In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is Munchausen syndrome by proxy.
While Munchausen by proxy is likely the name that’s most recognizable, the name for the disorder in the current version of the DSM (the DSM-5) is factitious disorder imposed on another. I’ll use the acronym FDIA for the rest of the post since it’s so much shorter.
So, who is Munchausen and what is their disorder? Baron Munchausen is a fictional character from the 18th century German novel Baron Munchausen’s Narrative of his Marvellous Travels and Campaigns in Russia. Baron Munchausen told wildly exaggerated tales of things that had happened to him. In 1951, Munchausen’s Syndrome was coined by Dr. Richard Asher to describe patients who presented with fabricated accounts and symptoms of illness.
Factitious Disorder Imposed on Another
Munchausen by proxy/FDIA refers to an individual who feigns illness in another person (most often a child) that they are caring for. Elderly parents of adult children may also be targets of FDIA. This is not done in a way that would provide any clear tangible benefit (e.g. monetary reward), but instead the main purpose appears to be garnering attention and sympathy.
This feigning of illness can include lying, contaminating samples for lab tests, and actively causing harm through measures like poisoning, suffocation, and starvation. The measures taken by the person with FDIA can be lethal, and the mortality rate among victims may be as high as 10%.
The University of Michigan identifies a number of characteristics typical of someone with FDIA:
- most commonly a mother
- has prior medical skills or experience
- seems very devoted to the child (or other victim)
- seeks out sympathy and attention
- makes excessive attempts to become close with health care providers
- needs power and control
- doesn’t believe their behaviour is harmful
Risk factors for developing FDIA include pregnancy complications, a history of childhood abuse, and factitious disorder imposed on self (also known as Munchausen syndrome).
Recognizing warning signs
Medscape lists several potential warning signs of FDIA, including:
- unexplained illnesses that are persistent or recurring
- a mismatch between the reported symptoms and what’s clinically observed
- there are signs and symptoms that only occur when the parent is present
- the parent is highly attentive and always present when the child is receiving care
- the child is often unable to tolerate forms of treatment that are tried
When apparent illnesses can’t be explained, this may lead to extensive testing and risky procedures being performed in an attempt to determine what the underlying medical condition might be, which ends up only reinforcing the pattern of the person with FDIA.
Diagnosing the disorder involves some careful investigative work, which may involve removing the child from the mother’s care, or using video surveillance. An article on Medscape states that “if a multidisciplinary team agrees on the procedure, hidden cameras can be used to record the interactions of the child and the suspected perpetrator in the hospital setting.” While this is something that would usually be considered a breach of privacy, it may be the only way to definitely establish the presence of FDIA.
FDIA is rare, involving only about 2 in 100,000 children as targets. A literature review by Feldman and Brown found articles from 24 different countries describing causes of FDIA, include non-Western nations. In the 122 cases described, the mother was the sole perpetrator 86% of the time. There were slightly more male than female victims. The presentation of the disorder was very similar worldwide.
Legal precedents have been established in the U.K. and Australia that FDIA is a description of behaviours rather than a psychiatric illness, and as a result psychiatrist testimony is inadmissible in court unless it refers specifically to harm done to the child.
The legal precedents raise an interesting question. Is this a twisted behavioural pattern, or is it an illness? I think I’d tend to have more sympathy when it comes to factitious disorder imposed on self (i.e. Munchausen syndrome) than FDIA (Munchausen by proxy), and I’d be more willing to accept that as an illness. I don’t have much sympathy, though, when it comes to harming a child. It’s understandable that sometimes parents who are in a psychotic or severe mood episode can harm their children without being able to appreciate the nature of what they are doing as a result of their illness, but there’s something very distasteful about a parent harming their child for the sake of attention. I think at that point it would shift from being a question of illness to a matter of child abuse, albeit with a clearly distorted way of thinking.
What are your thoughts on the validity of FDIA/Munchausen syndrome by proxy?
You can find the rest of my What Is series here.
- Cleveland Clinic
- Feldman & Brown (2002) in Child Abuse & Neglect
- University of Michigan Medicine