Factitious disorder imposed on another: A report of two case
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Factitious disorder imposed on another (FDIA), 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.

A 10-year-old girl presented 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.

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. 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.

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).

Source: https://www.ijpd.in/article.asp?issn=2319-7250;year=2021;volume=22;issue=3;spage=288;epage=289;aulast=Kushwaha
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