Factitious Disorder Imposed on Another: A Life-Threatening Italian Case

After attending this presentation, attendees will better understand Factitious Disorder Imposed on Another (FDIA), also termed Munchausen Syndrome by Proxy in some jurisdictions, which should be one of the possible differential diagnoses of recurring health issues in children. This presentation will impact the forensic science community by emphasizing the importance of a multidisciplinary evaluation of suspected somatoform disorders perpetrated by caregivers. FDIA continues to mystify health care professionals, law enforcement officials, and the judicial system.1 Even though the first cases were described in 1977, it remains puzzling as to why a parent would want to induce fictitious symptoms and illnesses onto a child.2 Many professionals do not consider FDIA as a diagnosis because the parent, usually the mother, is extraordinarily able to convince them that she is a “good” mother and wants the best for her child.3 This study reports a severe case of FDIA managed in the multidisciplinary unit dedicated to the evaluation of suspected abused children (“Bambi”) of the “Ospedale Infantile Regina Margherita” in Turin, Italy. After an 11-year-old boy had several prior hospitalizations in multiple other facilities over a period of eight years, he was hospitalized in the Endocrinology Department by his mother. The child was treated for various problems, including Hirsprung Disease and diabetes mellitus type 1 with life-threatening ketoacidosis. He was also subjected to invasive procedures (cystoscopy with bladder neck incision, rectal biopsy, intestinal resection with coloanal anastomosis, and botulin toxin injections). In the consultation processes with the “Bambi” team, the mother and the boy were interviewed separately. The child described himself drawing “Pinocchio” (a notorious character known for being a liar). In interactions with the mother, he always appeared dominant, blackmailing, and manipulative. The mother displayed a facility with medical language, even though she was not a health professional, and strongly identified with the role of therapist. She also displayed tentative and inconsistent parental behaviors and inefficient coping skills. The mother conveyed that she was the only caregiver and refused support from her partner, who had left her and their children a few months earlier. The woman had always cared for sick relatives and showed pride for this role. Her whole life had been focused on the illnesses of others, and she displayed considerable expertise in working with the social workers to obtain economic and other welfare benefits. A discrepancy between the severity of the reported facts and the woman’s emotional state was evident. A careful global assessment of clinical and family history found the heterogeneity of the child’s symptoms and their escalation over time. There was a lack of correlation between the symptoms’ progressions and therapies. There was always a temporal correlation between the stressful life events of the mother (death of her mother, abandonment by her husband) and the subsequent clinical deterioration of the child. Furthermore, when the woman was engaged in taking care of other relatives, the clinical condition of her son improved and his hospitalizations decreased. After a comparison between the “Bambi” unit personnel (pediatrician, medical examiner, psychologist, and trained nurse) and physicians of the Endocrinology Department, the situation was referred to the judicial authority, formulating the hypothesis of FDIA. Thanks to a brief period of intense observation, it was documented that a ketoacidosis crisis had been induced by incongruous insulin delivery by the mother. The subsequent psychiatric evaluation confirmed the mother’s diagnosis. The overall assessment of the case by a multidisciplinary team was fundamental to formulating the proper diagnosis of the mother’s psychological pathology. For many years, the child had been a victim of this particularly subdued form of maltreatment and, upon several occasions, had been subjected to unnecessary life-threatening interventions. In fact, the child’s false symptoms (in particular, the ketoacidosis crises) were an expression of the mother’s need to maintain the only function she had in her life: to be a caregiver. The diagnosis was further complicated by the fact that the child was actually suffering from various diseases, which were overtreated by the mother. This presentation provides attendees with a better knowledge of FDIA. This diagnosis should always be kept in mind when health care professionals evaluate cases of chronic pediatric diseases in the presence of an inappropriate correlation between symptoms and therapeutic efforts.4 Reference(s): 1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, 2013. 2. Roy Meadow. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 2(1977): 343-5, doi: 10.1016/S0140-6736(77)91497- 0. 3. John Stirling and the Committee on Child Abuse and Neglect. Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting. Pediatrics. 119 (2007): 1026-1030, doi: 10.1542/peds.2007-0563. 4. Bernard Kahan and Beatrice Crofts Yorker. Munchausen syndrome by proxy: Clinical review and legal issues. Behavioral Science and the Law. 9 (1991): 73-83, doi: 10.1002/bsl.2370090109.