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Key points
- Factitious disorder is a deliberate and conscious reporting of symptoms known to be false to receive medical treatment.
- Factitious disorder is a form of somatic symptom disorder.
- Factitious disorder symptoms are not manufactured for practical benefits but rather for psychological gain.
Marc Feldman described a set of behaviours that he termed: Münchausen by Internet. In his article, four case studies were presented, documenting how individuals misused internet-based virtual support groups: “…offering false stories of personal illness or crisis for reasons such as garnering attention, mobilizing sympathy, acting out anger, or controlling others.”1
Although digital resources for support can be helpful, their misuse has become a topic for media discussion and a backlash against those misusing these resources.2 Several high-profile cases of Münchausen have fueled this panic by Internet, such as that of a health blogger, who claimed to have cancer – entirely spuriously – not only misleading individuals about the disease but also collecting large amounts of money in the process.3
However, despite copious media reports and several documented cases in the medical literature, very little is known about Münchausen by Internet, perhaps now better termed digital factitious disorder (DFD). From what we do know, there are differences and similarities between real-world factitious disorder and DFD.
Factitious disorder is one of several conditions listed in the DSM-5 under somatic symptom disorder. These conditions include illness anxiety disorder (hypochondriasis), where people are preoccupied with the thought that they have a serious disease, and conversion disorder (functional neurological symptom disorder) where people report blindness, paralysis, or other neurological symptoms not attributable to a physical cause.
What distinguishes these conditions from factitious disorder is that factitious disorder is a deliberate and conscious reporting of symptoms known to be false to receive medical treatment. Factitious disorder is, in turn, distinguished from malingering (which is not a DSM category), as the latter is aimed at an external reward. In contrast, factitious disorder symptoms are not manufactured for practical benefits but rather for psychological gain.4
Factitious disorder can involve persons producing real physical symptoms in their bodies, although the symptoms can sometimes be feigned. Factitious disorder imposed on another (‘Münchausen by proxy) is when symptoms are created in another person’s body, often a child. The manufactured symptom range is vast, tending to involve symptoms whose real cause is hard to detect and easily produced or feigned – including one fabricated case of Fournier’s gangrene by injecting the scrotum with liquid and air.5
Up to 1 percent of psychiatric referrals have a factitious disorder, although the prevalence in the general population is much lower – about 1/10004.6
Most patients presenting with real-world factitious disorder are young women, about 30 years old, unmarried, but with relatively stable social networks.7 Although men also display it, as above, but typically at a later age of around 40 years.5
The initial onset of real-world Factitious disorder is believed to be about 25 years for both genders.4 The predictors of developing a factious disorder include anxiety or depression, being at risk of a medical condition, stressful and traumatic current life events, and past trauma (such as childhood sexual abuse – often manifest in an attachment disorder).8
Digital factitious disorder came to full media awareness after several headline-grabbing cases, including the health blogger described above.3 Due to its nature, individuals with DFD are unlikely to volunteer for research, so knowledge of DFD is based mainly on case studies (as is the situation for Factitious disorder itself). The case studies of DFD involve similar conditions to those reported in real-world factitious disorder and include: chronic myeloid leukemia,9 intersex conditions,10 and visual problems in a case of media-induced factitious disorder by proxy. 11
A large-scale study analysing postings from 556 people across multiple digital self-help communities noted that 47 percent of respondents had experienced fake reports of pregnancies from others (typically complicated, premature, or miscarrying).12 Astonishingly, 15 percent reported experiencing fake claims of death from others, sometimes of a child (i.e., by proxy), or sometimes of the putative posters themselves (usually by suicide, and usually reported by a sock puppet).
This study noted that those with DFD: “…appear to advantage themselves by occupying 'ideal victim' personae.’”12 It may be a case of If it looks too good to be true, maybe it is. This description resonates with the one given in Feldman’s original report of Münchausen by Internet.1
On the surface, DFD and factious disorder appear highly similar. However, some differences should not be ignored. Factitious disorder is very rare, about 0.1 percent of the population or less,4 but DFD may be much more common. This is a guess based on the high percentage of people reporting such digital experiences12 and comparing real-world and digital lying.
