Münchausen by Internet

Münchausen by Internet is a pattern of behavior in which Internet users seek attention by feigning illnesses in online venues such as chat rooms, message boards, and Internet Relay Chat (IRC). It has been described in medical literature as a manifestation of factitious disorder or factitious disorder by proxy. Reports of users who deceive Internet forum participants by portraying themselves as gravely ill or as victims of violence first appeared in the 1990s due to the relative newness of Internet communications. The pattern was identified in 1998 by psychiatrist Marc Feldman, who created the term "Münchausen by Internet" in 2000. It is not included in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

The development of factitious disorders in online venues is made easier by the availability of medical literature on the Internet, the anonymous and malleable nature of online identities, and the existence of communication forums established for the sole purpose of giving support to members facing significant health or psychological problems. Several high-profile cases have demonstrated behavior patterns which are common among those who pose as gravely ill, victims of violence, or whose deaths are announced to online forums. The virtual communities which were created to give support, as well as general non-medical communities, often express genuine sympathy and grief for the purported victims. When fabrications are suspected or confirmed, the ensuing discussion can create schisms in online communities, destroying some and altering the trusting nature of individual members in others.

Characteristics
The term "Münchausen by Internet" was first used in an article published in the Southern Medical Journal written by Marc Feldman in 2000. Feldman, a clinical professor of psychiatry at the University of Alabama at Birmingham, gave a name to the phenomenon in 2000, but he co-authored an article on the topic two years earlier in the Western Journal of Medicine, using the description "virtual factitious disorder". Factitious disorders are described in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (DSM) as psychological disorders involving the production of non-existent physical or psychological ailments to earn sympathy. These illnesses are feigned not for monetary gain or to avoid inconvenient situations, but to attract compassion or to control others. Chronic manifestation of factitious disorder is often called Münchausen syndrome, after a book about the exaggerated accounts of the adventures of Baron Münchhausen, a German cavalry officer in the Russian Army, that was written by Rudolf Erich Raspe. When another person's symptoms are caused, such as a child or an elderly parent's, it is called factitious disorder by proxy, or Münchausen syndrome by proxy.

Feldman noted that the advent of online support groups, combined with access to vast stores of medical information, were being abused by individuals seeking to gain sympathy by relating a series of harrowing medical or psychological problems that defy comprehension. Communication forums specializing in medical or psychological recovery were established to give lay users support in navigating often confusing and frustrating medical processes and bureaucracy. Communities often formed on those forums, with the goal of sharing information to help other members. Medical websites also became common, giving lay users access to literature in a way that was accessible to those without specific medical training. As Internet communication grew in popularity, users began to forgo the doctors and hospitals often consulted for medical advice. Frequenting virtual communities that have experience with a medical problem, Feldman notes, is easier than going through the physical pain or illness that would be necessary before visiting a doctor to get the attention sought. By pretending to be gravely ill, Internet users can gain sympathy from a group whose sole reason for existence is support. Health care professionals, with their limited time, greater medical knowledge, and tendency to be more skeptical in their diagnoses, may be less likely to provide that support.

People who demonstrate factitious disorders often claim to have physical ailments or be recovering from the consequences of stalking, victimization, harassment, and sexual abuse. Several behaviors present themselves to suggest factors beyond genuine problems. After studying 21 cases of deception, Feldman listed the following common behavior patterns in people who exhibited Münchausen by Internet:
 * Medical literature from websites or textbooks is often duplicated or discussed in great detail.
 * The length and severity of purported physical ailments conflicts with user behavior. Feldman uses the example of someone posting in considerable detail about being in septic shock, when such a possibility is extremely unlikely.
 * Symptoms of ailments may be exaggerated as they correspond to a user's misunderstanding of the nature of an illness.
 * Grave situations and increasingly critical prognoses are interspersed with "miraculous" recoveries.
 * A user's posts eventually reveal contradictory information or claims that are implausible: for example, other users of a forum may find that a user has been divulging contradictory information about occurrence or length of hospital visits.
 * When attention and sympathy decreases to focus on other members of the group, a user may announce that other dire events have transpired, including the illness or death of a close family member.
 * When faced with insufficient expressions of attention or sympathy, a forum member claims this as a cause that symptoms worsen or do not improve.
 * A user resists contact beyond the Internet, by telephone or personal visit, often claiming bizarre reasons for not being able to accept such contact.
 * Further emergencies are described with inappropriate happiness, designed to garner immediate reactions.
 * Other forum members post on behalf of a user, exhibiting identical writing styles, spelling errors, and language idiosyncrasies, suggesting that the user has created fictitious identities to move the conversation in their direction.

