Girish Mahajan (Editor)

Malingering

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Covid-19
ICD-10  Z76.5
eMedicine  article/293206
ICD-9-CM  V65.2
MeSH  D008306

Malingering is the fabricating of symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy. It is not a medical diagnosis. It falls under the broader scope of illness behaviour. Malingering is different from somatization disorder and factitious disorder. Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system, and false attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population. According to the Texas Department of Insurance, fraud that includes malingering costs the U.S. insurance industry approximately $150 billion each year. Other non-industry sources suggest it may be as low as $5.4 billion, ironically suggesting that insurance companies are over inflating the seriousness of the problem to divert more law enforcement towards health insurance fraud.

Contents

Symptoms

The symptoms most commonly feigned include those associated with mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. Generally, malingerers complain of psychological disorders such as anxiety. Malingering may take the form of complaints of chronic whiplash pain from automobile accidents. The psychological symptoms experienced by survivors of disaster (post-traumatic stress disorder) are also faked by malingerers.

Many dishonest methods are used by individuals feigning symptoms of malingering. Some of these include harming oneself, trying to convince medical professionals one has a disease after learning about its details (such as symptoms) in medical textbooks, taking drugs that provoke certain symptoms common in some diseases, performing excess exercise to induce muscle strain or other physical types of ailments, and overdosing on drugs.

DSM-V

According to the DSM-V, malingering may be suspected:

  • When a patient is referred for examination by an attorney
  • When the onset of illness coincides with a large financial incentive, such as a new disability policy
  • When objective medical tests do not confirm the patient's complaints
  • When the patient does not cooperate with the diagnostic work-up or prescribed treatment
  • When the patient has antisocial attitudes and behaviours (antisocial personality)
  • When a patient who claims to be schizophrenic informs the physician about being confused and is eager to discuss the delusions
  • Limitations

    A formal assessment of malingering requires the explicit confession of the patient. Even in such cases, clinical guidelines do not exist for interrogation techniques and a physician may elicit a false confession. It is advised to avoid an assessment of malingering. Legally the term may be considered prejudicial and excluded on the basis of its probative value. No current research exists regarding the frequency, behaviour or detection of successful malingerers. No neuropsychological inventories exist that can be used to conclusively determine if a patient is malingering; nor are they used to exclude a determination of malingering. Genuine neurological and psychiatric conditions may return false positives. Testing inventories cannot distinguish between exaggeration and fabrication. Psychological inventories rely on naivety. Criminally, an assessment may lead to punishment enhancement and medically; to denial of future treatment. The DSM-V criteria faces scrutiny for providing poor guidelines. As such physicians ultimately rely on their intuition and gut feeling for any assessment which is subject to prejudice and cognitive dissonance and which has been shown to be unreliable in synthetic tests.

    Malingering presumes an exhaustive diagnostic procedure has been performed. Exhaustive diagnostics are neither practical nor economically viable or judged to be in the best interests of the patient's health. Radiological and invasive exploratory procedures can be necessary for an accurate diagnosis yet pose a health risk to the patient. radiographic diagnostics expose the patient to radiation and surgical diagnostic procedures can carry a high risk of complications and mortality such as a lumbar puncture, the only reliable diagnostic procedure for diagnosing rare terminal forms of parasitization which the CDC reports as only being diagnosed post mortem 75% of the time. A physician invariably face limitations in the realms of resources, time and liability. Because an assessment, formal or informal, of malingering ceases the medical process, it may seem an attractive option for the physician and help them to cope with cognitive dissonance over their failure to effectively diagnose and treat a patient within constraints.

    Patients with unresolved illness may be adversarial towards physicians, attempting to game the triage system in order to receive specialist care. such cases fit the criteria for malingering yet the patient is still in need of medical care. For example, in a gatekeeper system, primary care physicians may restrict the availability of HIV testing to only patients who report high risk activity. A patient may then falsely report sexual and/or drug history and/or symptoms in order to elevate priority which can then go on to serve as diagnostically relevant history for an inaccurate path of further diagnosis.

    Medical practitioners often believe that they can detect deception. In two studies, experienced medical practitioners including psychiatrists failed to perform better than chance when asked to detect lying and simulated patients. In 12 other studies, detection rates ranged between 0 and 25% for the detection of simulated patients. It's impossible to detect malingering from a clinical perspective.

    The evaluative context (medical-legal and forensic) exerts distorting impact on the tendency of subjects to amplify or not the self-reported symptoms. This distorting effect is present also when subjects are truly suffering from mental pathology.

