Disease or deception: Munchausen by Proxy as a weapon of the weak.

This paper aims to trouble certain assumptions about the clinical nature of Munchausen by Proxy (MBP), which has been described in the medical literature as a rare "culture bound syndrome" having surfaced at a particular moment, late modernity, and in a particular "place", Europe and North America and their extensions. At the heart of this disorder is a lie perpetrated by disturbed mothers who masquerade as the concerned and anxious caretakers of one or more long-suffering children who are plagued by fictive or maternally-incited illnesses and, in the worst instance, who are subjected to death by maternal design. MBP is positioned within a broader comparative context as an extreme pole along a continuum of (mal-) adaptive maternal behaviors in response to unrecognized and unmet needs, not all of which are pathological. Second, the locus of the pathology is expanded to include not only the disturbed and troubled mother-child dyad, but also the relationship between mother and her doctors and other caregivers and protectors. In these medicalized transactions - shot through with power, love, and pain - the child emerges as an almost incidental or "transitional object", a mere pretext that gives voice and substance to the adults' (mothers' and professionals') narcissistic needs. Finally, the social and moral uses of illness as drama, performance, and pageantry, and as a passively aggressive "weapon of the weak", are identified as a key structure of MBP disease. Based on decades of research on maternal thinking and practice (often under extreme conditions) the paper is an attempt to demonstrate what a "critically applied and cross-cultural medical anthropology" can add to the clinical picture and to a broader social understanding of this seemingly bizarre, rare, and contested syndrome.