| Malingering | |
|---|---|
| Specialty | Psychiatry, clinical psychology |
| Differential diagnosis | Factitious disorder, somatization disorder |
Malingering is the fabrication, feigning, or exaggeration of physical or psychological symptoms designed to achieve a desired outcome, such as personal gain, relief from duty or work, avoiding arrest, receiving medication, or mitigating prison sentencing. It presents a complex ethical dilemma within domains of society, including healthcare, legal systems, and employment settings. [1] [2] [3]
Although malingering is not a medical diagnosis, it may be recorded as a "focus of clinical attention" or a "reason for contact with health services". [4] [2] It is coded by both the ICD-10 and DSM-5. The intent of malingerers vary. For example, the homeless may fake a mental illness to gain hospital admission. [5] Impacts of failure to detect malingering are extensive, impacting insurance industries, healthcare systems, public safety, and veterans' disability benefits. Malingered behaviour typically ends as soon as the external goal is obtained. [6]
Malingering is established as separate from similar forms of excessive illness behaviour, such as somatization disorder, wherein symptoms are not deliberately falsified. Another disorder is factitious disorder, which lacks a desire for secondary, external gain. [7] [6] Both of these are recognised as diagnosable by the DSM-5. However, not all medical professionals are in agreement with these distinctions. [8]
According to 1 Samuel in the Old Testament, King David feigned madness to Achish, the king of the Philistines. Some scholars believe this was not feigned but real epilepsy, and phrasing in the Septuagint supports that position. [9]
Odysseus was said to have feigned insanity to avoid participating in the Trojan War. [10] [11]
Malingering was recorded in Roman times by the physician Galen, who reported two cases: one patient simulated colic to avoid a public meeting, and another feigned an injured knee to avoid accompanying his master on a long journey. [12]
In 1595, a treatise on feigned diseases was published in Milan by Giambattista Silvatico.
Various phases of malingering (les gueux contrefaits) are represented in the etchings and engravings of Jacques Callot (1592–1635). [13]
In his Elizabethan-era social-climbing manual, George Puttenham recommends a would-be courtier to have "sickness in his sleeve, thereby to shake off other importunities of greater consequence". [14]
Although the concept of malingering has existed since time immemorial, the term for malingering was introduced in the 1900s due to those who would feign illness or disability to avoid military service. [15] In 1943, US Army General George S. Patton found a soldier in a field hospital with no wounds; the soldier claimed to be suffering from battle fatigue. Believing the patient was malingering, Patton flew into a rage and physically assaulted him. The patient had malarial parasites. [16]
Agnes was the first subject of an in-depth discussion of transgender identity in sociology, published by Harold Garfinkel in 1967. In the 1950s, Agnes feigned symptoms and lied about almost every aspect of her medical history. Garfinkel concluded that fearing she would be denied access to sexual reassignment surgery, she had avoided every aspect of her case which would have indicated gender dysphoria and hidden the fact that she had taken hormone therapy. Physicians observing her feminine appearance therefore concluded she had testicular feminization syndrome, which legitimized her request for the surgery. [17]
Classifying malingering behaviour into different categories allows for an easier assessment of possible deception, as created by Robert Resnick. [8] As individuals within institutions grapple with the challenges posed by malingering, a critical examination ethical duties emerges as imperative. Balancing compassion for those genuinely in need with the responsibility to uphold integrity and fairness, ethical obligations in addressing malingering extend beyond mere detection to encompass considerations of empathy, justice, and the broader implications for trust and societal welfare.
