Munchausen by Proxy Syndrome

David Allison, Philosophy, SUNY Stony Brook

Introductory Considerations

Within the tradition of psychoanalytic and psychiatric case studies, one generally tends to locate personal agency within a single subject. Even Freud's most unusual and celebrated cases, such as "Rat Man," "Schreber," "Wolf Man," etc., all the while being understood within the broader context of familial relations, nonetheless remain the individual subjects of psychoanalytic interpretation. However, in the case we will subsequently examine, namely, that of "Christopher," one is confronted by an entirely new dynamics of agency, an agency shared by two distinctly different and removed subjects. This double agency is characteristic of a recently discovered and enigmatic psychiatric disorder, Munchausen by Proxy Syndrome (MBPS).

Although the disorder may not be immediately recognizable, more than two-hundred articles in a broad range of professional journals have recently witnessed its arrival. Briefly, the syndrome, like all syndromes, is characterized by a number of unusual signs and behavior patterns in the subject, but, with MBPS, it is particularly alleged that the common factor consists of an individual (usually, a mother) inducing or feigning either physical or psychological symptoms -- and sometimes, both -- in another individual (usually, her child). Typically, in the course of the MBPS dynamics, the mother is said to produce a range of distressing symptoms in the child, but always in view of obtaining subsequent medical attention for her child. The MBPS mother then enjoins the physician to perform unneeded and extensive examinations, as well as invasive procedures, upon the child, thereby involving the doctor and hospital staff as unwitting participants in her deceptions. According to the standard descriptions of this syndrome, the mother typically denies any accusations of deception or abuse directed at her child. Nonetheless, psychologists, psychiatrists, medical practitioners, and various other health care professionals, all are of a single voice in alerting the general public to the menace which this syndrome represents, in that it appears not only as a disorder in the mother herself, but -- at the same time -- it constitutes a major new form of child abuse. The warnings are indeed harsh, and strict measures have been taken by medical authorities to mobilize public opinion so as to contain the damage wrought by this syndrome and to prevent its spread. Two researchers, who have been perhaps the most outspoken advocates for the diagnosis and aggressive control of MBPS, Herbert A. Schreier and Judith A. Libow, write:

The illnesses that have been presented in MBPS cover a remarkable range of organ systems and physical complaints...[including] some 100 different factitious or induced symptoms for which children have been brought to the attention of physicians, including abdominal pain, apnea, bleeding, diabetes, diarrhea, eczema, fevers, infections, lethargy, rashes, renal failure, seizures, shock, tachycardia, vomiting, and weight loss. And the list is expanding all the time, as new cases are seen and described in medical journals. Unfortunately, since these "illnesses" are nonexistent or induced by other substances or manipulations, they generally fail to respond to the physician's usual treatments, or show an unusual and unexpected course of recurrence or intensification. The medical picture tends to get progressively more complicated by the addition of new medications and invasive interventions as the physicians search for ever-more powerful treatments for these persistent "illnesses."

But the dire warnings do not stop here. To insure that these professional medical judgments be heeded by the greatest range of those who are responsible for protecting children, the FBI took it upon itself to simplify and disseminate this specialized information to law enforcement personnel throughout the U. S. In the official publication of the FBI, FBI Law Enforcement Bulletin, we are told that

Today, the consensus is that MBPS is not rare, is notoriously resistant to parental psychotherapy, and carries a very grim prognosis. Approximately 10 percent of MBPS victims die. Unfortunately, more police agencies and medical professionals will be confronted with this form of abuse in the future. Hopefully, the information discussed here will alert law enforcement officers, especially those who deal with cases of abuse, to the warning signs of MBPS and will assist them in identifying the perpetrators and helping the victims.

So mobilized, this information was subsequently communicated to social service agencies, family courts, counseling centers, and educational and health offices throughout the U.S. and elsewhere. At the present time, there is a burgeoning popular literature on the syndrome, and several television "talk shows" have devoted time to its diagnosis, prognosis and its sufferers. The print media, in particular, have featured a number of stories on the syndrome itself, its effects on contemporary family life, as well as having covered some of the more spectacular court cases involving MBPS. In short, MBPS has arrived, both as a pathology and as a popular phenomenon.

