Factitious Disorders: Ethical Considerations, Factitious Disorder by Proxy, Treatment

Ethical Considerations

Treating patients with factitious disorder often raises ethical ques-tions including those regarding confidentiality, privacy and medi-cal decision-making, and it is important to be alert to these issues. Often, patients with factious disorder will want to keep their diagno-sis confidential, even when to do so may harm the patient or others. For example, although a consulting physician may diagnose a patient with factitious disorder, the patient may refuse consent to reveal this information to the referring physician. If the consultant does inform the referring physician, she has violated the patient’s confidential-ity, but if she does not, the referring physician is likely to continue to treat the patient for the incorrect diagnosis. Dilemmas regarding patient privacy also arise with factitious patients. For example, hos-pital room searches could often help clarify the diagnosis or remove materials the patient is using to harm himself, but these searches also violate the patient’s privacy. Dilemmas surrounding medical decision-making can arise when a patient with factitious disorder refuses treatment or requests potentially harmful treatments. It can often be difficult to resolve these ethical dilemmas. In general, even though the factitious patient is deceptive within the doctor–patient relationship, the physician is not released from his or her respon-sibilities within that relationship, and the patient retains his or her rights of confidentiality, privacy and autonomy. As with all patients, emergency situations require different ethical guidelines. Often, an ethics consultation can be very helpful in sorting through the dif-ficult issues of patient care in the setting of factitious disorder

Factitious Disorder by Proxy

In factitious disorder by proxy, one person creates or feigns ill-ness in another person, usually a child, though occasionally the victim is an elder or developmentally delayed adult. Factitious disorder by proxy is not defined as a specific disorder in DSM-IV but instead is listed under the “not otherwise specified” heading with research criteria included. While rare instances of fathers perpetrating factitious disorder by proxy have been reported, the perpetrator is usually the mother. Usually the victim is a prever-bal child. While numerous symptoms have been reported, com-mon presentations include apnea, seizures and gastrointestinal problems. The mothers appear extremely caring and attentive when observed, but appear indifferent to the child when they are not aware of being observed (Eisendrath, 2001).

As in factitious disorder, the exact prevalence of facti-tious disorder by proxy is unknown. There have been studies of the annual incidence of factitious disorder by proxy in the general population in both the UK and New Zealand. In the former, the an-nual incidence of factitious disorder by proxy in children less than 16 years was found to be 2.0/100 000 (18 total cases) and in the latter, the annual incidence in children under 16 was 0.5/100 000 (128 total cases). As for the incidence within clinical populations, an Argentinean survey of 113 children with FUO found four (3.5%) cases of factitious fever. A survey of 20 090 children brought in with apnea found 54 (0.27%) to be victims of factitious disorder by proxy (Kravitz and Willmott, 1990). Finally, a review of chil-dren brought in for treatment of acute, life threatening episodes of diverse etiologies ranging from seizure disorders to electrolyte ab-normalities found 1.5% to be factitious (Rahilly, 1991). Factitious disorder by proxy appears to have a much higher mortality rate than self-inflicted factitious disorder. In Rosenberg’s survey of 117 victims, there was a 9% mortality rate (Rosenberg, 1987), and of the 54 victims of the disorder in the apnea survey, three index cases and five siblings were dead at follow-up (Kravitz and Wilmott, 1990). More recently, McClure found that eight of 128 index cases in the UK were fatal (6.25%) (McClure et al., 1996) while Denny reported no fatalities in 18 index cases (Denny et al., 2001).

The diagnosis of factitious disorder by proxy is usually made by having an index of suspicion in a child with unexplained illnesses. The diagnosis is supported if symptoms occur only in the parent’s presence and resolve with separation. Covert video sur-veillance has been used to diagnose this condition, though it raises questions of invasion of privacy. In general, it has been felt that the welfare of the child overrides the parent’s right to privacy.

As counterintuitive as it is to comprehend why anyone would induce illness in oneself, it can be even more difficult to understand inducing illness in one’s own child. The perpetra-tor in factitious disorder by proxy appears to seek not the “sick role” but the “parent to the sick child” role. This role is similar to the sick role in that it provides structure, attention from others, caring and relief from usual responsibilities. The parent also re-ceives some psychological benefit from inducing illness in his or her child. Based on case reports, the parent often has a comorbid personality disorder and a history of family dysfunction.

Treatment

Due to the high morbidity and mortality, treatment requires at least temporary separation from the parent and notification of lo-cal child protective agencies. The perpetrators often face crimi-nal charges of child abuse. There is high psychiatric morbidity in the children: many go on to develop factitious disorder or other psychiatric illnesses themselves. Psychiatric intervention is nec-essary to ameliorate this morbidity as much as possible in these children. There are some case reports of successful psychothera-peutic treatments of the parents in this disorder.