Interview: Mommy Makes Me Sick; Defining Munchausen by Proxy

Child abuse is heinous in all of its forms.  One specific type of abuse that I find particularly interesting is Munchausen by Proxy, because my mother was a perpetrator. Munchausen by Proxy (MbP) is a form of abuse in which a caregiver, typically a mother, deliberately makes another person, usually a child, sick.  A few years ago I went looking for support services to help me deal with being a survivor of MbP and that is how I came to meet Dr. Marc Feldman. 

What I learned from discussing the subject of MbP with Dr. Feldman was that there wasn't any support services or even counseling groups for MbP survivors. An MbP perpetrator could find help, but victims were on their own. I came to the conclusion that if I was going to figure out how to psychologically deal with what happened to me, I’d have to understand what was wrong with my mother to begin with. Was she mentally ill or was she making a choice. Did she know what she was doing; did she do it on purpose? This was the impetus for the following interview conducted in May 2008.

With a specialty in Factitious Disorder, Dr. Marc Feldman is an international expert in Munchausen syndrome, Munchausen by proxy, and malingering. He was formerly Vice Chair for Clinical Services at the University of Alabama, Birmingham (UAB), Medical Director of UAB’s Center for Psychiatric Medicine and the Clinical Professor of Psychiatry at the University of Alabama (UA), Tuscaloosa.

Michelle McKee:
The term factitious brings the word “lie” or “liar” to mind and the word “disorder” makes me think of something that is “pathological” or “habitual.” Therefore, Dr. Feldman, what is Factitious Disorder and is this just a ten-dollar term for pathological lying?

Dr. Feldman:
"Pathological lying" refers to lying consisting of a triad of features: it is impulsive or compulsive; it is repetitive; and it typically is ultimately self-defeating (e.g., the lie is exposed and undermines people's trust). It can involve anything--not just illness. One variant that often co-exists with full-blown Munchausen syndrome is called "pseudologiafantastica," or the telling of tall tales about one's personal history that mix fact and fiction. Such lies--the ones that are "a little" true--are the best kinds of lies because they are so difficult, generally, to detect. Pseudologia fantastica can be seen among MbP perpetrators as well.

Factitious Disorder(FD) is the feigning, exaggerating, or self-inducing of physical or psychological signs and symptoms to assume the "sick role." External incentives are absent, which contrasts with malingering, in which the principal goal for the disease enactment is external, and often tangible. Examples of malingering include obtaining opioids, evading criminal prosecution, getting disability monies, avoiding military service, etc.

FD is a mental disorder with its own chapter in DSM-IV-TR; malingering is merely listed in the Appendix as a condition that might warrant clinical attention but is not established to be a mental disorder. If the only way to understand the disease enactment is to invoke psychological processes, then the diagnosis is FD. Technically, FD and malingering cannot co-exist, but in reality they very often do because a person's motives for a piece of behavior can shift over time.

MM: How does Hypochondria differ from Factitious Disorder and Munchausen Syndrome?

Dr. Feldman: Hypochondriasis refers to the preoccupation with having a dreaded disease. These patients are convinced that they are genuinely ill but that doctors and others have failed to diagnose it properly. Some people consider chronic fatigue syndrome and fibromyalgia to be forms of hypochondriasis, but this is a bit controversial. Based on their convictions of illness, hypochondriacal patients may seek medical opinions repeatedly and from numerous practitioners. Hypochondriasis is one of the somatoform disorders, along with diagnoses such as pain disorder, somatization disorder, and conversiondisorder.

Munchausensyndrome is defined by the triad of 1) chronic and severe factitious disorder, 2) pseudologia fantastica, and 3) wanderlust (traveling from place to place to garner new audiences for the deceptions). The professional literature is uniform in stating that Munchausen Syndrome patients are predominantly male, but in my work, women have been more prevalent.
Munchausen by proxy is the feigning, exaggerating, or inducing of physical or psychological ailments in another person, typically by a mother against her child. Men have only rarely been implicated in Munchausen by Proxy maltreatment.

MM: Is Munchausen by Proxy (MbP) a form of mental illness?

Dr. Feldman: Munchausen by Proxy, isn't really an "illness," as I see it. It as a form of child abuse, not something a perpetrator "suffers from." In the same way that a mother doesn't "have" shaken baby syndrome, a mother doesn't "have" Munchausen by Proxy (MbP). However, the media almost always get it wrong, as do child protection agencies and courts.

