Psychiatrists frequently find themselves in situations in which they have to determine whether patients' psychiatric signs and symptoms are legitimate or feigned. In the emergency department, physicians are asked to determine whether patients are in need of inpatient hospitalization or whether there is an alternative motivation. Disability cases, workers' compensation, and civil liability cases are often influenced by treating psychiatrists' diagnoses and treatment recommendations.
The assessment of malingering can be difficult, because it challenges the trust inherent in the doctor-patient relationship. Nonetheless, in this column I hope to assist clinicians in understanding, detecting, and handling the disposition of patients who present with forged or exaggerated symptoms. With an outline of the types, motivations, and presentations of feigned mental illness, a physician can gather the relevant information to determine whether a diagnosis of malingering can be made.
The consequences of undetected malingering are extensive. The cost to society can be measured in dollars, safety, and health care availability. The Texas Department of Insurance reports that fraud that broadly includes malingering costs the insurance industry $150 billion annually, increasing the cost of insurance by $1800 per family.1 Malingering has obvious consequences for public safety when it causes bottlenecks in the criminal courts. In addition, in many parts of the country there are a limited number of psychiatric inpatient beds. It is not unheard of for a seriously mentally ill patient to spend days in an emergency department awaiting admission to an inpatient psychiatric facility. With the current resources, not including malingering in a differential diagnosis frequently blocks other, truly ill patients from receiving care. Last, it can be argued that the physician has an obligation to the malingerer, at least when in a therapeutic relationship, not to perpetuate and reinforce maladaptive behavior.
Malingering, however, is not always maladaptive. There are times when malingering is quite adaptive. Admission to a psychiatric ward may be a life or death matter in the cold of winter. A patient who is in danger from his or her cocaine dealer would find it incredibly adaptive to hide in a locked, guarded hospital for several days. Less dramatically, many well-adjusted, productive members of society can attest to calling in "sick" on a beautiful day as crucial to their mental health.
The DSM-IV TR defines malingering as "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs."2
Resnick3 goes further to provide us with more descriptive subcategories: pure malingering, partial malingering, and false imputation. Pure malingering is feigning a disorder that does not exist; exaggeration of existing symptoms is partial malingering; and attributing symptoms to an alternative cause defines false imputation.
1. Texas Department of Insurance: Consumer. Insurance Fraud. August 2006. Available at: http://www.tdi.state.tx.us/consumer/cb044.html. Accessed January 11, 2007.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
3. Resnick PJ. Malingering of posttraumatic stress disorders. In: Rogers R, ed. Clinical Assessment of Malingering and Deception. 2nd ed. New York: Guilford; 1997:130-152. 4. Resnick PJ. Malingering. In: Rosner R, ed. Principles and Practice of Forensic Psychiatry. 2nd ed. New York: Arnold; 2003:543-554.
5. Thompson JW Jr, LeBourgeois HW III, Black WF. Malingering. In: Simon RI, Gold LH, eds. Textbook of Forensic Psychiatry. Arlington, Va: American Psychiatric Publishing; 2004:427-448.
6. Reznek L. The Rey 15-item memory test for malingering: a meta-analysis. Brain Inj. 2005;19:539-543.
7. Rogers R. Development of a new classificatory model of malingering. Bull Am Acad Psychiatry Law. 1990;18: 323-333.
8. Rogers R, Sewell KW, Goldstein A. Explanatory models of malingering: a prototypical analysis. Law Hum Behav. 1994;18:543-553.