Notable cases
Feldman's article in the Western Journal of Medicine was picked up by The New York Times in a story by Denise Grady, who described three cases of Internet forum members who were "incorrigible fakers". These include a woman with a professed eating disorder who posted to a support group saying she was reporting from an intensive care unit via her laptop computer, and claimed to have had a stroke while online, to be followed by her mother's posts declaring that she too had to be hospitalized; the original poster's father purportedly continued to update the online group. In another example, a teenager frequenting a forum for mothers with premature infants—some of whom had endured lengthy, expensive, and painful medical procedures, or had died—claimed to have given birth to a premature baby and expressed her fears for her own child, after which she received support and sympathy from the 400-member group. The teenager confided to the group that her baby had also died, and soon after returned to the forum to announce she was again pregnant and feared her baby would be premature, which it turned out to be, more frail this time than the first. Forum members eventually became unsympathetic with her vivid descriptions of surgeries and confronted her. Grady also addresses a similar confrontation that occurred when a man who claimed to be a monk with end-stage cancer posted long descriptions of his trials and struggles with facing death alone, eventually arousing the suspicions of other forum members who were not convinced someone so sick could correspond with so much vitality.

Some deceptions may take many months to unravel, such as a case that lasted over a year involving a 15-year-old boy participating in an online support group for people enduring debilitating migraine headaches. Some of the group's members had been on disability pension or gone through drug regimens for years to no avail. The boy represented his mother as deaf and his father an alcoholic, and he reported seizures and hemophilia as complicating conditions. However, he also claimed to be a medical student who performed as a drummer in a band. Resources of the forum became constantly directed at the boy, especially when some members expressed doubt about his story. The boy's mother—previously noted by him to be neglectful—logged on to post that questions about his conditions would worsen them; when they did not cease, he left the group, saying the atmosphere violated "the spirit of the internet".

Internet venues unrelated to medical issues have also been the audience for such cases. A member of an online fan club for the musical Rent divulged numerous illnesses that caused her to slip in and out of comas, prompting some cast members to send sympathy cards. When other fan club members expressed their concern, even purchasing airline tickets to visit the sick woman, she reported that she had immediately improved.

From 1999 to 2001 a 40-year-old homemaker named Debbie Swenson perpetrated a ruse under the identity Kaycee Nicole, a 19-year-old woman in Kansas who shared the details of her battles with leukemia online. The Guardian newspaper reported that millions of Internet users read the fictional blog, as well as Swenson's own blog, in which she posed as Kaycee Nicole's mother, describing the trials of living with an intelligent and optimistic daughter who was dying. On May 16, 2001, Kaycee Nicole's death of an aneurysm was announced, shocking her readers and causing them intense grief. Soon however, Swenson caused skepticism in online communities. Although many cards and gifts had been previously sent, she refused to accept more. People began to learn that no one named Kaycee Nicole lived in Kansas, had been enrolled in schools, or admitted to local hospitals, and no obituary had been printed. The photo representing the girl was found to be that of a local basketball player, who was alive. After repeated questioning, Swenson posted that she had woven the stories of three cancer patients to create the character of Kaycee Nicole, who had never existed.

Causes
Feldman has admitted in several interviews that he has been the victim of people who email him to explain psychiatric symptoms, only to divulge eventually that they created it all to fool a doctor. For prolonged cases, he states the impetus for such behavior is the "longing for nurturing, sympathy, care and concern that they feel unable to get in appropriate ways," and that the admiration of forum members is a strong motivator to continue. As manipulation is integral to most cases, the need to control others to feel as if the perpetrator is in control of his or her own life is apparent, as is the pre-existence of underlying personality disorders. Many people who present factitious disorders crave sympathy and support because it was notably absent in childhood. In a story published in The Village Voice in 2001, a woman recovering from factitious disorder remembered her drive to create conditions that did not exist: "When I'd do something to attract the paramedics and police, I got an adrenaline rush. I believe I got addicted to it. At the time, it didn't occur to me I was hurting anyone but myself." A psychologist who was a member of the support group for premature infants stated in The New York Times article, "People who do this need something. I wonder if it's a metaphor for some other loss she experienced and is playing over and over again in different shapes."

Feldman reports that most of the cases of Münchausen by Internet communicated to him come from the United States, although he has corresponded with forum members making inquiries from Australia, Canada, New Zealand and the United Kingdom. Reports parallel manifestations of factitious disorder, peaking between a person's 20s and 30s.

