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Munchausen by Internet: Current Research and Future Directions
Andy Pulman1, MA; Jacqui Taylor2, BSC, MSc, PhD
1School of Health & Social Care, Bournemouth University, Bournemouth, United Kingdom
2School of Design, Engineering & Computing, Psychology Research Centre, Bournemouth University, Bournemouth, United Kingdom
Corresponding Author:
Andy Pulman, MA
School of Health & Social Care
Bournemouth University
Royal London House
Christchurch Road
Bournemouth, BH1 3LT
United Kingdom
Phone: 44 1202 962749
Fax: 44 1202 962736
Email: apulman@bournemouth.ac.uk
Abstract
Background: The Internet has revolutionized the health world, enabling self-diagnosis and online support to take place irrespective
of time or location. Alongside the positive aspects for an individual’s health from making use of the Internet, debate has intensified
on how the increasing use of Web technology might have a negative impact on patients, caregivers, and practitioners. One such
negative health-related behavior is Munchausen by Internet.
Objective: Munchausen by Internet occurs when medically well individuals fake recognized illnesses in virtual environments,
such as online support groups. This paper focuses on the aspect of Munchausen by Internet in which individuals actively seek to
disrupt groups for their own satisfaction, which has not yet been associated with the wider phenomena of Internet trolls (users
who post with the intention of annoying someone or disrupting an online environment).
Methods: A wide-ranging review was conducted to investigate the causes and impacts of online identity deception and
Munchausen by Internet drawing on academic research and case studies reported online and in the media.
Results: The limited research relating to motivation, opportunity, detection, effects, and consequences of Munchausen by
Internet is highlighted and it is formally linked to aspects of trolling. Case studies are used to illustrate the phenomenon. What
is particularly worrying is the ease with which the deception can be carried out online, the difficulty in detection, and the damaging
impact and potential danger to isolated victims.
Conclusions: We suggest ways to deal with Munchausen by Internet and provide advice for health group facilitators. We also
propose that Munchausen by Internet and Munchausen by Internet trolling should be formally acknowledged in a revised version
of the Diagnostic and Statistical Manual DSM-5. This will assist in effectively identifying and minimizing the growth of this
behavior as more people seek reassurance and support about their health in the online environment. We also suggest directions
for future research.
(J Med Internet Res 2012;14(4):e115) doi:10.2196/jmir.2011
KEYWORDS
Munchausen by Internet; Internet trolls; identity deception; malingering; factitious disorder; deviance; social networking sites;
health support groups
Introduction
Lying to receive medical attention is not a new concept.
Although it was not until the 1800s that factitious disorder was
formally recognized, evidence of malingering dates back as far
as Roman times. Munchausen syndrome was first described in
1951 [1], followed in 1977 by Munchausen syndrome by proxy
[2]. More recently, the increasing use of the Internet to provide
support for illnesses and other medical issues has introduced
the concept of health-related online identity
deception—Munchausen by Internet (identified in 2000) [3].
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This paper reviews the research about the origins and evidence
relating to these disorders. The limited research relating to
motivation, opportunity, detection, effects, and consequences
is highlighted with case studies. We conclude with practical
and theoretical suggestions. We suggest practical ways for the
health care community to deal with Munchausen by Internet
and provide advice for health support group facilitators. We
propose that Munchausen by Internet and Munchausen by
Internet trolling be formally acknowledged and suggest future
research directions.
Types of Deception Regarding Health
Malingering
Malingering is defined as a deliberate behavior for a known
external purpose [4]. Resnick [5] described three types of
malingering: (1) pure malingering in which the individual
falsifies all symptoms; (2) partial malingering in which an
individual has symptoms but exaggerates the impact they have
on daily life; and (3) false imputation in which the individual
has valid symptoms but is dishonest as to the source of the
problems. Other forms of malingering are simulation in which
a person emulates symptoms of a specific disability and
dissimulation in which the patient denies the existence of
problems that would account for the symptoms (eg, drug abuse).
Historically, the Roman physician, Galen, presented the earliest
evidence of malingering in the second century AD. One patient
pretended to suffer from colic in order to avoid a public meeting
and another faked a knee injury in order to remain home while
his master took a long journey [6]. Causes of malingering vary.
Although the malingering individual is seeking tangible gains,
such as time away from work or avoiding an activity, the
underlying motivation differs [3].
