Fabricated or induced illness

DISORDERS WITH SOMATIC PRESENTATION Fabricated or induced illness Christopher Bass David P H Jones Fabricated or induced illness (previously called Munchausen’s Syndrome by Proxy or MBP) is a form of child abuse in which a parent falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care whilst disclaiming knowledge of the cause of the problem. The disorder has been renamed fabricated or induced illness or FII and has attracted considerable interest and controversy.1 A number of women who were thought to have induced illness in their children were acquitted recently in the UK courts, and these highly publicized cases have led some commentators to question the existence of this disorder.2 Regrettably, this adverse publicity has drawn attention away from key aspects of induced illness, which are: • it is a form of child abuse • in the majority of cases it is perpetrated by the mother, often in a general hospital • detection requires detailed and painstaking enquiry involving the collection of information from many different sources and discussion with different agencies (e.g. social services, general practice, police). In this paper we will briefly outline the prevalence and clinical characteristics of the disorder, before describing the psychopathology of the perpetrators and methods of assessment. Finally, an approach to management will be outlined with special reference to those characteristics in the mother that may allow for reunification with the child after the diagnosis has been established. Evidence for the existence of factitious or induced illness We propose a ‘hierarchy’ of evidence, which ranges from detailed accounts by victims, to confessions from perpetrators and large published case series (Figure 1). Individual cases have attracted considerable interest, for example, Beverly Allitt in the UK and Julie Gregory in the USA (see Further Reading), and the Department of Health has published a detailed account of this disorder.1 The largest case series has recently been published and includes Christopher Bass is Consultant in Liaison Psychiatry at the John Radcliffe Hospital, Oxford, UK. He trained in medicine at Cambridge University and St. Thomas’ Hospital in London, and in psychiatry at King’s College Hospital, London, UK. His main areas of research and clinical interest include patients with persistent medically unexplained physical symptoms and patients with fabricated illnesses. David P H Jones is Consultant Child Psychiatrist at the Park Hospital, Oxford, UK. He trained in paediatrics and child psychiatry in the UK and has worked in the USA at the Henry Kempe Centre, Denver, CO. His research interests include interviewing children, child maltreatment, and children’s consent to treatment. PSYCHIATRY 5:2 60 © 2006 Elsevier Ltd DISORDERS WITH SOMATIC PRESENTATION Of the medically unexplained symptoms reported by these patients, a high proportion are ‘pseudo-neurological’ (faints and pseudo-seizures) and gastroenterological (abdominal pain and nausea). It is also of interest that the most commonly ‘induced’ symptoms in the children are epilepsy and syncope.5 In many of the mothers, the use of healthcare services is chaotic with frequent visits to different A&E departments, frequent changes of GP (sometimes instigated by the GP) and lack of continuity of care. Because of this, the most useful source of reliable and documented biographical information is often held by social services. Approximately 90% of the mothers also have evidence of coexisting personality disorders, the most common being borderline, histrionic, antisocial and paranoid disorders. Half of the mothers in one series also reported previous episodes of (often repeated) deliberate self-harm.4 A minority of patients have forensic histories, and in these, the most common previous convictions are for shoplifting. Fabricated or induced illness: does it exist? Evidence comes from: • Victim accounts (e.g. Gregory J. Sickened. Century, 2004) • Perpetrator accounts • Third-party accounts • Scientific/forensic evidence • Epidemiology (McClure R et al., Arch Dis Child 1996; 75: 57) • Case series (451 cases)3 • Individual cases (Beverly Allitt. Clothier Report. London: HMSO, 1994) • Department of Health. Area Child Protection Committees – www.dfes.gov.uk/acpc/ • Textbooks (e.g. Eminson M, Postlethwaite R, eds. Munchausen syndrome by proxy abuse: a practical approach. Oxford: Butterworth Heinemann, 2002) 1 Assessment of the mother 451 cases from many different countries.3 Information from these various sources provides unequivocal evidence that fabricated or induced illness indeed exists. Assessment of a patient where FII is suspected is a complex process that requires the collection of information from a wide variety of sources (with the patient’s consent). The diagnosis of FII cannot and should not be established on the basis of a ‘one-off’ interview with the mother conducted in the outpatient department. It is important to read the medical records of the mother (both hospital and primary care) and, if possible, of the abused child/children as well as records from social services and, where relevant, police records. The