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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