Dying for attention: Why do some people pretend to be sick?

For seven years, Amanda C. Riley, a former school principal from America’s West Coast, battled Hodgkin’s lymphoma. She was young, beautiful, and adored by those in her tight-knit Christian community, and documented every moment of this journey online – from losing all her hair to a “miracle” pregnancy while undergoing chemotherapy.

The only problem? It was all a ruse.

Amanda Riley (left) and Australian cancer fraudster Belle Gibson (right).Credit: Aresna Villanueva

Riley’s story is the subject of a new documentary, Scamanda, which charts the lengths she went to in order to maintain her veil of sickness. In 2021, Riley pleaded guilty to defrauding more than $US100,000 from donors ($158,909) and was sentenced to five years in prison.

Narratives about people faking illnesses have shot into the mainstream again with the release of Apple Cider Vinegar, a fictionalised Netflix show inspired by Australian cancer fraudster Belle Gibson. But what drives people to engage in these complex, often decades-long ruses? Money, fame and sympathy are part of the equation, but experts say that’s not all there is to it.

Dying for attention, money – or something else?

People who fake illness typically fit into one of two diagnostic categories, says Dr Peter Ashkar, a forensic psychologist and clinical neuropsychologist based in Sydney.

The first of these is factitious disorder, more commonly known as Munchhausen’s Syndrome.

Ashkar defines this as the “falsification or deliberate causation of symptoms, whether they be physical or psychological, that allows the individual to present as sick or unwell, particularly in the absence of obvious external rewards”.

Their motivations are often enigmatic.

If they are driven by an obvious secondary gain – often financial – then their behaviour is categorised as malingering, a term originally created to describe those who feigned illness to avoid military service.

Ashkar points out these are different to people suffering from hysteria or delusions, who genuinely believe themselves to be sick.

But Dr Chris Millard, a senior lecturer in the history of medicine and medical humanities at the University of Sheffield, says placing perpetrators into one of these two categories isn’t always so simple.

“Human beings are super complicated, and I think humans themselves are very bad at telling you what their motives are, even when they’re being honest. So when they’re being dishonest, it’s absolute carnage,” he says.

Both Riley and Gibson profited from their ruses, but they also enjoyed fame, praise for their bravery and resilience, and sympathy. One might surmise that if their motives were purely financial, there would be far easier ways to make a quick buck.

“This is where it starts to get difficult because you’re saying, well, the only thing we can get this person on, the only way that we can actually stop them from doing something is by convicting them of fraud. That doesn’t mean that’s why they’re doing it,” says Millard.

Millard believes viewing faking illness as a need that permeates every aspect of someone’s life is the most accurate. He points to Gibson, who continued to lie even after getting caught.

“Even though she’s defrauded and hurt many, many people, I find her a very tragic case because it’s really clear that there is some need that we can’t really define very well that is not being met or is not being managed properly,” he says.

How common is factitious disorder?

Munchhausen’s is an incredibly rare disorder – some estimates put it at 1 per cent of the population. But Ashkar says accurately gauging its prevalence is tricky since many people who pretend to be unwell will be diagnosed as legitimately unwell in the health system.

Looking at recent high-profile cases of medical deception, one might assume Munchhausen’s is the domain of young women. But is this true?

There is conflicting research on whether factitious disorder is more common in men or women. Ashkar says the “best” studies suggest it is more prevalent in women. A systematic review from 2016 found 66.2 per cent of those sampled with factitious disorder were women.

Millard suspects Munchhausen’s gendered associations might also be symptomatic of “the kind of young photogenic women who attract certain kinds of attention in online spaces. Part of this is the glossy image of the wellness industry, which has been exploited by some of these people”.

Faking it in the internet age

While people pretended to be sick long before the internet, the digital age has expanded the opportunities.

Such scams even have a name – Munchhausen’s by Internet – a term coined by American psychiatrist Dr Marc Feldman. The multiplication of virtual support groups for any and every illness, Feldman writes in an online article, “provide an inexpensive, convenient and readily accessible forum for people who choose to misrepresent themselves as ill.”

Millard says these groups operate from a baseline of trust that people like Riley and Gibson easily exploit.

Can we still trust people who say they are sick?

So, what do cases like Riley’s and Gibson’s say about how we should approach stories of illness online?

Millard thinks leading with distrust, or cynicism, is unhelpful, partly because there are no “reliable red flags” for factitious disorder, but also because people in the medical system today – particularly women – are already often ignored.

“A wholesale withdrawal of trust from people trying to access healthcare will not help anyone – not the vast majority of patients struggling to be heard even in the best of times, and not chronic fakers,” he says.

And as difficult as it may be, Millard thinks we need to treat people like Riley with sympathy, since they also need help.

“When it is discovered that someone’s problem is not the one they present with but is to do with a deep unmet emotional need, we need to be more agile in changing the therapeutic approach and try to avoid blame as much as possible,” he says.

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