Factitious Disorder by Proxy: Rethinking the Diagnostic Formulation

By Eric G. Mart, Ph.D., ABPP

Factitious disorder by proxy (FDBP) is an unusual diagnosis which has garnered increasing attention in recent years. The disorder was first identified by Sir Roy Meadow (1977). He referred to it as Munchausen's syndrome by proxy (MSBP) and this name is often used interchangeably with FDBP in the literature on the subject. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) the disorder is characterized by "Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care," (p. 726) in order to assume the sick role by proxy.

The diagnosis remains controversial, and FDBP is included in an appendix of the DSM-IV entitled "Criteria Sets and Axes Provided for Further Study." Proposed diagnoses are included in this appendix because an APA task force has determined that insufficient information was available to warrant inclusion as an official diagnosis. The DSM-IV indicates that the following conditions must be met for the diagnosis to apply.

1. Medical symptoms are induced, fabricated or exaggerated in a victim by a caretaker.

2. The behavior is designed to achieve the secondary gain associated with taking on the sick role by proxy.

3. Obvious external gain is not the motivating factor.

4. The behavior is not better explained by another diagnosis.

The DSM-IV cautions that this diagnosis must be differentiated from physical or sexual abuse that is not motivated by the goal of assuming the sick role by proxy, and from malingering, which is predominantly motivated by external incentives. It should also be noted that while the victim of FDBP may be of any age (for example, an elderly incapacitated individual), the literature focuses almost entirely on children as the victims and mothers or female caretakers as the perpetrators.

This diagnosis has been a source of considerable controversy in the fields of medicine and psychology. There is disagreement about the name of the disorder as well as the extent to which motivational issues figure in making the diagnosis. Most recently, the APSAC Taskforce on Munchausen by Proxy, Definitions Working Group (2002), has attempted to develop a bifurcated approach to the disorder. The Taskforce has proposed the use of the term Pediatric Condition Falsification (PCF) for the diagnosis of child abuse through falsification of medical or psychiatric symptoms in a child by a caretaker. The Taskforce recommends that the DSM-IV diagnosis Child Abuse-61.21 be applied if the focus is on the victim, and Child Abuse-995.5 if the focus is on the perpetrator. In this diagnostic scheme, if MBP [FDBP] is involved, the DSM-IV diagnosis Factitious Disorder Not Otherwise Specified-300.19 would be applied to the perpetrator.

This approach has certain advantages over previous diagnostic formulations. There has always been some confusion about whether the child victim or the perpetrator of FDBP carries the diagnosis. This new formulation would create a diagnosis with two sets of criteria analogous to the two components that comprise the definition of a crime: actus reus (prohibited act) and mens rea (guilty mind). PCF would correspond to the actus reus, which refers to the action component of the crime, while FDBP would correspond to the mens rea, which refers to the intentional nature of the act. Accordingly, under the proposed APSAC criteria, PCF might be diagnosed in the absence of FDBP, but FDBP could not be diagnosed without a corresponding diagnosis of PCF.

Despite this, considerable problems remain with the diagnostic formulation of FDBP. For example, the aforementioned APSAC position paper indicates that while the absence of external incentives, such as economic gain, is one of the diagnostic criteria for FDBP, "it is clear from the work of people in the field (Meadow, 1995) that external incentives such as economic gain, escaping difficult life circumstances, and/or wresting attention or custody from an inattentive or abandoning spouse may be present" (APSAC Taskforce on Munchausen by Proxy, Definitions Working Group, 2002, p. 108). While this may very well be true, it blurs FDBP diagnostic criteria, leaving the clinician to determine which motivation is primary.

This ambiguity inevitably leads to difficulties in making the diagnosis of FDBP. For example, a parent who persistently fabricates allegations of sexual abuse of a child by a spouse in order to obtain custody would not be diagnosed with FDBP, nor would a paranoid mother who sees abuse everywhere, nor would a parent who is overanxious and fabricates symptoms in order to obtain the attention that she believes her sick child needs. However, a person who committed the identical acts of falsification and/or exaggeration would be diagnosed with FDBP if elements of attention seeking or secondary gain appeared to be present; this distinction is left for the clinician to make on the basis of extremely subjective criteria.

