Continuing Education Activity

Malingering is falsification or profound exaggeration of illness (physical or mental) to gain external benefits such as avoiding work or responsibility, seeking drugs, avoiding trial (law), seeking attention, avoiding military services, leave from school, paid leave from a job, among others. It is not a psychiatric illness according to DSM-5 (Diagnostic and Statistical Manual of Mental Diseases, Fifth edition). The DSM-IV-TR failed to provide any precise criteria because malingering is not considered a psychiatric diagnosis, but the manual does state it is a condition that may be a focus of clinical attention. Although malingering was excluded from the index in DSM-5, it remains a "V" code, and the criteria for when to consider malingering remains unchanged. External (secondary) gain is necessary for differentiating malingering from factitious disorder (a disorder in which patient consciously creates physical or psychological symptoms to assume the sick role, the primary gain). Malingerers show poor compliance with treatment and stop complaining about the assumed illness only after gaining the external benefit. This activity reviews the common presentation of patients that are malingering and discusses the role of the interprofessional team in evaluating and treating this condition.

Objectives:

• Identify malingering and explain its most common purposes.
• Summarize the reason malingering was not included in the DSM-5 criteria.
• Describe the typical treatment compliance patterns of a patient that is malingering.
• Outline the common presentation of patients that are malingering and discusses the role of the interprofessional team in evaluating and treating this condition.

Introduction

Malingering is falsification or profound exaggeration of illness (physical or mental) to gain external benefits such as avoiding work or responsibility, seeking drugs, avoiding trial (law), seeking attention, avoiding military services, leave from school, paid leave from a job, among others. [1][2][3]It is not a psychiatric illness according to DSM-5 (Diagnostic and Statistical Manual of Mental Diseases, Fifth edition). The DSM-IV-TR failed to provide any precise criteria because malingering is not considered a psychiatric diagnosis, but the manual does state it is a “condition that may be a focus of clinical attention.” Although malingering was excluded from the index in DSM-5, it remains a "V" code, and the criteria for when to consider malingering remains unchanged. External (secondary) gain is necessary for differentiating malingering from factitious disorder (a disorder in which patient consciously creates physical or psychological symptoms to assume sick role, the primary gain). Malingerers show poor compliance with treatment and stop complaining about the assumed illness only after gaining the external benefit.[4]

Etiology

Malingering has no specific etiology, but the causes include socio-economic conditions. It is commonly reported among prisoners avoiding trial, students avoiding school, workers avoiding work, homeless hoping for economic compensation/rations. Drug abusers commonly fake sickness, painful conditions, or insomnia to receive drugs of abuse including opioids such as nalbuphine, benzodiazepines, among others. Malingering is reported in people trying to avoid military service. It has a close association with an antisocial personality disorder and histrionic personality trait.[5][6]

Epidemiology

The prevalence of malingering is difficult to determine. In an estimate of malingering in forensic populations, prevalence reached 17%. In another study conducted by Department of Psychology, the University of New Orleans, the prevalence of malingering in patients suffering from chronic pain with financial incentive was found to be between 20% to 50% depending on the diagnostic system used. There have been efforts to determine the frequency of malingering in populations, but the reliability of those sources is questionable. Although it is presumed that the frequency of malingering is higher in females than males, there is no data to back up this presumption.

Pathophysiology

Malingering is associated with an anti-social personality disorder and histrionic personality trait. To get an external (secondary) gain, the individual fakes an illness that can be of physical or psychological nature. The patient consciously lies about his or her condition to get a benefit, and upon achieving the benefit, they stop complaining. No medicine or intervention can cure malingerers. Upon detailed history, the malingerer may exhaust their excuses and give up.

DSM-5 states that if any combination of the following 4 complains is present in a patient, then malingering should be considered.[7]

1. The medicolegal context of the presentation, for example, a lawyer sending his client for evaluation or patient presents with an illness while facing trial
2. Marked discrepancy between the individual's "claimed stress or disability" and "objective finding and observation"
3. Lack of compliance with diagnostic evaluation, treatment regimen and follow up care
4. Presence of anti-social personality disorder

History and Physical

A careful and detailed history taking is necessary to rule out malingering.

