Munchausen Syndrome by proxy Act 193 Taps into Complex Issues in Effort to Limit Diagnostic Errors

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In the 2018 regular session, House Bill No. 145 placed limitations on who may diagnose the disorder known as “Munchausen Syndrome by proxy,” which is known in the DSM-5 as factitious disorder imposed on another or FDIA. The bill, by Representative Kenny Cox, was signed by the Governor and became Act 193.

Formally known as Munchausen syndrome by proxy (MSP), this condition is a mental illness in which a person acts as if an individual he or she is caring for has a physical or mental illness when the person is not really sick. In some cases, illnesses may be actually produced by the caretaker.

Act 193 directs that no physician or other health care provider shall diagnose the condition of factitious disorder imposed on another (formerly “Munchausen syndrome by proxy”) unless he or she meets certain criteria, such as being licensed, qualified by his or her license and training to diagnose, able to provide a certain level of quality in the evaluation, and other stipulations. The new law indicates that the evaluator must review relevant records, history, current clinical conditions, and obtain records from external sources searches schools, childcare providers, and family.

While these quality controls and expectations are standard for psychological evaluation, Representative Cox’s measure suggests that problems have been encountered in the past in this complex area where teasing out the accuracy of claims and symptoms could require a deeper understanding of illness-deception.

The measure was signed by the governor recently and became law as Act 193. However, the real complexities of the matter may still cause issues for those practitioners who are not highly trained to understand nuances and pitfalls regarding illnessdeception.

Dr. Michael Chafetz, a nationally recognized expert when it comes to malingering in forensic and medical
assessments, points to the complexities in understanding these issues.

“Every practitioner who makes a diagnosis has two potential positive outcomes and two potential errors,” said Chafetz. “If the diagnosis is made and is correct, it is a good thing because the patient has the pathology identified and can get appropriate treatment. If the diagnosis is correctly rejected (because no evidence for the pathology could be adduced), it is a good thing because the patient is spared the wrong treatment for pathology that does not exist.”

“The flip side of the positive outcomes involves the errors that are potentially made,” he said. “If the practitioner makes a diagnosis of a condition that the patient does not have, that is a false-positive error. Everyone involved with the case is now acting on false new information about the patient.

“On the other hand, if the practitioner rejects the diagnosis for a condition that the patient does have, that is a false-negative error,” he explained. “This error can be problematic, as no one involved with the case will get on board with the appropriate interventions.”

In decision-making, there is often a trade-off between false-positive and falsenegative errors, and the importance of not making one or the other depends on the relative merits of the outcomes, he explained. “For example, in cancer screening and bomb detection, a false negative error can be more costly than a false-positive error. TSA certainly does not want to miss a bomb, and the radiologist certainly does not want to miss a possible cancer. These false-positive errors may cause some discomfort, but they sure beat the alternatives!”

In Factitious Disorder Imposed on Another, both kinds of errors have realworld consequences. “If the practitioner makes a false-negative error, missing the parental deceptions, the parent does not get diagnosed, which increases the potential for a child to suffer abuse,” Dr. Chafetz said.

“If the practitioner makes a false-positive misdiagnosis of the parent, that parent may face drastic consequences with the possibility of termination of their parental rights.”

He noted that Factitious disorder (FD), like malingering (M), involves deceptive behaviors. In fact, both FD and M are similar in that they both involve deception of others. Malingering involves deception in a medico-legal setting, whereas FD typically occurs in a medical or psychological setting.

The “by-proxy” or “imposed on another” conditions for both disorders are meant to convey that an individual, usually a caretaker, is creating the deception by use of a person under their care.

Dr. Melissa Dufrene and Chafetz have studied these exact issues, in Chafetz, M.D., & Dufrene, M. (2014). Malingering-by-proxy: Need for child protection and guidance for reporting. Child Abuse & Neglect, 38, 17551765.

Both of the by-proxy or imposed conditions can lead to child abuse, he explained. In their guidance article, Chafetz and Dufrene developed guidelines for reporting.

Dr. Chafetz has also discussed these conditions in a physicianeducation article, Chafetz, M.D. (2018). Factitious Disorder Imposed on Another and Malingering by Proxy: Controversies, Recognition, Responsibilities, and Management. American Physician Institute, CMEtoGo, Volume 7, Issue 2.

It is important to recognize that both conditions, M and FD, involve deception of others. Typically, psychological treatments do not take into account the deception, he said.

While Act 193 may help somewhat to make sure qualified professionals are called upon for these complex issues, there could still be a lot of confusion for those that do not have the tools and methods to evaluate these serious issues.

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