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Motivation and emotion/Book/2021/Factitious disorder imposed on another motivation

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Factitious disorder imposed upon another:
What motivates factitious disorder imposed upon another?

Overview

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Factitious disorder imposed on another (FDIA), previously known as Munchausen syndrome by proxy, describes a psychological condition in which person in a care-giving role deliberately inflicts illness or falsifies results of their patient in a medical setting[1]. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) indicates that this is a severe emotional disorder, with no expectation of material gain, which differentiates it from malingering or a scam/con.[2] The incidence of FDIA is estimated to be between 0.002%[3] and 1%[4] of the population, and has a mortality rate of 6-10%[5]. In most legal settings, FDIA is considered medical abuse.[6]

A female caregiver is the culprit in >93% of cases.[7] The majority of victims are children, but the elderly, infirm, and even pets can also be affected.[8] The motivations behind factitious disorder imposed upon another remains unclear, but some psychological frameworks suggest some possible contributing mechanisms.[9]

Case study: Clauddine (Dee Dee) and Gypsy Rose Blanchard

 
Figure 1: Gypsy Rose, smiling and holding a doll. Age unknown.

Gypsy Rose Blanchard was born in 1991 to parents Dee Dee and Rod Blanchard, who had separated a few months before her birth.

From a few months old, Dee Dee reported Gypsy as suffering from sleep apnoea, though several hospital stays proved this not to be the case.

Over the years until her murder by Gypsy and her boyfriend in 2015, Dee Dee had inflicted the following upon her daughter: shaving her head to promote the appearance of a cancer patient, rubbing anaesthesia on Gypsy's gums to promote drooling - which she used to convince health workers to put Botox in her salivary glands, insisting she be confined to a wheelchair for muscular dystrophy (which a muscular biopsy indicated that she did not have) and gave her seizure medication for non-existent seizures - the combination of which and the Botox led Gypsy's teeth to decay and fall out.

Dee Dee took Gypsy to numerous specialists over the years, as well as frequenting the Emergency Departments of nearby hospitals for minor ailments. Dee Dee also falsified a birth certificate for Gypsy to make her appear younger than her years, leaving Gypsy herself confused about her age.


Focus questions

  1. What are the motivations behind FDIA?
  2. What are the warning signs of FDIA?
  3. What is the prognosis for the perpetrator and victim?

About factitious disorder imposed upon another

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Factitious disorder imposed upon another (FDIA) is both an official diagnosis under the DSM-5, and considered a form of medical abuse.

FDIA can be described as a set of behaviours portrayed by a caregiver falsifying medical test results, invalidating test results[10] or deliberately inflicting symptoms or illnesses to their patient which can and has been done in myriad ways: adding salt or faeces to a patient's drip[11], rubbing faeces into wounds, allowing wounds to otherwise fester through non-treatment, burning, breaking of bones[12], poisoning, starving, suffocating, or dehydration[13]. The resulting symptoms are then brought to the attention of health workers.

The most frequent victims are children, with their mothers overwhelmingly being the perpetrator[14]. Healthcare workers can become unknowingly complicit in this abuse by ordering unnecessary tests, medications and even surgeries.

Motivation and aetiology

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Reasons that motivate the infliction of Factitious disorder upon another are still unclear.[15] There are however a number of theories which may assist in understanding the motivations behind this psychological phenomenon.

Psychological

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Psychological disorders

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Based on psychological theory and research, FDIA is considered a somatoform disorder and often shares comorbidities with other psychological disorders. For example, depression and anxiety tend to often co-occur in perpetrators of FDIA.[16] Patients with these comorbidities tend to fare better in prognosis[17] than those suffering from personality disorders, which were found in a significant number of perpetrators, notably Histrionic and Borderline personality disorder.[18] Up to 70 percent of those perpetrating or falsifying illness in their children also have a history of falsifying illness in themselves[19].

