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FACTITIOUS DISORDER BY PROXY
LETTERS TO THE EDITOR
had a 20% (1 2 [2.5/3.1]) reduction in symptoms compared with what would have been expected in the absence of treatment. Those with more than 21 sessions had a 42% (1 2 [1.8/3.1]) reduction in their symptom counts compared with untreated expectations. The mean raw (i.e., unadjusted) pretreatment symptom count of these 2 groups combined was 9.1, while the mean raw posttreatment symptom count was 5.2. Our total symptom count is also probably a conservative measure because it takes no account of possible reductions in the frequency or intensity of symptoms that were still suprathreshold at follow-up. We entirely agree that it would have been helpful to have information about the forms of therapy used. We did not, but would the study “be useful only if we knew which treatment(s) helped” as Dr. Gotlib suggests? Earlier studies concluded that outpatient “treatment as usual” had no measurable effect. Our work contradicts this negative conclusion and provides a potential explanation for earlier failures to find treatment effects (not taking pretreatment trajectories into account). As a child and adolescent psychiatrist, I find this heartening, and our findings may be helpful to those whose task it is to persuade legislators and insurers that there is need for (and value in) services for psychiatrically disturbed children. Adrian Angold, M.R.C.Psych. Center for Developmental Epidemiology Duke University Medical Center Durham, NC Angold A, Costello EJ (2000), The Child and Adolescent Psychiatric Assessment (CAPA). J Am Acad Child Adolesc Psychiatry 39:39–48 Angold A, Costello EJ, Burns BJ, Erkanli A, Farmer EMZ (2000), Effectiveness of nonresidential specialty mental health services for children and adolescents in the “real world.” J Am Acad Child Adolesc Psychiatry 39:154–160 Angold A, Hay DF (1993), Precursors and causes in development and psychopathology: an afterword. In: Precursors and Causes in Development and Psychopathology, Hay DF, Angold A, eds. Chichester, England: Wiley, pp 293–312
FACTITIOUS DISORDER BY PROXY To the Editor: Schreier (2000) notes a case of factitious disorder by proxy in which a mother, to obtain special consideration at school for her children’s hypersensitivities, “allergies,” and learning disabilities, had her house sprayed with DDT while the children were present. Given that DDT has been banned in the United States since 1972, plus the fact that school accommodations for chemical sensitivity and/or learning disability were virtually nonexistent that long ago, this report is startlingly implausible. Factitious disorder by proxy is the DSM-IV code for a condition more widely known as Munchausen by proxy syn4
drome (MBPS). Accusations of MBPS are often brought against mothers whose children have atypical patterns of symptoms and whose assertive demands for help have become annoying to clinical staff. That is, charges may be based on clinician countertransference rather than evidence (Allison and Roberts, 1998). I am personally familiar with four cases in which this was so. Vaguely described or implausible cases, especially when contributed by a noted expert on the topic (Schreier and Libow, 1993), add to the air of authoritarian vengeance surrounding many accusations of MBPS. Frank Albrecht, Ph.D. Caroline County Health Department The Regional Clinic at Talbot Easton, MD Allison DB, Roberts MS (1998), Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome. Hillsdale, NJ: Analytic Press Schreier HA (2000), Factitious disorder by proxy in which the presenting problem is behavioral or psychiatric. J Am Acad Child Adolesc Psychiatry 39:668–670 Schreier HA, Libow JA (1993), Hurting for Love: Munchausen by Proxy Syndrome. New York: Guilford
Dr. Schreier replies: The case referred to by Dr. Albrecht occurred during the 1990s. It involved two children, aged 9 and 7, said to have chronic fatigue syndrome, chemical sensitivity, and other unexplained medical illnesses. Although the children always looked healthy in school, the school administration gave in to the mother’s demands for special air filters, careful instructions on walking routes around school to avoid exposure to various “toxins” (e.g., carpets), and special class placements. The mother herself exposed the children to pesticides when she had their new home treated as they were moving in. She also installed new carpets. Despite this, the children continued to appear well in school. I have pointed out in both articles on psychiatric presentations of MBPS that the diagnosis of psychiatric illness falsification is more difficult to make than that of medical falsification, due to the very nature of the presentations of psychiatric illness in children and the effect they may have on their parents: e.g., symptoms are often not present consistently, and a parent of an ill child may appear disturbed as a result of the child’s illness. Furthermore, even seriously disturbed children may be able to be withdrawn from psychotropic medication in the structured setting of a hospital. Those of us working with this difficult disorder strongly warn against misdiagnosing MBPS, distinguishing it “from cases involving overly-anxious . . . . [or] noncompliant parents of chronically ill children who may appear ‘difficult’ and . . . those with children with bona fide problems who attempt to [get] benefits from . . . resistant medical, social or educational systems” (Schreier, 1997, p. 108).
