Malingering
Classification and external resources
ICD-10	Z76.5
ICD-9	V65.2
MeSH	D008306

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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.^[1] Legally, it is often referred to as fabricated mental illness or feigned mental illness (see United States v. Binion).^[2] The disorder remains separate from somatization disorders and factitious disorders in which primary psychological gain, such as the relief of anxiety or the assumption of the "patient role", is the goal.^[3] The symptoms most commonly feigned reportedly include those associated with mild head injury, fibromyalgia and chronic fatigue syndrome, and chronic pain.^[4][1][5] Malingering imposes substantial burdens on the healthcare system.^[6]

Contents 1 History 2 Symptoms 3 Predisposing factors 4 Diagnosis and detection 4.1 Diagnosis 4.1.1 DSM-IV-TR 4.2 Detection 5 Treatment 6 Impact on society 7 Related conditions 8 See also 9 References

[edit] History

In the Hebrew Bible, David feigns insanity to escape from a king who views him as an enemy.^[7] 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, whilst the other feigned an injured knee to avoid accompanying his master on a long journey. ^[8]

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. ^[9] 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.^[9]

[edit] 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.^[9] 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, sometimes called "partial malingering".^[who?] In these cases, malingering is sometimes described as a "functional overlay" on an existing disease.

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, so pain conditions are often feigned.^[4]

[edit] 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).^[who?] Malingering is more common in women than men^{[citation needed]} 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.

[edit] Diagnosis and detection

[edit] Diagnosis

[edit] DSM-IV-TR

The DSM-IV-TR states that malingering is suspected if any combination of the following are observed^[10]

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.^[1]

[edit] Detection

Some feature 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 (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 factitious disorder 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) (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.^[11]

[edit] 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.

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.

[edit] 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."^[6]

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.^[12]

In many militaries, malingering is an offense. Examples include the United States military^[13] and the Singapore Armed Forces.^[14]

[edit] Related conditions

• Factitious disorder
• Ganser syndrome
• Munchausen syndrome

[edit] See also

• Rorschach_test#Protection_of_test_items_and_ethics

[edit] References