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.     

Examiner Errors on the WAIS-R: A Source of Concern

Munchausen syndrome (MS) is characterized by patients' chronic and relentless pursuit of medical treatment for combinations of symptoms of consciously self-inflicted injury and falsely reported symptomatology. MS patients are adults, as are perpetrators of Munchausen syndrome by proxy (MSBP). MSBP is an unusual form of child abuse in which a parent, usually the mother, brings a child for medical attention with symptoms falsified or directly induced by the mother. Most reports of MSBP have been of a few cases appearing in medical and pediatric literature. Motivation in both disorders is unclear, and diagnosis and treatment present difficult problems that require more research.     

Munchausen syndrome by proxy: Clinical review and legal issues

Well-established policies and procedures govern the identification, management, and treatment of most variations of child abuse. For many therapists, such cases have become “routine”. Munchausen syndrome by proxy is an under-recognized form of child abuse in which a parent feigns or creates illness in a child specifically to have the child subjected to unnecessary diagnostic tests and treatments by medical practitioners. Variations range from false reports of fevers or allergies, to life-threatening abuse, such as surreptitious poisonings or injections with toxic substances. This article reports a case example of Munchausen syndrome by proxy, provides a review of historical, diagnostic and management issues, and discusses legal issues relevant to detection of the perpetrator and protection of the child victim.     

'More in sickness than in health': a case study of Munchausen by Proxy in the elderly

The case of a 69-year-old male with features of Munchausen's Syndrome by Proxy is described. The identified patient was referred to 25 different medical teams, over a four-year period, through the insistence of his 55-year-old female companion, an ex-nurse. Significant factors relating to the diagnosis of patients with Munchausen by Proxy are discussed, and comparisons made between the syndrome as originally described in children and those features presenting later in life. Munchausen by Proxy involving the elderly, may also involve abuse. The authors wish to draw attention to some of the systemic issues involved in such a process, and discuss possible interventions. Attention is also drawn to the difficulties in management of this particular case, and the possible widespread prevalence of less florid and therefore, unrecognized cases in the elderly.     

Personality and sexually deviant behavior

The present research expands on the relationship between subclinical paraphilia and Big Five and Dark Triad personality traits in an online sample of 585 adults. In this sample, sexually deviant courtship behaviors such as exhibitionism and voyeurism were related to high levels of narcissism while transvestism related to greater openness to experience. Further, there were gender differences in the relationship between sadomasochism and personality with sadomasochism reflecting greater openness in men and Machiavellianism in women. These findings suggest that deviant sexual behaviors represent both a degree of antisocial personality functioning and a degree of personal openness that depends on the specific behavior being examined and that more research is needed in this area.     

Rethinking Sadomasochism: Feminism,Interpretation, and Simulation

In reexamining the “sex war” debates between radical feminists and lesbian feminist sadomasochists, I find that the actual practice of sadomasochism provides the basis for a philosophically more complex position than has been articulated. In response to the anti-SM radical perspective, I develop a distinction between simulation and replication of patriarchal dominant/submissive activities. In light of this important epistemological and ethical distinction, I claim that the radical feminist opposition to SM needs reassessment.     

German dominatrices’ choices of working names as reflections of self-constructed social identity

Professional dominatrices tend to practice under pseudonyms. On the assumption that generalizable patterns in their pseudonym choices may reflect the self-constructed identity and emphases of professional domination and submission, this paper undertakes a detailed linguistic analysis of the working names chosen by 141 dominatrices based in Germany. The most typical form of name chosen involves a title and a personal first name without an accompanying surname (e.g. Lady Barbara), suggesting an ambiguous position on the continuum between distance and intimacy. Foreign-language titles (e.g. Lady) are also found to be preferred to German-language ones (e.g. Herrin), pointing to the role of language symbolism in creating a sense of sophistication and internationalism. The most preferred title choices also largely avoid direct references to power. In terms of name choice, although direct references to aspects of sadomasochism are not unrepresented, the predominant choices seem to identify a group of women who construct themselves as cultured, educated, classy, and feminine. Elements of mysticism and mythology are also present, which seem to support psychoanalytic—and especially Kleinian—theories of fetishism and sadomasochism. Further research should aim at replicating the analysis with dominatrices based in countries other than Germany.     

A Constellation of Stigmas: Intersectional Stigma Management and the Professional Dominatrix

In this article, we explore stigma management among dominatrices, a relatively understudied profession within the literature on sex work. Our analysis is based on in-depth interviews with current and former dominatrices and published memoirs and blogs written by women who have worked in the industry. We argue that the professional dominatrix occupies a unique position within the sex industry, responding to stigma directed toward her both as a sex worker and practitioner of sadomasochism. Our research has implications for understanding the management of intersecting stigmas and the relationship between stigma management and social ideologies of gender, sexuality, and sex work.     

Reply to Commentary

This commentary is a response to questions and discussion points raised by Peter Fonagy and Mary Target in “Playing with the Reality of Analytic Love.” It includes a discussion of the relationship between attachment and sexuality, in addition to issues concerning seductiveness, sadomasochism and therapeutic change.     

