Garnett Spears spent much of his short life in and out of hospitals. His mother, Lacey, moved him from town to town and doctor to doctor as he got sicker and sicker with a mysterious illness. Last year, he died at the age of 5. Last week, Lacey was convicted of second-degree murder for his death. Prosecutors alleged that she had been poisoning her son with high doses of sodium through a feeding tube in his stomach, then carting him to the hospital to elicit sympathy from doctors and friends.
In 1951, a British doctor named Richard Alan John Asher coined the term “Munchausen syndrome” to refer to patients who feign or induce illness in themselves for no obvious reason. (It’s distinct from “malingering,” where a person fakes or induces illness for a tangible goal, like convincing a doctor to prescribe a certain medication or securing a favorable court verdict.) By 1977, researchers had identified a new permutation of the syndrome—“Munchausen by proxy”—wherein the subject fakes illness in another person; one of the first recorded cases involved a mother who, like Spears, poisoned her toddler with sodium. But Spears didn’t just poison Garnett; she also tweeted about his illness (@GarnettsMommy), blogged about it (“Garnett’s Journey”), and documented it with photographs posted to MySpace. Some argue that Spears was exhibiting an even newer form of Munchausen than had previously been identified: “Munchausen by proxy by Internet.”
The Diagnostic and Statistical Manual of Mental Disorders—the industry guidebook produced by the American Psychiatric Association—recognizes the Munchausen-like disorders “Factitious Disorder Imposed on Self” and “Factitious Disorder Imposed on Another,” but it includes no specific entry for cases that play out over the Internet. In fact, none of the hundreds of disorders outlined in the DSM reference Internet-specific ailments; the APA does not recognize “Internet Addiction” or “Online Gambling Disorder” or “Internet Gaming Disorder.”
Dr. Marc Feldman, a psychiatrist and a leading Munchausen researcher, coined “Munchausen by Internet” in 2000 to refer to cases with an online element. Since then, the term has been popularized by Wikipedians and journalists, inspiring deep dives in the Village Voice, the Stranger, Gawker, and Wired. But in the psychiatric community, the idea of updating the literature with Internet-specific diagnoses is controversial. While some doctors believe that psychiatric classifications need to keep pace with new technologies in order to properly diagnose modern patients, others argue that such “diagnostic inflation” risks stigmatizing novel human behaviors—like spending a lot of time online—instead of focusing on the psychiatric root of the problem. The conflict, in other words, lies between those who believe that the Internet has the power to inspire new disorders affecting the human brain, and those who see it as just a new vehicle for expressing old mental illnesses.
“The Internet is impacting everything in society, and it’s moved so fast that the field of medicine, including psychiatry, is struggling to catch up,” says Jeffrey Lieberman, Chairman of Psychiatry at the Columbia University Medical Center and a former president of the AMA. But at the same time, “we don’t want to call every new fad or cultural change an illness, because there’s little value in pathologizing the great diversity of normal human behavior.”
In 1840, the U.S. census recognized just two categories of mental disorders: “insane” or “idiots.” As medical science progressed, doctors were able to distinguish illnesses more precisely, and as environmental factors shifted, new complications arose: DSM-approved disorders like “Tobacco Use Disorder” and “Caffeine Withdrawal” did not exist before humans started smoking cigarettes and drinking coffee.
In the 2013 DSM-5, the APA wrote that “Internet Gaming Disorder” is a condition worthy of future study, but declined to include it as an official diagnosis. (Proposed symptoms include a “preoccupation with Internet games,” experiences of “irritability, anxiety, or sadness” when Internet games are taken away, and jeopardizing “a significant relationship, job, or educational or career opportunity because of participation in Internet games.”) The APA has signaled a willingness to incorporate Internet-related symptoms into its descriptions of existing disorders. The entry for “Illness Anxiety Disorder” in the current DSM, for example, notes that sufferers sometimes “research their suspected disease excessively (e.g., on the Internet).” And the ADHD entry urges practitioners to note how a patient reacts to “consistent external stimulation” including content absorbed “via electronic screens.”
