Proxy

Proxy (pronounced prok-see)

(1) The agency, function, or power of a person authorized to act as the deputy or substitute for another.

(2) The person so authorized; substitute; agent.

(3) An authorization, usually in writing, empowering another person to vote or act for the signer, as at a meeting of stockholders.

(4) An ally or confederate who can be relied upon to speak or act in one's behalf.

(5) In computing, short for proxy server.

(6) In computing, as proxy server, an interface for a service, especially for one that is remote, resource-intensive, or otherwise difficult to use directly; technically a proxy server is a piece of software but in casual use the term is often applied also to the hardware on which it’s run.

(7) In the administration of the courts of canon law, the written appointment of a proctor in suits in the ecclesiastical courts.

(8) In science, a measurement of one physical quantity that is used as an indicator of the value of another.

(9) In munitions, a slang term for a proximity device (a mine, torpedo, missile etc) which explodes when in proximity to the target, rather than having to make physical contact.

(10)In geopolitics, as proxy war, a conflict between two or more state or non-state actors conducted on behalf of or with extensive support from other parties not directly participating in the hostilities except as “advisors”

(11) In psychiatry, as Munchausen syndrome by proxy (MSbP), a mental disorder in which a factitious disorder imposed on another for the purpose of gain the attention of medical professionals.  Now technically known as 

1400–1450: From the late Middle English prokesye, proccy & procusie (agency of one who acts instead of another, office or authority of a substitute; letter of power of attorney), a contraction of the Anglo-French procuracie and the Anglo-Norman procuracy & procuration, from the Medieval Latin procuratia, from the Latin prōcūrō (I manage, administer) & prōcūrātiō (a caring for, management) from procurare (manage).  The present participle was proxying, the simple past and past participle proxied and the noun plural proxies.

The meaning "person who is deputed to represent or act for another" is from 1610s whereas of things, "that which takes the place of something else" dates from the 1630s.  The practice of proxy voting has a long history but the term appears first to have been used Rhode Island in 1664 although then it described voters sending written ballots rather than attending the election, as opposed to would now be thought a “true” proxy system, as had be used in the assembly elections of 1647.  Proxy wars date from antiquity but the term seems first to have been used in 1955, during the high Cold War.

In computing, following the proxy server, there exists a whole ecosystem of related products & protocols including caching proxy, closed proxy, complexity-hiding proxy, dynamic proxy, firewall proxy, forward proxy, open proxy, protection proxy, remote proxy, smart-reference proxy, surrogate proxy, synchronization proxy etc.  In just about any field, there seem to be proxy somethings, including proxy statement, proxy indicator, proxy measurement, proxy abuse, proxy battle, proxy bullying, proxy card, proxy marriage, proxy murder, proxy pattern, proxy voting etc.

Munchausen syndrome by proxy (MSbP)

Although the American Psychiatric Association (APA) insist the condition has been re-named factitious disorder in another (FDIA), most still prefer the more poetic Munchausen syndrome by proxy (MSbP).  It also once was called factitious disorder imposed on another FDOA) or factitious disorder by proxy (FDP) but most agree MSbP is best.  Its primary characteristic is the production or feigning of physical or psychological symptoms in another person (usually a young child or sometimes but the proxy subject can be an adult or even an animal) under the care of the person with the disorder. The symptoms are problems which are inexplicable, persistent or resistant to interventions that, based on clinical experience, would have worked, after adequate evaluation and treatment attempts.  MSbP is a variation of Munchausen syndrome (which the APA list as factitious disorder (FD)), a mental disorder in which those affected feign (or sometimes even induce) disease, illness, injury, abuse, or psychological trauma to draw attention, sympathy, or reassurance to themselves.  The name is from the fictional character Baron Munchausen from the 1785 novel Baron Munchausen's Narrative of his Marvellous Travels and Campaigns in Russia, by German author Rudolf Erich Raspe (1736-1794), a collection of extraordinary stories, based (loosely) on the tales told by the real-life Baron Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720-1797).  The real baron was prone to quite some exaggeration in the tales of his travels but never went as far as Herr Raspe who included in his volume the eighteenth century baron flying to the moon.

Factitious disorder (FD) is an umbrella category including a range of mental disturbances in which patients intentionally act physically or mentally ill without obvious benefits.  The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR (2000)) distinguished FD from malingering, which was defined as faking illness when the individual has a clear motive (typically to avoid work, benefit financially or evade legal difficulties).  FD used to be known as "hospital addiction", "pathomimia" or "polysurgical addiction" and variant names for individuals with FD included "hospital vagrants", "hospital hoboes", "peregrinating patients", "problem patients" and "professional patients".

The syndrome has a long tradition.  The English physician Hector Gavin (1815-1855) in 1843 published On Feigned and Factitious Diseases in which he documented, drawing mostly from the records of soldiers and seamen, the means used to simulate or produce symptoms and the best techniques a clinician could use to of uncover impostors.  Two thousand-odd years earlier, the noted Roma physician Aelius Galenus (Galen, 129-216 AD) wrote of six cases in his journals and from then to the present, the medical literature is littered with examples but modern, systematic study didn’t really begin until 1961 when British endocrinologist and haematologist Richard Asher (1912-1969) published a paper.  It had been Dr Asher who, in 1951, had coined the term Munchausen syndrome to describe a chronic subtype of FD and his work is worth reading even by the medically untrained and otherwise uninterested, such is the vivid quality of the writing and the seductive use of language.  It was in these years that the condition began more fully to be understood as distinct from malingering and the term Munchausen syndrome most appropriately refers to the subset of patients who have a chronic variant of FD with predominantly physical signs and symptoms.  In practice, however, many still use the term Munchausen syndrome interchangeably with FD.  The American Psychiatric Association first classified Munchausen syndrome in the third edition of the DSM (DSM-III 1980) so, historically, the condition was under-diagnosed and the current view is these patients feign illness or injury not to achieve a clear benefit, such as financial gain, but rather to gain the sympathy and special attention often given to people who are truly ill.  There is often a willingness to undergo painful or even risky tests and operations in order to obtain this attention.  Munchausen syndrome is considered a mental illness but can just as helpfully be thought a symptom because it is associated with severe emotional difficulties.