Malingering was widespread throughout Russia during the early
1950s because people sought to escape sanctions or coercion
[7]. Russian physicians were limited by the state to only four
medical dispensations. Patients were identified as: (1) needing
medical care, (2) thinking they needed medical care, (3) faking,
or (4) making direct pleas for medical dispensation. Low social
trust is exhibited when certain ethnic groups have low trust in
health care as an institution because of historical oppression
and deception of their cultural group [8]. The early dependence
upon doctors by poor Russian laborers has been said to have
altered the doctor-patient relationship to one of mutual mistrust
and deception [7]. If an individual patient trusts their doctor
because the doctor has been assessed as trustworthy over time,
this is an example of interpersonal trust. Recent health care
literature has explored the role of patients’ trust in patient
behaviors such as adhering to medical advice, malpractice
litigation [9], and seeking health care services [10]. Some
researchers believe that recent changes in health care practices
are undermining the trust relationship between patients and
physicians [11], with particular emphasis on the fact that
technology is replacing the human element in medical practice
thereby reducing patient’s trust in physicians [9]. Trust has been
defined as a feeling (often based on inconclusive evidence) of
certainty that a person or a thing will not fail [12]. There are
several trust relationships. The three trust relationships relevant
to this discussion are: (1) interpersonal trust defined as a
human’s trust with another human whether face-to-face or
through a device; (2) social trust defined as a human’s trust
with a system or institution; and (3) trust in automation defined
as a human’s trust with technology or a device.
There are no quantifiable numbers on how many people might
misuse the Internet to abuse trust relationships, but many
researchers have shown how the Internet lends itself to deception
[3]. People might malinger online for external incentives, such
as money or gifts, but fraud is usually the principle motivation
[4]. Within the medical arena, the Internet offers anonymous
access to vast amounts of information on illnesses and support
groups for rare diseases, opening up opportunities for people
with the urge to pretend they are sick and abuse trust [13].
Factitious Disorder and Munchausen Syndrome
Factitious disorder (FD) is an umbrella category covering a
group of mental disturbances in which patients intentionally
feign physical or mental illness without obvious benefit. Gavin
[14] first described “factitious disease” in 1843. He described
soldiers and seamen who mimicked illness to incite compassion
or attention. The exact incidence of FD is unknown, but studies
suggest that approximately 9% of hospitalized patients on
specialty services in tertiary care have FD [15]. Modern study
began in 1951 with an article by Asher [1], who coined the term
“Munchausen syndrome” to describe a subtype of FD. The name
came from a German baron who liked to embellish stories of
his military exploits to impress listeners. Subsequently, lying
and Munchausen were connected in German culture [16]. A
series of patients whose medical histories consisted mainly of
falsehoods and who visited and deceived hospitals and doctors
have been described in the medical literature [1].
People with Munchausen syndrome go to incredible lengths to
appear sick or to make themselves sick. For example, a young
woman surreptitiously ingested laxatives to cause diarrhea,
hypokalemia, and weight loss, and another young woman
feigned cancer with the help of fabricated medical records in
order to receive chemotherapy [17]. Those with Munchausen
syndrome who have medical training are especially convincing.
Others read up on diseases so they can mimic symptoms
accurately [18]. Some become so proficient that they can fool
doctors into ordering needless tests and even operations in some
cases. Munchausen syndrome tends to be chronic and people
with it usually become habitual deceivers [19]. Savino and
Fordtran [17] proposed that it was likely that many cases of
factitious cancer were never discovered and predicted that with
advances in computer technology the quality of forged medical
records would improve in the future. This is shown by the recent
case of an individual using medical images obtained from the
Internet to support claims of ankle dislocation [20].
Munchausen Syndrome by Proxy and Fabricated or
Induced Illness
In 1977, Munchausen syndrome by proxy (MSP)—also known
as factitious disorder by proxy—was first described by Meadow
[2]. One mother had poisoned her toddler with excessive
quantities of salt and another mother had introduced her own
blood into her baby’s urine sample. MSP refers to a parent or
other adult caretaker who repeatedly seeks medical attention
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for their children, whose symptoms they have faked or induced,
sometimes causing real harm to the child, and/or subjecting
them to unnecessary investigations and interventions. Many
hypotheses have been proposed to explain MSP. Some have
noted that patients with the condition often present traumatic
events—particularly abuse and deprivation and numerous
hospitalizations in childhood—and as adults may have lacked
support from family and friends. Others consider that it allows
patients to feel in control as they never felt in childhood [21].
Savino and Fordtran suggested that it might represent the
patient’s attempt to cope with emotional distress [17].
In the United Kingdom, MSP is now termed “fabricated or
induced illness” (FII) [22], although MSP is still widely used
in other countries. The British Paediatric Surveillance Unit
(BPSU) carried out a study of FII cases and identified 97 cases
in the United Kingdom over a two-year period. This equated to
1 child in every 5000 being affected by FII, but it is likely that
this figure underestimates the true scale of the problem. Another
study estimates that the number of children affected by FII could
be as high as 1 in 1100 [22].
