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On June 2015, 48-year-old Clauddine “Dee Dee” Blanchard was found in bed lying in a pool of her own blood with multiple fatal stab wounds. A day later, her daughter Gypsy Rose was found states away in Wisconsin, at the home of her boyfriend. The Act, a disturbing crime show based on real events, follows the story of a mother (Dee Dee) who physically, mentally, and emotionally abused her daughter (Gypsy Rose) to make her appear ill and actually sick at times. Although never definitively/properly diagnosed, Dee Dee had a condition known as Munchausen syndrome by proxy (MSP)—now referred to as factitious disorder imposed on another (FDIA)—a psychological disorder in which the caretaker, most often a mother, intentionally fabricates, feigns, or induces real symptoms or illnesses in the child to fulfill their own self-serving psychological needs (“Munchausen syndrome by proxy,” n.d.).
MSP is a rare but serious form of child abuse that often goes undetected and undiagnosed. Someone, such as a mother, with MSP may deliberately do extreme things to fake symptoms of illness in their child. These can include: administering inappropriate medicines, poisoning, withholding food, or withholding prescribed medicines. She may also fake symptoms of illness by tampering with medical tests (i.e., adding blood to the child’s urine or stool sample, heating thermometers so it looks like the child has a fever), making up lab results, and lying to medical professionals about the child’s health or condition. She may even subject the child to unnecessary painful and risky medical procedures. This is often done for their own personal psychological gains, such as to gain attention and sympathy from doctors and nurses, or for tangible gains, such as money, donations, and property (Staff, 2018). The etiology of MSP is complex and unknown, but a common theme found in women with MSP is that “they all suffered some loss through maternal rejection or lack of maternal attention or love during infancy. As a result, they have an unsatisfied psychological need” (Thomas, 2003, p. 175). Resultingly, that need is fulfilled by the attention and admiration given to the mother from the medical team.
To diagnose MSP, health care providers must first notice the clues. Physicians must do a thorough review of all the child’s medical records to look for medical discontinuities or patterns that suggest something is off. According to Stirling (2007), physicians must ask 3 questions:
- Are the history, signs, and symptoms of disease credible?
- Is the child receiving unnecessary and harmful medical care?
- If so, who is instigating the evaluations and treatment? (p. 1028)
One hallmark way to confirm suspicions of MSP is to separate the caregiver from the child and then see if the child’s symptoms improve. They can also interview anyone who has had personal contact with the child or caregiver (i.e., family members, school personnel, neighbors). If necessary, secretly videotaping the interactions between the suspected caregiver and child when alone can be useful. Unfortunately, MSP is extremely difficult to detect and diagnose due to all the dishonesty involved. Individuals with MSP typically do not appear psychotic and victims of MSP exhibit real symptoms of illnesses, making it difficult for physicians to distinguish real illnesses from the ones that were induced. Additionally, there are ethical issues that may complicate a diagnosis from being made. It is difficult for most health care professionals to believe that a mother would intentionally hurt their own child and implicating someone of doing so is a serious accusation.
In case, Dee Dee is a textbook example of someone with Munchausen syndrome by proxy. For years, Dee Dee had faked and induced multiple medical illnesses in her daughter, Gypsy, to gain attention and sympathy from the world. She claimed Gypsy suffered from several disabilities and conditions—including epilepsy, leukemia, muscular dystrophy, sleep apnea, severe asthma, multiple sclerosis, a heart murmur, mental retardation, chromosomal disorders, digestive disorders—when in reality she was perfectly healthy. Dee Dee claimed Gypsy had sleep apnea at only 3 months old and made her use a CPAP machine at night. She fed Gypsy cold medicine when Gypsy wasn’t feverish. She claimed Gypsy was paralyzed from the waist down when she was 5 years old, forcing her to use a wheelchair despite being able to walk on her own. She had a feeding tube inserted for Gypsy’s alleged acid reflux and then used the tube to feed her PediaSure and unneeded medications. She convinced Gypsy that she had a sugar allergy and never let her eat anything with sugar in it (e.g., cupcakes). She told everyone that Gypsy was mentally disabled with “the mental capacity of a 7-year-old” (Meyboom, 2019). She would shave Gypsy’s head bald so she appeared to be undergoing chemotherapy, telling her that “your hair’s gonna fall out anyway, so let’s keep it nice and neat” (Meyboom, 2019). She even forced Gypsy to undergo multiple unnecessary surgeries, such as having her salivary glands and most of her teeth removed.