This issue would be less important if it were not for the fact that the FDBP diagnosis brings with it considerable baggage. For example, a number of prominent authors on the subject have indicated that the diagnosis is associated with high degrees of mortality as well as physical and psychological morbidity (Rosenberg, 1987; Alexander, Smith, & Stevenson, 1990). As a consequence, courts tend to respond more strongly in alleged cases of FDBP than in cases involving more common forms of child abuse. This is of concern since there is no empirical evidence that the perpetrators of FDBP have, as a group, a higher level of psychopathology than parents who are found guilty of more straightforward forms of physical or sexual child abuse.

Some of the literature on FDBP also suggests that this is a multi-generational disorder and that the parents and siblings of the alleged perpetrator may somehow be involved in the genesis and perpetuation of the disorder. As a consequence, despite the fact that most states have statutes mandating good faith attempts to place children taken by the courts into the care of blood relatives, prosecutors and child protection workers often object to such placements on the grounds that the child will be in danger because of FDBP family dynamics. It is of note that in cases where children are taken from parents with severe substance abuse problems there is no such tendency to avoid placement with relatives, even though substance abuse clearly has a familial component. In such cases, courts and CPS workers generally ascertain that no active substance abuse problems are observed in the relatives, rather than deny placement on the basis of a vague suspicion that something in the family dynamics makes them unsuitable caretakers.

The literature also suggests that the underlying psychopathology of FDBP parents is severe and refractory to treatment, and that reunification is therefore unlikely to be feasible. As a consequence these cases often move toward termination of parental rights more quickly than is usual in other types of child abuse cases. For example, in their discussion of therapy for FDBP perpetrators and the issue of parental termination, Sanders and Bursch state: "If partial or no progress has been made in therapy, reunification is not recommended. If it appears that progress is not being made in a timely manner (perhaps within 6 months), the court might consider a more rapid progression toward termination of parental rights as it may not be likely that the parent would be able to reunify with the child" (Sanders & Bursch, 2002, p. 122).

One of the major problems with the diagnostic formulation of FDBP is that dynamics and characteristics that are continuous variables are treated in the bulk of the scholarly and scientific literature as though they were dichotomous. Put another way, although many of the characteristics associated with FDBP vary along a continuum, they are approached as though they were either present or absent. This has led to a tendency to lump a wide variety of behaviors of varying intensity into one ill-fitting category. FDBP has become a procrustean bed, with unfortunate results.

A better way to approach this complex diagnosis would be to describe the disorder in terms of its central dynamic variables. The most important of these variables are secondary gain, severity of abuse, and psychopathology of the perpetrator. Of these, secondary gain through assumption of the sick role by proxy is the characteristic that most differentiates FDBP from ordinary child abuse. However, secondary gain is not unique to FDBP; all illnesses and injuries have the potential to produce secondary gain. An incapacitating back injury may cause pain and distress, but it may also allow the sufferer to escape a disliked job. The secondary gain may be minor and may be far outweighed by the negative effects of the injury, the advantages and disadvantages of the injury may be closely balanced, or the benefits of being out of work may far outweigh the negative effects of the symptoms. In some cases, an individual with pre-existing hypochondriacal or somatizing tendencies may exhibit a complex interplay between psychological factors and the bona fide physical effects of injury. Those working in the area of rehabilitation are aware that these factors exist on a continuum, and they assess this issue carefully in every case so as to develop appropriate treatment plans and interventions.

This interplay between physical and psychological factors likewise occurs in individuals diagnosed with FDBP and in parents who are not perpetrating FDBP but have sick or handicapped children. For example, a mother with a chronically ill child may prefer the role of nurse and companion to the demands of competitive employment. If this desire is strong enough it might lead to symptom exaggeration, fabrication or induction. But there is almost certainly a population of mothers who do not need to engage in these behaviors because their children are ill enough to require them to assume the sick role by proxy without the necessity of engaging in FDBP. Other parents may exaggerate symptoms, perpetuating their involvement in the caretaker role so as to enjoy the secondary gain provided by the sick role by proxy, but lack sufficient motivation to engage in outright fabrication. The picture is further complicated by the issue of external incentives, which the APSAC definitional taskforce has suggested can play a role in the symptom picture and genesis of FDBP in combination with secondary gain through assumption of the sick role. The balance between secondary gain and external incentives is likely to vary from case to case rather than being an either/or situation, and both factors should be assessed as occurring along a continuum rather than as either present or absent.

