn, npnjarem-
cin ce onxonna npexa sanocnennxa. Aeiapn cy cyx-
nann na nein neo6jamnnnn xera6onnuin nopexehaj,
a ispostavilo se da je majka trovawemizazivala sva-
iy ennsoy xexonnaxcioi ionanca [9]. Temiohe y n-
jagnostikovawu, kao i medikolegalne manipulacije
od strane osoba obolelih od MSPilustruje iprimer
ry6e npornn exnnenrnoi crpyunaia [34] iojy je no-
nela majka zbog pogrenopostavqene dijagnoze bole-
crn io nenoi erera (y crnapn, prne snocranmana
majke s MSP), onocno cnyuaj nanaecroionmnei e-
uaia unjn cy ponremn nano onrynnn yunrema sa
nonanmano qnsnuio snocranmane (o6a ponrema cy
nxana ncnxosy, a euai nopexehaj nonamana, naxep-
no nsasnan qnsnuin nopexehaj n exonnonanne npo-
6nexe) [19]. \ nnreparypn cy onncann cenca io ere-
ra iojy je neiona xajia nemrauin nsasnana y6pnsiana-
nex nmynauie [33], iao n rponana inosannnox n ino-
nnnnox [36] iojn cy oripnnenn rei nocne roicniono-
minx anannsa. \ cnyuajy mecroxeceunoi erera io
iojei cy ce janmann ennnencnjcin nanan [37] njaino-
stikovana je hipoglikemija izazvana namernimtro-
nanex nepopannnx anrnnja6ercinx neiox. Bneo-
nasop 6onecnnia iojn ce nanasno na xexannuioj nen-
tilaciji na Odeqewu pedijatrijske intenzivne ne-
ge pokazao je da je majka vrila namernu ekstubaci-
jy [38]. Ko oojuera ca 6nnarepannnx peiypenrnnx
ieparoionjynirnnnrncox [39], nocne 6pojnnx njaino-
crnuinx nocrynaia, ycranonmeno je nonpe|nnane iay-
crnuinx cpecrnox, oi je io pyioi 6onecnnia nep-
zistentno krvavqewe iz uha u stvari bilo posledi-
na rpayxe iojy je erery nanocnna xajia [40].

Bnmeionmnnx naineanex prana snocranma-

wa osoba s MSP ustanovqena je tendencija ponavqa-
na snocranmana (io oio rpehnne 6onecnnia), a io
176

oio nononnne prana sa6eneenn cy xponnunn nope-
xehaj nonamana (necniypnocr, exonnonanna necra-
6nnnocr, nopexehaj recra peannocrn) n cnxnroxn
crpecoienoi nopexehaja [41,42].
Hpnnniox nocrynana ca prnaxa snocranmana
osoba s MSP najnannje je mro npe nocrannrn npa-
ny njainosy, a sarnx npnxennrn aeinarno neuene
o6jeirnnnoi nopexehaja io prne snocranmana , ys
ncronpexeno o6es6e|nnane samrnre prne o amnx
manipulacija osobe sa MSP iao nounnnrema snocra-
vqawa, koji, po pravilu, ne priznaju svoju odgovor-
nost i pokazuju tendenciju da zlostavqawe ponove
[13, 43-43]. Taio|e ce caneryje npeirno, 6ecioxnpo-
misno i hitno konfrontirawe i neutralisawe
osobe sa MSP, rj. nonomene nonnnnjcie npnjane n
noiperane ipnnnunoi nocrynia ca ry6ox sa nacn-
qe u porodici, a u okviru sudskog postupka sudsko-
xennnncio, ncnxnjarpnjcio n ncnxonomio nemraue-
ne prne, iao n ncnxnjarpnjcio n ncnxonomio nemra-
uene. Bes npanonpexene nnrepnennnje nocrojn pnsni
a ce nounnnrem snocranmana npecenn y nony cpen-
ny n raxo nacrann ca snocranmanex. Hpnxapna oio-
nopnocr je o6es6e|ene o6po6nrn sa ere 6onecnnia,
mro ce uecro nocrne caxo aio ce ere onojn o no-
unnnrema snocranmana, xaiap n npnnpexeno. \np-
kos zlostavqawu, dete je vezano za roditeqe i pati
s6oi onojenocrn o nnx. \ionnio je xoiyhe, oco6y
obolelu od MSP, iao n pyie unanone noponne rpe6a
yimyunrn y yiorpajno neuene, ioje rpe6a a eyiyje
ponrema aanrnnnnjnx naunnnxa saonomena cno-
jnx norpe6a, xe|yrnx, saca nnje onncan ionsncren-
ran eqniacan nnn cnennqnuan npoipax neuena oco-
ba obolelih od MSP.
