Malingering

Malingering is the fabrication, feigning, or exaggeration of physical or psychological symptoms designed to achieve a desired outcome, such as personal gain, relief from duty or work, avoiding arrest, receiving medication, or mitigating prison sentencing. It presents a complex ethical dilemma within domains of society, including healthcare, legal systems, and employment settings.^[1][2][3]

Although malingering is not a medical diagnosis, it may be recorded as a "focus of clinical attention" or a "reason for contact with health services".^[4][2] It is coded by both the ICD-10 and DSM-5. The intent of malingerers vary. For example, the homeless may fake a mental illness to gain hospital admission.^[5] Impacts of failure to detect malingering are extensive, impacting insurance industries, healthcare systems, public safety, and veterans' disability benefits. Malingered behaviour typically ends as soon as the external goal is obtained.^[6]

Malingering is established as separate from similar forms of excessive illness behaviour, such as somatization disorder, wherein symptoms are not deliberately falsified. Another disorder is factitious disorder, which lacks a desire for secondary, external gain.^[7][6] Both of these are recognised as diagnosable by the DSM-5. However, not all medical professionals are in agreement with these distinctions.^[8]

According to 1 Samuel in the Old Testament, King David feigned madness to Achish, the king of the Philistines. Some scholars believe this was not feigned but real epilepsy, and phrasing in the Septuagint supports that position.^[9]

Odysseus was said to have feigned insanity to avoid participating in the Trojan War.^[10][11]

Malingering was recorded in Roman times by the physician Galen, who reported two cases: one patient simulated colic to avoid a public meeting, and another feigned an injured knee to avoid accompanying his master on a long journey.^[12]

In 1595, a treatise on feigned diseases was published in Milan by Giambattista Silvatico.

Various phases of malingering (les gueux contrefaits) are represented in the etchings and engravings of Jacques Callot (1592–1635).^[13]

In his Elizabethan-era social-climbing manual, George Puttenham recommends a would-be courtier to have "sickness in his sleeve, thereby to shake off other importunities of greater consequence".^[14]

Although the concept of malingering has existed since time immemorial, the term for malingering was introduced in the 1900s due to those who would feign illness or disability to avoid military service.^[15] In 1943, US Army General George S. Patton found a soldier in a field hospital with no wounds; the soldier claimed to be suffering from battle fatigue. Believing the patient was malingering, Patton flew into a rage and physically assaulted him. The patient had malarial parasites.^[16]

Agnes was the first subject of an in-depth discussion of transgender identity in sociology, published by Harold Garfinkel in 1967. In the 1950s, Agnes feigned symptoms and lied about almost every aspect of her medical history. Garfinkel concluded that fearing she would be denied access to sexual reassignment surgery, she had avoided every aspect of her case which would have indicated gender dysphoria and hidden the fact that she had taken hormone therapy. Physicians observing her feminine appearance therefore concluded she had testicular feminization syndrome, which legitimized her request for the surgery.^[17]

Classifying malingering behaviour into different categories allows for an easier assessment of possible deception, as created by Robert Resnick.^[8] As individuals within institutions grapple with the challenges posed by malingering, a critical examination ethical duties emerges as imperative. Balancing compassion for those genuinely in need with the responsibility to uphold integrity and fairness, ethical obligations in addressing malingering extend beyond mere detection to encompass considerations of empathy, justice, and the broader implications for trust and societal welfare.

• Pure malingering: feigning a disorder or illness that is nonexistent. It is arguably the most simple to detect. This is because malingerers of this type tend to provide unreliable, additional symptoms when describing their supposed disorder, since they have to create an entire story from scratch. It is, therefore, difficult to entirely accurately mimic real-world scenarios.^[18][19]
• Partial malingering: purposefully exaggerating symptoms for an existing disorder or illness. This may be particularly difficult to detect, because those who partake in this would be building on their own genuine traumatic experiences, rather than completely falsifying claims.^[18][19]
• False imputation: attributing of existing symptoms to a cause that the patient knows is unrelated to their illness. Identifying this type of malingering is less difficult than partial malingering, as patients may inaccurately transpose symptoms from their real experience to the supposed cause of their disorder. This entails inaccurate storytelling and would indicate deliberate deception.^[18][19]

Veterans may be denied disability benefits if their doctor believes that they are malingering, especially regarding post-traumatic stress disorder. In navigating these ethical dimensions, it becomes essential to foster a nuanced understanding that acknowledges the complexities inherent in distinguishing genuine suffering from deceptive behavior, while also safeguarding against the misuse of resources and the erosion of trust in systems designed to support those in need. PTSD is the only condition for which the DSM-5 explicitly warns clinicians to observe in case of malingering. Distinguishing malingered PTSD from genuine symptoms is challenging due to the range of the nature and severity of the disorder. An assessment showed that in over 10% of cases, veterans were falsifying or exaggerating their service history.^[20][21]

Research that focuses on malingering attention deficit hyperactivity disorder are largely centred around university or college students. This is because of the significant benefits that may be gained if the student is successful, including student financial aid and exemptions for academic work. Medicinal treatments of ADHD may also be nootropics, which would enhance cognitive performance in examinations.^[20]

Malingering is a court-martial offense in the United States military under the Uniform Code of Military Justice, which defines the term as "feign[ing] illness, physical disablement, mental lapse, or derangement."^[22] According to the Texas Department of Insurance, fraud that includes malingering costs the US insurance industry approximately $150 billion each year.^[23][24] Other non-industry sources report it may be as low as $5.4 billion.^[25]

Richard Rogers and Daniel Shuman found that the use of DSM-5 criteria results in the accurate identification of only 13.6–20.1% of actual malingerers (true positives).^[26] However, 79.9–86.4% of individuals are misclassified as malingerers (false positives) using the same criteria. Being falsely accused of malingering may cause adverse reactions, some of which lead to violence. Thus, the accurate detection of malingering is a pressing societal issue.^[27]

There are multiple methods to evaluate malingering, such as the Minnesota Multiphasic Personality Inventory-2, which is the most validated test. Other tests include the Structured Interview of Reported Symptoms, which is used for psychiatric symptoms, and the Test of Memory Malingering (TOMM), intended for false memory deficits.^[18] Culture and education also likely affect overall performance in these tests. Research found that Colombian adults with low literacy skills perform significantly worse on the Test of Memory Malingering, so there are concerns with the impact of education levels on malingering assessments.^[28]

Existing criteria for one malingered disorder may not be applicable to a different disorder. For example, tests for malingered PTSD may not work for malingered neurocognitive disorders; therefore, there is a need for newer criteria to be created.^[20]

Although there is no singular test that definitively discerns malingering,^[18] medical professionals are told to watch out for certain behaviours that may indicate deliberate deception.

Signs that illustrate malingering include:^[20][29]

• providing contradictory statements about symptoms;
• dramatic or peculiar behaviour that is meant to be convincing;
• behaviour that is inconsistent with described symptoms;
• acting adverse to accepting treatment for their supposed disorder;
• overenthusiasm about negative symptoms through going into extensive detail;
• sudden termination or onset of symptoms

Look up malingering in Wiktionary, the free dictionary.

• Doctor shopping
• Drug seeking behaviour
• Falsifiability
• Ganser syndrome
• Hypochondriasis
• Insanity defense
• Münchausen syndrome
• Ocular malingering
• Structured Inventory of Malingered Symptomatology
• Syndrome K, illness fabricated by doctors to protect Jews from Nazis