Attention

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Factitious disorder imposed upon another is thought by many professionals to be motivated by receiving positive attention, praise, and sympathy for their plight. It is often found that the caregiver will spend excessive time talking to doctors and other healthcare professionals. Another possible attention motive is for the caregiver to place themselves vicariously in the patient's role.[20]

Environmental

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Many studies have found that up to 60%[21] of offenders suffered from early adverse experiences. The main experiences that were demonstrated to have been present in caregivers and perpetrators include illness, abuse and/or neglect in childhood[22][23], a history of maladaptive coping mechanisms and significant trauma[24].

Partly due to a lack of studies into the syndrome, there remains no one definitive motivation identified for the imposition of factitious disorder onto another.

Profiles

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FDIA by its nature involves more than one individual. FDIA has one person in a caregiving role as perpetrator, and one in the sick role, as a victim.

Victims

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The victims in FDIA are usually children 6 years old and younger, with boys and girls equally likely to be in the sick role[25]. Adult victims, with a dependency on the caregiver have also been reported, usually the elderly or those with a disability.[26]

Perpetrators

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Although FDIA is a relatively rare disorder with the causes behind it difficult to identify, the role of the perpetrator or caregiver indicates some commonalities.

The perpetrator/caregiver is almost always female and usually a mother. Most caregivers are between 20 - 50 years old, and some are themselves healthcare providers. The caregiver is often extremely friendly with healthcare professionals, appears to seek out attention, particularly positive attention, praise and sympathy, and in some cases may have a factitious disorder themselves.[27][28]

History

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[Provide more detail]

General history

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While child abuse, including medical child abuse, is nothing new; the phenomenon of FDIA was not publicly identified until 1976 and the disorder went through much controversy before being accepted as a genuine condition in the medical and psychiatric community, albeit with some reservations[29].

FDIA was previously known as Munchausen's syndrome by proxy, a term coined in a 1976 paper by John Money and June Werlwas. It was also used in 1977 by paediatrician Roy Meadows. "Munchausen" was a fictional character who told outlandish and exaggerated stories about himself.[30] Munchausen's syndrome as an official diagnosis was added to the DSM classification in 1980,[31] however it was not until 2000 that "by proxy" was added as an appendix proposal[32]. Factitious disorder imposed upon another was then removed from the appendix and finally added as a discrete diagnosis in the DSM-5 in 2013[33], with the change of term reflecting the previously absent focus on the victim.

Prominent cases

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Factitious disorder imposed on self is a disorder similar to FDIA, with the exception that the fabrication or deliberate causing of illness is not imposed upon another, and is instead restricted to oneself.

Like FDIA, the cause or motivations of factitious disorder imposed upon self are not fully explained and share some similarities with the proposed causes of FDIA. It is also a disorder that, though involving deliberate action on behalf of the individual, has a largely unconscious motivation and appears to be driven by a strong desire for validation, sympathy and praise.

The same emotional problems and personality disorders found in perpetrators of FDIA also often co-occur in factitious disorder imposed on self, many of the warning signs exhibited in FDIA [34]. There appears to be no extrinsic reward in this set of behaviours[35].

Warning signs and diagnosis

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Although FDIA can be an elusive disorder to identify by physicians or healthcare workers, both the perpetrator and victim can show a number of warning signs.

Warning signs - Perpetrator

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  • Seeing many different doctors and hospitals in search of treatment (also known as "Doctor Shopping")[36]
  • Refusal or reluctance to allow doctors to see the patient alone
  • Unusually knowledgeable about hospital procedures and rare illnesses[37]
  • Overly friendly or familiar with healthcare professionals[38]
  • Illness or death connected with the imposer in a caregiving role [39] [40]
  • Extensive medical history or diagnosis of factitious disorder imposed on self
  • Welcoming or even proposing invasive surgeries upon the patient
  • Telling an unusual amount of stories seemingly designed to elicit sympathy or praise
  • Unusually comfortable in hospital environment[41]

