Factitious Disorder Imposed on Another (Munchausen by proxy)

Back

Practice Essentials

Factitious disorder imposed on another (FDIA; formerly known as factitious disorder by proxy and other similar names) has as its cardinal characteristic the production or feigning of physical or psychological symptoms in another person (usually a young child or sometimes an adult or animal) under the care of the person with the disorder. It is currently understood as including the condition commonly known as Munchausen syndrome by proxy (MSBP) and is also often termed as medical child abuse.

Signs and symptoms

Warning signs that raise the possibility of this disorder include the following:

These warning signs do not mean that FDIA is occurring, but rather indicate a need for futher investigation and verification of what is occurring.

See Presentation for more detail.

Diagnosis

Evaluation must be based on specific findings, with investigations aimed at establishing what is going on and why. Laboratory tests, imaging, and other studies performed should be appropriate to the presenting problem, but not inappropriately pursued. If factitious symptoms or signs are found, attention should be given to detecting the potential method by which they are occurring. Evaluation may also need to include other family members. 

During assessment of a potential victim in a case of FDIA, clinicians should ask themselves the following questions:

See Workup for more detail.

Management

Case management of probable or confirmed FDIA involves the following, many of which will occur simultaneously:

See Treatment for more detail.

Background

A study from 1992 suggested that parental responses to children occupy a continuum.[1] At one end of the continuum is the parent who exhibits classic neglect, disregarding symptoms in a child who is truly ill. At the other end is the parent who fabricates or generates factitious symptoms in a child who is otherwise healthy. In between are the parents who are appropriately concerned about a child’s symptoms and who make appropriate efforts to seek care for the child.

Factitious disorder imposed on another (FDIA; formerly factitious disorder by proxy) has as its cardinal characteristic the production or feigning of problems in another person (usually a young child, but sometimes an adult or animal) under the perpetrator’s care. Although this disorder is not rare, it can be difficult to detect and confirm.[2]

In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),[3] the diagnosis of factitious disorder imposed on another includes the disorder originally known as Munchausen syndrome by proxy (MSBP),[4] a term that continues to be commonly used by the general public. It is a covert, potentially lethal, and frequently misunderstood form of abuse (typically, child abuse). It was first identified by Sir Roy Meadow[4] in relation to cases of two mothers’ tampering with urine specimens. At the time, Munchausen syndrome (now called factitious disorder) was the term applied to people who presented themselves as ill. The name recalls the storied Baron von Munchhausen, who went from place to place during his career and often told tall tales.after his retirement from the military. 

Many people, professional and lay, had a difficult time believing that parents would harm their children in this way. An accumulation of documented cases and its “discovery” by popular media gradually brought wider recognition, although motivations and dynamics are still poorly understood. Nor has it always been clear whether it should be regarded more as a form of abuse or a mental illness. For example, the term medical child abuse (MCA) was proposed by Roesler and Jenny to describe the excessive, unnecessary, and harmful (or potentially harmful) medical or surgical treatments imposed on the child at the instigation of a caregiver.[5]  

In 2002, the term pediatric condition falsification (PCF) was introduced by the American Professional Society on the Abuse of Children (APSAC) to describe the condition in the abused child. APSAC defined it as comprising factitious disorder by proxy (as the disorder was then known) in the perpetrator and PCF in the victim. In 2018, the APSAC issued updated clinical and case management guidelines for FDIA/MSBP.[6]

FDIA is not a psychosis. The caretaker voluntarily and consciously simulates, falsely reports, and/or induces symptoms of a problem and then takes the victim to seek professional attention, disavowing knowledge of the source of the problem. The deception may arise from a desire for attention, anger, a need for control over others, or other intangible motivations. Perpetrator dynamics are poorly understood in most cases. Note that if the primary motivation appears to be material gain (e.g., receipt of money for a disabled person), the principal diagnosis is malingering. However, in many cases of FDIA, there is tangible gain that appears to be secondary to the non-tangible gain. FDIA and malingering are not mutually exclusive.[7]

Most of the symptoms in known and documented cases are physical complaints; feigning of behavioral symptoms appears to occur to a lesser extent. However, the full range of presentations is essentially unlimited. Physical presentations commonly include vomiting, diarrhea, respiratory arrest, asthma, seizure, recurrent conjunctivitis, clumsiness, syncope, fever, infection, bleeding, failure to thrive, or electrolytic disturbance. 

Clinicians are trained to elicit the history of a sick child from his or her parents. This standard approach carries extra risk if FDIA is occurring. Typically, a perpetrator—usually the biological mother—recounts serious symptoms that cannot be ignored. Often, these symptoms depend on observation (e.g., seizures, apnea). These reports may result in the performance of many laboratory tests and other procedures, including hospital admission and surgery.

Most known victims of FDIA are infants and young children, although cases have been reported of dependent adults and animals. Victims who are able to speak for themselves usually do not, out of motivations such as fear, belief in what the perpetrator has told them about their condition, or loyalty to the abuser. Victims not uncommonly suffer serious injury or even die.

Inconsistencies, improbable findings, or inexplicable test results should raise the suspicion of FDIA. For example, polymicrobial sepsis in a central line is extremely rare and should elicit consideration of the possibility of tampering. As another example, finding carbamazepine in the blood of a patient to whom the drug was not prescribed or finding a high level in a patient in whom it was discontinued should suggest possible FDIA. Of course, other reasonable potential causes must be ruled out before a conclusion is made that FDIA is occurring.

