1. what motivates people to fake illness online?
J Med Internet Res. 2012 Jul-Aug; 14(4): e115.
Munchausen past Internet: Electric current Research and Future Directions
Monitoring Editor: Gunther Eysenbach
Andy Pulman, MA 
i and Jacqui Taylor, BSC, MSc, PhD2
1School of Health & Social Intendance, Bournemouth University, Bournemouth, United Kingdom
2Schoolhouse of Pattern, Engineering & Computing, Psychology Research Centre, Bournemouth Academy, Bournemouth, United Kingdom
Andy Pulman, School of Health & Social Intendance, Bournemouth Academy, Majestic London House, Christchurch Road, Bournemouth, BH1 3LT, United Kingdom, Phone: 44 1202 962749, Fax: 44 1202 962736, E-mail: ku.ca.htuomenruob@namlupa.
Andy Pulman
1School of Health & Social Care, Bournemouth University, Bournemouth, United Kingdom
Jacqui Taylor
twoSchoolhouse of Design, Engineering & Computing, Psychology Research Heart, Bournemouth University, Bournemouth, United Kingdom
Received 2011 Nov 22; Revisions requested 2011 Dec 16; Revised 2012 Mar 6; Accustomed 2012 Jun 15.
Abstract
Background
The Internet has revolutionized the health world, enabling cocky-diagnosis and online back up to take place irrespective of time or location. Alongside the positive aspects for an individual's health from making utilise 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 past Internet.
Objective
Munchausen past Internet occurs when medically well individuals false recognized illnesses in virtual environments, such every bit 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 non yet been associated with the wider phenomena of Net trolls (users who post with the intention of abrasive someone or disrupting an online environment).
Methods
A wide-ranging review was conducted to investigate the causes and impacts of online identity charade and Munchausen past 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. Instance studies are used to illustrate the phenomenon. What is particularly worrying is the ease with which the deception tin be carried out online, the difficulty in detection, and the damaging impact and potential danger to isolated victims.
Conclusions
We advise ways to deal with Munchausen by Cyberspace and provide advice for health grouping facilitators. We also advise that Munchausen by Net and Munchausen by Internet trolling should exist formally acknowledged in a revised version of the Diagnostic and Statistical Manual DSM-5. This will aid in effectively identifying and minimizing the growth of this beliefs as more people seek reassurance and support about their health in the online environment. We also advise directions for time to come research.
Keywords: Munchausen by Internet, Cyberspace 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, bear witness of malingering dates back as far as Roman times. Munchausen syndrome was starting time described in 1951 [1], followed in 1977 by Munchausen syndrome past proxy [2]. More recently, the increasing utilise of the Internet to provide support for illnesses and other medical problems has introduced the concept of health-related online identity deception—Munchausen by Internet (identified in 2000) [three].
This paper reviews the enquiry about the origins and evidence relating to these disorders. The express 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 Cyberspace and provide advice for health support group facilitators. We suggest that Munchausen past Cyberspace and Munchausen by Internet trolling be formally acknowledged and advise future research directions.
Types of Deception Regarding Wellness
Malingering
Malingering is defined as a deliberate behavior for a known external purpose [4]. Resnick [5] described three types of malingering: (one) 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 (iii) simulated imputation in which the individual has valid symptoms but is dishonest every bit 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 corruption).
Historically, the Roman physician, Galen, presented the primeval evidence of malingering in the 2d century AD. I patient pretended to suffer from colic in lodge to avoid a public coming together and another faked a knee joint injury in order to remain domicile 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 on 1950s because people sought to escape sanctions or compulsion [7]. Russian physicians were express past the state to only 4 medical dispensations. Patients were identified as: (1) needing medical care, (2) thinking they needed medical care, (3) faking, or (4) making directly pleas for medical dispensation. Low social trust is exhibited when certain ethnic groups have low trust in health intendance as an institution considering of historical oppression and deception of their cultural grouping [8]. The early dependence upon doctors by poor Russian laborers has been said to accept altered the medico-patient relationship to ane of mutual mistrust and deception [7]. If an individual patient trusts their md because the md has been assessed equally 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 [ten]. 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 engineering science is replacing the human being element in medical practice thereby reducing patient's trust in physicians [ix]. Trust has been defined as a feeling (often based on inconclusive show) of certainty that a person or a thing will non fail [12]. There are several trust relationships. The 3 trust relationships relevant to this word are: (1) interpersonal trust divers as a man's trust with another man whether contiguous or through a device; (2) social trust defined equally a human being's trust with a system or institution; and (iii) trust in automation defined equally a human's trust with technology or a device.