Remarkably, Munchausen by Proxy Syndrome did not exist as such until l977, when a British pediatrician, Roy Meadow, published an article in The Lancet, bringing two brief case histories of the Syndrome to public attention. Twenty six years earlier, another British physician, Richard Asher, anecdotally -- with the fabulist, Baron von Munchausen in mind -- coined the term "Munchausen Syndrome" in order to describe the fanciful behavior of three other individuals, who would previously have been diagnosed as malingerers, hysterics, or hypochondriacs. The three subjects Asher discussed, repeatedly sought medical treatment for what he considered to be largely simulated and fabricated, i.e., nonexistent, illnesses. Thinking that such cases might prove to be costly and burdensome to administer -- until one could establish that the subjects were in fact not ill, and hence, didn't need medical treatment -- Asher deemed it important enough to bring these cases to the attention of hospital officials, if only to warn them that there were such subjects, and that they might be otherwise difficult to diagnose. In the end, Asher thought his effort to be a practical and helpful matter and that, almost as an afterthought, his notice might help facilitate "a cure of the psychological kink which produces the disease [i.e., Munchausen's syndrome]."

From 1951 to 1977 the original Munchausen syndrome aroused sporadic suspicion and attention among medical authorities -- much of which was centered around a series of published letters and brief papers responding to Asher's original article. In the handful of technical articles that appeared during this period on the subject, Munchausen's syndrome was treated as a more or less unspecified factitious disorder among others, and usually in relation to other types of common disorders, particularly, malingering, hypochondria, and hysteria. Once Meadow introduced the Munchausen syndrome by proxy, however, locating the new disorder in a nexus of transferences between parent and child, between patient and doctor, the by proxy syndrome seemed far more specific, and therefore far more accessible to analysis, understanding, and intervention. Given the immense increase in public awareness -- and of reporting -- of child abuse cases in the l980's and 1990's, as well as the dramatic rise of reported cases or illnesses resistant to standard diagnosis, such as Sudden Infant Death Syndrome (SIDS), Shaken Baby Syndrome, False Memory Syndrome, Chronic Fatigue Syndrome, various stress-related disorders, etc., MBPS became a focal point in the diagnosis of this type of disorder, largely because it offered itself as a model through which empirically difficult to ascertain cases could be explained. It provided a dynamic which could detail aberrant behavior, abuse, sexual perversion, molestation, etc., within multiple dyadic relations, especially those cases in which the subjects' own motives could not be clearly recognized or understood. It remained for the professional literature, medical clinicians, and psychiatric diagnosticians to codify the syndrome, to give it a defining set of signs and symptoms, and to assign sufficiently generalized etiologies to the disorder, such that it might emerge as a publicly recognizable phenomenon, and hence, that appropriate intervention would be of great utility in lessening the frequency of child abuse.

Despite the extensive literature and public concern that has arisen in response to adult Munchausen's and MBPS, we have argued at length elsewhere that these two syndromes are little more than "constructions" of institutionalized medical power. Our claim is that MBPS and adult Munchausen are not self-standing, verifiable, and specifiable disorders at all, but rather, they are brought into existence through a set of historically evolved discourses and operations which stem from particular medical institutions and individuals. As such, these discourses and operations tend to cohere over a period of time into a medical model, itself driven by a set of taxonomic classifications and an underlying set of perceived social threats and cultural biases. Once these classifications are refined, reified, set into the recursive domain of professional literature, supported by statistical data and by physician consensus, etc., the disorder becomes effectively "established." Or, as Jean Baudrillard has said, "it is the map that precedes the territory." The adult Munchausen and MBPS "maps," the broad set of taxonomic designations and signs, furthermore, serve as a means to provoke our recognition of its alleged subjects. In this sense, the Munchausen "map" signifies or denotes a readily identifiable group of so-called sufferers -- who, we should add, are by and large powerless to resist their own classification, and who have typically been traditional targets for the exercise of medical power and social control in any case: that is, women, the poor, "hateful patients," the homeless, drug abusers, the mentally ill, "derelicts," etc. It is in these respects, then, that MBPS, much like witchcraft and hysteria before it, is able to establish its legitimacy and its social urgency. If there are historical precedents, appropriate taxonomies, statistical quantifications, sufferers and victims, etc., then the disorder must be studied. And since it poses a real threat, it must be contained. But most importantly, and by the same imperative, it must exist.

