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PAXIL AND SELF-SCRATCHING
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
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