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    MUNCHAUSEN BY INTERNET: FAKING ILLNESS ONLINE
    by Marc D. Feldman
    Online Support for People with Illness

    The Internet is a medium of choice for millions of people who need health-related information. Medical websites have multiplied exponentially over the past several years. Thousands of virtual support groups have sprung up for those suffering from particular illnesses. Whether formatted as chat rooms, as newsgroups, or in other ways, they offer patients and families the chance to share their hopes, fears, and knowledge with others experiencing life as they are. These online groups can counter isolation and serve as bastions of understanding, deep concern, and even affection.

    Unfortunately, cyberspace resources are sometimes deliberately misused by people intent on deceiving others. False product claims in spam are perhaps the best-known example. But even in the relative intimacy of health support groups, individuals may choose to mislead others by pretending to have illnesses they do not. They divert the attention of the group toward their feigned battles with cancer, multiple sclerosis, anorexia nervosa, or other ailments. The eventual discovery of the deceptions can be devastating. One group member called it "emotional rape" to have cared so deeply about a person who lied to her and others from his first post on.
    Munchausen by Internet

    For decades, physicians have known about so-called factitious disorder, better known in its severe form as Munchausen syndrome (Feldman & Ford, 1995). Here, people willfully fake or produce illness to command attention, obtain lenience, act out anger, or control others. Though feeling well, they may bound into hospitals, crying out or clutching their chests with dramatic flair. Once admitted, they send the staff on one medical goose chase after another. If suspicions are raised or the ruse is uncovered, they quickly move on to a new hospital, town, state, or in the worst cases — country. Like traveling performers, they simply play their role again. I coined the terms "virtual factitious disorder" (Feldman, Bibby, & Crites, 1998) and "Munchausen by Internet" (Feldman, 2000) to refer to people who simplify this "real-life" process by carrying out their deceptions online. Instead of seeking care at numerous hospitals, they gain new audiences merely by clicking from one support group to another. Under the guise of illness, they can also join multiple groups simultaneously. Using different names and accounts, they can even sign on to one group as a stricken patient, his frantic mother, and his distraught son all to make the ruse utterly convincing.
    Clues to Detection of False Claims

    Based on experience with two dozen cases of Munchausen by Internet, I have arrived at a list of clues to the detection of factititous Internet claims. The most important follow:

    1. the posts consistently duplicate material in other posts, in books, or on health-related websites;
    2. the characteristics of the supposed illness emerge as caricatures;
    3. near-fatal bouts of illness alternate with miraculous recoveries;
    4. claims are fantastic, contradicted by subsequent posts, or flatly disproved;
    5. there are continual dramatic events in the person's life, especially when other group members have become the focus of attention;
    6. there is feigned blitheness about crises (e.g., going into septic shock) that will predictably attract immediate attention;
    7. others apparently posting on behalf of the individual (e.g., family members, friends) have identical patterns of writing.

    Lessons

    Perhaps the most important lesson is that, while most people visiting support groups are honest, all members must balance empathy with circumspection. Group members should be especially careful about basing their own health care decisions on uncorroborated information supplied in groups. When Munchausen by Internet seems likely, it is best to have a small number of established members gently, empathically, and privately question the author of the dubious posts. Even though the typical response is vehement denial regardless of the strength of the evidence, the author typically will eventually disappear from the group. Remaining members may need to enlist help in processing their feelings, ending any bickering or blaming, and refocusing the group on its original laudable goal.

    References: Feldman, M.D. (2000): Munchausen by Internet: detecting factitious illness and crisis on the Internet. Southern Journal of Medicine, 93, 669-672
    Feldman, M.D., Bibby, M., Crites, S.D. (1998): "Virtual" factitious disorders and Munchausen
    by proxy. Western Journal of Medicine, 168, 537-539
    Feldman, M.D., Ford, C.V. (1995): Patient or Pretender: Inside the Strange World of Factitious Disorders. New York, John Wiley & Sons
    Cybersickness
    Munchausen by Internet Breeds a Generation of Fakers
    by Francine Russo
    June 27 - July 3, 2001
    Over nearly three years, from 1998 to 2000, a woman—let's call her Anna—posted to an online support group for people with mental illness. To the larger circle of readers, she acted mostly as friendly counselor. But to a select few, she e-mailed stories of escalating catastrophes. Her husband and two children had perished in a plane crash, she wrote. As a kid, her father had molested her, and she had suffered multiple personality disorder. Finally, she told her trusted—and trusting—confidants that she had just been diagnosed with leukemia.

