Factitious disorders, and their offspring factitious disorder Munchausen syndrome by proxy, necessarily implicate medical and health care professionals in their systems of abuse. Doctors are involved whether they wish it or not, and too frequently they are (unwittingly) complicit. These disorders challenge our ways of thinking about our patients, our professional identities and the contract or ‘bargain’ implicit within the therapeutic relationship. This contract is itself rapidly changing in these times of patients' increasing access to information and heightened expectations. Factitious disorders are part of a specific group within the category of somatoform disorders in which patients typically — and sometimes angrily — deny their emotional distress and reject psychological explanation and help. Frequently, they are met with a response from a health care professional that is iterative of this denial and reinforces the ‘somatic’, rather than with curiosity for the truths that lie beyond the ‘fabulation sickness’.

As Eminson writes, “Exploration of the beliefs of the healthcare provider is the starting point for study of Munchausen syndrome by proxy abuse”. It seems ironic, but not inappropriate, that a group of ‘fabricators’ whose pathological drive is to ‘medicalise’ their existential, psychosocial and relationship difficulties, should (belatedly) force the medical profession to examine exactly this damaging feature of its own practice. Until recently, the profession has mostly responded to the challenge of factitious illness by evasion or rejection. To quote David Taylor in the book's Foreword, “It can confuse healthcare professionals whose orientation is primarily within the constraints of bioscientific medicine”, since there is no disease but much psychopathology. Further, as he writes, “In factitious illness… the truth is discoverable only in terms of an account of the fabric of the lives of the participants… the participants, in my view, include the professionals who have been caught up (or out) in the fiction”. Thus does this volume meet the challenge posed by these extraordinary behaviours and the divides they cause, with a challenge, indeed, to health care professionals themselves.

Eminson, in Chapter 1, addresses the confusions of definition and different diagnostic categorisations that these behaviours have spawned, and places them within the wider contexts of ‘abnormal illness behaviour’ and ‘abnormal consultation behaviour’. She cites three ‘ingredients’ required for Munchausen syndrome by proxy abuse: first, a health care system in which doctors, nurses and other health care personnel have almost unlimited resources and technology to undertake investigations and interventions with children; second, a dependent child available for a parent (or person in loco parentis) and under her or his control, influence or command; and third, a parent, or person in loco parentis, presenting the child to the health care system with invented symptoms or fabricated signs.

It will be noted that ‘motivation’ (e.g. the adoption of the sick role for their child and the gaining of attention thereby for themselves) is not included. Eminson provides a clear and constructive critique of those definitions that do include motivation, such as those of Meadow (Reference Meadow1995), Schreier & Libow (Reference Schreier and Libow1993) (as well as other psychodynamic formulations) and DSM—IV (American Psychiatric Association, 1994). She argues that motivation is just too problematic a criterion in what is a multidetermined and heterogeneous group of behaviours, and that its use forecloses prematurely on what as yet is poorly understood. Although I have sympathy with this purist approach, the use of the child by the adult as ‘collateral’ in accessing health care does demand understanding — and although there may be a complexity of motivations, it is difficult to resist the statement that (whatever else they are doing) they are ‘adopting the sick role’.

Eminson's two introductory chapters (formidable in their own right) are followed by a range of more specifically focused chapters. These include: accounts of diverse presentations of Munchausen syndrome by proxy in out-patients and in hospital settings; discussion of methods of ‘confirmation’ of factitious illness, including an extended consideration of the contentious issue of covert video surveillance; reviews of neurological, community paediatric and mental health presentations of Munchausen syndrome by proxy; a chapter on the overall child protection process; an account of legal aspects; and, most important, an overview of the state of the art of management, treatment and outcome.

There is a fascinating chapter giving an American perspective on the abuse of exceptional and high-achieving children as part of parental ‘achievement by proxy’ in areas such as sport, examination achievement, musical virtuosity, film performance and beauty contests. Would Leo, the father of the young Wolfgang Amadeus Mozart, have qualified for this ‘label’, I wondered.

Chapter 9 addresses the important fact that the clinician is dealing with uncertainty in most work in this area. What is needed is mature and balanced clinical judgement, especially in these days of too literal an interpretation of evidence-based practice.

Finally, in Chapter 14, the effect of these behaviours on health care staff, and ways of management and damage limitation are discussed. Support and good supervision are essential if the divisiveness that these cases engender is to be minimised.

The book is packed with clinical case vignettes, illustrating the heterogeneous presentations of the group of behaviours that go under the name of Munchausen syndrome by proxy abuse. Most pleasing of all is the cross-referencing of case examples, so that, for example, the authors of Chapter 4 comment from their own viewpoint on case vignettes contained in a number of other chapters. The coherence of the differently authored chapters and sense of editorial authority enhance the reader's confidence in the maturity of thinking and the balance of the viewpoints that the volume presents.

In my opinion this book will establish itself as the essential text for the wide range of professionals working with children, families and adults who are concerned to recognise, prevent, manage and try to understand and ‘treat’ these conditions. I would like to believe, also, that it will spur medical and other health care professions to a wider consideration of what basic assumptions underlie health care ‘contracts’ — so that the ‘normal’ patient—therapist contract (whatever that is) can be informed by the ‘incongruous’ and ‘abnormal’ consultation and illness behaviour so eloquently described in this volume.