FREE CHAPTER from ‘A Practical Guide to Factitious Illness in Care Proceedings’ by Sharan Bhachu

CHAPTER ONE – DEFINING FACTITIOUS ILLNESS DISORDERS

Introduction

Munchausen’s and Munchausen’s by proxy, factitious illness (FII), medically unexplained symptoms and perplexing presentations are all terms which are banded around without any real clear meaning to what they exactly relate to and often strike fear into the hearts of practitioners before they have even begun to understand what may be happening within an unusual or unexplained family situation. Understanding the proper definition of this group of disorders is key to identifying and understanding what may be going on. These cases have very unusual features and require a different depth of knowledge and understanding alongside that of any other type of care proceedings. The aim of this book is to provide a level of resource to allow practitioners who are instructed on such cases to understand the context of such cases and the best ways in which to present the best possible case for whichever party they are instructed to represent.

The Royal College of Paediatrics and Child Health (RCPCH) have, as of March 2021, updated their guidance on FII¹. They had introduced the term of perplexing presentations in 2013 and expand on this with additional material to support management in the latest version. The guidance is an invaluable source of information for all practitioners involved in cases whereby FII of some sort or another is suspected, ranging from social workers/professionals and those representing family members or a child.

As referenced above, factitious or induced illness or disorder is, in fact, a group of disorders. Historically factitious disorders were conjointly referred to as Munchausen’s² or Munchausen’s by proxy³. This did not help the identification or understanding of often complex and often subtly nuanced situations and many professionals went on to adopt the terms of factitious illness/disorders, which is now used universally. The RCPCH have used the term ‘Fabricated or induced illness’ since the early 2000’s and professionals and practitioners have been actively discouraged from using the terms Munchausen’s as a catch-all.

The most recent DSM-5⁴ defines factitious disorder in the following two ways:

Factitious disorder imposed on self

1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

2. The individual presents himself or herself to others as ill, impaired, or injured.

3. The deceptive behavior is evident even in the absences of obvious external rewards.

4. The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Factitious disorder imposed on another (previously Disorder by proxy):

1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deceptions.

2. The individual presents another individual (victim) to others as ill, impaired, or injured.

3. The deceptive behaviour is evident even in the absences of obvious external rewards.

4. The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

In cases involving FII on self, the attention is focused on the adult who presents themselves with deliberate, feigned or exaggerated symptoms. FII on another, will present with the focus on another – a child/ren for our purposes. FII on another is also referred to as either fabricated (whereby the carer deliberately makes up and reports false symptoms of an illness) FII or induced (whereby the carer deliberately induces symptoms of an illness). Whichever disorder is present, it is the motive that is relevant to the welfare issues for the child. The motive of a perpetrator of FII, whether on themselves or another is to present themselves or another with factitious symptoms, behaviours or illnesses in order to gain the role of an ill person or a carer of an ill child. The more complex issue of the reasoning behind that motive is considered later in this book.

The RCPCH guidelines make a clear distinction between FII being a clinical situation where there may or may not be intent, if intent is not clear, and those situations whereby evidence is available to indicate that the motivation on behalf of the carer is to convince the medical professionals that the child has the illness, with recurring presentations to health and other professionals. The latter clearly forms abuse and child protection procedures are triggered.

It is also of note that although induction is and can be considered a form of physical abuse, the relevant factor is the motive of the carer and is almost always accompanied with repeated and recurrent presentations to professionals which then allows it to be considered under the umbrella of FII.

It is noteworthy that the diagnosis on the latter relates not to the person/child being presented as ill but the person presenting them. This is another example of the clear intention by professionals involved in child protection to move the focus away from the child and onto the perpetrator, allowing the overriding objective of care proceedings and child protection in general – that of the best interests and welfare of the child – to be met.

So when a carer deliberately causes a child to display symptoms of a particular illness or general unwellness to gain medical attention, it is important to note how that deception or inducement is happening. Often there are three main forms; fabrication, falsification or inducement. This could be of medical records, results or symptoms and can lead to unneeded procedures and treatments being provided to the child as the doctors to whom the child has been presented make efforts to understand and treat them. In very serious cases, the child may have been poisoned or the perpetrator may have tampered with medical equipment or medication prescribed to the child in good faith and based on the false history given by the carer.