A multidisciplinary team approach is recommended to confirm the diagnosis and protect the victim. Long-term psychiatric follow-up is necessary for both the child and the perpetrator, although the outcome for perpetrators is often poor. Educating providers in healthcare, protective services, and other fields about the disorder and establishing local task forces may facilitate timely diagnosis and management. These systems may, unknowingly, play a partial role in the perpetration of FDIA.

Diagnostic criteria (DSM-5 and American Academy of Pediatrics)

In DSM-5, factitious disorder is divided into the following 2 types:[3]

When an individual falsifies illness in another (eg, a child, an adult, or a pet), the diagnosis of the perpetrator is factitious disorder imposed on another. The specific DSM-5 criteria for factitious disorder imposed on another are as follows[3] :

As noted, this diagnosis is applied to the perpetrator, not the victim; the victim may be given an abuse diagnosis. Depending on definitions in the area where the abuse has occurred, various categories of abuse and/or neglect may apply. For example, educational neglect might be considered if the feigned problem has led to many school absences.[9]  Under no circumstances should the diagnosis of FDIA be construed as the perpetrator “having” a mental disorder that causes, accounts for, or “explains away” the behavior.

For purposes of comparison, the specific DSM-5 criteria for factitious disorder imposed on self are as follows[3] :

In both types of factitious disorder, the duration is specified as either a single episode or recurrent episodes (≥2 events of falsification of illness or induction of injury).

According to the American Academy of Pediatrics Committee on Child Abuse and Neglect, the healthcare worker must substantiate the credibility of the signs and symptoms, determine the necessity and benefits of the medical care, and question who is the instigator of the evaluations and treatments. To make the diagnosis, the presence of the following 2 factors must be established:

The latency period between the start of abuse and its discovery can be relatively long. Several barriers often delay the timely detection and confirmation of FDIA, including the following:

Pathophysiology

There is no pathophysiology known to be associated with factitious disorder imposed on another (FDIA) perpetration. 

Etiology

Most cases of factitious disorder imposed on another (FDIA) have been reported in the pediatric medical literature. The exact psychopathology and any pathophysiology of most perpetrators are unknown.

A number of theories for the pathogenesis of FDIA have been postulated. The psychodynamic literature emphasizes a reaction to loss or a way to obtain attention and nurturing, a way to feel powerful, or a way of just acting out as possible explanations. Some investigators offer unspecified brain dysfunction as an explanation. The abuser may have experienced abuse as a child or may have failed to develop empathy for some unknown reason. Other theories include rejection of the child, perhaps resulting in part from an interruption in early bonding,[11]  a pathologic relationship with the child, psychological rewards received from the medical community or other high-status individuals because of the sick child, or a disguised need for help.

The following psychiatric comorbidities may be present:

Epidemiology

United States statistics

The incidence and prevalence of factitious disorder imposed on another (FDIA) in the United States, though not precisely known,[12] are almost certainly higher than was once estimated. In 1991, Schreier and Libow surveyed 880 pediatric neurologists and 388 pediatric gastroenterologists in the United States, with return rates of 21.8% and 32.4%, respectively.[13] Among physicians who responded, 212 reported contact with 192 suspected and 273 confirmed children victimized by FDIA.

It is estimated that approximately 625 cases of poisoning and suffocation attributable to FDIA can be expected in the United States each year. This estimate basically refers to clinically significant cases diagnosed or treated in a hospital setting and may underestimate the number of cases seen in outpatient clinics and nonmedical settings.

A 2004 meta-analysis showed that pediatric condition falsification (PCF) was the cause of 0.3% of all cases of ALTEs.[14] Another quite controversial report suggested that intentional suffocation was the cause of about 10% of all cases of SIDS.[15] In a series of 135 cases reported by K. Feldman et al., 25% of the children had renal or urologic related issues.[16]

International statistics

FDIA is increasingly recognized and reported worldwide in the medical literature. More than 700 cases from 52 countries have been reported; however, these reflect only the most severe cases and cases that have been substantiated. The true overall prevalence is unknown. Cases have come from many developing, nonmedicalized societies as well as developed countries.[17]

One group found that 1% of children with asthma had been subjected to FDIA.[18] In another report of children with food allergies, 16 of 301 children (5%) had been subjected to FDIA.[19]

In an English town with a population of 200,000, 39 cases of intentional suffocation of children were reported over 20 years (1 case per 25,000 population).[20] A survey by the British Pediatric Association Surveillance Unit found 128 cases of reported MSBP in the United Kingdom and Ireland over a period of 2 years, with an incidence of 2.8 cases per 100,000 children younger than 1 year and an incidence of 0.5 cases per 100,000 children younger than 16 years.[21]  This last study was notable for its highly conservative process to confirm MSBP, which may undercount the number of actual cases.

Age-related demographics

Demographics of perpetrators

Demographics of perpetrators is unknown, but appear to be largely people in their child-rearing years.