Munchausen by Internet and Munchausen by Proxy by
Internet
In 1983, the case of “Joan and Alex” shocked users of a CB
radio channel of the national network, CompuServe, when a
male psychologist (Alex) masqueraded as a disabled woman
(Joan) in an attempt to use the trust and intimacy attained in the
online interactions for his own social gain [23]. In 2000,
Munchausen by Internet was identified by Feldman [3] to
describe an individual seeking attention by playing out a series
of dramatic near-fatal illnesses and recoveries that increasingly
strain credulity. A Google search for the term yields more than
7000 search results. There is also an extensive Wikipedia entry
[24] that has been revised 285 times since its creation in
2007—an average of 61.5 edits per year—suggesting that the
term has now comfortably entered the online vernacular of
Internet users. Munchausen by Internet can have devastating
effects within online discussion groups, destroying trust when
the hoax is exposed [3]. The virtual communities that were
created to give support, as well as general non-medical
communities, often express genuine sympathy and grief for the
purported victims. However, when fabrications are suspected
or confirmed the ensuing discussion can create schisms,
destroying some communities and altering the trusting nature
of members in others.
As yet, Munchausen by Internet has not been officially
recognized by the American Psychiatric Association in the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV). The DSM-5 is currently in review, but makes no
mention of Munchausen by Internet although FD is listed in
two proposed subtypes: (1) factitious disorder imposed on self
and (2) factitious disorder imposed on another. However, these
entries make no reference to the Internet in the diagnoses [25].
A generic search on the DSM-5 review website for the term
“Internet” locates one relevant mention in illness anxiety
disorder under somatic symptom disorders, but this does not
mention FD. One of the diagnostic criteria is that the person
“performs related excessive behaviors (eg, checking one’s body
for signs of illness, repeatedly seeking information and
reassurance from the Internet or other sources)...” [26]. The
DSM-5 review proposes minor modifications to factitious
disorders under the umbrella of somatic symptom disorders in
their own chapter. The most important modification is the
elimination of the distinction between factitious disorders
involving predominantly physical versus psychological
symptoms. Also, factitious disorder by proxy is now termed
“factitious disorder imposed on another” [25], with the
perpetrator receiving the diagnosis, not the victim.
New cases of Munchausen by Internet are identified regularly.
Recent examples demonstrate the versatility of using online
formats for FD, including the adoption of multiple personae
and the substantial time and effort expended to contrive complex
and dramatic fake identities and conditions [27]. One case
documented a brother-sister dyad who created an elaborate
narrative to lure a woman into providing time and attention
under false pretences. Elizabeth, the victim, had multiple
sclerosis and was seeking online support through a social
networking website hoping to connect with others coping with
chronic illness [27]. In another case, after being diagnosed with
a chronic illness, Helen sought to better understand her rare
condition by turning to Internet resources for more information
[27]. Her research led her to discover an online support
community and she joined a support group designed specifically
for people with her disease. Helen created a number of fake
personae: “Isabelle” (Helen’s good friend), “Justin” (her
boyfriend), and Justin’s father and sister to carry on the story
after “Justin” passed away. Helen also fabricated two other
storylines including one that featured an ailing mother who had
tragically lost two children to illness. Another case concerned
a 44-year-old woman who said she had been diagnosed with
chronic myeloid leukemia. Had the documents presented by her
not aroused suspicion, she would have undergone a bone marrow
aspirate and chemotherapy [28].
Munchausen by Internet has also expanded to MSP on the
Internet [29]. In 2009, Emily McDonald was arrested for injuring
her daughter, Dakota, who had been in and out of hospital since
her premature birth. When Dakota did not recover in hospital
and her blood cultures showed odd results, staff became
suspicious and set up a camera in her hospital room. On video,
they caught McDonald putting fecal matter into Dakota’s
feeding tube. McDonald’s case appeared to be MSP; however,
she was also posting about her daughter and her illness on her
own blog (no longer publically accessible). Although not
diagnosed with MSP, she admitted to second-degree injury to
a child and was sentenced to 20 years in jail [30].
Munchausen by Internet
Negative Impact from Health-Related Online Support
Debate has intensified on how the increasing use of Web
technology might have a negative impact on patients, caregivers,
and practitioners. For example, there can be a high ratio of false
or irrelevant information compared to useful information on the
Web. Eysenbach et al [31] systematically reviewed studies of
health website evaluations and found that the most frequently
used quality criteria included accuracy, completeness, and
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technical criteria related to site design (eg, visual appeal, layout,
and readability). In their review, the authors noted that in 70%
of the studies they had examined, the quality of health-related
Web content was found to be low according to the authors of
the reviewed studies. The incidence of false data in online
self-help groups is unknown, although assumed to be high
because of the absence of group rules and guidelines and few
controls to prevent people from posting erroneous or off-topic
information. Joinson [32] noted that the format of a childcare
email list, which seemingly encouraged venting and the name
calling of parents and children amidst unconditional support of
other caregivers, created an environment which led to the
acceptance of practices that were not child-centered and were
potentially damaging to the children. This was because the
legitimization of negative attitudes and approaches could have
led to the continuation of these behaviors. The online
“pro-anorexia” underground is a movement that supports those
with anorexia and adopts an anti-recovery perspective on the
disease [33]. While encouraging a non-healthy diet to sustain
an anorexic lifestyle, the movement also recommends the radical
use of weight-loss pharmaceuticals—conventionally used to
treat obesity—to pursue and maintain low body weight. There
are similar movements in other online disease communities,
such as supporters of chronic fatigue syndrome who advise
abundant rest and avoidance of activity for sufferers, which is
in direct opposition to medical advice [34]. Finally, the Internet
may also play a major role in the development and spread of
beliefs that are unsupported by scientific evidence. For example,
the spread of information about Morgellons disease on the
Internet has led to several cases of delusional parasitosis [35].
