Clinical Vignette
Patient: "Mrs. O," 38-year-old stay-at-home mother. The identified patient is her 5-year-old daughter "Lily," who has been hospitalized 18 times for symptoms that only Mrs. O witnesses and that resolve during inpatient observation.
Chief Concern: Mrs. O: "Lily keeps having these episodes — seizures, vomiting blood, high fevers. I've taken her to 8 different hospitals. No one can figure out what's wrong with my baby. I'm the only one who sees how sick she really is."
History of Present Illness: Lily has been hospitalized 18 times across 8 different hospitals in 3 years for various presentations: seizures (5 admissions), hematemesis (4 admissions), recurrent fevers of unknown origin (4 admissions), hypoglycemia (3 admissions), and apneic episodes (2 admissions). During ALL hospitalizations, Lily's symptoms resolve within 24-48 hours of admission and are never witnessed by medical staff. Seizures are reported only by Mrs. O and are never captured on monitoring. Hematemesis specimens, when tested, have tested positive for adult hemoglobin (not the child's). Hypoglycemic episodes occur only during Mrs. O's unsupervised visits. Fevers documented by Mrs. O at home are not reproducible with calibrated hospital thermometers. Mrs. O presents as a devoted, knowledgeable, and concerned mother. She maintains an elaborate medical binder with Lily's 'history.' She has an active social media following as a 'warrior mom' advocating for her 'medically complex child.' She resists discharge ('she's not well enough'), requests additional testing, and seeks new specialists. Between hospitalizations, Lily is described by her school as 'perfectly healthy and active.' When Mrs. O is denied unsupervised access during a recent hospitalization, all symptoms ceased for the entire 5-day admission.
Medical History: Lily: 18 hospitalizations, all with negative workup. No confirmed medical condition. Developmentally normal per school. Mrs. O: history of Factitious Disorder Imposed on Self (discovered during chart review — she had 6 hospitalizations for 'mysterious' infections prior to Lily's birth).
Mental Status Exam: Mrs. O (perpetrator): articulate, emotionally engaged when discussing Lily's 'illnesses.' Uses medical terminology fluently. Describes symptoms with dramatic detail. Becomes agitated when confronted with the pattern (no symptoms observed by staff). Denies any fabrication: 'Are you calling me a liar?' No overt psychosis. No depression. Maintains calm composure when not discussing confrontation.
Step 1: Factitious Disorder Imposed on Another DSM-5-TR Criteria
The diagnosis is given to the PERPETRATOR (Mrs. O), not the victim (Lily). Lily receives a child abuse diagnosis.
Criterion A: Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another (the victim), associated with identified deception.
Hematemesis specimens contain adult hemoglobin (fabrication). Symptoms occur only in Mrs. O's presence (temporal correlation with perpetrator access). Fevers not reproducible by hospital thermometers. Hypoglycemia only during unsupervised visits. When unsupervised access was removed, all symptoms ceased for 5 days. MET — multiple lines of evidence.
Criterion B: The individual presents another (the victim) as ill, impaired, or injured.
18 hospitalizations across 8 hospitals. Elaborate medical binder. Social media 'warrior mom' persona. Continuously presents Lily as medically complex. MET.
Criterion C: The deceptive behavior is evident even in the absence of obvious external rewards.
No financial gain identified (no disability payments, no lawsuits). No custody battle. The motivation appears to be the attention, sympathy, and caregiving role associated with having a 'sick child.' Social media following as 'warrior mom' provides social reinforcement. MET.
Criterion D: Not better explained by another mental disorder.
Not delusional disorder (Mrs. O knows Lily is not genuinely ill — her behavior is deceptive, not delusional). Not psychosis. Her prior personal Factitious Disorder history (6 self-hospitalizations) suggests a pattern of illness fabrication that has shifted from self to child. MET.
Step 2: Warning Signs and Detection
| Warning Sign | Significance | This Case |
|---|---|---|
| Symptoms only when caregiver present | Highest sensitivity indicator: symptoms resolve completely when caregiver access is restricted | ALL symptoms ceased when unsupervised access removed |
| Symptoms never witnessed by staff | If symptoms are never observed during monitored hospitalization, fabrication is likely | 18 admissions, no staff-witnessed event |
| Laboratory inconsistencies | Specimens inconsistent with the patient's physiology indicate contamination or substitution | Adult hemoglobin in child's specimen |
| Doctor shopping / hospital hopping | Prevents any single institution from recognizing the pattern | 8 different hospitals in 3 years |
| Caregiver 'too knowledgeable' | Excessive medical knowledge, uses jargon, requests specific tests | Elaborate medical binder, medical terminology fluency |
| Caregiver welcomes invasive procedures | Does not resist tests/procedures that a protective parent would question | Requests additional testing, resists discharge |
Mandatory Reporting
FDIA constitutes medical child abuse. When identified, clinicians have a MANDATORY DUTY TO REPORT to Child Protective Services. The immediate priority is Lily's physical safety: removal from Mrs. O's unsupervised access. The psychiatric diagnosis applies to Mrs. O; the child abuse designation applies to Lily.
Diagnostic Formulation
Diagnostic Conclusion
Factitious Disorder Imposed on Another (Perpetrator Diagnosis: Mrs. O) (F68.A): All 4 DSM-5-TR criteria met. Multiple lines of evidence confirm fabrication/induction of illness in her 5-year-old daughter. History of personal Factitious Disorder (6 self-hospitalizations). No external rewards identified. Mandatory CPS report filed. Immediate intervention: restrict unsupervised access to Lily. Psychiatric referral for Mrs. O. Long-term monitoring of Lily for medical and psychological sequelae of medical child abuse.
Teaching Points
- In FDIA, the DSM-5-TR diagnosis is given to the PERPETRATOR, not the victim. The victim receives a child abuse diagnosis (maltreatment code). This reflects that the mental disorder (deceptive illness fabrication) resides in the perpetrator's behavior, not the child's experience.
- FDIA is a form of medical child abuse. The child is subjected to unnecessary medical procedures, hospitalizations, and treatments driven by the caregiver's fabricated or induced illness narratives. The physical and psychological harm to the child can be severe and long-lasting.
- The transition from self-directed Factitious Disorder to FDIA is documented: some perpetrators first fabricate their own illness (Munchausen syndrome) and later shift to fabricating illness in a dependent (child, elderly parent). Mrs. O's personal history of self-hospitalizations before Lily's birth exemplifies this transition.
- Hospital hopping (presenting to multiple different hospitals) is a key perpetrator strategy that prevents pattern recognition. Electronic health record interoperability and regional alert systems are protective measures, but many cases are still identified only after prolonged harm.
- Healthcare providers have a mandatory legal duty to report suspected FDIA to child protective services. The threshold for reporting is REASONABLE SUSPICION, not certainty. Clinicians should not delay reporting to 'gather more evidence' if the existing evidence is concerning. The CPS investigation is the forensic arm; the clinician's role is to identify and report.