Veterans may be denied disability benefits if their doctor believes that they are malingering, especially regarding post-traumatic stress disorder. In navigating these ethical dimensions, it becomes essential to foster a nuanced understanding that acknowledges the complexities inherent in distinguishing genuine suffering from deceptive behavior, while also safeguarding against the misuse of resources and the erosion of trust in systems designed to support those in need. PTSD is the only condition for which the DSM-5 explicitly warns clinicians to observe in case of malingering. Distinguishing malingered PTSD from genuine symptoms is challenging due to the range of the nature and severity of the disorder. An assessment showed that in over 10% of cases, veterans were falsifying or exaggerating their service history. [20] [21]
Research that focuses on malingering attention deficit hyperactivity disorder are largely centred around university or college students. This is because of the significant benefits that may be gained if the student is successful, including student financial aid and exemptions for academic work. Medicinal treatments of ADHD may also be nootropics, which would enhance cognitive performance in examinations. [20]
Malingering is a court-martial offense in the United States military under the Uniform Code of Military Justice, which defines the term as "feign[ing] illness, physical disablement, mental lapse, or derangement." [22] According to the Texas Department of Insurance, fraud that includes malingering costs the US insurance industry approximately $150 billion each year. [23] [24] Other non-industry sources report it may be as low as $5.4 billion. [25]
Richard Rogers and Daniel Shuman found that the use of DSM-5 criteria results in the accurate identification of only 13.6–20.1% of actual malingerers (true positives). [26] However, 79.9–86.4% of individuals are misclassified as malingerers (false positives) using the same criteria. Being falsely accused of malingering may cause adverse reactions, some of which lead to violence. Thus, the accurate detection of malingering is a pressing societal issue. [27]
There are multiple methods to evaluate malingering, such as the Minnesota Multiphasic Personality Inventory-2, which is the most validated test. Other tests include the Structured Interview of Reported Symptoms, which is used for psychiatric symptoms, and the Test of Memory Malingering (TOMM), intended for false memory deficits. [18] Culture and education also likely affect overall performance in these tests. Research found that Colombian adults with low literacy skills perform significantly worse on the Test of Memory Malingering, so there are concerns with the impact of education levels on malingering assessments. [28]
Existing criteria for one malingered disorder may not be applicable to a different disorder. For example, tests for malingered PTSD may not work for malingered neurocognitive disorders; therefore, there is a need for newer criteria to be created. [20]
Although there is no singular test that definitively discerns malingering, [18] medical professionals are told to watch out for certain behaviours that may indicate deliberate deception.
Signs that illustrate malingering include: [20] [29]
Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention, while the depressive episodes last at least 2 weeks.
The Diagnostic and Statistical Manual of Mental Disorders is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is the main book for the diagnosis and treatment of mental disorders in the United States and Australia, while in other countries it may be used in conjunction with other documents. The DSM-5 is considered one of the principal guides of psychiatry, along with the International Classification of Diseases (ICD), Chinese Classification of Mental Disorders (CCMD), and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world. Psychiatry like Medicine is not an exact science» and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.
Factitious disorder imposed on self, also known as Munchausen syndrome, is a factitious disorder in which those affected feign or induce disease, illness, injury, abuse, or psychological trauma to draw attention, sympathy, or reassurance to themselves. Munchausen syndrome fits within the subclass of factitious disorder with predominantly physical signs and symptoms, but patients also have a history of recurrent hospitalization, travelling, and dramatic, extremely improbable tales of their past experiences. The term Munchausen syndrome derives its name from the fictional character Baron Munchausen.
Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.
Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia (psychosis) and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorders including anxiety disorders.
A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."
Conversion disorder (CD), or functional neurologic symptom disorder, is a diagnostic category used in some psychiatric classification systems. It is sometimes applied to patients who present with neurological symptoms, such as numbness, blindness, paralysis, or fits, which are not consistent with a well-established organic cause, which cause significant distress, and can be traced back to a psychological trigger.
A factitious disorder is a mental disorder in which a person, without a malingering motive, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain a patient's role. People with a factitious disorder may produce symptoms by contaminating urine samples, taking hallucinogens, injecting fecal material to produce abscesses, and similar behaviour. The word factitious derives from the Latin word factītius, meaning "human-made".
Ganser syndrome is a rare dissociative disorder characterized by nonsensical or wrong answers to questions and other dissociative symptoms such as fugue, amnesia or conversion disorder, often with visual pseudohallucinations and a decreased state of consciousness. The syndrome has also been called nonsense syndrome, balderdash syndrome, syndrome of approximate answers, hysterical pseudodementia or prison psychosis.
