User:AlexJoMcDonough/Factitious disorder imposed on another

Signs and symptoms
In factitious disorder imposed on another, a caregiver makes a dependent person (typically a child) appear mentally or physically ill in order to gain attention. To perpetuate the medical relationship, the caregiver systematically misrepresents symptoms, fabricates signs, manipulates laboratory tests, or even purposely induces harm to the dependent (e.g. by poisoning, suffocation, infection, physical injury). It is important to note the caregiver must not be conducting this behavior for obvious external reward, such as money. Studies have shown a mortality rate of between six and ten percent, making it perhaps the most lethal form of abuse.

Warning signs
Warning signs of the disorder include:


 * A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling, and unexplained.
 * Physical or laboratory findings that are highly unusual, discrepant with patient's presentation or history, or physically or clinically impossible.
 * A parent who appears medically knowledgeable, fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients' problems.
 * A highly attentive parent who is reluctant to leave their child's side and who themselves seem to require constant attention.
 * A parent who appears unusually calm in the face of serious difficulties in their child's medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to more sophisticated facilities.
 * The suspected parent may work in the health-care field themselves or profess an interest in a health-related job.
 * The signs and symptoms of a child's illness may lessen or simply vanish in the parent's absence (hospitalization and careful monitoring may be necessary to establish this causal relationship).
 * A family history of similar or unexplained illness or death in a sibling.
 * A parent with symptoms similar to their child's own medical problems or an illness history that itself is puzzling and unusual.
 * A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with a serious illness.
 * A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment.
 * A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgment of their abilities.
 * A child who inexplicably deteriorates whenever discharge is planned.
 * A child that looks for cueing from a parent in order to feign illness when medical personnel are present.
 * A child that is overly articulate regarding medical terminology and their own disease process for their age. Alternatively, a child that does not report any of their own symptoms and only the parent elaborates on the symptoms.
 * A child that presents to the Emergency Department with a history of repeat illness, injury, or hospitalization.

Prevalence and Statistics
In one study, the average age of the affected individual at the time of diagnosis was four years old. Slightly over 50% were aged 24 months or younger, and 75% were under six years old. The average duration from onset of symptoms to diagnosis was 22 months. By the time of diagnosis, six percent of the affected persons were dead, mostly from apnea (a common result of smothering) or starvation, and seven percent had long-term or permanent injury. About half of the affected had siblings; 25% of the known siblings were dead, and 61% of siblings had symptoms similar to the affected or that were otherwise suspicious. The mother was the perpetrator in 76.5% of the cases, the father in 6.7%.

Most present about three medical problems in some combination of the 103 different reported symptoms. The most-frequently reported problems are apnea (26.8% of cases), anorexia or feeding problems (24.6% of cases), diarrhea (20%), seizures (17.5%), cyanosis (blue skin) (11.7%), behavior (10.4%), asthma (9.5%), allergy (9.3%), and fevers (8.6%). Other symptoms include failure to thrive, vomiting, bleeding, rash, and infections. Many of these symptoms are easy to fake because they are subjective. A parent reporting that their child had a fever in the past 24 hours is making a claim that is impossible to prove or disprove. The number and variety of presented symptoms contribute to the difficulty in reaching a proper diagnosis.

Aside from the motive (most commonly attributed to be a gain in attention or sympathy), another feature that differentiates FDIA from "typical" physical child abuse is the degree of premeditation involved. Whereas most physical abuse entails lashing out at a child in response to some behavior (e.g., crying, bedwetting, spilling food), assaults on the FDIA victim tend to be unprovoked and planned.

Also unique to this form of abuse is the role that health care providers play by actively, albeit unintentionally, enabling the abuse. By reacting to the concerns and demands of perpetrators, medical professionals are manipulated into a partnership of child maltreatment. Challenging cases that defy simple medical explanations may prompt health care providers to pursue unusual or rare diagnoses, thus allocating even more time to the child and the abuser. Even without prompting, medical professionals may be easily seduced into prescribing diagnostic tests and therapies that may be painful, costly, or potentially injurious to the child. If the health practitioner resists ordering further tests, drugs, procedures, surgeries, or specialists, the FDIA abuser makes the medical system appear negligent for refusing to help a sick child and their selfless parent. Like those with Munchausen syndrome, FDIA perpetrators are known to switch medical providers frequently until they find one that is willing to meet their level of need; this practice is known as "doctor shopping" or "hospital hopping".

The perpetrator continues the abuse because maintaining the child in the role of patient satisfies the abuser's needs. The cure for the victim is to separate the child completely from the abuser. When parental visits are allowed, sometimes there is a disastrous outcome for the child. Even when the child is removed, the perpetrator may then abuse another child: a sibling or other child in the family.

Factitious disorder imposed on another can have many long-term emotional effects on a child. Depending on their experience of medical interventions, a percentage of children may learn that they are most likely to receive the positive parental attention they crave when they are playing the sick role in front of health care providers. Several case reports describe Munchausen syndrome patients suspected of themselves having been FDIA victims. Seeking personal gratification through illness can thus become a lifelong and multi-generational disorder in some cases. In stark contrast, other reports suggest survivors of FDIA develop an avoidance of medical treatment with post-traumatic responses to it.

The adult caregiver who has abused the child often seems comfortable and not upset over the child's hospitalization. While the child is hospitalized, medical professionals must monitor the caregiver's visits to prevent an attempt to worsen the child's condition. In addition, in many jurisdictions, medical professionals have a duty to report such abuse to legal authorities.

Diagnosis
Munchausen syndrome by proxy is a controversial term. In the World Health Organization's International Statistical Classification of Diseases, 10th Revision (ICD-10), the official diagnosis is factitious disorder (301.51 in ICD-9, F68.12 in ICD-10). Within the United States, factitious disorder imposed on another (FDIA or FDIoA) was officially recognized as a disorder in 2013, while in the United Kingdom, it is known as fabricated or induced illness by carers (FII).

In DSM-5, the diagnostic manual published by the American Psychiatric Association in 2013, this disorder is listed under 300.19 Factitious disorder. This, in turn, encompasses two types:


 * Factitious Disorder Imposed on Self
 * Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy); the diagnosis is assigned to the perpetrator; the person affected may be assigned an abuse diagnosis (e.g. child abuse).

Both types include an optional specifier to identify if the observed behavior was a single episode or part of recurrent episodes.