Question 1

What is the appropriate term to be using for this presentation - Munchausen by proxy, factitious disorder by proxy (or imposed on another), or medical child abuse? Thank you

Marc Feldman · Accepted Answer

As you've inferred, there are quite a few terms that have been applied to this form of maltreatment. Professor Meadow coined the term "Munchausen syndrome by proxy" in 1977, and that term may be the best known of all, along with the same phrase without the word "syndrome" (a syndrome is a constellation of signs and symptoms, whereas Munchausen by proxy is abuse, so I have simply called it "Munchausen by proxy" in many of my writings). Lately, I prefer the term "medical child abuse (MCA)," because it is descriptive and easier to understand. But, in 2013, the American Psychiatric Association decided that this abusive behavior was sometimes associated with a mental disorder they call "factitious disorder imposed on another" (FDIA).  So I sometimes use MCA and sometimes FDIA, depending on the issues in a particular case. But every individual who engages in MCA, whether they meet criteria for FDIA as well, is a perpetrator, and that point can never be forgotten. Unfortunately, the evolving terminology has been used by some attorneys and others to try to debunk the entire phenomenon as "psychobabble," but that is simply a bald attempt to delegitimize it and exonerate the perpetrator.

Question 2

Hi Dr Feldman, the terms can be quite confusing. What is the easiest way to remember the differences between Munchausen Syndrome, Munchausen by proxy and Munchausen by Internet?

Marc Feldman · Accepted Answer

You're right, and if I hadn't been immersed in this work for so long, I too might be confused. There is no mnemonic that I know of, but all you really need to know is that "Munchausen syndrome" is the most severe and chronic form of factitious disorder (when one fabricates illness in oneself). The American Psychiatric Association is no longer using the term "Munchausen" for any ailment, but the public (and most professionals) haven't given it up! Munchausen by proxy is a form of medical abuse that victimizes others (usually children, the elderly, or pets). Munchausen by Internet is when the same behaviors occur either partly or entirely online.  I hope I haven't confused the issue further! By the way, I've attached the article from the Southern Medical Journal in which I introduced the term "Munchausen by Internet," a special interest of mine.

Question 3

What is a factitious disorder, and what are its causes?

Marc Feldman · Accepted Answer

To some degree, I have spent 25-30 years trying to figure out the precise answers to those questions! But I will say this: factitious disorder is when an individual falsely reports, exaggerates, fabricates, or actually induces a medical or emotional/behavioral/educational problem to garner emotional gratification. That gratification can come from the resulting attention and sympathy; from gaining a sense of self-definition as a "patient" or "parent of a patient"; from gaining control over others; from accruing enhanced self-esteem by associating with high-status individuals such as doctors; and more. I would encourage you to take a look at my latest book, "Dying to be Ill," for detailed information about all the possible reasons, and my take on them. Look in particular at Chapter 5.

Question 4

Are there mild forms of Munchausen by proxy?

Marc Feldman · Accepted Answer

MBP always involves emotional abuse and generally involves physical abuse as well (at the hands of the perpetrator and often, unwittingly, doctors and/or others). But there are gradations to this form of maltreatment as with other forms of abuse/neglect. For instance, 6 to 9 percent of known MBP cases culminate in the death of the victim (at least among published reports), and one would obviously view those cases as irreparably severe, unlike those that have no lasting physical effects.

Question 5

What are the early signs of Munchausen by proxy?

Marc Feldman · Accepted Answer

To answer this question, I would make reference to the list of warning signs published in a consensus guideline by the MBP Committee of the American Professional Society on the Abuse of Children (APSAC). It is attached. Though I might quibble a bit with some of the choices the APSAC Committee made, it is nevertheless a good starting point. Note that one does not need to find evidence for all of the indicators to make the diagnosis; there is no set number that is required for that purpose. In early MBP, for instance, you might only be able to establish a few.

Question 6

What's it like to be a victim of Munchausen by proxy?

