Factitious Disorder Imposed on Another (Munchausen by proxy)

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Practice Essentials

Factitious disorder imposed on another (formerly factitious disorder by proxy) has as its cardinal characteristic the production or feigning of physical or psychological symptoms in another person, usually a child or adult 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).

Signs and symptoms

Common presentations of factitious disorder imposed on another (including MSBP) include the following:

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

During clinical assessment of the victim in a case of suspected MSBP, clinicians should ask themselves the following questions the following questions:

See Presentation for more detail.

Diagnosis

Evaluation must be based on specific symptoms, with specific tests aimed at detecting the potential method by which the factitious symptoms are being induced.

Laboratory tests that may be considered include the following:

Other studies that may be helpful, depending on the clinical circumstances, are as follows:

If no physical cause of the symptoms is found, a retrospective review of the child’s medical history, with careful consideration of the family history and the mother’s medical history might provide clues suggesting MSBP.

See Workup for more detail.

Management

Treatment of factitious disorder imposed on another involves treating the following:

A stepwise approach to the management of this disorder may be summarized as follows:

See Treatment for more detail.

Background

Factitious disorder imposed on another (formerly factitious disorder by proxy) has as its cardinal characteristic the production or feigning of physical or psychological symptoms in another person, usually a child or adult under the care of the individual with the disorder. Secondary or external factors are not present, and the person often lacks other mental or physical illnesses. Although this disorder is not uncommon, it can be difficult to detect and confirm.[1]

In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),[2] the diagnosis of factitious disorder imposed on another includes the disorder originally known as Munchausen syndrome by proxy (MSBP),[3] a term that continues to be commonly used in clinical practice. MSBP is a covert, potentially lethal, and frequently misunderstood form of abuse (typically, child abuse).

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 MSBP as comprising factitious disorder by proxy (as the disorder was then known) in the perpetrator and PCF in the victim.

In factitious disorder imposed on another, the caretaker voluntarily and consciously simulates or induces symptoms of an illness and then takes the child or other person to seek medical attention, disavowing knowledge of the source of the problem. The deception may arise from anger or a desire for attention, which is satisfied by having a relationship with a practitioner.

Most of the symptoms are physical complaints; feigning of mental symptoms occurs to a lesser extent. Physical presentations 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 in this setting. Typically, a parent with the disorder—usually the biologic mother—recounts serious but vague symptoms. This information may result in the performance of many laboratory tests and other procedures, including surgery. Out of fear, the child does not contradict the information. The outcome for the child could be serious injury or even death.

Inconsistent illness descriptions, improbable physical findings, or inexplicable test results should raise the suspicion of factitious disorder imposed on another. 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 MSBP.

A multidisciplinary team approach is mandatory to confirm the diagnosis and protect the victim. Long-term psychiatric follow-up is necessary for both the child and the perpetrator. Educating healthcare providers about the disorder and establishing local task forces may facilitate timely diagnosis and management. The health care system may, unknowingly, play a partial role in the perpetration of unnecessary testing and treatments. Appropriate awareness of MSBP by medical providers may prevent or minimize potential harm to victims.

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

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

When an individual falsifies illness in another (eg, a child, an adult, or a pet), the diagnosis is factitious disorder imposed on another. The specific DSM-5 criteria for factitious disorder imposed on another are as follows[2] :

This diagnosis is applied to the perpetrator, not the victim; the victim may be given an abuse diagnosis. For example, the term medical child abuse (MCA) was proposed by Roesler and Jenny to describe the excessive, unnecessary, and harmful medical or surgical treatments unknowingly imposed on the child at the instigation of a caregiver.[5]

For purposes of comparison, the specific DSM-5 criteria for factitious disorder imposed on self are as follows[2] :

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 of MSBP, 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 MSBP, including the following:

Various authors have suggested other criteria for identifying MSBP. In 1998, Parnell and Day developed 18 guidelines based on their experience and the recommendations of other authors.[7] These guidelines were divided into 3 categories according to specific features identified in the victim, the perpetrator, and the family—including many of those described above. A number of institutions have used hidden video cameras to record the child in the hospital in an effort to obtain evidence that might confirm the diagnosis.[8, 9]

Pathophysiology

Most cases of factitious disorder imposed on another have been reported in the pediatric literature. The exact pathophysiology is unknown.

