Factitious disorder imposed on another: a diagnostic dilemma

Here we discuss a case of factitious disorder imposed on another (FDIA).
An 18-year-old girl was brought to the dermatology department by her mother with a history of recurrent ulcers over the legs which healed on conservative management since childhood. On examination, ulcers were multiple, well defined, angulated, superficial with oozing, hyperpigmented borders (fig. 1). There were multiple hyperpigmented and atrophic scars on the legs. We suspected epidermolysis bullosa, cutaneous vasculitis and pyoderma gangrenosum. Routine investigations were normal. Skin biopsy showed nonspecific histopathological findings. Staphylococcus aureus was grown on culture. She was treated with antibiotics and occlusive dressings and did not develop any fresh lesions in these 20 days (fig. 2). She came with fresh lesions after a week, at an easily accessible area with similar morphology suggestive of self-inflicted injuries. This raised a suspicion of factitious disorder.
On the psychiatrist’s evaluation, the patient had depressive symptoms with a Hamilton Depression score of 16, suggesting mild to moderate depression. International personality disorder examination (IPDE) suggested emotionally unstable personality disorder (EUPD)-borderline type personality. She was started on fluoxetine 20 mg and amitriptyline 25 mg for depression. In the ward, nursing staff observed the mother inflicting injuries with a twig and worsening of ulcers, which raised the suspicion of FDIA.
FDIA is a form of abuse where an individual deliberately produces or feigns clinical illness in a person under his or her care. It is also known as Munchausen syndrome by proxy, coined by Meadow in 1977 [1]. Predisposing factors are psychiatric illness, medical history with repeated hospitalization, and resentment against health professionals. Among 9%, it mimics acute or chronic skin disease, leading to misdiagnosis [2].
The victim revealed an uneventful childhood, denied the mother’s role in causing the ulcers and cooperated with management. The devastating effects of FDIA are behavioural issues, post-traumatic stress disorder, suicidal ideation, anxiety, depression, and low self-esteem with a 9–12% mortality rate due to complications [2, 3]. Our patient had depression with borderline type of EUPD. Perpetrators are described as intelligent, articulate and medically sophisticated. They invariably have mental illness or history of factitious disorder [3]. The initial source of the...


View full text...