Marc Feldman · Accepted Answer

I answered a similar question earlier on. In it, I referenced the publications about MBP survivors Mary Bryk and Hannah Milbrandt, and I would suggest you have a look. My latest book, "Dying to be Ill," also has first-hand accounts from adults victimized by MBP in childhood.

Question 7

What is the difference between Munchausen syndrome by proxy and malingering by proxy?

Marc Feldman · Accepted Answer

Munchausen by proxy and malingering by proxy have a lot in common--indeed, the essential features are the same. Both involve the fabrication or induction of signs and symptoms (physical and/or psychological) in another person (or even a pet). But in Munchausen by proxy (MBP), the principal goal is intangible; that is, the perpetrator is after some form of emotional satisfaction, perhaps by obtaining attention and nurturance as the parent of a child whose illness is defying diagnosis and treatment. In contrast, malingering by proxy (MAL-BP) is primarily in pursuit of an external--and usually tangible--incentive. These external goals can include disability payments; gifts and donations; evasion of criminal prosecution or military service; etc. Note the important point that MBP and MAL-BP can co-exist because people often have more than one reason for engaging in a behavior. A particular case can also shift from MBP to MAL-BP or vice versa.

Question 8

Do you think that trans kids are the new sick kids for parents with MBP? I see similar patterns in the validation, affirmation & attention that these mums receive, & wonder if there is any research into this, or any planned. Being trans offers the possibility of being medicalised for life.

Marc Feldman · Accepted Answer

I am not transphobic at all, but I have to acknowledge that what you say is sometimes true. For instance, in my book, "Dying to be Ill," I included a first-person narrative from the aunt of a little boy whose mother was continually claiming he was transsexual. This could be true, but it was apparent that, despite his own wishes, she was dressing the child in traditionally "female" clothing, sometimes painting his fingernails, and rewarding him for making statements about really being a girl. The motives for such behavior are variable, but can be similar to those seen in more common cases of MBP. Last year, I was emailed by an adult who said he was "living in seclusion as a male eunuch" because others (he didn't say who) convinced him earlier in life that he was transsexual. He was still profoundly distressed and tried (without success) to take legal action. This anecdote shows how external manipulation of an individual's gender identity can be very damaging.

Question 9

How does MSBP affect the individual (young, elderly, or person with disability) who has an illness or injury placed on them?

Marc Feldman · Accepted Answer

I answered a similar question or two early on. In it, I referenced the publications about MBP survivors Mary Bryk and Hannah Milbrandt, and I would suggest you have a look. My latest book, "Dying to be Ill," also has first-hand accounts from adults victimized by MBP in childhood.

Question 10

I’m an adult “survivor” of munchausen by proxy. My childhood is such a blur and so confusing, and it feels like I have endless emotional problems as a result of MBP. Where can I begin the healing process?

Marc Feldman · Accepted Answer

Only one study of adult survivors of MBP has, to my knowledge, been published.  As you would expect, many of the patients 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.  Many were pre-verbal or early-verbal when the MBP took place, so needless to say, their memories are limited or absent. Others had trouble with so-called "reality testing": discerning generally what is true and real and what is not wholly true. So, it isn't at all surprising that you were deeply affected and have emotional issues to combat. For first-person accounts of MBP victimization and the effects in adulthood, Google the names "Mary Bryk" and "Hannah Milbrandt." Both are courageous survivors who came forward to share their experiences, for which psychotherapy is usually essential. My latest book also has first-person narratives from women who prevailed over the psychological effects of MBP.

Question 11

Are there documented cases of Munchausen by proxy by Internet in step-parents? What patterns can one look out for when there is a real child involved and the fabricated illnesses are psychological? Should anything be done if there is no evidence yet of the behavior directly affecting the child?