    Gwen Grabb, a psychotherapy intern and mother of three in Los Angeles, says the group believed Anna because she took on the role of helping others, revealing her own difficulties much later, and to an intimate audience. "She was very bright," recalls Grabb. "She was very supportive and kind. One day, she started telling me about `the crash,' what they found in the black box, how you could hear her daughter screaming. I had known her a year. I believed her."

    But as the tales became more elaborate and grotesque, Grabb grew suspicious. Along with another group member—Pam Cohen, a bereavement counselor in the Mid-Atlantic region—she did some research and discovered Anna was making it up. It was a shock to all, but worse than that to Cohen. "It is like an emotional rape," she says. People may have been upset over the online life and fatal cancer of the fictional Kaycee, whose creator admitted last month she'd invented the high school character for expressive purposes. But that was geared to a general audience, however easily suckered. Pretenders like Anna hurt a much more vulnerable group—folks who may be seriously ill and are seeking help.

    The Internet was made for such fakers, says Dr. Marc D. Feldman, a psychiatrist at the University of Alabama at Birmingham and an expert on Munchausen syndrome and factitious disorder. People like these, he explains, suffer from a form of Munchausen, a condition in which they either feign illness or victimization, or actually induce illness or injury in order to gain sympathy and become the center of attention. With another variation, Munchausen by proxy, caretakers seek these rewards by making their charges sick. Cyberspace has added a new twist—one Feldman labels Munchausen by Internet.

    To credibly represent themselves as ill—often with obscure and dramatic maladies—Munchausen sufferers often study medical literature, and even go so far as to poison themselves to simulate particular symptoms. "On the Internet," Feldman explains, "it's very easy to fake. All you have to do is click and you go to another disease site. You can become an expert on anything in 30 minutes by visiting Google." By the time Feldman published his article "Munchausen by Internet" in the Southern Medical Journal in July of last year, he'd already studied over 20 cases of cyberMunch. "The incidence is increasing rapidly," he reports.

    Feldman runs his own site, and provides a link to another started this year by Cohen, Victims of Factitious Liars). Cohen says the people who congregate at her site feel betrayed, but they understand the fakers are seriously troubled.

    The irony in these Munchausen cases is that those pretending to be ill really are sick, but they rarely go to the right kind of doctor. When confronted on the Web, they often disappear. In person, they may show some contrition even though they resist treatment. One of Dr. Feldman's first Munchausen patients was a profoundly depressed young woman who was feigning terminal breast cancer. He hospitalized her and successfully treated her with psychotherapy and drugs. "We tell them we'll give them treatment for their emotional illness," Feldman explains, "that they don't need to be ill to see a doctor anymore."

    Getting them proper treatment could prevent a lot of harm. Off-line, by some estimates, people with Munchausen and similar disorders consume as much as $20 billion annually in unnecessary medical procedures. Those taken in by online Munchausen sufferers are often homebound. For them, the Internet is a lifeline to the outside world. "To discover that their love and nurturing have been misdirected is like being taunted with their own illness," Feldman says. "It's devastating."

    Diane Hamilton, a librarian in Cape May, New Jersey, and a migraine sufferer, brought one such case to Dr. Feldman's attention. From 1998 to 1999, a visitor posted to a long-standing migraine support group on Usenet. He claimed to be a 15-year-old medical student. Not only did he have migraines, he said, but he also had a seizure disorder and hemophilia.

    At first he won great love and approval from the group. Then his stories become more and more incredible. His mother was deaf and his father was alcoholic and abusive. He had to skateboard three miles a day to get the bus to medical school, and he had a nightclub job as a drummer. When group members began to question his stories more and more aggressively, his "mother" signed on to say how their doubt might plunge the boy into another episode of depression. Finally, as he was met with increasing skepticism, both the "teen" and his "mother" disappeared from the site, having victimized a vulnerable group..