In an article published in The Guardian, Steve Jones, a communications professor at the University of Illinois at Chicago, gave his perspective on the Kaycee Nicole case. Jones credits the anonymity of the Internet for impeding people's abilities to realize when someone is lying: "Given the mutability of identity, how are we to negotiate social relations that, at least in the realm of face-to-face communication, were fixed by recognition of identity?" Online interaction has only been possible since the 1980s, steadily growing over the years. After analyzing several cases of online deception and interaction, social theorists Adam Joinson and Beth Dietz-Uhler write in a 2002 Social Science Computer Review article that deception on the Internet is a paradox: the faceless nature of online communications not only gives opportunity to the unscrupulous and attention-seekers, but also allows earnest users to express themselves more freely, representing a truer version of themselves. Typically, Internet deception takes the form of gender masking or presenting one's own idealized image of oneself. Joinson and Dietz-Uhler cite a chapter in Network and Netplay, in which researchers note the purpose of some forums is to allow their members to participate in a kind of online party, affording chances to pretend and perform: "the type of play on the Internet is usually allowed only in children or adults during masked balls or carnivals". More practical issues such as age, location, marital status, and occupation are also frequently changed online, or left ambiguous to preserve users' privacy or continue identity play.

Discovery and impact on online communities
Forum members whose ruses are discovered by their support groups are frequently banned from such communities—sometimes after demanding that site administrators do so—moving to other websites to display other ailments. Denise Grady noted in The New York Times that the woman with the eating disorder moved to a group for sexual abuse survivors then another where she claimed to be dying of AIDS. An article in The Weekend Australian highlighted an example of this in 2003: a woman in London admitted to belonging to online support forums dedicated to helping members cope with migraines, grieving over dead children, and breast cancer, all at the same time. She told a psychiatrist that she would study a specific malady and subsequently present herself with its symptoms; her time at each forum followed a daily schedule. Others disappear and simply stop posting, such as the monk who claimed to have cancer.

When confronted with inaccuracies or inconsistencies, those who are suspected of perpetrating fabrications may compound the deceit by accusing forum members of imposing greater stresses upon them, exacerbating their conditions, or worsening their depression. Users may employ sockpuppets—separate online identities controlled by the same person—to accuse other forum members of disloyalty and persecution, or support the user who is under suspicion. Feldman's 1998 article in the Western Journal of Medicine notes a case in which a member of a support group for people with Chronic Fatigue Syndrome created a husband, sister-in-law, and family friend who simultaneously engaged in arguments with and about the original member; when the amount of attention directed toward the original member became inadequate, she claimed the sister-in-law committed suicide in response to the lack of support.

Other perpetrators suggest that their lying may actually assist group members, as one member of a Harry Potter fan forum posted following the discovery that she had not, in fact, died of tuberculosis: "After realising the effect my bravery in my illness had on people, I then used it as a vehicle to try and get some of the idiot emo kids on [the forum] to buck up and realise they don't really have it all that bad ... the lie was worth something, wasn't it? How bad is a lie if it helps?"

Because no money is exchanged and laws are rarely broken, there is little legal recourse to take upon discovery of someone faking illness. However, a participant in a 7,000-member online support group brought a lawsuit against a website for defamatory language in 2005. The lawsuit followed heated discussion on the website about his dire predicaments and related crises, which seemed to contradict medical knowledge and his own accounts. The lawsuit was withdrawn after the presiding judge intended to allow cross-examination of the plaintiff's medical history.

Such dramatic situations often polarize online communities, making many members feel ashamed for believing elaborate lies while others remain staunch supporters. Members who admit to feigning their conditions often respond by implicating the gullibility of forum members, suggesting it is their own fault for being deceived. Feldman admits that an element of sadism may be evident in some of the more egregious abuses of trust. A grief counselor named Pam Cohen, who witnessed the outpouring of emotion for Kaycee Nicole, likened the personal devastation resulting from genuine concern, sympathy, and support that forum members gave to the 19-year-old and her mother only to discover none of it was true, to "emotional rape". Joinson and Dietz-Uhler in Social Science Computer Review, address deception perpetrated on some forums—specifically IRC and multi-user dungeons—and state that masquerading is so common that hoaxes are expected, and their perpetrators are sometimes even praised for creating realistic ones.

Other perpetrators react by issuing general accusations of dishonesty to everyone, following the exposure of such fabrications. The support groups themselves often bar discussion about the fraudulent perpetrator, in order to avoid further argument and negativity. Many forums do not recover, splintering or shutting down. In 2004, members of the blog hosting service LiveJournal established a forum dedicated to investigating cases of members of online communities dying—sometimes while online. Writer Howard Swains referred to the online deaths as "pseuicides" in Wired.com. New Zealand PC World Magazine called Münchausen by Internet "cybermunch", and those who posed online "cybermunchers". The LiveJournal forum reported in 2007 that of the deaths reported to them about 10% were real.