6/22/15&

Lacey#Spears#
27#year#old#mom#convicted#of#killing#5#year#old#son#
Garnett#by#poisoning#him#with#salt#

Munchausen
Syndrome by Proxy
AKA##Factitious#Disorder#Imposed#on#Another#(FDIA)#
#
Janet#Cahill,#Ph.D.##
Professor#Emerita#Dept.#of#Psychology#
Rowan#University#

Denition#
#
A#dangerous#type#kind#of#maltreatment#in#
which#caregivers#deliberately#and#repeatedly#
exaggerates,#fabricates,#and/or#induces#a#
problem#or#problems#in#someone#under#their#
care.##

First#use#in#mental#health#
1951##Richard#Asher##British#MD##used#the#term#
for#adult#evidencing#a#sick#role#by#fabricating#
dramatic#physical#ailments.#
He#referred#to#this#as#Munchausen#Syndrome#
In#1977,#Roy#Meadows##a#pediatrician##coined#the#
term#Munchausen#Syndrome#by#Proxy#to#describe#
parents#or#other#caregivers#who#fabricated#or#
induced#sickness#in#another#in#their#charge#to#
meet#their#own#needs#for#attention#

Induced#high#quantities#of#salt#into#(unnecessary)#
stomach#tube#
23#visits#to#hospital#before#Garnetts#death#
Interacted#with#hundreds#of#medical#professionals#
#Lacey#a#heavy#social#blogger#
Judge#said#she#had#MBP#

In#the#beginning#
There#was#Baron#von#
Munchausen.#
Lived#from#1720[1797#
Prussian#Calvary#ocer#
Fought#in#Russo[
Turkish#War#

#A#Disorder#with#Many#
Names#
Munchhausen#Disorder[#Asher#1951[#in#DSM#III#
and#IV#
Munchausen#by#Proxy##proposed#Rx#in#DSM#
IV[TR#
Finally#in#DSM#5#as#Factitious#Disorder#Imposed#
on#Another##
British##Fabricated#or#Induced#Illness#by#
caregivers#

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MBP#to#FDIA#
First#MBP#

Then##

Munchausen#by#proxy#
(MBP)#became#the#name#
for#a#subtype#of#child#
abuse.##

Then#PCF##Pediatric#
condition#falsication#

Came#to#include#other#
abuse##not#just#medical#
but#also#psychological,#
educational#

#and#nally#Factitious#
Disorder#Imposed#on#
Another#(FDIA)#

FDP##factitious#disorder#
by#proxy#

DSM4#TR##
Factitious#Disorder[#not#otherwise#specied#
The#DSM[IV#places#FD#by#proxy#(MBP)#into#this#
category,#dening#it#as:#
#the#intentional#production#or#feigning#of#
physical#or#psychological#signs#or#symptoms#in#
another#person#who#is#under#the#individual's#
care#for#the#purpose#of#indirectly#assuming#the#
sick#role.#

DSM#5#
300.19#Factitious#Disorder#Imposed#on#Another#
A##Falsication#of#physical#or#psychological#signs#or#
symptoms,#or#induction#of#injury#or#disease,#in#another,#
associated#with#identied#deception#
B.#The#individual#presents#another#individual#(victim)#to#others#
as#ill,#impaired#or#injured.#
The#deceptive#behavior#is#evident#even#in#absence#of#obvious#
external#rewards#
The#behavior#is#not#better#explained#by#another#mental#
disorder,#such#as#delusional#disorder#or#another#psychotic#
disorder#
Note[#the#perpetrator,#not#the#victim,#receives#this#diagnosis#

Specify:#Single#episode#or#recurrent#episode#

Note#the#Absence#of#
Intent#in#DSM#5#

DSM#5#Narrative#
The#another#could#be#a#child,#adult#or#pet.##
The#victim#gets#an#abuse#diagnosis#
Does#not#preclude#actual#condition##could#be#ill##but#
illness#is#exaggerated#through#deception#
Prevalence#unknown#due#to#deception[#estimate#of#1%#for#
all#of#factitious#disorder#
Rule#out##
Malingering[#(presence#of#obvious#external#rewards)#
Somatic#symptom#disorder#
Borderline#personality#disorder#

