Malingering Clinical Presentation

According to the DSM-5, malingering should be suspected in the presence of any combination of the following: ^[1]

• 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 ^[5]

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. ^[6]

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. ^[3]

Typically, deficits on physical examination do not follow known anatomical distributions. Otherwise, there are no specific techniques of physical examination that reliably detect malingering. ^[7]

The following can be found on a Mental Status Examination: ^{[8, 9]}

• 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. ^[6]

• Individuals with malingering may attempt to feign any other type of mental status abnormality, but usually do so in a manner that is erroneous or grossly exaggerated.

Functional assessments may yield suggestive findings. Functional capacity evaluations, such as those routinely performed in Occupational Therapy assessments, observe a person’s performance across a variety of task-related activities.  Malingering patients often exert less effort than those suffering from genuine physical disabilities. Further, their performance across various individual tests is more variable than would be expected in the context of physical injury or illness. They may come across as more impaired in obviously work-related task tests than in those measuring daily living functions. They may perform more poorly on complex tasks, perhaps reflecting lower levels of effort, or greater difficulty in creating the expected response of an injured person. Behavioral observations are even more useful when paired with testing results (below). ^[10]

Malingering often occurs in the context of antisocial personality disorder. Common contexts that may precipitate malingering behavior include the following:

• Criminal prosecution

• Military service

• Workers' compensation claims

• Desire for drugs ^{[1, 11]}

Although neuroimaging cannot be used for diagnostic assessment, subjects who were instructed to perform deliberately on a cognitive test as if they had suffered brain injury with memory impairment, displayed greater activation in the superior and medial prefrontal cortices when feigning injury compared with optimal performance.  The spatial pattern implies that the malingering brain must exert more effort both to recall the correct answer and to suppress it. ^[12]

Hostile or threatening behavior may ensue if the malingerer's claims are challenged, or if the physician fails to respond to his/her demands for disability certification, medications, etc.