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In June 2015, 48-year-old Claudine “Dee Dee” Blanchard was found dead in her bed. A day later, police found her daughter: the girl had been hiding in the apartment of her boyfriend, Nicholas Godejohn, who had killed Dee Dee and stabbed her seventeen times. After a year-long investigation, the court sentenced Gypsy Rose Blanchard to ten years in prison and her boyfriend to life in prison.

For twenty-four years, Claudine physically and emotionally oppressed her daughter, forcing her to pretend she was sick. Although the woman was never accurately diagnosed during her lifetime, forensic psychologists believe Blanchard suffered from a condition known as Munchausen syndrome by proxy (MSP). Munchausen syndrome is a psychological disorder in which the caregiver, in most cases the mother, intentionally induces symptoms of various illnesses in the child in order to meet the child’s psychological needs.

Munchausen syndrome is a rare but severe form of child maltreatment that often goes undiagnosed. To identify the condition, clinicians must thoroughly investigate the client’s background in case there is a discrepancy between the parents’ statements and previous medical reports. One of the most important ways to confirm suspected MSP is to separate the caregiver and child to see how the patient’s health changes. Diagnosing MSP is extremely difficult because sufferers often appear to be mentally healthy, while their children may show symptoms of real illnesses, making it difficult for doctors to distinguish between true physiological disorders and those caused by a parent.

Dee Dee Blanchard is a prime example of a person with Munchausen syndrome by proxy. She used basic medical knowledge from her work as a nurse’s aide to confirm Gypsy’s long list of illnesses. Blanchard was able to convince doctors that her daughter was paralyzed from the waist down, even though the girl could walk independently and did not need a wheelchair. Depending on which doctor she spoke to, Dee Dee changed her family story. To one cardiologist, for example, she pretended that many members of her family had died of heart attacks. As a result, doctors and nurses became unwitting accomplices in a fraudulent scheme, prescribing unnecessary surgeries and medications for the girl.

Munchausen syndrome most often develops in people who were neglected or abused by their parents in childhood, says Mark D. Feldman, MD and an honorary member of the American Psychiatric Association. After studying the Blanchard family’s case in depth, Dr. Feldman concluded that the cause of Dee Dee’s mental disorder was her strained relationship with her own mother, who had humiliated her daughter all her life. As a result, Claudine satisfied her need for attention by creating conditions in which Gypsy could not even physically get along without her.

Like other people with MSP, Dee Dee satisfied her psychological needs not only at the expense of her child, but also at the expense of those around her. She gained public recognition for devoting all her time to caring for her “sick” daughter. People donated money to help the family: in 2009, the girl received the “Child of the Year” award and $5,000 for her resilience from the Olya Foundation, a nonprofit dietitian community and advocacy group.

So it went for more than twenty years until 2015, when Gypsy plotted murder to get rid of her mother’s overprotectiveness and run off with her boyfriend. “The control was total, just as sometimes control over a kidnapped victim is total. Claudine’s daughter was indeed a hostage, and I think we can understand the crime that happened afterwards from the perspective of a hostage trying to escape,” Dr. Mark Feldman said.