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3. The DSM-IV (1994) [Fourth Essay]
As if to throw more uncertainty into an already confused situation, the DSM-IV in 1994 included its first description of MSBP, which it called “Factitious Disorder By Proxy.” (37) The DSM-IV-TR (“text revision”) of 2000 copied the 1994 treatment word-for-word, and its pagination will be reflected in what follows. What should be clear at the outset, however, is that FDBP was not adopted as a new category of mental disorder in the DSM-IV but was noted along with other Factitious Disorders and then described in Appendix B, where conditions deserving further research before inclusion in the official DSM list were placed. It is sort of like an 11 year-old who placed third in his/her state spelling bee and attending but not participating in the National Spelling Bee in Washington DC, because only the top two from the state could qualify for the National Bee, and hoping for future inclusion in subsequent years.
(37) The Diagnostic and Statistical Manual of Mental Disorders already had an entry for "Factitious Disorders" (i.e., Munchausen Syndrome) in its 3rd edition (1980), but the 1994 edition was the first where FDBP was noted. The exotic-sounding name "Munchausen" was dropped so that syndromes would be named in a descriptive rather than appellative way.
Factitious illnesses are presented in 300.16-.19. They are characterized by “physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role.” (38) Sec. 300.19 is entitled “Factitious Disorder Not Otherwise Specified.” The note in the text of the DSM says that this category includes those who don’t meet the criteria for Factitious Disorder. “An example is factitious disorder by proxy: the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care for the purpose of indirectly assuming the sick role.” A further discussion of this “wanna-be” syndrome is, as mentioned, in Appendix B.
(38) DSM-IV-TRS (2000), p. 513.
(39) Ibid., p. 517.
The Appendix B description of FDBP, beginning on page 781, is consistent with many of the list of symptoms given by the court in the Jessica Z case, described above. I need not go into all the language. One example will show how familiar we all are with the general description by now: “The essential feature is the deliberate production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care.” (40) The mother’s medical knowledge, efficient and cooperative care, anger when confronted, etc. are then confidently related. At the end of the description, the DSM-IV appendix gives us four “Research criteria for factitious disorder by proxy.”
(40) Ibid., p. 781.
“A. Intentional production or feigning of physical of psychological signs or symptoms in another person who is the individual’s care.
B. The motivation of the perpetrator’s behavior is to assume the sick role by proxy.
C. External incentives for the behavior (such as economic gain) are absent.
D. The behavior is not better accounted for by another mental disorder.” (41)
(41) Ibid., p. 783.
While there is some similarity between this and Rosenberg’s four 1987 criteria, there are significant differences. First, there is no mention here of repeated seeking of medical advice or “doctor shopping.” Second, there is no mention of mother’s reaction when confronted. Indeed, since Rosenberg’s data contradict her third point, perhaps the DSM folk felt that they should quietly drop any reference to that subject. Third, the DSM definition stresses what might be called the “mental state” of the perpetrator. The perpetrator does this so she (usually the mother) can “assume the sick role.” That is, the DSM suggests that the psychological motivation is attention-getting. This criterion throws a sort of monkey wrench into the definition because it suggests that in order to have FDBP (equivalent to the earlier MSBP) one needs to divine the mother’s motivation until you discover that her motivation is to shift the focus from the child to herself. Fourth, the DSM specifically emphasizes that no monetary incentives are present. Here we see the need of the DSM-makers to make a “consistent” manual. That is, they want to distinguish this possibly-new syndrome called FDBP from another recognized disorder, Malingering—where a person feigns or induces illness in order to secure monetary gain (social security disability or unemployment benefits, for example). So, we see a “systematizing” desire in the DSM definition, which is absent in Rosenberg’s definition.
As noted, however, the primary difference between the two definitions lies in the emphasis on perpetrator intent. Perhaps it is understandable for a psychological manual to emphasize intent, since it, like law, is interested not simply in manifestations but also in motivations. Yet the potential inclusion of FDBP in the DSM-IV has another potentially ominous sign especially for those who would like some clarity in the MSBP/FDBP mess. By placing it in the Appendix, the mental health profession was taking the tentative, but fairly firm, step of saying that the diagnosis of this “syndrome” or “disorder” rested with them. If that is the case, it is something that is diagnosed after examination and not before, by a mental health professional, who is interested not simply in manifestations but also in intent.
