Fabricated or Induced Illness

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Fabricated or Induced Illness (FII) is the formal name of a type of abuse in which a caregiver feigns or induces an illness in a person under their care, in order to attract attention, sympathy, or to fill other emotional needs. It is also known as Munchausen Syndrome by Proxy (MSbP), due to its similarity to Munchausen syndrome, in which a person feigns or induces illness in themselves for similar emotional reasons.

In FII a caregiver, usually the mother, feigns or induces an illness in another person, usually her or his child, to gain attention and sympathy as the "worried" parent. Although cases with feigned or induced physical illness receive the most attention, it is also possible in parents who emotionally abuse their child, then claim psychiatric and/or genetic problems.

The term has also been used to refer to medical professionals who purposely cause inflicted injury or discomfort to a patient so they are able to later treat or heal the patient and receive attention or compliments from co-workers; this is also referred to as "playing god".

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[edit] Initial Description

In 1977, the English pediatrician Roy Meadow, professor of Paediatrics at the University of Leeds, England, described a form of child abuse in which mothers deliberately induced or falsely reported illnesses in their children. He referred to this behaviour as Munchausen Syndrome by Proxy. Its formal name since March 2002 is now Fabricated or Induced Illness (FII) according to the Royal College Of Paediatrics and Child Health.[1]

During the 1990s and early 2000s, Roy Meadow was called as an expert witness in several murder cases where FII was at issue, some of which resulted in parents being convicted of murdering their children and imprisoned. In addition, several children were taken into care. During 2003 a number of high-profile acquittals brought Meadow's ideas into serious disrepute. Some people deny even the existence of FII, despite observations on hospital surveillance cameras which have caught abusers in the act. Around 250 cases resulting in conviction in which Meadow was an expert witness were reviewed, with few changes. Meadow was investigated by the British General Medical Council over one aspect of one case - the statistical likelihood of sudden infant death syndrome occurring twice in a family. The GMC in July 2005 came to a verdict of guilty of "serious professional misconduct" which High Court judge Mr Justice Collins described at appeal as "irrational" and set aside. The case had almost nothing to do with SIDS, since neither prosecution nor defence suggested that the children involved suffered SIDS, and Collins' judgement raises important points concerning the liability of expert witnesses - his view is that referral to the GMC by the losing side is an unacceptable threat and that only the Court should decide whether its witnesses are seriously deficient and refer them to their professional bodies. The case of Dr Jayne Donegan may also be relevant to this.

There are now more than 2,000 reports of FII in the professional and lay literature, with 10 books devoted to the subject. These reports reaffirm that MSbP is not simply a Western phenomenon; reports have come from developing countries throughout the world.

In 2003, Sickened, an autobiographical account of the Munchausen Syndrome by Proxy abuse Julie Gregory suffered as a child, was published.

In 2003, the documentary film MAMA/M.A.M.A. was released, which questioned the validity of Munchausen Syndrome by Proxy, arguing that in many cases doctors' overmedication of infants may be the real cause of their infirmity rather than the mother's mental illness. The film contains an interview with Sir Roy Meadow. [www.munchausenmovie.com] is the official site for the film.

It has been established in legal rpecents in Australia and the U.k. that Munchausen Syndrome By Proxy does not exist as a medico-legal entity. The relevant extracts from these judicial findings are : In June 2004 in an Appeal Hearing, the Supreme Court of Queensland, Australia have made the following findings in regard to MSBP/FII. [R v LM [2004] QCA 192.].

“As the term factitious disorder (Munchausen Syndrome By Proxy) is merely descriptive of a behaviour, not a psychiatrically identifiable illness or condition, it does not relate to an organised or recognised reliable body of knowledge or experience. “

The Queensland Supreme Court further ruled that the determination of whether or not a defendant had caused intentional harm to a child was a matter for the jury to decide and not for the determination by expert witnesses, i.e.

