What are some of the factors associated with mother’s inflicting consistent harm on their children? Munchausen by proxy. A review of the literature.
The literature on Mynchausen’s syndrome by proxy is considerable and growing at a rapid rate. Many professionals are sure that the condition exists and there appears to be an equally certain number in the non-professional sector who argue vociferously that such professionals are misguided. The purpose of this review is to determine the evidence base for the condition (Sackett, 1996). and to try to present a rational assessment of the very emotive arguments in this area.
The first article that we shall consider is the book by Feldman (et al 1994) which appeared a decade ago, but is useful as it was considered by many to be the “gold standard” on the topic in its time. The book itself is written as a series of case narratives followed by a discussion on each. This is clearly instructive, but the most important seminal feature of the book is the fact that it was the first to draw a clear distinction between factitious illness and malingering.
It describes the authors’ perception that factitious disorders lie along a spectrum from the benign use of illness on one extreme to the syndrome of Mynchausen’s syndrome by proxy at the other.
It is fair to comment that, inevitably, thinking has progressed since this book was published and the basic amalgamation of factitious illness with malingering no longer finds a resonance with mainstream practice today. Malingering is defined here as “conscious manipulation for external gain such as compensation” while factitious disorder is defined as “an unconscious motivation to gain attention or control”. More modern opinion believes that many people who seek compensation after trauma are genuine, as can be their symptoms, whether they are purely physical or psychological.
The more modern appreciation of the problem would consider that malingering is a conscious manipulation – and therefore not an illness, whereas the factitious disorders generally are essentially unconsciously motivated and therefore more akin to a hysterical conversion disorder and therefore a true illness.
The next book to consider is a more recent publication which takes the same presentation – discussion format, as the last. This book (Gregory 2004) is remarkable as it is written by a survivor of the abuse from Mynchausen’s syndrome by proxy and, in our opinion, should be read by every worker in the field.
It presents a remarkably perceptive insight into the mechanisms of the disorder together with a remarkable analysis of the actual resultant coping mechanisms employed by the proxy child who progressively gains both insight and resilience as she gets older and approaches adulthood. It is equally important for the consideration that the author develops for her younger siblings as she becomes aware of them being damaged in the same way. From the healthcare professional’s point of view, there are a number of truly insightful comments including:
But the memories that hang heaviest are the easiest to recall. They hold in their creases the ability to change one’s life, organically, forever. Even when you shake them out, they’ve left permanent wrinkles in the fabric of your soul.
Such books as these two are clearly inspirational and edifying, but they do not contribute to the evidence base directly. For that we must turn to the peer reviewed literature. Professors Craft and Hall (2004) have published an excellent review of the pertinent issues which looks, with a degree of concern, at the media presentation of the issues.
They suggest that the presentation of Mynchausen’s syndrome by proxy in the media tends to both glamorise and demonise the condition in a way that is very unhelpful to the healthcare professionals working in the area. They cite tabloid phrases such as “Meadow’s discredited theory of Munchausen syndrome by proxy” as being truly hostile to the overriding needs of the victims.
The paper itself sets out the evolution of the condition from Caffey’s 1942 paper, where the condition was described but not named, through the papers by Money and Werlwas (1976) to the present day assessment of the condition. The authors specifically consider the issues of Mynchausen’s syndrome by proxy in relation to severe child abuse and apparent cot death, and provide what should perhaps be considered a most authoritative resume on the issue.
In terms of specific psychopathology we can turn to papers such as the one by Eminson D (et al 2000) who suggest that the perpetrators have an increased incidence of personality disorder or, more rarely a psychotic illness.
Firstman R (et al 1998) point to the fact that women who suffer from the condition tend to have reported a number of “fantasies, obsessions and anxieties” regarding their babies which typically focus on their perceived inability to care adequately for them.
Golden M (et al. 2003) adds the observation that many of these fantasies include the worry that the mother may actually harm the child together with the observation that there is an associated increase in the incidence of Post natal depression in these cases.
Caffey 1942, quoted in Royal College of Paediatrics and Child Health. Fabricated or induced illness by carers. London: RCPCH, 2002.
Craft AW and D M B Hall 2004 Munchausen syndrome by proxy and sudden infant death BMJ, May 2004; 328: 1309 – 1312 ;
Eminson DM, Postlethwaite RJ. 2000 Munchausen syndrome by proxy abuse: a practical approach. Oxford: Butterworth Heinemann, 2000.
Feldman MD, Ford C, Reinhold T 1994 Patient or Pretender: Inside the Strange World of Factitious Disorders London: Wiley, ISBN 0-471-58080-5
Firstman R, Talan J. 1998 The death of innocents. New York: Bantam, 1998.
Golden MH, Samuels MP, Southall DP. 2003 How to distinguish between neglect and deprivational abuse. Arch Dis Child 2003;88: 105-7.
Gregory J 2004 Sickened: The True Story of a Lost Childhood London: Century books ISBN 1 844 13442 3
Money and Werlwas (1976) Quoted in Fisher G, Mitchell I. Is Munchausen syndrome by proxy really a syndrome? Arch Dis Child 1995;72: 530-4.
Sackett, (1996). Doing the Right Thing Right: Is Evidence-Based Medicine the Answer? Ann Intern Med, Jul 1996; 127: 91 – 94.
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