More research is required to be able to provide evidence-based advice to victims of suspected Munchausen by Internet trolls and for facilitators of discussion groups to effectively manage interactions. As this is one area of the literature that does not yet yield much information, one methodology that could possibly be adopted for further study is based on qualitative content analysis (QCA), which is gaining much support in studies of social interactions in online support communities [61
]. QCA provides a way to study manifest and latent content within a body of text. Analysis of what the text says describes the visible components, referred to as the manifest content
. Analysis of what the text talks about 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 illness. The manifest content is usually presented in categories, whereas the latent content is expressed as themes. QCA differs from pure qualitative research as it allows the researcher to emphasize differences between and similarities within codes and categories. Therefore, it could be used to differentiate types of Munchausen by Internet and its different motives.
When Munchausen by Internet seems likely, it might be practical to have some established group members gently question any dubious post owner privately. Although the typical response is vehement denial regardless of the strength of the evidence, the author typically will disappear from the group. In some Munchausen by Internet cases, much like FD cases, individuals 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 fake personae [27
]. Savino and Fordtran [17
] suggested some useful steps for confronting patients suspected of FD:
1. Let the patient know what you suspect but without outright accusation.
2. Support the suspicion with facts.
3. Provide empathetic and face-saving comments.
4. Avoid probing to uncover the patient's underlying feelings and motivations so as to minimize disruption of emotional defences that are essential to her function.
5. Assure the patient that only those who need to know will be informed of the suspicion of factitious disease.
6. Make sure the staff demonstrate continued acceptance of the patient as a person worthy of their help.
7. Encourage psychiatric help, but if the patient resists do not force the issue.
However, once a perpetrator has been confronted, remaining members of the online group may need psychological help at an individual or group level depending on the extent of the deception and the health topic concerned. For example, individuals may need help in processing their feelings. As a group, help could be directed toward dealing with conflict and blame, 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 actions and concrete objects that govern what people do, not what they think or feel. Historical law assumes a physical world constrained by time and space, but virtual environments have significantly different functionality. This means the virtual world is a functionally different world; it may not be appropriate, or even possible, to transfer laws from the physical to the electronic world. Therefore, laws must be re-invented by re-applying legitimacy concepts to virtual contexts such as formulating direct policy to protect health information users in the new world 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 best results within a physician-patient relationship can be achieved by approaching the dilemma from diverse angles [28
Historically, the consequences for perpetrators have tended to be minor because few can be pursued or punished unless the wronged individuals are able to prove that the perpetrators have committed an illegal act. However, a 2005 legal case 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 respond without fear of successful legal reprisal. They might also be able to win a precedent-setting civil case [64
]. Indeed, there is a strong case for considering the sadistic misuse of health-related forums as a form of cybercrime, rather than as an everyday negative risk of using the Internet that must be tolerated and accepted. Consider if a malicious user deliberately (or accidentally) gave out medical information that resulted in a worsening of health or had fatal consequences. Internet protocol (IP) addresses of Munchausen by Internet trolls could be identified and Internet service providers (ISPs) could be enlisted to help identify and “out” frequent perpetrators such as been seen in recent online copyright disputes. Social network providers, such as Facebook, should tighten up their own procedures or, as an alternative, group users might want to consider relocating to more private group-based Internet communities, such as private Wikis [51
]. Although these do not have the same large population of users, they might increase the security and lessen the chance of encountering a Munchausen by Internet troll online.
Enhanced self-regulation is the most positive action to reduce group risk. It might also be advisable for a health support group to identify a gatekeeper. Although adding extra layers of security and formality before a user could post might be viewed as onerous, the long-term benefits might be worth the additional effort. Facilitators could also clearly state to all members that although most people participating in support groups are honest, all members should balance their empathy with some degree of circumspection. Group members should be especially careful about basing any of their own health care decisions on uncorroborated information supplied in groups, just as they should with any other source on the Internet [65
We have 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 Internet. However, there is a clear, compelling need to recognize that in addition to Munchausen by Internet being classed as a condition in its own right, there is a subset of people currently tagged as Munchausen by Internet sufferers who are actually Munchausen by Internet trolls purposefully harming well-intentioned support groups and abusing members for their own pleasure or enjoyment. We propose that Munchausen by Internet and Munchausen by Internet trolling be 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 by group users or by 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.”