Factitious disorder imposed on another (FDIA), also known as fabricated or induced illness by carers (FII) or medical child abuse, and originally named Munchausen syndrome by proxy (MSbP) after Munchausen syndrome, are terms used to describe a situation in which a caregiver creates the appearance of health problems in another person. The victim is typically the caregiver's child, but is occasionally an adult partner.Münchausen syndrome by adult proxy: a perpetrator abusing two adults American Psychological Association. Mercia D. Sigal et al. 1986. Retrieved July 4, 2024. The abuser may create the appearance of health issues by altering test samples, injuring the victim, falsifying diagnoses, or using contrived photographs or videos. Such "evidence" can be used to convince both the victim and others of underlying health conditions. Permanent injury (physical or psychological) or even death of the victim can occur as a result of the caretaker's actions. The behavior is generally thought to be motivated by a desire for sympathy or attention from other people.
The causes of FDIA are generally unknown, but many physicians and mental health professionals believe that it is associated with the caregivers having experienced traumatic events during childhood (for example, parental neglect, emotional deprivation, psychological abuse, physical abuse, sexual abuse, or severe bullying). The primary motive is believed to be a desire for attention and sympathy, often with an underlying inclination to lie and manipulate others (including health professionals). Financial gain is also a motivating factor in some individuals. Common risk factors for FDIA include pregnancy related complications, past neglect or trauma, and prior diagnosis of factitious disorder imposed on self. The victims of the abuse are considered to have been subjected to a form of trauma, physical abuse, and medical neglect.
Management of FDIA in the affected 'caregiver' may require removing the affected child and putting the child into the custody of other family members or into foster care. It is not known how effective psychotherapy is for FDIA, yet it is assumed that it is likely to be highly effective for those who are able to admit they have a problem and who are willing to engage in treatment. However, psychotherapy is unlikely to be effective for an individual who lacks awareness, is incapable of recognizing their illness, or refuses to undertake treatment. The prevalence of FDIA is unknown, but it appears to be relatively rare, and its prevalence is generally higher among women. More than 90% of cases of FDIA involve a person's mother. The prognosis for the caregiver is poor. However, there is a burgeoning literature on possible courses of effective therapy. The condition was first named as "Munchausen syndrome by proxy" in 1977 by British pediatrician Roy Meadow. Some aspects of FDIA may represent criminal behavior.
Signs and symptoms
Factitious disorder imposed on another (FDIA) is a condition in which a caregiver falsifies, exaggerates or induces illness in a dependent and presents them as ill, presumably for some form of attention or psychological gain, and not solely motivated by external gains. The caregiver or partner systematically misrepresents various symptoms, fabricates signs, manipulates laboratory tests, manipulates clinicians and other health professionals, or purposely harms or injures the victim (e.g. by poisoning, drugging, causing infection(s), or even by causing physical injury).
Most individuals with FDIA present about three medical problems in some combination of the 103 different reported symptoms. The most-frequently reported problems are apnea (26.8% of cases), anorexia or feeding problems (24.6% of cases), diarrhea (20%), seizures (17.5%), cyanosis (blue skin) (11.7%), behavioural problems (10.4%), asthma (9.5%), allergy (9.3%), and fevers (8.6%). Other symptoms include failure to thrive, vomiting, bleeding, rash, and infections. Many of these symptoms are easy to fake because they are subjective. A parent reporting that their child had a fever in the past 24 hours is making a claim that is impossible to prove or disprove. The number and variety of presented symptoms contribute to the difficulty in reaching a proper diagnosis.
Unique to this form of abuse is that health care providers sometimes actively enable the abuse (iatrogenic harm). By reacting to the concerns and demands of perpetrators with FDIA, medical professionals can be manipulated into a partnership that continues the maltreatment of the child. Challenging cases that defy simple medical explanations may prompt health care providers to pursue unusual or rare diagnoses, thus allocating even more time to the child/victim and the abuser. If the health practitioner resists ordering further treatment, the FDIA abuser can threaten action to make the medical system appear negligent for refusing to help a sick child. Clinicians should maintain a high index of suspicion when confronted with persistent unexplained illness in a dependent, and may need to limit further invasive investigations once concern arises to avoid unnecessary or harmful medical care.
