Factitious Disorder Imposed on Another

Formerly this disorder has been referred to as Munchausen by Proxy and later, Factitious Disorder by Proxy. In the current version of the American Psychiatric Association's Diagnostic Criteria, Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), the disorder is referred to as Factitious Disorder Imposed on Another, (DSM-V 300.19). The perpetrator and not the victim is given this diagnosis. The victim is given an abuse diagnosis.

By way of explanation, Factitious Disorder Imposed on Another is distinguished in the DSM-5 from Factitious Disorder imposed on Self. This later disorder is characterized by an adult falsely claiming physical or psychological symptoms in order to assume the sick role and gain attention in the absence of obvious external rewards. Such adults subject themselves to numerous unnecessary medical procedures. These individuals typically become experts in medical terms and feign symptoms associated with a diagnosis, such as cancer or gastric pain.

Factitious Disorder Imposed on Another is the falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception. In such cases the adult perpetrator presents another individual, who is typically a child in their care, as ill, impaired, or injured. The parent creates or exaggerates symptoms regarding the child, associated with a feigned underlying illness, in order to obtain the vicarious attention received through the child's symptom. In doing so, the parent seeks out unnecessary and dangerous medical treatment for the child. This is a form of child abuse that usually includes physical and emotional abuse as well as medical neglect. Some studies have found that the mortality rate of this disorder occurs in 9% of the children subjected to this type of abuse. One example of this type of abuse is a parent who alleges their infant has a serious illness because of their inability to gain weight. Typically, doctors perform many tests and potentially life threatening procedures to diagnose the problem. Eventually in one such case, cameras installed in a pediatric unit found the child's mother substituting colored water for the infant's formula. Another example is a parent who claimed her child's behavior was aggressive and out of control at home. The parent obtained psychiatric care for the child, requesting medication to treat the behavioral problem. The parent continued to report escalating problems of aggression. The child was eventually put on anti-psychotic medication to control the behavior. Such medication is potentially life threatening to the child. Eventually when the parent's description of the child's behavior was found to be inconsistent with the school's observation of the child, a report to Child Protection was made and a diagnosis of Factitious Disorder Imposed on Another was made. The child was removed from the home and taken off all medications. The child immediately improved and demonstrated only minimal adjustment problems. In summary, as in other forms of child abuse, typically the parent vehemently denies abusing the child. Such parents are extremely effective in persuading well-meaning professionals, attempting to treat the child, by the parent's overtly excessive concern for the child. Such a parent obtains the attention they are seeking from the child's treatment providers and the child becomes increasingly sicker as increased inappropriate medical tests and medications are provided.

The diagnosis of Factitious Disorder Imposed on Another requires demonstrating that the individual is taking surreptitious action to misrepresent, simulate, or cause signs or symptoms of illness in the absence of obvious external injury or illness. When a preexisting medical condition may be present in the child, the deceptive behavior or induction of injury by the child's caretaker, on the child, causes others to view the child as more ill or impaired which can lead to excessive clinical intervention.

The diagnosis of Factitious Disorder Imposed on Another is like an eating disorder, or substance abuse disorder. All three diagnoses involved the persistence of the behavior and the intentional efforts to conceal the disordered behavior through deception. Factitious disorder Imposed on Another often rises to the level of child maltreatment. In these cases, the mental disorder of the parent results in abuse to the child.

Pediatric Condition Falsification (PCF) is a relatively new term that is being used as a diagnosis for this form of child abuse. Factious Illness assumes that the caretaker's motivation is to use the child as a means of gaining attention for themselves. While this is true in some cases, other motives of the offending caretaker can also be to manipulate a spouse, manipulate the medical system, perpetrate fraud, or to escape an unhappy home or relationship. Courts tend to be unwilling to remove children from their parents for this disorder. Instead, even if the parent's behavior and medical care is found to endanger the child's life, such parents are usually referred to treatment. Psychotherapy for such individuals is unsuccessful because therapists attempt to treat the more overt signs of depression in the abusing adult. Current treatment, instead of attempting to diagnose the underlying condition in the parent who medically endangers a child in their care, recognizes that the parent's behavior is another form of abuse. Diagnosing or explaining the motive is very difficult and unnecessary to make a diagnosis of child abuse.

The treatment of this type of parental abuse, like other forms of child abuse, is usually complicated by the perpetrators denial. Parents often continue to deny the abuse even when they are shown video recordings of their actions. These parent perpetrators appear caring, sincere, and usually able to convince family members to believe them. When investigated, such perpetrators escalate their production of the child's symptoms to prove to the medical community that the child's illness is real. Throughout the course of the child's feigned illness, the perpetrator is apt to change physicians to avoid detection.

If the problem is admitted, psychological treatment is more effective. However, long term social service involvement is usually required to keep the perpetrator in treatment. Often the child needs to be removed from the parent and placed in another setting. Reunification is a difficult and lengthy process. Consequently, Court involvement is required to turn legal custody of the child over to Child Protection or another family member, while the offending parent is receiving treatment. Dialectical Behavior Therapy (DBT) is the most effective form of treatment. Treatment should begin in a group DBT program where the skills to control intense emotions is learned. This usually requires one year of treatment. In the second year of therapy, the client engages in deep trauma work to address the underlying history of their own childhood abuse. The intense trauma work is most successful when the parent perpetrator has learned how to use the treatment skills of emotional regulation.

Psychological testing with a parent diagnosed with Factitious Disorder Imposed on Another often reveals both the presence of a personality disorder and/or depression. Such parents have typically experienced significant physical, sexual, or emotional abuse in their family of origin. Borderline Personality Disorder is a common diagnosis seen in parents engage in this form of child abuse. This disorder involves frantic efforts to avoid abandonment as well as a pattern of unstable and intense relationships, alternating between idealizing the other and devaluing the other. Impulsivity is noted in ways that are self-damaging such as spending, sex, and binge eating. There are marked changes in mood with such individuals including intense irritability, or anxiety that typically lasts only for a short period of time. The individual experiences chronic feelings of emptiness, inappropriate and intense anger, or difficulty controlling anger, and at times dissociation. The result is that the parent misinterprets the child's behavior, has limited ability to cope with the demands of being a parent, and resents the demands placed on the parent by the child. The parent retaliates, consciously or unconsciously, by seeking out attention for themselves. In order to do so, the parent identifies the child as "sick" and seeks out unnecessary medical attention for the child. Unfortunately, such parents often abuse their children for years before they are diagnosed.

It is imperative that Courts as well as therapists understand the dynamics of Factitious Disorder Imposed on Another. This is a form of child abuse that needs to be treated as such in order to protect the victimized child.