Fabricated or Induces Illness in Adults
1. Introduction and Definitions
This guidance will support practitioners in all partner organisations to understand and respond to suspected fabricated and induced illness in adults.
Fabricated or induced illness (FII) is most commonly associated with children. However, there are increasing numbers of incidents involving adults with and without capacity, and younger adults going through the transition into adulthood.
Fabricated or induced illness is not always a safeguarding concern, but it can be when:
- Another person has intentionally (or unintentionally) induced the illness;
- Another person has used coercive or controlling behaviour to force the adult to fabricate or induce the illness (psychological or domestic abuse);
- Another person is fabricating an illness in themselves for the purpose of coercing or controlling the adult (psychological or domestic abuse);
- The illness has been induced because the adult is neglecting their own needs (self-neglect).
Fabricated illness
This involves an adult presenting as ill when they are not. For example, claiming to hear voices or have chest pain.
Induced illness
This involves an adult doing something to themselves to cause (or induce) illness. For example, rubbing dirt into a wound to cause an infection or drinking a harmful substance to bring about vomiting.
Fabricated or induced illness by proxy
Fabricated or induced illness by proxy occurs when the presenting illness has been fabricated (made up) or induced (caused) by a third party. This may be a carer, friend, family member or professional. It could also be multiple people coordinating the fabrication or inducement of illness (for example several family members or professionals working together).
The following are the main (but not all) ways in which an illness in an adult can be fabricated or induced by proxy:
- Fabrication of signs and symptoms;
- Fabrication of past medical history;
- Falsification of hospital charts, records, letters and documents and specimens e.g., bodily fluids;
- Exaggeration of symptoms/real problems;
- Inducing illness by a variety of means such as overuse of medication, causing injuries, withholding food etc.
Failing to identify a case of fabricated or induced illness by proxy can lead to harmful or unnecessary medical interventions being carried out, based upon symptoms that have been falsely described, fabricated or induced.
2. Causes of Fabricated or Induced Illness in Adults
2.1 Professional curiosity
There are many reasons why an adult may present with a fabricated or induced illness, and it is important to use professional curiosity to investigate all potential causes and ensure the most appropriate and proportionate response.
See: Professional Curiosity.
2.2 Self – harm
Self-harm is when someone intentionally damages or injures their body.
Types of self-harm may include, but are not limited to:
- Cutting the skin;
- Burning the skin;
- Punching the body;
- Poisoning;
- Misusing alcohol or drugs (including not taking prescribed medication);
- Not engaging with or sabotaging treatment to improve a condition;
- Eating disorders.
Some of the reasons that adults may self-harm include, but are not limited to:
- Expressing or coping with emotional distress (trauma);
- Trying to feel in control;
- A way of punishing themselves;
- Relieving unbearable tension;
- A cry for help;
- A response to intrusive thoughts;
- A desire for attention from others.
Self-harm should be considered as the possible cause of an induced illness and, where self-harm is a factor, a trauma informed approach should be taken, and adults supported to access appropriate support from mental health services.
For further information and guidance about identifying and treating self-harm, see: Self-harm.
2.3 Abuse or neglect
Fabricated or induced illness may be a sign of abuse or neglect, particularly when the adult has numerous unexplained injuries (sprains, bruises, lacerations etc.), or their presenting symptoms indicate:
- Overdose, misuse or omission of prescribed/unprescribed medication;
- Neglect/omission of basic needs (hydration, nutrition);
- Neglect/omission of care and support needs (e.g., continence care, oral care);
- Self-neglect of basic or care and support needs by the adult themselves.
Where fabricated or induced illness presents, consideration should be given to whether:
- Another person has intentionally (or unintentionally) induced the illness (fabricated or induced illness by proxy);
- Another person has used coercive or controlling behaviour to force the adult to fabricate or induce the illness (psychological or domestic abuse);
- Another person is fabricating an illness in themselves for the purpose of coercing or controlling the adult (psychological or domestic abuse);
- The illness has been induced because the adult is neglecting their own needs (self-neglect).
