Malingering

Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Common examples of secondary gain include financial compensation, avoidance of work, obtainment of prescription medications, and avoidance of criminal charges. After ruling out organic medical diseases, providers must confront the individual in a nonjudgmental fashion.

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Epidemiology and Etiology

Epidemiology

  • Higher prevalence in men than women 
  • Most common in medicolegal or military settings
  • Common in hospitalized patients
  • Common in patients seeking workers’ compensation or disability benefits

Etiology

  • No association with any biological factors or familial/genetic patterns 
  • Associated with antisocial personality disorder

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Clinical Presentation and Diagnosis

Clinical presentation

  • Multiple vague complaints incongruent with a known medical illness and associated with personal gain
  • Head injury is the most common symptom, followed by chronic pain.
  • Depressive symptoms account for 15% of cases. 
  • Reluctance to participate in physical exam or diagnostic testing
  • Unwillingness to accept a good prognosis, even after extensive testing
  • Long history of several hospital stays
  • Symptoms improve once the desired outcome is achieved.

Diagnosis

  • Not listed as a diagnosis in the DSM-V (presented alongside somatoform disorders as a differential diagnosis)
  • Requires careful history taking (may require the acquisition of prior or external medical records)
  • Intentional failure of subjective testing
  • Observation of behavior by video is incongruent with the patient presentation, which may support the diagnosis and aid in patient confrontation.
Table: Features of malingering compared to important differential diagnoses
Willingness to undergo evaluationIntentional deceptive behaviorEvidence of external reward
Illness anxiety disorder+
Somatic symptom disorder+
Factitious disorder++
Malingering++

Management

Clinicians must remain clinically neutral and provide a differential investigation.

Identify common secondary gains:

  • Avoidance of criminal responsibility 
  • Financial gain
  • Avoidance of work 
  • Admission to hospital for shelter 
  • Prescription medication

Therapeutic interaction may only be abandoned after the patient is adamantly unwilling to interact with the clinician (other than manipulation for a secondary gain).

Differential Diagnosis

  • Conversion disorder: the presence of symptoms or deficits affecting voluntary motor or sensory function suggestive of a neurological condition but unexplained by medical findings. No identified secondary gain is present in conversion disorder. 
  • Somatic symptom disorder: patients present with multiple somatic complaints and excessive thoughts about the severity of their symptoms. Patients with somatic symptom disorder unintentionally exaggerate their symptoms. The secondary gain in somatic symptom disorder is not as important as in malingering. 
  • Factitious disorder: patients intentionally falsify symptoms to assume the sick role. Patients with factitious disorder merely want medical care and attention without any identified secondary gain.

References

  1. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 25, Other conditions that may be a focus of clinical attention, pages 812–815. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Dent, L (2020). The identification and management of malingering in clinical settings.

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