MM: You say that MbP from your perspective is not an illness but child abuse. Therefore, I have to ask you, is child abuse related to a mental illness or is it a behavior choice.

Dr. Feldman: Child abuse is a behavioral choice, in my opinion, at least in MbP cases (an exception might be a phenomenon such as postpartum psychosis resulting in abuse/death of the child, because then the mother has lost contact with reality). These mothers are not psychotic nor necessarily impulsive; often considerable planning is necessary for them to carry out the deceptions. Some perps may claim that the behavior occurred during psychogenic "blackouts," but I'm not aware of any cases in which this was found to be true.

MM: In MbP the perpetrator makes another sick in order to garner attention for themselves. How do the perpetrators of MbP differ from those caregivers who have been termed “Angels of Death?” Don't both sets of perpetrators seek to garner attention for themselves by inflicting extreme illness to another party?

Dr. Feldman: The Angels of Death and MbP perpetrators have so much in common in many cases that I equated them in my co-edited 1996 book, TheSpectrum of Factitious Disorders. The relevant chapter analyzes numerous Angel of Death cases, calling them "hospital epidemics" of MbP. But some Angels of Death are "merely" homicidal and not particularly attention-seeking, and in those cases, the MbP term wouldn't be appropriate.

MM: To what extent do perpetrators of MbP seek to harm their victims? Do they seek to cause the eventual death of their victim or is the death of the victim counterproductive?

Dr. Feldman: There are some cases--relatively few--in which the MbP perpetrator seems to delight in the bereavement experience, enjoying funeral and burial rituals, etc. I think that's how the Waneta Hoyt case in upstate New York can be conceptualized, and it may also be true for the Marie Noe case in Philadelphia. But generally, the death of the victim is counterproductive because it removes the "object" they manipulate in MbP. Overall, though, it has been estimated that 9-10 percent of MbP victims eventually die, either as a direct result of the abuse or the iatrogenic complications caused by misdirected treatment efforts.

MM: How well informed is the medical community on the signs and symptoms of MbP?

Dr. Feldman: Overall, I think the medical community is inadequately informed. The reason is that MbP is not routinely taught in medical schools or residency programs. In a 1993 study I did with Barbara Ostfeld, we found that child psychiatrists were quite uniformly aware of the phenomenon, but that most family practitioners and social workers--who, after all, are on the front lines in dealing with families--were unaware even of the term "MbP," let alone what it takes to diagnose a case.

MM: I am pretty sure that if I decide that I want to have half a lung removed I can eventually find someone who will be more than happy to come up with a diagnosis to support the procedure and eagerly bill for it. Therefore, how culpable are the doctors who are involved in these cases, they're trained professionals, how can they be so easily duped?

Dr. Feldman: Regarding the apparent ease with which physicians can be duped: this isn't a surprise to me. Physicians are taught nothing about medical deception in medical school or residency. Even as a psychiatric trainee, I never even heard the word "factitious"; it was only after I submitted my first article about a patient who feigned cancer that I heard the term. In the article, I had called it "malingering," and the reviewers pointed out my mistake.

During medical school, a supervisor got angry with me for writing statements such as "According to the patient, she has shortness of breath" or "The patient states he has chest pain." He said that I was demonstrating that I already doubted what I was being told by not stating it as simple fact, and so I had to re-write the entry simply as "She has shortness of breath" and "He has chest pain." Also, doctors are taught (correctly) that the best clue to what is going on with a patient is what the patient and family have to say about it and that we must form an "alliance" with both (particularly in psychiatry, but actually in all fields). We are not taught ever to doubt what is being said. So, again, it doesn't surprise me that doctors can not only be gullible but also wind up being, as one author put it, "professional participants" in MbP maltreatment.

MM: Is there a victim profile for MbP, such as confined to a particular age group, gender, economic background? What about the perpetrator, is there a profile for them?

Dr. Feldman: MbP perpetrators tend to have personality disorders, especially borderline, antisocial, histrionic, and narcissistic personality disorders--the so-called "Cluster B" personality disorders, histories of psychiatric treatment earlier in their lives, histories of substance abuse, and, often, personal histories of factitious disorder that they now seem to want to extend to the next generation.

They may have been abused themselves earlier in life, but this is hard to know because the perpetrators often provide false historical information in a kind of attempt to exonerate or explain away their behavior. Clearly, the problems these mothers have allow them to objectify and dehumanize their children. Occasionally, a perpetrator might have an underlying mental disorder such as major depression or bipolar disorder that fuels their behavior to some extent, and we tend to view those cases as more treatable because mood disorders are quite treatable.