The result of the DSM-IV’s inclusion of FDBP as a potential mental disorder in 1994 is not the same as throwing a match on dry tinder; it is more like speaking Middle English to an interlocutor who is asking you questions about your life. The interlocutor would think, after a while, that unnecessary confusion is being brought into a situation that ought to be able to be handled much easier. Thus, the presence of the DSM-IV definition added to the confusion. Whereas some confusions are, in poet Wallace Stevens’s felicitous phrase, “blessed rage for order,” many are simply a result of terminological, definitional, and empirical confusion. The latter is certainly the case for MSBP/FDBP.
4. A Reaffirmation--1994
When rampant confusion, inconsistency, and unjust application of a suspected disorder exist, the most urgent desideratum is for someone to enter into the situation, declare a sort of truce and then try to sort out some of the confusions listed so far in this paper. In words of the Book of Job, it would have been nice for a “mediator” of sorts to “lay his hands on us both” (i.e., Job and God, the antagonists in this drama) and bring reason to the discussion. (42) Or, alternatively, it would have been nice had someone decided to stop honoring an MSBP diagnosis until these issues had cleared up. Even the United States Supreme Court, which isn’t in this day known to be too sympathetic to criminal defendants, decided in 2007 to put all executions in America on hold for several months until it could bring clarity to the topic of the constitutionality of lethal injection as a form of capital punishment. (43)
(42) Job 9:33-37
(43) Resolved in the Baze case in April 2008. The executions have now started up again.
Instead of pursuing what one might call a “rational” course, the literature continued to cry for prosecution of MSBP perpetrators and continued vigilance to smoke out examples of it. Typical of this wave of reaffirmation even while significant questions remained unresolved is a 1994 law review article. (44) Though not ultimately significant in the MSBP/FDBP debate, this article serves to indicate that law was fully oblivious to the “early-warning” signs I have laid out so far. Naivete is coupled with advocacy in such a blatant fashion that one can only conclude that the rather thick film of ideology has occluded vision. The article claimed that incidents of child abuse continue at an “alarming rate.” “Suspected cases” of child abuse have to be reported. Although some commentators argue that overzealous reporting may result in exaggerated statistics, “reports are generally made out of genuine concern for the welfare and safety of the child.” (45) And, now that we have MSBP we can “broaden” the scope of child abuse. Cases that “normally” would be “weeded out” in the course of overzealous reporters may, in fact, “become an exclusive subcategory of child abuse.” (46) Even though MSBP is a complex phenomenon that professionals are “struggling” to understand, it needs to be identified early and prosecuted vigorously. After all, the fate of children is at stake.
(44) "Munchausen Syndrome by Proxy: Broadening the Scope of Child Abuse," 28 U of Richmond Law Review, pp. 1175ff (1994).
(45) Ibid., p. 1178.
(46) Ibid., p. 1179.
The article then went on to report on a “recent and growing understanding” of the disease which has led to “increased numbers of reports and diagnoses” each year. Much of the published literature addressing MSBP, according to our author, considers only the sensationalized cases. “However, there are innumerable [!] cases in hospitals and courtrooms throughout the world [we really have expanded the scope of inquiry, haven’t we?!] that are discovered and treated; unfortunately, even more go unrecognized and unreported.” (47) Of course there might be some danger in overzealous suspicion and identification but since it is being done for the benefit of the child, most allegations are at least driven by a good heart.
(47) Ibid., p. 1186.
I really need go no further in describing the nature of this article, an article which was typical in the legal literature of the mid-1990s. Without any foundation the authors suggest that the number of MSBP cases was far more than reported, and that the responsibility then rested on all of us to ferret out this most noxious form of child abuse. Like the hypothesis of hundreds of miniscule undiscovered islands that still exist in the Pacific Ocean, so the MSBP hypothesis proposed that there were still hundreds of cases of undiscovered MSBP. MSBP was not only a serious condition but it was a seriously underreported phenomenon. To be clear, my paper does not deny the existence or danger of child abuse, but the allegations brought forward in this 1994 article rested on such a gossamer web of unsubstantiated allegations that little clarity or truth could possibly be injected into the debate.