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Perspectives
given on Munchausen Syndrome
by proxy
(May
2007 Issue)
By Nan Shnitzler
Munchausen Syndrome by proxy is a baffling and elusive disorder.
Like Munchausen Syndrome, named for an 18th century German dignitary
who wildly embellished his exploits as a soldier and sportsman,
it involves fabricating illness to attract attention. Unlike Munchausen's,
it can be a form of child abuse in which a primary caretaker, typically
a mother, deliberately falsifies, exaggerates or induces medical
or psychological symptoms in a child and lies about it.
"There is a subgroup of adults who harm other adults in their care.
That's Munchausen by proxy as well," says Catherine Ayoub, R.N.,
M.N., Ed.D., "but the classical picture is a mother harming a child."
The diagnosis has been controversial. DSM-IV encompasses Munchausen
Syndrome under "factitious disorders." Several conditions for "factitious
disorder by proxy" are listed in Appendix B for further study.
A multidisciplinary task force hopes their work will clarify the
diagnosis, according to Ayoub, of Harvard University, who chaired
the group under the auspices of the American Professional Society
on the Abuse of Children (APSAC). The task force reviewed the literature
and came up with working definitions, published in 2002, to help
clinicians and courts better identify Munchausen Syndrome in victims
and families and to establish a mandate for appropriate services.
They realized the disorder had two inextricable components: a child
victim of "pediatric condition falsification" caused by an adult
perpetrator with "factitious disorder by proxy (FDP)." The perpetrator
acts from deep-seated psychological needs for attention or assimilation.
The task force claims Munchausen by proxy is under diagnosed because
the falsification is covert and the perpetrators are remarkably
convincing.
But identical behavior absent the guiding motivation is not considered
FDP, for example, if symptom falsification is motivated by the desire
to discredit a spouse in a custody battle.
For that and other reasons, Eric Mart, Ph.D., ABPP, a forensic
psychologist licensed in New Hampshire and Massachusetts and author
of "Munchausen's Syndrome by Proxy Reconsidered" has called for
abandoning the Munchausen by proxy diagnosis in favor of specific,
detailed descriptions of how the parent is alleged to have harmed
the child, as is done in most child abuse cases. He thinks the dynamics
of Munchausen by proxy are too broad to be bottled into diagnostic
categories, not that the offending behavior doesn't exist.
"Don't misunderstand, there's no question that some parents abuse
their children using medicine and the medical system," Mart says.
"When I express doubts, it's not that people do this, but that the
formulation of the syndrome is the problem."
Mart says that the accumulated Munchausen by proxy literature is
mostly recursive and that scant empirical research has been performed.
He thinks competing definitions of Munchausen by proxy hamper scientific
studies.
"If you apply three or four different definitions, you can't research
it well because everybody is researching something different," Mart
says.
Prior to being director of clinic services for the Massachusetts
juvenile court, Patricia Cone, Ph.D., J.D. was a staff forensic
psychologist at Dartmouth-Hitchcock Medical Center. She agrees the
science has room for advancement, but won't ignore the DSM diagnosis
just because it appears in the appendix.
"As with any provisional diagnosis, we have to move carefully and
not jump to conclusions about the presence or absence of signs,
and try not to view the world through one particular lens," Cone
says.
Absent the smoking gun of catching a parent red-handed or clear
video evidence of tampering, the next best telltale for Munchausen
by proxy is a child who gets dramatically better when the parent
is away. Coupled with medical evidence that makes no sense, Cone
says, at that point she would start to think about the possibility
of Munchausen by proxy. Separating the child from the parent, while
not to be done lightly, would be a "natural experiment."
"If you think the parent is the agent of harm, you remove the parent
and the harm goes away, I find that to be powerful information,"
Cone says.
Psychiatrist Thrassos Calligas, M.D. of the McLean ward at Boston's
Franciscan Hospital for Children says he assumes the parents are
acting in good faith.
"Munchausen by proxy is not the first thing that comes to mind.
It's a rare condition," Calligas says.
But if clinicians perceive inappropriate affect in a parent, for
example, hiding a smile over a flare up of symptoms, insisting on
invasive tests or getting oddly excited over a new batch of diagnostic
results, they will tend to pay more attention to the medical inconsistencies,
Calligas says.
"The issue is this is really child abuse based on severe personality
psychopathology in a parent," Calligas says. "Treatment has to involve
external controls like DSS and the court system in order to manage
the case. It's not something that can be contained within the clinician's
office."
Ayoub points to her long-term study of 50 legally-ruled Munchausen
syndrome by proxy families in which two completed a 10-year treatment
process. The key to success was an integrated treatment team of
every provider that touched the family: individual therapists, family
therapists, pediatricians, court representatives, DSS, school personnel.
The team met monthly to share information; confidentiality was held
in the group.
"What these mothers do is divide and conquer," Ayoub says. "That's
why the team approach is so important."
And that's Ayoub's message to psychologists. If the case knowledgebase
is fragmented among providers, they won't know the perpetrator is
lying, thus providing an opportunity to feed the pathology as she
manipulates the players. It might take hundreds of hours, but the
case information must be integrated, Ayoub says.
"Even if you've been practicing for 25 or 30 years, you can't do
quick and dirty evaluations from a mental health perspective," Ayoub
says. "Providers coming back to say, 'This mom was just fine. She
was willing to do anything we want,' are doing a disservice."
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