Malingering: Key Points in Assessment

The assessment of malingering presents a significant challenge for mental health clinicians. The traditional clinician-patient relationship is based on the assumption that a patient is in genuine need of treatment, so clinicians may feel uneasy about initiating malingering assessment. This uneasiness is understandable given the potential for escalation of an individual's behavior when confronted with the clinician's suspicions of malingering,^1,2 not to mention the rare potential for lawsuits alleging malpractice following a diagnosis of malingering.^3-5

Mental health clinicians are nevertheless likely to encounter cases of malingering. Mittenburg and associates⁶ reported that in a recent study of 33,531 cases seen by members of the American Board of Clinical Neuropsychology during a 1-year period, probable malingering and symptom exaggeration were found in 30% of disability evaluations, 29% of personal injury evaluations, 19% of criminal evaluations, and 8% of medical cases. This is consistent with earlier studies on base rates of malingering identified during mental health evaluations.^7,8

While forensic settings in general harbor higher base rates of malingering, some clinical settings, such as those in which compensation-seeking veterans receive evaluation/treatment for posttraumatic stress disorder (PTSD), may have rates that approach or exceed base rates enumerated in forensic settings.⁹ Therefore, mental health clinicians should have familiarity with key points in malingering assessment.

HISTORICAL BACKGROUND
Malingering was documented in biblical times. David "feigned insanity and acted like a madman" to avoid a king's wrath (1 Samuel 21:11-16). In 1843, malingering found its way into the English medical literature.¹⁰ Four years later, a French surgeon described the use of ether to distinguish feigned from real disease.¹¹ In the late 19th century and early 20th century, the introduction of worker's compensation led to numerous pejorative terms such as compensation neurosis to describe suspected malingering.¹² During World War II, the British dropped pamphlets over German troops instructing them how to feign injury in order to obtain military leave.¹³ Recently, a German CD-ROM named the "Sickness Simulator" was available for purchase on the Internet; the program instructed employees on how to malinger in order to obtain sick leave.¹⁴

DEFINITIONS AND SUBTYPES
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." Malingering is not a psychiatric disorder; DSM-IV-TR includes it in the section "Other Conditions That May Be a Focus of Clinical Attention."

Resnick¹² comments on potential subtypes of malingering: pure malingering involves complete fabrication, partial malingering involves exaggeration of existing symptoms, and false imputation occurs when an evaluee intentionally attributes symptoms to a cause that has little or no relationship to the development of the symptoms.

Malingered conditions
Malingered psychiatric conditions may include dissociative identity disorder,¹⁵ psychosis,¹⁶ suicidality/mood disorders,¹⁷ and PTSD.¹² Malingered conditions that cross the spectrum of psychiatry and neurology include acute dystonia,¹⁸ amnesia,¹⁹ cognitive deficits,²⁰ dementia,²¹ seizure,²² and sleep disorder.²³ In addition, there have been several case reports of "malingering by proxy" in the pediatric setting.^24,25

Psychiatric disorders that may be mistaken for malingering
Both malingering and factitious disorders involve feigning of physical or psychological illness. The motivation for feigning associated with factitious disorders is a desire to assume the sick role rather than an obvious external incentive such as disability payments.²⁶ In malingering, external incentive should be tangible. An example is a case in which a criminal defendant feigns mental illness in an attempt to be designated incompetent so as not to be executed.²⁷ On the other hand, a patient with factitious disorder who repeatedly injects insulin to induce hypoglycemia may jeopardize his or her own well-being—a high personal cost just to assume the sick role.

Mental health clinicians should also consider somatoform disorders in the differential diagnosis when a question of malingering is raised.¹ Furthermore, clinicians should be careful not to ascribe atypical presentations to feigning before considering a workup to rule out causes for atypical presentations, such as syndromes occurring secondary to drug ingestion or secondary to an occult medical condition. A simplified guide may be helpful in making this differentiation (Figure).

The adaptational model of malingering proposed by Rogers²⁸ asserts that malingerers engage in a "cost-benefit analysis" during assessment. "Malingering is more likely to occur when (1) the context of the evaluation is perceived as adversarial, (2) the personal stakes are very high, and (3) no other alternatives appear to be viable." In the context of this model, individuals malinger based on their estimate of success in obtaining the desired external incentive.

According to DSM-IV-TR, malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medicolegal context of presentation; (2) marked discrepancy between the person's claimed stress or disability and the objective findings; (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen; and (4) the presence in the patient of antisocial personality disorder (ASPD).

There has been debate about whether DSM-IV-TR's "singling out" of individuals with ASPD is appropriate.^29,30 Research in this area suggests that limiting the consideration of malingering only to those with ASPD will result in significant underdetection.¹