Malingering

Malingering
Classification and external resources
Specialty psychiatry, psychology
ICD-10 Z76.5
ICD-9-CM V65.2
eMedicine article/293206
MeSH D008306

Malingering is the fabricating of symptoms of mental or physical disorders for a variety of reasons such as financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; or as a mitigating factor for sentencing in criminal cases. It is not a medical diagnosis.[1] Malingering is typically conceptualized as being distinct from other forms of excessive illness behaviour[2] such as somatization disorder and factitious disorder, e.g., in DSM-5, although not all mental health professionals agree with this formulation.[3]

Failure to detect actual cases of malingering imposes an economic burden on health care systems; workers compensation programs; and disability programs, e.g., Social Security Disability Insurance (United States) and U.S. Department of Veterans Affairs disability benefits. False attribution of malingering often harms genuine patients or claimants.[4][5]

Symptoms

The symptoms most commonly feigned include those associated with mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. Generally, malingerers complain of psychological disorders such as anxiety. Malingering may take the form of dishonest complaints of chronic whiplash pain from automobile accidents. The psychological symptoms experienced by survivors of disaster (post-traumatic stress disorder) are also faked by malingerers.[6]

Individuals use a variety of methods to feign symptoms of illness. Some of these include harming oneself, trying to convince medical professionals one has a disease after learning about its details (such as symptoms) in medical textbooks, taking drugs that provoke certain symptoms common in some diseases, performing excess exercise to induce muscle strain or other physical types of ailments, and overdosing on drugs.[6]

Limitations

In most instances, stating categorically that an individual is malingering requires an explicit admission by that individual. Legally the term may be considered prejudicial and excluded on that basis.[7] No current research exists regarding the frequency, behaviour or detection of successful malingerers. No neuropsychological inventories exist that can be used to conclusively determine if a patient is malingering, or to exclude a determination of malingering. Genuine neurological and psychiatric conditions may return false positives. Testing inventories cannot distinguish between exaggeration and fabrication. Psychological inventories rely on naivety. Criminally, an assessment may lead to punishment enhancement, and medically, to denial of future treatment. The DSM-V criteria faces scrutiny for providing poor guidelines. As such physicians ultimately rely on their intuition and gut feeling for any assessment, which is subject to prejudice and cognitive dissonance, and which has been shown to be unreliable in synthetic tests.[8][9][10][7]

Malingering presumes an exhaustive diagnostic procedure has been performed. Exhaustive diagnostics are neither practical nor economically viable or judged to be in the best interests of the patient's health. Radiological and invasive exploratory procedures can be necessary for an accurate diagnosis yet pose a health risk to the patient. Radiographic diagnostics expose the patient to radiation and surgical diagnostic procedures can carry a high risk of complications and mortality, such as a lumbar puncture, the only reliable diagnostic procedure for diagnosing rare terminal forms of parasitization, which the CDC reports as only being diagnosed post mortem 75% of the time.[11] A physician invariably faces limitations in the realms of resources, time and liability.[12][13][14] Because an assessment, formal or informal, of malingering ceases the medical process, it may seem an attractive option for the physician and help them to cope with cognitive dissonance over their failure to effectively diagnose and treat a patient within constraints.[15][16][17][18][19][20][21][22][23][24]

Patients with unresolved illness may be adversarial towards physicians, attempting to game the triage system in order to receive specialist care. Such cases fit the criteria for malingering, yet the patient is still in need of medical care.[25] For example, in a gatekeeper system, primary care physicians may restrict the availability of HIV testing to only patients who report high risk activity.[26] A patient may then falsely report sexual and/or drug history and/or symptoms in order to elevate priority which can then go on to serve as diagnostically relevant history for an inaccurate path of further diagnosis.