Core#Components#of#
Denition#

P.326#The#diagnosis#of#factitious#disorder#
emphasizes#the#objective#identication#of#
falsication#of#signs#and#symptoms#of#illness,#
rather#than#an#inference#about#intent#or#
possible#underlying#motivation.#

FDIA#is#dangerous#

DSM#5#also#also#FDIA#to#be#both#a#crime#and#a#
mental#illness.#

Exaggeration#
Fabrication#
Induction#

It#is#maltreatment#
Is#deliberate,#deceitful##behavior##calculated#
and#planned#using##

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Planned#versus#Reactive#
Most#incidents#of#physical#abuse#are#reactive#
(fork#and#chicken#incident)#
By#contrast##most#FDIA#is#planned#and#
deliberate##not#provoked#by#the#childs#
behavior.#

More#Common#then#We#
Think#
550#published#case#reports#
In#30#countries#
And#climbing#
Lasher#and#Sheridan#believe#it#is#not#rare#in#
child#abuse.#The#rarity#is#catching#the#
perpetrator#

Most#Common#
Symptoms#

Demographics#
Usually#the#mother#(about#75%)#father##7%#

Apnea#

Failure#to#Thrive#

Average#age#of#diagnosis##4#

Feeding#problems#

Vomiting#

Diarrhea#

Bleeding##

Seizures#

Rash#

Cyanosis#

Infections#

Behavior#problems#

Allergy#

Asthma#

fevers#

50%#under#24#months#
Death#rate#6[10%#

Can#Spread#to#other#Kids#
Of#those#25%#of#sibling#
known#to#be#dead#
60#of#siblings#had#
illnesses#with#no#clear#
causes#

Enmeshment#of#health#care#
professionals#
Dicult#to#determine#caregiver#is#lying#
Tricked#into#giving#more#intrusive#and#exotic#
tests#and#treatments#
Often#health#professionals#will#advocate#for#
more#treatment#against#the#judgment#of#other#
health#professional.##

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Primary#Goal##
Why#do#caregivers#do#this?##

Some#form#of#intangible#
gratication#for#the#
perpetrator#through#the#
problems#of#someone#
else.##
Attention#and#sympathy.#
Or#control#and#
manipulation#
Revenge#against#other#
parent##
Self[Perception#they#are#
extraordinary#parents#

Malingering#and#
FDIA##
Malingering#is#fabricating#
symptoms#for#external#gain.#
Such#as#SSI#or#avoiding#
responsibility#

Can#occur#in#the#same#
case.#
Presence#of#external#gain#
should#not#eliminate#
FDIA.#

Perpetrators#
Dicult#to#categorized#because##by#denition[#
they#are#deceitful#
Theories#of#motivation:#
Parents#come#from#psychological#deprived#or#
abusive#backgrounds#
Parents#want#to#be#in#control##they#view#
themselves#as#smart#that#the#professionals#and#
enjoy#manipulating#them.#
Attention#and#praise#
Secondary#gain##wish#trips#[#donations#

FDIA#vs.#Factious#
Disorder#

This#distinction#is#important#
and#requires#dierent#
expertise.##
Factious#exaggerating#or#
induction#a#symptom#in#
self[#
#Motivation#is#benets#of#
sick#role#

Uncertainty#over#
motivation#should#not#
eliminate#FDIA#

About#10%#also#have#FDIA#
FDIA##on#someone#else#

May#never#fully#
understand#motivation.#

FD[#classied#as#psychiatric#
disorder#
FDIA#as#maltreatment#and#
psychiatric#disorder#

Four#concepts#
FDIA##is#both#maltreatment#and#can#be#
diagnosed#as#a#psychiatric#disorder##
Should#not#be#conrmed#or#denied#on#basis#of#
motivation#
Should#not#be#conrmed#or#denied#on#the#
basis#of#incidental#external#gain.#

Diagnosis#Based#Upon#
Pattern#of#Behavior#
Regardless#of#motivation#and#gain,#FDIA#
should#be#diagnosed#based#upon#an#objective#
pattern#of#behavior#with:#
Deception#
Exaggeration#
Fabrication#
Inducement#

May#co[occur#with#a#variety#of#mental#health#
disorders#

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Perpetrator#Consistent#
Characteristics#
Individuals#with#primary#
responsibility#for#the#
child[usually#mothers#
(75[98%#of#time)#
They#supercially#present#
as#normal#and#good#
caretakers##their#
psychological#evaluations#
are#often#normal.#