They tend to be in the age range associated with having small children. I think that MbP, like abuse in general, is detected more often in lower socioeconomic families, but I don't have research data to back that up. I rarely encounter African-American perpetrators in MbP cases, and I'm not sure what to make of that.

Regarding victims, they are usually, but not always, pre-verbal or scantily verbal and therefore can't communicate about what's going on. They seem not to have bonded terribly well with the perpetrator, and there can be several reasons for this. One is that, as in abuse in general, there may be something about the child (in the eyes of the mother) that makes him/her "imperfect" and dissatisfying.

Only one study of adult survivors of MbP has, to my knowledge, been published. As you would expect, many of the patients (I think there were 12 in the study) had symptoms of post-traumatic stress disorder. Some avoided even medically necessary care because of their unpleasant memories, but a few became factitious disorder patients themselves, as if to "master" the trauma by making it their own.

MM: How common is MbP?

Dr. Feldman: It has been estimated by one researcher that there are around 1,200 new cases each year in the U.S., but that statistic makes a lot of assumptions that might not all be true. MbP is a form of abuse/neglect that is bathed in secrecy and I have the feeling that most--yes, most--cases are never identified.

MM: What needs to be done to better understand, identify, and treat MbP perpetrators?

Dr. Feldman: It has been very difficult to study MbP perpetrators because most deny their culpability even when faced with incontrovertible evidence, and therefore aren't amenable to research interviews.

It might help if there were a central database of MbP cases that accredited researchers could access in order to study perpetrators and victims more thoroughly. The victims tend not to be available because the focus is on placement once MbP is identified, and so once again study is stymied.

The broader problem, though, is that many jurisdictions still aren't even aware of MbP as a form of child maltreatment, and obviously one can't diagnose something one has never heard of. So, cases slip through the fingers of anyone who might try to study the phenomenon.

MM: What percentage of the population is affected, or believed to be affected, by MbP as victims and as perpetrators?

Dr. Feldman: We have no information to answer this question. Again, it would be very helpful if there were a central repository of MbP data, but it doesn't exist.

Very little formal research into MbP has ever been performed and government and private foundations in the U.S. have never contributed a dime in grant monies for these issues.

MM: Are children the only victims of MbP? What about the same type of behavior by a caregiver against, for example, an elderly individual or someone who is already disabled, would that also be classified as MbP?

Dr. Feldman: Yes, these would also count as MbP cases. We use terms such as "Munchausen by Adult Proxy" to label such behavior, which can have the very same motives as when a child is the victim. We should be aware too, that MbP can be perpetrated against pets in order for the perpetrator to receive attention and sympathy, care and concern, from the vet and/or others.

MM: What should someone do if they suspect abuse through Munchausen by Proxy?

Dr. Feldman: First, they need education about what MbP is and is not. They can quickly get this kind of information from the MbP chapters in my book, PlayingSick. Then, they need to match the facts of the given case to the knownfeatures and warning signs of MbP. Once they have this kind of information, they will be equipped to make a sound, organized report to their county child protection agencies. They need to cooperate with the authorities and remain available to assist, if possible. Of course, mandated reporters, such as physicians, must make the MbP report at the time they become suspicious that it is occurring, even in the absence of confirmation.

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Criminal Media

By Douglas Corleone

A major theme in my novel One Man’s Paradise is how the media affects the American system of justice. Is it possible for a defendant to get a fair trial when every aspect of the case is discussed ad nauseam prior to the trial on the three major national cable news channels? It seems that in the age of round-the-clock news, voyeur journalism, and odious overbearing pundits, the freedom of the press has wholly usurped the right to due process.

Take the Casey Anthony case for example. If you followed this case at all during CNN’s prime time line-up, chances are you made a decision on Casey Anthony’s guilt or innocence prior to her trial. And chances are that decision was been based largely on the slanted views of former prosecutors who now hold themselves out as investigative journalists. Worse yet, you most likely formulated your opinion based on evidence that may not have been admissible at trial.

In a nation where jurors regularly cash in on colossal press cases through book deals and the like, is it possible that a fan of Nancy Grace may find her way onto the jury of a highly publicized crime? You bet. Potential jurors lie all the time to get out of jury duty. But what about those potential jurors that lie in order to make their way into the box?

It’s a frightening notion that defendants might be judged on evidence inadmissible in court. Because it means that information and physical evidence obtained by law enforcement through improper means may not be useless after all. Even if such evidence is excluded by the trial judge, it is certainly fair game in the court of public opinion. This has set a dangerous precedent.