“the diagnosis of Drs. Pincus, Withers, and O’Loughlin that the appellant intentionally caused her children to receive unnecessary treatment through her own acts and the false reporting of symptoms of factitious disorder (Munchausen Syndrome) by proxy is not a diagnosis of a recognised medical condition, disorder, or syndrome. It is simply placing her within the medical term used for the category of people exhibiting such behaviour. In that sense, their opinions were not expert evidence because they related to matters able to be decided on the evidence by ordinary jurors. The essential issue as to whether the appellant reported or fabricated false symptoms or did acts to intentionally cause unnecessary medical procedures to injure her children was a matter for the jury’s determination. The evidence of Drs. Pincus, Withers, and O’Loughlin that the appellant was exhibiting the behaviour of factitious disorder (Munchausen Syndrome By Proxy) should have been excluded.”

Principles of law and implications for legal processes which may be deduced from these findings are that :-

1. Any matters brought before a Court of Law should be determined by the facts, not by suppositions attached to a label describing a behaviour. i.e. MSBP/FII/FDBP;

2. MSBP/FII/FDBP is not a mental disorder (i.e. not defined as such in DSM IV) and the evidence of a psychiatrist should not therefore be admissible;

3. MSBPFII/FDBP has been stated to be a behaviour describing a form of child abuse, and not a medical diagnosis of either a parent or a child. A medical practitioner cannot therefore state that a person `suffers’ from MSBPFII/FDBP and such evidence should also therefore be inadmissible. The evidence of a medical practitioner should be confined to what they observed and heard, and what forensic information was found by recognised medical investigative procedures;

4. A label used to describe a behaviour is not helpful in determining guilt and is prejudicial. By applying an ambiguous label of MSBP/FII to a woman is implying guilt without factual supportive and corroborative evidence;

5. The assertion that other people may behave in this way i.e. fabricate and/or induce illness in children to gain attention for themselves (FII/MSBP/FDBY) contained within the label, is not factual evidence that this individual has behaved in this way. Again therefore, the application of the label is prejudicial to fairness and a finding based on fact.

The Queensland Judgement was adopted into English law in the High Courts of Justice in Case No. WR03C00142 [A County Council v A Mother and A Father and X,Y,Z children] on 18 January 2005 by Mr. Justice Ryder. In his final conclusions regarding Factitious Disorder, Mr. Justice Ryder states that :- “I have considered and respectfully adopt the dicta of the Supreme Court of Queensland in R v. LM [2004] QCA 192 at paragraph 62 and 66. I take full account of the criminal law and foreign jurisdictional contexts of that decision but I am persuaded by the following argument upon its face that it is valid to the English law of evidence as applied to children proceedings. The terms ‘Munchausen Syndrome by Proxy’ and ‘Factitious (and Induced) Illness (by Proxy)’ are child protection labels that are merely descriptions of a range of behaviours, not a paediatric, psychiatric or psychological disease that is identifiable. The terms do not relate to an organised or universally recognised body of knowledge or experience that has identified a medical disease (i.e. an illness or condition) and there are no internationally accepted medical criteria for the use of either label. In reality, the use of the label is intended to connote that in the individual case there are materials susceptible of analysis by paediatricians and of findings of fact by a court concerning fabrication, exaggeration, minimisation or omission in the reporting of symptoms and evidence of harm by act, omission or suggestion (induction). Where such facts exist the context and assessments can provide an insight into the degree of risk that a child may face and the court is likely to be assisted as to that aspect by psychiatric and/or psychological expert evidence. All of the above ought to be self evident and has in any event been the established teaching of leading paediatricians, psychiatrists and psychologists for some while. That is not to minimise the nature and extent of professional debate about this issue which remains significant, nor to minimise the extreme nature of the risk that is identified in a small number of cases. In these circumstances, evidence as to the existence of MSBP or FII in any individual case is as likely to be evidence of mere propensity which would be inadmissible at the fact finding stage (see Re CB and JB supra). For my part, I would consign the label MSBP to the history books and however useful FII may apparently be to the child protection practitioner I would caution against its use other than as a factual description of a series of incidents or behaviours that should then be accurately set out (and even then only in the hands of the paediatrician or psychiatrist/psychologist). I cannot emphasise too strongly that my conclusion cannot be used as a reason to re-open the many cases where facts have been found against a carer and the label MSBP or FII has been attached to that carer’s behaviour. What I seek to caution against is the use of the label as a substitute for factual analysis and risk assessment."