It will be this unwarranted and extreme exercise of medical power and, thereby, its construction of "disordered" subjects that we find to be most egregious in "the case of Christopher," the central case study devoted to Schreier and Libow's ostensibly "definitive" analysis of MBPS, in their recent book, Hurting for Love: Munchausen by Proxy Syndrome. Simply stated, the imposition of this power, cast as a dyadic relation, on both subjects -- mother and child -- results in their strict objectification and complete dehumanization. The mother, "Edith," and the son, "Christopher," are merely treated as "instances" in an elaborate and formulaic scheme of taxonomic designations and etiological construction. The case history is central to Schreier and Libow's theoretical establishment of a general etiology for MBPS, but in the course of unfolding the case, the mother -- who supposedly was the subject of this complex psychiatric disorder -- becomes progressively transformed into the unidimensional figurehead of a criminal "perpetrator," and the child -- who would appear to be the subject of the mother's aberrant behavior -- becomes literally infantalized into a preverbal, neonate "victim." Remarkably, the psychological agency of the mother is first alleged to be distributed to the child in the form of an affectively invested "fetish" or "sacrifice," so as to induce the physician or care-giver to dispense his own affection and attention to the mother: hence, the title of their book, "Hurting for Love," which is a veritable catch-phrase for characterizing the etiology, the motivational dynamics, of the mother's disorder in the first place. So distributed to the child, the mother's agency virtually disappears as a matter of interest to Schreier and Libow. Who she is, how she experiences her world, what she thinks, how she lives and feels -- virtually her entire existential being -- simply is reduced to the service of confirming the authors' preexisting etiological model. The child, likewise, is now reconstructed -- not according to any usual familial relations of maternal or paternal devotion, love, position, respect, etc., but merely as a sacrificial cipher of seduction: abused, made ill, rendered helpless, or indeed killed, in hopes of drawing the attention of a "caring" and "well-educated" physician to the mother, who desperately hurts for love.

Reading the Case of Christopher

Chapter Five of Hurting for Love is devoted to the analysis of the core perversion: "The Perversion of Mothering." The case study that introduces the sections entitled "Mothering as a Masquerade" and "MBPS as a Perversion," concerns a young boy, "Christopher," who, we are told in the very first sentence, "died at the age of 4, after 25 hospital admissions and over 300 pediatric office visits." Surely, this is a dramatic opening -- the death of an MBPS child in the wake of such extensive medical attention -- to what promises to be the central case study of the crucial MBPS dynamics. Earlier, in the Preface to their volume, Schreier and Libow were careful to articulate their concern for the social and historical contexts of such studies, as well as the need for precision and detail in recounting the dynamics involved:

We are now much more aware of the dangers of taking such formulations out of their social and historical context. ....We hope, in our attention to the details of these dynamics as well as their social context, to provide the element often missing from clinical texts: that of leading the way toward an understanding that will then provide the means for prevention.

Such concerns are indispensable to the analysis of MBPS dynamics, especially in view of the authors' stated intention of making the volume "as encyclopedic as possible." Indeed, they go on to say that "We hope we have offered enough descriptive material to be practically useful and at the same time enable readers to arrive at their own hypotheses."

It is hard to imagine that the readers of Hurting for Love could arrive at anything but "their own hypotheses," if they take Schreier and Libow at their word: namely, that "The Case of Christopher" is "not particularly unusual" at all in this literature -- at least in its positive lack of detailing dynamics, its failure to provide an adequate social and historical context, and its utter paucity of descriptive detail. No wonder the authors had inserted a brief caveat the end of their Preface: "Clearly, our dynamic formulations are open to different interpretations."

The case of Christopher starts at the age of one month, and ends at the age of four, the mother having been indicted for his murder, but ultimately convicted of manslaughter. The mother ("Edith") first brought Christopher to the pediatrician's office, suffering from what she reported as "projectile vomiting, runny stools, and crying during bowel movements." Apparently convinced by these "reports" of the child's illness, his physicians fitted him with a nasogastric feeding tube, later replacing this with a percutaneous gastrostomy tube (surgically implanted). The early diagnosis was that of "a failure-to-thrive infant." The authors tell us that this initial set of procedures occurred somewhere "in the southeastern United States."