And how are such cases selected by the national news media? Clearly producers and pundits select their cases on the totality of the circumstances. First, it seems, they look at the victim. Preferably female, preferably Caucasian, preferably well-educated (or currently studying), preferably young, and preferably attractive, particularly in the face. Then the networks consider the defendant. The case is a keeper if the defendant has a lot to lose. Again, it’s preferred that the perpetrator be Caucasian, that he or she have some connection to the victim, and that he or she look totally out of place shackled in an orange jumpsuit while walking through the courtroom.

Setting is also important. A tropical island, such as the one in One Man’s Paradise, is ideal. But really any affluent neighborhood or popular vacation destination will do. Cruise ship murders work well, too. Especially, if searchers are unsuccessful at finding the body.

Of course, I’m not defending criminals. That was my profession for several years as an attorney in New York City, and I’m glad to say I’m done with it. But the way the media handle certain cases is an issue that needs to be addressed and soon. It’s bad enough when these media vultures swoop down and exploit victims’ families for ratings. It’s worse when they convict defendants based on hearsay and tainted evidence months, or even years, before the actual trial.

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This post was contributed by Douglas Corleone, a former New York City criminal defense attorney; he now resides in the Hawaiian Islands where he writes contemporary crime fiction. His first international thriller Good As Gone will be released on August 20, 2013. You can find out more about this author and his books by visiting his website, following him on Twitter or joining him on Facebook.

Fame & Acclaim through Murder: Our Iconic Killers

By Jeffrey A. Cohen

We all know the icon I mean.  We see him in literature, in film, in popular culture, in the news.  He’s the poet-murderer, the societal rebel, the killer as greater soul.  The killer in social protest.  He’s Mailer’s “hipster,” that existential hero and “true” individual, who expresses himself through violence, and gives us his reasons from prison.  

Years ago while in law school, I became fascinated with the phenomenon of the jailhouse literary sensation, and particularly, Jack Henry Abbott. He was the convicted murderer who became a cultural icon and literary shooting star when his book of letters to Norman Mailer, In the Belly of the Beast, was published in 1981. 

One irony of the Abbott case is that this evil man’s letters, irrationally justifying his lifetime of violent crime, resulted in public sympathy, literary acclaim, and even his parole (with Mailer’s assistance).  Another irony, a tragic one, is that within six weeks of his release Abbott killed again, the night before a laudatory review of his book would appear in the New York Times.  And a final irony—the most perverse of all—is that the man he stabbed in the heart, Richard Adan, 22, a night-shift waiter who refused him the use of an employees-only restroom, was by day pursuing his dream of becoming a writer himself. 

We tend to invest our violent criminals with special qualities—they’re poets (like Abbott), they’re rebels (like Gary Gilmore), they have greater souls, or they bravely act in the face of society’s most sacred rules—our antiheros.  Only, in truth, they are almost never heroes of any sort, and kill because they are less not more.  The jailhouse literary sensation and our other celebrity killers, bask in the limelight of a little life turned big through evil acts, and blossom and flourish in our misconceptions of them.

This is the spark behind The Killing of Mindi Quintana. In my novel, Freddy Builder kills Mindi Quintana and is writing the book about their relationship everybody wants.  It’s a lying rewrite of Mindi’s life and his own, and of his miserably thin involvement with her.  Freddy is a department store clerk with dreams he’s done little to further.  Now, as he awaits trial, excerpts of his book appear to acclaim, and interest grows in the case.  His own lawyer, Philip, watches with disgust as Freddy builds his acclaim from the bones of his victim.  And as a new celebrity killer takes the stage.

In the store, before killing Mindi, Freddy daydreams of his future this way:

“When he made it into high gear, he would know what to do: He would be witty for reporters, pensive when appropriate, insightful always, and clever sometimes. When people cared what he thought, he would think great things. When they came to him, he would know what to say.  When there was no question of his stature, they would admire his work.  All he needed was an occasion to rise to.”

The “occasion” is murder and my novel asks if Freddy is right. It asks if our iconic criminals are as often depicted in literature and the press, or if they are undeserving of attributions of special character, talent, or existential heroism.  The Killing of Mindi Quintana is about celebrity through murder and the fascination we have with our violent criminals.  And it delivers the blow we all wish for when we think of O.J. Simpson, Gary Gilmore, Jack Henry Abbott—the alleged killer with a book, or who gains fame through the backdoor of murder. 