Psychogenic non-epileptic seizures (PNES), also referred to as pseudoseizures, non-epileptic attack disorder (NEAD), functional seizures, or dissociative seizures, are episodes resembling an epileptic seizure but without the characteristic electrical discharges associated with epilepsy. PNES fall under the category of disorders known as functional neurological disorders (FND), also known as conversion disorders, and are typically treated by psychologists or psychiatrists. PNES has previously been called stress seizures and hysterical seizures, but these terms have fallen out of favor.
Pathological lying, also known as pseudologia fantastica, is a chronic behavior characterized by the habitual or compulsive tendency to lie. It involves a pervasive pattern of intentionally making false statements with the aim to deceive others, sometimes for no clear or apparent reason, and even if the truth is beneficial to the liar. People who engage in pathological lying often claim to be unaware of the motivations for their lies.
Factitious disorder imposed on another (FDIA), also known as fabricated or induced illness by carers (FII) and first named as Munchausen syndrome by proxy (MSbP) after Munchausen syndrome, is a mental health disorder in which a caregiver creates the appearance of health problems in another person, typically their child, and sometimes (rarely) when an adult simulates an illness in another adult partner. This might include altering test samples or injuring a child. The caregiver or partner then presents the person as being sick or injured. Permanent injury or death of the victim can occur as a result of the disorder. The behaviour might be motivated by the caregiver or partner seeking sympathy or attention.
The classification of mental disorders, also known as psychiatric nosology or psychiatric taxonomy, is central to the practice of psychiatry and other mental health professions.
Somatic symptom disorder, also known as somatoform disorder, or somatization disorder, is defined by one or more chronic physical symptoms that coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those symptoms. The symptoms are not deliberately produced or feigned, and they may or may not coexist with a known medical ailment.
A psychological injury is the psychological or psychiatric consequence of a traumatic event or physical injury. Such an injury might result from events such as abusive behavior, whistleblower retaliation, bullying, kidnapping, rape, motor vehicular collision or other negligent action. It may cause impairments, disorders, and disabilities perhaps as an exacerbation of a pre-existing condition.
Because of the substantial benefits available to individuals with a confirmed PTSD diagnosis, which causes occupational impairment, the distinct possibility of false diagnoses exist, some of which are due to malingering of PTSD. Malingering of PTSD consists of one feigning the disorder. Post-traumatic stress disorder (PTSD) is an anxiety disorder that may develop after an individual experiences a traumatic event. In the United States, the Social Security Administration and the Department of Veterans Affairs each offer disability compensation programs that provide benefits for qualified individuals with mental disorders, including PTSD. Malingering can lead to a decline in research and subsequent treatment for PTSD as it interferes with true studies. Insurance fraud may also come about through malingering, which hurts the economy.
Loren Pankratz is a consultation psychologist at the Portland VA Medical Center and professor in the department of psychiatry at Oregon Health & Science University (OHSU).
The Clinically Administered PTSD Scale (CAPS) is an in-person clinical assessment for measuring posttraumatic stress disorder (PTSD). The CAPS includes 30 items administered by a trained clinician to assess PTSD symptoms, including their frequency and severity. The CAPS distinguishes itself from other PTSD assessments in that it can also assess for current or past diagnoses of PTSD.
The Structured Inventory of Malingered Symptomatology (SIMS) is a 75-item true-false questionnaire intended to measure malingering; that is, intentionally exaggerating or feigning psychiatric symptoms, cognitive impairment, or neurological disorders.
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), malingering receives a V code as one of the other conditions that may be a focus of clinical attention.
Malingering accounts for nearly one-fifth of all medical care cases (i.e., doctor visits, hospitalizations) within the United States and combined medical and legal costs approach five billion dollars annually (Ford, 1983; Gouvier, Lees-Haley, & Hammer, 2003).
| Authority control databases: National |
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