ICD-116D51	FACTITIOUS DISORDER IMPOSED ON ANOTHER Factitious disorder imposed on another
ICD-10F68.1	Intentional production or feigning of symptoms or disabilities, either physical or psychological [factitious disorder]
DSM-5-TRF68.A	Factitious Disorder Imposed on Another

1. Definition and nosology

Factitious disorder imposed on another (ICD-11: 6D51 Factitious Disorder Imposed on Another; DSM-5-TR: F68.10) — the patient creates or feigns physical or psychological symptoms in another person (typically their own child, elderly or disabled dependent); they bring that person to the hospital as a victim. Originally termed ‘Munchausen by proxy’ (Meadow R. 1977).

The diagnosis is made in the perpetrator, not in the victim. This disorder is at the same time child abuse — child protection and legal intervention are mandatory.

2. History

• Meadow R. (1977) — ‘Munchausen syndrome by proxy’ Lancet.
• DSM-IV (1994) — In the research category.
• DSM-5 (2013) — official diagnosis.
• APSAC, AAP — child protection protocols.

3. Epidemiology

• Rare — annual incidence ~2/100,000 children (Sheridan M.S. Child Abuse Negl 2003 review); under-detection.
• Typical perpetrator — biological mother (>90%); victim — child (typically <5 years).
• Victims' mortality 6–9% (Sheridan); morbidity high.

4. Aetiology and pathogenesis

• Psychological needs of the patient — attention in the medical role, relationships, ‘hero’ image.
• Occupational burnout.
• History of trauma or neglect in the patient.

5. Clinical features

• Child's symptoms occur only with mother; improve when the child is put to bed and the mother is absent.
• Multiple clinics, atypical symptoms, “impossible” medical history.
• Mother — a medical professional or has extensive medical knowledge.
• The mother appears overly polite and an “ideal caregiver.”
• Typical induction methods: drug poisoning, mechanical obstruction of food or airway, blood collection, infection creation.
• Victim child with unexplained recurrent seizures, apnea, hypoglycemia, infection, skin injury.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Deliberate induction of physical or psychological symptoms or harm in another person (victim).

B. The patient presents the victim to others as ill or injured.

C. Deceptive behavior with no apparent material gain.

D. The behavior is not better explained by another mental disorder.

The diagnosis is made in the perpetrator, not in the victim.

6.2 Source-specific clarifications

• DSM-5-TR / ICD-11 — same.
• APSAC, AAP — child protection protocols; this clinical condition also category of child abuse.

6.3 Diagnostic algorithm

1. Clinical suspicion — atypical symptom pattern, related to mother.
2. Pediatrician, psychiatrist, social worker multidisciplinary team.
3. Obtaining medical documentation from other clinics.
4. Separation test — monitoring symptoms when the patient is separated from the caregiver.
5. Video monitoring (under child protection and legal intervention)
6. Toxicological and biochemical tests (evidence of creation).
7. Referral to child protection and legal coordination is mandatory.

6.4 Differential diagnosis

7. Examination and assessment

• Pediatric clinical assessment.
• Medical history gathering.
• Social service and child protection referral.
• Legal coordination.

8. Treatment

1. Victim's safety is the first priority — child separation (from mother or caregiver).
2. Child protection referral — legal protocols.
3. The patient's (perpetrator's) psychiatric treatment:
   • Psychotherapy (long-term);
   • Comorbid disorders (BPD, MDD, trauma);
   • Medical occupational context - occupational prohibitions may be considered.
4. Family intervention and sibling protection assessment.
5. Victim child's psychotherapy – trauma intervention.

Source-specific specifications

• APSAC — child protection protocols.
• AAP — pediatrician role.
• Coordination of the legal system is mandatory.

Treatment methods

1. Child Protection Referral — Absolutely when suspicion exists; APSAC, AAP protocols.
2. Multidisciplinary Group — Pediatrician + psychiatrist + social worker + forensic specialist.
3. Separation Test — The mother is separated from the victim; symptoms are observed.
4. Video Monitoring — Under legal and ethical supervision.

9. Prognosis

• For the victim – high mortality (6–9%) and morbidity without intervention.
• For the patient — improvement with psychotherapy; long-term follow-up.

10. Myths and misconceptions

Myth 1: “The mother is truly caring, the diagnosis is wrong”

Evidence: Clinical features (mother-attributed symptoms, atypical medical history) require substantial proof; clinical suspicion is sufficient for referral to child protection.

Myth 2: “This condition is not a psychiatric problem; it is just child abuse”

Evidence: both approaches important — child protection + perpetrator psychiatric treatment.

Myth 3: “Treatment of the perpetrator delays cessation of care for the victim”

Evidence: Victim safety first priority; psychiatric treatment separately continued.

Myth 4: “It only occurs in the mother”

Evidence: In most cases mother, but other caregivers — fathers, carers, healthcare professionals — can also be the perpetrator.

Myth 5: “Confrontation ‘treats’ the patient”

Evidence: Confrontation may necessitate transfer to another clinical unit; the patient is being followed up; child protection and forensic coordination are mandatory.

11. Sources

1. WHO. ICD-11. 6D51 Factitious disorder imposed on another. 2024.
2. APA. DSM-5-TR. 2022.
3. Meadow R. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet 1977;2(8033):343–345.
4. Sheridan M.S. The deceit continues: an updated literature review of Munchausen Syndrome by Proxy. Child Abuse Negl 2003;27(4):431–451.
5. APSAC Task Force. Munchausen by Proxy: Identification, Intervention, and Case Management. 2018.