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 1 , J A N UA RY 2 0 0 1
LETTERS TO THE EDITOR
It is difficult in a letter of this length to respond to Allison and Roberts’ (1998) charges of an “air of vengeance” or even “witch hunt” purportedly surrounding MBPS cases. Based on my first-hand knowledge of several of the cases discussed in their book (all of whom were convicted in courts of law), the authors’ highly selective quoting of the case facts, vituperative tone, and the ad hominem attacks they engage in elsewhere, I do not think that the views of these two philosophy professors should be taken as an objective assessment of the state of MBPS diagnostic practice. For example, they present the case of a woman honored at the Reagan White House for her work with fragile babies. Allison and Roberts say that “if Mrs. Eldridge was guilty of anything, it was of being susceptible to the abstract and fabricated MBPS template imposed on her by her accusers” (p. 275). Yet a judge in a foster care license hearing concluded that she had killed and gravely harmed children in her care. The state attorney general took the case because the local district attorney refused to charge her, and Mrs. Eldridge was found guilty of abusing the two children for whom charges were levied. Far from being convicted because she conformed to some “profile” or “fabricated template imposed upon her” (p. 275), it should be noted that MBPS was never even mentioned at her trial! Although one of these children had some nine life-threatening infections of her surgically implanted feeding tube (when two would be rare), lost 90% of her colon as a result of symptoms reported by Mrs. Eldridge, was not thriving or talking at age 5, and was reported to suffer from multiple seizures, Allison and Roberts’ presentation of the case fails to mention that this child became healthy simply by removal from the care of Mrs. Eldridge. They repeatedly leave out such crucial case data when it suits their argument. Our book (Schreier and Libow, 1993) includes a list of characteristics that were meant to “raise suspicions” (p. 202) of the possibility of illness falsification that then need further investigation by a physician “to verify or reject [that] diagnosis” (p. 203). We maintain that “separation tests” (such as occurred in the Eldridge case), or other means of demonstrating that a parent is falsifying medical conditions, should be the standard for diagnosis and criminal prosecution of abuse. The parent’s motivations for causing abuse through such falsification then needs to be assessed to determine whether a diagnosis of MBPS should be entertained. The MBPS diagnosis, if appropriate, is essential to make because of the high rate of reabuse by this group of parents, either upon reunification with their children or even during supervised visits. There are certainly many issues yet to be understood about this fascinating and disturbing disorder. However, it is disappointing to find a colleague, supposedly familiar with the problems of MBPS, citing a speciously argued polemic and questioning the motives and ethics of many of us who have
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 1 , J A N U A RY 2 0 0 1
labored in the field. The psychopathology of MBPS involving, as it does, incredible abilities to manipulate professionals makes it extremely difficult to balance the needs of seriously at-risk children, and the rights and needs of parents who may be suffering from such severe psychological disturbance. Herbert A. Schreier, M.D. Department of Psychiatry Children’s Hospital Oakland, CA Allison DB, Roberts MS (1998), Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome. Hillsdale, NJ: Analytic Press Schreier HA (1997), Factitious presentation of psychiatric disorder: when is it Munchausen by proxy? Child Psychol Psychiatry Rev 2:108–115 Schreier HA, Libow JA (1993), Hurting for Love: Munchausen by Proxy Syndrome. New York: Guilford
PAXIL AND SELF-SCRATCHING To the Editor: The following possible side effect of Paxilt (paroxetine) should, I believe, be brought to the attention of child and adolescent psychiatrists: A 16-year-old boy with a history of depression and an atypical eating disorder was being treated with Paxil 10 mg daily. His depression had remitted, but his obsessional eating patterns, although somewhat improved, had persisted. Therefore, the Paxil was increased first to 15 mg daily and then 2 weeks later to 20 mg daily. Three days later, at his psychotherapy session, he reported that he felt happier than usual, but not like himself. His affect was very mildly hypomanic. In addition, he reported that two nights earlier, while sitting and reading, he had begun scratching his leg with a tack. He had proceeded to scratch an intricate design into his entire right limb; he stated that he liked the design. Paxil was discontinued. Four days later his mood returned to normal; he reported that he had last scratched himself the night after the medication was stopped. Because his mood was mildly depressed, 2 months later the Paxil was reinstituted at a lower dose; the patient’s mood improved and there were no side effects. I have discussed this with a number of psychiatrists, including psychopharmacologists and a specialist in adolescent eating disorders. Most had never heard of such a phenomenon. However, one psychopharmacologist noted that he had seen the phenomenon of self-scratching (which appeared to me to be a rather atypical form of self-mutilation) secondary to Paxil in a number of individuals. Alex Weintrob, M.D. Clinical Associate Professor of Psychiatry Cornell University Medical College, New York 5
