The Frontier Psychiatrists is a newsletter. It's daily. It's health-themed. Today, the strange condition is making the news! Prior article on the topic here. This article begins with an imagined conversation between a doctor, taking a mentalizing stance, and a parent whose child has been admitted to inpatient psychiatry. The following dialog is an example of “mentalizing informed” best practices regarding these conversations.
Doctor:
“so what you’re saying, if I’m hearing you right, is that when you called the police to report that your son was missing, she wasn’t missing?”
Parent:
“that’s correct.
Doctor:
“And when you told the emergency room that you were worried about his depression, that wasn’t actually what you were worried about?”
Parent:
“I was worried about his depression.”
Doctor:
“Maybe I’m getting this wrong. Was it that you were afraid he would kill herself? Because he said she was going to kill herself?”
Parent:
“ yes, I told them he said he was going to kill herself.”
Doctor:
“But, hold on a second, we just asked your son, sitting right here, and he said that he had never claimed he was suicidal before the hospital visit..”
Parent:
“ Well, I was worried.”
Doctor:
“Dad, I know you’re worried, but when I’m wondering is, did your son tell you he was suicidal, and that’s why you told the hospital that he was suicidal?”
Parent:
“Well, no, he didn’t say exactly that.”
Doctor:
“so he didn’t say he was suicidal?”
Parent:
“no”
Doctor:
“but what you told the hospital was that he said he was suicidal?”
Parent:
“yes”
Doctor:
“but that wasn’t true.”
Parent:
“I was concerned for my son’s safety.”
Doctor:
“ I can see that; I mean, you’re here in family therapy all together because you’re so concerned for your son’s safety.”
Parent:
“yes, we’re all here because we’re concerned for him.”
Doctor:
“absolutely can see that, but one of the things I’m noticing is that the hospital thought he was high risk because he wouldn’t admit to being suicidal, so what you’re telling me is that he never actually said he was suicidal?”
Parent:
“that’s correct. I was the one who was worried about it.”
Doctor:
“ …and see what he told the inpatient doctors; that was correct? When he said he wasn’t suicidal, it’s because he wasn’t suicidal, according to him?”
Parent:
“yes”
Doctor:
“so they kept him longer in the hospital because they thought he was hiding something?”
Parent:
“Well, I was worried he was hiding how depressed he was.”
Doctor:
“…but one of the things that he was upset about was that nobody believed him?”
Parent:
“I guess that’s true.”
Munchhausen, by proxy, is a psychiatric disorder with an eponym that’s more popular than the name of the actual disorder. The actual disorder is called factitious disorder by proxy. Like in the above fictional story, somebody gets somebody else sick. That “sick” person is subjected to medical care, and that medical care makes them sicker.
Medical textbooks refer to the unconscious process that drives this as a need for “tertiary gain.” Defined thusly:
“Tertiary gain is the benefit that a third party receives from the patient's symptoms. It includes gaslighting wherein a person, such as a family member or healthcare worker for financial or other reasons, manipulates a patient into believing that they are ill.”
“Being thought of as a good parent?” That’s tertiary gain. Attention? That’s tertiary gain.
The crucial concept:
The actions are conscious, but the motivations are not.
This is much more common than people think. It’s very rare on a population basis. In the context of providing medical care, physicians will see people with this problem.
It can be pretty horrific. The movie “Mommy Dead and Dearest” does a remarkable job depicting how bizarrely down the rabbit hole that will go, with doctors fooled into providing treatments for fictitious illnesses gratifying a mother’s need for attention.
With psychiatric conditions, it’s a lot easier than with physical conditions, honestly. All you have to do? Say someone is crazy. Then, the medical system will do what it does, and you will be rewarded with endless doctor visits and hospitalizations. If you’re lucky—and I mean lucky in the sarcastic and dark use of the term—the person will have harm visited upon them by our often iatrogenic— “medical care caused harm”— system. Psychiatric care can be harmful to people who desperately need it, but imagine being someone who doesn't need it at all. This is the plot of “One Flew Over the Cuckoo's Nest.”
The irony is, with involuntary psychiatric care, you can almost guarantee someone will get more and more harmful care by saying someone else has a problem they don’t have because other people will reliably deny it! The gaslighting nature is built into the risk assessment done by inpatient psychiatry—we are terrified of people hiding their suicidal intent, and for understandable reasons.
I'm glad you've clarified the role of unconscious motivation in factitious disorder somewhat in this post (https://jqxvn.substack.com/p/contra-tfp-on-factitious-disorder). But I'm afraid there's some unclarity here when you discuss tertiary gain. In the scheme you reference, primary, secondary, and tertiary gains are all potentially subconscious motivations. Attention is a primary motivator, unless you're getting attention for someone else's condition, in which case it's a tertiary motivator. Financial gain is a secondary motivator in malingering, and a tertiary motivator in...whatever is malingering by proxy. Shortly, anything that's tertiary gain for FDoiA would be primary gain in FD (or secondary gain in malingering) so there's nothing special about the "tertiary gain" label that helps us understand the subsumed nature of FD/FDoiA psychopathology. So when you say "Medical textbooks refer to the unconscious process that drives this as a need for “tertiary gain," follow that up with the google pull quote from wikipedia about tertiary gain, and conclude that the crucial concept is conscious actions with unconscious motivations, I think some readers may be confused.
I was never able to find the reference to the unconscious in the DSM V (from the Take Care of Munchausen's post) but I'm not great at finding things, so maybe I overlooked it? I was really curious to see the whole quote in its context.