Medical lessons from a twisted tale
Gypsy Rose Blanchard was released from a Missouri prison Dec. 28 after serving eight years for the murder of her mother in response to lengthy medical abuse. Blanchard’s mother had led both her daughter and the world to believe that Blanchard was ill and disabled growing up: afflicted with leukemia and muscular dystrophy, and in need of a wheelchair and a feeding tube. As hospital-based psychiatrists, we believe our profession must learn important lessons from this tragic case.
Blanchard’s mother likely suffered from a condition known as Factitious Disorder Imposed on Another, characterized by the intentional induction or falsification of physical or psychological symptoms in another person. A related, better-known term is “Munchausen by proxy,” in which an individual travels from hospital to hospital, seeking unnecessary treatment for an unsuspecting relative. Abusers may be motivated by so-called “primary gain” stemming from the attention and praise one receives vicariously as a caregiver, as well as so-called “secondary gain,” like access to free housing from Habitat for Humanity and complimentary trips paid for by the MakeA-Wish foundation. Both appeared to motivate Blanchard’s mother.
In hospital-based psychiatry, we encounter patients with Factitious Disorder Imposed on Another more frequently than physicians in other specialties or employed in other settings. Blanchard’s own medical doctor acknowledged in a recent LifeTime documentary that he had never considered this diagnosis. Her case underscores the importance of having systems in place that prevent physicians
from unwittingly colluding with abusers and inadvertently harming vulnerable victims.
The concern for a diagnosis of Imposed Factitious Disorder typically arises when induced symptoms are suspected because few other plausible explanations for the patient’s condition exist. In colloquial terms, something just does not add up. For example, if a patient’s blood repeatedly tests positive for bacteria usually seen only in urine, that may raise concern among providers that the patient is clandestinely contaminating her intravenous access. Sometimes, this behavior is witnessed directly. On other occasions, only circumstantial evidence is available. In both cases, management typically
focuses on preventing further harm. Methods include separation of the perpetrator and victim, and in cases concerning minors, involving the relevant child protection agency. Often, the victim will benefit from therapy to address the psychological effects of trauma; the perpetrator may require such treatment as well. However, at its core, imposing factitious disorder is a criminal act.
In her recent memoir, “Released,” Blanchard, now 32, expresses her desire for the establishment of an oversight process that will “ensure that doctors are more observant of their patients’ care and trained to look for red flags” that may indicate something amiss. These “red flags” may include inconsistencies
in the reported history, a mismatch between visible and reported symptoms, improvement of symptoms in the absence of the abuser, and the presence of rare, multiple or implausible conditions. Frequently, the perpetrator may have a background in health care, which affords them specialized medical knowledge. In Gypsy’s case, her mother had previously worked as a nurses’ aide, accounting for her greater familiarity with medical terminology and systems.
The medical community must ask what physicians can do to better recognize such cases. At a minimum, doctors should be trained more consistently in the thoughtful detection of deception. Hospital-based psychiatrists have a key
role to play in the process. Of course, grave danger exists in approaching patient care with too much skepticism. Imposed Factitious Disorder is rare, and skepticism may reflect our own biases. For instance, well-documented evidence of racial and gender disparities in pain management has revealed that physicians clearly tend to believe some people more readily than others. Yet, unquestioning belief in the absence of proof can prove equally dangerous.
At the systems level, a centralized electronic medical record (EMR) could help link medical information between different institutions and even across state lines. In Blanchard’s case, her mother had claimed that
her medical records had been destroyed during Hurricane Katrina. Had Blanchard’s medical records been connected electronically, perhaps her physicians might have recognized odd patterns in her symptoms across time and geography, and connected the dots.
As human beings, we hope that Blanchard finds healing. As psychiatrists, we believe that the medical system must establish better checks and balances to prevent similar tragedies from occurring in the future.