    "Some of them had such bad migraines they had to be on Social Security disability," says Hamilton. "Others had them from head traumas from accidents. Many had been on drugs for years with no relief."

    After their encounter with the fake poster, the group never recovered. It split into factions of believers and doubters, its spirit of trust and caring broken.

    An even more bizarre case involved the 1997 duping of a Web-based fan club for the musical Rent. Many of the members had met while waiting on line for tickets in New York, and for them the club became a support network. Catherine Skidmore, a 26-year-old technology consultant in New York, was one of those taken in a student claiming to suffer from a fatal liver and nerve disease.

    "She showed up once with an IV shunt taped in her arm," Skidmore recalled. "And she'd go to the cast members and try to get sympathy." In this way, the woman was able to meet and have dinner with Rent stars Anthony Rapp and Gwen Stewart. When she returned to Chicago, the group started getting e-mail from a "friend" of the woman's. The messages were full of medical jargon and day-by-day accounts of the "sick" person's condition as she slipped into a coma. "I had lost a friend who didn't tell me she was dying," says Skidmore. "So I wrote to her and said I didn't want her to be alone."

    Skidmore and others in the group prayed, sent messages, and bought tickets to fly to Chicago. But whenever they were about to leave, the friend, who refused to give the name of the hospital, would write that Rachel had miraculously recovered.

    Eventually, these Lazarus-like revivals aroused suspicion. Group members uncovered the hoax by calling all the hospitals in Chicago. Rapp's boyfriend, Josh Safran, was one of the fraud detectors. "I can't believe the lengths she went to. Her e-mails were very medically proficient. And everybody's lives were so messed up. It was total drama." Although Safran was skeptical early on, he hesitated to mention his doubts. "If she turned out to be sick after this, we were horrible people."

    The people who perpetrate these hoaxes don't usually consider the ways they're harming others. One former Munchausen patient, a 40-year-old computer technician on the West Coast, used to hurt herself and pretend she'd been the victim of an attack or accident. "I called them 'scenarios,'" she explains. "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."

    For those who do not want to be victimized by such folks, however sick they may or may not be, Dr. Feldman has developed a series of cues for online detection. Some warning signs are posts that copy textbook material or other online sites verbatim, and a series of dramatic declines followed by miraculous recoveries. Be suspicious when the person makes fantastic claims, he says, resists telephone contact, or complains that the group is not supportive enough. Be very suspicious if a "friend" or family member posts for the sick person—displaying the same writing style and spelling errors.

    The treatment for the support-group fakers is psychotherapy. The treatment for their victims is...another support group. Victims of Factitious Liars already has 42 members who post regularly about their own victimization and brainstorm about how to get publicity and funding to treat Munchausen. Cohen and Grabb are hoping to make a documentary on the Munchausen phenomenon and have recently received a substantial contribution from an individual donor.

    Paradoxically, one of the issues Cohen and Grabb must confront is that a member on their own site could be lying. "Look for inconsistencies in the story over time," Cohen advises her group. "If you become suspicious, e-mail me and let me know. For the most part, we have to take what people say at face value. But let's all be aware that we could get used and get emotionally attached to someone who is an online liar."
    DISEASE OR DECEPTION? THE MYSTERY OF FACTITIOUS DISORDERS
    Marc D. Feldman, M.D.

    Jenny (a pseudonym) was one of those "invisible" people we all know and overlook each day. A secretary for a manufacturing company, Jenny was as a diligent employee, but one who hadn't developed many friends at work. Nevertheless, she seemed to find all the companionship she needed in her relationship with her live-in boyfriend. Week in and week out, her world seemed never to change, and yet she seemed satisfied. Then one day everything, suddenly and quietly, fell apart.

    Jenny's boyfriend announced he was leaving her: he had fallen in love with another woman and was moving out. Horrified and adrift, with no one to call on for comfort, Jenny chose a remarkable way out of her loneliness. She mobilized an instant support network by showing up at work one day and announcing, "I've just been diagnosed with breast cancer. And it's too late. It's terminal."

