Malingering, factitious disorder, and related somatic disorders present with unique diagnostic and treatment challenges. Reporting of symptoms that are excessive, nonexistent, or exaggerated beyond available medical evidence is a central feature of each condition, and this can make the clinical differentiation of these disorders a daunting task. Treatment is similarly difficult because, by the very nature of these conditions, a patient’s self-report cannot be relied upon prima facie and traditional treatment approaches often do not address the underlying impetus for the reported symptoms. Management of such patients is an unwelcome undertaking for many mental health providers, and many non-psychiatric physicians prefer to avoid it altogether. Psychiatry and other mental health services, therefore, may provide a unique role by recognizing and addressing these conditions in their own patients and by providing useful consultation to providers of other specialties in instances of noncredible symptom report.
Criteria. As documented in DSM-5, malingering is not a mental disorder but is, instead, a condition that may be a focus of clinical attention. While listed under a general heading of “Nonadherence to Medical Treatment,” malingering is not simply nonadherence. Rather, malingering is defined as an intentional production of grossly exaggerated or feigned symptoms motivated by an external incentive, such as obtaining financial compensation or evading criminal prosecution. Thus, while malingering should be considered whenever the veracity of a patient’s self-report is called into question, a dubious symptom report, in and of itself, is not sufficient to diagnose malingering. Similarly, attempts to obstruct or derail evaluation or treatment due to poor participation, nonadherence, or vague or inconsistent reporting are not enough to determine the presence of malingering. To determine that a patient is malingering, the following conditions must be met:
• Symptoms are feigned or grossly exaggerated
• Excessive symptom production must be intentional
• The symptom production is motivated by an external incentive (eg, avoiding work or military duty or criminal prosecution, or obtaining financial compensation or drugs)
DSM-5 supportive indicators. Both DSM-IV-TR and DSM-5 provide 4 conditions under which malingering “should be strongly suspected.” These include medicolegal context, discrepancy between self-report and medical findings, poor patient cooperation, and antisocial personality disorder. While these conditions are included to potentially aid clinicians in flagging cases in which malingering should be considered, it is important to be aware that these supportive features are neither necessary nor sufficient to determine malingering.
Some argue that the previously listed indicators—particularly antisocial personality disorder and uncooperativeness during an evaluation—should be ignored because they do not adequately distinguish malingerers from nonmalingerers.1,2 For example, many malingerers are not uncooperative; indeed, they may appear very cooperative and compliant if they believe that such behavior will help to manipulate their providers into believing their symptoms.3 Thus, these proposed indicators should not be viewed as diagnostic criteria or central features of malingering.
Is it really malingering? Caution is recommended when you are unsure whether a determination of malingering is actually appropriate. It is not uncommon for patients with depression, anxiety, or chronic pain to report symptoms or to demonstrate signs that exceed those expected for their medical or psychiatric conditions. In some patients, such displays are unintentional and may reflect a transfer of psychological symptoms to physical symptoms, a heightened preoccupation and concern with physical or psychological symptoms, or an increased perception of symptom intensity relative to other patients with similar afflictions.
Beyond keeping in mind that some displays of symptom magnification may be unintentional or not motivated by external incentives (and, therefore, not malingering), remember that a diagnosis of malingering can have serious negative consequences for patients. Malingering is not just a clinical term used by physicians; it is also a forensic term used by attorneys and it can have legal implications. As such, some forensic clinicians have indicated that the term malingering be reserved for cases where the evidence for the diagnosis is incontrovertible.2,4 In cases where it is unclear whether a patient is malingering, it may be more appropriate to describe the patient’s behavior with terms such as unreliability (presentation of inaccurate information), nondisclosure (withholding of information), deception (attempts to distort or misrepresent information), or atypical (presentation of unusual information).1
Similar to malingering, a diagnosis of factitious disorder also requires conscious and intentional falsification of physical or psychological symptoms. Thus, both etiologies should be considered in any case where a volitional attempt to deceive medical providers via exaggeration or feigning of symptoms is suspected. Despite these similarities, the 2 conditions differ in regards to patients’ motivation to deceive. Malingering requires that deception be motivated by an external incentive. A diagnosis of factitious disorder requires that the deception occur even in the absence of an external incentive. This suggests that individuals with factitious disorder are motivated by an internal incentive, where deceptive behaviors might serve the purpose of gaining nurturance, attention, or sympathy from family, friends, or medical providers.
Dr Martin is a Neuropsychology Post-Doctoral Fellow and Dr Schroeder is Assistant Professor and Board-Certified Clinical Neuropsychologist in the department of psychiatry and behavioral sciences at the University of Kansas School of Medicine in Wichita, KS. The authors report no conflicts of interest concerning the subject matter of this article.
1. Rogers R. An introduction to response styles. In: Rogers R, ed. Clinical Assessment of Malingering and Deception. 3rd ed. New York: The Guilford Press; 2008:3-13.
2. Young G. Malingering, Feigning, and Response Bias in Psychiatric/Psychological Injury: Implications for Practice and Court. New York: Springer; 2014.
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4. Boone KB. Assessment of Feigned Cognitive Impairment: A Neuropsychological Perspective. New York: The Guilford Press; 2007.
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