Warning signs - Patient

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  • Inconsistent recall of medical history[42]
  • Excessive scarring and inexplicable injuries[43]
  • Unusual findings in blood and /or urine samples that suggest tampering[44]
  • Reluctance to speak without cues or directions from caregiver
  • Extensive medical history from a number of different hospitals and caregivers
  • Vague symptoms that could apply to numerous illnesses or disorders[45]
  • Failure to improve after medical treatment, or relapse for unknown cause[46]
  • Symptoms that improve when removed from caregiver
  • Numerous unrelated symptoms[47]
  • Symptoms that fail to match any testing results[48]

Epidemiology

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Factitious disorder imposed upon another has a wildly large discrepancy between reported statistics, from between 0.002% up to 1%[49] Unfortunately, it is difficult to provide exact statistics for the prevalence of FDIA due to the secrecy and dishonesty that is the nature of this disorder. Additional factors that add to this discrepancy can be physicians unwilling to believe that they have been fooled, the perpetrator and victim vanishing from the system if the perpetrator thinks that they may be under suspicion, and the unknown prevalence of healthcare professionals who themselves have FDIA.

The mortality rate of FDIA in the victim is estimated to be between 6 and 10%.[50]

Diagnosis

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The complexity of FDIA makes prognosis difficult to predict for a number of reasons. Typically the patient does not know and the caregiver will deny that there is a problem. If confronted or suspicious, there is a risk that the caretaker will withdraw the patient from physician's observations. Additionally, the unclear motivations behind the behaviour add to the difficulty of confirming an FDIA diagnosis.[51] Other factors that prevent effective FDIA diagnosis are listed above in the epidemiology section.

Doctors must first rule out any physical illness or differential diagnosis before considering an FDIA diagnosis. If these are not found, a review of the patient and caretaker's medical history is advised.[52] Unfortunately this can be time consuming, yet another barrier to an FDIA diagnosis. Often, child protective services, mandated reporters, doctors and law enforcement have to work as a team to get sufficient evidence for a diagnosis and carry out treatment.[53]

If FDIA has enough indicators, the DSM-5 should be consulted[54].

DSM-5 criteria

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DSM-5 criteria for the diagnosis of factitious disorder imposed on another:

  1. Falsification of psychological or physical signs or symptoms, or induction of disease or injury in another, associated with identified deception
  2. The individual presents another individual (victim) to others as injured, ill, or impaired
  3. The deceptive behaviour is apparent even in the absence of external incentives
  4. The behaviour is not better explained by another mental disorder

Differential diagnoses

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There are instances where the behaviours in FDIA are better explained by another mental disorder. Clinicians should rule these out before arriving at a diagnosis of FDIA. These include:

Prognosis and treatment

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The complexity of FDIA makes prognosis difficult to predict due to a number of factors; the patient not knowing or the caregiver denying that there is a problem,[59] the deception of physicians by the caregiver, the tendency for perpetrators to move away when the abuse is discovered, and general unwillingness to receive help.[60] Both parties in cases of FDIA require treatment. Victims should be removed from the care of perpetrators.[61]

According to research, patients generally require years of therapy, such as CBT[62]. There are no specific medications for either perpetrators or victims of FDIA, however, medications such as antidepressants and antipsychotics may have some use for related conditions such as depression[63] [64]. However, due to the nature of FDIA, may create an extra risk by misuse.[65] [66]

The mortality rate of victims is between 6 and 10%, and surviving victims may go on to perpetuate factitious disorder themselves[67][68] and also have an elevated risk of suicide[69]. victims are also more disposed towards developing post traumatic stress disorder, chronic pain, and weight problems, as well as emotional dysregulation[70].

Jurisprudence

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There has been difficulty in prosecution of such cases. In 2005, UK paediatrician Roy Meadow was struck off from the medical register following findings he had given misleading evidence that led to conviction of Sally Clark for the murder of her two children, who had both died from Sudden Infant Death Syndrome (SIDS)[71].

