Disorder and Early Sorrow
This review of Simon Blackburn’s Truth brings up Munchausen’s by proxy:
For a more serious example of the misuse of “objective facts” by people in power, he blasts the proponents of “Munchausen’s Syndrome by Proxy,” which Blackburn calls “a description invented by a British pediatrician for a ‘condition’ in which mothers harm or kill their babies in order to gain attention for themselves. By insinuating the quite false idea that science had ‘discovered’ this ‘condition,’ and therefore in some sense was on the way to understanding it, and then by ceding power to ‘expert witnesses’ who could pronounce upon its presence, the medical profession assisted in the conviction of many innocent mothers whose babies had died of natural causes.”
The subject is in the news as we speak, as a professor of forensic statistics explains what he takes to be a mistake in Roy Meadow’s analysis of the odds that two children in the same family could have SIDS, to the General Medical Council’s Fitness to Practice panel.
These ‘conditions’ that are ‘discovered’ are interesting. Apparently there is – or is said to be – a ‘condition’ ‘called’ (by whom?) Body Integrity Identity Disorder. People who have this rare ‘condition’ apparently (as far as I can make out) are convinced they have an arm or leg too many and pine their lives away longing to have the superfluous limb chopped off. Now…I don’t know, but where I come from, that kind of thing isn’t considered a ‘condition’ so much as just being stark staring stupid. Could that be the problem here? Could the people (who are they?) who named this ‘condition’ Body Integrity Identity Disorder, simply have been confused? Could they just have mistaken a peculiar belief with a ‘condition’? People have lots of peculiar beliefs, you know; that doesn’t mean they’re sick, it just means they’re not firing on all cylinders. A certain amount of cautious skepticism would seem to be in order.
Two Australian philosophers believe surgeons should be allowed to cut off the healthy limbs of some “amputee wannabes”. Neil Levy and Tim Bayne argue that patients obsessed with having a limb amputated should be able to have it safely removed by a surgeon, as long as they are deemed sane…Dr Levy, of the University of Melbourne’s Centre for Applied Philosophy and Public Ethics, said some patients suffered so severely from the rare condition – known as Body Integrity Identity Disorder (BIID) – they tried to remove the limb themselves…Only a few thousand people worldwide are believed to have the disorder.
By whom? Who are all these people? All these shadowy people who named the ‘Disorder’ and have beliefs about how many people in the world have it – who are they, and how do they know?
But more to the point, this seems like a glaring example of exactly what Blackburn is talking about – of ‘insinuating the quite false idea that science had ‘discovered’ this ‘condition,’ and therefore in some sense was on the way to understanding it, and then by ceding power to ‘expert witnesses’ who could pronounce upon its presence’ – and then give surgeons the okay to cut off legs and arms that don’t need cutting off. It’s like
‘Reactive Attachment Disorder’, the made-up ‘disorder’ that got Candace Newmaker killed by ‘therapists’ in a rebirthing exercise. It’s also like ‘recovered memory’ and ‘multiple personality disorder’ and no doubt a good few other disorders and syndromes. If it just prompts some therapeutic hand-holding and hanky-clutching, it’s not so terrible (unless the afflicted want to tell us about their affliction, in which case it’s time to discover an urgent appointment elsewhere), but when it starts getting people squashed in mattresses or mutilated or thrown in prison or permanently estranged from parents or children – it’s a bit dodgy.
I don’t think I can contribute anything to understanding BIID, but it’s apparently not a new discovery. I read quite a lengthy article about it a few years ago; I couldn’t swear to it that the condition had even been named (I could scarcely believe it wasn’t a hoax; it’s one thing to pull someone’s leg, another to pull it off). I may even have printed it out, which doesn’t mean I can lay my hands on it at short notice. I seem to remember, though, that the author or authors tried to introduce it as a no-holds-barred, haywire version of the same impulse that leads to the kind of cosmetic surgery for which no one would think of confining you to a straitjacket (also kind of pointless, unless you have arms).
I find it rather worrying that becuase Roy Meadow made a mistake, and becuase there is doubt as what exactly a disorder is, that people are coming to think that the actions described by Munchausen’s syndrome by proxy don’t happen. Parent do cause factitious illness in their children, by poisoning or other means. Just becuase the name is in doubt does not mean that all parents accused of making their children ill (eg poisoning) or cause them to have unnecessary operations (eg. putting blood in other bodily fluids) must be innocent because it can’t happen because MSbP doesn’t exist.
These things happen and we should be more concerned about protecting children than in choosing a name.
