Question 1

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 2

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 3

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 4

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 5

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 6

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 7

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 8

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 9

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 10

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.

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