There are no quantifiable numbers on how many people might misuse the Cyberspace to abuse trust relationships, merely many researchers have shown how the Internet lends itself to deception [3]. People might circumlocute online for external incentives, such every bit coin or gifts, just fraud is normally the principle motivation [iv]. Within the medical arena, the Internet offers anonymous admission 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 [xiii].
Factitious Disorder and Munchausen Syndrome
Factitious disorder (FD) is an umbrella category roofing a group of mental disturbances in which patients intentionally feign concrete or mental disease without obvious do good. Gavin [xiv] starting time described "factitious disease" in 1843. He described soldiers and seamen who mimicked disease to incite pity or attention. The verbal incidence of FD is unknown, but studies suggest that approximately 9% of hospitalized patients on specialty services in 3rd care have FD [fifteen]. Modern study began in 1951 with an article by Asher [one], who coined the term "Munchausen syndrome" to describe a subtype of FD. The name came from a German businesswoman who liked to embellish stories of his military exploits to print listeners. Afterwards, lying and Munchausen were continued in German culture [16]. A series of patients whose medical histories consisted mainly of falsehoods and who visited and deceived hospitals and doctors accept been described in the medical literature [1].
People with Munchausen syndrome get to incredible lengths to announced ill 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 then they can mimic symptoms accurately [18]. Some become so proficient that they can fool doctors into ordering needless tests and fifty-fifty operations in some cases. Munchausen syndrome tends to exist chronic and people with it usually become habitual deceivers [xix]. Savino and Fordtran [17] proposed that information technology was probable that many cases of factitious cancer were never discovered and predicted that with advances in reckoner 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 back up claims of ankle dislocation [20].
Munchausen Syndrome by Proxy and Fabricated or Induced Illness
In 1977, Munchausen syndrome past proxy (MSP)—also known as factitious disorder by proxy—was outset described past Meadow [2]. I 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 developed flagman who repeatedly seeks medical attention for their children, whose symptoms they accept faked or induced, sometimes causing real impairment to the child, and/or subjecting them to unnecessary investigations and interventions. Many hypotheses accept been proposed to explicate MSP. Some have noted that patients with the condition oft present traumatic events—especially abuse and deprivation and numerous hospitalizations in childhood—and equally adults may accept 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 information technology might stand for the patient'due south effort to cope with emotional distress [17].
In the United Kingdom, MSP is now termed "fabricated or induced illness" (FII) [22], although MSP is even so widely used in other countries. The British Paediatric Surveillance Unit (BPSU) carried out a report of FII cases and identified 97 cases in the United kingdom over a 2-year period. This equated to 1 child in every 5000 being affected by FII, but it is likely that this effigy underestimates the true calibration of the problem. Some other study estimates that the number of children affected by FII could be as high as i 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 person psychologist (Alex) masqueraded as a disabled woman (Joan) in an attempt to utilise the trust and intimacy attained in the online interactions for his own social proceeds [23]. In 2000, Munchausen by Internet was identified by Feldman [three] to describe an individual seeking attention past 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 cosmos in 2007—an average of 61.5 edits per yr—suggesting that the term has now comfortably entered the online vernacular of Internet users. Munchausen by Internet tin have devastating effects inside online discussion groups, destroying trust when the hoax is exposed [3]. The virtual communities that were created to give support, besides as general not-medical communities, often limited genuine sympathy and grief for the purported victims. Notwithstanding, when fabrications are suspected or confirmed the ensuing discussion tin can create schisms, destroying some communities and altering the trusting nature of members in others.