PRIKAZ BOLESNIKA
Tpnecerrpoionmnoj cny6ennnn n pasneenoj
xajnn xanonernoi erera noueriox 2004. ionne ns-
peuena je npanocnanox npecyox nanenoi cya
xepa 6es6enocrn o6anesnoi ncnxnjarpnjcioi neuena
n uynana y sarnopenoj ycranonn s6oi ipnnnunoi e-
la zaputawa i zlostavqawa cnoi xanonernoi cnna.
\ o6pasnoeny npecye, nsxe|y ocranoi, nnme a je
ornuna ,nperxonnx neionnio ionna ...snocranma-
na ere, ...oxerana ia y pasnojy, cnpeuanajyhn ia a no-
xa|a miony, repajyhn ia na nsonannjy, ...nanoehn ia
da zajedno s wom neosnovano prijavquje policiji,
zdravstvenim i kolskim ustanovama da je nad wim
izvreno silovawe, trovawe iliprebijawe od stra-
ne pasnnx nnna (neionaremnna y eujex nprnhy, py-
iona, yunrema, neiapa)". Hpexa nsnemrajy nanenoi
centra za socijalni rad, bolesnica je tokom pret-
hodnih godina u naoj zemqi i inostranstvu vie
puta mewala mesto boravka, razvela se i udaqila od
po6nne, ,ys nspaeny ncqyninnjy y ponremcrny,
iao n 6nsapno nonamane". Hpexa pacnononnoj xe-
dicinskoj dokumentaciji, wen maloletni sin je, na
weno insistirawe, promenio vie predkolskih
n mioncinx ycranona n xnoio nyra cy ia y pasnnun-
tim ustanovama i gradovima pregledali lekari raz-
nnunrnx cnennjannocrn. \ nsnemrajnxa neiapa coxa-
rnuapa nanoe ce xajunne an6e - ioje ,npenase n cqe-
py qanracrnie" - a je ere xanrpernpano na nepnep-
san naunn, cnnonano n ceicyanno snocranmano, a xaj-
ia o6nja ncnxnjarpnjcio neuene n a 6n cny6a co-
nnjannoi crapana rpe6ano a noiae nnrepeconane
sa xajiy n ere. \ noxenyrnx nsnemrajnxa ncimyue-
no je seksualno zlostavqawe deteta, ali se ukazuje
na to da je izvesne telesne povrede, koje je majka pred-
stavqala kaorezultat seksualnog zlostavqawa, dete-
ry nanena pyia oco6a, xoiyhe xajia. Bonecnnna ce nn-
me nyra o6pahana ncnxnjarpnxa, ann je cne o noipe-
tawa sudskog postupka odbijala da nastavi predlo-
eno neuene, a c npexena na npexe xenana je n xecro
6opania. Hanxe, ncnxnjarpn cy y nnme nanpara nocra-
nmann pasnnunre njainose, iao mro cy nopexehaj nn-
unocrn, napanonna cxnsoqpennja n, ionauno, cyxa-
nuta psihoza i Minhauzenov sindrompreko posred-
nnia, iaa cy ce o6parnnn n nonnnnjn, nanenox
nenrpy sa connjannn pa n ncrpanox oemeny na-
nenoi cya.
Sudskomedicinskim pregledima maloletnog de-
teta ustanovqene su povrede u vidu krvnih podliva
ioe na ynyrpamnoj crpann ecne 6yrnne n y ecnox
pojasnom predelu koje su nastale kao posledica dej-
crna ryne xexannuie cnne. One nonpee, iaio nnme y
saoptewu, nisu mogle nastati u vezi s eventualnom
analnom penetracijom, odnosno prodirawem stra-
noi rena y uxap. ,Ca cniypnomhy ce xoe ncimyun-
ti da su ove povrede nastale *** (datum 1), a to se
nanon iao npexe nonpe|nnana, onocno cnnonana.