When a new permutation of human behavior pops up—like staring at an electronic screen for hours on end, or obsessively researching an illness online—it inspires scientific debate as to whether it constitutes a totally normal activity, a symptom of some existing disorder, or a sign of a new disorder deserving its own classification. (The battle over whether people can get “addicted” to the Internet, for example, has been waged across psychiatric journals for years.) Part of the difficulty in parsing the distinction stems from the fact that most mental disorders are diagnosed exclusively based on the patient’s symptoms, not on laboratory tests or brain scans. As Lieberman puts it, “We’ve never been able to move beyond symptoms as the basis of the diagnosis for mental illnesses.” Since a patient can’t just take a blood test to see what psychiatric disorder she has, doctors must parse her symptoms and decide what psychiatric framework they fit into best. And at this point, problematic Internet-related behaviors are so new that there’s little scientific consensus on how they fit into established underlying disorders, or whether those patients would benefit from new and different courses of treatment.
In some cases, it’s pretty clear when an Internet-related symptom just constitutes a new expression of an existing disorder: “People have had psychotic disorders for hundreds if not thousands of years, but some common forms of paranoid delusions—like ‘the CIA is after me’ or ‘people are listening to my thoughts through a computer chip in my brain’—wouldn’t have existed hundreds of years ago, because we didn’t have computer chips and there was no CIA,” Lieberman says. But in other cases, the new symptoms suggest a possible shift in how the disorder actually affects the brain. In an early examination of the idea of Internet addiction published in the Social Science Computer Review in 2005, Bryant University psychologist Janet Morahan-Martin noted that compulsive online gambling, for example, “is a new variant of an old behavior, but patterns of disturbed gambling behavior may be different online than not online.” In many cases, for example, “pathological patterns of gambling may be accelerated online because online gambling is always accessible and provides instantaneous feedback.”
In the case of Munchausen and Munchausen by proxy, Feldman argues that the online manifestation of the disorder is so distinct from the traditional version that it needs its own classification. “It used to be thought that the whole goal of this behavior was to mislead medical professionals, to get nurses and social workers and doctors to provide sympathy and concern,” Feldman says. The most committed deceivers, who were splashed with the term title “hospital hobos” in the 1990s, would go so far as to have unnecessary procedures performed on themselves or others, then hop to a new doctor’s office or hospital to continue the deception. But now, “the Internet has expanded the base of people who are engaging in this kind of behavior,” Feldman says. A person can convincingly feign a new disease by scanning Wikipedia or WebMD, or by downloading false medical records or radiographs and whisking them to the doctor’s office. A modern sufferer doesn’t even necessarily need to report to the doctor or alter her physical appearance in order to perpetrate the ruse. She can just start up a blog or hop onto an online self-help group, and voila: She has “late-stage ovarian cancer” or a “very sick kid.” I asked Feldman what old-school “hospital hobos” would think of this new class of online faker, and he told me: “I would imagine they would have some contempt for their amateurism.”
In 2012, a pair of professors at Bournemouth University published a review of existing research on Munchausen by Internet in the Journal of Medical Internet Research, and recommended that Munchausen by Internet be formally recognized by the DSM as a discrete disorder. Feldman told me that mental health professionals need to be aware of how syndromes like Munchausen play out online in order to effectively diagnose patients and get them help. Officially codifying the online expression of the disorder would alert doctors to the fact that their patients may be spreading medical misinformation online or leveraging their social networks to harm other people, and also allow them to see certain behaviors as potential signs of illness. Spears, for example, skipped from doctor to doctor to help cover her tracks, but she was tweeting all the way. That doesn’t necessarily mean that the mental health system should recognize separate online and analog versions of every disorder known to science, but it should, at least, recommend greater mentions of the Internet in the descriptions of symptoms. “All of us are taught in medical school to pay attention to the patient's ‘biopsychosocial’ condition,” Feldman says. “That should include the use of the Internet.”