Abstract
Fascinating, infuriating or just plain boring? I guess it depends on your point of view. The authors are academic philosophers at the State University of New York at Stony Brook and both profess an interest in psychoanalysis yet neither appears to have any clinical experience of any kind. Thus what ensues is an academic treatise on diagnosis in psychiatry, particularly as it relates to Munchausen syndrome and Munchausen by proxy syndrome.
Part one provides a scholarly review of ‘The socialmedical construction of disorders’ with separate chapters on witchcraft, hysteria and Munchausen by proxy (MBPS), drawing interesting analogies between them. The authors' perspective is illustrated by the following, in relation to MBPS (p.68): A physician says a person is sick because the nosological data specify that he is sick, even without the patient's knowing it. In other words, the text of the DSM-III, which was constructed by and for physicians to legitimate their authority to determine the course, treatment and very existence of illnesses, is the main determinant of those illnesses.
This argument has a familiar ring to those who lived through the antipsychiatry movement of the 1970s. Nevertheless it does provide a cautionary note about the reification of diagnoses and their changing nature over time.
In part two they focus more explicitly on ‘The historicaltextual construction of Munchausen and MBPS’ tracing it from the original description of Munchausen syndrome by Asher in 1951, through its adaptation to paediatrics by Meadow in 1977 to the more recent enthusiasm for the diagnosis of MBPS in the United States as expounded by Schreier and Libow in 1993. The last has led to a number of notorious cases before various courts in the USA.
The main purpose of the book finally becomes clear in part three, ‘The construction completed’, namely, a stinging critique of Hurting for love: Munc hausen by proxy syndrome, Schreier and Libow [1].
The authors' lack of clinical experience means that they undervalue the heuristic value of MBPS and the attention it has brought to a number of children who present with disorders that remain difficult to diagnose. In the case of MBPS, at least part of the problem arises because health professionals often have difficulty countenancing the notion that a parent (usually mother in this instance) could knowingly hurt her child and that an important motivating factor is her wish to remain involved in the system of health care, unnecessarily where her child is concerned. One hazard of the current enthusiasm for MBPS is that its use may confound serious cases of child abuse simply because they present with a ‘medical’ condition rather than more obvious injuries. Whether the DSM-IV preference for the diagnosis of factitious disorder (by proxy) represents an advance remains to be seen.
For those with a superficial or passing interest in this controversial topic the book offers little. For the clinician attempting to manage children and families presenting with possible MBPS the book offers almost nothing apart from raising some important questions about this and other diagnostic entities. However, for those who are regularly asked to provide an opinion about possible instances of MBPS, in the clinical context or the medicolegal, it is a timely reminder of the need to be cautious about accepting fashionable explanatory models uncritically, not least because one may find oneself facing hostile cross-examination if one is overinclusive in the use of diagnoses such as MBPS.