Dee Dee proved to be a master manipulator and liar. In most cases, caretakers with MSP have some type of medical background, enabling “some sophistication in the fabrication of symptoms” (Klebes & Fay, 1995, p. 93). As expected, Dee Dee used basic medical knowledge from her days as a nurse’s aide to validate Gypsy’s lengthy list of medical conditions. She gave Gypsy unnecessary medications to mimic the symptoms of disease the doctors thought they were treating. In one case, Dee Dee numbed Gypsy’s gums so that she would excessively drool to convince the doctors to surgically remove her salivary glands. At medical appointments, Dee Dee was the “voice” for Gypsy, describing her various symptoms and conditions and never letting Gypsy actually speak for herself. She would change her family history depending on which doctor she was talking to. For example, to a cardiologist she would falsely disclose that many members of her family died of heart attacks. To cover up Gypsy’s lack of medical records, Dee Dee would claim that they were destroyed in Hurricane Katrina. As a result, doctors and nurses became unwitting accomplices in Dee Dee’s scheme, performing surgeries and prescribing medicines that weren’t needed.
An individual with MSP is typically pleasant and socially competent; they come off as sincere, compassionate, and cooperative with health care providers. Despite being the source of the harm or illness, the mother (or caregiver) constantly tries to portray an outward image of perfection. Using manipulation, they “appear very loving and attentive to their child, thereby delaying suspicion by the health care staff” (Klebes & Fay, 1995, p. 95). As with Dee Dee’s case, Dee Dee was friendly, genuine, and extremely caring to everyone around her. She always seemed completely devoted to the well-being of her child. And Gypsy, despite being “sick,” was always seen with a beaming smile. So to anyone outside their relationship, Gypsy and Dee Dee appeared to have the ideal mother-daughter relationship—living a beautiful, loving life as best friends. But behind closed doors, Dee Dee was overbearing, controlled every aspect of her daughter’s life, and allowed her few personal freedoms. She isolated herself and Gypsy from friends and relatives, home-schooled her, and kept her sheltered and naïve about the outside world. She used physical and psychological abuse to control and coerce Gypsy into keeping up “the act” as a sick person. She manipulated Gypsy into staying in the wheelchair by telling her that “if you walk around, you’ll only get sicker” (Meyboom, 2019). In the presence of others, Dee Dee would hold Gypsy’s hand and tightly squeeze if she said anything that contradicted her health. What seemed like a gesture of love was actually a means of oppression.
As noted before, many women with MSP developed an unsatisfied psychological need due to maternal rejection or the lack of maternal attention or love during childhood. Therefore, a likely etiology in the development of Dee Dee’s MSP was due to the strained relationship with her own mother, Emma Pitre. Emma was an incredibly overbearing mother who constantly belittled Dee Dee and never showed her any love or affection. When Gypsy was born, Emma did everything in her power to prove that Dee Dee wasn’t a good mother to Gypsy. As a result, Dee Dee fulfilled her need for love and attention (that she couldn’t get from her mother) by making up medical conditions and forcing care onto Gypsy so she would always feel needed.
Like others afflicted with MSP, Dee Dee gained a personal psychological fulfillment from the role as a long-suffering, devoted mother.By caring for and sacrificing everything for her “chronically sick and disabled” daughter, Dee Dee received attention, sympathy, and financial gain from their doctors, community, and the world. She earned praises for devoting all her time into taking care of her “sick” daughter. People would donate money to help them out. Habitat for Humanity built them a house in Missouri after their home was destroyed by Hurricane Katrina. In 2009, Gypsy received the “Child of the Year” award for her resilience along with $5,000. To maintain her role, Dee Dee ensured that Gypsy remained sick and vulnerable to satisfy her need for attention, admiration, and recognition as an excellent parent.
