The relationship usually, but not always, involves a mother and her child.
The term Munchausen syndrome by proxy (MSBP) was named after Baron Munchausen, an aristocratic literary figure from 18th-century Germany, with a reputation for tall stories.
The correct name for MSBP is now factitious disorder imposed on another (FDIA). If the person invents illness for themselves, this is factitious disorder imposed on self (FDIS). The disorder has also been known as fabricated illness (FI).
FDIA: A mental health issue
Factitious disorder is classified as a mental illness.
People with Munchausen's syndrome by proxy seek to gain attention by inventing illnesses for their dependents.
A person with FDIS tries to gain attention by being the patient.
The person with FDIA gains attention by caring for someone, usually her own child, who is sick. She receives praise for her devotion during the many hospitalizations that the "patient" goes through, and uses the sick child to develop relationships with doctors and health care workers.
The earliest recorded case of fabricated illness was in 1951, and the first "by proxy" case was in 1976.
How common it is remains unclear, partly because of the secrecy practiced by those who have the disorder. One estimate suggests that 2 in every 100,000 children may experience it.
Sometimes it is not the mother but the father who has FDIA, and the receiver may not be a child, but an older teen, a person in their 20s or a vulnerable adult, such as an elderly person who is dependent on a caregiver.
The person with the condition often has a history of abuse or other mental health issues.
The fact that the abuser appears to care greatly about their dependent makes it harder to spot the deception.
To support claims that the child is ill when no illness is present, the person with FDIA may invent signs and symptoms. They may say that the child has convulsions, an eating disorder, pain, allergies or ADHD, when this is not true.
Alternatively, they may make the child ill by getting them to swallow a substance, injecting something into them to make them sick, or smothering them.
This can be fatal.
If a child has repeated and unexplained illnesses, or multiple illnesses, if the symptoms only occur when the parent is present, and if the parent seems to know a lot about medicine, despite not having previous training in the field of health care, these could be signs of FDIA.
While the child is in the hospital, the parent may stay with them all the time and attend to them well, but they may appear less concerned about the child's well-being than the health care professionals do.
The other parent tends not to be involved in the care of the child, or their involvement is minimal.
The parent may talk to the medical team a lot and try to develop a friendly relationship, but if challenged, they may become aggressive, confrontational, and possibly abusive.
The parent may be keen for the child to undergo tests that most parents would only agree to if absolutely necessary. They may encourage doctors to perform tests and procedures that are painful for the child.
Documents or other sources may indicate that the mother has changed doctors frequently, or has visited different hospitals for her child's treatment.
Patterns of abuse
Cases of FDIA fall into one of six categories of patterns of abuse, ranging from less severe to extremely severe.
Someone with the condition may:
- Invent signs and symptoms and tamper with test results, to encourage the diagnosis of an illness
- Deliberately not provide the child with nutrients
- Deliberately trigger symptoms, such as applying a chemical on the skin to cause a rash or irritation, but not including smothering or poisoning
- Use a low toxicity poison on the child, for example, a laxative to cause diarrhea
- Use a high toxicity poison on the child, for example, insulin to induce hypoglycemia, or excessively low blood sugar level
- Make the child lose consciousness by deliberately smothering them.
The most common fabricated symptoms include:
- Fits, or seizures
- Apnea, involving bouts of breathlessness
- Hyperactivity, learning difficulties, and other psychological symptoms
- Allergies and rashes.
A child who experiences FDIA is exposed to ongoing abuse, with a chance of serious psychological damage. The child is put at a disadvantage by multiple hospitalizations, and in physical danger from unnecessary surgical procedures and tests.
The exact causes of FDIA are unclear, but experts believe that a past traumatic experience in the abuser's life may play a role. In some cases, it stems from a personality disorder.
Some personality disorders are linked to a traumatic childhood event or experience.
Some mothers involved in FDIA may have experienced neglect or abuse when they were children, experienced a tragic loss of a family member, or were brought up in dysfunctional families.
It is very difficult to detect a case of FDIA, because it is extremely rare, and doctors can normally expect parents to tell the truth about their child's health.
A child whose parent has FDIA may spend a lot of time in the hospital.
If a physician suspects a case of FDIA, they will usually refer the case to a senior pediatrician, who will then look at the medical evidence to determine whether the child's signs and symptoms have a clinical explanation.
If the child is old enough, the doctor may try to talk to them alone, but this can be difficult because the parent tends to stay next to the child all the time.
The medical team will double check the blood and urine samples for evidence of added substances, including unprescribed medicines, toxins, or blood in urine samples.
The case may then be passed to the police and social services, and the child may be taken away from the parent to be cared for by other adults, depending on the level of risk.
Treatment involves two patients, the caregiver and the child.
The caregiver will receive intensive psychotherapy and family therapy.
Psychotherapy will focus on why mother decided to fake or induce symptoms and illness in the child, and then look for ways to resolve the problem. This will include learning to form relationships that are not associated with being ill.
Family therapy looks at family tensions and parenting skills, and will seek to restore the relationship between the child and the caregiver.
Patients who accept that they have a problem can normally be treated successfully.
Recovery for the child
If a case of FDIA is established, a medical team will work to get the child back to good health, possibly followed by long-term counseling to help overcome the trauma and stress caused by the abuse.
There is little research about what happens to people after this kind of experience, but studies suggest that children may experience delays in development, behavioral problems and anxiety. Attention problems have been noted.
The child may have missed schooling due to time spent in medical care. They may continue to believe that they really are sick, and they may need psychiatric help later in life.
A 1995 study of 10 adults whose mothers had FDIA reported that they felt unloved and unsafe while growing up, and that they had emotional and physical problems. As adults, they experienced insecurity and symptoms of post-traumatic stress, and they avoided medical treatment.
According to one expert, the person will need "years of therapy and support."
There are also online discussion boards for people who have undergone this experience during childhood.