Equally yet, Munchausen by Internet has not been officially recognized by the American Psychiatric Association in the Diagnostic and Statistical Transmission 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 2 proposed subtypes: (1) factitious disorder imposed on self and (2) factitious disorder imposed on another. Withal, 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 disease anxiety disorder nether 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 data 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 almost important modification is the emptying 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 past 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 endeavour expended to contrive complex and dramatic fake identities and weather [27]. I case documented a brother-sister dyad who created an elaborate narrative to lure a woman into providing time and attention under fake 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 meliorate empathise her rare status by turning to Net resources for more information [27]. Her enquiry 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'due south proficient friend), "Justin" (her swain), and Justin's father and sister to carry on the story after "Justin" passed away. Helen also fabricated two other storylines including 1 that featured an ailing mother who had tragically lost two children to illness. Another case concerned a 44-twelvemonth-quondam adult female who said she had been diagnosed with chronic myeloid leukemia. Had the documents presented by her not angry suspicion, she would take undergone a bone marrow aspirate and chemotherapy [28].
Munchausen by Net has also expanded to MSP on the Internet [29]. In 2009, Emily McDonald was arrested for injuring her girl, 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 prepare a photographic camera in her hospital room. On video, they caught McDonald putting fecal matter into Dakota's feeding tube. McDonald'southward case appeared to be MSP; however, she was as well posting most 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 kid and was sentenced to 20 years in jail [30].
Munchausen by Cyberspace
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 case, there can be a high ratio of faux or irrelevant data compared to useful information on the Spider web. Eysenbach et al [31] systematically reviewed studies of health website evaluations and found that the most oft used quality criteria included accuracy, completeness, and 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 wellness-related Web content was establish to exist low according to the authors of the reviewed studies. The incidence of false information in online self-help groups is unknown, although assumed to be high because of the absence of grouping 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 e-mail listing, which seemingly encouraged venting and the name calling of parents and children amidst unconditional support of other caregivers, created an environs which led to the acceptance of practices that were not kid-centered and were potentially dissentious 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" secret is a motion that supports those with anorexia and adopts an anti-recovery perspective on the illness [33]. While encouraging a non-good for you diet to sustain an anorexic lifestyle, the move likewise recommends the radical apply of weight-loss pharmaceuticals—conventionally used to treat obesity—to pursue and maintain low trunk weight. There are like movements in other online disease communities, such equally supporters of chronic fatigue syndrome who suggest 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 behavior that are unsupported by scientific evidence. For case, the spread of data virtually 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 sensation of the capacity of the Net to enable and spread shared delusional ideation was essential to current medical practice.
Review of Contempo Munchausen past Net Literature
We conducted a review of Munchausen by Cyberspace literature over the previous 2 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, simply none were relevant because they either independent citations which referred to former research or had no specific link between Munchausen syndrome and the Cyberspace. The Technorati search engine was used in improver to search the blogosphere for recent blog postings or blogs on the terms "Munchausen by Internet" and "Munchausen" generated during the kickoff one-half of 2012, just no relevant blogs or posts were identified.
Motivation
Considering many instances of Munchausen past Cyberspace have place in a group state of affairs, social psychology offers a number of theories that can be applied to explicate this type of online behavior. Drawing on disinhibition theory, Suler [37] highlighted two features of the Net 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 audition can reduce concern for others' views. Similarly, Taylor and MacDonald [38] applied the theories of de-individuation and social identity to explicate more uninhibited behavior and more self-disclosure in some online settings. Drawing on motivations for charade and group effects, Mealy et al [39] found that lies motivated past a desire to benefit others were considered to be more acceptable than lies that primarily benefited the cocky. Additionally, lying to the out-group (the social group to which someone does non place) was perceived equally being more than acceptable than lying to the in-group (the social group to which someone psychologically identifies themselves with equally a member).
