Diagnosing Munchausen by Proxy
Munchausen Syndrome by Proxy or MSBP is a diagnosis given to a mother or care giver to describe aspects of their behaviour. This behaviour usually includes subjecting what appears to be a previously healthy child to unnecessary and often painful tests or medical interventions i.e.: scans, x-rays and even surgical procedures to gain attention from the medical profession.
Many theories exist as to why a woman may fabricate illness in her child. Common to most theories is a traumatic loss earlier in the mother’s life; such a loss may be represented by maternal rejection and the lack of love and attention as an infant. It may also be representative of the “loss of a parent, loss of a parent’s love through neglect or abusive treatment, or loss of self through childhood illness or traumatic disillusionment” (Bach, 1991).
The problem appears to be that many professionals describe MSBP as different things. There have been debates all over the world on the subject. Some have said it is a mental illness and some say that it doesn’t exist, others question whether if it does, then can it even be called MSBP, as Munchausen by Proxy is after all, just a term, referring to a list of symptoms, named after a fictitious storybook character Baron Munchausen, who enjoyed a series of fanciful adventures.
Dr Marc Feldman, thought to be a leading expert on the subject, believes that it does exist and describes what he believes to be the behaviour of a person thought to have MSBP on his website.
“They deliberately mislead others into thinking they (or their children) have serious medical or psychological problems, often resulting in extraordinary numbers of medication trials, diagnostic tests, hospitalizations, and even surgery . . . that they know are not really needed.Â In short, factitious disorder, Munchausen syndrome, malingering, and Munchausen by proxy involve illness deception, or “disease forgery.”
They may feign illness – e.g., by fakingÂ a seizure orÂ acting as if they have multiple personalities.
They may falsify lab results – e.g., by adding blood or protein to a urine specimen.
They may exaggerate a medical problem – e.g., by claiming occasional mild back pain is crippling.
They may aggravate an existing ailment – e.g., by manipulating a wound so it doesn’t heal.
They may induce an actual illness – e.g., by injecting themselves or their child with bacteria to cause a raging infection.
They may “dissimulate” – e.g., by initially avoiding treatment so that a minor medical problem becomes serious”.
“In variations of the root problem, some seek the HERO or VICTIM role, rather than the
In another article by Feldman Parenthood Betrayed, The Dilemma of Munchausen by Proxy he explains that MSBP mothers need to feel ‘special’ and ‘that virtually all have personality disorders.
Other professionals however, disagree with this opinion fiercely and in 2004, Earl Howe the Opposition spokesperson on children and health in the House of Lords, was reported to have said in the article Justice out of Balance that he believed that professionals were replacing the term MSBP with a diagnoses of Personality disorder, to assist arrest. .
In the article Munchausen by Proxy written by Ibrahim Abdulhamid MD he says:-
“Perpetrators are frequently described as caring, attentive, and devoted individuals. However, not all perpetrators fit this impostor parent profile. Some can be hostile, emotionally labile, and obviously dishonest. Although they have no obvious psychopathology, perpetrators can be deceiving and manipulative. Their ability to convince others should not be underestimated. Their abuse is premeditated, calculated, and unprovoked. The mother may have previous health care knowledge or training, and she is often fascinated with the medical field. In 1 study, 80% of the documented perpetrators, all mothers, worked in health care or child-care facilities. She aspires to establish close relationships with medical staff and frequently becomes a source of support for staff members or the families of other patients.”
Here we see that Abdulhamid’s describes a ‘profile’. The idea of a MSBP profile has built up over the years and has been used frequently to assist the diagnoses of MSBP abuse. The ‘profile’ is a list of traits believed to be common in a MSBP type character, unfortunately this profile also describes many innocent women as well and this is concerning many professionals.
Dr Helen Hayward-Brown, one such professional is worried about the use of the ‘profile’ saying:-
‘It is a nightmare waiting on the step of every sick child’.
‘ordinary mothers and fathers are being accused of child abuse because their children have an illness that some pediatricians cannot diagnose, or the parents strongly question the doctors over the child’s treatment’. Justice out of Balance
She goes on to say how parents are often trapped and uses the example that being an over protective parent is one part of the MSBP profile but then explains that equally so to is being a negligent parent, putting parents into a no win situation.