True, Clio, but then I didn’t say it did mean that. But the question is (for instance) how often do these things happen, and how does one find out.
And it isn’t quite a matter of a stark choice between protecting children and choosing a name. If a child’s parent is not causing factitious illness, then imprisoning that parent for doing so isn’t protecting the child – it’s harming the child.
I think there’s a legitimate difference between stark staring stupid and stark staring mad, OB. Clearly, people who truly and sincerely desire and seek to seriously disable and disfigure themselves are, not to put too fine a point on it, barmy. These are people with malfunctioning minds. But one can be quite intelligent and still be a raving lunatic (need I cite examples?), so it’s just plain rude (and unhelpful) to call them stupid.
The real question is, are Levy & Bayne stupid for suggesting that an appropriate treatment for people with the desire to self-mutilate is to satisfy their desire? I think not. Misguided, perhaps, but not stupid. But I don’t think the reasons why are as obvious as they might seem – which will require a bit of length to explain…
Hmm. I’m not sure it is all that clear, G – at least not from that article it’s not. It’s not clear if they really do have malfunctioning minds or if they just have as the article said ‘one strange belief.’ But my comment expressed that non-clarity, I think. I said where I come from that’s what people call strange beliefs – which is true – some ‘strange beliefs’ do get called stupid. Others don’t. It’s not clear what kind of strange belief this one is. It’s not clear that it’s not the same kind of thing as people wanting to pump stuff into their tits, which I have always thought just remarkably stupid.
(I did actually start to type stark staring mad – but then when I got to the ‘mad’ part – I hesitated – and realized I wasn’t sure whether it was mad or not. In a way it’s harsher to call people mad than stupid, because madness is more serious and harder to fix. More like a sentence than an impatient description.)
Ophelia, have you read Phantoms in the Mind by V.S. Ramachandran? In that book, he describes how the brain has a ‘map’ of the body which is somewhat independent of the actual state of the body. (I can’t lay hands on my copy, I’m afraid, so I can’t be sure whether Ramachandran covers something like the following scenario or not.) If someone’s ‘body map’ happens not to represent a limb which is in actual fact attached to their body (which would be the mirror image of phantom limb syndrome, I suppose), it could easily lead to a sense that one would be better off without that limb. Such a condition would also seem to be something that one could do little about through application of one’s rational faculties. Therefore, one might suffer from this condition and not actually be mad or stupid. If indeed, people who feel that they would be happier without a particular limb find that this is the case after having it removed, then I think it’s fair to say that they’re not deluded.
Rowan, no, I haven’t. Interesting – it does sound like phantom limb turned inside out. Very unpleasant, that would be. Hmmm…
(But can people develop a map of the body that has never been dependent on the actual state of the body? Phantom limb is based on the previous reality. I wonder what phantom excess limb would be based on…
Still – it does ring a bell, actually. Something I’ve read in Oliver Sacks maybe? Hmm. People after strokes, I think – bits of themselves seem alien, stuck on – repulsive. Gah – that would be horrible.)
Okay, OB, I see your point. The article from The Age is not the first I’ve read about this, so I already had a solid “messed up body image, possibly a neurological inverse of phantom limb syndrome” concept of the disorder to back up my assessment of crazy, not just dumb.
On that note, I think Levy’s description of these people being perfectly sane except for this “one, very strange, belief” is extremely suspicious. It’s not just a belief: This disorder, if it can be characterized at all, is characterized by an overriding conviction that one is really properly an amputee, but trapped in a whole person’s body – tied with a powerful desire to alter oneself to fit that body image. To describe this belief/desire complex using Levy’s “otherwise perfectly sane” dodge seems on the face of it to be an unjustifiable gloss. But what’s being glossed over?
I think there’s some sort of agenda hidden around here somewhere, but I can’t dig it up without reading the original journal article. Frankly, I’m not sure it’s worth it.
Anyway, there’s a little more background in this article:
http://www.abc.net.au/science/news/health/HealthRepublish_1395891.htm
I recall a big furore about this sort of thing (chopping limbs off people who didn’t want them) over here a few years ago. At the time I think they were talking about it in relation to body dysmorphic disorder, eating disorders and transexualism.
I have to say that, I’m with Rowan on this, I can’t understand a disorder of this kind without at least a partial neurological basis (yep, just like with stroke, the whole “it’s not my hand, it must be your hand, you’ve got three hands!”).
RE: Munchausen Syndrome by Proxy. I think the problem is that we aren’t talking about a classic psychiatric syndrome here, but rather a behaviour pattern. How do you know if someone has MSBP? Because they harm their child. That is why it is ‘diagnosed’ by paediatricians and not psychiatrists.
