Munchausen by proxy: what is it, behaviors, causes

You may have seen appeals to help sick children, your heart breaking for all the tests, procedures, and surgeries they have to go through to get better. You may think about how these children miss out on having fun, playing outside, and just being kids. 

Now imagine if those illnesses, diseases, or injuries happened because someone else deliberately caused them to happen. For most parents, that’s unimaginable, but people with a rare disorder called Munchausen syndrome by proxy purposely create illnesses in their children to get attention. 

While this condition is rare, it’s important to know the signs so you can watch out for them. 

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Munchausen syndrome by proxy (MSbP) is a serious mental illness where a person deliberately invents, exaggerates an existing condition, or causes an illness in another person. The perpetrator is generally an adult doing this to a child or anyone under their care (Tozzo, 2018).

Why is it called Munchausen syndrome by proxy?

Baron von Munchausen is a fictional character from 18th-century German tales. He had marvelous adventures, but they were all invented and untrue. In 1951, Richard Asher published an article in the Lancet describing people who deliberately made up illnesses as having “Munchausen syndrome.” Asher chose the name based on people creating and exaggerating symptoms to gain attention (Yates, 2016). 

Twenty-six years later, in 1977, Professor Roy Meadow, head of pediatrics in Leeds, described two mothers who purposely injured their children. He called this behavior “Munchausen syndrome by proxy” (Comert, 2018).

At first, many medical professionals were hesitant about this diagnosis and did not include it in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for over 35 years. However, it finally became a recognized psychiatric condition. These disorders were renamed in the DSM-5 as factitious disorders (APSAC, 2017).

There are two types of Munchausen disorders. 

The first is Munchausen syndrome, now called factitious disorder imposed on self (FDIS). FDIS is self-inflicted, where people purposely pretend they are sick or even go so far as to make themselves sick.

The second is Munchausen syndrome by proxy, now called factitious disorder imposed on another (FDIA). Some people call it factitious disorder by proxy. Whatever name you choose, a factitious disorder imposed on another is where a person deliberately fabricates a mental or medical condition for another person or makes that person sick (Hausteiner-Wiehle, 2020). 

Munchausen syndrome by proxy or FDIA typically happens when a caregiver, usually the mother, makes up symptoms or harms a child to cause real symptoms, to make it look like the child has a physical or mental medical problem. Sometimes, this can happen to an adult who is being cared for (Hausteiner-Wiehle, 2020). 

FDIA is a rare mental illness. Estimates worldwide of children affected by Munchausen syndrome by proxy (FDIA) are 0.4 per 100,000 children under 16 years and 2 to 2.8 per 100,000 for infants under one year old (Comert, 2018).

Studies show that the perpetrator or abuser is overwhelmingly female. She is either the biological mother or another female caregiver. Fathers or male caregivers are rarely the perpetrators but are usually distant or absent. They may not visit the child in the hospital or even deny that they are victims of abuse (Schreier, 2004). 

Male and female children are equally likely to be child victims of FDIA (Sheridan, 2003).

Between 6–10% of all FDIA cases involving children die. Factitious disorder imposed on another is a life-threatening form of child abuse (Faedda, 2018).

Factitious disorder imposed on another involves two people. Symptoms will appear in both the caregiver/perpetrator and the victim.

Caregiver/perpetrator symptoms

The American Professional Society on the Abuse of Children Task Force says the primary behavior of the caregiver/perpetrator is falsification. These falsifications can include (APSAC, 2017): 

• Lying outright with inconsistencies or omitting important information about the victim’s health 

• Faking or exaggerating the child’s medical symptoms, especially those that are impossible to disprove

• Changing the victim’s medical history to be different from the medical record 

• Altering or adulterating laboratory tests to get abnormal test results

• Neglecting to give the child prescribed medicine, treatments, or even food to worsen symptoms

• Directly creating symptoms or injuring the child

• Coaching the child to corroborate stories

Other symptoms of the caregiver/perpetrator can include (Faedda, 2018):

• They may refuse to leave the victim alone with a healthcare professional.

• They may have some medical training.

• They don’t question medical procedures or surgeries, even if they are invasive or painful. On the contrary, they may even request further interventions.

• The child may have been to multiple hospitals or healthcare professionals, including out-of-state.

• They may want to be seen as “good” or “devoted” caregivers and seek attention or approval from medical staff.