A study from 1992 suggested that parental responses to children occupy a continuum.[10] 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.

Parents with MSBP who inflict abuse on their children have psychological problems that warrant professional intervention. In 1997, Bryk published a detailed description of the prolonged and horrifying abuse she sustained at the hands of her own mother.[11] This instructive article is recommended reading for any medical professional who may come into contact with the victims of this particularly insidious form of abuse.

A number of theories for the pathogenesis of factitious disorder imposed on another 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. In this theory, the mother may have experienced abuse as a child, or she may be simply rejecting her childhood for some unknown reason.

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 disorders should be alert to the impact of these illnesses on any dependent children, especially if evidence suggests lying from an early age.[12]

Etiology

Research has not yet established a single cause for factitious disorder imposed on another. Major causes may include the following:

The following psychiatric comorbidities may be present:

Epidemiology

United States statistics

The incidence and prevalence of factitious disorder imposed on another in the United States, though not precisely known,[13] 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.[14] Among physicians who responded, 212 reported contact with 192 suspected and 273 confirmed children exposed to MSBP.

It is estimated that approximately 625 cases of poisoning and suffocation attributable to MSBP can be expected in the United States each year. Schreier had predicted an incidence of 1200 new cases per year in the United States, but this number was subsequently revised downward, to about 200 per 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.

International statistics

Factitious disorder imposed on another is increasingly recognized and reported worldwide. More than 700 cases from 52 countries have been reported in the literature; however, these reflect only the most severe cases and cases that have been substantiated. The true overall prevalence is unknown.

One group found that 1% of children with asthma had been subjected to MSBP.[15] In another report of children with food allergies, 16 of 301 children (5%) had been subjected to MSBP.[16]

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).[17] 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.[18]

Age-related demographics

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.[19] McClure et al reported a median victim age of 20 months at diagnosis, with a distribution skewed toward younger individuals.[18]

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.[20] In a review of 451 published cases, Sheridan found that affected children were usually younger than 4 years.[21] 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.[22] In their literature review, they also found 42 victims reported from 1966 to 2002.

Siblings may receive the same abuse that the reported MSBP victim receives, and from the same parent. According to Rosenberg, 8.5% of siblings were abused.[19] In a series of 27 infants who were suffocated, 48% had a sibling who allegedly died of sudden infant death syndrome (SIDS).[20] 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 MSBP, 15 children had 18 siblings who previously died, and 5 of these deaths were classified as SIDS. In another report, 28 children subjected to MSBP 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 MSBP with 210 siblings revealed that 61% of the siblings had symptoms and 25% had died.[21]

In a series of 135 victims reported by Feldman et al from 1974 to 2006, 31 of 34 children had siblings who were also victimized resulting; 6 of these siblings died.[23]

Sex-related demographics

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

In more than 95% (perhaps as many as 98%[24] ) of cases of MSBP, the mother is the perpetrator of the child’s illnesses. In a review by Sheridan, mothers were the perpetrators in 76.5% of 451 cases, and fathers were the perpetrators in 6.7%.[21] In a series of 135 patients reported by Feldman et al, The mother was the perpetrator in almost all of the cases.[23]

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

Race-related demographics

To date, no racial or ethnic predilection for this condition has been determined. However, most of the mothers in published reports have been white.

Prognosis

Generally, prognosis in factitious disease imposed on another depends on patient characteristics. Patients with a good prognosis have the following characteristics:

Patients with a poor prognosis may exhibit the following signs:

Reported morbidity and mortality 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.[21]

Morbidity may result either from the abuse or from multiple interventions performed by unwitting physician facilitators. McClure et al reported that 122 of 128 abused children were hospitalized as a result of abuse; of the 128, 119 received unnecessary invasive interventions, 45 had major medical illnesses, 31 had minor physical ailments, and 8 died.[18] In a survey of 51 clinics treating infant apnea, 54 of 20,090 children had been subjected to MSBP.[25] Cardiopulmonary resuscitation was performed in 21 of the 54, and 24 were hospitalized.

