Malingering

What is Malingering?

Malingering refers to the intentional act of pretending or severely exaggerating illness, either physical or mental, to get external benefits. These benefits could be avoiding work or responsibilities, obtaining drugs, evading a court trial, seeking attention, dodging military services, getting time off from school or paid leave from work, among other things.

It’s important to note that according to DSM-5, which stands for the Diagnostic and Statistical Manual of Mental Diseases fifth edition, malingering is not considered a psychiatric illness. The previous version, DSM-IV-TR, didn’t provide exact criteria for diagnosing malingering, but it did mention that it is a “condition that may require clinical attention”. Although malingering is not listed in the DSM-5 index, it’s still recognized under a “V” code, and the guidelines for when to consider malingering stay the same.

External (or secondary) gain, such as those previously mentioned, is needed to tell malingering apart from a factitious disorder. The latter is a condition in which a person consciously invents physical or psychological symptoms to play the role of a patient, a behavior known as primary gain. People who are malingering often don’t follow treatment plans and stop complaining about the invented illness after they’ve achieved the external benefit they were seeking.

What Causes Malingering?

Malingering, or pretending to be sick, doesn’t have one specific cause. Instead, it’s often caused by social or economic conditions. Examples usually include prisoners trying to avoid trial, students trying to skip school, workers avoiding their job, or homeless people hoping to get financial help or food.

It’s also common for drug users to fake illnesses, pain, or sleep problems to get prescription drugs they abuse, such as nalbuphine and benzodiazepines. Malingering is often reported in people trying to avoid serving in the military too.

This behavior is often associated with antisocial personality disorder, which is a mental health disorder where a person has a long-term pattern of manipulating, exploiting, or violating the rights of others. It can also be linked to histrionic personality traits, where a person has a pattern of excessive attention-seeking behaviors, usually beginning in early adulthood.

Risk Factors and Frequency for Malingering

It’s hard to determine how often people fake or exaggerate illness or injury, which is known as malingering. In one study of people involved in legal cases, the rate was about 17%. A study by the University of New Orleans’ Department of Psychology found that among people dealing with chronic pain who could gain financially through compensation, the rate was 20% to 50%, depending on how it was diagnosed. However, these figures may not be reliable. It’s often believed that women are more likely to malinger than men, but there’s no solid evidence to support this.

• The rate of malingering is hard to determine.
• In legal cases, about 17% of people might malinger.
• Among chronic pain patients who could get financial compensation, 20% to 50% might malinger, depending on the way it’s diagnosed.
• These numbers might not be reliable.
• It’s often thought that women are more likely to malinger than men, but there’s no proof of this.

Signs and Symptoms of Malingering

To rule out a person pretending to be sick (a condition known as malingering), it’s important to carefully observe their actions and answers during a detailed discussion about their condition. As a part of this process, you need to:

• Look for inconsistencies in the individual’s behavior
• Inquire about the person’s personality traits
• Understand the person’s legal situation
• Ask questions quickly to spot irregularities in their responses
• Use open-ended and leading questions, for example, asking about symptoms that are unrelated to the supposed illness
• Watch for over-the-top descriptions of mental health symptoms

A mental status exam should also be conducted, which will look at the following:

• Appearance and behavior: Is the person unkempt and not making eye contact?
• Mood: How are they portraying their emotional state?
• Thoughts: Are they exhibiting exaggerated delusions?
• Perception: Are they reporting intense hallucinations?
• Insight: Are they acknowledging their alleged illness?
• Cognition: Assessing this may be challenging, as the individual might be uncooperative or dishonest

It’s recommended to conduct multiple examinations to look for discrepancies in the results. Completion of different tasks on many different visits should be observed, as inconsistency in the same task’s performance could hint at malingering. Additionally, it’s worth looking into the person’s history of hospitalization, medication usage, family background, and social history.

Testing for Malingering

Diagnosing malingering, which is intentionally faking or exaggerating symptoms for personal gain, is based on a person’s medical history, a physical exam, and psychological tests. There are no lab tests that can straightforwardly say if someone is malingering. However, lab tests can help rule out true, physical illnesses or validate genuine diseases.

