Munchausen by Proxy and Other Factitious Abuse

Practical and Forensic Investigative Techniques

Kathryn Artingstall

• Publisher: CRC Press
• Year: 2016
• ISBN:
  9781315352909
• Edition: 1
• Topic: Derecho
• Subtopic: Derecho penal

This book covers Munchausen and Munchausen by Proxy (MBP) though the terms have recently changed. The 2013 DSM-V—the update to the American Psychiatric Association's (APA) diagnostic and classification tool—has classified both Munchausen and MBP as "Factitious Systematic Abuse." While thought to have occurred primarily with children and their caregivers, recent research shows a more widespread problem: such medical abuse to spouses, the disabled, the elderly—even pets. Many involve repeat and long-term instances of hospital and medical fraud. This book covers the syndrome itself, interviewing and investigative aspects, victimology, as well indicators in the event of homicide and death.

Merging Understanding amid Worlds

1

The most incomprehensible thing about the world is that it is comprehensible.

Albert Einstein

History of Factitious Disorder by Proxy

Factitious disorder (FD) imposed upon another or factitious disorder by proxy (FDP) is not a newly established idea or recognition of behavior. Some of the earliest described situations associated with FDP date back to the eighteenth century when the German baron Von Munchausen (1720–1797) entertained friends and neighbors with stories, which over the years became more and more exaggerated and finally quite unbelievable.^[1]

When the baron, at the age of 74, married a 17-year-old girl, his wedding night was spent alone and it is said that his bride “danced with another.” Shortly thereafter, the baron’s wife gave birth to a son who was named Polle. It was whispered at that time “the life of the Munchausen child will likely be short.” The child died under suspicious circumstances before he reached his first birthday.^[2]

Unusual behavioral patterns among young men gained notoriety in the writings of Charcot, who in 1877 described adults who attempted to gain hospitalization and treatment for self-inflicted injuries or falsified medical documentation. The term “mania operative passive” was coined as a result of this recognized condition.^[3]

In 1951, Dr. Richard Asher described a similar pattern of abuse whereby people fabricated illness and traveled from doctor to doctor—inventing false stories or illness causation, which led to complex medical investigations and hospital procedures, including surgeries. Asher coined the term Munchausen syndrome and applied it to this behavior.^[4]

In 1977, Dr. Roy Meadow, a British pediatrician, described an extreme form of child abuse in which mothers deliberately induced or falsified reported illness in their children and referred to this behavior as Munchausen syndrome by proxy. Meadow described cases of children who were unnecessarily treated for numerous medical problems that were falsified by their mothers.^[5]

Dr. Donna Rosenberg bolstered awareness of Munchausen by Proxy (MBP) with the authoring of Web of Deceit in 1987. Dr. Rosenberg’s research included a review of 117 cases of MBP child abuse and provided intuitive foresight into the potential application of MBP within modern medicine.^[6]

During the 1990s, a crossover occurred from the medical profession into the criminal justice system for criminally investigated cases involving an FDP (then known as Munchausen [syndrome] by proxy) factor. The concept of FDP was virtually unknown within criminal justice circles although recognition and documentation of the behavior had been occurring regularly within the medical field up to that point. Confusion surrounded the concept of FDP, and it largely centered on the descriptor that FDP behavior was a syndrome accompanied with a perception of illness and inferred lack of accountability for a person’s actions. Spirited deliberation occurred as members of the criminal justice system sought criminal prosecution when FDP behavior crossed the threshold into specified willful victimization covertly executed through an unknowing third-party delivery system. Munchausen by Proxy (MBP) dropped the term “syndrome” from the official description of behavior. Initial criminal cases of child abuse and child homicide utilizing the mode of FDP provided understanding that FDP is a delivery system of inflicted harm but it is also a confusion factor for juries. FDP was utilized (ineffectively) as a defense within trial as defendants were portrayed as innocent due to their illness. Substantive charges of criminal victimization acts were muddied with the notion that purported mental illness seen within MPB absolved the defendant of accountability. Over time, the choice was to divest a criminal case of the primary inference upon the delivery system (FDP) of the criminal act and try a case based upon the identified crime. What this did was open the door to further use of FDP as a criminal defense, and prosecutors found that although they may have elected to not introduce FDP, they needed to counter prepare for FDP being raised as a criminal defense. Criminal cases involving an FDP factor were always media sensations, and this is accurate today.