The term Munchausen syndrome by proxy was in 1977 coined by British pediatrician Roy Meadow.  Meadow became famous also for the rule he published in his 1977 book The ABC of Child Abuse, which stated that in a single family, "one sudden infant death is a tragedy, two is suspicious and three is murder, until proved otherwise", this coming to be known as "Meadow's Law" and influential among UK social workers and child protection agencies.  His framing of the rule reflected his dogmatism and his reputation suffered as a consequence of his being struck from the British Medical Register by the General Medical Council (GMC) because of the erroneous and misleading evidence he provided in several trials which resulted in wrongful convictions although GMC’s ruling was overturned on appeal, on what might be described as public policy grounds.  Dr Meadow subsequently voluntarily relinquished his registration, thereby ensuring he could not be compelled to appear before the GMC regarding any previous professional conduct.

MSbP however survived the controversy.  Those with FD tend to be women aged 20-40 years and employed in medical fields such as nursing or other discipline where those employed enjoy familiarity with medical technology while those with chronic FD (Munchausen syndrome) are predominately unmarried, white, middle-aged men estranged from their families.  Perpetrators of Munchausen syndrome by proxy are typically mothers who induce illness in their young children although the conduct by fathers or others is not unknown.  The causes of FD, whether physical or psychiatric, are difficult to determine because affected patients are often lost to follow-up when they leave the hospital.  Magnetic resonance imaging (MRI) has been used and abnormalities in the brain structure of some patients with chronic FD have been detected but this does no more than suggest the possibility there may be some biological or genetic factors in the disorder shouldn’t be excluded.  The results of EEG (electroencephalography) studies are usually reported as non-specific and the suggestions for the causes of these disorders cast a wide net including (1) traumatic events and numerous hospitalizations during childhood, (2) FD allows patients to feel in control as they never did in childhood, (3) a coping mechanism, learned and reinforced in childhood and, intriguingly, (4). The “care-eliciting behaviors” theory, a process of unconscious identification with an important person, who genuinely has the pathology the patient is feigning.

Many authors have also underscored the co-occurrence of some pathological personality traits or disorders such as (5) identity disturbance, (6) unstable interpersonal relationships and (7), recurrent suicidal or self-mutilating behaviors which are similar to those encountered in borderline personality disorder.  Also noted have been instances of deceitfulness, lack of remorse, reckless disregard for safety of self, repeated failure to sustain constant work behavior and the failure to conform to social norms but these are common features not only of FD but of many antisocial personality disorders.  There is little agreement or evidence as to what causes Munchausen syndrome or Munchausen syndrome by proxy. Some theories suggest that the patient (or caregiver) may have experienced just about any of the conditions or experiences suffered by those with a variety of mental disorders and there seems to be no one thing or subset either exclusive or predictive.

In the DSM-5 (2013), the FD conditions were placed in the category Somatic Symptom and Related Disorders and the most precise definitional clauses were added, FD assigned to individuals who falsify illness in themselves or in another person, without any obvious gain  This combination of intentional falsification and lack of any obvious gain sets factitious disorder apart from similar conditions, such as somatic symptom disorder (where someone seeks excessive attention for genuine concerns) and malingering (where an individual falsifies symptoms for personal gain).  The condition is noted as both to diagnose and treat and, being rare (1% of individuals in hospital present with criteria matching the disorder), but the prevalence of factitious disorder throughout the general population is unknown.  Diagnosis of factitious disorder often requires a number of investigatory steps in order to accurately identify the condition without wrongful accusation, and treatment options can be both limited and difficult to administer if the individual refuses to admit the deception.  There are four primary criteria for diagnosing factitious disorder:

(1) Intentional induction or falsification of physical or psychological signs or symptoms.

(2) The individual presents themselves as ill, impaired or injured to others.

(3) The deceptive behavior persists even in the absence of external incentives or rewards.

(4) Another mental disorder does not better explain the behavior.

Factitious disorder may be diagnosed as either a single episode or as recurrent episodes (two or more instances of illness falsification and/or induction of injury) and Factitious disorder in another (formerly known as previously called Munchausen syndrome by proxy) may be broadly diagnosed using essentially the same four criteria as:

(1) Intentional induction or falsification of physical or psychological signs or symptoms in another person.

(2) The individual presents another individual (the victim) as ill, impaired or injured to others.

(3) The deceptive behavior persists even in the absence of external incentives or rewards.

(4) Another mental disorder does not better explain the behavior.

As with factitious disorder, factitious disorder in another may be diagnosed as either a single episode or as recurrent episodes (two or more instances of illness falsification and/or induction of injury). With factitious disorder in another, the victim may be assigned an abuse diagnosis as a result of the perpetrator’s behavior or actions.