Demographics of victims

The abusive behavior characteristic of MSBP commonly starts early in the victim’s life; infants and young children are those most frequently exposed to MSBP. According to Rosenberg, the median age of the child at the time of MSBP diagnosis is 39.8 months, though children older than this have also been affected by caretakers with this condition.[22] McClure et al reported a median victim age of 20 months at diagnosis, with a distribution skewed toward younger individuals.[21]

A report by Meadow found that suffocation began between the first and third months of life and lasted 6-12 months or until the patient died.[23] In a review of 451 published cases, Sheridan found that affected children were usually younger than 4 years.[24] Awadallah et al reported a 14-year-old MSBP victim and 9 victims older than 6 years who were referred to child protective services between January 2001 and June 2003.[25] In their literature review, they also found 42 victims reported from 1966 to 2002. A 2015 review of adult victims of FDIA disclosed that these victims ranged from 21 to 82 years old.[26]

Demographics of victim's siblings

Siblings may suffer the same abuse that the reported FDIA victim receives, and from the same parent. According to Rosenberg, 8.5% of siblings were abused.[22] In a series of 27 infants who were suffocated, 48% had a sibling who allegedly died of Sudden Infant Death Syndrome (SIDS).[23] A survey of pediatric neurologists and gastroenterologists found that almost 25.8% of children who were abused had siblings who also were abused.

In a survey of 83 index cases of FDIA, 15 children had 18 siblings who previously died, and 5 of these deaths were classified as SIDS. In another report, 28 children subjected to FDIA had 41 siblings, 12 of whom died suddenly; 11 deaths were classified as SIDS, and 1 was attributed to gastroenteritis. Five parents admitted to killing 9 of the siblings. A meta-analysis of 451 cases of FDIA with 210 siblings revealed that 61% of the siblings had symptoms and 25% had died.[24]

In a series of 135 victims reported by K. Feldman et al from 1974 to 2006, 31 of 34 children had siblings who were also victimized; 6 of these siblings died.[16]

Sex-related demographics

Demographics of perpetrators 

In a 2017 review of 796 cases of FDIA, the mother was the perpetrator of the child’s illnesses in 95.6%[11]

Demographics of victims

Boys and girls are exposed to FDIA with approximately equal frequency.

Race-related demographics

To date, no racial or ethnic predilection for this condition has been determined. However, most of the perpetrators in published reports have been white, when race was mentioned at all.

Prognosis

Prognosis of perpetrators

Generally, prognosis in factitious disease imposed on another (FDIA) depends on perpetrator characteristics.Those with a good prognosis—admittedly rare--have the following characteristics:

Patients with a poor prognosis may exhibit the following signs:

Prognosis in victims

Reported morbidity and mortality in victims vary considerably, ranging from infection of unknown origin to unexplained death. The incidence of death and serious medical complications is not precisely known. Mortality ranges from 9% to 31% among index cases, with most investigators reporting a mortality of 9–10%. In a review of the literature, Sheridan reported a 6% mortality and a 7.3% long-term injury rate for index cases.[24]

Morbidity may result either from the abuse or from multiple interventions performed by unwitting medical and other providers. McClure et al. reported that 122 of 128 abused children were hospitalized as a result of the abuse; of the 128, 119 received unnecessary invasive interventions, 45 had major medical illnesses, 31 had minor physical ailments, and 8 died.[21] In a survey of 51 clinics treating infant apnea, 54 of 20,090 children had been subjected to FDIA.[28] Cardiopulmonary resuscitation was performed in 21 of the 54, and 24 were hospitalized.

Children subjected to FDIA present not only with induced physical ailments but also with fabricated psychological symptoms. Like those abused in other ways, children subjected to FDIA can also have long-term emotional, psychological/behavioral, and educational disorders. Lacking good parental models, it is possible that they will treat their own children as they were treated.

McGuire and K. Feldman described 6 children who had behavioral problems, including feeding disorders in infants; withdrawal, hyperactivity, and oppositional behaviors in preschoolers; and conversion symptoms in older children and adolescents.[29] Older children often tolerated and cooperated with their parents in their own abuse and fabricated medical illnesses of their own.

Bools et al reported the outcome of 54 children aged 1–14 years who were subjected to FDIA.[30] Several of them had behavioral problems, such as emotional and conduct disorders, achievement problems, nonattendance at school, fears and avoidance of specific places or situations, sleep disturbances, or features of posttraumatic stress disorder (PTSD). Boys had more disturbances than girls. Most of the children who remained with their mothers were exposed to repeated fabrication or were described as having other problems. Children with unacceptable outcomes were older than others at the time of abuse and were more likely to have siblings who had also been subjected to abuse.

Libow reported the results of a 33-item questionnaire administered to 10 adults who identified themselves as survivors of FDIA during childhood.[31] At the time of abuse, the respondents felt unsafe and unloved by their parents. As children, they had emotional stress and serious depression. They also reported problems with school and education as a result of absenteeism, lack of attention, or anxiety. As adults, they had insecurity, low self-esteem, depression, and symptoms of PTSD.

Patient Education

There is no evidence to suggest that education of the factitious disorder imposed on another perpetrator is useful, as the perpetrator’s problem is not a lack of knowledge. It may be important to educate the family and professional staff about FDIA. Education for the victim, such as the book by Feldman and Yates, Dying to be Ill: True Stories of Medical Deception, may be useful if/when the victim is able to understand psychological concepts.

Ethical and Legal Issues

The Federal Child Abuse Prevention and Treatment Act defines child maltreatment as “[a]ny recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation . . . or an act or failure to act which presents an imminent risk of serious harm.” Factitious disorder imposed on another (FDIA) is usually difficult to prove; abusers are typically not caught in the act, and cases are usually based on circumstantial evidence.