    It was also a lie. Jenny had found a remarkable and desperate way to mobilize an instant support network of sympathetic co-workers. Eventually she enrolled in a breast cancer support group, shaved her head to mimic the effects of chemotherapy, and dieted to lose 50 pounds all to keep the illusion alive.

    Jenny was suffering not only from a broken heart, but from an emotional ailment called "factitious disorder." People with factitious disorder feign or actually induce illness in themselves, typically to garner the nurturance of others. In bizarre cases called "Munchausen syndrome by proxy," they even falsify illness in another person (such as their own children) in order to garner attention and sympathy for themselves as the heroic caregiver.

    Desperate? Of course. Yet more common than you might think. Experts estimate that one percent of hospitalized patients are faking their ailments. The medical bills in one case alone amounted to $6 million. Clearly factitious disorders are sapping an already-burdened health care system.

    They also defy the imagination. Patients have bled themselves into anemia and then showed up at a doctor's office stating they haven't a clue about how they became so ill. Others have secretly taken laxatives to induce diarrhea, or mimicked seizures so convincingly that neurologists hospitalized them on the spot.

    The good news: this phenomenon is finally coming out of the closet. In recent months, newspapers, magazines, and TV news programs have all described cases of factitious disorder, helping both health professionals and the general public to become aware. At the same time, factitious disorder patients are recognizing that, twisted as their behavior may seem even to themselves, help is available.

    In Jenny's case, the ruse of cancer came crashing down when the leaders of the breast cancer support group discovered that she had lied about her medical care. Referred for psychiatric care, Jenny revealed feelings of overwhelming depression, and this deep depression had fueled her factitious behavior. Treated with antidepressant medication and psychotherapy, Jenny ended her illness portrayals and moved on--decisively--with her life. She has never resorted to factitious illness again.

    The first step for factitious disorder patients is to realize they cannot go it alone. Though this is a hurdle they inevitably find intimidating, they simply must reach out to a therapist. The therapist can help them realize why the feigned illnesses began in the first place: why had the need for sympathy become so intense? The therapist can also discover underlying emotional problems--as in Jenny's case--that must be treated at once, and also provide the very caring these patients had previously had to go to extremes to elicit. Finally, the therapist can help teach the patient ways to get needs met without resorting to self-defeating, and even literally self-destructive, actions.

    Families who suspect that a loved one has factitious disorder are invariably hungry for education about it. Consulting with a knowledgeable professional or reading about the disorder are important steps to take before they actually confront the patient. Heavy-handed, punitive confrontation doesn't work. Instead, we now know that factitious disorder is among the trickiest of psychological ailments to address, and intervention must be informed, carefully planned, and, above all, humane.

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    Munchy - thanks for the articles.

    I was most facinated with this:

    "Based on experience with two dozen cases of Munchausen by Internet, I have arrived at a list of clues to the detection of factititous Internet claims. The most important follow:

    1. the posts consistently duplicate material in other posts, in books, or on health-related websites;
    2. the characteristics of the supposed illness emerge as caricatures;
    3. near-fatal bouts of illness alternate with miraculous recoveries;
    4. claims are fantastic, contradicted by subsequent posts, or flatly disproved;
    5. there are continual dramatic events in the person's life, especially when other group members have become the focus of attention;
    6. there is feigned blitheness about crises (e.g., going into septic shock) that will predictably attract immediate attention;
    7. others apparently posting on behalf of the individual (e.g., family members, friends) have identical patterns of writing."

    All 7 of these have been replicated on this support board, and previously on other support boards.

    It is scary at how duped we all were - sad too.

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    Found this at debunkingn**e.com:

    The Health Dramas

    N**e claims to have undergone an unusually high number of highly dramatic near-death experiences, beating incredible medical odds.
    To take just one 5-week period in March/April 2005, N**e claimed to have survived:
    5 cancer-related operations on his gastrointestinal tract,
    The loss of 45% of his blood,
    3 ‘deaths’ from heart attacks (with subsequent resuscitations, obviously),
    2 major brain surgeries, with survival odds of only 10% & 1%,
    1 serious blood infection.