In response, Vila-Rodriguez and MacEwan [36] recommended
in a letter to the American Journal of Psychiatry that an
awareness of the capacity of the Internet to enable and spread
shared delusional ideation was essential to current medical
practice.
Review of Recent Munchausen by Internet Literature
We conducted a review of Munchausen by Internet literature
over the previous two years by using both academic and social
media sources. Searches using the term “Munchausen by
Internet” were conducted on both PubMed and Google Scholar.
In 2012, there were 8 published articles listed on Google
Scholar, but none were relevant because they either contained
citations which referred to old research or had no specific link
between Munchausen syndrome and the Internet. The Technorati
search engine was used in addition to search the blogosphere
for recent blog postings or blogs on the terms “Munchausen by
Internet” and “Munchausen” generated during the first half of
2012, but no relevant blogs or posts were identified.
Motivation
Because many instances of Munchausen by Internet take place
in a group situation, social psychology offers a number of
theories that can be applied to explain this type of online
behavior. Drawing on disinhibition theory, Suler [37]
highlighted two features of the Internet that made deception
easier: (1) asynchronicity allows a dynamic approach to identity
presentation and enables quick changes between identities and
styles, and (2) the lack of feedback and the anonymity or
unfamiliarity of the audience can reduce concern for others’
views. Similarly, Taylor and MacDonald [38] applied the
theories of de-individuation and social identity to explain more
uninhibited behavior and more self-disclosure in some online
settings. Drawing on motivations for deception and group
effects, Mealy et al [39] found that lies motivated by a desire
to benefit others were considered to be more acceptable than
lies that primarily benefited the self. Additionally, lying to the
out-group (the social group to which someone does not identify)
was perceived as being more acceptable than lying to the
in-group (the social group to which someone psychologically
identifies themselves with as a member).
Other areas of psychology offer theories of relevance, for
example those relating to self-presentation and identity.
Research has shown a link between low self-esteem and the
need for popularity to the way individuals manipulate
relationships and the way they perceive others’ online
relationships [40]. Walther [41] noted there is a propensity for
disinhibition, projection, and transference, wherein there are no
visual or auditory inputs that can place the text in its proper
context or assist the correct interpretation of that text. People
fill in the missing pieces in the picture of others they meet
online, not fully aware that the picture they are forming is based
partly on their own unconscious desires regarding who they
want that person to be and how they want them to act. This
occurs at the same time as the person is taking advantage of the
anonymity inherent in text-only communications to present their
best possible face. A feedback loop can arise as these selective
presentations are responded to in-kind, creating a hyperpersonal
aspect to Internet communications. The Hyperpersonal Model
[42] proposes that the Internet affects three parts of the
communication process. These can be applied to understand
the way in which Munchausen by Internet users manipulate the
Internet to manage impressions and also to explain how others
make interpersonal impressions based on that information. The
three parts of the communication process are:
1. Receivers who have an idealized perception of the message
sender because subtle context cues take on a stronger value in
online communication. An absence of face-to-face cues means
that receivers may be acutely sensitive to any subtle social or
personality cues, so partners build impressions of one another
based upon minimal cues.
2. Message senders have a greater opportunity to optimize their
self-presentation to others and themselves.
3. The asynchronous channel allows more time for senders and
receivers to consider the messages they send and receive, so
that only using text can create an idealized picture.
It is possible that some Munchausen by Internet sufferers could
be driven by the simple enjoyment of online deception as
highlighted by a study of Web users that found that most online
deceivers felt a sense of enjoyment while engaging in online
deception [43]. In 1999, a columnist was introduced in the UK
newspaper, The Observer, following his aborted suicide attempt
and detailing the columnist’s last few months before he killed
himself [44]. After protest, it was revealed that the column was
a spoof. Chris Morris, an innovative but controversial British
broadcaster, wrote the columns that highlighted the inherent
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cruel, dark comedy of fooling gullible members of the public
with stories of fake medical conditions. This willingness of
broadsheet media to embrace and portray a borderline style of
comedy can have unpleasant outcomes within an Internet
environment. One clue might lie in the power granted by online
communities to quantify the sympathy for an illness or the shock
of a death through comments boxes or replies to a journal thread
[13]. During a lengthy battle against terminal illness, blog
writers can attract support from thousands of friends who follow
them through treatments and who become emotionally involved
when they die. In more than one example, bereaved online
friends have created tribute websites where they have posted
poetry and photographs in memorial books. This can feed the
desire of a narcissist and as they create an imaginary online
long-term condition leading to a fake death, can provide a lonely
individual with attention that they may never have previously
known. This view is supported by Feldman [3], who linked the
engaging and intense nature of these deceptions to sadism. This
motivation can be seen to be at both intrapersonal (sadistic) and
interpersonal (attention) levels.
