Munchausen by Proxy and Other Factitious Abuse: Practical and Forensic Investigative Techniques

Munchausen syndrome, or factitious disorder, alone (FD) or by proxy (FDP), can be a baffling, frustrating, infuriating, and life-threatening condition encountered in medical and surgical, pediatric, and psychiatric practices. In this book, the author, a former police officer, shares decades of experience in the classification, recognition, unmasking, and resolution of the condition. The book regards FDP as a criminal process wrapped in psychiatric nomenclature. Ms. Artingstall's premise is that individuals who perpetrate physical abuse on children or other unwitting subjects must be uncovered and prosecuted, not excused via insanity pleas. The author is an experienced and wily huntress, appropriate to the task of helping both medical professionals and law enforcement to see past the manifold presentations of FDP cases.

FDP entails intentional production of a medical condition in another person, usually a child, without external gain, distinguishing it from malingering. The boundaries are blurred when, for example, the author discusses malingering by proxy and FDP scenarios with apparent external gain, such as securing or retaining child custody. There are differential diagnoses, some rare (e.g., Ganser's syndrome) and some familiar (e.g., somatoform disorders). Although the author tries to parse them, including a reference from this Journal,¹ her preoccupation with protecting children obscures coming to terms with the dynamics of the perpetrator; the patient is clearly the victim in proxy cases. Thus, when it comes time (Chapter 15) to address expert testimony, there is little useful information on developing a narrative for criminal sentencing; instead there are details of the modus operandi of the perpetrator.

The 39-page opening chapter could be a stand-alone review of FDP. It starts with some history. Baron von Munchausen, an 18th-century raconteur, was implicated in the death of his wife's infant, the product of her wedding-night indiscretion. The subsequent literature on Munchausen-related conditions, the author says, underestimated their incidence and did not squarely confront the fake patients. Even through the 20th century, FDP was regarded as a medical condition, without sufficient attention to the nefarious underlying behaviors.

Ms. Artingstall resents attempts to explain away criminality cloaked as illness. Sympathy from the public toward persons with mental illness comes from ideas such as irresistible impulse and insanity defenses. This effect “is amplified when crimes are egregious and offend the sensibility of people” (p 4), seen also after mass killings.² However, the author argues, features of FD and FDP should not be regarded as symptoms, in the usual sense of a mental disorder that can serve as an excuse against criminal charges. In the case of FDP, “When a child or elderly victim dies as a result of abuse that is caused by the factitious behavior of the perpetrator, a homicide has occurred” (p 12). No excuses.

Ms. Artingstall is convincing that FDP is a “delivery system” for criminal abuse. Expert witnesses and law enforcement are necessary for establishing a criminal case, although, “While custodial arrests of FDP suspects are not contingent upon a medical diagnosis of FDP, both are connected to the establishment and provability of evidence to support the theory of one another” (p 14). The author focuses, throughout the book, on medical and law enforcement personnel learning about behavior patterns among FDP perpetrators. She endorses profiling, tempered by contextual and cultural understanding. It would be interesting to know of cases in which medical professionals who are too quick to diagnose abuse via FDP are liable when genuine illness is found, analogous to mislabeling patients as malingerers.³ There is reference to Internet-based support groups for those falsely accused and for primary and secondary victims.⁴ However, I could not find support for the following unreferenced statement: “In 2015, there are 13,000,000 Internet sites regarding ‘Munchausen support’” (p 21, italics original).

The text is aided by many tables, figures, and flow charts, as well as vignettes and case law. It is marred, at times, by redundancy, faulty copy editing, and opaque sentences; for example, “When a person reaches an actionable place where he or she is responsible, directly or indirectly for inflicted harm or injury onto a victim, that person has crossed a threshold into deliberate measurable abuse” (p 23). Overall, while the book is not aimed at forensic psychiatrists, it is a useful resource to experts aiding the prosecution in suspected abuse cases, for practitioners of emergency psychiatry, and for those in a liaison role with pediatrics or integrated care. For defense cases, Ms. Artingstall does not attend to the psychodynamics that underlie FD and FDP. Support for the mitigation narrative must come from older literature and from the details of defendants' developmental history.

• © 2017 American Academy of Psychiatry and the Law