In 2004, the Queensland Court of Criminal Appeal ruled that the condition was 'not a diagnosis of a recognised medical condition, disorder or syndrome' and therefore expert evidence about it was inadmissible[72]. More recent cases of abuse of this kind have resulted in criminal convictions for child abuse in Australia[73] and the removal of children by child protection agencies and children's courts[74].

In media

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The unusual and seemingly inexplicable nature of FDIA has caught the interest of professionals and laypeople alike, and some cases have been highlighted in news media, with Gypsy Rose Blanchard (detailed above) being one of the more confronting and famous examples.

FDIA has also been depicted in fictional media, popular examples being the 1999 movie The Sixth Sense, in which a mother is shown to be poisoning her daughters for unknown reasons and the novel Sharp Objects published in 2006. Rapper Eminem raps about being a victim of FDIA in his song Cleanin' out my closet.

Conclusion

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FDIA is a psychological disorder, the precise motives behind which remain largely unclear. However, some psychological frameworks suggest various possible mechanisms that may contribute to the motivations, such as illness or illnesses during childhood, a history of maladaptive defence mechanisms, developmental disorder, a wish to vicariously place themselves in a "sick" role, high need for praise and sympathy, and significant trauma during childhood. The underlying cause or causes are largely unconscious and intrinsically motivated.

The main perpetrators of FDIA are women, although there is no discernible difference in the likelihood of either male or female victims. Victims are overwhelmingly children in a position of dependence on the perpetrator.

FDIA remains difficult to identify and healthcare professionals should be aware of the warning signs in perpetrator and patient that may indicate FDIA. Treatment recommendations include the removal of the client from the caregiver's influence, with extensive therapy provided to both.

The condition generally has a poor prognosis due to a number of factors; under-reporting to the relevant authorities (which would effectively prompt physiological evaluation and treatment), the dependent nature of the relationship between the victim and perpetrator, the maladaptive behaviour of a person with FDIA, (which is not only covert, but appears to the observer to be consistent with recognised standards of caregiving) and the lack of extrinsic motivators, such as financial gain which appear to be either secondary considerations or entirely absent.

The take home message is that FDIA is an uncommon but dangerous and sometimes fatal disorder. Early identification of FDIA and immediate intervention to commence treatment, give both the patient and victim the greatest chance of management and recovery.