Stokes [45] argued that online social networks offer more
methods to manage the impressions of others than are available
through structured websites. He referred to a study that found
Facebook users’identities were not the identities that they had
established in the offline world, nor were they close to the
identities that they had constructed in other anonymous online
environments. They were the hoped-for possible identities users
wanted to have in the offline world, but had not yet been able
to establish.
There is little research regarding the psychology of Munchausen
by Internet, but there are indications that some online
self-presentation may be motivated by narcissistic or sadistic
tendencies, as is the case with FD. In one analysis of patients
with FD, it was found that 9 patients (50%) had borderline
personality disorder, 6 (33%) had narcissistic personality
disorder, and only 3 patients (17%) did not demonstrate
coexisting self-pathology [15]. A study of Internet dating sites
by Ellison et al [46] found that people acted differently in social
networking environments depending on whether or not they
were interacting anonymously. This finding has important
implications for understanding identity in the online world
because it indicates that online self-presentation varies according
to the nature of the online setting. Oltmanns [47] described
narcissism as a pervasive pattern of grandiosity, a need for
admiration, and an exaggerated sense of self-importance.
Mehdizadeh [48] associated the term with positive self-views
of agentic traits, including intelligence, physical attractiveness,
and power. Central to most theoretical models of narcissism,
the use of social relationships is employed to regulate narcissistic
esteem. However, narcissists do not focus on interpersonal
intimacy, warmth, or other positive aspects of relational
outcomes. Instead, they use relationships to appear popular and
successful, and they seek attractive, high-status individuals as
romantic partners [49]. Despite their tendency to seek out many
superficial, empty relationships, narcissists rarely pursue these
commitments for long periods of time. Relationships are pursued
solely when an opportunity for public glory presents itself [49].
Netiquette and Trolls
The aspect of Munchausen by Internet where individuals
actively seek to disrupt and cause problems for their own
satisfaction or enjoyment (sadism versus narcissism) has until
now not been consciously associated with the wider phenomena
of Internet “trolls.” We believe that this connection should be
formally acknowledged to assist in controlling, effectively
identifying, and minimizing the growth of this behavior as more
people seek reassurance and support about their health in an
online environment. Netiquette (short for “network etiquette”)
is the dos and don’ts of online communication covering common
courtesy online and the informal “rules of the road” of
cyberspace [50]. A troll is someone who posts or sends messages
online with the intention of annoying someone or disrupting a
discussion or environment [51]. The practice of trolling has
been compared to the fishing term in which a line is set in the
water and the bait is dragged slowly back and forth in the hope
of getting a bite [52].
Donath [52] outlined the ambiguity of identity in a disembodied
virtual community and provided a concise overview of identity
deception games, which trade on the confusion between physical
and epistemic communities. Trolling has been portrayed
disdainfully in mainstream media outlets, often referencing the
willingness of some Internet trolls to go to extreme lengths in
their attempts to elicit reactions. In 2010, the Australian
government became involved after trolls defaced the Facebook
tribute pages of two murdered children. The Australian Minister
of Communications decried the attacks as evidence of the need
for greater Internet regulation [53]. In the wake of these events,
Facebook responded by strongly urging administrators to be
aware of ways to ban users and remove inappropriate content
from Facebook pages. It is recommended that ignoring a troll
is almost always the best approach, because if nobody responds
the troll will eventually get bored and go away [51]. Experienced
participants in online forums know that responding tends to
encourage trolls to continue disruptive postings—hence the
oft-seen warning, “do not feed the troll” (DNFTT). However,
experts tend to inhabit the tougher, streetwise environs of
Internet technical or film forums rather than in the supportive
and empathetic environment of an online health support group,
which can cause more of a shock when Munchausen by Internet
trolls are unmasked.
Opportunity
Recupero [54] highlighted instances of psychiatric patients
engaged in impression management to influence the outcomes
of psychiatric interviews [55]. Impression management also
plays an important role in online conversations. Barak [56]
believes that many Internet users prefer others to perceive and
interact with an online persona and that material chosen to post
online can help to deepen a preferred social impression.
Conversely, profiles posted on social networking sites (eg,
Facebook) may contain information contradicting the evaluee’s
intended impression. Photographs, perhaps artificially
composed, and other material can be posted and tagged online
showing a person’s name or identity without their knowledge
or permission regardless of whether the person is familiar with
or naïve about Internet influence. Similarly, records of negative
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behavior can remain online for years becoming part of an
individual’s digital footprint [57].