When FDIA is suspected, the law requires physicians and other designated professionals to notify the authorities. Details will differ depending on the jurisdiction, but typically protective services must be involved for children and elders (all dependent adults in some jurisdictions). Reports to and action by animal welfare organizations and law enforcement may be important. It may be necessary for the reporter to educate the involved agency(ies) about the nature of FDIA and especially what has happened to the victim and how this behavior constitutes maltreatment. Offering written resources about how to investigate may be very useful for agencies and law enforcement personnel.[32]

Steps for the immediate protection of the victim may be initiated by law enforcement and/or protective services. Often this involves removal of the victim from the home, at least until the situation can be completely assessed. A court order may be needed to remove the victim from the perpetrator and/or keep the victim in a safe placement. In this case, or in later court proceedings, the personnel assisting with making the report may be required to testify.

Once protective measures are in place, the perpetrator should be confronted with the evidence. This confrontation should be planned carefully with protection in place for the victim, perpetrator, and involved professionals. The perpetrator will almost certainly deny the charge and may attempt to remove the victim from the hospital or placement. If allowed any contact with the victim, perpetrators may intensify the abuse in an attempt to “prove” that the problem is “real.” Perpetrators have also been known to decompensate mentally, threaten professionals, and kill or threaten to kill themselves. Criminal prosecution of the perpetrator is usually indicated, but almost all states lack specific criminal statutes governing FDIA abuse per se. Criminal prosecution may occur under charges such as assault or torture, but is often not pursued. 

The accused perpetrator is likely to continue to deny the behavior. Common defenses include assertions that the perpetrator “just did what the doctors said,” did not do what was alleged, is mentally ill and did not know what he/she was doing, and/or was compelled to commit the behavior due to mental illness. Other defenses have included attacks on the reporting professional (e.g., the doctor didn’t know what was wrong with the victim, so blamed the caregiver), or even that FDIA cannot be “proven” to exist.  Throughout the court process, a consultant and/or attorney with experience in FDIA cases can provide strategies to counter these defenses, present evidence in court, and support the professionals involved. 

FDIA cases can be very painful for those involved. It is difficult to admit that caregivers can abuse in this way. Often personal relationships have been formed with perpetrators, and these end in disillusionment and feelings of betrayal or shame. The professional who has been fooled by the perpetrator often feels embarrassed and ashamed about their part in the abuse. In spite of the difficulties, time commitments, and even dangers that may be involved with FDIA cases, both law (for mandated professionals) and ethics require that they be reported to protective services. Where the law and/or responding agencies are inadequate, the ethical response is to work for change. Changes may be effected through education, support for more training and funding, support for new legislation or legal reform, etc. It is recognized that busy professionals have limited time and energy, but a letter written, the offer to do a case conference, or support for an organization working for change can all be helpful.

History

Factitious disorder imposed on another (FDIA) generally presents through an apparently genuine problem in another person, brought to a provider for services. An assessment appropriate to the presenting problem is then undertaken, but results are inconsistent with the history as given. (This is often a long process including repeat tests, consultations with specialists and subspecialists, etc. Eventually it is suspected, then confirmed, that the problem was exaggerated and/or fabricated and/or induced. This leads to a conclusion of FDIA.

The victim’s symptoms usually occur, or at least begin, solely in the perpetrator’s presence and subside in his/her absence. The perpetrator’s partner, other family members, and healthcare workers are sometimes called to witness symptoms or a physiologically normal event (e.g., mild discoloration with crying). The perpetrator later uses these witnessed events to substantiate an alleged illness of the child.

Characteristics of perpetrators

Individuals who perpetrate abuse in this manner are frequently described as caring, attentive, and devoted individuals—at least when they are being observed. However, not all perpetrators fit this profile. Some can be hostile and/or emotionally labile. Although they may have no obvious psychopathology, even on psychological testing, perpetrators can be deceiving and manipulative. They may be ingratiating with professionals. Their ability to mislead and convince others, including professionals such as the family pediatrician, should not be underestimated. Their abuse is premeditated, calculated, and unprovoked.

Bass et al suggest that a chronic somatic symptom disorder or factitious disorder is present in mothers who cause their children to be ill. In their study, half of the mothers exhibited pathologic lying; for some, this dated back to adolescence and often continued into adult life. The authors suggest that any psychiatrists who encounter women with chronic somatic symptom disorder or factitious disorder should be alert to the impact of these illnesses on any dependent children, especially if evidence suggests lying from an early age.[33]

Few publications have reported fathers as the primary perpetrators in substantiated cases. In these cases the fathers did not fit the devoted-parent profile, but were described as emotionally disturbed and mentally unstable.[34] Other reported perpetrators in cases of FDIA have been stepparents, grandparents, foster parents, and other caregivers (e.g., babysitters).

Typical characteristics of known perpetrators in  FDIA may be summarized as follows:

The perpetrator may have previous healthcare knowledge or training[35] and often is fascinated by the medical field. In one study, 80% of the documented perpetrators—all of them mothers—worked or had worked in healthcare or child-care facilities. Perpetrators aspire to establish close relationships with medical staff and frequently become a source of apparent support for staff members or the families of other patients.