See also

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References

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  1. ↑ Bursch, Brenda; Emerson, Natacha D.; Sanders, Mary J. (2019-10-14). "Evaluation and Management of Factitious Disorder Imposed on Another". Journal of Clinical Psychology in Medical Settings 28 (1): 67–77. doi:10.1007/s10880-019-09668-6. ISSN 1068-9583. http://dx.doi.org/10.1007/s10880-019-09668-6. 
  2. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  3. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  4. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  5. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  6. ↑ "Munchausen syndrome - Better Health Channel". www.betterhealth.vic.gov.au. Retrieved 2021-10-17.
  7. ↑ Yates, Gregory; Bass, Christopher (2017-10-01). "The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) – A systematic review of 796 cases". Child Abuse & Neglect 72: 45–53. doi:10.1016/j.chiabu.2017.07.008. ISSN 0145-2134. https://www.sciencedirect.com/science/article/pii/S0145213417302636. 
  8. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  9. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-08-29.
  10. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  11. ↑ Myers, John E. B. (2005-01-01). Myers on Evidence in Child, Domestic, and Elder Abuse Cases (in en). Wolters Kluwer. ISBN 978-0-7355-5668-3. https://books.google.com.au/books?id=-krZZF9dl-sC&pg=PA282&redir_esc#v=onepage&q&f=false. 
  12. ↑ Libow, Judith A. (1995-09-01). "Munchausen by proxy victims in adulthood: A first look". Child Abuse & Neglect 19 (9): 1131–1142. doi:10.1016/0145-2134(95)00073-H. ISSN 0145-2134. https://www.sciencedirect.com/science/article/pii/014521349500073H. 
  13. ↑ "Munchausen syndrome - Better Health Channel". www.betterhealth.vic.gov.au. Retrieved 2021-10-17.
  14. ↑ "Munchausen syndrome - Better Health Channel". www.betterhealth.vic.gov.au. Retrieved 2021-10-17.
  15. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-08-29.
  16. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  17. ↑ Carnahan, Kevin T.; Jha, Anupam (2021). Factitious Disorder. Treasure Island (FL): StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557547/. 
  18. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  19. ↑ Carnahan, Kevin T.; Jha, Anupam (2021). Factitious Disorder. Treasure Island (FL): StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557547/. 
  20. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  21. ↑ Bass, Christopher; Jones, David (2011-08). "Psychopathology of perpetrators of fabricated or induced illness in children: case series". The British Journal of Psychiatry 199 (2): 113–118. doi:10.1192/bjp.bp.109.074088. ISSN 0007-1250. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/psychopathology-of-perpetrators-of-fabricated-or-induced-illness-in-children-case-series/6BA67E14F41D8533288F7F183A057D8C. 
  22. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  23. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  24. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  25. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  26. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  27. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  28. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  29. ↑ Pankratz, Loren (2006-01-01). "Persistent Problems With the Munchausen Syndrome by Proxy Label". Journal of the American Academy of Psychiatry and the Law Online 34 (1): 90–95. ISSN 1093-6793. PMID 16585239. http://jaapl.org/content/34/1/90. 
  30. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  31. ↑ Jaghab, Kamil; Skodnek, Kenneth B.; Padder, Tanveer A. (2006-3). "Munchausen's Syndrome and Other Factitious Disorders in Children". Psychiatry (Edgmont) 3 (3): 46–55. ISSN 1550-5952. PMID 21103164. PMC 2990557. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990557/. 
  32. ↑ Faedda, Noemi; Baglioni, Valentina; Natalucci, Giulia; Ardizzone, Ignazio; Camuffo, Mauro; Cerutti, Rita; Guidetti, Vincenzo (2018). "Don't Judge a Book by Its Cover: Factitious Disorder Imposed on Children-Report on 2 Cases". Frontiers in Pediatrics 6: 110. doi:10.3389/fped.2018.00110. ISSN 2296-2360. https://www.frontiersin.org/article/10.3389/fped.2018.00110. 
  33. ↑ Zeshan, Muhammad; Cheema, Raminder; Manocha, Pankaj (2018-09-01). "Challenges in Diagnosing Factitious Disorder". American Journal of Psychiatry Residents' Journal 13 (9): 6–8. doi:10.1176/appi.ajp-rj.2018.130903. https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2018.130903. 
  34. ↑ "Munchausen syndrome - Better Health Channel". www.betterhealth.vic.gov.au. Retrieved 2021-10-17.