I was inspired to write my novel The Killing of Mindi Quintana by several aspects of the Jack Henry Abbott case: the dubious attribution of exceptional talent to his writing in In the Belly of the Beast; the public’s fascination with him for having killed; and the cruel irony of his killing Richard Adan—an aspiring writer who worked in obscurity to achieve what his killer was awarded for a lifetime of crime.

I think of what Abbott accomplished as “fame and acclaim through the backdoor of murder.”  He was a pre-packaged jailhouse literary sensation, his letters to Norman Mailer on prison life chopped into pieces for Belly, edited, organized under subject headings, and graced with a forward by Mailer himself.  I am always struck in reading his letters by Abbott’s ethos of violence, his monumental narcissism, and the disjointed philosophy he constructed from his prodigious reading to justify his lifetime of violence.  (When I think of Belly, I think of the Unabomber’s manifesto—where would he be in our pantheon of criminal icons had he had a Mailer as his champion?)

Abbot’s self-acquittal in Belly is internally inconsistent, irrational at times, remorseless, and in many places lacks credibility—it is unpersuasive.  To read his letters is to know he should not have been paroled.  But I am concerned, too, with something else: I am concerned about a public and literati eager to call him a genius for too little, a cultural tendency I explore in The Killing of Mindi Quintana.

I am not unmindful of the high quality of Abbott’s writing here and there, which it would be dishonest to ignore.  But his logic, his ideas and credulity are all doubtful, and his ability to do anything more than rant eloquently in short bursts is not apparent.  All of this argues against his merit as a writer; and I am suspicious of both what was left on the cutting room floor, and the nature of the editing of what we do get to read.

I recommend reading In the Belly of the Beast yourself and coming to a personal conclusion.

It was in the late ‘70’s, while Mailer was working on The Executioner’s Song about Gary Gilmore, that Jack Henry Abbott first wrote him offering a primer on prison life through his letters. Gilmore, the first man to be executed in the United States after a ten-year hiatus, famously abandoned his right to appeal in favor of an expeditious execution.  Like Abbott, Gilmore was a state-raised convict who had spent mere months outside prison as an adult before being released to commit heinous crimes.

As Belly does Abbott, The Executioner’s Song lionizes Gilmore through Gilmore’s letters from prison, carefully selected and edited. Mailer writes of that editing,  “…[I]t seemed fair to show [Gilmore] at a level higher than his average…. Besides he wrote well at times.” (Song at pg. 1052)  Fair to whom?  The reader looking for an accurate depiction of Gary Gilmore? 

Mailer brings to bear far more material than merely Gilmore’s letters to portray him as a poetic soul, a talented artist, a lover, good writer, and thinker. Mailer’s Gilmore is an existential hero, defying society by breaking its laws, and by killing, loving, and then dying on his own terms. Song also chronicles a moving prison love story between Gilmore and Nicole, his girlfriend of all of two months before his arrest for two murders.

The love story before prison was more prosaic: Nicole had grown bored of Gilmore and abandoned him.  Their breakup, in fact, occasioned the murders.  On successive nights, distraught over Nicole, Gilmore killed a gas station attendant and then a motel manager.  He had each lie facedown on the floor in his place of business, had each tuck his arms underneath his body, and shot each twice in the back of the head.  With Gilmore’s arrest, Nicole’s love is rekindled.

Gilmore’s letters, like Abbott’s, showcase an extreme narcissism and a remorselessly violent credo. In a number of his letters, Gilmore asks Nicole to commit suicide so that no other man will ever have her.  She tries and fails to kill herself.  He tries, not so hard, and fails, too.

The wind in the hair of these killers is supplied off camera by those creating the narrative we hanker for.  My job, as I saw it, in The Killing of Mindi Quintana, was to skewer the icon, to show the ersatz killer-poet for true.  We don’t all kill because we’re poets, it turns out; some of us kill because we’re not poets—then pretend to be when others see one in us.

In The Killing of Mindi Quintana, a department store clerk turned jailhouse literary sensation, builds his acclaim with his victim’s bones, as he writes his book.  His defense attorney watches with disgust until he can watch no more. 

I hope with my novel to steal the back the wind from the hair of a false rebel, and to deliver a comeuppance to the killer with a book.

This post was contributed by Jeffrey A. Cohen, a writer, technology entrepreneur and former trial attorney currently residing in Philadelphia. You can find out more about this author and his book by visiting his author page on Amazon, following him on Twitter, joining him on Facebook or LinkedIn.

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