Medical practitioners often believe that they can detect deception. In two studies, experienced medical practitioners including psychiatrists failed to perform better than chance when asked to detect lying and simulated patients. In 12 other studies, detection rates of simulated patients ranged between 0 and 25%.[9][8] It's impossible to detect malingering from a clinical perspective.[27]

The evaluative context (medical-legal and forensic) exerts distorting impact on the tendency of subjects to amplify or not the self-reported symptoms. This distorting effect is present also when subjects are truly suffering from mental pathology.[28]

History

Antiquity

In the Hebrew Bible, King David feigns insanity to Achish, king of the Philistines (I Sam. 21:10-15). This is by many supposed not to have been feigned, but a real epilepsy or falling sickness, and the Septuagint uses words which strongly indicate this sense.[29] Odysseus was stated to have also feigned insanity in order to avoid participating in the Trojan War.[30] Malingering has been recorded historically as early as Roman times by the physician Galen (Quomodo morbum simulantes sint deprehendendi), who reported two cases. One patient simulated colic to avoid a public meeting, while the other feigned an injured knee to avoid accompanying his master on a long journey.[31]

Renaissance

During the Renaissance, a treatise on feigned diseases (De iis qui morborum simulant deprehensis) by Giambattista Silvatico, was published at Milan in 1595. Various phases of malingering (les gueux contrefaits) are well represented in the etchings and engravings of Jacques Callot (1592–1635).[32] In his social-climbing manual, Elizabethan George Puttenham recommends that would-be courtiers have "sickness in his sleeve, thereby to shake off other importunities of greater consequence" and suggests feigning a "dry dropsy [...] of some such other secret disease, as the common conversant can hardly discover, and the physician either not speedily heal, or not honestly bewray."[33]

Modern period

Lady Flora Hastings was accused of adultery stemming from court gossip following abdominal pain. Because she refused to be physically examined by a man for reasons of modesty befitting a lady in her position, the physician assumed her to be pregnant. She later died of stomach cancer.

General George S. Patton, in what became known as 'the Greek Incident', found a soldier in a field hospital but with no wounds, claiming to be suffering from battle fatigue. Upon discovering this and believing that the patient was malingering, Patton flew into a rage, physically assaulted the patient, called him a coward and did not stop until he was physically restrained. The patient was later found to have contracted malaria and to be suffering from dysentery.

Antonio Damasio described a case study in Descartes' Error of his patient, 'Elliot.' He wrote, "Several professionals had declared that his mental faculties were intact-meaning that at the very best Elliot was lazy, and at the worst a malingerer." As a result, Elliot's disability benefits were withdrawn. Neuropsychological testing "revealed a superior intellect." Neuropsychological evaluations thought at that time to be sensitive such as the Wisconsin Card Sorting Test did not reveal impairment in function associated with the frontal lobes or brain damage and functional impairment in general. Elliot had previously had surgery to remove a meningioma "the size of a small orange." Following his surgery he had floundered into a series of poor decisions which ultimately resulted in divorce and bankruptcy from a previously "enviable position." [34]

Few cases are as famous as Harold Garfinkel's study of Agnes Torres. In the 1950s, Agnes feigned symptoms and lied about almost every aspect of her medical history. Fearing doctors at UCLA would refuse her access to her desired sexual reassignment surgery, Garfinkel concluded that she had avoided every aspect of her case which would have indicated gender dysphoria so as to avoid being treated as an "effeminate homosexual" and psychiatric patient. She lied that she had not taken hormone therapy and her examining physicians concluded that it would be impossible for someone so young to have stumbled upon a therapy and instituted it at such a young age so as to produce such brilliant feminizing effects. As such they concluded that their patient had testicular feminization syndrome, legitimizing in their professional opinion the validity of her request for sexual reassignment surgery. While not evaluating the patient, Garfinkel commented that the complexity of the deception was of such intricate construction intended towards the singular goal of the particular desired medical intervention.[35]

United States Armed Forces

Malingering is a court-martial offense in the United States Armed Forces under Article 115 of the Uniform Code of Military Justice, which provides that:

Any person subject to this chapter who for the purpose of avoiding work, duty, or service–
(1) feigns illness, physical disablement, mental lapse or derangement; or
(2) intentionally inflicts self-injury;
shall be punished as a court-martial may direct.[36]