As to the validity of the term, the fact is that many parents deliberately harm their children, and the hidden camera footage exists to demonstrate this sad fact.
The connection between Roy Meadows, the latest infanticide cases, and MSBP, is a bit more complicated than it first appears. Roy Meadows reported MSBP in, I think, the ’80s, with well documented cases of mothers harming their babies and making up symptoms, seemingly to get attention (Munchausen syndrome is making up illnesses that you have yourself – also a common medical problem).
Roy Meadows’ involvement in the infanticide/cot death trials was broader and probably involved his “Meadow’s law” about multiple cot deaths being suspicious, and where he quoted his dodgy statistic. However, in at least one of the cases, the one where he quoted his statistic in fact, the conviction was quashed due to evidence being witheld by the pathologist.
“But more to the point, this seems like a glaring example of exactly what Blackburn is talking about – of ‘insinuating the quite false idea that science had ‘discovered’ this ‘condition,’ and therefore in some sense was on the way to understanding it, and then by ceding power to ‘expert witnesses’ who could pronounce upon its presence'”
Just look at how that quotation makes its point almost entirely through scare quotes.
In making this sneaky piece of rhetoric, Blackburn (and you) are in good company. I think it was Earl Howe that accused Meadows of making up the disorder of MSBP without any evidence.
But the point I want to make is that by documenting a large number of cases with a similar pattern, be it MSBP or BIID, doctors are indeed ‘discovering’ a condition. Just because it is phenomenological does not make it somehow invalid. Presumably any behaviour pattern, illness or psychiatric disorder, without a well established biological foundation would also get your condemnation?
I’m curious as to what you think of the reality of transexualism, is there such a thing as men (or women) who want to be physically the opposite gender, or has science, ‘quite falsely’ ‘insinuated’ that it has ‘discovered’ such a phenomenon? “Now…I don’t know, but where I come from, that kind of thing isn’t considered a ‘condition’ so much as just being stark staring stupid”, don’t you think? We certainly shouldn’t be giving these people councilling, and, if we’re convinced they really really want it, lop off their genitalia.
We’ve got a few good links on this at Mind Hacks. Rowan has got it right – this situation is very likely to have some neurological origin. OUr brain codes body representation, in terms of a somatosensory (feeling) map of the body, and a motor map (movement/engagement). These maps seem to be set down from an early age and follow a develomental path; although learning may contribute to its end result it does not totally specify it, as it is bound by certain biological facts such as the density of sensory nerve endings for that area. Phantom limb is when a well-articulated part of the map does not correspond to reality, and is generally found in cases where the limb previously existed. One could imagine in principle phantom limb for a never-existing limb – a third leg or a trunk – but that would require the development of a map area without the contributions either of learning, nor of gene-pool contribution (humans don’t have trunks among their phenotype), and would require some hugely unlikely macromutation. However, the opposite case, of no map of a body area, doesn’t involve such likely odds, as it merely requires that the map was formed incomplete, due to mutation, faulty development, or even later damage (e.g. some kind of hypoxic damage, encephalitis or direct head injury). No representation for that body part, no sense of it being part of you.
Ophelia,
Ramachandran does indeed describe a patient who was born with no arms but had phantoms, albeit shorter than normal human arms. The people who made her prostheses came to a compromise between them not looking odd and feeling right to her.
Oliver Sack’s A Leg to Stand On describes his own experiences of the loss of use of a limb and the psychological effect it had on him. It’s well worth a read, if you haven’t already.
Thanks, Alex – that makes sense of a lot of this.
I think my initial view of it was influenced by something a correspondent told me (a year or two ago) about amputation wannabes – who apparently (if I understood it correctly, which may well be doubtful) are just kind of fans of the disability movement and want to join, as opposed to having a flawed body map. I jumped to the conclusion that BIID was just a label for that.
I have read that, Rowan – definitely worth a read. I should read Ramachandran now.
I believe there is supposed to be a group of people who get a sort of sexual thrill from amputation and things like that – a kind of S&M to the nth degree.
Yeah – the article at ABC says 15% of wannabes in the very small study it cites (52 people) cite sexual arousal as a reason.
(It’s difficult not to want to tell them ‘oh grow up, forget about your stupid sexual thrill, go do something useful.’) (Compassionate, aren’t I.)
Science may not have ‘discovered’ MSbP, but Roy Meadows certainly described it, and therefore allowed it to be spotted. Following the last paediatrician witch hunt (not the current one!) out of 200 convictions only 20 were considered to need review, of which only 1 was overturned. But that doesn’t make good press!