had a 20% (1 2 [2.5/3.1]) reduction in symptoms compared with what would have been expected in the absence of treatment. Those with more than 21 sessions had a 42% (1 2 [1.8/3.1]) reduction in their symptom counts compared with untreated expectations. The mean raw (i.e., unadjusted) pretreatment symptom count of these 2 groups combined was 9.1, while the mean raw posttreatment symptom count was 5.2. Our total symptom count is also probably a conservative measure because it takes no account of possible reductions in the frequency or intensity of symptoms that were still suprathreshold at follow-up. We entirely agree that it would have been helpful to have information about the forms of therapy used. We did not, but would the study “be useful only if we knew which treatment(s) helped” as Dr. Gotlib suggests? Earlier studies concluded that outpatient “treatment as usual” had no measurable effect. Our work contradicts this negative conclusion and provides a potential explanation for earlier failures to find treatment effects (not taking pretreatment trajectories into account). As a child and adolescent psychiatrist, I find this heartening, and our findings may be helpful to those whose task it is to persuade legislators and insurers that there is need for (and value in) services for psychiatrically disturbed children. Adrian Angold, M.R.C.Psych. Center for Developmental Epidemiology Duke University Medical Center Durham, NC Angold A, Costello EJ (2000), The Child and Adolescent Psychiatric Assessment (CAPA). J Am Acad Child Adolesc Psychiatry 39:39–48 Angold A, Costello EJ, Burns BJ, Erkanli A, Farmer EMZ (2000), Effectiveness of nonresidential specialty mental health services for children and adolescents in the “real world.” J Am Acad Child Adolesc Psychiatry 39:154–160 Angold A, Hay DF (1993), Precursors and causes in development and psychopathology: an afterword. In: Precursors and Causes in Development and Psychopathology, Hay DF, Angold A, eds. Chichester, England: Wiley, pp 293–312
FACTITIOUS DISORDER BY PROXY To the Editor: Schreier (2000) notes a case of factitious disorder by proxy in which a mother, to obtain special consideration at school for her children’s hypersensitivities, “allergies,” and learning disabilities, had her house sprayed with DDT while the children were present. Given that DDT has been banned in the United States since 1972, plus the fact that school accommodations for chemical sensitivity and/or learning disability were virtually nonexistent that long ago, this report is startlingly implausible. Factitious disorder by proxy is the DSM-IV code for a condition more widely known as Munchausen by proxy syn4
drome (MBPS). Accusations of MBPS are often brought against mothers whose children have atypical patterns of symptoms and whose assertive demands for help have become annoying to clinical staff. That is, charges may be based on clinician countertransference rather than evidence (Allison and Roberts, 1998). I am personally familiar with four cases in which this was so. Vaguely described or implausible cases, especially when contributed by a noted expert on the topic (Schreier and Libow, 1993), add to the air of authoritarian vengeance surrounding many accusations of MBPS. Frank Albrecht, Ph.D. Caroline County Health Department The Regional Clinic at Talbot Easton, MD Allison DB, Roberts MS (1998), Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome. Hillsdale, NJ: Analytic Press Schreier HA (2000), Factitious disorder by proxy in which the presenting problem is behavioral or psychiatric. J Am Acad Child Adolesc Psychiatry 39:668–670 Schreier HA, Libow JA (1993), Hurting for Love: Munchausen by Proxy Syndrome. New York: Guilford
Dr. Schreier replies: The case referred to by Dr. Albrecht occurred during the 1990s. It involved two children, aged 9 and 7, said to have chronic fatigue syndrome, chemical sensitivity, and other unexplained medical illnesses. Although the children always looked healthy in school, the school administration gave in to the mother’s demands for special air filters, careful instructions on walking routes around school to avoid exposure to various “toxins” (e.g., carpets), and special class placements. The mother herself exposed the children to pesticides when she had their new home treated as they were moving in. She also installed new carpets. Despite this, the children continued to appear well in school. I have pointed out in both articles on psychiatric presentations of MBPS that the diagnosis of psychiatric illness falsification is more difficult to make than that of medical falsification, due to the very nature of the presentations of psychiatric illness in children and the effect they may have on their parents: e.g., symptoms are often not present consistently, and a parent of an ill child may appear disturbed as a result of the child’s illness. Furthermore, even seriously disturbed children may be able to be withdrawn from psychotropic medication in the structured setting of a hospital. Those of us working with this difficult disorder strongly warn against misdiagnosing MBPS, distinguishing it “from cases involving overly-anxious . . . . [or] noncompliant parents of chronically ill children who may appear ‘difficult’ and . . . those with children with bona fide problems who attempt to [get] benefits from . . . resistant medical, social or educational systems” (Schreier, 1997, p. 108).