Young Christopher soon "was receiving as many as 14 medications for chronic infections, asthma, allergies, and feeding disorders." Presumably he was diagnosed by physicians as having these various illnesses and disorders, but Schreier and Libow seem to qualify this by going on to say "A purported 'immunoglobulin deficiency' turned out to be a delayed maturation of immunoglobulin synthesis." But what is the difference between a "purported" immunoglobulin deficiency, and the fact that Christopher wasn't sufficiently mature enough to synthesize it in the first place? With a lack of immunoglobulin, it is fully understandable that the child would be particularly susceptible to the illnesses mentioned. Which is doubtless why he was prescribed medication. The authors then relate how Edith claimed that the child had a high temperature at home, but that he often had a normal temperature in the doctor's office: "Frequently Christopher would show up with a history of l05-l07°F temperature the night before, but his temperature was found to be normal in the doctor's office." Did it occur to the authors that a fever "frequently" goes down in the course of a day? Or that the pediatrician was disinclined to make "well baby visits" at night to single-parent mothers who live in one-bedroom apartments and who sleep on couches -- parents who have to wait until office hours begin the following day? Aren't such parents frequently instructed to give the child two aspirins, and bring him to the office the next day? Is it further unusual that a child who is diagnosed as having "frequent infections" and immunological disorders might frequently have a high fever?

What is unfortunately typical in "one fairly typical case" is the typical lack of detail given about any one of these health concerns. It is assumed in the case history -- which is supposed to establish a diagnosis and etiology -- that the mother is already caught up in her MBPS behavior, that from the start she is practicing her deception on everyone: surgeons, doctors, pediatricians, consultants and therapists. What Schreier's role is as a consultant (it should be noted that Libow is added as a "consultant" only when Schreier's earlier article gets subsequently republished as a book chapter under both of their names) is neither stated in the article nor in the book. Was he brought in as "expert witness" only at the mother's trial? He has served in this capacity on several occasions, after all, and recently in the Ellen Storck case. Indeed both authors have enjoyed considerable professional celebrity recently, having been-- in their own words -- "interviewed for three news magazine television programs," as well as having been "approached repeatedly by network talk shows to see if we would agree to appear alongside a Munchausen by Proxy mother." But the nature of their consultation on the case of Christopher remains unstated. What does get voiced immediately is the typical suspicion directed towards the mother: the section's first sentence announces Christopher's death. His mother "reported" a series of symptoms, which in turn led to the surgical implant of Christopher's gastrostomy tube. The implication is that the symptoms were induced by the mother. The nasogastric feeding tube and the gastrostomy tube were resorted to "Despite normal workups at a major medical center that specialized in the treatment of children," as the authors relate it. Why should this be "despite normal workups"? The mother wasn't authorized to perform a diagnosis or surgery. We are given no information that she even so much as requested it. Was the surgery itself performed in this "major medical center that specialized in the treatment of children"? After all, the physicians' own diagnosis was "failure-to-thrive." This initial suspicion is maintained by the invocation of "as many as 14 medications," medications which were prescribed by physicians after all. Even though a "purported" immunoglobulin deficiency didn't register, the fact that Christopher couldn't himself synthesize immunoglobulin did. Why the use of "purported" if not to maintain suspicion about the whole case? The issue of disappearing fevers is likewise brought forth, as if to suggest that they were simulated: outside the pediatrician's office. The authors hardly blame the pediatrician for not responding "frequently" to Christopher's late night fevers by making a house call, or for failing to instruct the mother to take a cab to the hospital ER room, should the child once again have one of his l07°F fevers.

Schreier and Libow (or Schreier) go on to relate a series of disturbing and painful symptoms suffered by Christopher in the course of his brief four years: bruises ("secondary to a fall or running 'into a concrete wall'."), vomiting, low sugar levels (the mother, "though medically knowledgeable, was 'using the wrong scoop for his glucose'."), weight loss, diarrhea, dehydration, etc. Numerous steps were taken to correct his continuing problems, but, "despite all these efforts, Christopher continued to fail. But it came as 'a surprise and a shock' to Edith when he died, for he appeared to her to be doing so much better physically."

