In a big reveal on Sunday night's episode of Sharp Objects, we learn that Adora has been slowly poisoning her daughter, thanks to a condition called Munchausen by proxy — but what exactly is Munchausen, and why does it occur?
"The best definition [of Munchausen by proxy] is to think of a caretaker who feigns, exaggerates, or induces an illness — typically in their own child — in order to gain concern and attention for themselves," says Marc Feldman, MD, clinical professor of psychiatry at the University of Alabama and author of Dying To Be Ill: True Stories Of Medical Deception. "They’re typically not primarily after drugs or money from GoFundMe accounts or other tangible goals, they’re after something intangible, which is the love and nurturance provided by other people in reaction to them appearing to have a sick child."
Dr. Feldman says that although experts have debated whether or not it is a mental disorder, it's definitely a form of abuse.
"Munchausen by proxy is increasingly called medical child abuse, especially in the court system, because it’s more descriptive — the term Munchausen by proxy doesn’t tell you much about what’s going on whereas medical child abuse is descriptive and makes clear that this is a form of abuse first and foremost," he says.
There's no one known cause for Munchausen, but Dr. Feldman says that about 95% of perpetrators are women, and 35% of them have a history of being nurses, respiratory therapists, physical therapists, though they're rarely doctors.
"They’ve always had a fascination with medical matters, and being involved in healthcare may give them access to drugs and syringes they can use to sicken their child," he says. "They also almost always have personality disorders like borderline personality disorder, which just means they have long-term maladaptive ways of trying to get their needs met. They use hurtful actions instead of words to get their needs met."
And as for the perpetrators mostly being women, he says that some people refer to Munchausen by proxy as a "perversion of mothering," or a distortion of the care a mother typically gives a child.
"We expect moms to be loving and caring and they often do take the lead when it comes to caring for their child, but this is an aversion to that natural instinct," he says.
[It's] a caretaker who feigns, exaggerates, or induces an illness — typically in their own child — in order to gain concern and attention for themselves.
Marc Feldman, PhD
Though he says that it's estimated that there are between 600 and 1200 new cases each year in the U.S., that number might still be vastly underreported, partly because doctors aren't typically taught about Munchausen in their training (thereby making it harder to diagnose), and because people who have it are usually in a huge amount of denial about what they're doing.
"You could show the mother covert videotapes of her harming the child, and she would still deny it," he says, adding that he once saw a case where a mother was shown footage of herself suffocating a child, and upon seeing it, said, "I was just tickling his mouth."
"It just shows how tenacious that denial tends to be," he says. "Rarely do they admit what they've done even when faced with evidence."
That's why, when it comes to diagnosis, it's rare for doctors to come to a conclusion based on directly observing what someone is doing to their child. Instead, Dr. Feldman says, doctors may thoroughly go through medical records for inconsistencies between what a person says about the child's health and what the records show.
"We’re concerned when we see doctor shopping and hospital shopping, where they take the child from place to place seeking new audiences for the deceptions," he says.
But beyond hospital and doctor shopping, Dr. Feldman says that the best indication of Munchausen by proxy is determined through a separation test, where doctors separate the caretaker and child to see if the child's health improves in the time being.
If the child does improve, that's what he calls a "positive separation test" that proves someone played a role in a child being sick. And once Munchausen is diagnosed, he says, doctors may be able to treat any underlying illness the caretaker may have.
"Most people say that if [the caretaker] doesn't admit to it upfront, there's no chance of psychotherapy working, but I take a more optimistic view," he says. "If they have a depression or anxiety disorder that’s thriving the abuse, or they're obsessed with physical symptoms in general, we may be able to treat the underlying disorder that’s precipitating the abuse. And if so, the prospects improve a lot."