Marc Feldman · Accepted Answer

There are actually three questions here. First, there are few reports of Munchausen by Proxy by Internet (MBPBI) in the professional literature, at least by that name. But I am certain that MBPBI cases arise a lot; they just are not written up for publication. Though I don't recall a documented case of MBPBI involving a stepparent, there is no reason to think that such cases don't occur. In fact, they may be even more common because of the lack of the bonding that normally occurs between biological children and their biological parents.  Second, it can be very difficult to identify psychological MBP (as it is sometimes called) because the diagnoses--whether of ADHD, autism spectrum disorder, psychosis, developmental disorder, etc.--are based so heavily on what the parent has to say. Inconsistencies are generally key: inconsistencies between the reports the abuser makes or inconsistencies between objective findings and those reports. The American Professional Society on the Abuse of Children (APSAC) has published MBP Guidelines that list some of the more compelling warning signs or patterns, whether the falsifications involve physical or psychological ailments (and these can co-exist in a given case, as when a parent falsely alleges that a child is depressed and lethargic from chronic Lyme disease for which there is no evidence). I have attached those warning signs for your convenience. Finally, recognition of MBP--whether among family members, friends, police, and/or child protection workers--depends on a thorough understanding of what MBP is and is not. Reading about MBP in books such as my latest one can help immeasurably, and prepare one to make a report or intercede in other ways, even if there is no current evidence of effects on the child.

Question 12

My developmentally disabled sister has broken both her feet and I suspect she is doing it to herself. I have suspected it for awhile (there have been many other incidents and she enjoys the attention she receives from doctors and nurses). My mom is very defensive about it and I wonder why. Insights?

Marc Feldman · Accepted Answer

This question raises a lot of other questions that cannot be answered with real specificity with the information provided. For instance, if your sister is in a wheelchair, she may have run over her own feet or toes, or your mother could have done it. But I have not come across deliberately broken feet before in any case. It isn't that easy to do. And it is possible that your sister enjoys the attention from medical personnel without its meaning that she is engaged in self-harm. But maybe she did! I just can't tell.

This question reminds me of a case from my last book. An older man with Down syndrome was observed by his brother to develop increasing medical problems for which it seemed that adequate treatment was not always sought. He wondered whether their 90-year-old mother was neglecting or actively abusing him--for instance, by deliberately running her motorized wheelchair into the man. I doubted it but did read the medical records. However, the man died of pneumonia and had other physical infirmities that were unlikely to have been caused by anyone. His age was advanced for a Down syndrome patient and that might have compounded his intellectual disability. Eventually, I decided that I would never be able to reach a conclusion, such as assigning culpability to anyone. I was at a loss, as I am with your question!

Question 13

Hi Dr Feldman, what is the best way to approach this topic if you suspect a relative of MBP?

Marc Feldman · Accepted Answer

First, you will need education about what MBP is and is not.  You can get this kind of information from my latest book, "Dying to be Ill."  Then, you need to match the facts of the given case to the known features and warning signs of MBP.  Once you have a good understanding, you will be equipped to decide whether to proceed with a sound, organized report to your county child protection agency or even the police. Prematurely alerting the alleged perpetrator to the suspicions can lead them to flee with the child; seriously sicken the child to "prove" their case; sign the child out of the hospital against medical advice; and the like. I would recommend that a therapist who is knowledgeable about MBP assist in each case because the facts and situation may require a different approach. You also would 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 reasonably suspicious that it is occurring, even in the absence of confirmation.

Certainly, as I suggested, you need to be aware of the warning signs of MBP. There are a host of lists of "red flags" in various publications, but here are several on which most experts would agree:

1	Excessive past healthcare service use, such as doctor-shopping
2	Information provided by the mother is evasive or she blocks access to outside information sources
3	Medical investigations are all normal despite severe symptoms
4	The symptoms and signs make no objective medical sense
5	There is evidence for medications, syringes, etc. that the mother has used inappropriately on the child
6	The mother is clearly eager for the child to have surgical procedures
7	The child consistently fails to respond to treatments that would be expected to be effective.

Question 14

Hi Dr Feldman. It seems that most perpetrators are female, why do you think this is?

