AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Malingering is intentional production of false or exaggerated symptoms motivated by external incentives, such as obtaining compensation or drugs, avoiding work or military duty, or evading criminal prosecution. Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), malingering receives a V code as one of the other conditions that may be a focus of clinical attention.¹

Pathophysiology

Malingering is deliberate behavior for a known external purpose. It is not considered a form of mental illness or psychopathology, although it can occur in the context of other mental illnesses.

Mortality/Morbidity

The total cost of health insurance fraud in the United States (including untruthful claims by patients and medical personnel) was more than $59 billion in 1995, resulting in a cost of $1050 in added premiums for the average American family.²

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Strongly suspect malingering in the presence of any combination of the following:
• • Medicolegal presentation (eg, an attorney refers patient, a patient is seeking compensation for injury)
  • Marked discrepancy between the claimed distress and the objective findings
  • Lack of cooperation during evaluation and in complying with prescribed treatment
  • Presence of an antisocial personality disorder³
• Malingering often is associated with an antisocial personality disorder and a histrionic personality style.
• Prolonged direct observation can reveal evidence of malingering because it is difficult for the person who is malingering to maintain consistency with the false or exaggerated claims for extended periods.
• The person who is malingering usually lacks knowledge of the nuances of the feigned disorder. For example, someone complaining of carpal tunnel syndrome may be referred to occupational therapy, where the person who is malingering would be unable to predict the effect of true carpal tunnel syndrome on tasks in the wood shop.
• Prolonged interview and examination of a person suspected of a malingering disorder may induce fatigue and diminish the ability of the person who is malingering to maintain the deception. Rapid firing of questions increases the likelihood of contradictory or inconsistent responses. Asking leading questions may induce the person to endorse symptoms of a different illness. Questions about improbable symptoms may yield positive responses. However, because some of these techniques may induce similar responses in some patients with genuine psychiatric disorders, exercise caution in reaching a conclusion of malingering.
• Persons malingering psychotic disorders often exaggerate hallucinations and delusions but cannot mimic formal thought disorders. They usually cannot feign blunted affect, concrete thinking, or impaired interpersonal relatedness. They frequently assume that dense amnesia and disorientation are features of psychosis. It should be noted that these descriptions also may apply to some patients with genuine psychiatric disorders. For example, individuals with a delusional disorder can have unshakable beliefs and bizarre ideas without formal thought disorder or affective blunting.⁴
• The most common goals of people who malinger in the emergency department are obtaining drugs and shelter. In the clinic or office, the most common goal is financial compensation.⁵

Physical

Typically, deficits on physical examination do not follow known anatomical distributions.

The following can be found on a Mental Status Examination:^{6, 7}

• A patient's attitude toward the examining physician is often vague or evasive.
• Mood may be irritable or hostile.
• Thought processes are generally cogent. Thought content is marked by preoccupation with the claimed illness or injury.
• Threats of suicide may follow any challenge to the veracity of the claim, or a response deemed by the malingerer to be inadequate. 
• As noted under History, persons with malingering psychotic disorders often exaggerate hallucinations and delusions but cannot mimic formal thought disorders. They usually cannot feign blunted affect, concrete thinking, or impaired interpersonal relatedness. They frequently assume that dense amnesia and disorientation are features of psychosis. These descriptions may also apply to some patients with genuine psychiatric disorders. For example, individuals with a delusional disorder can have unshakable beliefs and bizarre ideas without formal thought disorder or affective blunting.⁴

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Antisocial personality disorder
Dissociative disorder
True medical or psychiatric illness related to presenting complaints

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Tests

• The Minnesota Multiphasic Personality Inventory (MMPI) can detect inconsistent or atypical response patterns associated with malingering (see Media file 1). The F scale and the F-K index are the most valuable indicators. Several subscales, such as the Fake Bad Scale, have been extracted from MMPI profiles.
• Multiple other psychological tests have been validated for detection of malingering, including the Test of Memory Malingering, the Negative Impression Management Scale, and the Rey 15-Item Test.⁸