Hpeineox nsnpmennx (aryx 2) nnje nn|en ipn-
ni podliv u desnompojasnompredelu, koji je konsta-
ronan nononnnx npeineox o (aryx 3). Onaj ipn-
nn nonnn je nacrao y npexenciox nnrepnany nsxe|y
ona na npeinea (aryx 2 n 3)."
Psihijatrijskim i psiholokim ispitivawem
erera yrnp|enn cy snauajno saocrajane y nnreneiry-
annox pasnojy, exonnonannn npo6nexn n nopexehaj
nonamana. Hcnxnjarpnjcinx n ncnxonominx ncnn-
rnnanex xajie erera yrnp|eno je a ona ,6onyje o
ymennoi o6omena, najneponarnnje xponnune npnpo-
e, ioje je nocrojano n y npexe nsnpmena ipnnnunoi
dela koje joj se stavqa na teret i koje se ispoqava otu-
|enex o crnapnocrn s6oi cyxanyrnx neja n nonpe-
xennx xanynnnannja". \ xnmmeny nemraia ame ce
navodi da u simbiotskom odnosu sa detetom majka
npnnncyje erery nnacrnre ncnxornune npoyinnje n
na raj naunn ia cxemra y nniancynnpann ncnxornunn
cner, yipoanajyhn n saycranmajyhn ereron pasnoj
6es niainoi ynna y ro. Bemrann cy cxarpann a xaj-
ia erera y npexe nsnpmena ipnnnunoi ena ioje joj
se stavqa na teret nije bila sposobna da shvati zna-
uaj cnoi ena, nnrn je 6nna y xoiyhnocrn a ynpanma
cnojnx nocrynnnxa. ,Hocrojn pnsni a ona y 6yyh-
nocrn nononn eno cnnuno onoxe ioje joj ce cranma na
reper, re cxarpaxo a je nnnionano nspehn joj xepy
6es6enocrn o6anesnoi ncnxnjarpnjcioi neuena n uy-
nana y spancrnenoj ycranonn sarnopenoi rnna."
Preko Centra za socijalni rad su tokom sudskog
postupka organizovani zatita deteta odvajawem
o xajie n cxemraj y cpenny ioja he xy oxoiyhnrn
pasnoj 6es pnsnia. Hpexa nsnemrajnxa Henrpa, ere
se u novoj sredini adaptiralo i ponovo krenulo u
miony.
177

Heocrarai ioncensyca o njainocrnuinx ipnre-

rijumima zaMSP, pogotovoupogledumotivacije oso-
ba obolelih od MSP, kod nas je dodatno komplikovan
npnxenox [ecere pennsnje Me|ynapone inacnqnia-
cije bolesti (ICD-10), koja nigde eksplicitno ne po-
xnne onaj nopexehaj, npn uexy je npo6nexarnuan n
samprevod (ilije u pitawu tamparska greka) i-
pe opennne, ioja 6n onasnna y o6snp - ,Haxepno
izazivawe ili simulirawe telesnih simptoma psi-
xnuinx necnoco6nocrn (cnxynnpann nopexehaj)".
Problem motivacije osobe obolele od MSP kao po-
unnnrema ipnnnunoi ena snocranmana nnje caxo no-
sonomin, neh nxa n os6nmne qopensnuie ionorann-
je. Hanxe, cxarpa ce a y noiney xornna sa crnapa-
we simptoma, s aspekta namernog i svesnog sticawa
nnune iopncrn (rsn. ceiynapne o6nrn), MSP i osta-
ne nemrauie nopexehaje xoexo crannrn y cpenny
cneirpa na unjex cy jenox ipajy coxaroqopxnn no-
pexehajn, a na pyiox cnxynnpann nopexehajn. [oi
je io coxaroqopxnnx nopexehaja cnxnroxaronoinja
nenamerna i nesvesna, uz potpun izostanak uvida u
wenu genezu, kod simulirawa je stvarawe simptoma
nornyno cnecno n naxepno, rj. y qyninnjn nnune, naj-
uemhe eionoxcie, iopncrn, iao mro cy, na npnxep, o-
bijawe sudske kompenzacije, penzije, smetaja, izbe-
ianane saioncinx caninnja nr. Crnapane cnxnroxa
kod MSP je namerno, dok patoloko ponaawe ima
ioxnynsnnnn o6pasan n necnecny xornnannjy.