Marc Feldman · Accepted Answer

Almost all of the known perpetrators, as reflected in a recent study of 796 of them, are not only female, but the mother of the victim(s). I have seen a couple of articles that claim that MBP doesn't exist, but instead is a way to further oppress women. They say it is an inherently misogynistic diagnosis. It hardly needs to be pointed out that these theories are absurd, because there are more than 700 studies from around the world that affirm the finding that is the basis of your question. I will propose that MBP is in some ways a behavior based in opportunity, and, as the primary caregivers in most situations, mothers have access and credibility when it comes to the alleged health or illness of their children. MBP families tend also to have a tacit or explicit assignment of "traditional" roles, where the father is the breadwinner and the mother tends to all matters involving the home and children. Alternatively, the father is absent or largely unavailable in many of these situations. Women also tend to "act out" in more subtle ways than men. Women present more commonly to medical offices, whereas men who are acting out clearly predominate in prisons. One point a colleague made was this: the behavior is a disguised cry for help.  Mothers are supposed to be self-sacrificing and are "allowed" to ask for help for a child.  If they ask for themselves (for instance, for depression, loneliness, or boredom), there is a stigma because they are not "supposed" to feel that way. This postulate become less convincing in the many cases in which the mother vigorously courts the media, celebrities, and government officials in a way that is unlikely to reflect depression.

Question 15

I’m aware I have MBP but I want to stop. Are there any support groups for people like me? Can we ever be cured?

Marc Feldman · Accepted Answer

It is an excellent prognostic sign that you acknowledge the MBP behaviors and want to stop. Most of the mothers in these cases tenaciously deny what they have done--even when presented with videotapes of the abuse. I was struck by this denial even very early in my career, and wrote a medical article about it in 1994. But it sounds like you have surmounted this obstacle. There are no relevant online or real-life support groups that I know of, but recently Drs. Mary Sanders and Brenda Bursch published an important article entitled, "Psychological Treatment of Factitious Disorder Imposed on Another/Munchausen by Proxy Abuse" in the Journal of Clinical Psychology in Medical Settings. I do not have permission to post it here, but you can reach out to the authors via a Google search. The article might help inform a psychotherapist who wants to help you, but isn't sure about what to do.

I would note that I keep referring to "mothers" in my answers, but that's because a recent review article by Yates and Bass showed that almost all the perpetrators in such cases are the mother of the victim(s). Fathers and others are rarely represented.

Question 16

What reasons might there be behind a parent developing Munchausen syndrome by proxy (MSBP)?

Marc Feldman · Accepted Answer

There is no evidence that MBP is genetic or inborn. But many perpetrators have experienced abuse or emotional neglect in childhood, and came to realize that the way to get attention and relief was to pretend to be sick. As adults, they continue this same behavior, but use the body of their child to get their needs met. They almost universally have developed personality disorders, such as borderline personality disorder; that simply means that they have long-term, potentially self-defeating ways of coping with stressors. They may never have developed healthy mechanisms for doing so.

Question 17

What distinguishes MSBP as a mental health issue versus a criminal offence when there is actual illness or injury caused rather than simply made up?

Marc Feldman · Accepted Answer

In 2013, the American Psychiatric Association opted to associate MBP with a mental disorder called "factitious disorder imposed on another" (FDIA). People with FDIA fabricate or induce illness in another person (or pet) by deceiving health care professionals and others. Increasingly, however, the term "medical child abuse" (MCA) is being used to make it clear that the behavior is abusive, and not every perpetrator who engages in MCA has FDIA. For instance, some are delusional, and actually believe the child is sick without meaning to deceive others. Still, the behavior constitutes abuse, and would still qualify as MCA. Note that even falsely reporting (i.e., making up) an illness can be very serious if doctors perform procedures and prescribe medications as a result. Also, perpetrators who "simply" lie often progress to actually inducing illness if they don't garner enough emotional gratification.

Question 18

What does a person gain from MSBP?