    Antiquity

    In the Hebrew Bible, King David feigns insanity to Achish, king of the Philistines (I Sam. 21:10-15). This is by many supposed not to have been feigned, but a real epilepsy or falling sickness, and the Septuagint uses words which strongly indicate this sense. Odysseus was stated to have also feigned insanity in order to avoid participating in the Trojan War. Malingering has been recorded historically as early as Roman times by the physician Galen (Quomodo morbum simultaneous sint deprehendendi), who reported two cases. One patient simulated colic to avoid a public meeting, while the other feigned an injured knee to avoid accompanying his master on a long journey.

    Renaissance

    During the Renaissance, a treatise on feigned diseases (De iis qui morborum simulant deprehensis) by Giambattista Silvatico, was published at Milan in 1595. Various phases of malingering (les gueux contrefaits) are well represented in the etchings and engravings of Jacques Callot (1592–1635). In his social-climbing manual, Elizabethan George Puttenham recommends that would-be courtiers have "sickness in his sleeve, thereby to shake off other importunities of greater consequence" and suggests feigning a "dry dropsy [...] of some such other secret disease, as the common conversant can hardly discover, and the physician either not speedily heal, or not honestly bewray."

    Modern period

    Lady Flora Hastings was accused of adultery stemming from court gossip following abdominal pain. Because she refused to be physically examined by a man for reasons of modesty befitting a lady in her position, the physician assumed her to be pregnant. She later died of stomach cancer.

    General George S. Patton, in what became known as 'the Greek Incident', found a Soldier in a field hospital but with no wounds, claiming to be suffering from battle fatigue. Upon discovering this and believing that the patient was malingering, Patton flew into a rage, physically assaulted the patient, called him a coward and did not stop until he was physically restrained. The patient was later found to have contracted malaria and to be suffering from dysentery.

    Antonio Damasio described a case study in Descartes' Error of his patient, 'Elliot.' He wrote, "Several professionals had declared that his mental faculties were intact-meaning that at the very best Elliot was lazy, and at the worst a malingerer." As a result, Elliot's disability benefits were withdrawn. neuropsychological testing "...revealed a superior intellect." Neuropsychological evaluations thought at that time to be sensitive such as the Wisconsin Card Sorting Test did not reveal impairment in function associated with the frontal lobes or brain damage and functional impairment in general. Elliot had previously had surgery to remove a meningioma "the size of a small orange." Following his surgery he had floundered into a series of poor decisions which ultimately resulted in divorce and bankruptcy from a previously "...Enviable position."

    Few cases are as famous as Harold Garfinkel's study of Agnes Torres. In the 1950s, Agnes feigned symptoms and lied about almost every aspect of her medical history. Fearing doctors at the UCLA would refuse her access to her desired sexual reassignment surgery, Garfinkel concluded that she had avoided every aspect of her case which would have indicated gender dysphoria so as to avoid being treated as an "effeminate homosexual" and psychiatric patient. She lied that she had not taken hormone therapy and her examining physicians concluded that it would be impossible for someone so young to have stumbled upon a therapy and instituted it at such a young age so as to produce such brilliant feminizing effects. As such they concluded that their patient had testicular feminization syndrome, legitimizing in their professional opinion, the validity of her request for sexual reassignment surgery. While not evaluating the patient, Garfinkel commented that the complexity of the deception was of such intricate construction intended towards the singular goal of seeking the particular desired medical intervention.

    Soviet Union

    Because malingering was widespread throughout the Soviet Union to escape sanctions or coercion, physicians were limited by the state in the number of medical dispensations they could issue.

    With thousands forced into manual labour, doctors were presented with four types of patients:

    1. those who needed medical care;
    2. those who thought they needed medical care (hypochondriacs);
    3. malingerers; and
    4. those who made direct pleas to the physician for a medical dispensation from work.

    This dependence upon doctors by poor labourers altered the doctor-patient relationship to one of mutual mistrust and deception.

    United States Armed Forces

    Malingering is a court-martial offense in the United States Armed Forces under Article 115 of the Uniform Code of Military Justice, which provides that:

         Any person subject to this chapter who for the purpose of avoiding work, duty, or service–
    (1) feigns illness, physical disablement, mental lapse or derangement; or
    (2) intentionally inflicts self-injury;
         shall be punished as a court-martial may direct.

    References

    Malingering Wikipedia


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