Tests that help rule out other conditions may include:

• A complete blood count, which measures the cells in your blood including white cells, red cells, and platelets.
• Serum electrolytes, which evaluates the levels of vital minerals in your body.
• Renal function tests to check your kidney’s health.
• Liver function tests that determine how well your liver is working.
• Blood alcohol level to check if alcohol is impacting your health.
• Blood and urine toxicology screening, which might flag malingering in cases where drug abusers are seeking opioids.

Imaging tests like a CT scan or an MRI of the brain may also be used to make sure that there aren’t any physical disorders in the brain causing symptoms.

There are also specific psychological tests that can indicate malingering. These tests include:

• The Minnesota Multiphasic Personality Inventory (MMPI), which is a detailed questionnaire that assesses personality traits and identifies mental disorders.
• The F-scale, which measures how likely someone is to fake symptoms or lie on a test.
• The Test of Memory Malingering, which checks if someone is pretending to have memory problems.
• The negative impression management scale, which measures how negatively a person presents themselves.
• The Rey 15-item test, which is a memory test used to detect whether a person might be malingering.
• The Temporal Memory Sequence Test, another method to check for uge of memory problems.
• The Symptom and Disposition Interview (SDI), which gathers additional information about the patient’s symptoms and their attitude towards them.

Treatment Options for Malingering

Understanding that your doctor should not directly argue with you or dismiss your beliefs is crucial. It’s also important that your doctor doesn’t accuse you of pretending to be sick. These actions could lead to disagreements, legal issues, or in worst case scenarios, violence. Instead, your doctor should address your concerns indirectly, explaining the science of your condition while respecting your personal beliefs.

In order to avoid causing harm, invasive diagnostic procedures and treatments should be utilized only when the benefits clearly outweigh the risks. To help manage your health, your doctor might suggest a few methods such as:

• Behavioral therapy, which can help you change or eliminate unhealthy behaviors.
• Psychotherapy, which involves talking about your condition and related issues with a mental health professional.
• Counseling, which provides guidance on how to handle your health situation.

What else can Malingering be?

Before jumping to conclusions about someone feigning illness, doctors have to rule out several other possibilities:

• Organic disorder: Checking for any physical illness that might be causing the symptoms.
• Conversion disorders: Looking for any external stressors that could be causing physical symptoms.
• Factitious disorder, such as Munchausen syndrome: Identifying if the patient is pretending to be sick for attention or other gains.
• Hypochondriasis: Determining if the patient is excessively worried about having a serious illness.
• Somatic symptom disorder: Evaluating if the patient has a significant focus on physical symptoms that result in major distress and problems functioning.
• Psychosis or schizophrenia: These are thought disorders which can impact one’s perception of reality.
• Depression or mania: Conditions which are mood disorders, they can affect one’s everyday life.
• Dissociative disorders: Assessing if the patient has disruption and/or discontinuity in normal mental functions.

What to expect with Malingering

The outlook for someone who is pretending to be sick or injured, known as malingering, can be hard to predict. Usually, these individuals continue their act until they achieve what they want or gain some benefit.

Possible Complications When Diagnosed with Malingering

When someone is faking an illness (known as malingering) and their demands aren’t met, they may respond aggressively. This could potentially lead to a heated argument, putting the doctor at risk of facing legal action.

Potential Risks:

• Aggressive behavior from the patient
• Possible conflicts
• Risk of a lawsuit

Preventing Malingering

Teaching patients about this situation can be challenging. The recommended treatment plan includes cognitive behavior therapy, psychotherapy, and counseling.

Cognitive behavior therapy is a type of treatment that helps patients understand and change thought patterns that lead to harmful actions or feelings. Psychotherapy, also known as talk therapy, is used to help patients manage their problems by talking them through with a mental health professional. Counseling, on the other hand, provides guidance to patients by helping them make decisions or cope with problems. These treatments aim to help the patient better understand and manage their situation.