The perpetrator often appears unexpectedly calm in the face of the perplexing problems that the victim is experiencing. She/he tends to insist on pursuing additional diagnostic and therapeutic options, regardless of the pain and discomfort they may inflict on the victim, and almost always resists discharge orders and negative diagnostic findings. If a provider becomes suspicious or reluctant to continue evaluations, she/he may take the victim elsewhere. From this has come the observation that some perpetrators are “doctor shoppers” or “doctor addicts.”[36]

Perpetrators recognize their wrongful behavior but take great care to conceal it, rarely admitting to their abusive activities. Relations among the perpetrator, the victim, and the primary treating professional may be extended and complex. This heightened level of involvement may hinder the provider from considering FDIA in the differential diagnosis list. It may turn providers, other staff, neighbors, media, etc. into staunch advocates for the abuser.

A significant percentage of perpetrators also induce symptoms in themselves, or have done so in the past. The pattern of lying and fabrication may extend to other aspects of their lives (e.g., employment, education, marital status, and illnesses). Severe mental illness (eg, schizophrenia) is rare, though the presence of 1 or more personality disorders is common. The perpetrator may also have a history of an excessive drive to seek attention, even beginning in childhood. The family history may reveal various types of abuse, unusual diseases in multiple family members, and family interactions that reward illness.

Characteristics of others

Characteristics of siblings or close associates of victims

It has often been found that siblings of victims have been the targets of FDIA abuse, and often in the same way. At the extreme, multiple children may have been killed. For this reason, assessments in cases of FDIA should not be limited just to the victim. We hypothesize that close associates of non-pediatric victims might also be abused, or have a history of abuse, in the same way. For example, if someone is caring for several elders in their home, and one presents with FDIA abuse, it would be indicated to assess the current and past residents in the home.

Characteristics of the perpetrator’s partner

The mother’s partner/victim’s father is often portrayed in the literature as disengaged from the family.[34] Common characteristics of the father as described there include the following:

Partners who are trusting and unsuspecting may support the perpetrators and unknowingly become passive accomplices in the ongoing abuse. Other partners are abusive or uncommitted in their relationships with the mothers. In some cases, the abusing mother may be fabricating her child’s symptoms in an attempt to bring her partner back into the family.

Although this is the picture portrayed in the literature, clinical experience suggests that many fathers, especially when they are no longer in the abuser’s home, are highly concerned, recognize the possible abuse, and take action—often at considerable sacrifice—to protect their children.

Characteristics of healthcare professionals

Whether particular characteristics of certain physicians facilitate this type of abuse is unclear. Squires and Squires discussed several factors in the modern medical environment that may prevent earlier diagnosis of this condition, such as the following:[37]

Characteristics of victims

Victims experiencing FDIA-related abuse can present with an array of ailments in different organ systems. Reports from the first 20 years after the condition was identified describe in children 68 symptoms, signs, and laboratory findings in 117 cases of FDIA, with approximately 70% of induced or fabricated symptoms occurring in the hospital.[22]

More than 100 symptoms have been reported overall, with the most common being abdominal pain, vomiting, diarrhea, weight loss, seizures, apnea, infections, fevers, bleeding, poisoning, lethargy, and rash. One group reported multiple illnesses in 64% of 56 index children subjected to medical abuse.[38] Other reports indicate that some children initially present with a single serious event (e.g., a severe episode of apnea with no previous history of fabrication).

These signs and symptoms may be: 

All of these can be highly dangerous, because all of them can lead to medical or other testing, procedures, medications, etc. These may have side effects, cause pain, lead the victim to miss school or other normal activities, lead to stigmatization, and so on.

Older FDIA victims often go along with the deceptions by confirming even the most unlikely stories about their medical histories, whether from fear or from persuasion. Some of them believe that they are ill with a mysterious disorder that the physicians cannot figure out; others are aware that the mother’s explanation is improbable but fail to speak, fearing punishment, disbelief, or rebuttal. A report on FDIA cases in older children (> 6 years) found induced illnesses in 57%, tampering with records or specimens in 14%, and false reporting in 62%.[25]

Some examples of common victim presentations, with indications of how they may be exaggerated, fabricated, and/or induced, include the following. Note that these are only a small number of possible presenting problems and abuse methods.

Physical Examination

Physical examination of the perpetrator

This is seldom indicated.

Physical examination of the victim

Complete mental status, physical, and neurologic examinations should be performed to assist with the evaluation, the treatment of any problems present, and to exclude other disease processes.

Other Assessment Considerations

During assessment of a potential victim in a case of factitious disorder imposed on another (FDIA), clinicians should ask themselves the following questions:[42]

Complications

Complications in perpetrators

Under stress, perpetrators may decompensate mentally, become (or present themselves as) ill, and even threaten or commit suicide. If they are hospitalized during the investigation of the victim’s situation, this step will require information exchange (subject to legal requirements), education of treating professionals, and enhanced case coordination.

Complications in victims

Even if the abuse is “only” exaggeration, factitious disorder imposed on another (FDIA) can set off a cascade including serious problem-related complications, continued or heightened abuse, multiple hospitalizations, disability, and the death of the victim. Research suggests that the death rate for child victims of FDIA is approximately 10%.[24]

Clinicians should remember that the presence of a real problem does not preclude the presence of FDIA. Cases in which genuine problems co-exist with FDIA abuse can be very difficult to untangle.