process of preparation before interviewing the mother in whom FII is suspected often involves the collection and reading of a considerable amount of information, as well as interviews with key informants (e.g. social workers, grandparents; Figure 3). This process may take many hours, and during the reading of the (usually) extensive medical and social work notes the assessor should be looking for evidence of inconsistencies in the medical Clinical presentations and prevalence Different ‘levels of disturbance’ have been described, ranging from a carer presenting a factitious history alone (e.g. ‘he keeps having fits’) to simulation or tampering of body fluids (e.g. producing red urine as blood in the urine), and actual induction of disease (e.g. injecting insulin or administering anticonvulsant medication). Although the induction of disease carries a greater risk of causing serious physical harm to the child, repeatedly taking the child to the GP or accident and emergency (A&E) department with fabricated symptoms can lead to potentially dangerous iatrogenic complications, especially if the child is subsequently subjected to repeated invasive procedures such as a lumbar puncture. FII is most often seen in children less than 5 years of age and in one survey 85% of the perpetrators were mothers. The combined annual incidence of FII, non-accidental poisoning, and non-accidental suffocation in the UK and Republic of Ireland in children under 16 years of age is at least 0.5 per 100,000, and for children aged under 1 year, at least 2.8 per 100,000. Relationship between somatizing disorder, self harm, and substance misuse for 41 mothers Psychopathology of the perpetrators 5 There have been very few published accounts of the psychopathology of the perpetrators of FII. The evidence from a systematic UK study4 and our own clinical experience is that most women have endured disrupted childhoods characterized by privation, physical and sexual abuse, and significant loss or bereavement, with up to half spending time in foster care. The most frequent psychiatric disorder is a somatoform disorder, with three-quarters having a chronic and enduring disorder characterized by the reporting of multiple, recurrent, and frequently changing physical symptoms, which may co-exist with previous episodes of anxiety and depression (Figure 2). It is often difficult to differentiate between chronic somatization and fabricated illness in these patients, but there is evidence that in a substantial number fabricated illness co-exists with somatoform disorders. PSYCHIATRY 5:2 Self-harm (26) Somatizing disorder (34) 12 14 7 1 2 0 Substance misuse (10) Adapted, with permission, from Bools C et al., 1994.4 2 61 © 2006 Elsevier Ltd DISORDERS WITH SOMATIC PRESENTATION history, comments from medical and social work practitioners about parenting skills, evidence of antisocial behaviour or dissimulation/ frank lying in the records. Examination of past medical, psychiatric and social work records may reveal long-standing emotional and behavioural difficulties, especially if the mother has a history of referral to a child and adolescent psychiatry service, as is the case in three-quarters of these patients. If a patient (a suspected perpetrator) has been referred from the Courts after her child has been placed in temporary foster care pending a psychiatric report, it is often useful to obtain information about the mother’s parenting skills and quality of the supervised visits to the child. This information can be gleaned from the child’s foster mother or, where relevant, the guardian ad litem. Ideally, a case conference should be convened so that the various key workers can exchange opinions and compare facts, before making any decision about the future care of the child (see below). Pseudologia fantastica Common features of pseudologia fantastica: • compulsive • fantastic (often self-aggrandizing) • recurrent and often enduring • destructive to the quality of life of the liar • ‘kernel’ of truth embedded in a matrix of falsehoods • underlying motive to gain attention from others • when confronted may acknowledge falsehoods • age of onset 16 years • 40% have CNS abnormalities Adapted from King B, Ford C,1988.6 4 A note on pseudologia fantastica Scrutiny of the medical and social work records sometimes reveals evidence of pathological lying and the fabrication of stories during childhood and adolescence. In some cases lying is established in early life and persists throughout adolescence and into adult life as an enduring personality trait or characteristic. In other patients it appears to be related to stressful life events, but is only very rarely associated with episodes of pathological wandering. Repeat ‘hoax’ telephone calls and even fire-setting can occur during these periods. In some patients a recrudescence of lying is associated with an escalation of ‘treatment-seeking behaviour’ both in the mother and the child in whom illness is being induced. Pseudologia fantastica (PF) is a dramatic form of pathological lying that consists of grandiose stories often built on a matrix of truth.6 Fact and fiction are woven together until the two are virtually indistinguishable (Figure 4). Unlike a delusional psychotic person, the pseudologue will abandon the story or change it if confronted with contradictory evidence or sufficient disbelief. About 40% of recorded cases of PF occur in patients with a history of some brain abnormality, primarily epilepsy, abnormal EEG, previous head injury, or CNS infection. In those cases where neuropsychological testing has been performed, a majority showed verbal abilities (dominant hemispheric functions) that were significantly better than performance abilities (non-dominant hemispheric function). It has been suggested that the more logical and critical portions of the brain (frontal lobes and non-dominant hemispheres) fail to monitor verbal output adequately. Relation between factitious disorder in mother and FII in children Factitious disorder in adults and FII in children can co-occur, so the detection of one should trigger a search for the other.7 Psychiatrists whose work brings them into contact with parents with chronic somatoform or factitious disorders should be alert to the impact of these disorders on the patients’ children. The important relationship between these disorders is shown in Figure 5. Management of perpetrator after child has been taken into care Following a detailed assessment of the mother, the Court may decide that reunification of mother and child poses too great a risk to the child. In these cases the child is often taken into foster care. Often in these circumstances the mother may deny parenting difficulties. The mother may then require further management (usually for the treatment of long-standing personality difficulties/disorder). The mother may also wish to have another child. The Court may then ask the psychiatric expert a number of specific questions such as: • what is the optimum treatment for the mother and in what setting, by whom, and for how long? Assessment of the child’s mother: preparation • Medical records of the child’s mother: hospital and GP (written and typed) • Medical records of child/children • Social work records/reports • Police records/videos • Legal documents: statements of mother and father or report of child’s guardian • Interview with mother and partner (audiotaped, with consent) • Interview with grandparents • Telephone interview with GP, social worker, paediatrician and guardian Factitious disorder and FII may be inter-related • 75% of mothers who fabricate illness in their children have a history of factitious or somatoform disorder • 85–90% of mothers also have Axis II disorders (antisocial, histrionic, borderline i.e. Cluster B) • Factitious disorder can sometimes emerge in a parent only after FII has been identified and confronted • Pre-existing factitious disorder in a mother can be abandoned after birth and extended to the next generation through FII 3 PSYCHIATRY 5:2 5 62 © 2006 Elsevier Ltd DISORDERS WITH SOMATIC PRESENTATION Effects Harm may be caused directly through induction of ill health, indirectly through unnecessary hospitalization, investigation or treatments, or, finally, psychological harm. Direct effects include a mortality rate possibly up to 10%, as well as the direct effects of harm induced, or the doctor’s response to fabrication. Indirect psychological harm includes emotional and behavioural problems, school non-attendance, and major concentration difficulties in well over half of all cases. Furthermore, affected children live in a fabricated sick role and may eventually go on to simulate illness themselves.9 The family context within which FII is perpetrated may also account for up to three-quarters of indexed children being affected by other forms of maltreatment, neglect, further fabrications, or inappropriate medicating. • what are the specific criteria for ‘improvement’ after psychological treatment? For example, what measures would indicate change/improvement in the mother? Key outcome measures include: • acknowledgement of the fabrications • cessation of deliberate self-harm and substance misuse • cessation of lying • remaining in a stable relationship with social supports • being able to work in a collaborative fashion with health and social services. Regrettably, few women are able to achieve these goals. Should reunification of the mother and child be attempted? This is a controversial topic, especially when there is evidence of a recurrence rate of 20% among those children who remain with their birth parents.8 Other siblings are also at risk. Outcome of intervention Single case reports and two case series provide the evidence on intervention. We followed up all seventeen children from sixteen families selected for admission to a specialist unit between 1992 and 1996.10 There was one recurrence, leading to mild harm to the child. Overall, the children’s development, growth, and adjustment were Intervention and other psychological treatment Plans for intervention should be based on what is known about the effects of FII, and the outcome of intervening. Prognostic factors in fabricated and induced illness Domain Poor prognosis Better prognosis Maltreatment Induced harm Sadistic element Accompanying child sexual abuse or physical abuse Deaths of previous children