Computers allow people with sufficient technical skills to access
medical records and use them to falsify medical histories [20],
while the open trusting environments of communication
forums—established for the sole purpose of giving support to
members facing significant health or psychological
problems—are easily infiltrated because of the social nature of
the groups. This is an endemic problem with online
communication as the Internet helps to break down the physical
barriers that assist in preventing the spread of lies [58]. The
proliferation of newsgroups and chat rooms offers a limitless
audience for fake narratives with people able to move from one
support group to another [18]. Some, pretending to be ill, have
joined more than one, and some might sign on to a single group
multiple times by using different names and acting out different
roles. A sock puppet is an online identity used for purposes of
deception. The term, a reference to the manipulation of a hand
puppet made from a sock, originally referred to a false identity
assumed by a member of an Internet community who spoke to,
or about, himself while pretending to be another person, but it
now includes other uses of misleading online identities, such
as those created to praise, defend, or support a third party [59].
The development of FD in online groups and forums is made
easier by the anonymous and malleable nature of online identity
along with easy access to the Internet, which allows sock
puppets to thrive without any negative consequences to
themselves. For example, Andrea, a 40-year-old single mother,
began posting on an ovarian cancer forum that she had concerns
over her worsening abdominal pain. Shortly after joining the
forum, Andrea announced that she had been diagnosed with
ovarian cancer. After being confronted by suspicious group
members, Andrea confessed to her deception and the use of
sock puppets. In addition to playing herself during her illness
and online death, she had posed as her daughter “Brittney” and
her daughter’s boyfriend “Chris” [27].
Detection
Although some Munchausen by Internet perpetrators display a
remarkable degree of research and endurance, able to stretch
the fiction over many months, even the most dedicated can slip
up eventually. Outwardly, there might not be any clues to
suggest that they are anything other than normal support group
members, but slight details can introduce contradictions and,
although anyone caught up in the deception may be willing to
forgive a slight oversight, some are more methodical. They are
prepared to investigate so that few contradictions will escape
over time. Savino and Fordtran [17] suggested that diagnosis
of factitious cancer is usually made by detection of
inconsistencies in medical history, by evidence of fabrication
of medical records, by lies patients tell about their health
insurance, or by doctors who begin to doubt the patient’s story.
A story of prolonged survival with a usually lethal cancer has
helped reveal factitious cancer in some cases. Based on his
experience with Munchausen by Internet, Feldman [3] listed
some methods of detection:
1. Posts consistently duplicating material in other posts, books,
or health-related websites.
2. Characteristics of the supposed illness emerging as
caricatures.
3. Near-fatal bouts of illness alternating with miraculous
recoveries.
4. Fantastical claims, contradicted by subsequent posts, or flatly
disproved.
5. Continual dramatic events in the person's life, especially when
other group members have become the focus of attention.
6. Feigned blitheness about crises that will predictably attract
immediate attention.
7. Others apparently posting on behalf of the individual having
identical patterns of writing.
Griffiths et al [20] recommended that all clinicians question
histories that did not match examination findings, ensuring that
all radiographs were adequately labeled with patient-specific
information, and being aware of radiographic inconsistencies.
There are several strategies commonly employed in confronting
FD. In one case series, patients were carefully confronted with
the factitious nature of their illness. Although 13 of the 33
(approximately 39%) admitted feigning illness, most of the
patients’ illnesses improved following this strategic
confrontation [15]. In most cases, group members’ discovery
of Munchausen by Internet can lead to a similar strategic
confrontation [3,27] with the typical response being a protest
of innocence and an allegation of mistreatment by the group,
followed by disappearance [3]. Due to the elusive nature of
online identities, most wronged group members are unable to
pursue the fakers. Many either lock their journals so that only
their friends can access them, or else purge them entirely and
deny the fraud. Suspicious group members are sometimes able
to take screenshots as evidence of the fraud, but many
perpetrators slip away, either sufficiently chastened to stop the
deceptions or to simply reappear in another online group.
Effects and Consequences
The Munchausen by Internet troll can be costly in several ways.
A troll can disrupt the discussion on a newsgroup, disseminate
bad advice, and damage the feeling of trust in a Web community.
Furthermore, in a group that has become sensitive to
trolling—where the rate of deception is high—some honest but
naïve question can be quickly rejected as trolling. This can be
off-putting to a new user who is immediately bombarded with
accusations when venturing a first post. Even if an accusation
is unfounded, being branded as a troll can be damaging to an
online reputation. Herring et al [60] discussed the difficulty
inherent in monitoring trolling and maintaining freedom of
speech in online communities, concluding that inevitably
harassment was more likely to occur in environments where
lack of censure was a key factor. In wider discussion forums,
the broadly accepted ethic of free speech may lead to tolerance
of trolling behavior, further complicating the members’efforts
to maintain an open-yet-supportive discussion area, especially
for sensitive topics. Reactions from Internet forums have been
critical of media portrayals of trolls, stating that trolling is
nothing new and has become part of accepted Internet culture.