A collaborative family-systemic approach to treating chronic illness: irritable bowel syndrome as exemplar

This article describes an evolving collaborative relationship between a family therapist and a physician focused on the treatment of irritable bowel syndrome, a highly prevalent disorder which has several psychological characteristics. We began with a unique approach utilizing (1) simultaneous treatment by both specialists; (2) a focus on the relationship context of illness. This approach draws on family systemic theory and practice as well as a circular model of mind and body interaction. Because the intervention was significantly helpful to patients, the premises which informed it were then incorporated into a five session group treatment model. Results and clinical report support the efficacy of a collaborative systemic approach between a medical specialist and family psychologist in treating adult chronic illness.     

Why should medicine consider a theory of practice? Introduction to the issue

In reference to historical developments, this article introduces the topic of this special issue of Theoretical Medicine and Bioethics, that is, the relationship(s) between theory and practice. The authors emphasize the need for scientific research in this neglected area for the sake of both clinical practice and medical education.     

Playing with Fire: Countertransference and Clinical Epistemology

This article explores both theoretical and practical concepts related to the therapist's use of the self in psychotherapy. Particular emphasis is placed on the potential clinical value of countertransference. It is argued that awareness and resolution of personal issues are required for therapists to draw profitably from their own experiences in working with clients. Specific steps in translating the concept of the wounded healer into clinical practice are offered, along with examples from the author's own practice.     

Sadomasochism as Make‐Believe

In “Rethinking Sadomasochism,” Patrick Hopkins challenges the “radical” feminist claim that sadomasochism is incompatible with feminism. He does so by appeal to the notion of “simulation.” I argue that Hopkins's conclusions are generally right, but they cannot be inferred from his “simulation” argument. I replace Hopkins's “simulation” with Kendall Walton's more sophisticated theory of “make‐believe.” I use this theory to better argue that privately conducted sadomasochism is compatible with feminism.     

Newborn screening for fragile X syndrome

Newborn screening for fragile X syndrome (FXS) is technically possible, and in the relatively near future accurate and inexpensive screening technologies are likely to be available. When that happens, will America's public health system adopt newborn screening for fragile X syndrome? This article addresses this issue by first placing screening for FXS in the context of the history and current status of newborn screening policy and practice. Lack of a proven medical treatment may stand as a barrier to newborn screening, but strong arguments can be made that early intervention provides important services for identified newborns and their families. Furthermore, other arguments could be used to justify newborn screening, including informed reproductive risk, medically necessary information, and consumer demand. Fragile X syndrome is offered as a prototype for many of the issues that will face society as more genetic disorders are discovered and new technologies for screening are developed.     

Pain, aggression, fantasy, and concepts of sadomasochism

Traumatized infants and children may exhibit syndromes of aggressive, pain-seeking, and self-destructive behavior resembling the so-called sadomasochism seen in adults. Three hypotheses are offered to account for the repetition of sadomasochistic phenomena in childhood and later character disorders: 1) pain and painful affects are sources of aggression; 2) the need to control aggression plays an important role in the development of psychic structure; 3) child abuse and trauma impair the ability to use fantasy for the mastery of impulses. Difficulty in expression and control of aggression are central issues in character disorders.     

Medicine: business or profession?

As professionals, doctors have a contractual relationship with society that trains them and confers on them exclusive power to practice medical care. In the contract, power and responsibility should be balanced. When the power is conferred by society to a profession, the profession should take responsibility for society, including the provision of high quality services, and maintain high standard principled conduct and integrity.     

Innovative Practice,Clinical Research,and the Ethical Advancement of Medicine

Innovative practice occurs when a clinician provides something new, untested, or nonstandard to a patient in the course of clinical care, rather than as part of a research study. Commentators have noted that patients engaged in innovative practice are at significant risk of suffering harm, exploitation, or autonomy violations. By creating a pathway for harmful or nonbeneficial interventions to spread within medical practice without being subjected to rigorous scientific evaluation, innovative practice poses similar risks to the wider community of patients and society as a whole. Given these concerns, how should we control and oversee innovative practice, and in particular, how should we coordinate innovative practice and clinical research? In this article, I argue that an ethical approach overseeing innovative practice must encourage the early transition to rigorous clinical research without delaying or deferring the development of beneficial innovations or violating the autonomy rights of clinicians and their patients.     

Social ethics,the philosophy of medicine,and professional responsibility

The social ethics of medicine is the study and ethical analysis of social structures which impact on the provision of health care by physicians. There are many such social structures. Not all these structures are responsive to the influence of physicians as health professionals. But some social structures which impact on health care are prompted by or supported by important preconceptions of medical practice. In this article, three such elements of the philosophy of medicine are examined in terms of the negative impact on health care of the social structures to which they contribute. The responsibilities of the medical profession and of individual physicians to work to change these social structures are then examined in the light of a theory of profession.