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Malingering

Author: David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
Contributor Information and Disclosures

Updated: Jul 17, 2008

Introduction

Background

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, Text Revision (DSM-IV- TR) , malingering receives a V code as one of the other conditions that may be a focus of clinical attention.¹

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.²

Clinical

History

• 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 disorder³
• 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.⁴
• The most common goals of people who malinger in the emergency department are obtaining drugs and shelter. In the clinic or office, the most common goal is financial compensation.⁵

Physical

Typically, deficits on physical examination do not follow known anatomical distributions.

The following can be found on a Mental Status Examination:^6,7

• A patient's attitude toward the examining physician is often vague or evasive.
• Mood may be irritable or hostile.
• Thought processes are generally cogent. Thought content is marked by preoccupation with the claimed illness or injury.
• Threats of suicide may follow any challenge to the veracity of the claim, or a response deemed by the malingerer to be inadequate. 
• As noted under History, persons with 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. These descriptions may also 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.⁴ Treatment & Medication: MalingeringFollow-up: MalingeringMultimedia: MalingeringReferences

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  References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Press Inc; 2000:683.

  2. LoPiccolo CJ, Goodkin K, Baldewicz TT. Current issues in the diagnosis and management of malingering. Ann Med. Jun 1999;31(3):166-74. [Medline].

  3. Faust D. The detection of deception. Neurol Clin. May 1995;13(2):255-65. [Medline].

  4. Resnick PJ. Defrocking the fraud: the detection of malingering. Isr J Psychiatry Relat Sci. 1993;30(2):93-101. [Medline].

  5. Purcell TB. The somatic patient. Emerg Med Clin North Am. Feb 1991;9(1):137-59. [Medline].

  6. Donaghy M. Symptoms and the perception of disease. Clin Med. Nov-Dec 2004;4(6):541-4. [Medline].

  7. Malone RD, Lange CL. A clinical approach to the malingering patient. J Am Acad Psychoanal Dyn Psychiatry. Spring 2007;35(1):13-21. [Medline].

  8. Anderson JM. Malingering: A constant challenge in disability arenas. J Controversial Med Claims. May 2008;15(2):1-9.

  9. Udell ET. Malingering behavior in private medical practice. Clin Podiatr Med Surg. Jan 1994;11(1):65-72. [Medline].

  10. Voiss DV. Occupational injury. Fact, fantasy, or fraud?. Neurol Clin. May 1995;13(2):431-46. [Medline].

  11. McDermott BE, Feldman MD. Malingering in the medical setting. Psychiatr Clin North Am. Dec 2007;30(4):645-62. [Medline].

  12. Ziegler SJ. Pain, patients, and prosecution: who is deceiving whom?. Pain Med. Jul-Aug 2007;8(5):445-6; author reply 447-8. [Medline].

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  Further Reading

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  Keywords

  malingering, false symptoms, exaggerated symptoms, accident neurosis, compensation neurosis, faking, fraud, lying, factitious disorder, FD, hypochondriasis

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  Contributor Information and Disclosures

  Author

  David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
  David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry
  Disclosure: Nothing to disclose.

  Medical Editor

  Barry I Liskow, MD, Vice Chairman, Director Psychiatry Residency Program, Professor, Department of Psychiatry, University of Kansas Medical School
  Barry I Liskow, MD is a member of the following medical societies: American Academy of Addiction Psychiatry
  Disclosure: Nothing to disclose.

  Pharmacy Editor

  Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
  Disclosure: Nothing to disclose.

  Managing Editor

  Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
  Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
  Disclosure: Nothing to disclose.

  CME Editor

  Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
  Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
  Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other; Pfizer Honoraria Speaking and teaching

  Chief Editor

  Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
  Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
  Disclosure: Nothing to disclose.