In the end, an autopsy revealed that Christopher had died of "chronic ipecac poisoning," and that "the poisoning had to have gone on for 2 to 3 years to have caused the deterioration in the heart muscle that was found at autopsy." What 25 hospitalizations -- at least some of them at a major medical center, somewhere in the southeastern United States -- and over 300 pediatric office visits failed to disclose, an autopsy did. Assuming that the ipecac poisoning was the cause of the deteriorated heart muscle (discounting a marathon four year period of intensive medical treatment, medication, and the attendant stress all this would impose upon an already sick infant), Edith was charged with murder, but this sentence was reduced to manslaughter "once the dynamics of MBPS were explained to the district attorney." Presumably, the diagnosis of MBPS was arrived at after Christopher's death, after all the hospitalizations, pediatric visits, and autopsy reports. While Schreier and Libow do mention the subject of a conference held at "the medical center," to discuss Christopher's case, where a child psychiatrist suggested the possibility that the child's disorder might be based on a "learned behavior pattern," Edith declined to have the child submit to an inpatient psychological examination. What her reasons were for this is left unstated by the authors-consultants. It would be consistent to surmise, certainly by this point in this typical case history, that, if she were aware of her own alleged MBPS disorder, she would hardly wish her imposture to be discovered.

Edith herself, we are told, was shocked by the child's death. She admitted to giving Christopher ipecac "only a few times in the last months of his life." Her reasons for administering ipecac to her child are, in this case, at least stated:

Edith later admitted that because Christopher begged for food and because he was denied so many other activities of a normal childhood, she felt that she should give him something enjoyable to eat, followed by ipecac to cause him to vomit.

About Edith herself, her own history, the circumstances of her life, her employment, her friends, the social context she occupied, etc., we are given precious few details. Many details must be inferred from what little information we are given. How old Edith was when she had the child is unstated. Likewise it is unstated if she were married at the time of Christopher's birth. As for her first marriage, which is, after all, a significant detail in the life of a mother, we are told absolutely nothing about it nor about her first husband. This is itself peculiar in a chapter entitled "The Perversion of Mothering," especially when Schreier and Libow end the chapter by stating their hopes of "attempting to understand the prerequisites of normal female development." Here is the summation of her formal education, her employment skills, the first husband, and the marriage:

Following a junior college education, Edith went to work in a hospital, where she met her first husband. After about 2 years the husband left her.

Edith's employment history is then related to us in likewise cursory detail: "she subsequently held a number of low-paying jobs..." Two years after the "breakup" of the marriage, she had herself admitted to a psychiatric hospital. Some time after this -- it is not specified -- she married again, to "a young man." By the time of Christopher's protracted medical visits, however, Edith's godmother (familiar with the family dynamics) recounted that they "lived in a one-bedroom apartment" and "the mother slept on the couch so that Christopher could have his own bedroom." With no mention of the husband sleeping anywhere, nor any detail about him at all, not even a name, one suspects that the second marriage also suffered what Schreier and Libow dismissingly term a "breakup."

Interestingly, a third "breakup" figures prominently in Edith's history, but Schreier and Libow fail to pursue this -- as if two divorces were already more than sufficient to account for the traditionally expected "absent father" component of the MBPS syndrome. This third "breakup" was that of Edith's own parents. The account is given in striking brevity in Hurting for Love. Edith, we are told,

came from an upper-middle-class family that lived in a suburb where her father held a responsible executive position. The marriage broke up when Edith was in elementary school.

The version given in Schreier's earlier Menninger Bulletin article differs in that Edith's age is given at the time of the divorce, the status of the father's occupation is somewhat differently related, but most importantly, an extremely significant mention is made concerning the father's philandering -- something which is simply omitted, dropped, in the later version:

Her father worked as an executive in a large corporation. He had reportedly had affairs before the marriage broke up when Edith was 7 or 8 years old.

Recall that young Christopher underwent 25 hospital admissions, 300 pediatric visits, that a conference was held on the case, that extensive court proceedings were held, that consultants and evaluators were brought in on the case, etc. The specific documentation alone must be archival in proportions! That Schreier and Libow, who claim to advance a socio-dynamic model of understanding the MBPS syndrome fail even to mention the possibly disastrous role of the father in this case, simply appears inconceivable. In the absence of communicating this information, much less raising it as an issue, the remark about Edith's own mother, just seven lines further on in the text, seems relatively innocuous: "Edith's claim that her mother was upset when she found out she was pregnant with Edith was confirmed by her mother." If this remark is taken in conjunction with a subsequent recollection, given on the very next page, one begins to see the possibility of an enormously precarious situation for the young Edith: "She said that she always felt that her mother had not loved her, and indicated that there were no physical expressions of affection in the family."

