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 sick role, the primary gain). Malingerers show poor compliance with treatment and stop complaining about the assumed illness only after gaining the external benefit.
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.
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.
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.
A careful and detailed history taking is necessary to rule out malingering.
Mental Status Exam
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:
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:
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. 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:
Prognosis is unpredictable. Generally, the malingerer keeps on malingering until his incentive/external gain is fulfilled.
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.
Malingerer usually avoids psychiatric consultation. Referral to another physician is not advised.
Patient education in this scenario is a difficult task. The patient should undergo cognitive behavioral therapy, psychotherapy, and counseling.
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.
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.  [Level V]
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