Factitious Disorder Imposed on Another (Munchausen by proxy) Clinical Presentation

Updated: Jun 25, 2020
  • Author: Marc D Feldman, MD; Chief Editor: Glen L Xiong, MD  more...
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Presentation

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:

  • Biologic mother
  • Past exposure and experience with the healthcare system
  • Seemingly excellent care of the victim when observed, yet, in some cases, less concern for the victim than for meeting their own needs
  • Inappropriate affect, such as levity, ebullience, or lack of appropriate concern, when discussing the victim’s problem
  • Possible history of factitious disorder imposed on self
  • Possible reporting of falsehoods or dramatic stories about their lives (e.g., history of abuse, rescuing the victim under difficult circumstances)

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:

  • Dependency
  • High level of denial
  • Tendency to be very supportive of his female partner. Believing the story as told to him by the perpetrator, he may be hostile, even assaultive, when suggestions of FDIA are raised. 
  • Little apparent  involvement in the child’s care; may never visit the hospital

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]

  • Medical training and practice environments that encourage pursuit of rare conditions and consultations with subspecialists
  • Excessive reliance on electronic medical records that are difficult to analyze
  • Health Insurance Portability and Accountability Act (HIPAA)-related barriers and actual and perceived barriers to accessing medical records
  • Unlimited access of perpetrators to information via the Internet
  • Pressure on healthcare workers to obtain higher patient satisfaction ratings

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: 

  • Fabricated: Reported, but did not actually occur. Example: Mother says that the child had a seizure, but the child did not. Note that many of the conditions above are diagnosed based solely on a caregiver’s description.
  • Exaggerated: A real situation, but not as serious as the caregiver reports. Example: The baby sitter says that “there was blood everywhere.” Exaggeration must be distinguished from anxiety and lack of knowledge.
  • Induced: The caregiver causes the problem to occur. For example: the caregiver injects insulin, causing hypoglycemia.

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.

  • Bleeding
    • Exaggeration: A small amount of genuine bleeding has occurred, but the amount is overstated by the perpetrator.
    • Fabrication: Use of colored substances or someone else’s blood (e.g., the perpetrator’s) to simulate bleeding.
    •  Induction: Mechanisms such as poisoning with warfarin (a component of some rat poisons) or administration of other anticoagulants.
  • Seizures
    • Exaggeration: Normal behavior (e.g., daydreaming) falsely reported as seizure activity.
    • Fabrication: The abuser rewards the victim for appearing to have a seizure.
    • Induction: The victim has a genuine seizure as a result of medication overdose.
  • Recurrent apnea or apparent life-threatening events (ALTEs)
    • Exaggeration: The victim has had a brief breathing pause (within normal limits), but the perpetrator reports a long pause requiring cardiopulmonary resuscitation.
    • Fabrication: Monitoring devices are manipulated to make it appear that long breathing pauses are occurring.
    • Induction: The perpetrator suffocates, then resuscitates, the victim. [39]
  • Diarrhea and vomiting
    • Exaggeration: A baby’s normal “spitup” is reported as massive, projectile vomiting.
    • Fabrication: Samples of vomitus or stool are presented that did not come from the victim.
    • Induction: Emetics, [40, 41]  laxatives, [41] or salt are used to produce genuine diarrhea and/or vomiting.
  • Fever
    • Exaggeration: The victim has genuine fever, but the perpetrator lies about how high the temperature went.
    • Fabrication: The perpetrator presents fabricated medical chart records.
    • Induction: The perpetrator injects the victim with pathogens.
  • Rash
    • Exaggeration: The victim has a mild rash, but the perpetrator says it is extensive.
    • Fabrication: The perpetrator paints or colors the skin to simulate a rash.
    • Induction: The perpetrator applies caustic agents to the skin.
  • Hypoglycemia
    • Exaggeration: The perpetrator falsely reports extreme lethargy.
    • Fabrication: The perpetrator dampens the victim’s skin to simulate sweating (an early sign of hypoglycemia).
    • Induction: The perpetrator withholds food or injects unwarranted insulin.
  • Multiple infections with varied and often unusual organisms
    • Exaggeration: The perpetrator falsely reports that the child, who is coughing, was exposed to COVID-19 at day care.
    • Fabrication: The perpetrator presents documentation, which he/she created, asserting that the child was recently treated for strep throat, an infection the child has never had.
    • Induction: The perpetrator contaminates the victim’s feeding tube with her own feces.
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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.

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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]

  • Is the potential victim safe? If possible, potential victims should be hospitalized, placed in foster care, or otherwise separated not only physically from the perpetrator but also from any contact, either direct or indirect. This serves two purposes: (1) protection from the possibility of further abuse and (2) helping to evaluate the presenting problem (the “separation test.”) If the problem improves or resolves during separation from the suspected perpetrator, it is evidence that the problem did not exist as reported. If the problem does not improve or resolve, it is more likely to be genuine.
  • Is the potential victim’s condition consistent with the caregiver’s description? In one example, two boys were reported to need wheelchairs due to muscular dystrophy. One of the treating professionals reported, “We can’t keep them in their wheelchairs. They want to run up and down the halls.”
  • Is the potential victim’s condition consistent with usual presentations of the purported problem?  For example, an infant reported to be failing to thrive should not eat vigorously when offered milk in the hospital.
  • Have records or reports of previous evaluations and interventions been verified with the practitioner independently of the caregiver’s report? Do they endorse the problem as the caregiver reports it? It is very common for professionals to take the word of a caregiver that the victim was seen by a previous professional and given a particular diagnosis. Checking with these professionals, even if written records have been presented, often reveals that the story told by the perpetrator is false. 
  • Has any objective observer witnessed the problem? This is an important criterion, and witness reports can be very useful, but they must be considered carefully. Did the witness see the entire incident from beginning to end (and not just the part that the perpetrator wanted the witness to see)? 
  • Do negative test findings reassure the caregiver? “Normal” caregivers are relieved when told that the problem under consideration has been ruled out. In contrast, FDIA perpetrators will often press for more evaluation and testing, as though they want some problem to be found.
  • Is treatment being provided to the potential victim primarily because of someone’s persistent demands? (see above)
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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.

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