It is estimated that 60 percent of people avoid lying in real life,13 but only half of this number avoid lying on the Internet.14 Many expect lying on the Internet and lie for that very reason (i.e., fit in).12 The very nature of digital communication may be encouraging lying. If the community in question is health-based, then the lie may reflect the nature of what brings that community together. Interestingly, there is an over-representation of health workers displaying factitious disorder in the real world.
Several reasons could underlie any higher prevalence of DFD compared to its real-world counterpart.15 In all the following cases, keep in mind the contrast with a patient trying to fake an illness in a physician’s surgery. The asynchronicity of the digital post and its reading allows concealment of reality, making lying easier – it also has the clear advantage for the would-be Fournier’s faker, for example, of not having to inject their scrotum with sewage.
The anonymity of the digital audience allows quick changes between identities, facilitating a lack of effective feedback or sanction on deceptive actions. Finally, the relative unfamiliarity of the digital audience with the medical conditions being faked may promote ease of deception.
Digital media provide novel opportunities for the expression of Factious Disorder. Many DFD symptoms resemble real-world factitious disorder, but it is too early to say whether they are the same condition. It may be that the properties of digital communication have allowed a mutation of factitious disorder into something more malignant; or maybe a more malignant strain, previously checked by social conventions, has become digitally dominant; or it may be that DFD is a cry for help in the young, who are too scared to discuss their real problems.
Whatever its nature, DFD merits (somewhat ironically) some attention.
References
1. Feldman, M.D. (2000). Munchausen by Internet: detecting factitious illness and crisis on the Internet. Southern Medical Journal, 93(7), 669-672.
2. Shepherd, H. (23.6.21). Is illness appropriation TikTok's most troubling trend? I-d Magazine. Tiktok illness faking trend - i-D (vice.com)
3. Montague, J. (29.4.15). Munchaussen by internet: the sickness bloggers who fake it online. the sickness. The Guardian. Münchausen by internet: the sickness bloggers who fake it online | Mental health | The Guardian
4. Bass, C., & Wade, D.T. (2019). Malingering and factitious disorder. Practical Neurology, 19(2), 96-105.
5. Tseng, J., & Poullos, P. (2016). Factitious Disorder presenting with attempted simulation of Fournier's Gangrene. Journal of Radiology Case Reports, 10(9), 26–34.
6. Bass, C., & Halligan, P. (2014). Factitious disorders and malingering: challenges for clinical assessment and management. Lancet, 383,1422–32.
7. Krahn, L.E., Li, H., O'Connor, M.K. (2003). Patients who strive to be ill: factitious disorder with physical symptoms. American Journal of Psychiatry, 160, 1163–8.
8. Jafferany, M., Khalid, Z., McDonald, K.A., & Shelley, A.J. (2018). Psychological aspects of factitious disorder. The Primary Care Companion for CNS Disorders, 20(1).
9. Caocci, G., Pisu, S., & La Nasa, G. (2008). A simulated case of chronic myeloid leukemia: the growing risk of Munchausen's syndrome by internet. Leukemia & lymphoma, 49(9), 1826-1828.
10. Cadet, P., & Feldman, M.D. (2012). Pretense of a paradox: Factitious intersex conditions on the internet. International Journal of Sexual Health, 24(2), 91-96.
11. Guha, P., Singh, O.P., & Ghosal, M. (2004). Media induced factitious disorder by proxy. Indian Journal of Psychiatry, 46(1), 81.
12. Lawlor, A., & Kirakowski, J. (2017). Claiming someone else's pain: A grounded theory analysis of online community participants experiences of Munchausen by Internet. Computers in Human Behavior, 74, 101-111.
13. Serota, K.B., Levine, T.R., & Boster, F.J. (2010). The prevalence of lying in America: Three studies of self-reported lies. Human Communication Research, 36(1), 2-25.
14. Drouin, M., Miller, D., Wehle, S.M.J., & Hernandez, E. (2016). Why do people lie online? “Because everyone lies on the Internet”. Computers in Human Behavior, 64, 134–142.
15. Pulman, A., & Taylor, J. (2012). Munchausen by internet: current research and future directions. Journal of Medical Internet Research, 14(4), e115.
