Munchausen Syndrome by Proxy (Factitious Disorder Imposed by Another)

Munchausen syndrome by proxy is a mental health disorder in which a caregiver, most often a mother, routinely makes up fake symptoms or causes real symptoms in a child or adult victim 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, Munchausen syndrome by proxy is also considered a very serious form of child abuse.

Munchausen syndrome and Munchausen syndrome by proxy are now classified as “factitious disorder imposed on another” or FDIA in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This change represents the belief that this disorder describes a behavioral pattern rather than an underlying psychiatric syndrome.

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

Symptoms of Munchausen by Proxy

The signs and symptoms of factitious disorder imposed on another (FDIA) will likely be present in both the caregiver and the child or adult victim. 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:

• Deception from caregiver
• Caregiver's reports are different from that of medical personnel
• Caregiver has medical knowledge and may work in a medical setting 
• Caregiver has the desire to be seen as "good" at what they do
• Caregiver routinely seeks approval and attention from medical staff 
• Refusal of caregiver to leave the victim's side when they are assessed
• Victim's medical history is spotty, vague, or inconsistent
• Recommendations for invasive diagnostic and surgical procedures are accepted without question or concern by the caregiver 

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:

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

Causes

The exact cause of FDIA or Munchausen Syndrome by proxy is not clear. However, experts say that both biological and psychological factors play a role in the development of this disorder.

One theory suggests that people with FDIA experienced a history of neglect or psychical, sexual, or emotional abuse as a child. The caregiver may also have a psychiatric disorder such as personality disorder, bipolar, anxiety, or depression. Other theories point to the loss of a parent at a young age or major stress. 

Types of Munchausen by Proxy

Munchausen syndrome by proxy always involves a caregiver and a victim, typically a child or other adult. Munchausen syndrome, on the other hand, is when a person presents themself to others, more specifically medical personnel, as sick.

Both are considered factitious disorders with Munchausen syndrome by proxy classified as factitious disorder imposed on another (FDIA) and Munchausen as factitious disorder imposed on oneself or FDIS. 

In FDIA, “another” can be a child of the caregiver, such as mother and child, or it can be another adult the perpetrator is caring for. 

Diagnosis

Diagnosing Munchausen syndrome by proxy 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.

There is a set of criteria used to diagnose FDIA or Munchausen syndrome by proxy. To meet a clinical diagnosis, the following four criteria must be met:

1. 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
4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Treating Munchausen by Proxy

The treatment of FDIA or Munchausen syndrome by proxy generally requires treatment of the adult and the child or adult 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 treatment of Munchausen by proxy 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.