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LETTER TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 3  |  Page : 288-289

Factitious disorder imposed on another: A report of two cases


Department of Dermatology, Venereology and Leprosy, Government Medical College, Kota, Rajasthan, India

Date of Submission12-Apr-2020
Date of Decision28-Apr-2020
Date of Acceptance30-Mar-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Suresh Kumar Jain
Department of Dermatology, Venereology and Leprosy, Government Medical College, Kota - 324 010, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_59_20

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How to cite this article:
Kushwaha RK, Mohta A, Sharma P, Jain SK. Factitious disorder imposed on another: A report of two cases. Indian J Paediatr Dermatol 2021;22:288-9

How to cite this URL:
Kushwaha RK, Mohta A, Sharma P, Jain SK. Factitious disorder imposed on another: A report of two cases. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Jul 25];22:288-9. Available from: https://www.ijpd.in/text.asp?2021/22/3/288/319947



Sir,

Factitious disorder imposed on another (FDIA),[1] formerly known as Munchausen syndrome by proxy, is a mental health condition wherein a caregiver fabricates or inflicts an injury to a person under his/her care, namely a child, elderly, or disabled person. FDIA is a form of child abuse.[2]


  Case 1 Top


A 10-year-old girl, referred by primary health center, presented to us with her mother with multiple excoriations over the left forearm for 5 months. According to a history, the lesions were intermittent, developed overnight, always noticed first by the mother. Lesions healed in 1–2 weeks; meanwhile, new lesions kept appearing. Medical records revealed several hemograms, skin-allergy-tests, and half-a-dozen prescriptions from various physicians in her area for scabies and insect-bite reaction.

While seeking a detailed history from child, the mother seemed anxious not allowing the child to be alone. Suspecting mother's involvement, we requested the father to send her home. The girl later admitted that whenever she would upset her mother, she dug nails into the child's forearm and harmed her by clawing. Next day, when a psychiatrist questioned the mother separately, after some hesitation, she admitted to inflicting injuries in rages of anger. On examination, there were multiple well-defined linear and angulated lesions in the various stages of healing (1–7 cm) with hyperpigmented border and atrophic scarring in old lesions [Figure 1].
Figure 1: Case 1- Linear and angulated excoriated lesions in various stages of healing

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  Case 2 Top


In another case, a 7-year-old girl presented with recurrent painful spontaneous bruises for 3 months. According to a history, bruises appeared at 3–4 days' interval, always noticed first by mother, faded slowly, and healed in 6–7 days. The father had sought treatment for her from several medical practitioners with no relief (diagnoses ranging from scurvy to platelet dysfunction), along with many inconclusive blood and urine investigations.

The suspicious arrangement of lesions prompted us to evaluate further. On examination, there were multiple oval, annular, red-violet macules with central sparing over the entire back [Figure 2]. The peculiarly similar morphology of all lesions (5–6 cm diameter) could be matched to have been made with suction using a cup or bowl. Patient's coagulation profile, hemogram, and other routine investigations were unremarkable. The mother was suspected to be the perpetrator, later confirmed after her psychiatric evaluation.
Figure 2: Case 2- Annular violaceous and erythematous macules with central sparing in a peculiarly similar morphology

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In both cases, after a careful objective history taking and lesion morphology, the diagnosis of FDIA was made. Families were referred to child psychiatrist and appropriate investigatory agencies to develop a long-term plan for children's well-being and safety. In case 2, the psychiatrist started mother on Escitalopram (20 mg/day).

The cardinal features of FDIA are illness fabrication by caregiver, persistently ill child subjected to multiple diagnostic procedures, and cessation of symptoms' progression after separation from perpetrator.[1] Up to 90% physically abused children have cutaneous manifestations.[3] Biological mothers (76.5%) are depicted to be major perpetrators and often display evidence of unresolved trauma or loss reactions.[4] They derive sympathy and pleasure from deceiving individuals they regard powerful.[5] They induce misguiding symptoms in victim but build the illusion of being so attentive toward the victim, usually no one suspects foul-play.

Clues to diagnose FDIA include repeated illness without any cause, constant deterioration despite repeated treatments, doctor shopping, and lying about prior treatment. Such caregivers often require long-term counseling/treatment.

Victims should be moved to a safe environment and counseled appropriately. A keen eye must be kept on the caregiver's interactions with the child. If there is immediate threat to victim's life, appropriate authorities should be informed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Faedda N, Baglioni V, Natalucci G, Ardizzone I, Cammuffo M, Cerutti R, et al. Don't Judge a Book by Its Cover: Factitious disorder imposed on children-report on 2 cases. Front Pediatr 2018;6:110.  Back to cited text no. 1
    
2.
Kumar R, Bhuria J, Mehta P, Jain S. Munchausen syndrome by proxy masquerading as pyoderma gangrenosum. Indian J Paediatr Dermatol 2014;15:123-4.  Back to cited text no. 2
  [Full text]  
3.
Kos L, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol 2006;23:311-20.  Back to cited text no. 3
    
4.
Sheridan MS. The deceit continues: An updated literature review of Munchausen Syndrome by Proxy. Child Abuse Negl 2003;27:431-51.  Back to cited text no. 4
    
5.
Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry 2005;187:328-33.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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