Psychosomatics 45:365-366, August 2004
© 2004 The Academy of Psychosomatic Medicine
Munchausen by Proxy and Malingering by Proxy
Marc D. Feldman, M.D., Birmingham, Ala.
Key Words: child abuse
TO THE EDITOR: The term "Munchausen by proxy" has long referred to a form of maltreatment in which an individual in loco parentis fabricates or produces illness (physical and/or emotional-behavioral) in another to assume the vicarious sick role.1 More recently, "malingering by proxy" has been used to refer to people whose motives for such abuse or neglect are external and often tangible.2 The following case displays both phenomena in a single person.
Case Report
Ms. A, a teacher's aide, expressed concerns about "statements" and "incidents" at home that were allegedly reported to her by a severely retarded female student. No worrisome verbalizations or events were ever detected by teachers, counselors, or others who had worked long-term with the student. Nevertheless, Ms. A individually met with teachers, a social worker, an assistant principal, a counselor, and a nurse, crying about feared abuse. Although the other personnel were unpersuaded, the aide reported suspected abuse to child protective services. The aide remained the central figure as police and child protective services thoroughly investigated the charges. The child and her family were subjected to property searches, interviews with specialists, and potential termination of parental rights. The charges were ultimately found to be totally untrue. Ms. A continued to speak of the case and her own unrequited effort to "save" the child. Once vindicated, the parents removed the child from the school.
The next year, Ms. A served as an aide to an autistic boy at the school. Now pregnant, Ms. A warned others that "nothing had better happen to this baby" as a result of the boy's behaviors. She also requested additional sick leave as a result of her prediction that the baby might be harmed in some way by the boy. For the next several weeks, she reported that the boy made inappropriate comments, touched her, and cursed her. Such behaviors had never been observed by anyone else. Soon thereafter, a co-worker heard a foot stomp on the floor and then heard the aide yelling at the boy. The aide reported that the boy had struck her in the abdomen. She filed a police report and met with and cried to the same personnel as before. Although there was never any indication of harm to the fetus, Ms. A remained at home, using others' accrued sick leave before starting to draw worker's compensation payments. The boy explained that the aide had poked him repeatedly whenever others were not around, verbally abused him, and told him that "your parents are going to pay for my doctor." Prior to these events, she had told other staff members that she wished to stay at home and had hoped to sue someone to help pay her medical bills from prior surgery.
Discussion
In the first instance, the aide engaged in Munchausen by proxy in an effort to garner attention and concern. She also basked transiently in the accolades of child protective services workers, who originally believed she had uncovered child abuse that others had missed. In the second situation, the aide engaged in malingering by proxy by attempting to incite an autistic student into violent behavior. Failing that, she staged an unconvincing punch that led to her being able to stay at home and still receive income—from workers' compensation and potentially from a hoped-for civil suit.
According to DSM-IV-TR, malingering and factitious disorder (called "Munchausen syndrome" in its extreme form) are mutually exclusive, the goal being external in the former and internal in the latter.3 However, my experience with numerous clinical and forensic cases has repeatedly shown that individuals can have multiple motivations for their medical or emotional-behavioral deceptions and that these diagnoses can co-exist. In a parallel way, the patient's Munchausen by proxy and malingering by proxy appear at least serial and possibly concurrent. The case provides further support for the concept of malingering by proxy and emphasizes the need for further attention to the possible co-existence of this behavior with Munchausen by proxy maltreatment.
REFERENCES
- Meadow R: Munchausen syndrome by proxy: the hinterland of child abuse. Lancet 1977; 8033:343–345
- Feldman MD: Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder. New York, Brunner-Routledge, 2004
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, APA, 2000, pp 513–517, 739–740
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