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

• Do not accuse the patient directly of faking an illness. Hostility, breakdown of the doctor-patient relationship, lawsuit against the doctor, and, rarely, violence may result.
• The more advisable approach is to confront the person indirectly by remarking that the objective findings do not meet the physician's objective criteria for diagnosis. Allow the person who is malingering the opportunity to save face.
• Alternatively, the physician may inform people who are malingering that they are required to undergo invasive testing and uncomfortable treatments (provided, of course, that such warning is true).
• The likelihood of success with such approaches is inversely related to the rewards for the malingering behavior.^{9, 10, 11, 7}

Consultations

People who malinger almost never accept psychiatric referral, and the success of such consultations is minimal. Avoid consultations to other medical specialists because such referrals only perpetuate malingering. However, in cases of serious uncertainty about the presence of genuine psychiatric illness, suggest psychiatric consultation.

Psychiatric consultation may be suggested as an augmentation to dealing with an acknowledged symptom. For example, the primary physician might propose, "Your pain has to be causing your system a great deal of stress, and we know that only makes the pain worse. Consultation from a psychiatrist might help us with your pain by reducing the stress." Without being confrontational, the physician must remain honest.^{2, 11, 7}

FOLLOW-UP

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Complications

Hostile or threatening behavior may ensue if the malingerer's claims are challenged, or if the physician fails to respond to his/her demands for disability certification, medications, etc.

Prognosis

Malingering behavior typically persists as long as the desired benefit outweighs the inconvenience or distress of seeking medical confirmation of the feigned illness.

Patient Education

While the physician may wish to educate the patient about better ways of achieving goals than by malingering, the reasons are usually more deeply rooted than just a cognitive deficit and require behavioral interventions, psychotherapy, and counseling. 

See Medscape's Patient-Provider Relations in Psychiatry & Mental Health Resource Center.

Family education

The physician should determine whether revealing the malingering to the family will do more harm than good. If the family is adversely affected by the malingering behavior, it may be helpful for family members to know that the evidence is strong that no physical ailment is causing the patient's distress. They may be encouraged to resist the patient's efforts to manipulate them to accommodate the feigned illness at their own. While malingerers are both resistant to accepting psychotherapy and refractory to its benefits, family members may benefit from family counseling to develop adaptive approaches to the malingering behavior.^{5, 9}

MISCELLANEOUS

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

Because malingering for the purpose of compensation constitutes criminal behavior, document the diagnosis meticulously. When in doubt, assuming that the patient is not malingering is a better course of action.¹²

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Differential diagnosis of malingering, factitious disorder, and somatoform disorders.
	View Full Size Image
Media type:  Graph

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Press Inc; 2000:683.
2. LoPiccolo CJ, Goodkin K, Baldewicz TT. Current issues in the diagnosis and management of malingering. Ann Med. Jun 1999;31(3):166-74. [Medline].
3. Faust D. The detection of deception. Neurol Clin. May 1995;13(2):255-65. [Medline].
4. Resnick PJ. Defrocking the fraud: the detection of malingering. Isr J Psychiatry Relat Sci. 1993;30(2):93-101. [Medline].
5. Purcell TB. The somatic patient. Emerg Med Clin North Am. Feb 1991;9(1):137-59. [Medline].
6. Donaghy M. Symptoms and the perception of disease. Clin Med. Nov-Dec 2004;4(6):541-4. [Medline].
7. Malone RD, Lange CL. A clinical approach to the malingering patient. J Am Acad Psychoanal Dyn Psychiatry. Spring 2007;35(1):13-21. [Medline].
8. Anderson JM. Malingering: A constant challenge in disability arenas. J Controversial Med Claims. May 2008;15(2):1-9.
9. Udell ET. Malingering behavior in private medical practice. Clin Podiatr Med Surg. Jan 1994;11(1):65-72. [Medline].
10. Voiss DV. Occupational injury. Fact, fantasy, or fraud?. Neurol Clin. May 1995;13(2):431-46. [Medline].
11. McDermott BE, Feldman MD. Malingering in the medical setting. Psychiatr Clin North Am. Dec 2007;30(4):645-62. [Medline].
12. Ziegler SJ. Pain, patients, and prosecution: who is deceiving whom?. Pain Med. Jul-Aug 2007;8(5):445-6; author reply 447-8. [Medline].

Article Last Updated: Jul 17, 2008