Initially, the behavior of FDP was seen as a medical (only) diagnosis. Medical cases originating in England and specifically the publication and works of Roy Meadow and David Southall opened the door internationally by providing knowledge that FDP behavior may not be isolated or as rare as previously described.

The numbers of worldwide cases studied, identified and published, gave rise to allegations of false reporting. Some people cried, “witch hunt” and falsification or improper diagnostic labeling as physicians concluded FDP behavior when diagnostic means failed to discover identifiable causes of a person’s illness. At times, FDP was accurate but sometimes it was not. What a deplorable situation for medical staff—continue testing in search of the cause of a person’s illness within a normal medical investigatory realm or give weight to the suspicion of FDP as a causation factor and take necessary steps to prove this medically aligned causation theory? Acknowledgment of the possibility of FDP as a causation factor is also acknowledgment that the medical profession is an unwilling causation instrument of medical harm. Liability rests on both sides of this quandary but, more importantly, the life of the victim hangs in the balance. The behavior of FDP was likely a criminal act, and this understanding forged an investigative union between physicians, police, prosecutors, psychiatrists, and (child) protective professions. The interdisciplinary team was assembled.

Understanding and defining FDP on a psychological level was limited to the understanding contained within the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition and the specifics of FDP were sketchy. Dr. Marc Feldman began publishing on research pertaining to cases involving FD and FDP factors and embraced the connective element of the interdisciplinary team. Issues of both FD and FDP are psychologically complex. Defining behavior, associative treatment pathways, and acceptable professional standardization of how a behavior is viewed is difficult. The inference that rests within presently accepted understanding of FDP is that the behavior may be viewed as a criminal act, and it is referenced in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V).

As the world changed into the new millennium in 2000, knowledge, publication, and recognition of FDP as a factor in abuse cases continued to evolve. Policing agencies called to investigate child abuse with an FDP element worked the cases as straightforward abuse situations but were required to understand the delivery factor of FDP. The concept of abuse with an FDP factor was identified in greater detail within other vulnerable populations—specifically the elderly. The proxy element found within all FDP cases was recognized within other categories including pets.

Secondary victims to the FDP abuse methodology were recognized, often within financially related genres, and this understanding began to spin off litigation within a civil court realm. Secondary victims may include the following: hospitals, hospital systems, privatized and governmental medical insurance entities, and specified physicians. Secondary victimization perspective is gained by recognizing that FDP abuse methodology is often a chronic series of criminal covert abuse actions and a highly organized scheme to defraud.

The behavior of FDP—not the diagnosis—was recognized not only by interdisciplinary professionals but by the general public as well. All cases involving the FDP cases were and continue to be media sensations and the public takes note. People came forth and expressed concern that their relative(s) may be victims of FDP behavior at the hands of someone they knew; suddenly, what could never be explained seemed to make perfect sense! Cases involving use of the elderly for monetary gain (tangible gain) while also providing the caregiver with belonging, nurturing, and other intangible gain were described. If the elderly person died, was this murder? Were these alleged behaviors and FDP abuse process, malingering by proxy or other deviant pathways with a singular goal of inheritance? Were any of these actions criminal, and who could be tasked with such complex investigations?