Other areas of psychology offer theories of relevance, for instance those relating to self-presentation and identity. Research has shown a link between low self-esteem and the need for popularity to the manner individuals dispense relationships and the way they perceive others' online relationships [40]. Walther [41] noted there is a propensity for disinhibition, project, and transference, wherein in that location are no visual or auditory inputs that can identify the text in its proper context or assist the correct interpretation of that text. People fill in the missing pieces in the motion-picture show of others they meet online, not fully enlightened that the picture they are forming is based partly on their own unconscious desires regarding who they desire that person to be and how they want them to act. This occurs at the same time as the person is taking reward of the anonymity inherent in text-merely communications to present their all-time possible face. A feedback loop can ascend as these selective presentations are responded to in-kind, creating a hyperpersonal attribute to Net communications. The Hyperpersonal Model [42] proposes that the Internet affects three parts of the communication process. These can be applied to empathise the way in which Munchausen past Internet users manipulate the Internet to manage impressions and likewise to explain how others brand interpersonal impressions based on that information. The three parts of the advice 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 absenteeism of contiguous 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 cocky-presentation to others and themselves.
three. The asynchronous aqueduct allows more fourth dimension for senders and receivers to consider the messages they send and receive, then that but 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 nigh online deceivers felt a sense of enjoyment while engaging in online deception [43]. In 1999, a columnist was introduced in the UK paper, The Observer, post-obit his aborted suicide attempt and detailing the columnist's last few months before he killed himself [44]. Afterward protestation, information technology was revealed that the column was a spoof. Chris Morris, an innovative but controversial British broadcaster, wrote the columns that highlighted the inherent cruel, dark comedy of fooling gullible members of the public with stories of fake medical weather. This willingness of broadsheet media to embrace and portray a borderline style of comedy can have unpleasant outcomes within an Internet surroundings. One clue might lie in the power granted by online communities to quantify the sympathy for an illness or the stupor of a death through comments boxes or replies to a journal thread [thirteen]. During a lengthy boxing against terminal illness, blog writers tin can concenter 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 want of a narcissist and as they create an imaginary online long-term condition leading to a fake death, tin provide a lonely private with attending that they may never have previously known. This view is supported past Feldman [three], who linked the engaging and intense nature of these deceptions to sadism. This motivation can exist seen to be at both intrapersonal (sadistic) and interpersonal (attention) levels.
Stokes [45] argued that online social networks offer more than methods to manage the impressions of others than are available through structured websites. He referred to a report 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 accept in the offline world, simply had non yet been able to found.
There is lilliputian inquiry regarding the psychology of Munchausen past Internet, simply there are indications that some online self-presentation may be motivated past narcissistic or sadistic tendencies, as is the case with FD. In one analysis of patients with FD, information technology 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 earth considering it indicates that online self-presentation varies co-ordinate to the nature of the online setting. Oltmanns [47] described narcissism every bit a pervasive pattern of grandiosity, a need for adoration, 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 nearly theoretical models of narcissism, the apply of social relationships is employed to regulate narcissistic esteem. However, narcissists do non 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 celebrity presents itself [49].
Netiquette and Trolls
The attribute of Munchausen past Net 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 help in controlling, finer identifying, and minimizing the growth of this behavior equally more people seek reassurance and support nearly their health in an online surroundings. Netiquette (short for "network etiquette") is the dos and don'ts of online advice covering mutual courtesy online and the breezy "rules of the road" of internet [50]. A troll is someone who posts or sends messages online with the intention of annoying someone or disrupting a discussion or surround [51]. The practice of trolling has been compared to the fishing term in which a line is set up in the water and the bait is dragged slowly back and forth in the promise 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 defoliation between concrete and epistemic communities. Trolling has been portrayed disdainfully in mainstream media outlets, often referencing the willingness of some Internet trolls to become to farthermost lengths in their attempts to elicit reactions. In 2010, the Australian government became involved after trolls defaced the Facebook tribute pages of 2 murdered children. The Australian Minister of Communications decried the attacks as prove of the need for greater Internet regulation [53]. In the wake of these events, Facebook responded by strongly urging administrators to exist aware of ways to ban users and remove inappropriate content from Facebook pages. Information technology is recommended that ignoring a troll is almost always the best approach, because if nobody responds the troll will eventually get bored and get away [51]. Experienced participants in online forums know that responding tends to encourage trolls to continue disruptive postings—hence the oft-seen warning, "exercise not feed the troll" (DNFTT). All the same, experts tend to inhabit the tougher, streetwise environs of Internet technical or picture forums rather than in the supportive and empathetic environment of an online wellness support group, which can crusade more of a daze when Munchausen by Net trolls are unmasked.
