Issues in the identification and long-term management of Munchausen by Proxy Syndrome within a clinical infant service

Munchausen by Proxy Syndrome is a version of Munchausen's Syndrome whereby a parent, usually the mother, simulates or fabricates disease in one or more of her children in order to seek medical attention. Because this disorder is usually identified in pediatric settings, current literature focuses on identification of the syndrome, with little discussion of treatment issues or management strategies other than confrontation of the parent and removal of the child from the home. With the increased availability of infant mental health services, infant clinicians are likely to be called on to evaluate and treat cases of this disorder. This paper reviews the Munchausen by Proxy literature for infant clinicians and describes the identification and long-term management of one Munchausen by Proxy case within the context of an infant home-visiting service. Pertinent issues that emerged included the difficulties inherent in documenting the mother's pathological behavior, the clinical tension between preventing flight from treatment but limiting harmful behavior, the need for a long-term collaborative relationship with a designated pediatrician, and the importance of further education of protective service workers about this syndrome.     

'In sickness and in health': the development of alternative discourses in work with families with parental illness

This paper outlines the development of clinical understanding and a clinical model for working with families with parental physical illness. The lens of gender to explore clinical process reveals blind spots and can uncover alternative perspectives on parental illness. The authors look at the very different needs of children and parents for coherent explanations. The impact of this way of working on therapists and the importance of reflecting teams, as part of the process of working collaboratively with families, are addressed.     

Collective Contexts in Conversation: Grounding by Proxy

Anecdotal evidence suggests that participants in conversation can sometimes act as a coalition. This implies a level of conversational organization in which groups of individuals form a coherent unit. This paper investigates the implications of this phenomenon for psycholinguistic and semantic models of shared context in dialog. We present a corpus study of multiparty dialog which shows that, in certain circumstances, people with different levels of overt involvement in a conversation, that is, one responding and one not, can nonetheless access the same shared context. We argue that contemporary models of shared context need to be adapted to capture this situation. To address this, we propose “grounding by proxy,” in which one person can respond on behalf of another, as a simple mechanism by which shared context can accumulate for a coalition as a whole. We explore this hypothesis experimentally by investigating how people in a task‐oriented coalition respond when their shared context appears to be weakened. The results provide evidence that, by default, coalition members act on each other's behalf, and when this fails they work to compensate. We conclude that this points to the need for a new concept of collective grounding acts and a corresponding concept of collective contexts in psycholinguistic and semantic models of dialog.     

Relaxation therapy for tension headache in the elderly: a prospective study

We evaluated the effects of an 8-week progressive muscle-relaxation therapy regimen on the headache activity of 10 elderly tension-headache subjects. Posttreatment assessment at 3 months revealed significant decreases in overall headache activity (50% or greater) in 7 subjects. Significant clinical or statistical prepost differences, or both, were also found for the number of headache-free days, peak headache activity, and medication index. This is the first prospective study of tension headache in an elderly population, and, unlike previous retrospective studies, it suggests that relaxation therapy may be an effective intervention in the treatment of such headaches.     

Anxiety and depression in cataract surgery: a pilot study in the elderly

To assess anxiety induced by a planned cataract surgery and to evaluate the correlations of rated anxiety and depression with optical acuity pre- and post-operatively, 278 patients ages 65 years or older were tested. Patients were divided into two groups: first-eye and second-eye cataract surgery. Anxiety and depression were evaluated using the Hamilton's Rating Scales for Anxiety and Depression, respectively. Pre-operatively, first-eye patients showed significantly higher anxiety than second-eye patients (F1,251 = 75.39, p < .001). First-eye patients rated peak anxiety on the day of the surgery, while patients scheduled for second-eye cataract surgery presented no fluctuations in rated anxiety (F1,251 = 49.60, p < .001). There was no correlation of preoperative anxiety or depression with the outcome of surgery (F(1,251)s = .83 and .58, respectively, p > .05). Postoperatively, anxiety and depression in patients without any improvement in their vision were rated significantly higher than in those presenting improved visual acuity after surgery (F1,251 = 566.17 and 300.25, respectively, p < .001).     

Gender detransition: a case study

Within the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.     

Incapable sex: a case study

Although it is well known that intimacy and sexual expression are an important part of being human and of healthy living, facilities such as nursing homes, adult group homes, or assisted living residences commonly struggle with knowing how to balance supporting residents who are incapable to have sexual lives with their duty to protect them from foreseeable harm. This article presents a challenging case and uses the British Columbia Supporting Sexual Health and Intimacy in Care Facility Guidelines to determine what should be done.     

Dysprosody in Broca's aphasia: a case study

A detailed acoustic analysis of timing, intensity, and fundamental frequency (F0) at different levels of linguistic structure was conducted on the speech output of a Broca's aphasic who was a native speaker of Thai. Timing was measured with respect to syllables, phrases, and sentences in connected speech. Intensity variation at the sentence level was measured in connected speech. F0 variation associated with the five Thai tones was measured in both isolated words and connected speech. Results indicated that timing was differentially impaired depending upon complexity of articulatory gesture and size of the linguistic structure. Timing, as well as intensity, was aberrant at the sentence level. In contrast, F0 contours of the five tones were spared at all levels of linguistic structure. Findings are interpreted to support the view that dysprosody in Broca's aphasia is more applicable to speech timing than to F0.     

Chaplaincy research: a case study

The authors report the pragmatic elements of conducting an empirical chaplaincy research project. The article offers the step-by-step process of implementing, coordinating, and completing a sound quantitative research project. The authors offer a definitive answer to the question, "Can a staff chaplain integrate providing pastoral care and doing a quantitative research project as principle investigator"?     

Helping adolescents in crisis: a case study

Suicide among adolescents is a major mental health problem in the United States. The most recent data on adolescent suicide indicate that approximately 5,170 of those between the ages of 15 and 20 took their lives. Several researchers asserted that in most cases something could have been done to prevent the actual suicide. The author developed five stages (suicidal signs, establishing rapport, making referral, constructive actions, and self-management) that may be used to help adolescents in distress. The five stages were used in a case study to demonstrate the roles played by teacher, friend, and parents in helping an adolescent through a crisis.     

Reduction of sadistic sexual arousal by olfactory aversion: a case study

A sexual sadist was treated by an olfactory aversion procedure for eight weeks. Pre-treatment assessment of sexual arousal showed high levels of response to sadistic stimuli as well as high arousal to non-sadistic heterosexual stimuli. In treatment the inhalation of the gas of an odoriferous chemical agent, valeric acid, was paired with slide presentations of sadistic materials while penile erection was monitored. The aversive stimulus immediately and permanently suppressed the response for the duration of treatment. In separate measurement sessions, with valeric acid absent, deviant response remained suppressed and nondeviant response was unaffected. Post-treatment reassessment revealed very low levels of response to sadistic stimuli. Follow-up sessions showed that the deviant response was absent eight months following the conclusion of treatment.     

Cross-cultural issues in infanticide: a case study

This article examines the case of a Mexican American woman who was found not guilty by reason of insanity for infanticide, the murder of her young son. A detailed case history is presented with a focus on cultural issues as they affect this woman's family dynamics, assimilation and acculturation, emotionality, spirituality, and seeking of mental health treatment. In addition, a theoretical conceptualization is presented, identifying the psychodynamic operations that laid the foundation for the crime, including the normal process of identity development and the mitigating factors of gender, culture, and psychopathology. The study explores the important influences of culture in the commission of this crime as well as in subsequent treatment, highlighting the changes in society and mental health treatment that need to be made to reduce the incidence of such family violence.