Malingering

Malingering is defined by the American Psychiatric Association as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives”.

This external gain may take the form of financial rewards, relief of responsibility at a job or at home, avoiding military service, or evading criminal responsibility.

Pure malingering is when an individual feigns a disorder that does not exist at all.

Partial malingering is when an individual has actual symptoms but consciously exaggerates them. Falsified symptoms often have a vague or artificial quality and lack the convincing nuances in personally experienced symptoms.

False imputation refers to the attribution of actual symptoms to a cause consciously recognized by the individual as having no relationship to the symptoms.

Malingering must be differentiated from a Factitious Disorder, which is the intentional, conscious production of false symptoms in order to enjoy the patient role, and from a Conversion Disorder which is the unconscious production of symptoms.

Malingering should be considered in all referrals seeking compensation after a personal injury.

Such individuals will be motivated by financial gain, a “face saving” solution for personal life crises, revenge against a hated employer or spouse, or where a claim for physical injuries has been unsuccessful.

Attorneys for the plaintiff may overdramatize the client’s impairment, whereas the defense attorney may imply that the plaintiff is a pure malingerer. As a result the litigant may feel it necessary to exaggerate their claim in order to obtain what they believe they fairly deserve.

Clinicians are hesitant to diagnose malingering for at least 3 reasons;

1. a wide range of diagnoses must be ruled out
2. may lead to stigmatization and subsequent inability to receive appropriate care
3. fear suit for defamation of character or physical assault for being labeled a liar

 Two methods of identifying malingering can provide strong evidence with considerable certainty;

1. When individual participates in activities for which they claim incapacity.
2. Individual confesses to malingering.

Characteristics of the malingerer;

1. Uncooperative, suspicious, aloof
2. Try to avoid examination, unless required as a condition for financial benefit
3. Refuses employment with partial disability
4. Describes accident in full detail (without gaps or inaccuracies)

A classical circumstance for malingering is that of PTSD (Post Traumatic Stress Disorder)

1. Malingerers overact, giving excessively dramatic reports of their symptoms
2. They are overly eager to share information OR
3. Being evasive, hesitating to discuss return to work or potential for monetary gain
4. May take offensive position by attempting to control the interview or by being hostile to the interviewer.
5. History of poor social and occupational functioning
6. History of sporadic employment with long absences from work
7. History of previous incapacitating injuries

Criteria to distinguish feigned memory from true memory deficits;

1. Overplaying memory deficits
2. Inability to recall overlearned data (such as name, gender, social security number)
3. Alleged impairment of procedural memory (such as how to drive)
4. Poor performance on tests labeled “memory testing”
5. Performing worse than chance on memory testing
6. Clear recollection of trauma with alleged memory loss

Inconsistency in the malingerer; two types

1. Internal inconsistency ;
   a. when a malingerer reports severe symptoms such as an inability to concentrate or gross memory loss then is able to clearly articulate multiple examples of  poor concentration and memory loss
   B.malingerer gives grossly conflicting versions to the same evaluator
2. External inconsistencies
   a. Inconsistency between what an individual reports and the symptoms that are observed (e.g. report of flashbacks yet appears calm and not distracted)
   b. Inconsistency between reported levels of functioning and the observations of others
   c. Inconsistency between self-reports and hospital or police records 

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 Collateral Information is crucial to validating the subjective report of symptoms.

1. Objective or material evidence, including materials, photos, recordings. A psychophysiologic assessment of body’s response to questions may be helpful.
2. Police reports or other witness accounts
3. Past mental health records
4. Employee files, school grades, tax returns may give information about claimant’s daily pre-trauma functioning

The Interview;

1. Must be done without revealing the criteria used to define any medical/psychiatric disorder.
2. Questions must be open-ended and avoid leading questions which would give clues to correct response.
3. Insist on detailed account of the symptoms.  Falsified symptoms often have a vague or artificial quality and lack the convincing nuances in personally experienced symptoms.
4. Observe complainant looking for behavioral manifestations of the disorder (such as irritability, lack of focus, exaggerated startle response).
5. Third parties should not be present during the interview, so as to avoid altering of story or reluctance to tell story.

Psychological Testing

1.  Commonly used tests; MMPI -2, Personality Assessment Inventory, Trauma Symptom Inventory, Structured Interview of Reported Symptoms
2. Feigning scales used to help detect malingering, yet still find false positives and false negatives.
3. Best used as a screening devise, not as final determinant.

Confronting the Malingerer

1. Avoid direct accusations of lying.
2. Rather, ask the examinee for clarification of inconsistencies.
3. Convey a sympathetic understanding of the temptation to exaggerate symptoms.
4. Avoid causing shame or indignation and allow suspected malingerer to “save face”.