While not condoning the viciousness of troll attacks, forum
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discussions regularly express concern that mainstream media
coverage of trolling ultimately results in more trolling because
widespread attention represents the reaction that trolls seek.
However, in the insular, empathic environment of a support
group, the reaction can be more severe. Grady [18] detailed the
case of a 15-year-old girl who communicated with members of
a virtual support group for parents of babies who were critically
ill. Kim claimed to have a baby requiring treatment and as she
detailed the timeline of her baby’s treatment, other members of
the group became personally involved and were devastated
when she said her baby had died. Subsequently, she appeared
online saying she was pregnant again and that she feared the
second baby would be born prematurely. After the early birth
of her second baby, the same cycle was reenacted, but this time
a group member (a psychologist and the mother of twins born
prematurely) gradually became suspicious. She confronted Kim,
who subsequently posted a confession and apology. Kim
withdrew from the group and was taken off the list by its owner,
but her behavior had a negative effect on a group who had been
trusting and close-knit until then [18]. Some parents expressed
feelings of betrayal, and many stopped posting messages. People
in the group agreed to provide information so that a coordinator
could verify they were really parents of premature babies. Some
new participants were put off by the atmosphere of suspicion,
but the group gradually bounced back. However, those who
encountered Kim would obviously never view new postings in
quite the same way again.
Application of the term “troll” is highly subjective. Some readers
may characterize a post as trolling, whereas others might regard
the same post as a legitimate discussion contribution, even if
controversial. Sometimes the term is used as a strategy to
discredit an opposing position by attacking its proponent. Calling
someone a troll makes assumptions about a writer’s motives.
Regardless of the circumstances, controversial posts may attract
a particularly strong response from those unfamiliar with the
robust dialogue found in some online, rather than physical,
communities. The popularity of Facebook means strangers can
often build and maintain relationships entirely on the Internet.
This anonymity permits any number of lies to be accepted as
truth, and inventive deceptions, with whatever motive, can be
carried all the way to an online grave. However, there is also
the potential danger that overzealous group members might
make the erroneous assumption that every death encountered
online is fake. Most social network sites now allow relatives of
deceased users to choose to keep profiles online as a memorial,
allowing users to post tributes and messages, sometimes
speaking of the dead in the third person, sometimes in the second
person. In effect, a profile site is converted into a tribute site, a
space of commemoration—a sort of open-ended electronic wake
[45]. In the case of a real death, it can be just as harrowing for
the bereaved to read comments claiming that the death has been
faked.
Conclusions
More research is required to be able to provide evidence-based
advice to victims of suspected Munchausen by Internet trolls
and for facilitators of discussion groups to effectively manage
interactions. As this is one area of the literature that does not
yet yield much information, one methodology that could
possibly be adopted for further study is based on qualitative
content analysis (QCA), which is gaining much support in
studies of social interactions in online support communities
[61]. QCA provides a way to study manifest and latent content
within a body of text. Analysis of what the text says describes
the visible components, referred to as the manifest content.
Analysis of what the text talks about involves interpreting the
underlying meaning of the text, referred to as the latent content.
Therefore, manifest content might highlight descriptions of
illnesses, while latent content could include descriptions of
feelings of sufferers and the context of an illness. The manifest
content is usually presented in categories, whereas the latent
content is expressed as themes. QCA differs from pure
qualitative research as it allows the researcher to emphasize
differences between and similarities within codes and categories.
Therefore, it could be used to differentiate types of Munchausen
by Internet and its different motives.
When Munchausen by Internet seems likely, it might be practical
to have some established group members gently question any
dubious post owner privately. Although the typical response is
vehement denial regardless of the strength of the evidence, the
author typically will disappear from the group. In some
Munchausen by Internet cases, much like FD cases, individuals
can be both perpetrators and patients. For example, the
previously described case of Helen who was diagnosed with a
chronic illness and went on to create a number of fake personae
[27]. Savino and Fordtran [17] suggested some useful steps for
confronting patients suspected of FD:
1. Let the patient know what you suspect but without outright
accusation.
2. Support the suspicion with facts.
3. Provide empathetic and face-saving comments.
4. Avoid probing to uncover the patient's underlying feelings
and motivations so as to minimize disruption of emotional
defences that are essential to her function.
5. Assure the patient that only those who need to know will be
informed of the suspicion of factitious disease.
6. Make sure the staff demonstrate continued acceptance of the
patient as a person worthy of their help.
7. Encourage psychiatric help, but if the patient resists do not
force the issue.