Marc Feldman · Accepted Answer

The principal goal is internal, though there may be concurrent external goals too (such as obtaining money from GoFundMe accounts). One does not rule out the other. The internal goal is some kind of emotional gratification. A prominent gain in most cases is attention and sympathy from appearing to be the indefatigable caregiver of a child with a baffling and/or serious illness. The care and concern that result can be seductive, and help to continue or increase the maltreatment. Other perpetrators feel a loss of control in their lives, and being able to mislead (and associate with) doctors and other high-status people allows them once again to feel "in control." Some have a sadistic streak that fuels the abusive behaviors, and others are rageful that the child has usurped their freedom. Still others lack a clear sense of self (they lack "ego strength" and a sense of self-definition), and being the mother of a terribly ill child becomes their identity, which paradoxically reduces their general anxiety about life.

Question 19

Has anyone studied the psychological effects on doctors regarding their role in the unnecessary and potentially harmful medical interventions done in this presentation?

Marc Feldman · Accepted Answer

Not to my knowledge. Part of the reason might be the lack of funding for Munchausen by proxy research. But there are other reasons. While primary care doctors like pediatricians, and pediatric specialists and subspecialists, are usually wonderful advocates for children and families, they can sometimes be an impediment to the intervention to intercede and stop medical child abuse because of denial. Often in my work, the primary care physician (PCP) simply cannot grasp that they have been badly misled, and that the medications and procedures that they have prescribed actually harmed the child. In their defense, they do not have the time to do the thorough chart reviews that are usually necessary in these cases, and they are not compensated if they do want to. There may be years between the first evidence of MBP and recognition by anyone that abuse has been occurring. I cannot tell you how many affidavits from PCPs I have read in which it is claimed that it is "impossible" that such a "fine mother" could ever be abusive--the evidence notwithstanding.

Question 20

Could parental obsession with food allergies be conceptualised as a form of MSBP?

Marc Feldman · Accepted Answer

The answer is a definite "yes," and I am encountering this variant more and more commonly. Perhaps the most common false claim I see is of gluten intolerance or celiac disease, though all tests and trials are negative. Often this is combined with startling claims of food and medication allergies that sharply constrict the foods and treatments that can be given. The usual victim is a child, and he/she can wind up underweight and subject to complex dietary regimens as a result of the false or exaggerated claims by the perpetrator. I have even served as an expert in a case in which the child was supposedly allergic to all food proteins such that she was only fed a limited liquid diet for seven years! Separation from the mother, with gradual introduction of "forbidden" foods, proved that she wasn't allergic to any foods. There are indeed some children with this rare disease, so doctors are sometimes co-opted into believing the caregiver rather than "risk" introducing a lot of solid foods.

I've taken the liberty of attaching a classic article on this subject.

Question 21

In your opinion would it be likely for an alexithymic individual to suffer from facticious disorder as a result of their deficit in emotional expression?

Marc Feldman · Accepted Answer

I don't know a lot about alexithymia, but your question is certainly interesting. In an effort to respond, I asked a knowledgeable colleague to handle this question for me. Here is his (rather complex) response. I hope it helps.
______________________________________________________

The research on alexithymia and dissociation, and their relation to excessive illness behavior, is a bit dodgy. The best of it suggests that the excessive illness behavior related to these things is a matter of information processing deficits - mistaking anxiety for dyspepsia. The acute attention to and processing of emotional information communicated by those we wish to deceive would be difficult for people who had alexithymia to any significant degree. And the emotional experiences that we believe FD may be designed to regulate, may not occur (or occur strongly enough) to fuel factitious illness behavior.

Question 22

What is the best way to proceed if you feel that a relative has munchausen?  I want to believe them and support them, but the stories get less believable and contradictory.

Marc Feldman · Accepted Answer

The single word "Munchausen " doesn't tell me enough to answer this question. Do you mean "Munchausen syndrome" (fabricating illness in oneself) or "Munchausen by proxy" (fabricating illness in another). This is a common source of confusion. It is also an important distinction because management would be different in the two conditions. Adding even more importance, some MBP perpetrators have past or current histories of Munchausen syndrome (aka factitious disorder imposed on self); one seems to be a risk factor for the other.

Munchausen Syndrome by Proxy

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