Malingering

Perhaps one of the most underdiagnosed syndromes of our time, Malingering is characterized by a deliberate fabrication of psychiatric or physical complaints for clear secondary gain such as material reward (e.g. controlled substances, money) or punishment avoidance. Surely, as long as there have been people, there too have existed malingerers. Probably the earliest reference appears in the Old Testament...

1 Samuel 21: 12-15: And David laid up these words in his heart, and was sore afraid of Achish the king of Gath.

And he changed his behavior before them, and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.

Then said Achish unto his servants, Lo, ye see the man is mad: wherefore then have ye brought him to me?

Have I need of mad men, that ye have brought this fellow to play the mad man in my presence? Shall this fellow come into my house?

In recent history, the incidence of Malingering appears to be on the rise, temporally related to the creation of the Social Security Disability Act in the 1970s, which has offered worthwhile enticements to those so inclined.

Typically, health care providers are reluctant to diagnose this condition, because of the difficulty in proving Malingering or honestly confronting a suspect without fear of creating embarrassment or provoking retaliation. Just how does a clinician tactfully convey to a "patient" that he doesn't believe his threats of suicide or claims of hallucinations? Also, most of us identify with the role (or rationalization) of healer, not detective; and therefore operate with the presumption that patients generally present with a therapeutic agenda. Less common and more unforgiving is the scenario that I unflatteringly refer to as "sociopathic symbiosis", in which an enterprising clinician, sharing a clandestine mission with a scheming patient, willfully diagnoses a serious mental/medical illness on the basis of subjective claims per se without objective supporting evidence from examination.

Clinical hints that a patient may be malingering include the presence of an antisocial personality or chemical dependency issue, noncompliance with the evaluation and treatment process, a medicolegal context to the presentation (e.g. referral by an attorney), and a marked disparity between subjective complaints and objective exam findings. Regarding the latter criterion, differential diagnosis can be tricky. Foremost among consideration, Factitious Disorder is a condition in which the patient also exaggerates or feigns symptoms to achieve a less obvious primary gain; that is, a primitive desire to satisfy attention needs by playing sick. Such individuals will often go to incomprehensible and masochistic lengths to attain their goal, such as by submitting themselves to a surgical procedure for faked abdominal pain. They are further contrasted from malingerers in lacking the other 3 aforementioned clinical criteria, and by classically displaying an affect of indifference rather than concern.

Psychological testing can be quite useful in assisting with the diagnosis. For example, the MMPI-II has validity scales (F,L,K) that can reliably detect both exaggeration and minimization of pathology. Specifically, an F minus K score of greater than 11 has consistently been associated with dissimulation in numerous studies.

All of this seems rather tedious, and the temptation is certainly there to follow the path of least resistance by simply giving the patient what he wants. However, before doing so, I'm reminded of Sir Walter Scott's poetic admonition, "Oh, what a tangled web we weave, when first we practise to deceive!".