However, once a perpetrator has been confronted, remaining
members of the online group may need psychological help at
an individual or group level depending on the extent of the
deception and the health topic concerned. For example,
individuals may need help in processing their feelings. As a
group, help could be directed toward dealing with conflict and
blame, and moving forward to refocus the group on its original
goals with the aim of protecting and encouraging the original
sense of trust. As Whitworth and de Moor [62] suggest, laws
in a physical community are expressed in terms of physical
actions and concrete objects that govern what people do, not
what they think or feel. Historical law assumes a physical world
constrained by time and space, but virtual environments have
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significantly different functionality. This means the virtual world
is a functionally different world; it may not be appropriate, or
even possible, to transfer laws from the physical to the electronic
world. Therefore, laws must be re-invented by re-applying
legitimacy concepts to virtual contexts such as formulating
direct policy to protect health information users in the new world
of Internet-based health searching and support. Legal sanctions
have yielded some results in controlling the “acting out” of
Munchausen’s syndrome, but the literature suggests that such
measures are ineffective and can sometimes even reinforce bad
behavior [63]. It is suggested that the best results within a
physician-patient relationship can be achieved by approaching
the dilemma from diverse angles [28].
Historically, the consequences for perpetrators have tended to
be minor because few can be pursued or punished unless the
wronged individuals are able to prove that the perpetrators have
committed an illegal act. However, a 2005 legal case concerning
self-help members pursuing an online campaign against a
Munchausen by Internet member who challenged posts as
defamatory suggests that wronged individuals are able to
respond without fear of successful legal reprisal. They might
also be able to win a precedent-setting civil case [64]. Indeed,
there is a strong case for considering the sadistic misuse of
health-related forums as a form of cybercrime, rather than as
an everyday negative risk of using the Internet that must be
tolerated and accepted. Consider if a malicious user deliberately
(or accidentally) gave out medical information that resulted in
a worsening of health or had fatal consequences. Internet
protocol (IP) addresses of Munchausen by Internet trolls could
be identified and Internet service providers (ISPs) could be
enlisted to help identify and “out” frequent perpetrators such
as been seen in recent online copyright disputes. Social network
providers, such as Facebook, should tighten up their own
procedures or, as an alternative, group users might want to
consider relocating to more private group-based Internet
communities, such as private Wikis [51]. Although these do not
have the same large population of users, they might increase
the security and lessen the chance of encountering a Munchausen
by Internet troll online.
Enhanced self-regulation is the most positive action to reduce
group risk. It might also be advisable for a health support group
to identify a gatekeeper. Although adding extra layers of security
and formality before a user could post might be viewed as
onerous, the long-term benefits might be worth the additional
effort. Facilitators could also clearly state to all members that
although most people participating in support groups are honest,
all members should balance their empathy with some degree of
circumspection. Group members should be especially careful
about basing any of their own health care decisions on
uncorroborated information supplied in groups, just as they
should with any other source on the Internet [65].
We have reviewed potential motivations and consequences for
Munchausen by Internet behaviors, but it is clear that further
research is necessary to investigate the psychology and methods
of coping with Munchausen by Internet. However, there is a
clear, compelling need to recognize that in addition to
Munchausen by Internet being classed as a condition in its own
right, there is a subset of people currently tagged as Munchausen
by Internet sufferers who are actually Munchausen by Internet
trolls purposefully harming well-intentioned support groups
and abusing members for their own pleasure or enjoyment. We
propose that Munchausen by Internet and Munchausen by
Internet trolling be formally acknowledged in a revised version
of DSM-5 (within the factitious disorder revisions), and that
this sphere of behavior needs wider consideration and action,
either by group users or by the creators of the host software. As
Berners-Lee [66] said, “Technologists cannot simply leave the
social and ethical questions to other people, because the
technology directly affects these matters.”
Acknowledgments
Publication was made possible by funding from the Bournemouth University Open-Access Publishing Fund (OAPF).
Authors' Contributions
All of the authors are responsible and qualified for the reported research. They have all participated in the concept and design,
analysis, and interpretation of data, and drafting and revision of the manuscript and approve the manuscript as submitted.
Conflicts of Interest
None declared.
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Abbreviations
BPSU: British Paediatric Surveillance Unit
DNFTT: Do not feed the troll
FD: factitious disorder
FII: fabricated or induced illness
IP: Internet protocol
ISP: Internet service provider
MSP: Munchausen syndrome by proxy
QCA: qualitative content analysis
Edited by G Eysenbach; submitted 22.11.11; peer-reviewed by PM Whitty, T Buchanen, M Feldman; comments to author 16.12.11;
revised version received 06.03.12; accepted 15.06.12; published 22.08.12
Please cite as:
Pulman A, Taylor J
Munchausen by Internet: Current Research and Future Directions
J Med Internet Res 2012;14(4):e115
URL: http://www.jmir.org/2012/4/e115/
doi:10.2196/jmir.2011
PMID:22914203
©Andy Pulman, Jacqui Taylor. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 22.08.2012.
This is an open-access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic
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J Med Internet Res 2012 | vol. 14 | iss. 4 | e115 | p.11http://www.jmir.org/2012/4/e115/ (page number not for citation purposes)
Pulman & TaylorJOURNAL OF MEDICAL INTERNET RESEARCH
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