If any of the above apply (or may apply), and the adult has (or appears to have) a need for care and support, the safeguarding duty may apply.
For further information, see Section 4, Safeguarding Response.
2.4 Other causes
If there is no evidence to suggest self-harm or abuse or neglect, other causes and motivators should be considered. There will always be a reason that the adult (or other person) is fabricating or inducing the illness.
Examples of other causes are:
- To expediate access to a social care, health or other service;
- Homelessness and housing issues;
- Poverty (being in hospital ensures warmth and a meal);
- Social isolation (being in hospital combats loneliness);
- Fraud (for example, to claim benefits).
In many cases, supporting the adult to address their primary concern can prevent further occurrences of fabricated or induced illness.
Factitious Disorder (sometimes known as Munchausen syndrome)
The cause of the fabricated or induced illness is unlikely to be Factitious Disorder. As such, it should only be considered as a possible cause when all other causes have been ruled out. Factitious Disorder is a very rare psychological condition where the main intention of the adult is to fabricate or induce illness in themselves so that people care for them and/or they are the centre of attention.
3. Indicators of Fabricated or Induced Illnesses in Adults
Note: Even if fabricated or induced illness is suspected, access to medical treatment (including emergency treatment) should never be delayed.
This is an incredibly complex and challenging area of practice. The indicators in this section should act as triggers for further investigation and do not on their own confirm that an illness is fabricated or induced.
- All the circumstances of the case and evidence from the full range of available sources should be carefully considered by an appropriate medical professional;
- Historical evidence of fabricated illness should not alone be the basis upon which a decision is made that an adult’s current illness is fabricated;
- Medical tests and investigation should be carried out as necessary to confirm the presence (or not) of an illness.
3.1 General indicators that an illness may be fabricated or induced
The following list is not exhaustive:
- Reported or actual symptoms are not explained by any medical condition that the adult is, or may be experiencing;
- Physical examination/results of medical investigations do not explain reported or actual symptoms;
- There is an inexplicably poor response to medication or treatment of the reported symptoms;
- New symptoms are swiftly reported on resolution of previous ones;
- Over time, repeatedly presenting to different medical professionals in a range of settings (either with the same or varying symptoms)-including GP hopping and seeking multiple opinions to try and validate symptoms;
- Known excessive use of medical websites.
Concerns may also be raised by other professionals or agencies who may notice discrepancies between reported and observed medical conditions.
3.2 Additional indicators that an illness may be fabricated or induced by proxy
Aside from the general indicators in 3.1 above, the following are some additional things that could indicate fabricated or induced illness by proxy:
- During health appointments/examinations, the other person does not allow the adult to speak for themselves or limits their opportunities to do so;
- Symptoms are not observed in the absence of the other person;
- Regardless of the adult’s views, the other person is insistent on additional tests/examinations, including repeated requests for tests already carried out, as well as failing to accept the results of tests or examinations;
- Regardless of the adult’s views, the other person is keen for them to be admitted into hospital, for follow up appointments or referrals to specialist services to be made, or for new medication to be prescribed;
- The other person repeatedly presents the adult to different medical practitioners in a range of settings (either with the same or varying symptoms). For example, GP, contacting 101, A & E, walk in centres, pharmacy);
- The adult’s normal daily activities are being restricted beyond that expected with any medical condition they have.
3.3 Perplexing presentation
‘Perplexing presentation’ is the term used to describe the situation when the current state of health of the adult may be caused by a fabricated or induced illness, but it is not yet possible to confirm.
Assumptions should not be made about the outcome of any assessment or investigations carried out at this time. Sometimes, the cause is a rare or misdiagnosed illness or even misinterpretation of behaviour associated with a known condition e.g., Autism. As such, it is important that the right specialism is involved in any assessment and subsequent determination, so that the appropriate course of action or treatment is taken.
If there is perplexing presentation and there are concerns that the adult may be experiencing fabricated or induced illness by proxy, a safeguarding concern should be raised until known otherwise. All relevant safeguarding procedures regarding raising a concern apply.
For further information, see: Disclosure and Raising a Concern.
