Factitious Disorder Imposed on Another (Munchausen by proxy)

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]

• Factitious disorder imposed on another (formerly factitious disorder by proxy; MSBP)

• Factitious disorder imposed on self (more chronic and severe forms of which are commonly labeled as Munchausen syndrome[8] )

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] :

• Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception

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

• The deceptive behavior is evident even in the absence of obvious external rewards

• The behavior cannot be better explained by another mental disorder, such as delusional disorder or another psychotic disorder

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] :

• Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception

• The individual presents himself or herself to others as ill, impaired, or injured

• The deceptive behavior is evident even in the absence of obvious external rewards

• The behavior cannot be better explained by another mental disorder, such as delusional disorder or another psychotic disorder

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:

• Harm or potential harm to the child (or other victim) from excessive intervention

• A caregiver who is fabricating illness or pursuing unnecessary treatment; the motivation of the perpetrator is not important in diagnosing the abuse (as it has sometimes been considered in other diagnostic criteria)

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:

• Failure to consider it in the differential diagnosis

• Lack of knowledge about FDIA on the part of pediatricians and other professionals[10]

• Uncertainty with regard to differentiating normal parental anxiety or concerns from a pathologic seeking of care

• Tendency of the provider to believe the history the caregiver provides

• Ability of the caregiver to present a highly persuasive and compelling history, sometimes accompanied by fabricated documentation

• Involvement of several providers, often in different setting and sometimes different cities, states, or even countries

• Fear of making a false accusation and its subsequent legal repercussions

• Lack of collaboration or poor relationships among medical, legal, and child-protection agencies; reluctance to become involved in a child protective case

• Reluctance to separate the victim from the family to evaluate the victim's medical condition without the caregiver's involvement

• Reluctance to admit the possibility that the caregiver has been fooled

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

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:

• Narcissistic, antisocial, and borderline personality traits or disorders
• Somatic symptom disorder
• Factitious disorder imposed on self
• Pathological lying (also called pseudologia fantastica)
• Illness anxiety disorder (also called health anxiety disorder or hypochondriasis)
• Depression ^[11]

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 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:

• They understand, admit to, and assume responsibility for their behavior ^[27]
• They can improve their coping skills
• They can place their victim’s needs above their own

Patients with a poor prognosis may exhibit the following signs:

• They demonstrate a high degree of denial
• They are uncooperative or noncompliant with therapy
• They have a personality disorder

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.

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.

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.

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.

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.

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)

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.

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]

• Assess the problem as presented, noting findings and inconsistencies, until it is clear whether there is a “real” condition of concern, a purported condition that does not exist, or both. Provide treatment as indicated for any real conditions. 

• If possible, admit the victim to the hospital or other controlled setting to closely observe the suspected perpetrator–victim interaction and the suspected perpetrator’s behavior, and determine the temporal relation between the symptoms and the perpetrator’s presence.

• Depending on the victim’s age and abilities, have a non-accusatory discussion with the victim of what he/she thinks is going on.

• Consider completely separating the victim from the suspected perpetrator’s presence and influence to protect the victim and to confirm attenuation or cessation of the symptoms in the suspected perpetrator’s absence.

• Obtain consultations from FDIA experts, law enforcement, institutional risk management, attorneys familiar with FDIA, and other professionals, as needed.

• Obtain the necessary body fluid or other samples for toxicology screens and any other relevant investigations. 

• If local laws and institutional policies allow, consider the use of hidden cameras (ie, covert video surveillance[44, 39] ) to monitor and record the interactions of the victim and the suspected perpetrator in the controlled setting.[43] If this is done, real-time monitoring must also occur, for the protection of the victim and the institution. Consultation with an attorney and the police is strongly recommended.

• Interview suspected perpetrator’s partner (if any) and any other pertinent family members when the suspected perpetrator is not present, to gain their view of what is going on. The possibility of FDIA should not be brought up in these interviews, since it may cause the suspected perpetrator to flee with the victim.

• Arrange for social service, psychological, and/or psychiatric evaluations of the victim, as indicated.

• Arrange for social service, psychological, and/or psychiatric evaluations of the suspected perpetrator, if indicated; however, barring a confession, there are no pathognomonic findings on psychological testing or psychiatric interviews of alleged perpetrators. Indications for inpatient assessment and/or treatment of the alleged abuser include expressions of suicidal or homicidal ideations.

• Obtain and verify the suspected victim’s and the family’s pertinent medical and social histories, previous hospitalizations, and medical and legal records, if possible. Identify an individual, team, or task force to examine the records objectively.

• Obtain access to and review the suspected perpetrator’s social media posts for online efforts to attract sympathy and attention through narratives, photographs, etc. of the suspected victim.[45] This review may reveal  attempts to garner money and gifts from online sources, as in malingering by proxy. Police or court intervention may be necessary to obtain and memorialize such content. If the suspected victim has a social media presence, this should also be reviewed. 

• Inform the local protective services and/or law enforcement agencies of abuse suspicions in accordance with the law. Cooperate in their education if necessary and in the investigation process. 

• Confirm or disconfirm whether FDIA abuse is occurring.

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. 

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:

• Informing the perpetrator of the diagnosis. As already stated, this must be a planned confrontation with protection in place for the victim and all participants.

• If possible, remove the victim and other persons at risk (e.g., siblings) from the care and influence of the perpetrator. This action generally requires a court order.

• Create short- and long-term plans for the welfare of the victim and treatment of the perpetrator. Plans can include: 

  • Continued temporary placement of the victim with a specific reunification plan, or work towards permanent placement away from the perpetrator.

  • Management of the victim’s care by a single, well-informed professional (e.g., pediatrician who accepts that FDIA has been diagnosed).

  • Plans for long-term close monitoring of the situation by the court and/or protective agency.

  • Psychological/psychiatric care for the perpetrator and (if appropriate) the victim. Any therapist involved must understand and accept the diagnosis of FDIA. The perpetrator must agree to full communication with the protective agency and all other involved professionals.

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]

• Identified problems must be appropriately managed

• The perpetrator must show a genuine willingness to engage in therapy

• The perpetrator must admit fully what has happened and to assume responsibility for their behavior[27]

• The perpetrator must demonstrate understanding of why the behavior occurred

• The perpetrator must improve their coping skills and learn how to form relationships that are not associated with being ill or providing care for others

• The perpetrator must be able to place their victim’s needs above their own

• Parenting classes may also be needed to teach how to parent effectively while meeting the perpetrator’s own needs

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.

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:

• First, the victim must be placed in a safe environment where his or her symptoms can be monitored in the absence of the patient with FDIA; there, the victim can receive appropriate therapies

• Treatment may involve a variety of therapies, depending on the victim's age and situation

• The victim's true health status should be clarified and appropriate care provided

• A single practitioner who is familiar with the case and accepts that FDIA has occurred should be responsible for monitoring and treating the vitcim; however, managing a case involving FDIA often requires a team that includes social workers, foster care organizations, risk management, and law enforcement, in addition to healthcare providers

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

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:

• Psychiatrist

• Psychologist

• Social worker

• Attorney

• Law enforcement personnel

• Family court personnel

• Institutional risk manager

• Institutional discharge planner

• Protective services