It is clear that Schreier and Libow haven't troubled themselves too deeply about the family dynamics of the case -- this central defining case of "the perversion of mothering." In fact, one is tempted to think that family history and social context are fully afterthoughts. The extent to which the authors have looked into the family at all -- much less its dynamics -- can be illustrated by comparing two brief passages. The Menninger Bulletin article begins the paragraph on "Edith's history" with the following sentence: "Edith was the fourth of five children in an upper-middle-class family." Hurting for Love has it otherwise: "Edith's history provides many clues to why she developed MBPS. Christopher's mother was the second of 4 children." So many clues that they drop any mention of the father's reported affairs, alter her relative position as a sibling in the family, and even proceed to change its size. If this is medical or psychiatric research, one might be seriously tempted to forego treatment altogether!

Edith's own medical history appears to be an afterthought as well. It fully occupies three and one-half lines of the text: "Edith's medical history included many visits to emergency rooms, claims of numerous miscarriages, a history of peptic ulcer disease, some dysfunctional uterine bleeding, hypothyroidism, and chronic laxative abuse." In the earlier Menninger Bulletin version, Schreier added mention of the former "psychiatric hospitalization," as well as specifying that "she claimed to have had 8-l0 miscarriages."

Even though we don't know Edith's age at the time of her ordeal with Christopher, nor anything at all about her two husbands or two marriages, nothing about her background, other than as a child she came from an ostensibly middle-class family (probably retaining this status until "her father's leaving"), located somewhere in a nameless suburb of the "southeast," void of any markers as to the family's general education, culture, race, ethnicity, income, religion, community standing, etc., one may only speculate -- since this is all one can do, given the astounding lack of information on the case -- as to "who" Edith might have been, and how she might have found herself in the situation she did.

Edith certainly seems to have been a single parent at the time of Christopher's illness. She equally seems to have fallen considerably from any "middle-class" status, having passed through a series of "low-paying jobs," and sleeping on the couch so her son could occupy the only bed. If her father's reported philandering preceded Edith's birth, or was concurrent with her mother's pregnancy, it is understandable that her mother might have felt rage towards the father, and in all probability, would have at least mixed feelings towards the child who was his offspring. She probably would have felt betrayed and misused, at the very least. That the mother displayed "no physical expressions of affection" towards Edith, indeed that Edith felt the mother didn't love her, would certainly be consistent with such a dynamics. Having left the family years earlier, the father remarried, and in Edith's words, was "obviously not interested in her."

Given such circumstances, it would be understandable that Edith would seek affection outside the family. With two marriages and 8-l0 miscarriages, this would itself be sufficient proof of her repeated attempts to achieve some form of emotional fulfillment, however tragic the results. The court evaluators, we are told, noted that Edith had "a fairly normal affective range in interviews." Certainly, the number of miscarriages might also have damaged her health, resulting in "some dysfunctional uterine bleeding," and "many visits to emergency rooms." Nonetheless, Schreier and Libow are completely silent as to how these medical disorders might have played into her history and may have served to alter the diagnosis. But, once again, the authors qualify her every move with initial suspicion: all these disorders are merely "claims," and no one seems to have thought of discussing these "claims" with her, or with the attending physicians at the emergency rooms she ostensibly visited. Perhaps even more telling is their failure to explain to us the role of her "claimed" hypothyroidism. Was she hypothyroid or not? If she were, this would lend some explanation as to why she may have had some degree of mental impairment, decreased tolerance for medication, anemia, menstrual disorders and, thereby, numerous miscarriages. This might also have a strong bearing on why she was a chronic substance abuser -- in this case, "chronic laxative abuse," since one of the most common symptoms of hypothyroidism is constipation. Typical of many hypothyroid patients is that they have serious problems with weight gain and loss. Obesity is common in this population, as is extreme thinness. Precisely such people tend to have serious eating disorders, with attendant feelings of guilt, inadequacy, perceived loss of self-control, poor self-image, depression, etc. The psychological burdens suffered by such individuals often result in compensatory eating binges, followed by induced vomiting and laxative use -- to assuage their own sense of guilt for having binged in the first place (in fact, Edith's explanation of why she gave young Christopher ipecac closely follows this rationale). Equally often, the feelings of personal inadequacy and emotional frustration they undergo, are sought to be compensated for by an increased frequency of sexual activity or, often enough, they result in a dramatically decreased sex drive, or indeed, and commonly so, by a range of ordinary human affective relations, such as friendship, and, even, maternity. It would not take a clinical pathologist to note that all these indications could be suggested -- and discussed -- simply by following up on Edith's "claims." Also, the fact that hypothyroidism is often caused by an autoimmune disorder, might well account for her own repeated visits to the hospital. Add the frustration of a childhood abandonment by the philandering father, a mother who is emotionally dead to the world, the accumulated stress of two divorces, poverty, and being a single parent with a chronically sick child, and a "peptic ulcer" disorder would hardly be out of line, either.