Sa pasnniy o DSM-IV, Medouusvompredlogukri-
terijuma opravdano izbegava da izazivawe simpto-
xa io prne inannqniyje iao naxepno, jep ce rnxe
ns6eiana xoiyha ionqysnja y nesn c npannox inann-
qniannjox nnnocrn n ypauynmnnocrn oco6e ca MSP
iao nounnnrema snocranmana. Bnnocr nounnnrema
snocranmana je ncnxonomin onoc nounnnrema y o-
nosu na delo u dijapazonu od umiqaja do nehata, a
ypauynmnnocrn nounnnrema - cnoco6nocr nounnnre-
ma a cxnarn snauaj cnoi ena (pacy|nnane) n xoiyh-
nost da upravqa svojim postupcima (voqa) u vreme
nsnpmena ipnnnunoi ena ioje xy ce cranma na reper.
\ cnaiox nojennaunox cnyuajy ncnxnjarpy ce na cy-
du mora postaviti pitawe odnosa voqe i svesti kod
nounnnrema snocranmana tempore criminis, rj. a nn
je peu o ouynanox pacy|nnany n nomn cno6onoj o
ncnxonaronominx yrnnaja capannx y nopexehajy
duevnog zdravqa koji bi eventualno mogao poreme-
rnrn pacy|nnane nounnnrema snocranmana, ory|n-
rn ia o peannocrn n neiony nomy yunnnrn nepasyx-
nox. Kpnrepnjyx DSM-IV da ponaawe nije boqe
o6jamneno pyinx xenrannnx nopexehajex" je cynn-
man, jep cxncao njainocrnuinx ipnrepnjyxa je ynpa-
no y roxe a ce nsa6epe oionapajyha njainosa, a ue-
cro xoe noipemno a nanee na noxncao a rpe6a
ncimyunrn xoiyhnocr a ce njainosa MSP postavi
i kada se kod obolele osobe prepoznaje potpuna kli-
nnuia cnnia neioi pyioi ncnxornunoi nnn nencnxo-
rnunoi nopexehaja, mro nnje periocr [7, 8, 19, 31] c o6-
snpox na o6po nosnary unnennny o nncoiox ioxop-
biditetu MSP (mro nnycrpyje n nam npnias).
Bez video-nadzora postavqawe sigurne dijagnoze
MSP i dokazivawe pred sudom falsifikacije bole-
sti, trovawa i povreda, kao i zlostavqawa u porodi-
unox ipyiy neoxa je npo6nexarnuno, jep cy one xa-
nipulacije dugo i dobro prikrivene, tako da po-
ysann ouennnn nan noponunoi ipyia, no npannny,
nsocrajy, oi cy neynyhenn unanonn mnpe noponne
nornyno necnecnn npo6nexa. To ennxnuno o6jamna-
na npo6nexarnunocr cycioi nponecynpana iaa cy
u pitawu osobe obolele od MSP, kao i paradoksalnu
unnennny a cy ce ayropn y cnojoj nnmeionmnoj qo-
pensnuioj npaicn (o mecr ionna o 22 ionne nciy-
crna) npnn nyr cpenn c onainnx cnyuajex. \ nesn c
njainocrnionanex ioje yimyuyje xero iopnmhena
tajnog video-nadzora radi otkrivawa osoba obole-
lih od MSP iao nounnnnana ipnnnunoi ena snocra-
vqawa i wihovih manipulacija, treba naglasiti da
je, prema miqewu izvesnog broja pravnika, prime-
na ovog metoda kontroverzna, kako s legalne, tako i
c ernuie nosnnnje. Me|yrnx, xennnncin crpyuna-
ci ukazuju na to da priroda zloupotrebe kod MSP sa-
pn os6nmny onacnocr no spanme n nnor erera,
mro nocn nehy renny y nope|eny ca ponremcinx
(craparemcinx) npanox na npnnarnocr.