Earl Howe has also been extremely concerned about the use of the MSBP profile and in Oct 2001 said in a parliamentry discussion at the The House of Lords:-
”The danger of such a broad spectrum of behaviour being packaged into a single portmanteau term, MSBP, is that in the hands of those who are not sufficiently trained or experienced to know better, it is a label that is all too easily applied without due care. This is all the more true when one considers the so-called profile of characteristics that are said to mark out a person suffering from MSBP. These characteristics include such things as privation during childhood, repeated bereavement, miscarriage, divorce and past health problems. An over-intense relationship with the child and a desire to be the perfect parent are other supposed markers. Regardless of the fact that there are very many perfectly innocent, sane people around who might have such characteristics, the very idea of a tell-tale profile of this kind is an open invitation to apply the MSBP label without properly looking at what may or may not be happening to the child. Put at its simplest, there is all the difference in the world between a Beverley Allitt, whose severe personality disorder led her to murder young children, and a mother who invents reasons why she and her child should visit the doctor. Yet under the all-embracing banner of MSBP, and in the hands of the untrained, the two are treated as being practically indistinguishable. It does not matter whether one calls the condition “MSBP” or “factitious illness by proxy”, or by any other name. The point remains the same. ”
Lisa Blakemore-Brown a psychologist, expert in Autism and an author agrees, she feels that parents become under attack and blamed, if they dare to question doctors, particlularly if they believe that their child has become ill after a vaccine injury. She speaks of one particular case in Omissions Prove What and she also made a comment in the Open House: Have Your Say: Measles ‘endemic’ in Britain The Independant in 2008 saying:-
“In the Sally Clark case, Professor Meadow accused her of killing two children who had just been vaccinated, one just 5 hours earlier. To my certain knowledge, as a Psychologist specialising in Autism since 1993, and working as a generic Psychologist since 1984, many parents whose children reacted to a vaccine have been wrongly accused of MSBP. Known side effects have been morphed into child abuse. Workers have been taught to view them this way and act accordingly. Some have had their children taken from them, some were sent to prison and Sally Clark lost her children and her life.”
Earl Howe the opposition spokesman on health, once accused a professor of inventing a “theory without science” and refusing to produce any real evidence to prove that Munchausen Syndrome by Proxy actually exists. He says-
‘It is important to distinguish between the act of harming a child, which can be easily verified (and there are plenty of cases to prove that it happens), and motive, which is much harder to verify and which MSbP (controversially) tries to explain. For example, a caregiver may wish to harm a child simply out of malice (similar to domestic abuse by husband or wife) rather than in order to draw attention and sympathy, in which case, harming the child is merely incidental to the main purpose. In the former case, induced illness is likely to be a means of avoiding detection of domestic abuse (a more elaborate form of the excuse that the victim has “fallen down the stairs”).
Blakemore-Brown believes that the use of the profile has encouraged professionals to think in a ‘ medieval manner’.
Re: Influence of Bruce Clark
”Since the introduction of the Clark guidelines, the warped MSBP thinking has performed much as one would expect. It has snaked right through the system.
It has encouraged workers and professionals at all levels to think in a medieval manner and misconstrue what is in front of them. It has fostered a misplaced belief that the road to their suspicions is paved with robust science and indisputable medical evidence. It has fostered a misplaced belief that they are protecting children.”
Some professionals describe what they call some the ‘warning signs’ to watch out for when diagnosing a potential sufferer.
“The characteristic behaviour of the parent is pleasant, cooperative, and supportive of the medical staff; eager to be in the hospital, overly attentive to her child (takes temperature, administers medication, attempts to exclude medical support staff); and able to arouse sympathetic interest and involvement of hospital staff. In addition, the mother may have a nursing or medical background, have her own history of Munchausen syndrome, have a history of marital discord, deny deception, lack the usual parental concern, and have suicidal ideation or attempt suicide before or after discovery of the syndrome (Meadow, 1982). The mother may thrive in the medical environment and enjoy the attention and care she receives from the health care staff. She may have a history of frequent use of emergency rooms and ambulances”
However, if the parent has a disabled or frequently sick child, it is quite possible that they will be used to their local hospital as they may have been a frequent visitor with their child. If it is a good hospital the parent will feel at ease. If this is so, they may feel comfortable with the staff, even being on first name terms with many, and feel that they are simply being helpful and saving work for the busy staff. To many junior doctors and staff who are unfamiliar with the parent and their situation, this may appear to be very much in line with the above comments although I don’t know how a parent can be ”overly attentive to their child” and then to ”lack parental concern.”.
Prof Meadow mentions suicide attempts before and after diagnoses of MSBP. “have suicidal ideation or attempt suicide before or after discovery of the syndrome (Meadow, 1982).”
Again, for some parents with a disabled or ill child there is a total lack of help and support locally and it is possible that this lack of support will have a detrimental impact on a mothers mental health. She may well become suicidal or be driven to attempt suicide. This was highlighted in the news story regarding a couple who had a daughter with Asperger’s syndrome who felt unable to cope with the pressures.