• They may be the only ones with the victim in a medical setting, with no other visitors or family members present.

Symptoms in the victim

Warning signs of medical child abuse and neglect include (Faedda, 2018):

• A history of many injuries, illnesses, hospitalizations, medical procedures, and surgeries

• Medical problems that don’t seem to respond to treatment at home or appear only when they are with their abuser

• Symptoms get better when under proper medical care and away from their caregiver/perpetrator

• They don’t have their second parent there when being seen by healthcare professionals.

In FDIA, the caregiver makes the child victim present as physically or mentally ill. They will falsify the child’s symptoms, manipulate medical tests, or tamper with medical devices. Some deliberately harm the child by injecting poison or dangerous substances, causing infection, physically injuring them, or stopping them from breathing with suffocation (ASPAC, 2017).

There is no single cause of Munchausen syndrome by proxy (FDIA). However, physical and psychological factors can cause this disorder in the caregiver/perpetrator (Yates, 2017). 

Physical causes include a childhood history of physical, emotional, or sexual abuse. In addition, the abuser may have suffered the loss of a parent or had multiple traumatic experiences in childhood. They may have also had pregnancy-related complications with this or another child (Yates, 2017).

Psychological causes or underlying psychiatric disorders include bipolar disorder, personality disorders, depression, anxiety, or factitious disorder imposed on self (Yates, 2017). 

Many child abuse episodes happen when the parent feels infuriated by the child’s behavior or the parents feel out of control. FDIA is unlike other instances of child abuse because it is premeditated, planned, and not related to the child’s behavior (Schreier, 2004). The caregiver/perpetrator also manipulates healthcare professionals to enable the abuse (APSAC, 2017).

It is very challenging diagnosing FDIA, as the behaviors are all based on deception and dishonesty. The following four criteria are defined in the DSM-5 (APSAC, 2017):

1. The caregiver behaves covertly by falsifying or inventing physical or psychological symptoms or deliberately injuring or causing disease in another person.

2. The caregiver presents the victim as sick, impaired, or injured to other people.

3. This deceptive behavior is consistent and is present with no apparent benefit.

4. This behavior isn’t because of an underlying medical or mental health condition like delusional disorder or another psychotic disorder.

It takes two to tango with FDIA—so, the caregiver/abuser and the child victim both need to receive treatment. Specialized mental health counseling for people with Munchausen syndrome by proxy and their victims can help them move past the trauma of the medical abuse (APSAC, 2017). 

Immediate and extended family members, friends, medical professionals who have worked with the family, and community members may also be affected by the story of the abuse.

The abuser’s behavior is dependent on keeping the child victim sick to satisfy their needs. Therefore, the definitive “cure” for the victim is often to completely separate them from the perpetrator, at least until the perpetrator receives adequate mental health treatment. Child protective services may need to be involved with the entire family, even if the child victim is removed from their abuser. This is because the perpetrator may abuse another child in the family (APSAC, 2017).

Munchausen syndrome by proxy or factitious disorder imposed on another can have long-term effects on the victim. Once the victim is removed from their abuser’s care, they may need medical and psychological help. Both healthcare providers and mental health professionals may be part of a multi-disciplinary team to provide care. Medical care may involve treating or remedying symptoms caused by the abuser. Expert psychological or psychiatric care may help the child to understand and deal with the abuse they’ve gone through. Unfortunately, it may take significant time for the child to heal (Bursch, 2019). 

The caregiver/abuser may not seek treatment because they operate on deception and may not want to admit their behaviors. If they somehow recognize their actions and are willing to get help, they may want to seek out individual psychotherapy. Therapy may help them identify their thoughts, modify their behaviors, and develop coping skills and strategies to avoid causing additional harm to another person. However, it is more common for legal authorities or a protective agency to take over the case and mandate treatment (Bursch, 2019).

If a healthcare professional suspects that a child is a victim of FDIA or Munchausen syndrome by proxy, they must alert legal authorities and child protective services. The abuser may face criminal charges for medical abuse. Their treatment depends on their psychiatric evaluation and the legal issues involved in their case.

If you think someone you know has symptoms or behaviors of factitious disorder imposed on another, contact the legal authorities or your local child protection agency immediately. If you feel the child is in a life-threatening situation, call 911. Your actions could help save a child’s life.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

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Current version

June 30, 2021

Written by

Tobi Ash, MBA, RN, BSN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.