[edit] Clues that may indicate Fabricated or Induced Illness

Caution is required. Many of the items below are also indications of a child with organic, but undiagnosed illness. An ethical diagnosis of MSbP must include an evaluation of the child, an evaluation of the parents and of the family dynamics. Diagnoses based only on a review of the child's medical chart are now frequently[citation needed] being rejected in court.

  • A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling and unexplained.
  • Physical or laboratory findings that are highly unusual, discrepant with history, or physically or clinically impossible.
  • A parent who appears to be medically knowledgeable and/or fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients’ problems.
  • A highly attentive parent who is reluctant to leave their child’s side and who themselves seem to require constant attention.
  • A parent who appears to be unusually calm in the face of serious difficulties in their child’s medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to other, more sophisticated, facilities.
  • The suspected parent may work in the health care field themselves or profess interest in a health-related job.
  • The signs and symptoms of a child’s illness do not occur in the parent’s absence (hospitalization and careful monitoring may be necessary to establish this causal relationship).
  • A family history of similar or unexplained illness or death in a sibling.
  • A parent with symptoms similar to their child’s own medical problems or an illness history that itself is puzzling and unusual.
  • A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with serious illness.
  • A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment.
  • A parent who seems to have an insatiable need for adulation or who makes self-serving efforts at public acknowledgement of their abilities.

[edit] Prevalence by gender

It has been noted that MS applies mostly to men whereas FII perpetrators are disproportionately females. One study showed that in over 90% of cases of Munchausen by proxy, it is the mother who is the abuser (Vennemann et al., 2005). In other cases, the MSbP abuser is another female caregiver. Fathers have been the perpetrators in a handful of professional reports. The female preponderance may be attributed to the typical socialization pattern which encourages females to seek the sympathy and assistance of others while males who do so are considered to be "weak". It is not known whether this predilection to seek sympathy also has a gender-based genetic component. Neuropsychological testing of perpetrators has shown either normal results or nonspecific abnormalities.

MSbP may also be attributed to another prevalent socialization pattern, that which places females in the primary caretaking role.

[edit] Fabricated or Induced Illness / Munchausen Syndrome by Proxy in popular culture