But the medical indications are simply sidestepped in Schreier and Libow's account. As were the mother's early "reports" about the child's illness greeted with outright suspicion. As are the social and historical contexts of the case. Why is this? Because the whole of Edith's behavior and alleged history is held to be an imposture. From beginning to end we are repeatedly told that she is a liar, a simulator, and a living imposture of motherhood itself. Her illness -- her disorder -- consists precisely in a "perversion of motherhood." Even though she "appeared" to be a good mother, this is itself part of the MBPS imposture -- an imposture, we are repeatedly told, that is so difficult for nonspecialists and for the judiciary to understand. Despite Edith's own mother's claim that "She was the happiest person alive with that child. She kept him spotless. Everyone loved him," despite her godmother's assurance that "She was a wonderful mother," despite the psychiatric hospital admissions note testifying to her kindness and generosity, despite the court evaluators' claim that there was no sign of psychosis and that she seemed to have a normal affective range, despite all these "claims," Edith's whole life is but a "masquerade" of mothering: "As the case of Edith suggests, the mothers involved in MBPS appear on the surface to be constant, caring and concerned attendants to the needs of their infants." But this is, after all, only apparent. The key to the MBPS mother's "grossly disturbed behavior" of "masquerading" as a mother is reasserted, once again, to be the child's physician: "We believe the key is to be found in the mother's intensely ambivalent fantasy relationship with her child's physician which in astounding ways defines the use of her own infant."

Edith's imposture is purportedly exposed through her frequent lying. After noting, in Hurting for Love, that Edith was a relatively "mediocre" student in comparison with her siblings, Schreier and Libow quote one of her sisters as saying that after the parents' marriage broke up, "she 'got away with a lot more' than the rest of the kids, and was always a 'poor-me' person once she learned that she could get what she wanted that way." This is doubtless meant to suggest that Edith was destined from youth to be deceitful. But if we recall that Edith's mother was upset when she realized she was pregnant with Edith -- in the context of the poor relations with the husband -- and that Edith, perhaps quite justifiably, felt unloved by the mother in turn, this quote from one of the sisters might be read somewhat differently. In fact Schreier himself reads it differently, just one year earlier, in the Menninger Bulletin version: there, he quotes the same sister as saying that "Edith 'got by with a lot more' than her brothers and sisters...." In the latter quote, the suggestion seems less that Edith is deceitful, but perhaps that she was able to profit from the mother's guilt over the earlier rejection of this unwanted child -- a form of schuldgelt , perhaps. But this is a minor affair compared to the two "lies" that Schreier and Libow next bring forth.

Following the "break up" of the first marriage, and the succession of low-paying jobs, Edith had

as she admitted, a problem with 'lying.' She checked herself into a psychiatric hospital 2 years after the breakup of her marriage; the immediate cause was her failure to fulfill a promise to some friends that she could get them a producer for a show.

The extent to which this is a plausible "cause" for psychiatric admission is testified only by the failure of Schreier and Libow to discuss it. Perhaps this is a commonplace cause of psychiatric admission in California. After a broken family, a ruined marriage and the dreary prospects of a lifetime of poverty ahead -- not to speak of her physical aliments -- is this really a case of "lying"? She may well have felt upset that she let some friends down. After all, how many producers are running around the "southeastern United States" who are willing to employ someone like Edith as an agent? Alternatively, she may well have met a producer -- or, even a "faux" producer -- who let her down in his promises to advance her career as an agent. Who can possibly tell? The authors don't even bother to try. In fact, as Schreier had phrased this damning episode in the earlier Menninger Bulletin, "she checked herself into a psychiatric hospital after she was unable to follow through on a promise to some friends that she could get them a producer for a television show." Being "unable to follow through on a promise to some friends" gets transformed, in the course of one year, to a "cause" for psychiatric admission! And this serves as evidence to indicate that compulsive "lying" will be part of the etiology of "mothering as a masquerade," the duplicitous "perversion" of MBPS.