The#are#accomplished#
liars,#deceivers#and#
manipulators#
They#may#appear#to#be#
overanxious#and#
overprotective#
They#often#have#some#
backgrounds#as#health#
professionals.##

Disproportionately#
Moms#
About#75%#and#up#
Have#primary#caretaker#
role#
Often#pushed#other#
caregivers#out#of#family#

Perpetrator#Consistent#
Characteristics#(2)#
They#may#seek#attention#
from#a#variety#of#people#

They#may#not#involved#in#
CPS#

They#may#doctor#shop#or#
not#

They#may#have#a#personal#
history#of#exaggerated#
illness.#

They#usually#deny#what#they#
have#done,#despite#
overwhelming#evidence#
They#often#do#not#stop#their#
behaviors#when#they#are#
caught#

And#most#importantly##[#
they#are#usually#the#only#
ones#consistently#present#at#
or#in#association#with#the#
onset#of#symptoms.#When#
they#are#absent,#symptoms#
and#illness#are#not#reported#
or#may#begin#to#improve.##

Normal#Evaluations##
Competent#professional#
make#not#pick#up#the#
symptoms#
They#present#as#
functional##often#highly#
educated#and#well#
spoken#
Know#how#to#present#
their#history#
Often#do#well#during#
psychological#and#
psychiatric#exams#

Skilled#Liars#and#
Manipulators#

Supermoms#

Pattern#of#deliberate#deceit#

Often#anxious#and#overprotective#

Very#skilled##will#omit#or#add#information#from#
prior#doctors#

Present#themselves#as#supermoms#

Will#misrepresent#test#results#
Strep#throat#example#

Extraordinarily#devoted#to#the#their#children#
Will#often#enmesh#professions#into#their#
deceptions##workers#are#shocked#to#later#nd#
their#was#abuse#

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May#Have#Medical#
Background#
Can#speak#medical#or#psychological#lingo#
More#recently,#come#in#with#lots#of#
information#from#the#internet#
Can#describe#symptoms#and#treatments#
Increasing#amount#of#psychological#symptoms#

Doctor#Shopping#
May#or#may#not#occur.##
If#current#doc#does#what#
they#want##they#stay#put.#
If#not##start#shopping#
around
##
Experimental#treatment#
Practitioners#who#engage#
in#unusual#treatment#
Disparage#prior#doctors#
You#are#my#only#hope#
Obi#Wan#

History#of#Factitious#
Behavior#

Deny#in#Face#of#Evidence#
Even#when#presented#
with#test#results,#
documentation,#videos#
they#will#not#move#
their#position.##
Mom#used#own#blood#
in#babys#diaper.#Tests#
come#back##still#
denied#said#they#were#
faked.#

Continue#Once#Caught#
Even#when#under#investigation,#will#continue#
to#try#and#deceive#
Sometimes#will#escalate#
Case#example##

Consistently#present#
when#symptoms#present#

10[14%#have#some#history#of#personal#factitious#
illness.##

Current#case##mom#or#grandma#insisted#on#being#
present#at#every#test#24/7.#

Very#clever#at#getting#people#to#believe#someone#
else#witnessed#the#symptom#(i.e.#said#ER#doctor#
saw#seizure##but#ER#doc#said#mom#told#her#it#
occurred#in#the#car.#

Not#typical#CPS#cases##homes#are#clean,#no#
drugs,#have#jobs,#insurance#

Requires#separation#test#
Must#have#independent#validation#of#everything#

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Separation#Test#

Common#Red#Flags#

Most#important#indicator#is#the#symptoms#
reduce#often#dramatically#once#the#child#is#
separated#by#the#perpetrator#

CG#refuses#to#leave#side#of#
child#at#hospital#

Very#important#that#separation#be#complete#

Insist#no#one#else#can#provide#
the#kind#of#care#they#can#

Cannot#relay#on#any#information#from#the#
suspected#perpetrator#

Will#criticize#professionals#
who#dont#agree#with#them.#

Seem#more#comfortable#in#
the#hospital#

Unhappy#with#positive#results#
Pushing#away#fathers#or#
others#who#dont#cooperate#

