Clinical Presentation of Malingering
The DSM-5Opens in new window describes malingering as the intentional production of false or grossly exaggerated physical or psychologic problems, further stating that malingeringOpens in new window is not a mental disorder but is, instead, a condition that may be a focus of clinical attention.
Listed under a general heading of Nonadherence to Medical Treatment, 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.
To determine that a patient is malingering, the following conditions must be met:
- symptoms are feigned or grossly exaggerated,
- excessive symptom production must be with intention to deceive, and
- the symptom production is motivated by an external incentive.
Malingering should be suspected in the medicolegal context, when there is discrepancy between self-report and medical findings, when there is poor patient cooperation, and with antisocial personality disorder.
These conditions are included to potentially aid clinicians in flagging cases in which malingering should be considered, but it is important to be aware that these supportive features cannot determine malingering.
Both malingering and factitious disordersOpens in new window involve feigning of physical or psychologic illness. The motivation for feigning associated factitious disorders is a desire to assume the sick role rather than an obvious external incentive such as disability payments.
In malingering, external incentive should be tangible, usually related to work or criminal justice, while 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.
Medical Management and Diagnosis
Instruments intended to assess malingering are typically designed to minimize the number of false diagnoses of malingering on the principle that a false diagnosis is more harmful than a missed diagnosis.
Therefore, some individuals who are malingering may evade detection with psychologic testing alone, and clinicians should integrate all available data, with test results viewed as one piece of that data set. Also, specific malingering tests may not differentiate a factitious disorder presentation from malingering, so the use of clinical judgment about motivations for feigning is necessary.
A health care provider cannot rely on any single test to determine malingering, and symptoms of unresolved trauma can easily be confused with malingering tendencies, especially early on. It is important to document completely and to compare and triangulate data collected at different times and settings with other members of the health care team.
The physical therapist may see that pain patterns and activity limitations observed during treatment either change or disappear outside of the clinical setting as the client arrives or leaves the clinic or is seen outside of the professional relationship. Observations regarding effort, motivation, and inconsistent behavior offer valuable feedback.
If the physician has ruled out the possibility of an underlying systemic disorder accounting for the client’s clinical manifestations, then the best approach is to discuss the therapist’s concerns with the client over the lack of effort or inconsistent findings that have no apparent clinical meaning and consider referral to a competent counselor.
The therapist should avoid confrontation or directly labeling the person as a malingerer but remain focused on objective data and function. The therapist may need to make the difficult decision to terminate the episode of care after carefully considering all evidence.
If a clinician chooses to speak directly to the client regarding evidence of feigning to further the assessment or to give the client a chance to explain discrepancies, the following may be helpful, known as ABCS:
- Avoid accusations of lying;
- Beware of countertransference;
- Clarification, not confrontation;
- Security measures.
Security is included because some malingerers may respond by escalating their behavior to justify their self-reports and become physically aggressive or induce self-injury.
The therapist should not conclude too quickly that the person is malingering because systemic disorders, complex medical conditions, and unresolved trauma can masquerade as neuromusculoskeletal pathology and can present with apparent mismatching or disproportionate symptoms for the injury or pathology.