1. Watch carefully for discrepancies in person's behavior while taking prolonged, detailed history.
2. Dig deep into patient's personality (anti-social personality disorder, histrionic personality traits).
3. Find out about the legal status of the patient.
4. Ask rapid questions and see the incoherence between answers.
5. Ask an open-ended and leading questions. (Questioning about symptoms not related to the "illness faked by the patient" may also induce a positive answer. The patient not knowing much about the assumed disease may say yes to any question).
6. Watch for exaggeration of psychiatric symptoms like hallucinations and delusions.

Mental Status Exam

• Appearance and behavior: May appear disheveled, uncombed hair, untidy clothing, no eye contact, no rapport building. Irritated hostile behavior
• Mood: Answers low or elated and never normal euthymic. Cannot mimic lack of effect, anhedonia
• Thoughts: Exaggerated delusions, but cannot mimic formal thought disorders like schizophrenia; confused at times with true psychiatric thought disorders as patient with psychosis or schizophrenia can have bizarre delusions and unshakable beliefs
• Perception: Exaggerated hallucinations, both visual and auditory
• Insight: Have good insight about the disease. Almost always acknowledge suffering from the disease they fake
• Cognition: Cannot be assessed properly at times, because the patient may be noncompliant and may lie

Multiple examinations should be performed, and incoherences between the results should be noted. Various tasks are given to patients and performance on different occasions are noted. The inconsistent score in the same task performed multiple times suggest malingering.

Other areas to be investigated include:

• History of hospitalization, medication
• Current history of medication
• Family history
• Social history

Evaluation

The diagnosis of malingering is based on history, physical exam, and psychological tests. No diagnostic laboratory tests are available to diagnose malingering. Laboratory studies are, however, useful to exclude organic cause and genuineness of illness. These laboratory studies might include the following:

• Complete blood cell (CBC) count
• Serum electrolytes.
• Renal function tests
• Liver function tests (LFTs)
• Blood alcohol level
• Blood and urine toxicology screen (may also rule in malingering in case of drug abusers seeking opioids)
• Computed tomography (CT) scanning or magnetic resonance imaging (MRI) of the brain should be considered to rule out organic brain disorders

Other Tests:

• The Minnesota Multiphasic Personality Inventory (MMPI)
• The F-scale
• Test of memory malingering
• The negative impression management scale
• Rey 15-item test
• The temporal memory sequence test
• Symptom and Disposition Interview (SDI)

Treatment / Management

Do not confront the patient directly. Do not question the beliefs of the patient. Do not accuse the patient of feigning his or her illness. Patient-doctor conflict, a lawsuit against the doctor, and violence may result. Rather confront the patient indirectly.[8][9][10] Offer a scientific explanation but do not deny the beliefs of the patient. Invasive diagnostics and interventions ought to be avoided as their harm outweigh benefits. The physician can help by encouraging:

• Behavioral therapy
• Psychotherapy
• Counseling

Differential Diagnosis

1. Organic cause of the disease. Organic disorder, any physical illness must be ruled out before considering malingering.
2. Conversion disorders. Look for stressors and incentive.
3. Factitious disorder, for example, Munchausen syndrome; Differentiate between primary and secondary/external gain.
4. Hypochondriasis
5. Somatic symptom disorder
6. Psychosis, schizophrenia (thought disorders)
7. Depression, mania (mood disorders)
8. Dissociative disorders

Prognosis

Prognosis is unpredictable. Generally, the malingerer keeps on malingering until his incentive/external gain is fulfilled.

Complications

If the demands of a malingerer are denied, then the subject may show aggressive behavior which may result in an offensive conflict. The doctor may face a lawsuit.

Consultations

Malingerer usually avoids psychiatric consultation. Referral to another physician is not advised.

Deterrence and Patient Education

Patient education in this scenario is a difficult task. The patient should undergo cognitive behavioral therapy, psychotherapy, and counseling.

Pearls and Other Issues

There is no reliable data about the prevalence of malingering in the general population. No clear-cut criteria to rule out or rule in malingering. Care should be taken while dealing with a malingerer as he or she may seriously harm the physician.

Enhancing Healthcare Team Outcomes

Malingering is a very difficult disorder to diagnose and treat. The disorder is best managed by an interprofessional team involving a mental health nurse, psychiatrist and a psychotherapist. These patients can be confrontational and threaten lawsuits if their demands are not met. The outlook for most of these patients is guarded. Most eventually get into legal problems as a result of their psychiatric pathology. [11][12] [Level V]