Victim#Consistent#
Characteristics#

The#Masquerade#
Schreier#and#Libow##
Described#this#behavior#
as#a#masquerade)#
False#perception#they#
are#deeply#caring#and#
concerned#about#their#
children.#

Can#eect#one#child#or#several#children.#Can#be#a#series#
of#victims.#
Usually#infants#or#young#children##cant#contradict#
caretaker#
Most#commonly#diagnosed#between#3#and#5#years#old.#
Victims#should#not##be#assumed#to#be#colluding#with#
CG.#Older#children#sometimes#do#to#resolve#the#
intense#conict#they#are#under#
Usually#dont#have#other#CPS#risk#factors#(drugs,#DV,#
poor#housing)#
#

One#or#multiples#
Usually#focus#on#one#at#at#time.##
But#can#act#serially##
Sheridan#(2003)#25%#of#known#siblings#dead#
and#61%#had#symptoms#of#MBP##

Not#Typical#Child#
Protection#Case#
Less#likely#to#be#poor,#use#drugs,#have#
domestic#violence.#
No#marks#of#physical#abuse#
Homes#clean#
Parent#supercially#cooperative#
Have#health#insurance.#

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Other#Adults#
Non[oending#partner#physically#or#emotionally#
absent##or#driven#away#with#false#allegations#

Example#
Family#Team#meeting#

Some#family#members#may#become#enmeshed#

In[home#worker#with#
mom#for#5#years.#
Attacking#FDIA#
diagnosis.#Referring#to#
perpetrator#as#The#
most#dedicated#mother#
I#have#ever#met.#

Others#are#suspicious#but#afraid#to#act#

Left#the#room#in#tears.#

May#be#passive#or#uncritical#
Others,#including#some#health#care#providers#
convinced#it#is#real#

How#to#Diagnoses#
Videos#
Separation#test#
Extensive#record#reviews#
and#interview[#very#time#
consuming#
Need#all#the#pieces#of#the#
puzzle.##
Good#mechanism#is#the#
Parental#Capacity#
Evaluation#

Diagnostic#Findings#
Is#there#a#pattern#of#unnecessary#treatment?#
Is#primary#source#the#caregiver?#
Do#symptoms#diminish#away#from#caregiver?#
Is#there#evidence#of#deliberate#deception?#
Then#could#be#FDIA#

That#night,#mom#
caught#by#night#nurse#
pinching#the#oxygen#
supply#for#her#infant#
son##causing#him#to#
stop#breathing#and#
trigger#alarms.#
Then#denied#she#did#it#

Team#Eort#
Perpetrators#will#ght#
every#detail#
Requires#intense#review#
of#records#and#follow[up.##
Need#medical,#
psychological#experts#
and#cooperation#with#
DAG#and#prosecutors#
Enormous#burden#on#
caseworker#

Cant#be#too#zealous#
Roy#Meadow##British#
pediatrician#
Meadows#Law##3#SIDs#
=#murder#
Testied#as#an#expert#
witness#in#trials#

Careful#of#conrmation#
bias#

Need#observable#facts#
and#behaviors#

Lost#credibility#in#Sally#
Clark#trial#

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Case#Practice#Issues#
If#FDIA#suspected##
contacting#family#rst#not#
recommended#
Perpetrators#often#
escalate#under#suspicion#
Need#more#time#than#
usual#to#investigate#
Social#media#of#
suspected#perpetrator#is#
very#important#

First#step#is#to#protect#the#
victim[#separation#test#
Second#to#get#the#
records#
Recognize#both#a#
disorder#and#a#crime#
Need#a#team#CPS[#law#
enforcement,#medical,#
psychological,#DAG#

Treatment#of#Perpetrator#
Prognosis#not#good#
Often#supercially#compliant#but#still#deceptive#
Dont#place#with#friends#or#family#without#strong#
vetting#
Often#excluded#partner#is#a#good#resource#
Placement#needs#training#FDIA#
No#visitation#early#on[#any#contact#needs#extraordinary#
supervision##no#food,#drink,#whispering,#physical#
contact#

Treatment#2#
Should#not#be#sent#to#cookie#cutter#treatments#such#as:#
Parenting#classes#
FPS#
Generic#and#undened#counseling#

Need#very#well#trained#and#strong#therapist#who#will#not#
rely#on#parental#report#only.#Must#have#knowledge#or#MDP#
or#willingness#to#have#training#or#consults.#Many#times#
therapists#end#up#supporting#the#perpetrator#