Children subjected to MSBP present not only with induced physical ailments but also with fabricated psychological symptoms. Like those receiving other types of abuse, children subjected to MSBP can have long-term emotional and psychological disorders.

McGuire and 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.[26] 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 MSBP.[27] 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.

In this report,[27] most of the children who remained with their mothers were exposed to repeated fabrication or were described as having other concerns. 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 MSBP during childhood.[28] At the time of abuse, the respondents felt unsafe and unloved by their parents. As children, they had emotional stress and serious depression problems. 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

It is important to educate the patient, family, and medical staff about factitious disorder imposed on another. Patient education focuses on imparting techniques for helping patients improve their coping and stress-management skills. Family education regarding patterns of this disorder in previous generations of the family is necessary for effective treatment. If other children are present in the home, they should be evaluated for possible abuse as well.

In particular, family members should be educated about healthy ways for the patient to express his or her anger. They should be encouraged to allow the patient to express anger appropriately and not to consider such expression a hindrance to the recovery process.

For patient education resources, see the Children’s Health Center and the Mental Health and Behavior Center, as well as Child Abuse and Munchausen Syndrome. In addition, the following Web sites may be helpful:

Ethical and Legal Issues

The Federal Child Abuse Prevention and Treatment Act defines MSBP 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.” MSBP is difficult to prove; patients are typically not caught, and cases are usually based on circumstantial evidence.

Where factitious disorder imposed on another is suspected, the law requires physicians to notify the authorities, which may include the following:

In addition, steps for the immediate protection of the child must be initiated. Protection may involve removal of the child from the home, at least until the situation can be completely assessed. A court order may be needed to remove the child from the perpetrator.

Once protective measures are in place, the perpetrator should be confronted with the evidence. This individual will almost certainly deny the charge and will attempt to remove the child from the hospital. Criminal prosecution of the perpetrator may also be necessary.

Evaluation should not be limited to the child involved but should also include his or her siblings. Psychotherapy should be offered to the mother, the affected children, and the family. Pharmacotherapy may be appropriate when the mother has comorbid psychiatric conditions that are amenable to treatment. The family requires careful long-term monitoring, especially because of the danger that the mother could move her family and seek to perpetrate such behavior in a new location.

History

Common presentations of factitious disorder imposed on another (including Munchausen syndrome by proxy [MSBP]) include the following:

Warning signs that should alert healthcare workers to the possibility of this disorder include the following:

Characteristics of perpetrators

Individuals with factitious disorder imposed on another who perpetrate abuse are frequently described as caring, attentive, and devoted individuals. However, not all perpetrators fit this profile: Some can be hostile, emotionally labile, and obviously dishonest. Although they have no obvious psychopathology, perpetrators can be deceiving and manipulative. Their ability to convince others should not be underestimated. Their abuse is premeditated, calculated, and unprovoked.

As noted (see Pathophysiology), most reported cases involve parents and children. Although either parent may exhibit factitious disorder imposed on another, the mother is the perpetrator of the abuse in more than 95% of cases of MSBP. Typical characteristics of the mother with MSBP may be summarized as follows:

The high frequency with which mothers with this disorder are perpetrators of abuse obviously conflicts with the commonly held view that mothers are more concerned with the well-being of their children. Saad has suggested that in some female perpetrators, motherly instincts are subverted by narcissistic attributes and enhanced need for attention.[31]

The mother may have previous healthcare knowledge or training[32] and often is fascinated by the medical field. In one study, 80% of the documented perpetrators—all of them mothers—worked in healthcare or child-care facilities. Perpetrators aspire to establish close relationships with medical staff and frequently become a source of support for staff members or the families of other patients.

The mother usually appears unexpectedly calm in the face of the perplexing problems that her child is experiencing. She tends to insist on pursuing additional diagnostic and therapeutic options, regardless of the pain and discomfort they may inflict on the child, and almost always resists discharge orders and negative diagnostic findings. If a physician becomes suspicious or reluctance to continue evaluations, she may take the child elsewhere.