Economic costs

According to the Texas Department of Insurance, fraud that includes malingering costs the U.S. insurance industry approximately $150 billion each year.[4][6] Other non-industry sources suggest it may be as low as $5.4 billion, suggesting that insurance companies are over inflating the seriousness of the problem to divert more law enforcement towards health insurance fraud.[37]

See also

References

  1. ↑ Bienenfield, David (April 15, 2015). "Malingering". Medscape. WebMD LLC. Archived from the original on December 30, 2016. Retrieved December 30, 2016. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), malingering receives a V code as one of the other conditions that may be a focus of clinical attention.
  2. ↑ Hamilton, James C.; Hedge, Krystal A.; Feldman, Marc D. "Chapter 37: Excessive Illness Behavior". In Fogel, Barry S.; Greenberg, Donna B. Psychiatric Care of the Medical Patient (3rd ed.). Oxford University Press. pp. 743–755. doi:10.1093/med/9780199731855.003.0037. ISBN 9780199731855. OCLC 947145299.
  3. ↑ Hamilton, James C.; Feldman, Marc D.; Cunnien, Alan J. (2008). "Chapter 8: Factitious Disorder in Medical and Psychiatric Practices". In Rogers, Richard. Clinical Assessment of Malingering and Deception (3rd ed.). New York City, NY: Guilford. pp. 128–144. ISBN 9781593856991. OCLC 175174373.
  4. 1 2 Garriga, Michelle (March 2007). "Malingering in the Clinical Setting". Psychiatric Times. 24 (3). Archived from the original on November 19, 2009.
  5. ↑ Shapiro, Allan P.; Teasell, Robert W. (March 1998). "Misdiagnosis of chronic pain as hysteria and malingering". Current Pain and Headache Reports. 2 (1): 19–28. doi:10.1007/s11916-998-0059-5.
  6. 1 2 3 Dinsmoor, Robert Scott (2011). "Malingering". In Fundukian, Laurie J. The Gale Encyclopedia of Medicine. 4 (4th ed.). Gale. pp. 2737–2739. ISBN 978-1-4144-8646-8.
  7. 1 2 Conroy, Mary Alice; Kwartner, Phylissa P. (2006). "Malingering" (PDF). Applied Psychology in Criminal Justice. 2 (3): 29–51. Archived (PDF) from the original on May 10, 2017. Retrieved December 30, 2016. Courts can exclude relevant evidence if its probative value is substantially outweighed by the danger of unfair prejudice. Use of the term “malingering” can be highly prejudicial.
  8. 1 2 Rosen, Gerald M.; Phillips, William R. (2004). "A Cautionary Lesson from Simulated Patients" (PDF). The Journal of the American Academy of Psychiatry and the Law. 32 (2): 132–133. PMID 15281413. Archived (PDF) from the original on December 29, 2016. Retrieved December 29, 2016.
  9. 1 2 Palmieri, John (2009). "Lies in the Doctor-Patient Relationship". NIMH: Primary Care Companion Journal of clinical Psychiatry. 11: 163–8. doi:10.4088/PCC.09r00780. PMC 2736034. PMID 19750068.
  10. ↑ Webber, Miriam (2000). "A Clinical Approach to Evaluating Malingering in Forensic Neuropsychological Evaluations" (PDF). University of Albany. Archived (PDF) from the original on December 30, 2016. Retrieved December 30, 2016.
  11. ↑ "Naegleria fowleri — Primary Amebic Meningoencephalitis (PAM) — Amebic Encephalitis". Centre For Disease Control and Prevention. May 22, 2014. Archived from the original on December 29, 2016. Retrieved December 28, 2016. " Because of the rarity of the infection and difficulty in initial detection, about 75% of diagnoses are made after the death of the patient.
  12. ↑ Srivastava, Ranjana (September 7, 2016). "Do I really need 'the test'? Too many tests could do patients more harm than good". The Guardian. Archived from the original on December 28, 2016.
  13. ↑ Duckett, Stephen (September 30, 2015). "Removing overused treatments from Medicare isn't the answer". ABC News. Archived from the original on December 29, 2016. Retrieved December 28, 2016.
