Malingering

What is Malingering?

The presentation of false symptoms, fraudulent claims of illness or disease are diagnosed as malingering. Malingering is not a medical condition itself, but is rather the presentation of false symptoms or fraudulent claims of illness or disease for the purpose of some sort of external gain.

That gain can be positive in nature, including financial gain or attention. The gain can also be measured in avoidance of an unpleasant consequence. Exemption from military service, legal punishments, termination from employment for chronic absenteeism would be examples of this sort of gain for the patient. Malingering is difficult to diagnose because other actual medical conditions must be ruled out.

Malingering Symptoms

Feigned symptoms may include, but are certainly not limited to, neurologic conditions, dementia, physical disability, amnesia, learning disabilities, or psychological disorders. Malingering can be difficult to diagnose because other causes have to be eliminated and actual illness must be ruled out. Therefore, medical practitioners need to use multiple assessments and collateral data to identify patients who are attempting medical fraud.

The most common symptoms that malingering presents would include anxiety, depression, loss of memory (although not necessarily acute amnesia), dementia, headache, digestive issues, heart palpitations, shortness of breath, pain in the lower back or neck, pain in the extremities, and conditions related to chronic pain or dizziness.

The most effective malingerers do so by relying on a few general symptoms, avoiding specific or rare symptoms or those that would have obvious physical manifestations. They may claim a general feeling of sadness, or that they no longer enjoy activities that used to bring joy, or a physical symptom like heart palpitations or shortness of breath. These are conditions that could indicate a wide variety of illness or disease and are very difficult to prove do not exist.

Malingering Causes

The causes of malingering are as varied as the gain the patient is trying to derive. There really is not a medical or physiological root cause for malingering, although the condition can follow a bout of actual illness where the patient discovers the benefits of the condition which he or she then continue to present so they can continue to access the benefit. The gain could be positive in the form of financial gain, attention from others or exemption from activity. That gain could also take the form of avoiding a negative consequence such as punishment or legal action.

Because malingering is not an actual psychiatric disorder, the DSM-IV-TR (Diagnostic and Statistical Manual for Mental Disorders) puts malingering in the section titled “Other Conditions that May be a Focus of Clinical Attention”. Their definition of malingering is the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.”

With this understanding, then, the causes (or false manifestations as the case may be) are directly linked to the desired gain of the patient. For example, if the desired outcome is financial – particularly through litigation, the “causes” tend to be tied more to physical symptoms. Financial gain can take the form of insurance settlements, workers’ compensation, unemployment insurance or qualifying for social security disability. Pain, weakness, nausea, chronic headaches, etc. are all conditions and symptoms rely largely on self-reporting by the patient. It is very difficult to ascertain through testing or diagnosis the level of pain a patient is experiencing. There are also many conditions and diseases that would have to be ruled out through testing and observation to arrive at the conclusion that the patient is malingering.

If the desired outcome is avoidance or a wish to escape negative consequences, then symptoms may be more neurological in nature. This outcome would include avoiding punishment for accusations of dereliction of duty in the military or law enforcement, chronic absenteeism from work or school, or escaping legal consequences for an action by feigning mental illness, loss of memory or some other mental condition that would remove personal responsibility for that action. Acute anxiety, dementia, psychiatric conditions such as bi-polar disorder or agoraphobia, post-traumatic stress disorder and other similar conditions are also difficult to diagnose and rely on self-reporting of symptoms by the patient.

It is important to note that malingering is not the same as hypochondria or a patient who is faking an illness for more internal reasons. It is not equivalent to Munchhausen’s Syndrome or other Somatic Symptom Disorders. These diagnoses are defined as mental illnesses, and are driven by other motivations or mental instabilities. Malingering is, by definition, the feigning of symptoms and illness for external gain. It is not a mental disorder.

There are variations of malingering, mostly by degree. These include the complete feigning of symptoms or the exaggeration of symptoms that are actually present but to a lesser degree that the patient indicates. As a side note:

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.”

Malingering Treatment

Since malingering is the feigning of illness, the treatment essentially involves the ruling out of actual illness or disease and the identification of the pretense.

Some key factors to consider when assessing for malingering include:

Atypical presentation in the presence of tangible external incentive or noxious environmental conditions.