Complications in case management

Because FDIA cases challenge our social understandings of caregiving, they can be highly emotional.  Institutional policies (e.g., around reporting to protective agencies) and interpersonal politics can make case assessment and management more difficult. For example, other personnel have been known to conceal information, side with the perpetrator, and engage in “turf wars.” Higher-status personnel have sometimes not listened to information from lower-status personnel—to their detriment. FDÍA perpetrators’ ability to deceive, manipulate, and ingratiate themselves with selected people must not be underestimated. They may flatter the professional, saying, “You’re the only one who can help me.” They may set one or more staff members against another. Dual relationships with them should be avoided. They may join with others (e.g., on Internet groups) who have a vested interest in discrediting the concept of FDIA or those who practice in the field.

Approach Considerations

A stepwise approach to the diagnosis of FDIA may include some or all of the considerations listed below, as they apply to the situation:[43]

Laboratory Studies

There are no laboratory studies, imaging, or other tests appropriate for the perpetrator of factitious disorder imposed on another (FDIA). Note that psychological testing may help determine any pathology of the perpetrator, but cannot determine whether FDIA has been perpetrated.

Because of the varied presentations of FDIA, an exhaustive list of laboratory studies, imaging, and other tests appropriate to the victim is beyond the scope of this article. 

Approach Considerations

Treatment of factitious disorder imposed on another (FDIA) most centrally involves protecting and treating the victim (most commonly, a child). Attention should also be paid to the perpetrator (typically a parent, most frequently the biologic mother) and the family.[46, 47]

Common steps in case management following the confirmation of FDIA include:

Treatment of the FDIA Perpetrator

Treatment of the person who has perpetrated factitious disorder imposed on another (FDIA) involves thorough evaluation, individual therapy, and other facets. Without successful treatment, the relapse rate is high. However, treatment is difficult because those with the disorder often deny there is a problem. The success of treatment depends on the person’s ability and willingness to tell the truth. FDIA perpetrators may be so entrenched in their deception that they have trouble telling fact from fiction.

It is important not to overlook any real medical and other psychiatric illnesses that may be present. Clinical investigations are conducted to determine if there are other problems that require treatment.  Psychotherapy generally focuses on changing the thinking and behavior of the individual with the disorder.[12]  Therapy is aimed at decreasing anxiety, stressors, and other problems that perpetuate the illness. Elements of therapy in FDIA perpetrators include the following:[48]

If the patient cannot overcome the issues found, the prognosis for recovery is poor and reunification with the victim should not be considered.

No information is available regarding the use of medications in the treatment of FDIA per se.  Antidepressants or mood stabilizers can assist to the extent that depression or bipolar disorder are “driving” the abusive behaviors.

Treatment of the Abuse Victim

The primary concern in cases of factitious disorder imposed on another (FDIA) is to ensure the safety and protection of the victim. Treatment for the child comprises several areas, as follows:

Treatment of the Family

The family in which factitious disorder imposed on another (FDIA) has occurred may need consultation with mental or other health professionals to understand the deception, how the determination was made, and the prognosis and plans for the future. Continued mental health services may be necessary to assist one or more family members in coming to terms with the situation.

In some jurisdictions, family will be considered the first resource for victim placement. If this is part of planning, it is vital that potential caregivers understand and accept the FDIA determination, and agree to work cooperatively with protective services. 

If other children live in the victim’s home, their status should be evaluated, especially for purported problems similar to the victim’s. Appropriate treatment should be provided

Consultations

Many authorities feel that timely diagnosis and appropriate management of factitious disorder imposed on another (FDIA) are best achieved if professionals from multiple disciplines are involved. Consultations with the following may be indicated:

Author

Marc D Feldman, MD, Voluntary Adjunct Professor, University of Alabama School of Medicine; Clinical Adjunct Professor of Psychiatry and Behavioral Medicine, Adjunct Professor, Department of Psychology, The University of Alabama

Disclosure: Received income in an amount equal to or greater than $250 from: Taylor & Francis/Routledge Publishers.

Coauthor(s)

Mary S Sheridan, PhD, ACSW, Emeritus Professor of Social Work, Hawaii Pacific University

Disclosure: Nothing to disclose.

Chief Editor

Glen L Xiong, MD, Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SafelyYou, Blue Cross Blue Shield<br/>book co-editor for: Wolter Kluwer, American Psychiatric Publishing Inc.

Additional Contributors

Guy E Brannon, MD, Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Disclosure: Received income in an amount equal to or greater than $250 from: Sunovion; Forest.

Ibrahim Abdulhamid, MD, Associate Professor of Pediatrics, Wayne State University School of Medicine; Director of Pediatric Pulmonary Medicine, Clinical Director of Pediatric Sleep Laboratory, Children's Hospital of Michigan

Disclosure: Nothing to disclose.

Michael P Poirier, MD, Associate Professor of Pediatrics, Eastern Virginia Medical School; Attending Physician, Division of Emergency Medicine, Children's Hospital of The King's Daughters

Disclosure: Nothing to disclose.