Opportunity
Recupero [54] highlighted instances of psychiatric patients engaged in impression management to influence the outcomes of psychiatric interviews [55]. Impression direction also plays an important office in online conversations. Barak [56] believes that many Internet users prefer others to perceive and collaborate with an online persona and that material chosen to mail online can assistance to deepen a preferred social impression. Conversely, profiles posted on social networking sites (eg, Facebook) may contain data contradicting the evaluee's intended impression. Photographs, perhaps artificially equanimous, and other material tin be posted and tagged online showing a person'south name or identity without their noesis or permission regardless of whether the person is familiar with or naïve about Internet influence. Similarly, records of negative behavior tin remain online for years becoming part of an individual'due south digital footprint [57].
Computers let people with sufficient technical skills to access medical records and use them to falsify medical histories [20], while the open trusting environments of advice 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 audition for fake narratives with people able to movement from ane support group to another [18]. Some, pretending to be ill, have joined more than one, and some might sign on to a single grouping multiple times by using unlike names and acting out unlike roles. A sock boob is an online identity used for purposes of deception. The term, a reference to the manipulation of a hand boob 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 some other 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 fabricated easier by the bearding and malleable nature of online identity along with piece of cake access to the Cyberspace, which allows sock puppets to thrive without any negative consequences to themselves. For example, Andrea, a forty-year-sometime single mother, began posting on an ovarian cancer forum that she had concerns over her worsening abdominal hurting. Shortly after joining the forum, Andrea announced that she had been diagnosed with ovarian cancer. Later being confronted past suspicious group members, Andrea confessed to her charade and the utilise of sock puppets. In add-on to playing herself during her affliction and online death, she had posed every bit her daughter "Brittney" and her daughter's swain "Chris" [27].
Detection
Although some Munchausen by Internet perpetrators display a remarkable degree of inquiry and endurance, able to stretch the fiction over many months, even the most defended can sideslip upwardly somewhen. Outwardly, at that place might not exist any clues to suggest that they are anything other than normal support group members, just slight details can introduce contradictions and, although anyone caught upwardly in the charade may exist willing to forgive a slight oversight, some are more methodical. They are prepared to investigate and so that few contradictions will escape over fourth dimension. Savino and Fordtran [17] suggested that diagnosis of factitious cancer is commonly made by detection of inconsistencies in medical history, by testify of fabrication of medical records, past lies patients tell about their health insurance, or by doctors who brainstorm to doubt the patient's story. A story of prolonged survival with a unremarkably lethal cancer has helped reveal factitious cancer in some cases. Based on his experience with Munchausen by Net, Feldman [3] listed some methods of detection:
1. Posts consistently duplicating cloth in other posts, books, or health-related websites.
2. Characteristics of the supposed disease emerging equally caricatures.
3. About-fatal bouts of affliction 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 get the focus of attending.
6. Feigned blitheness almost crises that will predictably attract immediate attention.
vii. Others manifestly posting on behalf of the private 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 existence enlightened of radiographic inconsistencies.
There are several strategies ordinarily employed in confronting FD. In one case serial, patients were carefully confronted with the factitious nature of their disease. Although 13 of the 33 (approximately 39%) admitted feigning illness, virtually of the patients' illnesses improved following this strategic confrontation [15]. In most cases, group members' discovery of Munchausen past Cyberspace can atomic number 82 to a similar strategic confrontation [three,27] with the typical response existence a protestation of innocence and an allegation of mistreatment by the group, followed past 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 accept screenshots every bit evidence of the fraud, only many perpetrators slip away, either sufficiently chastened to terminate the deceptions or to simply reappear in some other online group.