  35. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  36. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  37. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  38. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  39. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  40. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  41. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  42. ↑ Jafferany, Mohammed; Khalid, Zaira; McDonald, Katherine A.; Shelley, Amanda J. (2018-02-22). "Psychological Aspects of Factitious Disorder". The Primary Care Companion for CNS Disorders 20 (1): 0–0. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. https://www.psychiatrist.com/pcc/mental/factitious-disorder/psychological-aspects-of-factitious-disorder/. 
  43. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  44. ↑ Giovannoni, Jeanne M. (1995-01). "Reports of child maltreatment from mandated and non-mandated reporters". Children and Youth Services Review 17 (4): 487–501. doi:10.1016/0190-7409(95)00035-b. ISSN 0190-7409. http://dx.doi.org/10.1016/0190-7409(95)00035-b. 
  45. ↑ Jafferany, Mohammed; Khalid, Zaira; McDonald, Katherine A.; Shelley, Amanda J. (2018-02-22). "Psychological Aspects of Factitious Disorder". The Primary Care Companion for CNS Disorders 20 (1): 0–0. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. https://www.psychiatrist.com/pcc/mental/factitious-disorder/psychological-aspects-of-factitious-disorder/. 
  46. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  47. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  48. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  49. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  50. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  51. ↑ Jafferany, Mohammed; Khalid, Zaira; McDonald, Katherine A.; Shelley, Amanda J. (2018-02-22). "Psychological Aspects of Factitious Disorder". The Primary Care Companion for CNS Disorders 20 (1): 0–0. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. https://www.psychiatrist.com/pcc/mental/factitious-disorder/psychological-aspects-of-factitious-disorder/. 
  52. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  53. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  54. ↑ Carnahan, Kevin T.; Jha, Anupam (2021). Factitious Disorder. Treasure Island (FL): StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557547/. 
  55. ↑ Carnahan, Kevin T.; Jha, Anupam (2021). Factitious Disorder. Treasure Island (FL): StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557547/. 
  56. ↑ Jafferany, Mohammed; Khalid, Zaira; McDonald, Katherine A.; Shelley, Amanda J. (2018-02-22). "Psychological Aspects of Factitious Disorder". The Primary Care Companion for CNS Disorders 20 (1): 0–0. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. https://www.psychiatrist.com/pcc/mental/factitious-disorder/psychological-aspects-of-factitious-disorder/. 
  57. ↑ Carnahan, Kevin T.; Jha, Anupam (2021). Factitious Disorder. Treasure Island (FL): StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557547/. 
  58. ↑ Jafferany, Mohammed; Khalid, Zaira; McDonald, Katherine A.; Shelley, Amanda J. (2018-02-22). "Psychological Aspects of Factitious Disorder". The Primary Care Companion for CNS Disorders 20 (1): 0–0. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. https://www.psychiatrist.com/pcc/mental/factitious-disorder/psychological-aspects-of-factitious-disorder/. 
  59. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  60. ↑ "Munchausen syndrome - Better Health Channel". www.betterhealth.vic.gov.au. Retrieved 2021-10-17.
  61. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  62. ↑ "Factitious Disorder (Munchausen Syndrome by Proxy)". Cleveland Clinic. Retrieved 2021-10-17.
  63. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  64. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  65. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  66. ↑ "Munchausen syndrome - Better Health Channel". www.betterhealth.vic.gov.au. Retrieved 2021-10-17.
  67. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  68. ↑ Jafferany, Mohammed; Khalid, Zaira; McDonald, Katherine A.; Shelley, Amanda J. (2018-02-22). "Psychological Aspects of Factitious Disorder". The Primary Care Companion for CNS Disorders 20 (1): 0–0. doi:10.4088/PCC.17nr02229. ISSN 2155-7780. https://www.psychiatrist.com/pcc/mental/factitious-disorder/psychological-aspects-of-factitious-disorder/. 
  69. ↑ "The Facts About Munchausen by Proxy Syndrome". Newport Academy. 2018-07-23. Retrieved 2021-10-17.
  70. ↑ "Factitious Disorders Questions, Symptoms & Treatment Guidelines". MedicineNet. Retrieved 2021-10-17.
  71. ↑ Gosline, Anna. "Top paediatrician guilty of professional misconduct". New Scientist. Retrieved 2021-10-17.
  72. ↑ "A new name for Munchausen Syndrome by Proxy: Defining fabricated or induced illness by carers". Child Family Community Australia. 2005-09-01. Retrieved 2021-10-17.
  73. ↑ "Mum jailed for poisoning her toddler". 7NEWS. 2019-09-20. Retrieved 2021-10-17.
  74. ↑ S v Department of Family and Community Services, 2014-03-31, retrieved 2021-10-17
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