Acknowledgements

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences,and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Angelo P Giardino, MD, PhD, MPH Associate Professor, Baylor College of Medicine; Chief Medical Officer, Texas Children's Health Plan; Chief Quality Officer, Medicine, Texas Children's Hospital

Angelo P Giardino, MD, PhD, MPH is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Robert Harwood, MD, MPH, FACEP, FAAEM Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Jon Donavon Mason, MD, FAAP, FACEP Professor of Emergency Medicine and Pediatrics, Department of Emergency Medicine, Eastern Virginia Medical School

Jon Donavon Mason, MD, FAAP, FACEP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Caroly Pataki, MD Clinical Professor of Psychiatry and Pediatrics, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

  1. Eminson DM, Postlethwaite RJ. Factitious illness: recognition and management. Arch Dis Child. 1992 Dec. 67(12):1510-6. [View Abstract]
  2. Galvin HK, Newton AW, Vandeven AM. Update on Munchausen syndrome by proxy. Curr Opin Pediatr. 2005 Apr. 17(2):252-7. [View Abstract]
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. 324-326.
  4. Meadow R. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 1977 Aug 13. 2(8033):343-5. [View Abstract]
  5. Roesler T, Jenny C. Medical Child Abuse. Beyond Munchausen Syndrome by Proxy. American Academy of Pediatrics; 2009.
  6. APSAC Task Force. Munchausen by Proxy (MBP): Clinical & Case Management Guidance. The American Professional Society on the Abuse of Children. Available at https://docs.wixstatic.com/ugd/4700a8_3a615184374e4210b739f7b75721b567.pdf. December 12, 2017; Accessed: June 25, 2020.
  7. Amlani A, Grewal GS, Feldman MD. Malingering by Proxy: A Literature Review and Current Perspectives. J Forensic Sci. 2016 Jan. 61 Suppl 1:S171-6. [View Abstract]
  8. ASHER R. Munchausen's syndrome. Lancet. 1951 Feb 10. 1(6650):339-41. [View Abstract]
  9. Frye EM, Feldman MD. Factitious disorder by proxy in educational settings: a review. Psychology Review. 2012. 24:47-61.
  10. Kaufman KL, Coury D, Pickrel E, McCleery J. Munchausen syndrome by proxy: a survey of professionals' knowledge. Child Abuse Negl. 1989. 13(1):141-7. [View Abstract]
  11. Yates G, Bass C. The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) - A systematic review of 796 cases. Child Abuse Negl. 2017 Oct. 72:45-53. [View Abstract]
  12. Forsyth B. 102. Lewis M, ed. Child and Adolescent Psychiatry. 3rd ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2002. 1223-1230.
  13. Schreier HA, Libow JA, eds. Hurting for Love: Munchausen by Proxy Syndrome. New York, NY: Guilford; 1993.
  14. McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. 2004 Nov. 89(11):1043-8. [View Abstract]
  15. Craft AW, Hall DM. Munchausen syndrome by proxy and sudden infant death. BMJ. 2004 May 29. 328(7451):1309-12. [View Abstract]
  16. Feldman KW, Feldman MD, Grady R, Burns MW, McDonald R. Renal and urologic manifestations of pediatric condition falsification/Munchausen by proxy. Pediatr Nephrol. 2007 Jun. 22(6):849-56. [View Abstract]
  17. Ifere OA, Yakubu AM, Aikhionbare HA, Quaitey GE, Taqi AM. Munchausen syndrome by proxy: an experience from Nigeria. Ann Trop Paediatr. 1993. 13 (3):281-4. [View Abstract]
  18. Godding V, Kruth M. Compliance with treatment in asthma and Munchausen syndrome by proxy. Arch Dis Child. 1991 Aug. 66(8):956-60. [View Abstract]
  19. Warner JO, Hathaway MJ. Allergic form of Meadow's syndrome (Munchausen by proxy). Arch Dis Child. 1984 Feb. 59(2):151-6. [View Abstract]
  20. Oliver JE. Successive generations of child maltreatment: social and medical disorders in the parents. Br J Psychiatry. 1985 Nov. 147:484-90. [View Abstract]
  21. McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child. 1996 Jul. 75(1):57-61. [View Abstract]
  22. Rosenberg DA. Web of deceit: a literature review of Munchausen syndrome by proxy. Child Abuse Negl. 1987. 11(4):547-63. [View Abstract]
  23. Meadow R. Suffocation, recurrent apnea, and sudden infant death. J Pediatr. 1990 Sep. 117(3):351-7. [View Abstract]
  24. Sheridan MS. The deceit continues: an updated literature review of Munchausen Syndrome by Proxy. Child Abuse Negl. 2003 Apr. 27(4):431-51. [View Abstract]
  25. Awadallah N, Vaughan A, Franco K, Munir F, Sharaby N, Goldfarb J. Munchausen by proxy: a case, chart series, and literature review of older victims. Child Abuse Negl. 2005 Aug. 29(8):931-41. [View Abstract]
  26. Burton MC, Warren MB, Lapid MI, Bostwick JM. Munchausen syndrome by adult proxy: a review of the literature. J Hosp Med. 2015 Jan. 10 (1):32-5. [View Abstract]
  27. Sanders MJ, Bursch B. Psychological Treatment of Factitious Disorder Imposed on Another/Munchausen by Proxy Abuse. J Clin Psychol Med Settings. 2020 Mar. 27 (1):139-149. [View Abstract]