Effects and Consequences
The Munchausen past Internet troll can be costly in several ways. A troll can disrupt the discussion on a newsgroup, disseminate bad communication, and harm the feeling of trust in a Web community. Furthermore, in a group that has go sensitive to trolling—where the charge per unit of deception is high—some honest just naïve question tin can be quickly rejected as trolling. This tin can exist off-putting to a new user who is immediately bombarded with accusations when venturing a beginning mail service. Fifty-fifty if an accusation is unfounded, being branded as a troll can exist 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 give-and-take forums, the broadly accepted ethic of free oral communication may lead to tolerance of trolling behavior, further complicating the members' efforts to maintain an open-withal-supportive discussion expanse, specially for sensitive topics. Reactions from Net forums accept been critical of media portrayals of trolls, stating that trolling is nothing new and has become part of accepted Internet civilization. While non condoning the viciousness of troll attacks, forum discussions regularly limited concern that mainstream media coverage of trolling ultimately results in more than trolling considering widespread attention represents the reaction that trolls seek. However, in the insular, empathic surroundings of a support group, the reaction can be more astringent. Grady [18] detailed the case of a 15-twelvemonth-old girl who communicated with members of a virtual back up group for parents of babies who were critically ill. Kim claimed to accept a baby requiring treatment and as she detailed the timeline of her infant'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 meaning again and that she feared the second infant would exist born prematurely. After the early nativity of her second baby, the same cycle was reenacted, but this fourth dimension a group member (a psychologist and the female parent of twins built-in 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, simply her behavior had a negative effect on a grouping who had been trusting and shut-knit until and then [18]. Some parents expressed feelings of expose, and many stopped posting messages. People in the group agreed to provide data and so that a coordinator could verify they were really parents of premature babies. Some new participants were put off by the temper 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.
Awarding of the term "troll" is highly subjective. Some readers may narrate a post equally trolling, whereas others might regard the same post as a legitimate give-and-take contribution, even if controversial. Sometimes the term is used as a strategy to discredit an opposing position past attacking its proponent. Calling someone a troll makes assumptions nearly a writer'south motives. Regardless of the circumstances, controversial posts may concenter a specially strong response from those unfamiliar with the robust dialogue found in some online, rather than concrete, communities. The popularity of Facebook means strangers tin often build and maintain relationships entirely on the Internet. This anonymity permits whatsoever number of lies to be accepted as truth, and inventive deceptions, with whatever motive, can be carried all the way to an online grave. All the same, there is also the potential danger that overzealous group members might brand the erroneous assumption that every expiry encountered online is fake. Most social network sites now allow relatives of deceased users to cull to keep profiles online equally a memorial, allowing users to post tributes and letters, sometimes speaking of the dead in the 3rd person, sometimes in the 2nd person. In issue, a contour site is converted into a tribute site, a space of commemoration—a sort of open-ended electronic wake [45]. In the instance of a real death, it tin can be but every bit harrowing for the bereaved to read comments claiming that the death has been faked.
Conclusions
More research is required to be able to provide prove-based communication to victims of suspected Munchausen by Internet trolls and for facilitators of give-and-take groups to effectively manage interactions. As this is one expanse of the literature that does not yet yield much data, one methodology that could possibly exist adopted for further study is based on qualitative content analysis (QCA), which is gaining much support in studies of social interactions in online back up communities [61]. QCA provides a mode to written report manifest and latent content within a torso of text. Analysis of what the text says describes the visible components, referred to as the manifest content. Analysis of what the text talks most 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 disease. The manifest content is ordinarily presented in categories, whereas the latent content is expressed every bit themes. QCA differs from pure qualitative research every bit it allows the researcher to emphasize differences between and similarities within codes and categories. Therefore, information technology could be used to differentiate types of Munchausen by Internet and its different motives.