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 1 , J A N UA RY 2 0 0 1
LETTERS TO THE EDITOR
It is difficult in a letter of this length to respond to Allison and Roberts’ (1998) charges of an “air of vengeance” or even “witch hunt” purportedly surrounding MBPS cases. Based on my first-hand knowledge of several of the cases discussed in their book (all of whom were convicted in courts of law), the authors’ highly selective quoting of the case facts, vituperative tone, and the ad hominem attacks they engage in elsewhere, I do not think that the views of these two philosophy professors should be taken as an objective assessment of the state of MBPS diagnostic practice. For example, they present the case of a woman honored at the Reagan White House for her work with fragile babies. Allison and Roberts say that “if Mrs. Eldridge was guilty of anything, it was of being susceptible to the abstract and fabricated MBPS template imposed on her by her accusers” (p. 275). Yet a judge in a foster care license hearing concluded that she had killed and gravely harmed children in her care. The state attorney general took the case because the local district attorney refused to charge her, and Mrs. Eldridge was found guilty of abusing the two children for whom charges were levied. Far from being convicted because she conformed to some “profile” or “fabricated template imposed upon her” (p. 275), it should be noted that MBPS was never even mentioned at her trial! Although one of these children had some nine life-threatening infections of her surgically implanted feeding tube (when two would be rare), lost 90% of her colon as a result of symptoms reported by Mrs. Eldridge, was not thriving or talking at age 5, and was reported to suffer from multiple seizures, Allison and Roberts’ presentation of the case fails to mention that this child became healthy simply by removal from the care of Mrs. Eldridge. They repeatedly leave out such crucial case data when it suits their argument. Our book (Schreier and Libow, 1993) includes a list of characteristics that were meant to “raise suspicions” (p. 202) of the possibility of illness falsification that then need further investigation by a physician “to verify or reject [that] diagnosis” (p. 203). We maintain that “separation tests” (such as occurred in the Eldridge case), or other means of demonstrating that a parent is falsifying medical conditions, should be the standard for diagnosis and criminal prosecution of abuse. The parent’s motivations for causing abuse through such falsification then needs to be assessed to determine whether a diagnosis of MBPS should be entertained. The MBPS diagnosis, if appropriate, is essential to make because of the high rate of reabuse by this group of parents, either upon reunification with their children or even during supervised visits. There are certainly many issues yet to be understood about this fascinating and disturbing disorder. However, it is disappointing to find a colleague, supposedly familiar with the problems of MBPS, citing a speciously argued polemic and questioning the motives and ethics of many of us who have
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 1 , J A N U A RY 2 0 0 1
labored in the field. The psychopathology of MBPS involving, as it does, incredible abilities to manipulate professionals makes it extremely difficult to balance the needs of seriously at-risk children, and the rights and needs of parents who may be suffering from such severe psychological disturbance. Herbert A. Schreier, M.D. Department of Psychiatry Children’s Hospital Oakland, CA Allison DB, Roberts MS (1998), Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome. Hillsdale, NJ: Analytic Press Schreier HA (1997), Factitious presentation of psychiatric disorder: when is it Munchausen by proxy? Child Psychol Psychiatry Rev 2:108–115 Schreier HA, Libow JA (1993), Hurting for Love: Munchausen by Proxy Syndrome. New York: Guilford
PAXIL AND SELF-SCRATCHING To the Editor: The following possible side effect of Paxilt (paroxetine) should, I believe, be brought to the attention of child and adolescent psychiatrists: A 16-year-old boy with a history of depression and an atypical eating disorder was being treated with Paxil 10 mg daily. His depression had remitted, but his obsessional eating patterns, although somewhat improved, had persisted. Therefore, the Paxil was increased first to 15 mg daily and then 2 weeks later to 20 mg daily. Three days later, at his psychotherapy session, he reported that he felt happier than usual, but not like himself. His affect was very mildly hypomanic. In addition, he reported that two nights earlier, while sitting and reading, he had begun scratching his leg with a tack. He had proceeded to scratch an intricate design into his entire right limb; he stated that he liked the design. Paxil was discontinued. Four days later his mood returned to normal; he reported that he had last scratched himself the night after the medication was stopped. Because his mood was mildly depressed, 2 months later the Paxil was reinstituted at a lower dose; the patient’s mood improved and there were no side effects. I have discussed this with a number of psychiatrists, including psychopharmacologists and a specialist in adolescent eating disorders. Most had never heard of such a phenomenon. However, one psychopharmacologist noted that he had seen the phenomenon of self-scratching (which appeared to me to be a rather atypical form of self-mutilation) secondary to Paxil in a number of individuals. Alex Weintrob, M.D. Clinical Associate Professor of Psychiatry Cornell University Medical College, New York 5