Factitious Disorder Imposed on Another (Munchausen by proxy) Workup

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

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

  • 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.


Laboratory Studies

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

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