The article describes the lengths the parents’ of a disabled child resorted to as a result of a total lack of support by the system. Their daughter who had Aspergers syndrome had ran up huge debts. The family had no support and no where to turn. So in sheer desperation they decided they could no longer cope and decided to end their lives. Tragically the mother died but the father did not. In their suicide note it read
“There is still no attempt to provide any form of help, therefore we have chosen that the only way out is to end our lives.
“…We came to Tenerife on a cheap one-way flight and have been sleeping on the beach for the last three nights while we pondered the situation, but we realise that we will have to end our lives as there is no help whatsoever.”
More recently a young mother felt she was forced to end hers and her daughters life in –
This is yet another case where the system failed a mother and a child who were in desperate need of help. This sadly can be the reality of a life with a disabled child. Leaving vulnerable families feeling that death for them is the only way out.
Other classic warning signs depicted include separation anxiety in the child and parental over-protectiveness.
“The child may cling to the mother and not demonstrate age-appropriate behaviour (Crouse, 1992). The child may initially display fear, negativism, and anxiety, and later progress to a passive, helpless state”
This equally can be normal behavior. A hospital can be a scary place for a child with many unfamiliar people. There may be a need for blood tests and examinations and this may make a child appear clingy or anxious This in turn may send a parent into overdrive, making them appear over protective. A child who is ill or in pain can also display fear, negativism, and anxiety.
Louisa J Lasher another said expert on the subject of Munchausen Syndrome by Proxy in her article Smothered with Something That Looks Like Love but Isn’t says:-
“The main thing these mothers are after,” says Louisa J. Lasher, MA, an international expert on the subject, “is the attention that they get from having a child with problems.” Commonly, these mothers will receive sympathy from friends and family. Sometimes church groups or community groups praise these mothers for their selfless duty to their sick child. Of course, to keep the praise coming, the lies must continue. Thus, the children suffer.
Lisa Blakemore-Brown has a differing opinion which was described by Jamie Doward in his Guardian article.
‘Between 1996 and 2002 Blakemore-Brown also raised her concerns in a series of letters to, among others, Tony Blair, health secretaries Frank Dobson, Alun Milburn and Health Minister Jacqui Smith. In each case she received a reply observing only that her concern had ‘been noted’. She also wrote to the Psychologist magazine, warning: ‘I cannot establish a robust scientific base and am aware of a number of cases in which mothers have had children removed on the basis of this diagnosis to discover later that their children had real illnesses or disorders which were missed when the notion of MSBP loomed large.’
See the copy of her letter here
MSBP is often described as a mental illness, this is probably because its counterpart Munchausen Syndrome is listed in both ICD 10 and DSM IV (the psychiatrist’s bibles) We have also seen Dr Marc Feldman and. Ibrahim Abdulhamid MD describe it as a personality disorder.
Both of these sites show references to Munchausen Syndrome being listed but not MSBP.( Munchausen Syndrome is when a person falsifies their ‘own’ illnesses to gain attention.)
However FDBP or Factitious Disorder by Proxy which is now a name sometimes used, is listed as a personality disorder and is in DSM IV and has been since 1994
In 1985 Sir Roy Meadow states:-
‘that as a rule mothers with MSBP appeared normal on psychological tests with no disorder apparent to the psychiatrist and Rosen et al describes a case where a mother he knew fell within normal limits and showed no sign of psychopathic tendency, however a psychodynamic interpretation of her data later resulted in a diagnoses of narcissistic personality disorder.’
Again this indicates that MSBP is a personality disorder but is it? Many professionals disagree as we have seen. If it is then why is it not just called a ‘personality disorder’ .in the same way as ‘narcissistic personality disorder’ is? For example ‘MSBP Personality disorder’.
Since 2002, MSBP has also been known as FII which is Fabricated or Induced Illness. FII is listed as a mental illness which is maybe why it is being more frequently used as the listing would give the diagnoses more weight.
All in all serious caution is required when making a diagnosis of MSBP type abuse. Much of the above can also be indications of a normal anxious parent with a sick child or indeed a child with organic, but undiagnosed illness or disability. People are by nature different and no one can fit the ‘profile’ of MSBP perfectly.
An ethical diagnosis of MSBP should include a detailed evaluation of the child, an evaluation of the parents and of the family dynamics. Diagnoses based only on a quick review of the child’s medical chart can often be misleading and can brand an innocent mother guilty. The profile of msbp shows that in the event a mother is wrongly diagnosed, the stigma would be much like a permanent imprint on their life. This would affect various aspects of their lives. The victim of a false diagnosis may then spend many years in a system clearing her name.