Harm to animals Fabrication Child Developmental delay Physical sequelae of factitious illness by proxy Development of somatizing behaviour Absence or delay of sequelae of abuse Parent Personality disorder Somatization Denial Lack of compliance Alcohol/substance abuse Abuse in childhood – unresolved Personality strengths Parenting and parent– child interaction Disordered attachment Lack of empathy for the child Own needs before child Normal attachment Empathy for the child Postive co-parenting Family Interparental conflict/violence Multigenerational abuse Shorter duration of fabicated illness by proxy Acknowledgement of abuse Compliance Treatment-responsive mental illness Adapted to childhood abuse Non-abusive partner Supportive extended family Professional Lack of resources Poorly informed and/or prejudiced Partnership with parents Long-term psychological treatment and social casework Social setting Violent, unsupportive neighbourhood Isolation Involvement with false allegation network Local child support facilities Social support Adapted from Jones D P H, Bools C N, 1999.11 6 PSYCHIATRY 5:2 63 © 2006 Elsevier Ltd DISORDERS WITH SOMATIC PRESENTATION child maltreatment which has occurred, deciding what the child and any siblings need to know, as well as other family members. Normally the script and care plan will incorporate the long-term perspective on the risk of repeating somatization, together with plans for minimizing this possibility or recognizing the signs of recurrence if they occur, i.e. a combination of relapse prevention and early intervention if problems do arise. The whole professional network will need to be working together if a plan for reunification is to go ahead safely. Substitute or alternative care will be necessary for those children where there is an unacceptably high level of persisting risk of recurrence or poor outcome for the child’s development. acceptable at follow-up. A better outcome was associated with: • acknowledgement of fabrication and the psychosocial context within which it occurred • less severe abuse • improvements in parental psychological functioning and empathy for the child • improved parent/child relationships and child attachment behaviours towards parents. A better outcome was seen where changes in the family system and a therapeutic alliance with the fabricator’s partner and extended family could be established. This enabled a safety network to be established around the child, which incorporated the parent’s continuing vulnerability. Prognostic factors can be organized into different ‘domains’ which are associated with better or poorer outcome (Figure 6).11 Families are selected for possible intervention where a psychiatric formulation is apparent and a treatment plan can be applied to this. Further factors that influence selection include: the potential for working in partnership, where there is some degree of parental acknowledgement of problems, and where better prognostic features exist. Long-term plans The primary healthcare team and one paediatrician are key professionals in any long-term care plan involving reunification. All professionals need to be alert to risks of a range of possible outcomes, including: • subsequent FII occurring in any form • significant parenting problems • parent/child relationship difficulties • psychological maltreatment. Effective management includes containment of fabricator’s longterm tendency to somatize or deceive, harnessing the strength of the non-abusive carer or family members, and management of any parenting breakdown that has accompanied FII behaviour. FII still induces considerable fear among professional groups, which can lead to difficulties within the professional system itself. This is important to overcome because long-term follow-up by primary health, paediatric, and child and family psychiatric teams will be necessary to maintain the child’s progress and prevent  future relapse, or a return to somatization by the abuser. Treatment phases Initial denial of responsibility is the norm, but this can waver in the face of parental digestion of the outcome of a split hearing within the Family Court. Total denial of maltreatment or any problems means that intervention is not feasible, except in the mildest of cases. If treatment aimed at reunification is embarked upon, a clear treatment plan with explicit criteria for success, shared with all professionals is necessary.12 The time-frame for intervention always needs to be sensitive to the developmental needs of the child. Treatment can be considered in terms of three phases:13 • acknowledgment • improving parental competence and sensitivity to the child • resolution phase. The acknowledgement is not restricted to admission of acts of induction or fabrication, but also includes a much broader acknowledgement by each parent of the scope and scale of parenting problems and any other varieties of maltreatment which affect the child. Often there are other aspects of parenting breakdown or parent/child attachment difficulties, within which context FII has occurred. The acknowledgement extends to the effect of all these aspects on the child, and on other family members. The phase