2nd February 2024

Malingering Disorders

This is the deliberate and premeditated false presentation of symptoms or health problems with the primary aim of accomplishing an external reward.

The external gain could be monetary, reimbursement from work, drugs-related, exemption from duty or legal issues. It could also be to gain external benefits such as evading work or obligation, looking for drugs, dodging trial (law), seeking attention, eluding military services, leave from school or paid leave from a job. 

It is not a mental illness.

Clinical presentation

• Overgeneralisation and exaggeration of symptoms
• Bizarre, inappropriate and inconsistent presentations
• No functional impairment outside of the diagnostic setting
• Excess claims, sick leaves
• Poor explanation between symptoms and facts
• No treatment found beneficial

Overall, both Malingering and Factitious disorders are abnormal healthcare-seeking behavioural conditions. The common feature is deception. Although it may be encountered in the clinical setting, malingering is not a diagnosis. To establish malingering is challenging. Symptoms from malingering are premeditated, and the motivation behind it is well calculated.

In malingering disorder, there is some external benefit, which is like a secondary gain. This distinguishes malingering from factitious disorder (a disorder in which a patient consciously creates physical or psychological symptoms to assume a sick role, the primary gain). Malingerers generally do not accept treatment, show poor compliance with management and stop complaining about the presumed illness only after obtaining what he or she wants.

There is no medication or intervention to cure malingerers. 

Causes/ Aetiology/ Associations

• Malingering has no precise cause but is associated with lower socio-economic conditions 
• Malingering is reported among convicts evading trial, students avoiding school, workforces dodging work, and homeless hoping for economic reimbursement and rations. 
• Drug abusers frequently forge some illness or sickness, sleeplessness just so that they can procure Diazepam or painkillers. 
• Malingering is noticed in people trying to avoid military service. 
• With regard to different personalities in malingering, histrionic and antisocial are comparatively more common.

Criteria -DSM-5 

• The medico-legal context of the presentation
• Marked discrepancy between the individual’s “claimed stress or disability” and “objective finding and observation”
• Lack of compliance with diagnostic evaluation, treatment regimen and follow-up care
• Presence of antisocial personality disorder 

Protracted and unrelenting thorough observation can divulge evidence of malingering because it is difficult for the person who is malingering to sustain uniformity and consistency with the incorrect or embroidered claims for lengthy periods.

The malingerer typically lacks understanding of the nuances of the feigned disorder. For example, someone complaining of nerve compression syndrome in the upper limb may be referred to occupational therapy, where the person who is malingering would be unable to predict the effect of true syndrome on tasks in an art shop or painting task. They might use simple techniques like adding contaminants to urine or heating a thermometer under a lamp to feign temperature to stay in the hospital.

Individuals malingering psychotic illness repeatedly overstress hallucinations and delusions but cannot impersonate formal thought disorders. They usually cannot fake blunted affect, concrete thinking, or impaired interpersonal relatedness. They frequently assume that dense amnesia and confusion are features of psychosis. 

It is observed that malingerers in ED work towards the external gain of obtaining shelter and or drugs whilst in offices or clinics, and their goal could be financial gains.

References

• Merten, T. and Merckelbach, H. (2020). Factitious disorder and malingering. New Oxford Textbook of Psychiatry, pp.1342–1349. doi:10.1093/med/9780198713005.003.0132.
• Tracy, D.K. and Rix, K.J.B. (2017). Malingering mental disorders: Clinical assessment. BJPsych Advances, 23(1), pp.27–35. doi:10.1192/apt.bp.116.015958.
• Turner, M. (1997). Malingering. British Journal of Psychiatry, 171(5), pp.409–411. doi:10.1192/bjp.171.5.409.
• Gorman, W.F. (1982). Defining malingering. Journal of Forensic Sciences, [online] 27(2), pp.401–407. Available at: https://pubmed.ncbi.nlm.nih.gov/7047677/
• Ubaid ullah Alozai and McPherson, P.K. (2018). Malingering. [online] Nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK507837/
• DT; BCW. Malingering and factitious disorder [Internet]. Practical neurology. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/30425128/ 
• PK; AUUMP. Malingering [Internet]. National Center for Biotechnology Information. U.S. National Library of Medicine; [cited 2022 Dec 21]. Available from: https://pubmed.ncbi.nlm.nih.gov/29939614/ 
• StatPearls. Malingering [Internet]. StatPearls. StatPearls Publishing; 2022 [cited 2022Dec21]. Available from: https://www.statpearls.com/articlelibrary/viewarticle/24687/