Diagnose and be damnedBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7240.1004 (Published 08 April 2000) Cite this as: BMJ 2000;320:1004
All rapid responses
I note that the continuing discussion of the "Marcovitch
matter" has apparently escaped a comment from any of your
U.S. readers. If you'll allow me, I'd like to suggest that
an interesting point (and an important opportunity for
insight) is being missed.
When parents bring a child to a physician, and the physician
rewards them with the diagnosis, "I'm happy to say I've
found the cause. It is you", it would seem self-evident that
a hypothesis which should strongly compete with one such as
"Munchausen-by-proxy" is -- quite simply -- simple physician
inadequacy, or frank incompetence.
It was a full century of incompetent physicians, of course,
who so cavalierly contrived such jargon ("diagnoses") as
"the schizophrenogenic mother"; and "the refrigerator
mother"; and "the perfectionist mother"; and "the smothering
mother"; and "the overprotective mother"; and "the
depressogenic mother"; and the "anxiogenic parent" -- in
schizophrenia; autism, anorexia nervosa, homosexuality,
Tourette syndrome, depression and anxiety, respectively (1).
Currently, the effort in "cot death" (a leader in which
effort (2) is the coiner of "Munchausen-by-proxy"(3)) is to
put the blame for medically-puzzling loss of an infant back
on the devastated mother and father. In "chronic fatigue
syndrome", the trick is to put blame on the patient (as
Wessely (4) might put it , "I have divined the cause. And
guess what? It's not some elusive virus. It is, quite
simply: 'You' (you and your 'cognitively-skewed' outlook on
What do we see in common here -- other than a reflex to
blame the ill, or the ill one's parents? Mystery. Medical
inadequacy. Frustration. Hubris. In that order. What else
-- in each instance -- do we see? Very puzzling
("frustrating") illnesses, each once facilely branded
"psychogenic", and each conveniently "caused" by either the
patient or parent -- but all now increasingly, and very
embarrassingly, being recognized as in fact subtly organic
(5). But how do you apologize to a century of disastrously
malserved parents, and patients? And after you brand a
"too-caring" mother as a "Munchausen" (or a "cot death"
survivor as a "baby-killer"), how do you put the shattered
family back together? And how do you get the mother out of
jail -- or, if you do get her out, how do you give back to
her and her family their lost years?
The utter disaster entailed in a "Muchausen-by-proxy"
diagnosis is such that one would think that the existence of
such a "disease", and the leveling of its diagnosis, would
be matters approached with the most exquisite care. But,
just the opposite. The very existence of the "disease" is
"suspect" (3). And the so-called "diagnoses" are shoddiness
incarnate (3). Simple instinct or intuition should of
course tell us that. But, for those who demand painstaking
scholarship, Allison and Roberts spend a full 290 pages
detailing the hubric conceit upon which this
parent-attacking "disease" is built, and with which it is so
easily, and capriciously, applied (3).
The U.S. and the U.K. are equals in these regards.
Unchallenged incompetence (and its integral companion,
hubris) in either land tends to shore it up in the other.
Take "mass hysteria" as example. I presume it is now quite
clear to most in the U.K. that the Royal Free Hospital
doctors and nurses who fell to some virus in the mid-50s
were not, as argued (6), simply a bunch of "mass hysterics".
But, as British author Wessely (7), American authors, and
especially our supposed "microbe hunters", the "CDC"
(Centers for Disease Control), remain deeply in love with
these kinds of poorly-aging psychogenic "explanations" of
puzzling presentations (8)(9).
When mystery presents, and you can find nothing but feel you
have to blame something, who better than the patients who
saddled you with the mystery or, if they are too young to
blame, how about their "much-too-concerned" parents? (As
Meadow extrapolated the "Munchausen" theory (itself suspect
(3)) on to his "Munchausen-by-proxy" blame of
"overly-concerned" parents (3), so Wessely has taken the
"mass hysteria" theory (also suspect (10)) on to his "mass
sociogenic illness by proxy" blame of "overly-concerned"
parents (7). For a nice example of transatlantic
psychogenic cross-talk, compare Wessely (7) and the CDC
(Conflict of interest: A healthy skepticism. Aside from
(1) This point's multiple references are available, by
return email, via request to author.
(2) Meadow R. Unnatural sudden infant death. Arch Dis Child.
(3) Allison DB, Roberts MS (1998). Disordered Mother or
Disordered Diagnosis? Munchausen by Proxy Syndrome.
Hillsdale NJ and London: The Analytic Press.
(4) Sharpe M, Wessely S. Cognitive behaviour therapy. Review
was unsystematic. BMJ. 1997 Nov 22;315(7119):1376
(5) The numerous references are available, by return email,
via request to author.
(6) McEvedy CP, Beard AW. Royal Free Epidemic 1955, a
reconsideration. BMJ. 1970. 1:7.
(7) Wessely S, Wardle CJ. Mass sociogenic illness by proxy:
parentally reported epidemic in an elementary school. Br J
Psychiatry. 1990 Sep;157:421-4.
(8) Small GW, et al. Mass hysteria among schoolchildren.
Early loss as a predisposing factor. Arch Gen Psychiatry.
(9) Philen RM, et al. Mass sociogenic illness by proxy:
parentally reported epidemic in an elementary school.
Lancet. 1989 Dec 9;2(8676):1372-6.
(10) Aldous JC, et al. An outbreak of illness among
schoolchildren in London: toxic poisoning not mass
hysteria. J Epidemiol Community Health. 1994
Competing interests: No competing interests