Another variable that is central to our understanding of FDBP cases is severity of abuse. Clearly, the potential for harm varies among different forms of child abuse: physical abuse can range from overuse of spanking to severe attacks resulting in broken bones or death, while sexual abuse may range from inappropriate touching over clothing to genital intercourse. While all of these acts have the potential for negative effects on children, society differentiates between mild and severe abuse through its courts, agencies and laws, and different remedies are applied depending on circumstances. Cases of milder child abuse are often dealt with through monitoring by CPS, parent training, and psychotherapy for both victims and perpetrators, while moderate levels of abuse may require the removal of children from their parents' custody for varying lengths of time. The most severe cases often prompt initiation of termination of parental rights proceedings and eventual adoption of children by third parties.

Varying degrees of severity are also seen in cases of abuse through FDBP. At the severe end of the spectrum are cases in which parents engage in the active induction of symptoms. Unfortunately, this can be done in ways that have the potential to kill; cases of intentional suffocation have been observed through covert video surveillance, and there are well documented cases of intentional poisoning with salt, emetics and laxatives. Other cases do not involve active induction of symptoms; instead, parents give physicians false reports of seizures, persistent vomiting, headaches, episodes of apnea, non-specific pain, and other complaints that do not lend themselves to immediate objective medical verification. While such fabrications are not as immediately dangerous as symptom induction, they can lead to the use of potentially dangerous (and unnecessary) medications, treatments, and surgical procedures. Finally, in some cases FDBP perpetrators exaggerate their victims' bone fide symptoms by overstating their frequency, severity and duration.

Clearly, the severity of the medically related abuse that forms the actus reus of FDBP varies along a continuum; despite this fact, there is a tendency to lump all such presentations together as though they all posed the same degree of risk to the victim. While there may be cases in which parents escalate their behavior, progressing from exaggeration to fabrication to active induction, the inevitability of such a progression has not been established through any empirical methodology. The existing literature relies on a few anecdotal case studies, some of which focused on selected cases in order to illustrate a particular perspective (Alexander, Smith, & Stevenson, 1990). One of the few empirical studies that actually focused on parents found guilty of more severe forms of FDBP found that parents generally did not escalate or persist in these behaviors after detection (Berg & Jones, 1999).

A third variable that should be considered in FDBP cases is the psychopathology of the perpetrator. Although some preliminary studies of FDBP mothers have examined the psychopathology of these perpetrators, no consistent pattern has emerged, and the research that exists has demonstrated that those identified as FDBP perpetrators vary widely in their level and type of psychopathology (Bools, Neale & Meadow, 1992, 1993, 1994; Parnell & Day, 1998). Some research suggests that many, but by no means all, of these perpetrators have suffered from factitious disorder or other forms of unusual illness related behavior. Some have histories of abuse, while some do not. Charactological problems are seen with some frequency but are not universal. Some of the mothers in these studies have severe forms of mental illness, but this is the exception rather than the rule. There are several reasons why conclusions drawn from these studies are of limited utility in supplying information for the purpose of establishing a profile of FDBP perpetrators or creating treatment protocols. First, as far as personality dynamics are concerned, the only real pattern that emerges is that there is no pattern. The second issue relates to the base rate problem; those trends that have emerged in studies of the personalities of FDBP perpetrators have a high base rate in many other clinical groups that do not engage in such behaviors. The characteristics seen in the studies of Bools, Neale and Meadow (1992, 1993, 1994) such as history of physical or sexual abuse, characterological problems, somatizing disorders, drug and/or alcohol abuse, and self harm, are commonly seen in patients suffering from PTSD and eating disorders, as well as custody litigants and a variety of other clinical groups.

Construing the psychopathology of FDBP perpetrators as a dynamic factor would not only help provide a more accurate reflection of the true state of affairs, but also would assist professionals and courts in determining appropriate interventions on a case by case basis. For example, individuals with high levels of psychopathy are unlikely to benefit from psychotherapeutic treatment, and any danger to children arising from such pathology is unlikely to be ameliorated through psychotherapy. Individuals with other types of personality disorders, as well as anxiety disorders or depression, may be more amenable to treatment. Individuals who have been found to have medically abused their children might receive diagnostic psychological evaluations to assist in the assessment of prognosis and in the choice of therapeutic modalities, such as psychopharmacological treatment, cognitive behavior therapy, parenting classes, and a host of other therapeutic modalities commonly used with parents who engage in more common forms of child maltreatment.