The second "major lie" committed by Edith followed her release from the "psychiatric institution." How long after is unclear. Whether she was already a mother by then is typically unspecified.

She told a major lie to a young man whom she subsequently married. She told him that she had cancer ["leukemia," in the earlier version] and required chemotherapy, and admission that apparently hastened their marriage. She would occasionally leave the house, telling her husband that she was going out for kidney dialysis but actually spending 4 or 5 hours driving around aimlessly before returning home.

One is tempted to think that the authors, both of whom have extensive professional experience in the field, have on occasion met someone in desperate enough circumstances to have employed an element of "deception" to achieve a bit of stability in his or her life. Primary gain and secondary gain are not, after all, so terribly remote from the ordinary human experience. Confronted with hypothyroidism, chronic substance abuse, a series of miscarriages and uterine bleeding, poverty, no family, perhaps a child, a stint in a psychiatric hospital, and a broken marriage behind her, would it not seem to be perfectly normal behavior to employ a bit of deception in hope of finding a sympathetic husband? Perhaps one equally as needy? Perhaps a lonely someone who is also "hurting for love"? After the marriage, one could always "claim" to have been misdiagnosed earlier. And what cost is there, really, to anyone, for taking a nice summer's drive for a couple of hours?

Earlier, in the context of discussing her psychiatric admission, Schreier and Libow claimed that Edith admitted to having a problem with "lying" (as quoted above). But it was not clear, at that point in their account, exactly when Edith said this or to whom she said it. In the penultimate paragraph of their "Case of Christopher," they specify this charge:

With one of her psychological examiners, Edith talked about her lying problem and noted that she had "fabricated a life for herself to such a degree that she began to believe her fabrications." Personality testing suggested dynamics of angry feelings, overt and covert, related to a sense of being hurt or unfairly treated.

Well, if this confession of her persistent lying is meant to be conclusive, it at least concludes the case study. The final brief paragraph, which we have already quoted, relates how once the dynamics of MBPS were carefully explained to the court, and especially, to the district attorney, the state felt compelled to reduce the charge from murder to manslaughter. Subsequently, the court would be better informed as to the perplexing character of MBPS, and the mothers who suffer from MBPS would doubtless be better understood and more compassionately treated.

There is yet one more striking difference, however small, between the text composed by Schreier in l992 for the Menninger Clinic Bulletin, and the text jointly composed by Schreier and Libow in l993. The year-earlier passage corresponds to the penultimate paragraph of the Christopher case study, in Hurting for Love. There, the account of Edith's "lying problem" is brought full circle: to her own confession of having "fabricated a life for herself to such a degree that she began to believe her fabrications." The only problem is that Edith doesn't say this at all in the earlier version. Such confessional testimony would be an elegant segueway into the following section of "Mothering as a Masquerade," and would lend some degree of credence to their already palpably implausible account. The year-earlier version reads as follows (emphasis added):

Edith talked about her lying problem to one of her psychological examiners, who noted that she had "fabricated a life for herself to such a degree that she began to believe her fabrications."

Hence, the confession to the "lying problem," the veritable descent into a world of fabrication, is one fully advanced by the "psychological examiner," not by Edith. This -- if the earlier "claim" is to be believed -- is subsequently, and in turn, fabricated into a confession, precisely by the very medical authorities who claim deception to be the core of the MBPS disorder. Given the series of preposterous assertions in their analysis, the lack of any confirmation, the typical absence of any medical or psychological acuity in their analysis of this typical case, it is hardly surprising that Meadow, in his Foreword to Hurting for Love, once again raises the real question: "What is the correct diagnosis: Munchausen by Proxy syndrome abuse or medical negligence?" Indeed, he continues, "It will be some time before there is reliable information about prognosis." It is likewise hardly surprising that, in the end, Edith "suggested dynamics of angry feelings...related to a sense of being hurt or unfairly treated."