Perpetrators typically recognize their wrongful behavior but take great care to conceal it, rarely admitting to their abusive activities. Relations among the mother, the child, and the primary physician may be extended and complex. This heightened level of involvement may hinder the physician from considering factitious disorder imposed on another as a differential diagnosis.

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

The mother’s partner is often disengaged from the family.[33] Common characteristics of the father 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.

About 10-25% of perpetrators also induce symptoms in themselves. The pattern of lying and fabrication may extend to other aspects of their lives (eg, employment, education, marital status, and illnesses. Severe mental illness (eg, schizophrenia) is rare, though the presence of 1 or more personality disorders may be common. The perpetrator may also have a history of an excessive drive to seek attention. The family history may reveal various types of abuse, unusual diseases in multiple family members, and family interactions that reward illness.

Whether a specific physician’s profile facilitates this type of abuse is unknown. Squires and Squires discussed several factors in the modern medical environment that may prevent earlier diagnosis of this condition, such as the following[34] :

Findings in victims

Children experiencing MSBP-related abuse usually present with an array of ailments in different organ systems. Reports from the first 20 years after the condition was identified describe 68 symptoms, signs, and laboratory findings in 117 cases of MSBP, with approximately 70% of induced or fictitious symptoms occurring in the hospital.

More than 100 symptoms have been reported, with the most common being abdominal pain, vomiting, diarrhea, weight loss, seizures, apnea, infections, fevers, bleeding, poisoning, and lethargy. One group reported multiple illnesses in 64% of 56 index children subjected to MSBP.[35] Other reports indicate that some children initially present with a single serious event (eg, a severe episode of apnea with no previous history of fabrication).

A 2004 meta-analysis showed that pediatric condition falsification (PCF) was the cause of 0.3% of all cases of ALTEs.[36] Another report suggested that intentional suffocation was the cause of about 10% of all cases of SIDS.[37] In a series of 135 cases reported by Feldman et al, 25% of the children had renal or urologic related issues.[23]

Older MSBP victims often collude with their mothers 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 or disbelief. A report on MSBP cases in older children (>6 years), found induced illnesses in 57%, tampering with records or specimens in 14%, and false reporting in 62%.[22]

Physical Examination

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

Siegel and Fischer suggested that pediatricians ask themselves the following questions during clinical assessment of the child in a case of suspected MSBP[38] :

Physicians must remember that persistent fabrication, exaggeration, and simulation reflect pathologic seeking of healthcare and are not benign. In some cases of MSBP, fabrication of symptoms may escalate to the induction of illnesses if the perpetrator wishes to continue being involved with the medical system or perceives the physician’s response as inadequate or unsatisfactory. Finally, clinicians should remember that the presence of a real illness does not preclude the presence of MSBP.

Complications

In its more severe forms, factitious disorder imposed on another can lead to serious complications, including continued abuse, multiple hospitalizations, and the death of the child. Research suggests that the death rate for victims of MSBP is approximately 10%.[21] MSBP is considered a form of child abuse; if suspected, it must be reported, and proper investigations must be carried out.

Approach Considerations

To diagnose factitious disorder imposed on another (including Munchausen syndrome by proxy [MSBP]), clinicians must be adept at evaluating patients with varied symptoms and a limited or confusing history. Children subjected to MSBP may present with a truly life-threatening induced condition, or they may be completely asymptomatic with a factitious history supplied by the caregiver.[39]

The challenge for the physician in such cases is to put the history and physical findings together in a coherent fashion. This is particularly difficult in the child abuse victim, especially when the caretaker may not be giving a truthful history. Involving multiple medical colleagues in the evaluation may be useful. Accessing the records of previous visits and discussing the case with other physicians who have seen the child are often helpful in making this difficult diagnosis.

Many tests can be done on an emergency basis to rule out life-threatening conditions, but admission and consultation are usually necessary before the diagnosis of MSBP can be proved.[40] Hospital rooms with hidden cameras may be helpful for making the final diagnosis in highly suspicious cases,[41] but their use must follow careful protocols. Child protective agencies, police, and hospital security coordinate the use of these surveillance systems.

