Factitious Disorder Imposed by Another (Munchausen Syndrome by Proxy)

Factitious disorder imposed on another (FDIA) is a mental health disorder in which a caregiver, routinely makes up fake symptoms or causes real symptoms in a child, elderly person, disabled person, or even a pet, to make it appear that the victim has a true physical or mental health issue.

These actions are typically a result of a maladaptive disorder or excessive attention-seeking by the caregiver. In addition to being a disorder, FDIA from a parent to their child is also considered a very serious form of child abuse.

Although FDIA is rare, the mortality rate is concerning. Between 6% to 10% of all FDIA cases will result in death, which makes it a very lethal form of abuse, regardless of the age of the victim.

Read on to learn more about this rare disorder. This article will explore the different types, symptoms, causes, and treatments of factitious disorder,

Symptoms of Factitious Disorder Imposed on Another

Although the signs and symptoms of FDIA may be most clearly visible in the victim of the abuse, it is the perpetrator who receives the diagnosis of FDIA. The abuser may also fake illness in themselves. It’s important that the doctor take note of the signs and symptoms in both parties and follow up on any concerns. 

In the caregiver, it’s important to look for the following signs:

• Refusal of caregiver to leave the victim's side when they are assessed
• The victim's medical history is spotty, vague, or inconsistent
• Caregiver has medical knowledge and may work in a medical setting 
• Caregiver's reports are different from that of medical personnel
• Caregiver has the desire to be seen as "good" at taking care of the victim
• Caregiver routinely seeks approval and attention from medical staff 
• Recommendations for invasive diagnostic and surgical procedures are accepted without question or concern by the caregiver 
• The caregiver will switch doctors if they are confronted with doubts or resistance by medical staff.

In addition, a caregiver will often ask for a second opinion, further interventions, and additional procedures. Often present in the caregiver are poor relationships with family and/or an absence of relationships with friends or other social networks.

The warning signs in a child or adult victim might include:

• History of multiple and repeated injuries, illnesses, medical procedures, surgeries, and/or hospitalizations
• Symptoms or signs of illness only appear in the caregiver’s presence
• Reported medical problems that don’t respond to treatment
• Signs and symptoms may improve while under medical care and return under the caregiver's care.
• Atypical presentation of a particular disorder or illness that includes normal test results and observations by medical personnel
• Absent second parent or other family to corroborate medical history, in the case of a child victim

Causes

The exact cause of FDIA is not clear. However, experts say that both biological and psychological factors play a role in the development of this disorder. The onset of FDIA tends to occur in young adulthood and may be triggered by an incident of a true medical illness or hospitalization in themselves or someone they are caring for.

One theory suggests that people with FDIA experienced a history of neglect or physical, sexual, or emotional abuse as a child, leaving them with an extreme need for attention and admiration. Other theories point to the loss of a parent at a young age by death, incarceration or abandonment. The caregiver may also have an underlying psychiatric disorder such as personality disorder, bipolar, anxiety, or depression.

Types of Factitious Disorder

Previously known as Munchausen syndrome and Munchausen syndrome by proxy, factitious disorder may be imposed on oneself (FDIS) or imposed on another (FDIA). Factitious disorders are categorized as somatic disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), and the presenting illness that is being imposed may be physical or psychiatric in nature.

In FDIA, “another” can be a child of the caregiver, or it can be another adult or pet that the perpetrator is caring for. It is most commonly diagnosed in mothers. FDIS, on the other hand, is when a person presents themself as sick to others, especially to health care professionals to receive medical attention.

Diagnosis

Diagnosing FDIA is challenging for doctors because of all of the dishonesty presented by the adult caregiver. One core principle in diagnosing this disorder is that deception is present in all cases. According to the DSM-5-TR, methods of falsifying an illness in someone else can include exaggeration, fabrication, simulation, and induction.

Exaggeration: This may involve exaggerating symptoms of real illness to gain more medical attention, testing, and procedures.

Fabrication: This is outright lying about medical history and symptoms, including the suggestion of neurological symptoms such as blackouts, seizures, and paralysis, or creating a false narrative about serious medical problems, like cancer and HIV.

Simulation: This occurs when symptoms are faked in the presence of others. This is more common in FDIS, where you can make up elaborate stories about your personal suffering and demonstrate symptoms in front of others. The victim of FDIA is not involved in the deception and will not intentionally fake symptoms; however, their lab results may be falsified by their caregiver.

Induction: This is when the caregiver induces symptoms by giving their victim medicine, poison, or bacteria to create symptoms. There are cases of children being injected with feces to create abscesses and sepsis. They may also physically harm their victim, such as by suffocation, to create symptoms of respiratory and cardiac distress.

To meet a clinical diagnosis for FDIA, the following four criteria must be met:

1. The perpetrator or caregiver engages in the deceptive falsification of physical or psychological signs or symptoms, or of induction of injury or disease in another
2. The person presents the victim to others as ill, injured, or impaired
3. The deceptive behavior is present in the absence of external incentives like money
4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

Treating Factitious Disorder

The treatment of FDIA or Munchausen syndrome by proxy generally requires treatment of the caregiver and the victim. That said, it can be difficult to get the perpetrator to seek treatment since they typically do not want to admit to their behaviors or seek treatment. Often, it’s an intervention on behalf of the child by a doctor or other protective agency that forces the issue. 

In the event that a parent/caregiver is willing to get help, and they are not being investigated for abuse, the attending primary care physician should refer out to individual or family therapy. The doctor and mental health experts should work together on a treatment plan for the family. 

If the child or the adult victim is removed from the perpetrator’s care, treatment may involve both medical and psychological interventions. Victims of FDIA will need psychotherapy or psychiatric treatment to help them understand and deal with the abuse they’ve been subjected to by a caregiver or parent.

They may also need ongoing medical follow-ups to monitor any physical harm inflicted by the caregiver. The doctor and mental health experts should form a hospital-based or community-based multidisciplinary child protection team to treat the victim. 

The perpetrator or offending parent may face criminal charges related to the abuse. Treatment for the caregiver/perpetrator will depend on legal issues surrounding the case and other psychiatric conditions. 

Coping

FDIA or Munchausen syndrome by proxy is a severe form of child abuse that requires immediate intervention from Child Protective Services and medical personnel.

Mental health professionals specializing in the treatment of FDIA are often called upon to treat the individual who is presenting such behavior. However, Child Protective Services are also required to take legal action (such as removing the child from the custody of the adult) upon investigation into the matter.

Regardless, it is necessary for both the perpetrator and the victim to receive adequate mental healthcare that would help them cope with and move on from the trauma of such a relationship.

That said, if a family member of the perpetrator or child is in need of support, information, or other services, reaching out to an expert can help them cope with the situation. 

A Word From Verywell

If you have concerns about FDIA for yourself, seek psychiatric and medical help right away. If you suspect someone you know is engaging in behavioral patterns associated with FDIA or Munchausen syndrome by proxy, contact the local Child Protective Services agency right away. If you believe a child is in imminent danger, call 911. In some cases, FDIA can be serious and life-threatening.