  14. ↑ Graber, Mark (May 28, 2013). "The hidden problem of medical misdiagnosis – and how to fix it". The Conversation. Archived from the original on December 29, 2016. Retrieved December 28, 2016.
  15. ↑ williamson, diane (September 27, 2009). "Finally heard, but too late". Worcester Telegram. Archived from the original on December 30, 2016. Retrieved December 30, 2016. when they told her to leave. So adamant was her insistence on staying that UMass Memorial police were called to escort the sick woman from the hospital. One month later, Ms. Chapman was dead. When doctors finally admitted her to UMass Memorial Sept. 3, metastatic cancer was found in her lungs, liver and spine.
  16. ↑ Croy, Liam (August 29, 2016). "Perth baby dies after being sent home from two hospitals". Yahoo 7 News. Archived from the original on December 30, 2016. Retrieved December 30, 2016. She claimed a nurse laughed at her when she asked if the symptoms could be connected.
  17. ↑ Devlin, Amanda (May 25, 2016). "Teenager, 16, died from meningitis 'after being sent home from hospital with a suspected migraine'". The Sun. Archived from the original on December 30, 2016. Retrieved December 30, 2016. Izzy’s symptoms were not typical of meningitis at the time of first presentation and we believe that both the assessment and treatment were appropriate.
  18. ↑ O'Connor, Brendan (December 20, 2016). "Alabama Inmate Commits Suicide Just Weeks After Testifying in Federal Mental Health Trial". Jezebel. Retrieved December 30, 2016. The state’s attorneys, Borden said, “went to great lengths to try to portray his suicide attempts as faking. It is tragic and devastating that it took a fatal hanging to perhaps finally make it clear that he wasn’t just faking. Jamie’s case is emblematic of the utter neglect and mistreatment of people with serious mental illness in ADOC prisons.
  19. ↑ Boodman, Sandra (December 6, 2016). "5 simple steps to avoid becoming a medical mystery". Chicago Tribune. The Washington Post. Archived from the original on December 30, 2016. Retrieved December 30, 2016. Local doctors had variously attributed his pain to a mental illness, malingering, drug-seeking behavior or a dental problem. An expert at a major teaching hospital in another state rapidly diagnosed and successfully treated him for a neurological disorder.
  20. ↑ Back, Alexandra (September 29, 2016). "Convicted killer refused bail after alleged breach of parole in Canberra". the Canberra Times. Archived from the original on December 21, 2016. Retrieved December 30, 2016. A parole officer told the court a doctor at Canberra Hospital had made an unsolicited call to the board, and said she believed he was using the condition to avoid his responsibilities. His condition could be managed in the AMC, the officer said.
  21. ↑ Orstroff, Jamie (June 1, 2016). "Family seeks justice after inmate at Tuscaloosa County Jail dies". CBS WIAT. Archived from the original on December 30, 2016. Retrieved December 30, 2016. Attorney David Schoen says Anderson had an ulcer that had perforated, causing his intense pain at the jail and leaving his stomach distended, classic symptoms of a duodenal ulcer that should have been obvious as such to jailers and medical staff.
  22. ↑ White, Tracie (May 23, 2016). "Stanford scientist's mission to help solve the mystery of CFS brings hope to patients". Stanford Medicine. Archived from the original on December 30, 2016. Retrieved December 30, 2016. Hillenbrand and so many others like her — including Dafoe — often get labeled as malingerers. Doctors refuse to treat patients...
  23. ↑ McFarling, Usha (November 21, 2016). "Wanted: Women's brains — to jump-start lagging research on female concussions". Stat News. Boston Globe News. Archived from the original on December 30, 2016. Retrieved December 30, 2016. “When a girl says she still needs to go to the nurse four weeks after a concussion,” she said, “she gets judged as a malingerer or someone with a mental health problem.”
