Malingering

Malingering
Specialty	Psychiatry, psychology

Malingering is a medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy. A common form of malingering in legal procedure prosecution is sometimes referred to as fabricated mental illness or feigned madness; a 2005 case, United States v. Binion addressed malingering hindering prosecution. The disorder remains separate from somatization disorders and factitious disorders in which primary and secondary gain, such as the relief of anxiety or the assumption of the "patient role", is the goal. The symptoms most commonly feigned include those associated with mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system for the countries that has one, and false attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population.

History

In the Hebrew Bible, David feigns insanity to escape from a king who views him as an enemy. Malingering has been recorded historically as early as Roman times by the physician Galen, who reported two cases. One patient simulated colic to avoid a public meeting, while the other feigned an injured knee to avoid accompanying his master on a long journey.

Because malingering was widespread throughout the Soviet Union 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 who thought they needed medical care (hypochondriacs); 3. malingerers; and 4. those who 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.

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. Patients may report a fictitious 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, sometimes called "partial malingering". In these cases, malingering is sometimes described as a "functional overlay" on an existing disease. Persons who have an intermittent disorder may feign a return of symptoms in order to gain some benefit. The indigent homeless may do this in cold weather, in order to obtain indoor lodgings.

Some conditions are thought to be easier to feign than others. For example, everyone has experienced pain and knows how a person in pain should appear to others. The medical literature, especially in psychiatry, has become keenly aware of the complex issues related to malingering.

Ganser syndrome was once thought to be a form of factitious disorder, or malingering psychiatric symptoms for psychological gain. This was seen when prisoners were released from extreme solitary confinement, often involving the inability to communicate with anybody, and perpetual darkness. However, the symptoms were different from other mental illness, but consistent from one prison to another, where the affected individuals did not know one another. It has since been determined to be a genuine syndrome, resulting from the stress of isolation.

Münchausen syndrome by proxy involves feigning illness of another person, or even causing their illness, in order to appear heroic in reviving the person, or to appear long-suffering to a sympathetic audience.

Malingering can also be positive, in that the person attempts to appear healthier than he is. This may be to obtain insurance, employment, or an occupational license. Memorizing an eye chart would be an example. Another example would be submitting a false urine sample, obtained from a different person.

Diagnosis and detection

Diagnosis

DSM-IV-TR

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

However, these criteria have been found to be of little use in actually identifying individuals who are malingering.

Detection

Some features at presentation which are unusual in genuine cases include:

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 (i.e., 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 (e.g., 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 knows he is being observed
15. Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
16. Reporting of wild psychological symptoms, and silly wrong answers on questionaires, not likely in patients with similar but real conditions.
17. Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
18. Coinciding indigence or homelessness of the patient, with impending cold weather and a need for indoor lodgings.
19. Giving approximate answers to questions, usually occurring in factitious disorder with predominantly psychological signs and symptoms (see Ganser Syndrome)
20. Eagerly endorsing symptoms suggested by a clinician, but not mentioned by the patient, though they would have been prominent and obvious had they been real.
21. A test for factitious mental disorders presents symptoms which are extremely improbable. Endorsing these symptoms which almost never occur can raise doubt of the person's sincerity.

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) (see Validity scales)
• The Test of Memory Malingering (TOMM)

The psychiatrist or neuropsychologist may use these tests, and use the DSM-IV TR criteria while adding a "dimensional analysis" to assist in diagnosis and treatment. Dimensional analysis consists of learning the patient’s history, information about similar cases, and the context of the illness, which could help differentiate cases of malingering from factitious disorders.

Treatment

Treatment is psychological, and varies according to the underlying cause of the individual'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. Medical personnel may tell the patient he has Munchausen's syndrome, expecting he will not know what that means, and will repeat it to the next medical facility he visits.

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.

Malingering for external gain does not necessarily involve a psychological problem. A person may rationally hope to avoid work, prison, or military service by pretending at an illness. They may also hope to gain a pension or an insurance settlement if it is believed they are ill or injured. Treatment is reserved for those with psychological reasons for feigning illness.

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.

The financial costs of malingering are thought to be high. In the United States "fraud that broadly includes malingering costs the insurance industry $150 billion annually, increasing the cost of insurance by $1800 per family."

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.

In many militaries, malingering is an offense. Examples include the United States military and the Singapore Armed Forces.

Related conditions

• Factitious disorder
• Ganser syndrome
• Munchausen syndrome

See also

• Rorschach test#Protection of test items and ethics