Standard medical workup is unlikely to provide useful information, aside from findings that exclude medical conditions that could account for psychiatric pathology in the parent. Evaluation must be based on specific symptoms, with specific tests aimed at detecting the potential method by which the factitious symptoms are being induced.

If no physical cause of the symptoms is found, a retrospective review of the child’s medical history, with careful consideration of the family history and the mother’s medical history (many perpetrators also have factitious disorder imposed on self) might provide clues suggesting MSBP. (Remember, it is the adult, not the child, who is diagnosed with MSBP.) Indeed, the most important or helpful part of the workup may be the review of all available old records. Too often, this time-consuming but critical task is forgotten, and the diagnosis is missed.

Laboratory Studies

Laboratory tests that may be considered include the following:

Other Studies

Computed tomography (CT) or magnetic resonance imaging (MRI) may be warranted if intracranial pathology is likely or if findings from neurologic examination are abnormal.

Psychological testing may be performed to help clarify the diagnosis. A separation test removes the mother from her child for the purpose of observation. In MSBP, the child’s medical condition typically improves in the parent’s absence, or the child may develop new abnormal findings or worsen after a visit with the parent.

Electroencephalography (EEG) and electrocardiography (ECG) should be considered if warranted by the clinical circumstances.

Approach Considerations

Treatment of factitious disorder imposed on another (including Munchausen disease by proxy [MSBP]) involves treating the victim (most commonly, a child), the perpetrator (typically a parent, most frequently the biologic mother), and the family.

Meadow, Schreier and Libow, and others have recommended a stepwise approach to the management of this disorder, which may be summarized as follows[14, 42] :

Hospitalization of the perpetrator or the victim may be necessary to ensure that the 2 parties are both safe but are separated from each other. The clinician must attempt to understand the patient’s disorder without becoming judgmental toward him or her; such negative judgments can hamper therapy. Indications for inpatient treatment include suicidal or homicidal ideations and grave disability (ie, patients who are dangerous to themselves or others or who cannot care for themselves).

Activity should be restricted if patients pose a danger to themselves or others or if they are gravely disabled.

If patients are charged with a crime or if they have been arrested, they may be incarcerated.

Treatment of the Abuse Victim

The primary concern in cases of MSBP is to ensure the safety and protection of the child. Treatment for the child comprises several areas, as follows:

Treatment of the Patient With MSBP

Treatment of the person with MSBP involves thorough evaluation, individual therapy, and parenting classes, among other facets. Without treatment, the relapse rate is high. However, successful treatment is difficult because those with the disorder often deny there is a problem. In addition, the success of treatment depends on the patient’s ability and willingness to tell the truth, and MSBP patients tend to be such accomplished liars that they begin to have trouble telling fact from fiction.

It is important not to overlook any medical and other psychiatric illnesses. Clinical investigations are conducted to determine if other problems that require treatment are present. Studies include the following:

Psychotherapy generally focuses on changing the thinking and behavior of the individual with the disorder.[13] Individual therapy is aimed at decreasing anxiety, stressors, and other problems that perpetuate the illness. Elements of therapy include the following:

No information is available regarding the use of medications in the treatment of MSBP.

Treatment of the Family

Family therapy starts with education regarding MSBP and discussions about whether reunification of the patient and child might be possible. If the family is reunited, supervision is mandatory to ensure the child’s safety.

If other children live in the patient’s home, their health status should be evaluated, and appropriate treatment should be provided. All members of the family should receive therapy, including parents, siblings, and the affected child.

Consultations

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

Siegel and Fischer have summarized the roles of the key professionals needed to diagnose MSBP as follows[38] :

Author

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.

Coauthor(s)

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.

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: Doctor On Demand<br/>Received income in an amount equal to or greater than $250 from: Blue Cross Blue Shield Federal Employee Program<br/>Received royalty from Lippincott Williams & Wilkins for book editor; Received grant/research funds from National Alliance for Research in Schizophrenia and Depression for independent contractor; Received consulting fee from Blue Cross Blue Shield Association for consulting. for: Received book royalty from American Psychiatric Publishing Inc.

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.

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