Case#Goal#
Should#not#automatically#be#reunication#
Very#dicult#to#treat#within#AFSA#guidelines#
Reunications#to#the#home#should#be#
considered#only#if#the#circumstances#are#
especially#favorable.#

Perpetrator#may#still#be#getting#positive#attention#as##a#
victim#of#CPS#
Have#to#work#within#CPS#timeframes#

Research#Evidence#
Scattering#of#approaches#with#weak#support.#
Feldman#and#Ford#(2000)#However,#not#
author#has#yet#described#a#consistently#
eective#or#specic#treatment#program#for#the#
factitious#disorder#by#proxy#maltreated,#
especially#if#acknowledgement#of#culpability#is#
not#forthcoming.#

Treatment#Research#
Very#thin.#
No#evidenced#based#protocol##most#studies#small#
In#all#cases##the#therapist#must#no#comprise#safety#of#the#victim.#
Success#depends#on#perpetrators#willingness#to#change#and#
insight#
Risk#of#therapist#being#enmeshed#with#perpetrator#very#high#
Rand#(1990)#therapy#so#dicult#shouldnt#be#used.#Use#case#
management#instead#

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Or#Aim#for#Favorable#
Indices#

So#can#try#
Treating#any#other#co[morbid#psychopathology#
Delusional#disorder#
Personality#Disorder#(BPD,#Paranoid,#Antisocial#,#
Narcissistic)#
Mood#disorder#
Or#discussing#how#their#needs#were#met#as#a#
child#
But#no#clear#evidence#these#will#work#

Perpetrator#admits#to#pattern#of#FDIA.#Show#
actual#insight#of#the#harm#it#caused.##
Will#demonstrate#alternative#behaviors#
Will#attend#to#childs#actual#developmental#
needs#
Really,#really#hard#to#judge#sincerity.##

My#own#view#
First#goal#is#insight##
Then#accurate#family#
history#
No#change#8[10#weeks#
consider#stopping[#Then#
switch#to#case#
management[#
Treatment#between#
perpetrator#and#child#
should#generally#be#
avoided#unless#very#real#
possibility#of#reunication#

.#
Reunication#should#not#
be#the#primary#case#goal#
No#contact#with#child#
No#criticism#of#current#
caregivers#
Attending#to#health#
behavior#of#child#
Appropriate#use#of#social#
media#
No#attempts#to#inuence#
child#or#placement#

Treatment#of#New#
Caregivers#
Education#on#FDIA#
Plan#to#restrict#access#
of#perpetrator#
Behavioral#parenting#
techniques#to#ignore#
sick#role#and#attend#to#
age#appropriate#coping#
skills#

Treatment#of#Victim#

Dont#assume#there#has#to#be#
treatment.#Even#less#research#
regarding#this#

Placement#in#a#nurturing,#stable#
environment#is#key#

Do#careful#assessment##if#there#are#
symptoms#treat#them#with#an#EBT#
approach.#

If#no#symptoms##dont#treat.##

Caregivers#should#receive#behavioral#
parenting#re[#dierential#response#
(not#attending#to#the#sick#role)#and#
skills#to#enhance#attachment#(e.g.#
PCIT)#

Bottom#Line#
Dangerous,#long#term#syndrome#that#is#very#
dicult#to#treat#with#very#high#recidivism#rate.#
Perpetrator##by#denition[#is#working#against#
CPS#and#the#best#interest#of#the#child#
In#most#cases,#safest#strategy#is#TPR.#

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Useful#references#
Lasher,(L.J.(and(Sheridan,(Ms.(S.(2004)(
Muchausen(by(proxy:(Identication,(intervention(
and(case(management.(London:(Routledge.(
Bools,#C.N.,#Neale,#B.A.#and#Meadow,#R.S.#(1994).#
Munchausen#syndrome#by#Proxy:#A#study#of#
psychopathogy.#Child&Abuse&and&Neglect,#18,#
773[778.##

Contact#Information#
Janet#Cahill,#Ph.D.#
jcahill@childfamilymh.com#

Felman,#M.D.##and#Ford,#C.V.#(1994)#Patient#or#
pretender:#Inside#the#strang#world#of#factitious#
disorders.#NewYork,#Wiley.##

11&