  28. Light MJ, Sheridan MS. Munchausen syndrome by proxy and apnea (MBPA). A survey of apnea programs. Clin Pediatr (Phila). 1990 Mar. 29(3):162-8. [View Abstract]
  29. McGuire TL, Feldman KW. Psychologic morbidity of children subjected to Munchausen syndrome by proxy. Pediatrics. 1989 Feb. 83(2):289-92. [View Abstract]
  30. Bools CN, Neale BA, Meadow SR. Follow up of victims of fabricated illness (Munchausen syndrome by proxy). Arch Dis Child. 1993 Dec. 69(6):625-30. [View Abstract]
  31. Libow JA. Munchausen by proxy victims in adulthood: a first look. Child Abuse Negl. 1995 Sep. 19(9):1131-42. [View Abstract]
  32. Weber MC. Investigating medical child abuse. FBI Law Enforcement Bulletin. August 20, 2018. Available at https://leb.fbi.gov/articles/featured-articles/investigating-medical-child-abuse.
  33. Bass C, Jones D. Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011 Aug. 199(2):113-8. [View Abstract]
  34. Morrell B, Tilley DS. The role of nonperpetrating fathers in Munchausen syndrome by proxy: a review of the literature. J Pediatr Nurs. 2012 Aug. 27(4):328-35. [View Abstract]
  35. Meadow R. Munchausen syndrome by proxy. Arch Dis Child. 1982 Feb. 57(2):92-8. [View Abstract]
  36. Libow JA, Schreier HA. Three forms of factitious illness in children: when is it Munchausen syndrome by proxy?. Am J Orthopsychiatry. 1986 Oct. 56 (4):602-611. [View Abstract]
  37. Squires JE, Squires RH Jr. Munchausen syndrome by proxy: ongoing clinical challenges. J Pediatr Gastroenterol Nutr. 2010 Sep. 51(3):248-53. [View Abstract]
  38. Bools CN, Neale BA, Meadow SR. Co-morbidity associated with fabricated illness (Munchausen syndrome by proxy). Arch Dis Child. 1992 Jan. 67(1):77-9. [View Abstract]
  39. Southall DP, Plunkett MC, Banks MW, Falkov AF, Samuels MP. Covert video recordings of life-threatening child abuse: lessons for child protection. Pediatrics. 1997 Nov. 100(5):735-60. [View Abstract]
  40. Carter KE, Izsak E, Marlow J. Munchausen syndrome by proxy caused by ipecac poisoning. Pediatr Emerg Care. 2006 Sep. 22(9):655-6. [View Abstract]
  41. Eldridge DL, Van Eyk J, Kornegay C. Pediatric toxicology. Emerg Med Clin North Am. 2007 May. 25(2):283-308; abstract vii-viii. [View Abstract]
  42. Siegel PT, Fischer H. Munchausen by proxy syndrome: barriers to detection, confirmation, and intervention. Child Serv Soc Policy Res Pract. 2001. 4:31-50.
  43. Lasher LJ, Sheridan MS. Munchausen by Proxy: Identification, Intervention, and Case Management. New York, NY: Routledge; 2004.
  44. Hall DE, Eubanks L, Meyyazhagan LS, Kenney RD, Johnson SC. Evaluation of covert video surveillance in the diagnosis of munchausen syndrome by proxy: lessons from 41 cases. Pediatrics. 2000 Jun. 105(6):1305-12. [View Abstract]
  45. Brown AN, Gonzalez GR, Wiester RT, Kelley MC, Feldman KW. Care taker blogs in caregiver fabricated illness in a child: a window on the caretaker's thinking?. Child Abuse Negl. 2014 Mar. 38 (3):488-97. [View Abstract]
  46. Bursch B, Emerson ND, Sanders MJ. Evaluation and Management of Factitious Disorder Imposed on Another. J Clin Psychol Med Settings. 2019 Oct 14. [View Abstract]
  47. von Hahn L, Harper G, McDaniel SH, Siegel DM, Feldman MD, Libow JA. A case of factitious disorder by proxy: the role of the health-care system, diagnostic dilemmas, and family dynamics. Harv Rev Psychiatry. 2001 May-Jun. 9 (3):124-35. [View Abstract]
  48. Feldman MD, Yates GP. Dying to be Ill: True Stories of Medical Deception. New York, NY: Routledge; 2018.
  49. Bryk M, Siegel PT. My mother caused my illness: the story of a survivor of Münchausen by proxy syndrome. Pediatrics. 1997 Jul. 100(1):1-7. [View Abstract]
  50. Kucuker H, Demir T, Oral R. Pediatric condition falsification (Munchausen syndrome by Proxy) as a continuum of maternal factitious disorder (Munchausen syndrome). Pediatr Diabetes. 2010 Dec. 11(8):572-8. [View Abstract]
  51. Kenedi CA, Shirey KG, Hoffa M, Zanga J, Lee JC, Harrison JD, et al. Laboratory diagnosis of factitious disorder: a systematic review of tools useful in the diagnosis of Munchausen's syndrome. N Z Med J. 2011 Sep 9. 124(1342):66-81. [View Abstract]
  52. [Guideline] Stirling J Jr. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics. 2007 May. 119(5):1026-30. [View Abstract]
  53. Meadow R. Management of Munchausen syndrome by proxy. Arch Dis Child. 1985 Apr. 60(4):385-93. [View Abstract]
  54. Berg B, Jones DP. Outcome of psychiatric intervention in factitious illness by proxy (Munchausen's syndrome by proxy). Arch Dis Child. 1999 Dec. 81(6):465-72. [View Abstract]
  55. Stirling J Jr, American Academy of Pediatrics Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics. 2007 May. 119 (5):1026-30. [View Abstract]