Jonathan Kellerman - Devil's Waltz

Female child showing panic at being treated or handled.

Mother with a paramedical training.

Nice mother.

Nice mother who might just be a monster. Scripting, choreographing, and directing a Grand Guignol, and casting her own child as unwitting star.

Rare diagnosis, but the facts fit. Up until twenty years ago nobody had heard of it.

“Munchausen syndrome by proxy,” I said, putting my notes down. “Sounds like a textbook case.”

Her eyes narrowed. “Yes, it does. When you hear it all strung together like this. But when you’re right in the middle of it... even now I can’t be sure.”

“You’re still considering something organic?”

“I have to until I can prove otherwise. There was another case — last year, over at County. Twenty-five consecutive admits for recurrent weird infections during a six-month period. Also a female child, attentive mother who looked too calm for the staff’s peace of mind. That baby was really going downhill and they were just about ready to call in the authorities when it turned out to be a rare immunodeficiency — three documented cases in the literature, special tests that had to be done at NIH. Moment I heard about it, I had Cassie tested for the same thing. Negative. But that doesn’t mean there isn’t some other factor I haven’t caught. New stuff keeps popping up — I can barely keep up with the journals.”

She moved her spoon around in her coffee.

“Or maybe I’m just denying — trying to make myself feel better for not seeing the Munchausen thing sooner. Which is why I called you in — I need some direction, Alex. Tell me which way to go with this.”

I thought for a while.

Munchausen syndrome.

A.k.a. Pseudologia fantastica .

A.k.a. factitious illness disorder.

An especially grotesque form of pathological lying, named after Baron von Munchausen, the world-class prevaricator.

Munchausen is hypochondriasis gone mad. Patients fabricating disease by mutilating and poisoning themselves, or just lying. Playing mind games with physicians and nurses — with the health-care system itself.

Adult Munchausen patients manage to get hospitalized repeatedly, medicated needlessly, even cut open on the operating table.

Pitiful, masochistic, and perplexing — a twist of the psyche that still defies comprehension.

But what we were considering here was beyond pity. It was an evil variant:

Munchausen by proxy .

Parents — mothers, invariably — faking illness in their own offspring. Using their children — especially daughters — as crucibles for a hideous concoction of lies, pain, and disease.

I said, “So much of it fits, Steph. Right from the beginning. The apnea and passing out could be due to smothering — those movement artifacts on the monitor could mean she was struggling.”

She winced. “God, yes. I just did some reading, found a case in England where movement artifacts tipped them off to the baby being smothered.”

“Plus, with mom being a respiratory tech, breathing could be the first system she’d choose to mess with. What about the intestinal stuff? Some kind of poisoning?”

“Most likely, but it’s nothing the tox panel could come up with when they tested.”

“Maybe she used something short-acting.”

“Or an inert irritant that activated the bowel mechanically, but passed right through.”

“And the seizures?”

“Same thing, I guess. I don’t know , Alex. I really don’t know .” She squeezed my arm again. “I’ve got no evidence at all and what if I’m wrong? I need you to be objective. Give Cassie’s mom the benefit of the doubt — maybe I’m misjudging her. Try to get into her head.”

“I can’t promise a miracle, Steph.”

“I know. But anything you can do will be helpful. Things could get really messy with this one.”

“Did you tell the mother I’d be consulting?”

She nodded.

“Is she more amenable to a psych consult now?”

“I wouldn’t say amenable, but she agreed. I think I convinced her by backing away from any suggestion that stress was causing Cassie’s problems. Far as she’s concerned, I think the seizures are bona fide organic. But I did press the need for helping Cassie adjust to the trauma of hospitalization. Told her epilepsy would mean Cassie can expect to see a lot more of this place and we’re going to have to help her deal with it. I said you were an expert on medical trauma, might be able to do some hypnosis thing to relax Cassie during procedures. That sound reasonable?”

I nodded.

“Meanwhile,” she said, “you can be analyzing the mother. See if she’s a psychopath.”

“If it is Munchausen by proxy, we may not be looking for a psychopath.”

“What then? What kind of nut does this to her own kid?”

“No one really knows,” I said. “It’s been a while since I looked at the literature, but the best guess used to be some kind of mixed personality disorder. The problem is, documented cases are so rare, there really isn’t a good data base.”

“It’s still that way, Alex. I looked up sources over at the med school and came up with very little.”

“I’d like to borrow the articles.”

“I read them there, didn’t check them out,” she said. “But I think I still have the references written down somewhere. And I think I remember that mixed personality business — whatever that means.”

“It means we don’t know, so we’re fudging. Part of the problem is that psychologists and psychiatrists depend on information we get from the patient. And taking a history from a Munchausen means relying upon a habitual liar. But the stories they tell, once you expose them, do seem to be fairly consistent: early experience with serious physical illness or trauma, families that overemphasized disease and health, child abuse, sometimes incest. Leading to very poor self-esteem, problems with relationships, and a pathological need for attention. Illness becomes the arena in which they act out that need — that’s why so many of them enter health professions. But lots of people with those same histories don’t become Munchausens. And the same history applies both to Munchausens who abuse themselves and the proxies who torment their kids. In fact, there’s some suggestion that Munchausen-by-proxy parents start out as self-abusers and switch, at some point, to using their kids. But as for why and when that happens, no one knows.”

“Weird,” she said, shaking her head. “It’s like a dance. I feel I’m waltzing around with her, but she’s leading.”

“Devil’s waltz,” I said.

She shuddered. “I know we’re not talking hard science, Alex, but if you could just dig your way in there, tell me if you think she’s doing it...”

“Sure. But I am a bit curious why you didn’t call in the hospital Psych department.”

“Never liked the hospital Psych department,” she said. “Too Freudian. Hardesty wanted to put everyone on the couch. It’s a moot point, anyway. There is no Psych department.”

“What do you mean?”

“They were all fired.”

“The whole department? When?”

“Few months ago. Don’t you read your staff newsletter?”

“Not very often.”

“Obviously. Well, Psych’s dissolved. Hardesty’s county contract was canceled and he never wrote any grants, so there was no financial backup. The board decided not to pick up the cost.”

“What about Hardesty’s tenure? The others — weren’t Greiler and Pantissa tenured, too?”

“Probably. But tenure, as it turns out, comes from the med school, not the hospital. So they’ve still got their titles. Salaries are a whole other story. Quite a revelation for those of us who thought we had job security. Not that anyone fought for Hardesty. Everyone thought he and his guys were deadwood.”