Malingering

Malingering is a medical and psychological term that refers to an individual fabricating or exaggerating the symptoms of mental or physical disorders for a variety of motives, including getting financial compensation (often tied to fraud), avoiding work, obtaining drugs, getting lighter criminal sentences, trying to get out of going to school, or simply to attract attention or sympathy. Because malingerers are usually seeking some sort of primary or secondary gain, this disorder remains separate from Somatization disorders and factitious disorders in which the gain is not obvious. Legally, malingering is often referred to as Fabricated mental illness or Feigned mental illness. See United States v. Binion.^[1]

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History

Malingering has been recorded as early as Roman times by the physician Galen, who reported two cases. One patient simulated colic to avoid a public meeting, whilst the other feigned an injured knee to avoid accompanying his master on a long journey. ^[2]

Widespread throughout Soviet Russia to escape sanctions or coercion, physicians were limited by the state in the number of medical dispensations they could issue. ^[3] With thousands forced into manual labour, doctors were presented with four types of patient; 1. those who needed medical care; 2. those that thought they needed medical care (hypochondriacs); 3. malingerers; and 4. those that made direct pleas to the physician for a medical dispensation from work. This dependence upon doctors by poor labourers altered the doctor-patient relationship to one of mutual mistrust and deception.^{[citation needed]}

Symptoms

There is a rich and diverse array of methods for feigning illness. Physical methods reported include trying to deceive measuring devices such as thermometers, inducing swelling, delaying wound healing, over-exercise, drug overdose, self-harm, or directly reporting diagnostic signs of disease, learnt from a medical textbook. ^[4] Patients may report a factitious history, such as describing epileptic seizures or a heart attack, sometimes supplementing this with the use of agents which mimic disease, such as taking neuroleptic drugs to mimic tremor. Detection is made more difficult in those who do have a diagnosed, organic disease already. In these cases, malingering is sometimes described as a "functional overlay" on an existing disease.

Predisposing factors

Malingering appears to be more common in societies with regimented, enforced labour (industrial malingering), universal military service (military malingering), or the ability to sue for damages arising from accidents (medicolegal malingering). Malingering is more common in women than men and is more prevalent amongst those employed in health-related fields. Psychodynamic theory suggests patients may have been neglected or abused as children and are attempting to resolve issues with their parents. ^[5]

Diagnosis and Detection

Diagnosis

DSM-IV-TR

The DSM-IV-TR states that malingering is suspected if any combination of the following are observed^[6]

1. Medicolegal context of presentation
2. Marked discrepancy between the person’s claimed stress of disability and the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying with prescribed treatment regimen
4. The presence of Antisocial Personality Disorder

However, these criteria have been found to be of little use in actually identifying individuals who are malingering. (Clinical assessment of malingering and deception 2nd ed. Rogers, Richard; New York, NY, US: Guilford Press, 1997.)

Detection

Some feature at presentation which are unusual in genuine cases include: ^[7]

1. Dramatic or atypical presentation
2. Vague and inconsistent details, although possibly plausible on the surface
3. Long medical record with multiple admissions at various hospitals in different cities
4. Knowledge of textbook descriptions of illness
5. Admission circumstances that do not conform to an identifiable medical or mental disorder
6. An unusual grasp of medical terminology
7. Employment in a medically related field
8. Pseudologia fantastica (ie, patients' uncontrollable lying characterized by the fantastic description of false events in their lives)
9. Presentation in the emergency department during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (eg, holidays, late Friday afternoons)
10. A patient who has few visitors despite giving a history of holding an important or prestigious job or a history that casts the patient in a heroic role
11. Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
12. Acceptance, with equanimity, of the discomfort and risk of surgery
13. Substance abuse, especially of prescribed analgesics and sedatives
14. Symptoms or behaviors only present when the patient is being observed
15. Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
16. Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
17. Giving approximate answers to questions, usually occurring in FD with predominantly psychological signs and symptoms (see Ganser Syndrome)

When malingering takes on a legal context it is more common either for private investigators to find evidence of malingering (say, videotaping a "paralysed" person walking around their home), or reports from friends, colleagues, or family members.

If a psychiatrist or neuropsychologist suspects malingering in a case of possible brain damage (i.e. caused by head trauma or stroke), they may look for a discrepancy between the patient's reported functions of daily living and their performance on neuropsychological tests. In theory, any neuropsychological test could be used in this way, depending on the context. No one test, administered by itself, can proffer a diagnosis of malingering, so a neuropsychological examination typically consists of a battery of tests. Three tests commonly used to determine malingering are:

• Computerized Assessment of Response Bias (CARB)
• Minnesota Multiphasic Personality Inventory (MMPI)
• The Test of Memory Malingering (TOMM)

Treatment

Treatment is psychological, and varies according to the underlying cause of the individiual's unique symptoms. Treatment options may include psychotherapy, family therapy, cognitive behavioural therapy, or pharmacotherapy. It is important that other members of the medical team such as nurses, ward assistants, and physical therapists are informed about the patients' history. On being confronted with a diagnosis of malingering, many patients discharge themselves immediately, only to present at another medical facility to try again.

Although malingering patients do waste a lot of resources, they are still entitled to the same safeguards as other patients. For instance, it is not considered ethical (or legal) to "blacklist" patients by warning other healthcare facilities about them without the patient's permission, searching through their personal effects to find evidence of malingering, or covertly videotaping them without their consent. ^[8]

Impact on Society

Malingering is damaging in three ways. Firstly, by reducing the productivity of industry or the military through absenteeism, secondly by depleting private and governmental social security, disability, worker's compensation, and insurance benefits, and thirdly by draining the medical system of resources. Malingerers take up the time and energy of medical personnel, as well as requiring detailed and expensive testing to rule out obscure conditions. Therefore malingering can deprive more seriously ill individuals of the care they deserve.

Malingering is regarded unfavorably by the criminal justice system. For example, in some cases feigning mental illness has led to a harsher sentence, because malingering during a competency evaluation resulted in a charge and enhanced sentencing for obstruction of justice.^[9]

Related Conditions

• Factitious disorder
• Ganser syndrome
• Munchausen syndrome

References