  24. ↑ Thompson, Angela (October 13, 2016). "Brain tumour survivor Trudy Davis wrongly discharged from Shellharbour Hospital, Professional Standards Committee finds". Illawarra Mercury. Archived from the original on December 30, 2016. Retrieved December 30, 2016. Last week the committee ordered Dr Chimpanda to undergo further training, concluding he had acted “significantly below the standard reasonably expected of a practitioner of his level of training and experience” by sending Ms Davis home.
  25. ↑ Donnelly, Laura (April 14, 2016). "NHS reconsiders 'self-check in' after patients fake symptoms to jump queue". The Telegraph. Archived from the original on December 29, 2016. Retrieved December 28, 2016. Whilst the majority of people use the kiosks responsibly, they do contain trigger questions which patients may use to mis-report the seriousness of their condition.
  26. ↑ "STI SCREENING". Melbourne Sexual Health Centre. May 1, 2015. Archived from the original on December 28, 2016. Retrieved December 28, 2016. The type of tests required to screen individuals for STI depends on the sexual history and risk behviour of the individual.
  27. ↑ Morgan, Joel (2009). "Neuropsychology of Malingering Casebook". google books. Psychology Press. Archived from the original on December 29, 2016. Retrieved December 29, 2016. Unless individuals confess to malingering, neuropsychologists cannot really know whether invalid test performance is conscious and deliberate or a reflection of other factors.
  28. ↑ Montrone, Alessandro (2016). "Use of Test sims in psychological assessment of distorting behavior: simulation. A pilot study". Italian Journal of Criminology. Archived from the original on March 5, 2017.
  29. ↑ John McClintock; James Strong, eds. (1894), "Madness", Cyclopaedia of Biblical, Theological and Ecclesiastical Literature, 5, Harper & Brothers, pp. 628b–629a
  30. ↑ Hyginus Fabulae 95 Archived February 9, 2013, at the Wayback Machine.. Cf. Apollodorus Epitome 3.7 Archived July 3, 2007, at the Wayback Machine..
  31. ↑ "Galen on Malingering, Centaurs, Diabetes, and Other Subjects More or Less Related", Proceedings of the Charaka Club, X (1941), p52-55
  32. ↑ Garrison, Fielding H. (1921). History of Medicine (3rd ed.). W. B. Saunders. pp. 201, 312. Archived from the original on August 7, 2016 – via Internet Archive.
  33. ↑ "The Art of English Posey: a Critical Edition." George Puttenham. Ed. Frank Whigham & Wayne A. Rebhorn. (2007) 379-380.
  34. ↑ Damasio, Antonio (1994). "3- A Modern Phineas Gage". Descarte's Error. G. P.Putnam's Sons. pp. 34–51. ISBN 0-399-13894-3.
  35. ↑ Garfinkel, Harold (1967). Polity Press, ed. Studies in Ethnomethodology, Chapter Five: Passing and the Managed Achievement of Sex Status in an Intersex Person, Part 1. Blackwell Publishing. pp. 116–185. ISBN 978-0-7456-0005-5.
  36. ↑ 10 U.S.C. § 915: Art. 115. Malingering
  37. ↑ Brennan, Adrianne M.; Meyer, Stephen; David, Emily; Pella, Russell; Hill, Ben D.; Gouvier, William Drew (February 2009). "The vulnerability to coaching across measures of effort". The Clinical Neuropsychologist. 23 (2): 314–328. doi:10.1080/13854040802054151. PMID 18609324. Archived from the original on December 29, 2016. Retrieved December 29, 2016 – via ResearchGate. Malingering accounts for nearly one-fifth of all medical care cases (i.e., doctor visits, hospitalizations) within the United States and combined medical and legal costs approach five billion dollars annually (Ford, 1983; Gouvier, Lees-Haley, & Hammer, 2003).
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