But is there an ‘it’ to be described? An ‘it’ that is usefully described as its own special ‘it’ as opposed to simply a crime? That’s not done with all crimes, surely. They aren’t subdivided into a multitude of different syndromes. Why is it useful to do it in this instance?
And is there a paediatrician witch hunt? Or is there a parent witch hunt. Or is there some of both.
It has a whiff of the sex-abuse, satanic ritual abuse, recovered memory panics in the US in the 90s. Caution seems advisable.
V.S. Ramachandran gave the Reith Lectures in 2003 (and they were wonderful); you can listen to them here.
“But is there an ‘it’ to be described? An ‘it’ that is usefully described as its own special ‘it’ as opposed to simply a crime? That’s not done with all crimes, surely. They aren’t subdivided into a multitude of different syndromes. Why is it useful to do it in this instance?”
Because it describes a particular pattern of abusing, and a particular pattern of childhood symptoms, and quite possibly a particular state of mind/psychological aberration.
Because it is a useful concept when you are faced with a child who has unexplainable symptoms, where experience has shown that some may be being injured by their parents. Doctors don’t name other crimes because they are not relevant to doctors.
We have a word for ‘infanticide’, and a very special set of considerations for it, in law, and in medicine, because it is not just another crime, it is not just like any other murder – it has different root causes. Child abuse is treated much the same, it simply is different.
“And is there a paediatrician witch hunt? Or is there a parent witch hunt. Or is there some of both.”
In most cases of MSBP there is good evidence that the parents are deliberately harming their children. They are hardly engaging in a witch hunt. In the sudden infant death cases mentioned in relation to Roy Meadows, he gave dodgy evidence in some of them but most had pathological evidence of abuse, and very few cases have been overturned due to his evidence being questioned.
“It has a whiff of the sex-abuse, satanic ritual abuse, recovered memory panics in the US in the 90s. Caution seems advisable.”
Not from this end it doesn’t. The recovered memory and satanic abuse panics were characterised by a cult-like adherance to an unproven view by social workers, police and ‘therapists’ – this case relates to about 3 women being wrongly imprisoned, and one or two paediatricians pronouncing outside of justifiable knowledge, and is primarily a failing of the expert witness system.
“That’s not done with all crimes, surely. They aren’t subdivided into a multitude of different syndromes. Why is it useful to do it in this instance?”
I believe that forensic psychologists and psychiatrists actually do come up with different ‘profiles’ for different types of crime.
“a cult-like adherance to an unproven view by social workers, police and ‘therapists'”
Just so, and there is also controversy over whether MSbP has been established or not.
PM – first you say you “don’t think” there is controversy over whether MSbP has been established or not, then you say that many people regard the label as unhelpful.
Then you make a very large assertion:
“Unlike satanic ritual abuse it is absolutely undeniable that induced factitious illness is a real phenomenon.”
Absolutely undeniable? That’s absurd.
(Was it you who also assured me a few months ago that there is no doubt at all of the reality of ‘race’ as a biological category? If so you may have a dangerous new syndrome [about whose reality there is no possibility of doubt]: hyper-reification syndrome. I’d get help for that if I were you.)
To meta quote myself:
“As there is no single psychological profile in Munchausen syndrome by proxy, and the label makes unwarranted assumptions about the parent’s mental state and motivation, many UK paediatricians feel that the term should be abandoned. The preferred term is now fabricated and induced illness.”
Fabricated and induced illness is the new preferred term -for the thing that usd to be called MSBP-. I.e., it is labelling something real, a real phenomenon, but the label carries with it unhelpful connotations.
See, perfectly consistent.
And as for the absolute undeniability that some parents deliberately harm their children, I propose to you the case of Teresa Milbrandt http://news.bbc.co.uk/1/hi/world/americas/2593691.stm
Obviously it is -possible- to deny that people deliberately harm their children to induce symptoms of disease, it is just not credible.
[Re: race, if I recall I was mostly objecting to your claim that biology proved that there was no such thing as race]
Not really perfectly consistent, no, but it seems to be just a question of wording, so not all that important.
Of course I’m not disputing that some parents deliberately harm their children, I’m just disputing the absolutism of your claim.
Race – but I didn’t claim that. Just for one thing, I don’t say biology ‘proves’ things anyway, any more than I say that things are absolutely undeniable. You seem to have made that translation that so many people make, of a more hedged assertion into ‘proof.’ That habit really does create havoc in discussions, because it means thinking one’s interlocutor is far more certain than she is or has claimed to be.