    We now know that during this time he was negotiating a contract with a laser physician for patient referrals (commonly known as ‘fee-splitting’). We proved that since April 1st 2005, he had been accepting such payments, and we proved that a full two months after these payments began, N**e was still insisting that he was not being paid. (This affiliation was later terminated by the laser specialist.)
    When you add income from patient referrals to his considerable book sales, it is clear that N**e has plenty of reasons to want to build his reputation as the ultimate rosacea guru.
    Over the years we have often been told that one expert or another has come seeking N**e’s guidance and will soon be working alongside him, but the promised collaborations always disappear. On several occasions, N**e claimed it was because the other person was professionally inept or financially corrupt. He is very quick to accuse innocent people of corrupt behavior.
    Although N**e tells us that he is our only real hope of finding a cure, the tragic truth is that by his attempts to ‘corner the market’ on rosacea sufferers, he is driving a wedge between rosaceans and the other professionals who want to help.
    For example, when challenged about his histrionic health crises, N**e flounced out of the Rosacea Research Foundation, the fund-raising group he had helped to create. As punishment, he dedicated himself to destroying the RRF. Medical professionals who wanted to join and support rosacea research feared to participate because no one wanted to be N**e’s next victim.
    We think N**e’s increasingly aggressive and temperamental behaviour, both publicly and privately, has caused confusion, anxiety, and difficulties for many of the people he interacts with. Far from being our only hope of finding a cure, we believe that N**e is standing in the way. If we truly want to move forward, we as a community can no longer afford to turn a blind eye to the havoc that Geoffrey N**e is wreaking.

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    Excellent read Munch. Thanks. I do hope everyone takes the time to read it all. Not sure about the last fictitious name being "Jenny"! I assure you it's not ME!

    Surely this has to set off some alarm bells, for even the most resistant N*se supporters. Like a certain member that I am not allowed to mention...otherwise that member might feel compelled to put up another series of '%^ 'posts. Urgh! Well, that member seems to be the last one posting in N*se's support now. Crazy really, after all that has been proven!

    ----

    Hey Millie

    At least we are aware of it now, huh! What if we were still in the dark and were still victims of MA by Internet?! (Sorry, Munch, that is your user name!) You know, unless a small group of people went out on a limb, attacked for doing so, we would not be aware of it. Well, yes, we would be, but would still have to deal with it on a day to day basis. Who would want that now?! Urgh!

    -----

    Anyway, there is a lot of things I would like to highlight in your quotes Munch but I think the entire post requires reading.

    Oh, please don't go me on saying they are your quotes! Had that one already. For clarity, I mean that you quoted them from someone else...hence they are your quotes...that you quoted from someone else. Urgh! Thanks to 'person whom I can not name'! Have to clarify and not be regular chatty. Blah! Yeah, right 'person who can not be named'...you've done NO damage here whatsoever! And I'm not even talking about N*se, just his last vocal voice here...although I fear there are more...still checking...

    Jen

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    Honestly, what is this diagnosis based on?

    As I recall, Dr Nase took steroids which caused lots of emotional as well as physical distress.

    Drugs like steroids are no kidding...they might disturbe hormonal balances so you might gain weight, might loose your ability to have sex, might become highly depressed from increased bloodpressure (hypertension inhibits serotonin production)

    People judge the actions of someone in crisis without looking at all possible explanations. I don't understand much of Dr Nase's collaboration with an ETS practitioner...but my lack of understanding and lack of sympathy doesn't allow me to hunt the man...leave the guy alone, report him to the police if you think he has done something wrong...or talk to him, see what he has to say. Who knows, it might be that the isolation causes him to do seemingly stupid things?

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    Quote Originally Posted by El Lechero
    Honestly, what is this diagnosis based on?

    As I recall, Dr Nase took steroids which caused lots of emotional as well as physical distress.

