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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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may either invent new ailments or exaggerate current symptoms. Common examples of secondary gain include financial compensation Compensation Respiratory Acidosis, 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.

Last updated: Nov 10, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Epidemiology and Etiology

Epidemiology

  • Higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in men than women 
  • Most common in medicolegal or military settings
  • Common in hospitalized patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • Common in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship seeking workers’ compensation Compensation Respiratory Acidosis or disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment benefits

Etiology

  • No association with any biological factors or familial/genetic patterns 
  • Associated with antisocial personality disorder Antisocial Personality Disorder A personality disorder whose essential feature is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The individual must be at least age 18 and must have a history of some symptoms of conduct disorder before age 15. Cluster B Personality Disorders

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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 Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
  • Depressive symptoms account for 15% of cases. 
  • Reluctance to participate in physical exam or diagnostic testing
  • Unwillingness to accept a good prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas, 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 evaluation Intentional deceptive behavior Evidence of external reward
Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one’s health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety Disorder +
Somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder +
Factitious disorder + +
Malingering + +

Management

Clinicians must remain clinically neutral and provide a differential investigation.

Identify common secondary gains:

Therapeutic interaction may only be abandoned after the patient is adamantly unwilling to interact with the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship (other than manipulation for a secondary gain).

Differential Diagnosis

  • Conversion disorder Conversion disorder Conversion disorder (CD), also called functional neurological symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Conversion Disorder: the presence of symptoms or deficits affecting voluntary motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function suggestive of a neurological condition but unexplained by medical findings. No identified secondary gain is present in conversion disorder Conversion disorder Conversion disorder (CD), also called functional neurological symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Conversion Disorder
  • Somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder: patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with multiple somatic complaints and excessive thoughts about the severity of their symptoms. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder unintentionally exaggerate their symptoms. The secondary gain in somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder is not as important as in malingering. 
  • Factitious disorder: patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship intentionally falsify symptoms to assume the sick role. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with factitious disorder merely want medical care Medical care Conflict of Interest and attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment 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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