4. Raising a Concern and the Safeguarding Response
Note: If you are concerned that an adult is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialing 999.
4.1 Raising a concern
If any of the following apply (or may apply), and the adult has (or appears to have) a need for care and support, the safeguarding duty may apply:
- Another person has intentionally (or unintentionally) induced the illness (fabricated or induced illness by proxy);
- Another person has used coercive or controlling behaviour to force the adult to fabricate or induce the illness (psychological or domestic abuse);
- Another person is fabricating an illness in themselves for the purpose of coercing or controlling the adult (psychological or domestic abuse);
- The illness has been induced because the adult is neglecting their own needs (self-neglect).
For further information, see: Disclosure and Raising a Concern.
When received, the concern should be managed in line with the requirements of the Care Act 2014.
For further information, see: Responding to a Concern.
4.2 Multi-agency working
Due to the complexities and challenges of this area of practice, a multi-agency approach is essential to manage risk, investigate and intervene in order to achieve a positive and sustainable outcome for the adult. This includes effective joint working and the sharing of relevant information, evidence and concerns in a timely way to ensure the most appropriate and proportionate response takes place at the right time.
4.3 Specific guidance for cases of fabricated and induced illness by proxy
Perplexing presentation
If there is perplexing presentation (it is not yet clear whether the adult is experiencing fabricated or induced illness by proxy), the safeguarding response should be proportionate and restrictive measures that cannot later be reversed, should not be instigated.
Enquiries
Where an enquiry takes place, the practitioner leading it should be mindful of the following:
- Being open and transparent with the person alleged to have caused harm may not be the best way to gather evidence from them or safeguard the adult at risk. This is because challenging them can cause their withdrawal and can also inadvertently lead to an escalation of ‘by proxy’ behaviour as they attempt to prove that they are doing no harm and that the adult really is ill;
- A person who fabricates or induces illness by proxy can demonstrate a seemingly advanced and sophisticated medical knowledge, and it is important that whoever speaks with them is equally well informed, able to identify inaccuracies and challenge appropriately;
- Prior to suspicions arising, the person alleged to have caused harm may have developed a plausible and convincing relationship with professionals involved in the case. To avoid conflicts of interest, and to ensure impartiality it can sometimes be beneficial for whoever speaks to them to not already know them.
Supporting the person alleged to be causing harm
In the same way as it is important to understand the reason why an adult may fabricate or induce an illness in themselves, it is equally as important to understand the motivators when this is by proxy. Not doing so can result in a disproportionate response or increase in risk.
Where an external factor such as poverty or housing is identified as the cause, the person should be signposted to or supported to access appropriate support and services to address the issues they are experiencing.
If the person is driven by their own desire for attention from medical professionals, their own need for support should be considered. Without support, their behaviour is unlikely to change, and the adult would remain at continued risk of further harm.
In some cases, the person may be a carer who is fabricating or inducing illness by proxy because they are finding caring too difficult, need additional support or are at risk of breakdown. In these cases, a carers assessment or reassessment of the adult’s needs may be a more appropriate and proportionate response to the situation.
False allegations against family members
False allegations of fabricated or induced illness by proxy against family members can have a devastating impact for the whole family, especially when action is taken that cannot be easily reversed or rectified.
Research into the prevalence and impact of fabricated or induced illness allegations in England, Scotland or Wales found several cases where false allegations were made against family members following either a request for help or a complaint being made against a service provider.
When a concern has been raised relating to a family member, part of the initial response should be to consider the motivations of the person making the allegation. In addition, any action that cannot be easily reversed or rectified should not be taken until the allegation has been fully investigated and substantiated.
Cerebra: The prevalence and impact of allegations of Fabricated or Induced Illness (FII).
5. When Fabricated or Induced Illness was a Concern in Childhood
If an adult was known as a child or young person to either fabricate or induce illness in themselves, or was at risk ‘by proxy’, it is important that Children’s Services share relevant information with Adult Services as part of the transition to adult care and support. This will help ensure that ongoing risks are managed, and that the adult continues to get any support they need from mental health or other specialist services.
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