    Drugs like steroids are no kidding...they might disturbe hormonal balances so you might gain weight, might loose your ability to have sex, might become highly depressed from increased bloodpressure (hypertension inhibits serotonin production)

    People judge the actions of someone in crisis without looking at all possible explanations. I don't understand much of Dr Nase's collaboration with an ETS practitioner...but my lack of understanding and lack of sympathy doesn't allow me to hunt the man...leave the guy alone, report him to the police if you think he has done something wrong...or talk to him, see what he has to say. Who knows, it might be that the isolation causes him to do seemingly stupid things?
    No I don’t buy into this, as Steroid use might be an excuse of sorts but only if Nase had really been taking them long-term to fight cancer but of course you are forgetting that he is a liar.

    In November 2005 Nase claimed to have been taking cancer-fighting steroids for more than a year. He said on ESFB that he was "slowly weaning off the steroids" and put up a link to a photo showing a box of drugs. His name was on the label but the dosage was only enough for 6 days! A doctor or medical adviser might agree to let a patient take 6 days worth of steroids for many reason but not for cancer.

    If you look at Nase's deposition of 30th September 2005 (under oath), he
    admitted that he had been in good health for at least the previous three
    months:

    Q. Dr. Nase, did you state publically and in postings that one of your
    reasons for leaving the IU job were health concerns?
    A. Did I state that was one of the reasons?
    Q. Yes. Did you state that publically?
    A. I honestly don't remember. I don't know.
    Q. Okay. Are health reasons a contributing factor to your failure to have
    further financial gain over the last three months?
    A. No.
    Q. Are you under -- on any medication today?
    A. No.
    Q. Have you been under any medication for the last three months?
    A. Just cold medication.

    Nase's sworn testimony was that he was so healthy right through the summer of 2005 that he never once took anything stronger than cold remedies. Yet from May to July he wrote dozens of posts to get sympathy, going on about how he was "still throwing up every day from seizures" while his brain tissue was healing, and how he was on lots of medications, including steroids and antiseizure drugs. Here are just a few little quotes to refresh your memory:

    "I have to retrain my left arm and fingers to type. So one or two posts per day is good rehab for me, but then my brain gets tired. (Signed) Geoffrey with no hair".

    "I have to retrain my left arm (I cant type -- my brain can see the letter A on the keyboard, but it cant tell my fingers to go to that spot), I have to retrain my left leg to walk correctly and work on my speech quite a bit."

    "The encapsulation (surrounded by connective tissue) was a gift from GOD because it allowed them to easily dissect the tumor out without surgically removing good tissue. My brain still swells and lose my speech, but it was wonderful."

    If you can't remember any of those, how about this Forum post from July 2, 2005:

    "I am having a pretty good head day. I had my last internal stint taken out and it feels much better. I also dropped one antisiezure medication due to the healing process and the severe mood swings that it caused."

    http://forum.rosaceagroup.org/viewtopic.php?t=615

    Nase then either continued on with his other antiseizure medications and
    strong steroids, or, as he admitted under oath, he took nothing stronger
    than a cold cure.

    That last post went on to blame his "severe mood swings" on his brain
    tumour: "they said this was a common side effect. They also said that it is
    quite common for people with tumors in my area to experience daily/hourly mood swings -- and this was in there for at least a couple years growing."

    So Nase lies and attacks people and stages hysterical near-death dramas
    because he was briefly on steroids or because he had a brain tumour or
    because he is a liar and a fantasist who gets off on that kind of thing. ...

    Doesn’t really take much working out – does it?

    Thanks

    Peter

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    Following on from my post yesterday on this thread I have been reflecting on this comment:

    Quote Originally Posted by El Lechero

    ..leave the guy alone, report him to the police if you think he has done something wrong...
    And this one he posted on another thread ""Honestly Peter....how about leaving Dr Nase alone until you can bust him for doing something illegal"

    Actually I must admit this is a very good idea (Thanks El Lechero) and should really be followed up. You see Nase has done many things which are illegal, which include multiple counts of perjury. Anybody could put together an excellent case from the abundance of evidence freely available on the internet and just hand the whole matter over to the police or I suppose possibly even better, the Indiana authorities so they can decide if he is breaking the law. If Nase can clear his name and prove that everybody else has been lying then let it end there. I am not au fait with American law but wouldn’t such a complaint have to be filed by an American citizen? Not sure but this is certainly something worth giving some thought to and I need to do some investigating.

    Peter

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