Spoiler warning: Plot and/or ending details follow.
  • In the 1976 movie Sybil, Sybil's mother may have been suffering from Munchausen syndrome by proxy, abusing her daughter frequently. This, however, could also be a case of PTSD, or may also have been from suffering schizophrenia.
  • In 1992, the American Dialect Society voted Munchausen's syndrome by proxy one of its words of the year, in the "Most Amazing" category. [1]
  • The 1999 movie The Sixth Sense had the posthumous solving of a case of MSbP as one of its later subplots.
  • Also, Takashi Miike's 2003 One Missed Call, an arguably deconstructionist take on the recent wave of Japanese horror movies, has a MSbP case at the heart of its revenging ghost tale.
  • In the Eminem song "Cleanin' Out My Closet", the rapper names himself as a "victim of Munchausen syndrome," accusing his mother of using him for drug-seeking purposes when he was young.
  • In an episode of NBC's Law & Order: Special Victims Unit, a woman poisons her granddaughter with mercury to induce symptoms similar to those associated with leukemia and claims she has been suffering from MSbP.
  • In one of Douglas Preston and Lincoln Child's Pendergast novels, Dance of Death, a character is accused of suffering from an unusual form of MSbP—committing murders in order to garner attention solving them.
  • First airing October 11, 2005, an episode of FX's Nip/Tuck features a patient suffering with Munchausen syndrome. She cuts herself to mimic the injuries left by the show's infamous face-slasher The Carver (and later actually becomes one of his victims).
  • An episode of ABC-TV's Grey's Anatomy first airing October 16, 2005, features a patient diagnosed with Munchausen syndrome. She is betrayed taking Amitriptyline, an antidepressant that turned her urine blue.
  • An episode of ITV's The Brief first aired on October 21 2005, featured a defendant (a nurse) played by Jennifer Ellison who exhibited the classic symptoms of Munchausen syndrome by proxy.
  • An episode of The X-Files (The Calusari, 2X21) featured Agent Dana Scully suspecting Munchausen syndrome by proxy in unexplained events surrounding a young child and his family.
  • An episode of FOX's House, M.D. first aired on December 13, 2005, featured a patient played by Cynthia Nixon who admitted to Munchausen syndrome after being tricked into taking Rifampin, an antibiotic that turned her urine orange, but who was later additionally diagnosed with a bacterial infection.
  • An episode of NBC's Law & Order: Special Victims Unit (S07E15), first aired on Tuesday February 7, 2006, featured a woman, played by Rebecca DeMornay, who suffered from Munchausen syndrome.
  • An episode of NBC's Conviction (S01E03), first aired on Friday March 17, 2006, featured a young girl who committed suicide arguably in part because of her mother's Munchausen's Syndrome by Proxy (this is only an inference, as the word "Munchausen" is not used).
  • An episode of NBC's ER (TV series) first aired on Thusday February 3, 2000, included a subplot in which a mother insists that her son undergo numerous tests and exploratory surgeries, against the advice of the E.R. doctors. The word "Munchausen" is not used, and Munchausen's Syndrome by Proxy can only be inferred.
  • In Every Time I Die song Romeo A Go-go, "munchausen by proxy of a muse" comes up in the opening song of their third album "Hot Damn!", a song about a night in the intensive care unit.
  • In the episode of JAG "Silent Service", Harm and Mac investigate a series of health problems that occurred in a nuclear submarine which led to the accidental destruction of a ship. It turns out that they were all caused by a corpsman who suffered from Muchausen Syndrome by proxy.
  • In the Drawn Together episode "Unrestrainable Trainable", Princess Clara gets Munchausen by Proxy when she receives accolades for nursing Wooldoor Sockbat back to health, causing her to begin deliberately keeping him sick with drain cleaner and a variety of other methods. The bottle of drain cleaner she uses is shown with a warning label, "Caution: Not to be used for Munchausen's by proxy".
  • In an episode of the British series Doctors (TV series) first aired on Wednesday 15th November 2006, a woman is diagnosed with Munchausen's syndrome after repeatedly faking illness in the form of stomach pain. She cuts herself to put blood in her urine, and has surgical scars on her stomach from previous medical investigations. She then pretends to attempt suicide when in actual fact she only took four tablets.
  • In the 2006 movie The Night Listener Robin Williams stars as a late-night radio presenter who befriends a fourteen year old boy that listens to his show and who has written a book about the heinous abuse he suffered as a child. Purportedly based on a true story, the boy's identity is called into question and MSbP is mentioned is reference to the boy's guardian who is shown in the final scene to spin a new web of lies about the child.

[edit] See also

[edit] External links

[edit] Notes

  1. ^ Roberts, Yvonne. "What makes mothers kill?", The Observer, 2002-04-21. Retrieved on 2006-08-25.

[edit] References

  • Feldman M.D. 2004. Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York: Brunner-Routledge.
  • Fisher, Jill A. 2006. Playing Patient, Playing Doctor: Munchausen Syndrome, Clinical S/M, and Ruptures of Medical Power. Journal of Medical Humanities 27 (3): 135-149.
  • Fisher, Jill A. 2006. Investigating the Barons: Narrative & Nomenclature in Munchausen Syndrome. Perspectives in Biology and Medicine 49 (2): 250-262.
  • Vennemann B., Große Perdekamp M., Weinmann W., Faller-Marquardt M., Pollak S., and Brandis M. 2005. A case of Munchausen syndrome by proxy with subsequent suicide of the mother. Forensic Science International, In Press, Corrected Proof. Abstract available.
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