of increasing parental competence and sensitivity to their children depends upon change both within individuals and family interactions. Normally, clinical work includes individual therapy and family work. The abuser will need help to distinguish his/her over-concern about their child’s health from healthy affection, care, and medical help seeking. Often the abuser’s needs are deflected from somatization into more direct and healthy help seeking for psychological disease. Resolution may be in the direction of a care plan with safe reunification for the child with his/her parents, or alternatively towards a separation if safety cannot be established. Normally a safe care plan will involve the abuser’s partner and/or other family members or friends in order to provide a safety net of adults around the abusing parent. Often at this stage the abuser will want to discuss the script for the episode of parenting breakdown and PSYCHIATRY 5:2 REFERENCES 1 Department of Health. Safeguarding children in whom illness is fabricated or induced. London: Department of Health, 2002. 2 Liddle R. Mumbo-jumbo syndrome. Sunday Times, June 26, 2005. 3 Sheridan M. The deceit continues: an updated literature review of Munchausen syndrome by proxy. Child Abuse Neglect 2003; 27: 431–51. 4 Bools C, Neale B, Meadow R. Munchausen syndrome by proxy: a study of psychopathology. Child Abuse Neglect 1994; 18: 773–88. 5 Barber M A, Davis P M. Fits, faints, or fatal fantasy? Fabricated seizures and child abuse. Arch Dis Child 2002; 86: 230–3. 6 King B, Ford C. Pseudologia fantastica. Acta Psychiatrica Scand 1988; 77: 1–6. 7 Feldman M, Rosenquist P, Bond J. Concurrent factitious disorder and factitious disorder by proxy. Double jeopardy. Gen Hosp Psychiatry 1997; 19: 24–8. 8 Bools C, Neale B, Meadow R. Follow up of victims of fabricated illness (Munchausen syndrome by proxy). Arch Dis Child 1993; 69: 625–30. 9 Sanders M. Symptom coaching: factitious disorder by proxy with older children. Clin Psychol Rev 1995; 15: 423–42. 10 Berg B, Jones D. Outcome of psychiatric intervention in factitious illnesss by proxy (Munchausen syndrome by proxy). Arch Dis Child 1999; 81: 465–72. 64 © 2006 Elsevier Ltd ASSESSMENT AND MANAGEMENT DISORDERS WITH SOMATIC PRESENTATION 11 Jones D P H, Bools C N. Factitious illness by proxy. In: David T, ed. Recent advances in paediatrics 17. Edinburgh: Churchill Livingstone, 1999. 12 Jones D P H, Hindley N, Ramchandani P. Making plans: assessment, intervention and evaluating outcomes. In: Rose W, Aldgate J, Jones D, eds. The developing world of the child. London: Jessica Kingsley, 2005. 13 Jones D, Byrne G, Newbold C. Management, treatment and outcomes. In: Eminson M, Postlethwaite R, eds. Munchausen syndrome by proxy abuse: a practical approach. Oxford: Butterworth Heinemann, 2002. FURTHER READING Adshead G. Evidence-based medicine and medicine-based evidence: the expert witness in cases of factitious disorder by proxy. J Am Acad Psychiatry Law 2005; 33: 99–105. (A thoughtful account of the roles and responsibilities of expert witnesses in child protection cases.) The Allitt Inquiry (Clothier Report). London: HMSO, 1994. (An account of the inquiry into the behaviour of nurse Beverly Allitt, who was charged with 4 murders and 9 attempted murders of children on a paediatric ward in 1991. ) Gregory J. Sickened. The story of a Munchausen by proxy childhood. London: Arrow Books Ltd, 2004. (This ‘victim’ account of a child being reared by a mother who induced illness was a best-seller in 2004–5.) Jones D P H. The effectiveness of intervention. In Adcock M, White R, eds. Significant harm: its management and outcome. 2nd ed. Croydon: Significant Publications Ltd, 1998. (A review of the outcome literature, and evidence concerning factors associated with recurrence of maltreatment.) Sanders M, Bursch B. Forensic assessment of illness falsification, Munchausen by proxy, and factitious disorder, NOS. Child Maltreatment 2002; 2: 112–24. (Useful guidelines for the assessment of fabricated or induced illness.) Practice points • The perpetrators of factitious or induced illness are usually women who have experienced high rates of early childhood neglect, privation and abuse • About three-quarters of women have a chronic somatoform disorder which often co-exists with a factitious disorder • Symptoms reported by the mothers are diverse, but pseudoneurological symptoms occur in as many as 20–40% (e.g. pseudo-seizures, syncopal episodes) • Personality disorder has been reported in as many as 90%, with antisocial, histrionic, borderline, avoidant and dependant traits being most commonly reported • The detection of factitious disorder in a mother with young children should trigger search for factitious or induced illness in her offspring • The effects of FII on children are severe and wide-ranging. They are partly due to fabrication and induction, and in part due to the frequently observed accompanying problems and parent/ child relationship difficulty, which accompany FII. • Better outcome is associated with improvements in parenting, family dynamics and an acknowledgement of responsibility for harm caused to the child PSYCHIATRY 5:2 65 © 2006 Elsevier Ltd