Why People Pretend to Be Unwell Online

"Münchausen by Internet" was first described over 20 years ago¹, and this digital factitious disorder (DFD) has been discussed previously in this blog². As with real-world factitious disorder, people with DFD consciously fake illness for no obvious external reward. They are not primarily motivated by gaining money by fraud, nor by avoiding doing something—their motivations are deemed "psychological"^1-3.

Of course, it is difficult to explore the reasons underlying either factitious disorder or DFD, as individuals displaying these characteristics are, by their nature, not known for their veracity². However, research and documentation concerning these disorders throw up some findings inducing speculation as to whether the motivations behind real-world and digital factitious disorders differ from one another.

These newly minted considerations may even bring into question assumptions made about the motivations behind the real-world Münchausen Syndrome. In fact, the motivations, and perhaps etiology, of this disorder may be psychologically darker than previously thought.

Real-world vs. digital expressions of factitious disorder

To be clear, there are many characteristics and symptoms of DFD that resemble real-world factitious disorder. However, the few that do not are of critical interest; even suggesting that personality disorder, rather than attachment disorder, is more commonly the root of DFD, compared to real-world factitious disorder. It may be that digital communication has "mutated" factitious disorder into something more malevolent, or perhaps this strain always existed in the real world and has just become dominant online.

An examination of who displays factitious disorder illustrates some differences between real-world and digital expressions. In the real world, people are diagnosed around 30-40 years of age⁴. Anecdotally, the age of those deceiving about their health digitally is much younger, perhaps even in the teenage years⁵ — a factor appearing to facilitate DFD being the social media platform, TikTok⁵, which tends to have a young client base.

Of course, factitious disorder could be expressed earlier in the real world than thought, and it is just more noticeable online. Alternatively, it may be that younger people have greater ease of access to health communities or practitioners online, allowing opportunities for DFD. If either of these reasons is true, then a rethink about the timeframe of real-world factitious disorder may be needed.

Considering the range of psychological motivations for factitious disorder or DFD—such as: attention, sympathy, anger, or controlling others¹—many are connected to bolstering the self. However, it is important to keep in mind that some of these strategies do this through rewards directly aimed at the self, such as gaining increased attention or sympathy; whereas, some seem aimed at elevating the self at the expense of others, such as anger or control. A question to ask, when looking at two apparently similar behaviours, is whether they have the same function. If they do not, then they are not really the same, despite their similarities. This may be the case for real-world and digital factitious disorders.

In the real world, the motivations underlying the expression of factitious disorder have long been taken to be purely psychological^1,3, often resulting from a need for attention, perhaps due to attachment problems⁴. While external motivation is hard to discern for factitious disorder, if one digs deep enough, something "external" can turn up. For example, in one case of factitious disorder presenting with simulation of necrotising fasciitis of the genitals⁶, hospitalisation for gangrenous testicles seemed preferable to arrest for burglary—although the precise nature of the reasoning behind this choice may, itself, be subject to some psychological scrutiny. Nevertheless, such motivations, while self-serving and external (i.e. avoidance), do not appear self-serving at the expense of others’ wellbeing (which is not true of factitious disorder inflicted on another, of course, but that is a separate disorder).

In contrast, DFD appears motivated, in several high-profile cases, by darker desires for gain at the expense of others. This may be in terms of fraudulently gaining money⁷, or by inflicting suffering or distress on other members of the community (akin to trolling)⁸. These types of motivations, potentially underlying DFD, suggest not so much an attachment disorder, as in real-world factitious disorder, but rather the "Dark Triad" of personality disorders—narcissism, Machiavellianism, and psychopathy¹⁰. Links have been made between the Dark Triad and real-world factitious disorder⁸, but most cases involve factitious disorder inflicted on another (or Münchausen by proxy)¹¹. Associations with real-world factitious disorder also involve bolstering a fragile ego through gaining attention. This is seen in hypersensitive narcissism, rather than the more aggressive grandiose narcissism; the former often resulting from poor attachment styles¹². However, the scales for DFD may be tipped to the "darker side"—whether that reflects a closer correspondence with Münchausen by proxy is a point requiring more research.

Attention Essential Reads

Why the Limits of Language Are the Limits of the World

Drop It Like a Squat: Exercise Breaks Can Enhance Attention

There is no doubt that DFD harms communities where practised^8,13. In one study, while members of a digital community were sympathetic to persons with DFD, the presence of DFD ultimately eroded trust in the group. It also produced reserve in participants, perhaps for fear of being labeled as having DFD¹³. The upshot was a reduction in benefit of self-help groups¹³. However, many younger people fabricating illness online may do so to get attention for another more serious medical problem. This could be due to fear about the serious real physical symptoms they cannot express^13,14. DFD may also signal the experience of sexual or physical abuse. In either case, hounding or silencing those with DFD may serve only to drive them underground^5,13.

The apparent differences between real-world and digital factitious disorders deserve attention, and beg the question: Why do digital media make people behave so badly? In the real world, lies perceived as motivated to benefit others are found more acceptable than lies motivated to benefit the self⁹. However, as it is harder to detect digital lies, and there are no great comebacks (at least, immediately)⁴, maybe digital media favour the self-focused lie. Perhaps these antisocial behaviours are easier to perform online, and just come through more clearly in the digital arena. Certainly, evidence points to the ease of online deceit as one driver for some differences².

Overall, motivations behind the expression of DFD have some similarities to, but also some differences from, real-world factitious disorder. DFD may well have darker motivations, involving personality disorders, compared to real-world factitious disorder, involving attachment problems. However, the lines are blurred, and it may be that DFD is an expression of an already existent, but less pronounced, trend in the real world. Digital communication simply allows the "darker side" of people to be manifest more easily.