Suspicion of voluntary control over symptoms as demonstrated by:

  • Bizarre or absurd symptomatology
  • Unusual symptomatic response to treatment
  • Atypical symptomatic fluctuation consistent with external incentives
  • Complaints grossly in excess of clinical findings
  • Substantial noncompliance with assessment or treatment

Malingering is also associated with Anti-Social Personality Disorder and a histrionic personality

Research into the arena of malingering is booming at present and that focus has provided new tools for diagnosing it. The Structure Inventory of Malingered Symptomatology (SIMS) is a survey of 75 true/false questions that patients self-report. It was developed by psychologist Harald Merkelbach and his colleagues at Maastricht University in the Netherlands.

Some other key considerations as clinicians attempt to identify if a patient is exhibiting malingering tendencies:

  • Look for possible external gain that may be associated with symptoms presented.
  • While interviewing the patient, note how many symptoms or conditions the patient is claiming and if those symptoms make sense as a whole. Are the claims of the patient reasonable in terms of known illnesses and conditions?
  • Avoid using leading questions when evaluating the patient, but rather use open-ended questions. Ask the patient to supply the details and characterize their symptoms.
  • Aggregate all known data regarding the particular patient to look for patterns of behavior.
  • Note any records that have been requested but for which the patient has refused to release for review.

Other psychological testing instruments that may be of use in diagnosing malingering would include:

The Test of Memory Malingering (TOMM) and the Structured Interview of Reported Symptoms, as well as more general standard personality measurement instruments (e.g., Minnesota Multiphasic Personality Inventory-2 and Personality Assessment Inventory). All of these instruments can be used as collateral data to help build a picture of the validity of the patient’s reported symptoms and levels of suffering.

Though malingering itself has no treatment since by definition there is no condition to treat, if the root cause is Anti-Social Personality Disorder, there are some treatments available for that condition. There are currently no medications approved to address Anti-Social Personality Disorder. The best available option for this disorder is psychotherapy, which has shown some success.

Also called talk therapy, this protocol can help address underlying factors that have helped create the disorder in the patient. Therapy may include anger management, assistance with substance abuse and identifications and treatment of other mental health issues. However, psychotherapy is only as effective as the willingness of the patient and the efficacy of the practitioner. In the treatment of Anti-Social Personality Disorder, it has only shown moderate success.

Malingering Prevention

Because Malingering is not an actual medical condition, there is no physical or physiological means of prevention.

Prevention of malingering then would come from legal protocols and consequences that would discourage patients from attempting the fraud at the outset. The United States Armed Forces treats malingering as an offense that carries court martial as the consequence.

In medicolegal settings, fraudulent presentation of symptoms can carry potentially criminal consequences and certainly civil settlements, such as court and legal costs. It can also result in enhancement of sentencing if it is proven that the guilty party has also attempted to feign illness or symptoms in an effort to effect the outcome of a trial or sentencing.

In terms of social security disability benefits, which is often the goal of malingering, a diagnosis of malingering can be the death toll for a claim for those benefits. While the Social Security offices generally use the opinions and records of the patient’s own physicians as the primary source for rendering judgement on a claim, with the thinking that those doctors are in the best position to provide a “detailed, longitudinal picture of impairment,” there was a shift in 2017. Based on that change, Social Security now looks at all medical opinions that have looked at a patient’s records, evidence, and treatment history.

In insurance cases, which is often the setting for malingering, the protocols and investigations that insurers will bring to bear where malingering is suspected can serve as a deterrent to the patient who might attempt it. Real financial cost as well as public humiliation and embarrassment are negative consequences that would have to be factored in by the patient.

In an employment setting, once malingering has been proven and other, real medical conditions have been ruled out, termination of employment is the outcome. This of course results in a loss of income, but also the loss of other benefits to the patient. Unemployment insurance is unavailable and obtaining other employment becomes difficult given the context of the termination.

Another, and potentially most serious, negative consequence of malingering is the refusal of continued medical treatment. Doctors, hospitals and clinics can terminate treatment of a patient if the diagnosis is malingering. Once a pattern of behavior has been established and/or the network of physicians and treatment providers have access to all the information, it becomes increasingly difficult for the patient to continue to access medical care of any kind. This could have potentially dangerous ramifications for the malingerer in the future in the event that an actual medical condition manifests itself.

Prevention of malingering is not really possible but making patients aware early in the process of what the negative consequences to that diagnosis might be based on the context of their situation may make malingering less prevalent. It is estimated by the Texas Department of Insurance, the cost of malingering and fraudulent claims to the United States insurance industry is as much as $150 billion dollars a year. While that cost may be somewhat inflated, fraud certainly impacts all Americans with regard to higher insurance premiums and health care costs.