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Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome By D. Allison & M. Roberts. London: Analytic Press. 1998. 297 pp. £31.95 (hb). ISBN 0-88163-2910-1

Published online by Cambridge University Press:  02 January 2018

Christopher Cordess*
Affiliation:
Rampton Hospital and Professor of Forensic Psychiatry, School of Health and Related Research, Section of Forensic Psychiatry, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA
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Abstract

Type
Book Reviews
Copyright
Copyright © 2000 The Royal College of Psychiatrists 

“The principal theme guiding this book”, write the authors in their introduction, “is that adult Munchausen's syndrome and Munchausen by Proxy Syndrome (MBPS)… are not self-standing, verifiable, and specifiable disorders at all… (but) rather are brought into existence through a set of historically evolved discourses… (and)… are to be understood as diagnostic ‘constructions’ and ‘fabrications’ that reflect and embody institutionalised medical power”.

I have become involved increasingly over recent years in the complex clinical and medico-legal ramifications and consequences of MBPS behaviour, and over this period I have become increasingly concerned. What is its nosological standing? Does it deserve ‘syndrome’ status? How is it that such frequently unbelievable and shocking behaviours appear to cohere so regularly and predictably?

In their wide-ranging and informed critique the authors discuss in their own words “a number of central problems that arise from the language and logic of the MBPS disorder; the problem of definition and recursivity (what has been called ‘enumerative inductivism’) in arriving at a classification; the formal understanding of what constitutes a syndrome or disorder; the logic of medical articulation, and questions of observation, validity and verification”. There is considerable intellectual enjoyment to be had from the first half of the book, which is an historical and contextual overview and deconstruction. As the authors emphasise, with the extension of ‘Munchausen's syndrome’ to its ‘proxy’ form there undoubtedly occurred a dramatic and problematic expansion of interested parties, players and institutions. The traditional dyadic relations of power between physician and - in this specialised area - the Munchausen's patient became extended with MBPS to include public concerns of child abuse, the whole social services apparatus, law enforcement agencies and the judicial system - “operating in concert with, and largely validated by, medical psychiatry - with an aim to isolate, ‘treat’ and remediate MBPS patients”.

There is much overlap with the work of Showalter (Reference Showalter1998), specifically her accounts of individual hysterias and hysterical epidemics which she calls ‘hystories’. The authors join common cause in their different ways in disputing the premature announcements of the death of hysteria; arguing instead that it has merely changed its forms, and that MBPS is one of its contemporary manifestations. Roy Porter's (Reference Porter1993) claim that the 19th century and the fin de siècle was hysteria's golden age, because of the ‘enhanced moral presence of the doctor’, may now be seen as only partly true; the ‘moral presence’ of the doctor increases, it can be maintained, as we enter a new millennium. The authors trace the ‘historically antecedent disorders’ of witchcraft as well as hysteria to a modern manifestation in MBPS. Their point is that all three ‘disorders’ focus upon “their bearers, hosts and purveyors: women. The disorders are held to threaten a fundamental (presumed) social stability brought on by a dramatic eruption of what will be held to be evil or madness”. It occurred to me as I read that the potential demonisation inherent in the current proposals for marginalisation and incarceration of an estimated 2000 ‘dangerous people (mostly men) with severe personality disorder’ in Britain, irrespective of whether they have actually offended against the law, might be seen to share many similarities with this socio-cultural analysis.

I was less impressed as the book progressed, partly because the authors are not clinicians, but rather philosophers teaching in the fields of the history of philosophy, psychoanalysis, aesthetics and cultural criticism. They are clinically naïve. They move rapidly from a review of the (undoubted) ‘biases entrenched in observer-generated approaches to human subjects’, through a passable criticism of Asher's (Reference Asher1951) original ‘Munchausen’ paper, a curiously mild critique of Meadow's (Reference Meadow1977) original description and later extensive work on MBPS, to an attempted hatchet job of the later psychological literature beginning with Rosenberg's (Reference Rosenberg1987) influential paper ‘Web of Deceit’. They reserve their real fire power for a prolonged assault on the psychodynamic formulations of MBPS in what has become the classic text on the subject by Schreier & Libow (Reference Schreier and Libow1993). This occupies most of the second half of the book. As a clinician I found myself disagreeing with so much of this diatribe that I began to suspect that a powerful critique had given way to a personal grievance, and that the clinical baby was increasingly being thrown out with the excited hyperbole. But then as a clinician I would say that, and that is part of the problem.

As well as being important in its own right about a relatively circumscribed subject, this book also comes at an especially significant and opportune time in what seems to be the rapidly increasing politicisation of psychiatry in Britain. In this sense it is representative of a general state of affairs beyond its relatively narrow subject matter. For example, the authors make the point that “in critically reading the works within the (factitious disorders) tradition, one realises that the actual subject of the texts is not so much medicine, medical science, diagnosis, or treatment of factitious disorder per se, but rather an entire set of narratives and techniques for alternately treating, managing, exposing, preventing, punishing and suppressing a whole series of ‘simulative’ and ‘transgressive’ acts and conditions”. This statement does indeed have especial resonance for this writer at a time when politicians, on behalf of society, seem to see no disadvantages in propelling state-employed doctors more and more into the role of law enforcers, and when psychiatrists - and especially forensic psychiatrists - are increasingly expected to act as ‘social hygienists’ and guardians of ‘appropriate’ public behaviour.

It is not often that one has the opportunity to read such a well researched and argued polemic directed against many of one's own clinical assumptions. I, therefore, strongly recommend this volume as a serious contribution to the emerging literature.

Footnotes

EDITED BY SIDNEY CROWN and ALAN LEE

References

Asher, R. (1951) Munchausen's syndrome. Lancet, i, 339341.Google Scholar
Meadow, R. (1977) Munchausen syndrome by proxy: The hinterland of child abuse. Lancet, ii, 343345.Google Scholar
Porter, R. (1993) Body and mind. In Hysteria Beyond Freud (eds S. Gilman, H. King, R. Porter, et al). Princeton, CA: University Press of California.Google Scholar
Rosenberg, D. A. (1987) Web of deceit: A literature review of Munchausen syndrome by proxy. Child Abuse and Neglect, 11, 547563.Google Scholar
Schreier, H. & Libow, J. (1993) Hurting for Love: Munchausen by Proxy Syndrome. New York: Guilford Press.Google Scholar
Showalter, E. (1998) Hystories. Hysterical Epidemics and Modern Culture. London: Picador.Google Scholar
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