The treatment plan for someone with MSP requires a multidisciplinary approach and is focused on managing the condition, rather than trying to cure it. In all cases, the safety of the child or victim is the highest priority—potentially by removing Gypsy from Dee Dee’s direct care. As for Dee Dee, intensive psychotherapy, such as CBT, is recommended to help change her thinking and behavior. During the sessions, the therapist should help Dee Dee identify the thoughts and feelings that caused her harmful behavior and teach her how to form healthy relationships that don’t rely on someone being sick. Unfortunately, a successful treatment is difficult because MSP is a compulsive behavior associated with a high degree of denial. They often deny there is a problem, even when evidence proves it, and tend to be such accomplished liars that they have trouble distinguishing fact from fiction. Until they are ready to recognize the truth, it will be difficult for treatment to be successful (Staff, 2018). Other treatment options include medications and depending on 1 primary care physician to be the “gatekeeper” to monitor future medical care usage. Although medications cannot cure MSP, it may be prescribed to treat additional co-morbid mental health disorders, such as borderline personality disorder, depression, or anxiety.
Nurses are instrumental in the early detection, identification, and treatment of MSP cases. Therefore, all nurses should be educated about the syndrome. They must watch for and be able to recognize the behavioral patterns that individuals with MSP display to catch it early on and prevent health care professionals from unwittingly becoming participants in this type of abuse. According to the Cleveland Clinic, people with MSP (or FDIA) often exhibit the following characteristics:
- They are often a parent
- They are excessively cooperative with doctors, nurses, and other health care providers
- They often appear overly concerned with the person they are caring for (“Factitious Disorder,” n.d.).
The Cleveland clinic also noted some warning signs in children as potential victims of FDIA:
- They have a history of many hospitalizations with strange symptoms
- Their symptoms are reported to be worsening, even though it is not witnessed by health care providers
- Their symptoms improve when the child is in the hospital, but gets worse when the child returns home
- The child’s conditions and symptoms do not align with hospital tests
- The child’s blood, stool, or urine show signs of chemicals (“Factitious Disorder,” n.d.).
Because MSP is a form of child abuse, every nurse is mandated by law and ethically required to report any suspicions of MSP to their state’s child protective service agency. This is done for the safety and protection of the child. Additionally, Klebes and Fay (1995, p. 97) notes that nurses must provide objective, detailed documentation of all assessments and observations. They should clarify in the notes if the history is given by the mother or child, and what is actually observed by health care providers. Nurses must also protect all records and carefully obtain and handle the child’s lab specimens because MSP mothers are known to tamper with and alter medical records. It is noted that they have even altered specimens in the presence of nurses or physicians. Although challenging to distinguish symptoms of MSP, increased awareness among nurses and doctors can boost the chances of detecting and treating MSP before a child’s life is severely endangered.
- Factitious Disorder (Munchausen Syndrome by Proxy). (n.d.). Retrieved from https://my.clevelandclinic.org/health/diseases/9834-factitious-disorder-imposed-on-another-fdia
- Klebes, C., & Fay, S. (1995). Munchausen syndrome by proxy: A review, case study, and nursing implications. Journal of Pediatric Nursing,10(2), 93-98. doi:10.1016/s0882-5963(05)80004-1
- Meyboom, J. P. (Producer). (2019). The Act [Television series]. Santa Monica, CA: Hulu.
- Munchausen syndrome by proxy: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved from https://medlineplus.gov/ency/article/001555.htm
- Staff, F. E. (2018, November 13). Munchausen Syndrome by Proxy. Retrieved from https://familydoctor.org/condition/munchausen-syndrome-proxy/
- Stirling, J. (2007). Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting. Pediatrics,119(5), 1026-1030. doi:10.1542/peds.2007-0563
- Thomas, K. (2003). Munchausen Syndrome by Proxy: Identification and diagnosis. Journal of Pediatric Nursing,18(3), 174-180. doi:10.1053/jpdn.2003.35
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