In factitious disorder (FD), an individual fabricates or induces illness primarily to garner emotional gratification. The term “Munchausen syndrome,” although absent from DSM-5, may be better known, and has been conceptualized as a severe manifestation of FD. The social media correlate, termed “Munchausen by internet” 2 decades ago and illustrated by the preceding cases, involves a poser who infiltrates groups to elicit nurturance and empathy for tragic but false or exaggerated circumstances. In the cases presented here, it has been established that no money, gifts, or other external rewards were provided to the posers. Therefore, these cases do not represent simple malingering (or “malingering by internet”). One of the authors (MDF) is aware of a text edit in the upcoming DSM-5-TR to clarify that factitious disorder, whether imposed on self or another, can be carried out partly or fully online.
With the COVID-19 lockdown, many helping professionals have moved to providing support online or via the telephone. This change may increase the number of professionals available to be targeted online and the overall number of active MBI cases. Notably, at least 2 of the cases in this report included explicit claims about COVID-19 restrictions. The nascent literature suggests that posers often exploit health headlines to mobilize the sympathy they seek.
We cannot firmly establish the number of actual individuals behind the ruses in these 5 case studies. Based on comparisons of the presentations among the cases, we concluded that there may be only 3 different posers described. “Jessica/Dakota” has been confirmed by a group of doulas to be known by at least 2 other names. The doulas have shared videos and photographs of her and confirmed they have all provided support to this one person. In all cases involving this person, her baby (sometimes twins) has complex medical conditions that result in their death. It is also common that a family member dies or is dying from a medical condition. The posers “Anna” and “Hayley” did not allow contact by video and did not share photographs. At least 3 doulas confirmed that they had supported “Anna,” and each confirmed the use of the same photograph of her professed mother-in-law. “Hayley” was unique in that the doula who supported her noticed that she used the word “pleases” rather than “please,” with this same idiosyncrasy found in messages from both “Hayley” and her partner.
Consistent with previous research on individuals who had been misled via MBI, the doulas who were deceived reacted in diverse ways. Several were interviewed after weeks or months to reassess their thoughts and feelings. Some of the doulas noted how much more suspicious they were of requests for their services. The few who had reported their experiences to the police were told that no crime had been committed because no money was taken. One of the doulas, Sara, developed an online training program for birthing assistants to teach them how to work online professionally but safely. As part of this training, she shares her own story. The first security step she recommends is an identity check by video at the earliest stage of contact. She also reinforces the need to see that the client is actually pregnant or has a baby with them. Sara notes that some people can “fake” a pregnancy convincingly (by using prosthetics or distending their abdomens) or use very lifelike dolls. She therefore also asks for the names and contact details of the client’s primary physician and midwife. She requests a nominal fee at the earliest stage, and urges doulas to execute a formal contract, even if care is being provided pro bono. One doula, Charlotte, now follows this advice and, as a result, feels that professionally, “I have locked my doors. They used to be wide open for anyone to walk through.”
Some doulas reported feeling bereaved themselves, while others remain angry, noting that they will never be compensated for their considerable work. Some feel “silly” or resigned. Anya recalled an initial sense of relief that the purported series of tragic events “hadn’t really happened to someone” and that she was no longer obliged to offer support. Charlotte stated that she has felt “stalked,” observing that even after the contact ceased, Charlotte continued to have the “feeling [the poser] is in every corner of my life.” She worries, for example, about whether she is being followed on social media, and she repeatedly checks that she has locked her doors at home.
Anya said that she had doubted the stories of “Hayley” on several occasions, but added, “It is very difficult to question a grieving mother or someone who is claiming rape had occurred.” She observed that her reaction was fueled by her awareness that society historically has had a narrative of “not believing women” who report sexual assault.
Many doulas worried about the safety of the posers, concerned that they may be a threat to themselves or others. Several doulas offered to help one of the posers to find psychological treatment, but that poser never accepted this assistance. Perhaps the most poignant comment of all came from a doula who stated, “Even when you walk away, you are left with a sense that you’ve let the patient down in some way.”
