Malingering

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Template:Short description Template:Merge from Template:Use mdy dates Template:Infobox medical condition (new) 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.<ref name="Gale">Template:Cite encyclopedia</ref><ref name="WHO">Template:Cite encyclopedia</ref><ref>Template:Cite book</ref>

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".<ref>Template:Cite web</ref><ref name="WHO"/> 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.<ref>Template:Cite web</ref> Impacts of failure to detect malingering are extensive, affecting insurance industries, healthcare systems, public safety, and veterans' disability benefits. Malingered behaviour typically ends as soon as the external goal is obtained.<ref name="Alozai 2023">Template:Citation</ref>

Malingering is established as separate from similar forms of excessive illness behaviour, such as somatization disorder, wherein symptoms have a psychological cause but are genuinely perceived as real, and factitious disorder, where symptoms are fabricated but not for secondary, external gain.<ref>Template:Cite book</ref><ref name="Alozai 2023"/> Both of these are recognised as diagnosable by the DSM-5. However, not all medical professionals are in agreement with these distinctions.<ref name="Rogers 2008">Template:Cite book</ref>

History

Antiquity

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.<ref>Template:Cite encyclopedia</ref>

Odysseus was said to have feigned insanity to avoid participating in the Trojan War.<ref name="Apollodorus">Template:Cite book</ref><ref name="Hyginus">Template:Cite book</ref>

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.<ref name="Lund">Template:Cite journal</ref>

Renaissance

In 1595, a treatise on feigned diseases was published in Milan by Giambattista Silvatico.

Various phases of malingering (Template:Lang) are represented in the etchings and engravings of Jacques Callot (1592–1635).<ref>Template:Cite book</ref>

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".<ref name="Puttenham">Template:Cite book</ref>

Modern period

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.<ref>Template:Citation</ref> 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.<ref name="Axelrod">Template:Cite book</ref>

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.<ref>Template:Cite book</ref>

Types

Classifying malingering behaviour into different categories allows for an easier assessment of possible deception, as created by Robert Resnick.<ref name="Rogers 2008" />

  • Pure malingering: feigning a disorder or illness that is nonexistent. It is arguably the most simple to detect. This is because malingerers of this type tend to provide unreliable, additional symptoms when describing their supposed disorder, since they have to create an entire story from scratch. It is, therefore, difficult to entirely accurately mimic real-world scenarios.<ref name=":1">Template:Cite web</ref><ref name=":2">Template:Cite journal</ref>
  • Partial malingering: purposefully exaggerating symptoms for an existing disorder or illness. This may be particularly difficult to detect, because those who partake in this would be building on their own genuine traumatic experiences, rather than completely falsifying claims.<ref name=":1" /><ref name=":2" />
  • False imputation: attributing of existing symptoms to a cause that the patient knows is unrelated to their illness. Identifying this type of malingering is less difficult than partial malingering, as patients may inaccurately transpose symptoms from their real experience to the supposed cause of their disorder. This entails inaccurate storytelling and would indicate deliberate deception.<ref name=":1" /><ref name=":2" />

Society and culture

Post-traumatic stress disorder

Template:Main Veterans may be denied disability benefits if their doctor believes that they are malingering, especially regarding post-traumatic stress disorder. PTSD is the only condition for which the DSM-5 explicitly warns clinicians to observe in case of malingering. Distinguishing exaggerated or feigned post-traumatic stress disorder (PTSD) from genuine presentations is considered difficult, particularly in compensation or forensic assessments.<ref name="JAAPL2019">Template:Cite journal</ref> Forensic reviews have estimated base rates of exaggeration or malingering in PTSD evaluations at approximately 15–20% or higher among individuals seeking financial compensation or pension benefits, although precise prevalence figures remain uncertain due to methodological limitations and variability in diagnostic instruments.<ref name="JAAPL2019" /> Recent psychometric research has also highlighted the limitations of commonly used screening tools for detecting feigned symptoms in veteran populations.<ref name="Wolf2020">Template:Cite journal</ref> In addition, record-verification studies in clinical samples of veterans have identified instances in which reported combat exposure did not correspond with official service records, indicating that misrepresentation of service history can occur.<ref name="ServiceVerify2005">Template:Cite journal</ref><ref name=":3">Template:Cite journal</ref>

Attention deficit hyperactivity disorder

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.<ref name=":3" /> An experimental study using a scenario method with an adult sample shows that personal and situational characteristics are relevant to understanding malingering.<ref>van Veen, F., Sattler, S., Mehlkop, G., & Hasselhorn, F. (2021). Feigning Symptoms to Obtain Prescription Stimulants: A Vignette-Based Study on Its Conditions. Journal of Drug Issues, 52(2), 225-249. https://doi.org/10.1177/00220426211055433</ref> Willingness to feign symptoms was lower in situations of social disapproval and when personal morality disapproved of feigning. The results also showed that this willingness decreased with age. Furthermore, it is important to note that the willingness to feign can be considered conditional upon the willingness to use these drugs and their specific antecedents.

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."<ref name="10USC">Template:UnitedStatesCode2</ref> According to the Texas Department of Insurance, fraud that includes malingering costs the US insurance industry approximately $150 billion each year.<ref name="Garriga">Template:Cite journal</ref><ref name="geom-malingering">Template:Cite encyclopedia</ref> Other non-industry sources report it may be as low as $5.4 billion.<ref>Template:Cite journal</ref>

Detection

Richard Rogers and Daniel Shuman found that the use of DSM-5 criteria results in a true-positive rate of only 13.6% to 20.1%; that is, among persons whom the criteria indicate to be malingering, only 13.6% to 20.1% are actual malingerers.<ref>Template:Citation</ref> The remaining 79.9% to 86.4% whom those criteria indicate to be malingering are in fact false positives, i.e., non-malingerers erroneously classified as malingerers. 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.<ref>Template:Cite web</ref>

Tests

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.<ref name=":1" /> 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.<ref>Template:Cite journal</ref>

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.<ref name=":3" />

Indicative behaviour

Although there is no singular test that definitively discerns malingering,<ref name=":1" /> medical professionals are told to watch out for certain behaviours that may indicate deliberate deception.

Signs that illustrate malingering include:<ref name=":3" /><ref>Template:Cite web</ref>

  • providing contradictory statements about symptoms;
  • dramatic or peculiar behaviour that is meant to be convincing;
  • behaviour that is inconsistent with described symptoms;
  • acting adverse to accepting treatment for their supposed disorder;
  • overenthusiasm about negative symptoms through going into extensive detail;
  • sudden termination or onset of symptoms

See also

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References

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