When Munchausen by Internet seems likely, it might exist practical to accept some established group members gently question any dubious mail owner privately. Although the typical response is trigger-happy denial regardless of the force of the bear witness, the author typically will disappear from the grouping. In some Munchausen past Cyberspace cases, much like FD cases, individuals tin 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 false personae [27]. Savino and Fordtran [17] suggested some useful steps for against patients suspected of FD:
1. Let the patient know what you suspect but without outright allegation.
2. Support the suspicion with facts.
3. Provide empathetic and face-saving comments.
iv. Avoid probing to uncover the patient's underlying feelings and motivations so as to minimize disruption of emotional defences that are essential to her part.
v. Clinch the patient that only those who demand to know will be informed of the suspicion of factitious disease.
vi. Make sure the staff demonstrate connected acceptance of the patient as a person worthy of their help.
7. Encourage psychiatric help, merely if the patient resists do non force the event.
Even so, once a perpetrator has been confronted, remaining members of the online group may need psychological assistance at an private or group level depending on the extent of the charade and the health topic concerned. For example, individuals may need assistance in processing their feelings. As a grouping, assistance could be directed toward dealing with conflict and arraign, 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 deportment and concrete objects that govern what people do, not what they retrieve or experience. Historical police assumes a physical world constrained past fourth dimension and space, merely virtual environments have significantly different functionality. This ways the virtual globe is a functionally different world; it may not be advisable, or even possible, to transfer laws from the physical to the electronic world. Therefore, laws must exist re-invented past re-applying legitimacy concepts to virtual contexts such as formulating direct policy to protect health information users in the new earth 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 all-time results inside a md-patient relationship tin be achieved past budgeted the dilemma from diverse angles [28].
Historically, the consequences for perpetrators take tended to be pocket-sized because few tin can be pursued or punished unless the wronged individuals are able to prove that the perpetrators take committed an illegal act. All the same, a 2005 legal example 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 reply without fear of successful legal reprisal. They might also be able to win a precedent-setting civil example [64]. Indeed, there is a strong case for because the sadistic misuse of wellness-related forums as a form of cybercrime, rather than equally an everyday negative risk of using the Internet that must be tolerated and accustomed. Consider if a malicious user deliberately (or accidentally) gave out medical information that resulted in a worsening of health or had fatal consequences. Cyberspace protocol (IP) addresses of Munchausen by Cyberspace trolls could be identified and Internet service providers (ISPs) could exist enlisted to help identify and "out" frequent perpetrators such as been seen in recent online copyright disputes. Social network providers, such every bit Facebook, should tighten upward their ain procedures or, as an alternative, grouping users might want to consider relocating to more private group-based Internet communities, such as individual Wikis [51]. Although these do not have the same large population of users, they might increase the security and lessen the gamble of encountering a Munchausen by Cyberspace troll online.
Enhanced self-regulation is the most positive action to reduce group risk. It might also exist advisable for a health support group to identify a gatekeeper. Although calculation actress layers of security and formality before a user could postal service might be viewed every bit onerous, the long-term benefits might be worth the additional endeavor. Facilitators could also clearly state to all members that although most people participating in back up groups are honest, all members should balance their empathy with some degree of caution. Group members should be especially careful about basing any of their own health care decisions on uncorroborated information supplied in groups, simply equally they should with any other source on the Internet [65].
We take 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 Net. All the same, there is a clear, compelling need to recognize that in addition to Munchausen by Internet beingness classed equally a condition in its own right, there is a subset of people currently tagged as Munchausen by Internet sufferers who are really Munchausen by Internet trolls purposefully harming well-intentioned back up groups and abusing members for their own pleasure or enjoyment. We propose that Munchausen past Net and Munchausen by Internet trolling exist 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 past grouping users or past 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 fabricated possible by funding from the Bournemouth Academy Open-Admission Publishing Fund (OAPF).
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 assay |
Footnotes
Contributed by
All of the authors are responsible and qualified for the reported inquiry. They have all participated in the concept and blueprint, analysis, and interpretation of information, and drafting and revision of the manuscript and approve the manuscript as submitted.
Conflicts of Interest:
None declared.
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Articles from Journal of Medical Cyberspace Research are provided here courtesy of Gunther Eysenbach
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510683/
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