Search for Understanding Behavior

In 2012, the U.S. Department of Health and Human Services documented 686,000 cases of child abuse and neglect. This was a rate of 9.2 per 1000 children. In 2012, 22 out of every 1000 children younger than 1 year were victims of abuse or neglect, and 2.2 per 100,000 were known to have died as a result of abuse or neglect. It is believed that many more deaths were unreported.^[7]

FDP was once considered vanishingly rare. Many experts now believe it is more common, with a reported annual incidence of 0.4/100,000 in children younger than 16 years, and 2/100,000 in children younger than 1 year. The perpetrator typically inflicts physical harm; although occasionally, she may simply lie about symptoms or tamper with laboratory samples.^[8] Early studies indicated that FDP is a behavior in which the offender is often the mother (94%–99%). The most common methods of inflicting harm are poisoning and suffocation and overall mortality is 6%–9%.^[9,10] FDP is considered a form of abuse.

It is estimated that every health official is likely to encounter at least one FDP child abuse case (fabricated illness) during their career.^[11] Physicians that are less than sure that FDP abuse is at the center of a patients’ illness are often reluctant to report their suspicions. The failure to consider the possibility of FDP in the differential diagnosis is the most common reason for failing to link FDP as the cause of a patients’ illness.^[12,13] Illness that is fabricated by a caregiver is an international problem and transcends cultural divides.^[14]

Mental Illness Defined

Mental illness is defined as any of various disorders characterized by impairment of an individual’s thoughts, emotions, or social functioning, including schizophrenia and mood disorders such as bipolar disorder.^[15]

There is general public presumption that people afflicted with mental illness during the commission of a crime lack the ability to control their actions. This generalized public understanding is amplified when crimes are egregious and offend the sensibility of people. It is often argued that persons thought to have mental illness may not be capable of differentiating between right and wrong behavior. People believed to have a mental illness are sometimes not prosecuted for their actions if a judge or jury believes that the mental illness either prevented the person from refraining from the criminal act or promoted the behavior.

A person who utilizes another as a proxy for purposes other than measurable (often monetary) gain, thereby invoking an FDP behavioral pattern, may be commonly viewed as mentally ill. This general premise becomes problematic in the overall criminal justice process of holding people accountable for their actions. It would be an error to assume that all who perpetuate FDP behavior are to be considered mentally ill just as it would be an error to assume the same for those perpetuating pedophilia, child abuse, child homicide, or other behaviors considered to be disorders.

Factitious Disorder

FD has historically been known as Munchausen syndrome. Current practice finds that the general descriptor of this behavior publicly attaches the label of Munchausen syndrome while the authoritative term used is FD. The clinical description of FD is found in the DSM-V^[16] and is listed as a recognized mental illness. FD is a self-imposed behavior that occurs when a person falsifies physical or psychological signs or symptoms or induces injury or disease by deception. The person presents themselves to others as if ill, impaired, or injured assuming the role of someone who is sick. The deceptive behavior isn’t dependent upon the presence of external rewards and cannot be explained by the presence of another mental disorder (such as delusional or psychotic disorder).

Diagnostic features of FD include the following:

• Falsification of medical or psychological signs and...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Series Editor
• Preface
• Acknowledgments
• Author
• 1 Merging Understanding amid Worlds
• 2 Offenders and Victims
• 3 Understanding Factitious Disorder and Factitious Disorder by Proxy
• 4 Assessing Potential Lethality of the FDP Abuse Offender
• 5 False Reports and Serial Victimization
• 6 Interviewing the Factitious Disorder/Factitious Disorder by Proxy Offender
• 7 Crime Scene and Evidentiary Procedures
• 8 The Multidisciplinary Approach to FDP Abuse/Homicide: Case Management
• 9 Factitious Disorder by Proxy (FDP) Abuse Victim Protection
• 10 Chronically Ill Child Caught in the Factitious Disorder by Proxy World
• 11 The Unseen Murder of Victims
• 12 Alternative Victimization
• 13 FDP Behavior as Defense Application
• 14 Significance of Fire in Factitious Disorder by Proxy and Factitious Disorder Cases
• 15 Criminality of FDP Abuse-Prosecutive Stance
• Epilogue
• Index