By: Elise Meng, Chemistry ‘27
On December 23rd, 2023, Gypsy Rose Blanchard was released from prison after serving seven years for the second degree murder of her mother Clauddine, “Dee Dee,” Blanchard. Her release garnered an immense amount of speculation and attention from various news outlets and social media with people sympathizing over the years of medical abuse forced upon her by her mother. The widespread knowledge of her release sparked many questions, primarily, What is Factitious Disorder Imposed on Another (FDIA) and how does it manifest? Although previously called Munchausen Syndrome by Proxy, psychologists are now using the term Factitious disorder imposed on another because it better describes a behavioral pattern rather than an underlying psychiatric condition [1]. FDIA occurs when a person, often the caretaker, falsifies medical symptoms in a victim, usually to satisfy a psychological need. This frequently causes the victim to appear more ill than they actually are and undergo many unnecessary procedures and medical appointments. While a lot of literature and statistics address cases that affect children, FDIA can also manifest in palliative care.
One of the biggest challenges of FDIA is the difficulty in identifying its manifestation, which contributes to underdiagnosis and underreport. Prevalence rates are generally unknown but recent statistics report that FDIA cases have been documented in over 50 countries. Around 0.5 to 2.0 per 100,000 children younger than 16 years old are affected, and 95.6% of these cases involve a mother who presents falsified symptoms on behalf of her child [2]. However, these are only estimates, and FDIA is still extremely under-identified and difficult to diagnose. Factors that cause such under-diagnosis include the lack of sufficient evidence, deception by the caregiver, and misleading illness [3]. FDIA can also present clinically different results in every case, and to a certain extent, any condition can be falsified. Two general warning signs of FDIA include a patient presenting with an abnormal condition or an inconsistent medical diagnosis.
Additionally, patients with chronic disabilities or conditions may be at a higher risk for FDIA as some abusers fulfill their own psychological needs by maintaining contact with medical professionals [4]. One of the more reliable methods for identifying illness falsification is to “conduct an exhaustive medical record review that allows behavioral analysis of the alleged abuser,” according to Bursch. Physicians will often use multiple sources to qualify or discredit reported symptoms.
In one case involving a two year old male toddler presenting with a fever of unknown origin, his mother used highly advanced medical terminology and descriptions to diagnose her son that were unrelated to his initial fever concern. She had also consulted twelve specialists and seven allied health professionals and most of these investigations yielded negative results. The patient’s pediatrician initiated contact with his previous physician and day care to uncover that the patient had been admitted to a children’s hospital for leukemia yet no medical records confirmed this diagnosis. It was not until six years and countless doctor visits later that the patient’s mother was imprisoned for drug trafficking. For this case, communication with the patient’s daycare and previous physicians, as well as access to an extensive medical record were imperative in confirming the pediatrician’s suspicions of FDIA.
Although FDIA is more common in younger patients, it can also occur in palliative care for end-of-life (EOL) patients. In palliative care, there is often a dependent relationship between EOL patients and their caregivers. Causes are generally the same as with younger patients, but in palliative care, there is also a financial aspect and financial exploitation has been frequently reported. In one case, a 93-year-old patient with advanced dementia endured more than 49 admissions and investigations in four years, most of which were unnecessary. Her primary caregiver, her grandchild, falsely claimed to be a medical student and made incorrect claims to medical professionals. Following the investigation of this case, her grandchild was said to likely have “derived secondary gains” of concerned attention from healthcare professionals and a sense of importance for caring for the patient [5]. There is an added difficulty of recognizing FDIA in EOL patients because caregivers may not completely falsify symptoms and can instead appear “over-caring.”
In 2024, there are models and precedents to follow in assessing FDIA but it is still often underdiagnosed, underreported, and sometimes, misdiagnosed. The main treatment for FDIA is to completely remove the patient from their caregiver’s presence and possibly undergo medical treatments to reverse the effects of unnecessary procedures [6]. Victims will often engage in therapy as FDIA can also have a large toll on the mental, not just physical health, of patients. Although there isn’t a strict formula in recognizing or diagnosing FDIA, medical professionals must stay vigilant and be cognizant of possible suspicious activity.
References:
[1] Faedda, N., Baglioni, V., Natalucci, G., Ardizzone, I., Camuffo, M., Cerutti, R., & Guidetti, V. (2018). Don't Judge a Book by Its Cover: Factitious Disorder Imposed on Children-Report on 2 Cases. Frontiers in pediatrics, 6, 110. https://doi.org/10.3389/fped.2018.00110
[2] Bursch, B., Emerson, N.D. & Sanders, M.J. Evaluation and Management of Factitious Disorder Imposed on Another. J Clin Psychol Med Settings 28, 67–77 (2021). https://doi.org/10.1007/s10880-019-09668-6
[3] Walters, I. C., MacIntosh, R., & Blake, K. D. (2020). A case report and literature review: Factitious disorder imposed on another and malingering by proxy. Paediatrics & Child Health, 25(6), 345+. https://link.gale.com/apps/doc/A644368226/AONE?u=nysl_sc_cornl&sid=ebsco&xid=1ffb8da7
[4] Abdurrachid, N., & Gama Marques, J. (2022). Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA). CNS Spectrums, 27(1), 16–26. https://doi.org/10.1017/S1092852920001741
[5] Goh, W. Y., & Chan, M. P. C. (2023). Factitious Disorder Imposed on Another in Palliative Care: A Case Report. Journal of Palliative Medicine, 26(8), 1165–1167. https://doi.org/10.1089/jpm.2022.0523
[6] Rosenbaum, Leah (2024, January 3).What is Munchausen by proxy, the mental illness that Gypsy Rose Blanchard's mother allegedly had. Business Insider. https://www.businessinsider.com/what-is-munchausen-by-proxy-2024-1
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