Malingering is intentional production of false or exaggerated symptoms motivated by external incentives, such as obtaining compensation or drugs, avoiding work or military duty, or evading criminal prosecution. Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), malingering receives a V code as one of the other conditions that may be a focus of clinical attention.
Pathophysiology: Malingering is deliberate behavior for a known external purpose. It is not considered a form of mental illness or psychopathology, although it can occur in the context of other mental illnesses.
Mortality/Morbidity: The total cost of health insurance fraud in the United States (including untruthful claims by patients and medical personnel) was more than $59 billion in 1995, resulting in a cost of $1050 in added premiums for the average American family.
Strongly suspect malingering in the presence of any combination of the following:
- Medicolegal presentation (eg, an attorney refers patient, a patient is seeking compensation for injury)
- Marked discrepancy between the claimed distress and the objective findings
- Lack of cooperation during evaluation and in complying with prescribed treatment
- Presence of an antisocial personality disorder
* Malingering often is associated with an antisocial personality disorder and a histrionic personality style.
* Prolonged direct observation can reveal evidence of malingering because it is difficult for the person who is malingering to maintain consistency with the false or exaggerated claims for extended periods.
* The person who is malingering usually lacks knowledge of the nuances of the feigned disorder. For example, someone complaining of carpal tunnel syndrome may be referred to occupational therapy, where the person who is malingering would be unable to predict the effect of true carpal tunnel syndrome on tasks in the wood shop.
* Prolonged interview and examination of a person suspected of a malingering disorder may induce fatigue and diminish the ability of the person who is malingering to maintain the deception. Rapid firing of questions increases the likelihood of contradictory or inconsistent responses. Asking leading questions may induce the person to endorse symptoms of a different illness. Questions about improbable symptoms may yield positive responses. However, because some of these techniques may induce similar responses in some patients with genuine psychiatric disorders, exercise caution in reaching a conclusion of malingering.
* Persons malingering psychotic disorders often exaggerate hallucinations and delusions but cannot mimic formal thought disorders. They usually cannot feign blunted affect, concrete thinking, or impaired interpersonal relatedness. They frequently assume that dense amnesia and disorientation are features of psychosis. It should be noted that these descriptions also may apply to some patients with genuine psychiatric disorders. For example, individuals with a delusional disorder can have unshakable beliefs and bizarre ideas without formal thought disorder or affective blunting.
* The most common goals of people who malinger in the ED are obtaining drugs and shelter. In the clinic or office, the most common goal is financial compensation.
Physical: Typically, deficits on physical examination do not follow known anatomical distributions. A patient’s attitude toward the examining physician often is vague or evasive.
Other Problems to be Considered:
Antisocial personality disorder
True medical or psychiatric illness related to presenting complaints
* The Minnesota Multiphasic Personality Inventory (MMPI) can detect inconsistent or atypical response patterns associated with malingering (see Image 1). The F scale and the F-K index are the most valuable indicators.
* Do not accuse the patient directly of faking an illness. Hostility, breakdown of the doctor-patient relationship, lawsuit against the doctor, and, rarely, violence may result.
* The more advisable approach is to confront the person indirectly by remarking that the objective findings do not meet the physician’s objective criteria for diagnosis. Allow the person who is malingering the opportunity to save face.
* Alternatively, the physician may inform people who are malingering that they are required to undergo invasive testing and uncomfortable treatments (provided, of course, that such warning is true).
* The likelihood of success with such approaches is inversely related to the rewards for the malingering behavior.
People who malinger almost never accept psychiatric referral, and the success of such consultations is minimal. Avoid consultations to other medical specialists because such referrals only perpetuate malingering. However, in cases of serious uncertainty about the presence of genuine psychiatric illness, suggest psychiatric consultation.
Psychiatric consultation may be suggested as an augmentation to dealing with an acknowledged symptom. For example, the primary physician might propose, “Your pain has to be causing your system a great deal of stress, and we know that only makes the pain worse. Consultation from a psychiatrist might help us with your pain by reducing the stress.” Without being confrontational, the physician must remain honest.
* Malingering behavior typically persists as long as the desired benefit outweighs the inconvenience or distress of seeking medical confirmation of the feigned illness.
* Because malingering for the purpose of compensation constitutes criminal behavior, document the diagnosis meticulously. When in doubt, assuming that the patient is not malingering is a better course of action.
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.
Widespread throughout Soviet Russia to escape sanctions or coercion, physicians were limited by the state in the number of medical dispensations they could issue. 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.
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. 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.
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.
The DSM-IV-TR states that malingering is suspected if any combination of the following are observed
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
Some feature at presentation which are unusual in genuine cases include:
- Dramatic or atypical presentation
- Vague and inconsistent details, although possibly plausible on the surface
- Long medical record with multiple admissions at various hospitals in different cities
- Knowledge of textbook descriptions of illness
- Admission circumstances that do not conform to an identifiable medical or mental disorder
- An unusual grasp of medical terminology
- Employment in a medically related field
- Pseudologia fantastica (ie, patients’ uncontrollable lying characterized by the fantastic description of false events in their lives)
- 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)
- 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
- Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
- Acceptance, with equanimity, of the discomfort and risk of surgery
- Substance abuse, especially of prescribed analgesics and sedatives
- Symptoms or behaviors only present when the patient is being observed
- Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
- Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
- Giving approximate answers to questions (eg, a horse has 3 legs; 7 X 6 = 41), 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 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.
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 deprives genuinely unwell individuals of the care they deserve.