Medically unexplained symptoms (MUS)

The range of possible scenarios within the factitious disorder spectrum is wide and far reaching. Not every situation will present as a result of an intentional deception yet identified deception is a clear and necessary part of the DSM diagnosis. It is too simple a definition and doesn’t cover many of the situations that arise in these complex care cases. Practitioners and social care/medical professionals may be faced with situations whereby the child presents with symptoms that are not as a result of deception but are in fact genuinely felt or experienced. Such symptoms may be of a psychosocial nature or a ‘functional disorder’. Often the carers are not involved in any form of induction of these symptoms or even any kind of deception and are fully able to work with the professionals involved to help and treat the underlying causes. These situations have evolved to become known and referred to as ‘medically unexplained symptoms’ (MUS), However, MUS does not automatically mean that FII is excluded.

Perplexing presentations

The RCPCH introduced the term ‘perplexing presentations’ (PP) to identify situations whereby FII (actual harming of children likely to amount to significant harm) has not yet occurred but there are concerning signs of discrepancies between the state of the child as reported by the carers and the independent observations and presentations of the child to medical professionals. These are the cases that often present as the most difficult to identify, with many children having a degree of underlying illness and therefore proving exaggeration in symptoms by the carer can prove to be very difficult. There is often significant involvement of many medical and other professionals, medical records and reported observations and presentations that may or may not have been independently observed. Perplexing presentation may well manifest well before any significant harm under the umbrella of FII is caused to the child but is likely in itself to cause repeated harm to the child.

These are issues which often arise in the context of private law disputes, whereby the threshold is not yet crossed to warrant the involvement of social services but is enough to instigate the appointment of a Rule 16.4 guardian to represent the child. Advocates should always be alive to the need for separate representation when there is a suspicion of perplexing presentations. Anything more serious that ventures into suspected FII territory may require consideration of a Section 37 report. The need for expert assessment should also be kept under consideration.

Other factitious disorders

Practitioners will also come other disorders that fall under the umbrella of being factitious but may or may not be recognized disorders. These often have a much less sinister connotation and usually solve unexplained situations with ease once identified. It is of note that these types of disorders are likely to manifest themselves on a much more obvious basis and should always be kept in mind.

Malingering

This is a disorder whereby the adult pretends to have an illness with the clear intention to procure a material benefit for themselves or to avoid a responsibility such as caring for a child.

Both malingering and FII require intentional deception but the difference between factitious disorder and malingering appear in the reason for the deception, which in malingering is tangible and rationally understandable. This is a complete contrast to FII whereby the motivation is to either take the role of being ill or as a carer of an ill child.

Malingering is not considered a mental illness and does not have any diagnostic criteria, therefore it does not require an expert to diagnose, and practitioners may consider whether findings of fact by a Judge are required to determine the truth of matter. An extreme example of this can be seen in cases whereby a parent who makes allegations that their child is being or has been sexually and/or physically abused by the separated parent in order to obviously avoid a relationship or contact with the other parent and child. These children are often presented at hospital or to the GP with repeated unverified reports of signs of sexual abuse and it can be very difficult to ascertain whether there is a psychological component or whether this is a straightforward type of malingering/parental alienation. The key is always in the detail.

Somatic symptom disorders (SSD)

These disorders tend to relate to presentations of illness or symptoms of the body rather than the mind but are often in fact an interplay between the psychological and the physical. The person may genuinely feel the pain or symptoms associated with a particular illness which clearly does not exist. It is unlikely to be intentional and the psychological component is highly relevant.

Summary

Having an idea of the range of conditions and disorders that come under the factitious umbrella is imperative for practitioners involved in these cases. These are cases that often do not make any sense to anyone around the family or there may be suspicions but no hard evidence to back up any referrals or pleading of the case, if at the stage of proceedings. Many social workers have not come across cases involving FII and while instinct is telling them that something is not right, they are often not experienced enough to identify that FII may well be the issue. Careful analysis and consideration of the records, not just medication or treatment related but the observations and presentations is vital to understanding how best to identify the issues and then consider how best to move forwards to safeguard and protect. The well-known cases such as salt poisoning are obvious and much more readily identifiable but it is the more nuanced, entrenched families whereby suspicions are raised but never amount to much more either because the carer changes tack or moves to a different area, often resulting in a confused and complicated set of records that require a forensic detailed analysis.

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