What Is Malingering?
Malingering is nothing but an act that all of us have practiced during our childhood. "Madam/ Sir, I am not well, so I did not come to school yesterday," a false excuse to bunk school. This act is a documented disorder termed malingering. Malingering can be defined as a profound exaggeration of physical or psychological symptoms to obtain external gains like a holiday from school, paid leave from a job, or avoiding law trials. It has not yet been determined as a mental disorder but is a topic of focus for researchers as the etiology is still unknown. Malingering is differentiated from other disorders by the factor of external gains; an individual does not benefit from medications and continues to complain about the illness till the external gains are not achieved. Once the gain is completed or over, the individual, without any treatment, stops complaining and is completely fine.
What Are the Causes of Malingering?
The etiology of the condition is unknown but is thought to be associated with socioeconomic factors. It is most commonly diagnosed in students to avoid school, prisoners to avoid trials, and drug addicts to obtain substances of abuse.
How Is Malingering Diagnosed?
Diagnosis of the condition is difficult as a person does not have any definite symptoms or signs, unlike other diseases. Malingering is mainly diagnosed by a detailed case history and physical examination. It can be a waste of time and assets of the medical system as unnecessarily; many tests have to be performed with no positive results to diagnose the disease.
According to the Diagnostic and Statistical Manual of Mental Diseases, Fifth edition, a person is considered to have, or a diagnosis of malingering is confirmed when an individual presents with the combination of any of the following symptoms:
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Medicolegal context of presentation, for example, a student feeling ill only at the time of an exam or a criminal falling ill at the time of trials.
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A marked discrepancy between the reported stress and the clinical findings.
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Non-compliance with treatment and follow-up regimen.
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History of antisocial personality disorder.
Other methods to confirm the diagnosis are a physical exam, psychological test, and detailed history.
Some of the tests that help in confirming diagnosis are as follows:
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The Minnesota Multiphasic Personality Inventory (MMPI).
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The F-scale.
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Test of memory malingering.
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The negative impression management scale.
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Rey 15-item test.
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The temporal memory sequence test.
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Symptom and Disposition Interview (SDI).
It is very important to confirm and be assured that the person is malingering because a false-positive diagnosis can leave a lifelong negative impact on an individual. Recent technical and scientific advances help in eliminating the chances of false-positive results and are helpful in accurate diagnosis.
Modern medicine uses the following techniques:
1) Lie detectors: professionals like police officers, doctors, and lawyers who interact with large groups of people on an everyday basis and are familiar with psychological behaviors are used in the diagnosis of the disorder as human lie detectors. The accuracy rate of this method is low.
2) Arousal-based approaches:
- Control Question Technique: A polygraph is a device that is used to detect psychophysiological arousal. To detect malingering a set of questions is prepared and asked along with the control questions, the result is positive when an individual presents hyper impulse to the relevant questions than to control questions and vice versa for the negative result.
- Guilty Knowledge Test (GKT): During this testquestioning paradigm is used along with a polygraph to unfold the truth, it is a set of questions with multiple choices that are relevant to the expected answer, the subject need not answer but the question is asked repeatedly and the response is checked if arousal is detected to the relevant answer multiple times, the subject is considered to have knowledge of the incidence.
A physician must be very careful while diagnosing malingering to prevent medico legal consequences and follow the ABCs for the diagnosis which are as follows:
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Avoid accusations of lying.
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Beware of countertransference.
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Clarification, not "confrontation."
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Security measures.
Can Malingering Be Confused With Other Disorders?
Malingering is often confused with conditions like,
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Factitious disorders like Munchausen syndrome; Differentiate between primary and secondary/external gain.
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Psychosis and schizophrenia (thought disorders).
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Depression and mania.
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Dissociative disorders.
How Is Malingering Treated?
No definite treatment is available for the patients with malingers, patients usually give up after pretending for a long duration, or start behaving normally once the purpose is fulfil medico-legal, clinisician must never let the person realize that he is aware that the patient is pretending to be ill, or never directly question disorders of an individual. This can lead to medico legal action against the physician as the patient can file a lawsuit against the physician.
Malingering is one most difficult disorder to treat considering the symptoms and behavioral patterns of the patient, if the demands of such individuals are not fulfilled they can become aggressive and harmful.
The treatment includes interprofessional therapy that includes a mental health nurse, a psychiatrist, and a psychotherapist. Behavioral therapy, psychotherapy, and counseling can be recommended in such cases.
Referral to other physicians is not advised as these patients do not trust others and avoid psychiatric consultation.
Prognosis:
The prognosis of the disorder is unknown or unpredictable as a person malingers till the external gains are fulfilled.
Conclusion:
Malingering is a condition where a person exaggerates or pretends to be ill in order to avoid work or activities like going to school, the diagnosis and prognosis of the disorder are difficult as the patient fakes illness and is completely fine once the gains are achieved, this condition is similar to psychotic disorders like schizophrenia, psychosis, etc. No definitive treatment is available as the symptoms are not very clear, but a physician has to be very careful and must have a detailed history to conclude the diagnosis, the treatment options include psychotherapy and counseling, but a referral is avoided.