The perpetrator with FDIA continues the abuse because maintaining the child in the role of 'patient' satisfies the abuser's unmet emotional needs. Generally, the cure for the victim is to be separated completely from the abuser and to receive necessary emotional support from other loved ones and adequate treatment, such as therapy. When (or if) parental visits are later allowed, sometimes there is a disastrous outcome for the child upon encountering their abuser, especially when the child has reached an age (e.g. adolescence) whereby he or she has been made aware of what occurred to them. The impact of having a parent or caretaker with FDIA on the victim can therefore be extremely traumatic, as the child previously believed their caretaker to be a genuinely loving and trustworthy adult. The betrayal and loss of their parental figure can cause immense emotional distress. Even if one child or victim is removed from the perpetrator, the perpetrator may then seek to abuse another child or family member: a sibling or even other child who still remains in the family. This may be more likely if the perpetrator has not, or refused to, engage in mental health treatment.
Factitious disorder imposed on another can have many long-term emotional effects on a child who has been victimized. Depending on their experience of medical interventions, some children may learn that they are most likely to receive the positive parental attention they naturally crave only when they are playing the 'sick' role in front of health care providers. Several case reports describe Munchausen syndrome patients suspected of themselves having been FDIA victims. Seeking personal gratification through illness can thus become a lifelong and multi-generational disorder in some cases. In stark contrast, other reports suggest that survivors of FDIA can develop a severe avoidance of medical treatment or medical professionals, sometimes experiencing post-traumatic responses to it.
Caregiver The adult 'caregiver' who has abused the child often seems comfortable, pleased, and generally not upset over the child's hospitalization. While the child is hospitalized, medical professionals must monitor the caregiver's visits to prevent an attempt to worsen the child's condition. In addition, in many jurisdictions, medical professionals have a duty to report such abuse to legal authorities.
Like those with factitious disorder imposed on self, FDIA perpetrators are known to frequently switch medical providers or clinics until they find a provider that is willing to diagnose and meet their level of need. This practice is often known as "doctor shopping" or "hospital hopping".
Early writings from the 1990s focused on the profile or motive of the perpetrator. However, as of the 21st century it has been recognized that these have little predictive value.
Diagnosis Use of the term "Munchausen syndrome by proxy" is discouraged. In the World Health Organization's International Statistical Classification of Diseases, 10th Revision (ICD-10), the official diagnosis is factitious disorder (301.51 in ICD-9, F68.12 in ICD-10). Within the United States, factitious disorder imposed on another (FDIA or FDIoA) was officially recognized as a disorder in 2013, while in the United Kingdom, it is known as fabricated or induced illness by carers (FII).
In DSM-5, the diagnostic manual published by the American Psychiatric Association in 2013, it is listed under 300.19 Factitious disorder. This, in turn, encompasses two types: Factitious Disorder Imposed on Self Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy); the diagnosis is assigned to the perpetrator; the person affected may be assigned an abuse diagnosis (e.g. child abuse).
Both types include an optional specifier to identify if the observed behavior was a single episode or part of recurrent episodes.
The diagnosis of factitious disorder imposed on another (FDIA) applies when one person falsifies, induces, or fabricates illness in another individual and presents them to others, most often healthcare professionals, as ill. The diagnosis is applied to the individual performing the falsification, not to the person being presented as ill. Clinical and safeguarding sources describe the affected person typically as a dependent, such as a child or incapacitated adult, who is under the care or control of the actor. When the person producing or feigning symptoms is a competent adult acting on their own behalf, even if accompanied by or receiving support from another individual who enables or participates in the deception, FDIA does not apply; the appropriate diagnosis then is factitious disorder (self-imposed) or malingering. The deceptive behavior occurs in the absence of external incentives, distinguishing FDIA from malingering.
Warning signs Warning signs include: A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling, and unexplained. Physical or laboratory findings that are highly unusual, discrepant with patient's presentation or history, or physically or clinically impossible. A parent who appears medically knowledgeable, fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients' problems. A highly attentive parent who is reluctant to leave their child's side and who themselves seem to require constant attention. A parent who appears unusually calm in the face of serious difficulties in their child's medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to more sophisticated facilities. The suspected parent may work in the health-care field themselves or profess an interest in a health-related job. The signs and symptoms of a child's illness may lessen or simply vanish in the parent's absence (hospitalization and careful monitoring may be necessary to establish this causal relationship). A family history of similar or unexplained illness or death in a sibling. A parent with symptoms similar to their child's own medical problems or an illness history that itself is puzzling and unusual. A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with a serious illness. A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment.