Malingering involves the intentional production or display of false or grossly exaggerated physical or psychological symptoms, with the goal of receiving a specific benefit or reward such as money, an insurance settlement, disability status, evasion of legal consequences or release from incarceration, or avoidance of work, jury duty, the military, or other types of service. Malingerers may, for example, alter a urine sample or raise the temperature of a thermometer with a lamp. Drug abusers may fake illness or pain to receive drugs of abuse such as opioids.
Some cases of malingering are relatively easy to detect, but some more discrete cases of malingering can be especially tricky for physicians, psychologists, or psychiatrists to identify. Malingering can lead to abuse of the medical system, with unnecessary tests being performed and time taken away from other patients.
Malingering is not recognized as a psychiatric disorder in the DSM-5. It is similar to, but distinct from, factitious disorder, in which an individual fakes symptoms of physical or mental illness but without a concrete motive or expectation of reward. Malingering is also distinct from somatic symptom disorder, in which someone experiences actual psychological distress due to imagined or exaggerated symptoms.
Malingering can take place on a continuum from “pure,” with all symptoms being falsified, to “partial,” in which symptoms are only exaggerated. A patient may feign symptoms of a specific disorder or deny the existence of a problem that may explain the symptoms they are experiencing. Malingering is not easy to detect because of the range of possible falsified or exaggerated symptoms a patient (or apparent patient) can present, as well as the difficulty in proving that an individual is insincere in their claims. Generally, a person will continue malingering until they receive the benefit they seek, including seeing multiple doctors. A thorough clinical interview is essential to understanding whether a person is malingering or in actual distress.
What red flags might a malingerer display?
There may be discrepancies in the malingerer’s stories, and inconsistencies in their behavior suggesting that psychiatric symptoms are being feigned. Clinicians who suspect malingering and generally advised to attempt to find out about a patient’s legal or financial status, to ask rapid questions to gauge coherence and consistency, to ask open-ended or leading questions, and to be on the lookout for exaggerated stories of generally uncommon symptoms such as hallucinations and delusions.
Is malingering a type of pathological lying?
How common is malingering?
Some research suggests that more than 7 percent of patients seeking psychiatric diagnosis or treatment are malingering. In a survey conducted by the American Board of Clinical Neuropsychology, of individuals who stood to gain concrete benefits from a diagnosis, malingering was suspected in 39 percent of those reporting mild head injury; 35 percent of those reporting fibromyalgia or chronic fatigue; 31 percent of those citing chronic pain; and 22 percent of those making electrical injury claims.
Is malingering common among criminals?
Yes. Some research suggests that as many as 20 percent of criminal defendants may exaggerate or fake psychiatric symptoms to hinder prosecution or lessen punishment. In many of these cases, and the most challenging, a psychiatric disorder may in fact be present, but a defendant may use their knowledge of their own condition to exaggerate it and convince an examiner that they require specific legal consideration or special treatment.
In other cases, defendants may lie about experiencing psychiatric conditions that could potentially limit criminal culpability, such as amnesia, psychosis, or multiple personalities. Examiners typically rely on a scale such as the Minnesota Multiphasic Personality Inventory-2-Restructured Form to gauge whether a defendant is malingering.
Malingering is an intentional act that is driven by a range of possible motivations. In many cases, a malingering patient seeks a benefit, such as time off from work or financial gain. But sometimes, a patient may falsify symptoms because they believe that the symptoms will inevitably arise sometime in the future. For example, an individual may falsely claim that they have symptoms of infection while they can receive compensation, because they believe that they will likely develop the infection at some future point.
If an individual’s malingering is successful and they receive a diagnosis—and the concrete benefits—they seek, they may claim that their symptoms have eased, or show poor compliance with treatment, potential signs for clinicians that malingering was involved. Such patients also typically refuse to participate in clinical trials or diagnostic studies.
Does a person who malingers seek sympathy?
Generally, the sympathy or emotional attention of others is not a primary motivation for malingering. When someone feigns or manufacturers the symptoms of a physical or psychological illness to enjoy the “privileges” of the sick, such as attention, sympathy, or care, as opposed to material benefits, they may be diagnosed with factitious disorder.
Can children be malingerers?
They can; some students may feign illness to avoid school, for example. But in cases when a child is involved in malingering, a parent or parents are typically pulling the strings. There have been multiple documented cases of parents going to great lengths to convince others that a child is seriously ill—shaving their head to make them appear to be undergoing cancer treatment, claiming they need treatment for nonexistent seizures, or giving them sleeping pills to make them lethargic—with the specific criminal goal of fundraising for their “care” or applying for unjustified medical benefits.
Some parents may make a child sick to draw attention to themselves, a form of child abuse sometimes referred to as “Munchausen by proxy,” and described in the DSM-5 as factitious disorder imposed on another, but when the motivation is financial and not emotional, malingering is involved.
There is no specific treatment for malingering; in these cases, exposure is the primary goal of the clinician. When a practitioner suspects that someone is malingering, they should consider a range of factors before making a final determination—whether their story is incongruent with known symptoms or other patients’ presentations; whether they are cooperative or elusive during evaluation; and whether they have legal problems or the potential for financial gain from diagnosis.
Psychological evaluation is also recommended as a way to detect malingering; specifically, some individuals who malinger may have antisocial personality disorder. Psychologists have multiple assessment tools in addition to the clinical interview that can provide objective, scientifically based information about whether an individual has responded honestly to a test.
Malingerers show poor compliance with treatment and stop complaining about the assumed illness only after gaining the external benefit.
How should clinicians address malingering?
Carefully. In some cases, when a clinician expresses suspicion about an individual’s symptoms, or challenges or denies their claims, the patient may become hostile or aggressive, threatening, among other things, legal action over claims of malpractice. Practitioners are generally advised to remain nonconfrontational and unemotional in a session with an apparent malingerer, relying on scientific facts such as test results, and to avoid invasive diagnostic procedures that may do harm to the malingerer.