OB: “Was it you who also assured me a few months ago that there is no doubt at all of the reality of ‘race’ as a biological category?”
PM: “Re: race, if I recall I was mostly objecting to your claim that biology proved that there was no such thing as race”
OB: “I don’t say biology ‘proves’ things anyway, any more than I say that things are absolutely undeniable”
Here’s part of the exchange, its more complicated because Mark Pitely was involved too:
http://www.butterfliesandwheels.com/notes.php?previousmonth=yes&mon=07&yea=2004&da=30
OB: “there is no ‘biological definition of race’. It’s just not a biological term”
PM: “OB, really, there is such a thing as race in biology. Just don’t get it confused with the social definition of race.”
PM (Quoting Gross): ““Race” is a word used widely and traditionally in biology to identify subpopulations within a species, that is, varieties, extended families, fuzzy subsets of individuals of common descent, sets more or less differentiable one from the other by appearance and/or behavior. It is no surprise that races or recognizable varieties in other species turn out to be distinguishable—although not necessarily easily—at the level of genetics.”
OB: “Ah – interesting article. Thanks, PM. I wasn’t aware of that book. I stand corrected! At least some biologists do find ‘race’ a useful term for differences among populations.”
Thanks for finding that, I was way too lazy. That was an interesting month, that July! A lot going on.
Interesting to note that you made the same ‘proof’ attribution mistake there (“‘science proves that there is no such thing as race’,”) and that Mark said he hoped he hadn’t said anything so silly – and yet you made the same attribution mistake again yesterday. Do try to learn not to do that. Seriously. I know that sounds patronizing, but seriously – it’s a big mistake to see your colleagues in an argument as claiming far more certainty than they are.
The Gross quotation makes it clear that the word is pretty vague. A semi-useful term to describe fuzzy differences, but tricky.
True enough, I had noticed that as well. But you brought the ‘race’ debate up, not me, and my recollection of the argument was wrong.
But note that I didn’t claim “that there is no doubt at all of the reality of ‘race’ as a biological category”, but rather disagreed with your statement that “there is no ‘biological definition of race’…It’s just not a biological term” by showing that it wasn’t true.
So we were both attributing falsely – but you started it so nah nah…
Whilst we’re back on the subject (no, not race):
Me: “Unlike satanic ritual abuse it is absolutely undeniable that induced factitious illness is a real phenomenon.”
You: “Absolutely undeniable? That’s absurd.”
You again: “Of course I’m not disputing that some parents deliberately harm their children, I’m just disputing the absolutism of your claim.”
Are you really making the fairly banal observation that, strictly speaking, anything can be doubted, however obviously true it is? Because all I said was that, unlike Satanic ritual abuse, where we can legitimately question whether it happens at all (e.g. all those enquiries such as the UK one and the Dutch one), there clearly are cases where parents induce the symptoms of illness in children (i.e. cases that could/would be labelled as MSBP), i.e. that “the phenomenon it was coined to describe really exists”. and I said this because you asked “But is there an ‘it’ to be described?”
Now when I said it was ‘undeniable’ that these cases occur, I was clearly not using the word in the sense that it is literally imposible to deny that these cases occur – because it is possible to deny anything (even that 2+2=4), and so the word ‘undeniable’ would be meaningless. So what I meant by ‘undeniable’ was, as I said, that “it is just not credible” to deny that these cases occur, given the evidence (as outlined in the refernces in the bmj article I gave).
[“Thanks for finding that, I was way too lazy. That was an interesting month, that July! A lot going on.”
It was bloody difficult actually, until I realised that google indexes the archives]
Well I did say it seemed to be just a question of wording so not all that important. I wasn’t initially sure what you did mean. I get what you meant by undeniable now, but I didn’t until you explained.
Google indexes the archives? Wozzat mean?
I bet it was difficult. My top chief main primary wish item for B&W is an archive for Notes and Comment – but the webmaster refuses to make one. I’ve begged and pleaded and sworn and thrown things, but he just says No.
Because you have links to old notes on your website google indexes them like it would any other pages when the spider wanders through the site, all you need to do to find them is an advanced search on google, limit it to the B&W site, and then search away.
Jesus knew about BIID:
“If ever your hand makes you stumble, cut it off; it is finer for you to enter into life maimed than with two hands to go off into Gehenna, into the fire that cannot be put out. And if your foot makes you stumble, cut it off; it is finer for you to enter into life lame than with two feet to be pitched into Gehenna.” –Mark 9:43-45.