Ultimately, viewing FDBP as a multifaceted phenomenon would allow a more productive, flexible approach to working with alleged perpetrators. Rather than attempting to decide whether a particular instance of medical child abuse meets or does not meet the diagnostic criteria of FDBP, courts and evaluators would be able to approach cases with an eye toward the individual characteristics and dynamics of the instant case. As matters stand, adjudicatory processes often become bogged down in an either/or debate about the presence or absence of FDBP. These debates do not "advance the ball" when it comes to deciding whether aspects of a parent's behavior caused harm or placed a child at risk, nor do they help with disposition of cases if the response to a finding of FDBP is invariably a prescription for long-term foster care or termination of parental rights.

In addition to re-conceptualizing FDBP as a multiaxial phenomenon, abandonment of the diagnostic labels presently associated with medical child abuse would likely improve the way such cases are dealt with, both diagnostically and therapeutically. This step has been suggested by other authors (Mart, 1999; Morley, 1995; Fisher & Mitchell, 1995), and events over the past ten years have borne out the merit of these suggestions. The initial conceptualization of FDBP by Meadow was useful in the same way that Kempe's identification of battered child syndrome created awareness of the physical abuse of children, but the term "battered child syndrome" has been abandoned in favor of the more generally descriptive term "child abuse." Cases of child abuse are now prosecuted by providing the court with an exact description of the abusive acts alleged, and there is no need for recourse to a syndrome label or diagnosis. The FDBP diagnosis should also be retired, and replaced with an exact description of what the parent is alleged to have done or caused to happen that harmed or had the potential to harm the child before the court. This would have the effect of divesting these cases of the unhelpful baggage that now encumbers these diagnoses, such as the overly broad, unscientific behavioral profile, inflated mortality rates, and inaccurate and negative prognostic statements.

The alternative formulation for FDBP suggested by the APSAC taskforce (Pediatric Condition Falsification and MSBP) only sidesteps the issue. The PCF diagnosis has a high potential for reification while providing no advantages over a simple statement of allegations that a parent has exaggerated, fabricated or induced a child's symptoms of illness; the FDBP portion of the APSAC formulation simply perpetuates the use of an unhelpful and outmoded diagnosis. A non-diagnostic, general term such as medical child abuse (uncapitalized) would provide a more accurate and useful replacement for the current diagnostic labels.

Other concerns have been raised in the literature that support the argument for retirement of the FDBP/PCF diagnosis, including the high potential for overdiagnosis (Morley, 1995). The low base rate of the diagnosis, coupled with excessively broad diagnostic criteria and the misuse of profile data, ensures an unacceptable level of false positive diagnosis of the condition; this effect is most pronounced in cases of alleged fabrication, and most particularly in allegations of symptom exaggeration, as identification of this phenomenon is quite subjective.

Another argument for the abandonment of MSBP, FDBP and PCF diagnostic labels is the fact that this step would free investigators to utilize a more flexible and productive methodology in assessing allegations of medical child abuse. In such cases, a medical team should examine the medical history and records of the alleged victim, utilizing an hypothesis testing model, and then provide the court with a bill of particulars detailing the specific abusive acts the parent is alleged to have committed. The bill of particulars is essential, since allegations often change form in such cases, shifting from suspicions of active symptom induction, to fabrication, to exaggeration when the more serious charges cannot be substantiated. Such "moving target" prosecutions of these cases practically ensures a lack of rigor and fairness, as does testimony about the presence or absence of the FDBP profile, which has no empirically derived discriminant validity. It is disturbing to see courts allowing testimony about the supposed behavioral characteristics of FDBP mothers, while it would be unthinkable to allow testimony that an alleged child molester did not "fit the profile" of a sexual offender. These types of testimony inevitably lead to situations in which the court is forced to make important decisions about child protection based on highly subjective evidence of limited or non-existent probative value. It should also be borne in mind that erring on the side of child safety is not as simple as it seems; many children suffer separation anxiety when precipitously removed from their families, and abuse is not unknown in foster care.

If a case is determined to be founded after presentation of concrete evidence of medical abuse, psychological/psychiatric assessments of the perpetrator, the victim, and the family should be undertaken in order to develop a clear picture of the issues and dynamics (including the harmfulness of the behavior, the role of secondary gain, and the psychopathology of the perpetrator) in order to develop a safety/reunification plan or to determine whether such a plan is feasible. All of this would be done without recourse to the FDBP label, thereby avoiding the unfortunate and counterproductive effects of this diagnosis. In the final analysis, there is much to be gained and nothing to lose through abandonment of FDBP and adoption of a policy of simply describing acts that may constitute medical abuse.

References

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