Konfrontacija osobe obolele od MSP je jedan de-
nniaran rpenyrai n, c o6snpox na xoiyhnocr 6ypne
peainnje (ioja ne ncimyuyje n cynnnno nonamane
nnn ecianannjy snocranmana), noemna je ncronpexe-
na ncnxnjarpnjcia ioncynrannja n o6es6e|nnane ne
samo medicinske, nego i pravne i socijalne zati-
te deteta (policijska prijava, sudski postupak, an-
iaonane nanenoi nenrpa sa connjannn pa, peiy-
nncane craparemcrna na ererox). Cinonocr oco6e
sa MSP ka ponavqanom obrascu patolokog ponaa-
wa dovodi do permanentne opasnosti po dete, to
nanae a ce oco6n ca MSP, kaopsihijatrijskiobole-
nox nounnnremy ipnnnunoi ena, roiox cycioi no-
crynia open ncnnrnnane y 6onnnuinx ycnonnxa,
a uz zakonsku sankciju izrekne i mera bezbednosti
o6anesnoi ncnxnjarpnjcioi neuena, ys oipannuanane
nnn ycipahnnane npmena ponremcioi npana.

Saionnrocrn nacrania Mnnxaysenonoi cnnpoxa

preko posrednika jo su u sferi spekulativnih di-
namskih teorija sumwive prediktivne vrednosti,
neion roi je xponnuan a npoinosa noma, 6yyhn a
zasadnije opisankonzistentanefikasanilispeci-
qnuan npoipax neuena oco6a o6onennx o MSP. C o6-
snpox na ro a je y nnrany cnennqnuan o6nni sno-
cranmana, iojn capn peanny onacnocr ne caxo no
renecno n ymenno spanme, neh n no nnor prne
(uglavnom deteta) i koji se veoma teko dijagnosti-
iyje n neun, onaj nopexehaj nxa remie xenioneian-
ne ionorannje ioje sacnyyjy nany oionapajyhnx
crpyunnx ipyiona y namoj cpennn.
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179

MUNCHAUSEN SYNDROME BY PROXY
Aleksandar A. JOVANOVI
1
, Vesna R. POPOVI
1
, Slobodan SAVI
2
, ore ALEMPIJEVI
2
, Nada JANKOVI
1
1
Institute of Psychiatry, Clinical Centre of Serbia, Belgrade;
2
Institute of Forensic Medicine, School of Medicine, University of Belgrade, Belgrade
ABSTRACT
This review deals with bibliography on Munchausen syn-
drome by proxy (MSbP). The name of this disorder was intro-
duced by English psychiatrist Roy Meadow who pointed to
diagnostic difficulties as well as to serious medical and legal
connotations of MSbP. MSbP was classified in DSM-IV among
criteria sets provided for further study as factitious disorder
by proxy, while in ICD-10, though not explicitly cited, MSbP
might be classified as factitious disorders F68.1. MSbP is a spe-
cial form of abuse where the perpetrator induces somatic or
mental symptoms of illness in the victim under his/her care
and then persistently presents the victims for medical exami-
nations and care. The victim is usually a preschool child and the
perpetrator is the childs mother. Motivation for such patholog-
ical behavior of perpetrator is considered to be unconscious
need to assume sick role by proxy while external incentives
such as economic gain are absent. Conceptualization of MSbP
development is still in the domain of psychodynamic specula-
tion, its course is chronic and the prognosis is poor considering
lack of consistent, efficient and specific treatment. The authors
also present the case report of thirty-three year-old mother
who had been abusing her nine year-old son both emotionally
and physically over the last several years forcing him to, togeth-
er with her, report to the police, medical and educational insti-
tutions that he had been the victim of rape, poisoning and
beating by various individuals, especially teaching and medi-
cal staff. Mother manifested psychosis and her child present-
ed with impaired cognitive development, emotional problems
and conduct disorder.
Key words: Munchausen syndrome by proxy; factitious disor-
ders; child abuse
Aleksandar A. JOVANOVI
Institut za psihijatriju
Kliniki centar Srbije
Pasterova 2, 11000 Beograd
Telefon: 011 264 1097
E-mail: shrinks@eunet.yu
Pyionnc je ocranmen \pennmrny 18. 10. 2004. ionne.