Assessing and Managing Malingering

Challenges in Assessing and Managing Malingering, Factitious Disorder, and Related Somatic Disorders | Psychiatric Times

Though infuriating, it’s good to know what kind of “reasoning” we’re up against in our dealings with the medical system.

Our access to opioids is so precarious that we can’t display the slightest hint of exaggeration or mental instability around our pain management doctors. Once we’re labeled as malingering in any sense of the word, pain treatment may become unavailable.

This article is written as though a doctor (psychiatrist) can, in just the few insurance-reimbursed appointments allowed, can know a patient’s innermost thoughts and motivations, whether their actions are deliberate or not, whether they are truthful or lying, and make an objective judgment about what is in the patient’s mind.  

This is the extreme arrogance of psychiatry, believing a practitioner can accurately discern a person’s thoughts, beliefs, and feelings from just a few sessions.

Malingering

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.  

It’s already been decided that it’s malingering and now they’re just trying to figure out which kind of malingering.  It seems never to be considered that “available medical evidence” may be incomplete or wrong.  

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,

To determine that a patient is malingering, the following conditions must be met:

  1. Symptoms are feigned or grossly exaggerated
  2. Excessive symptom production must be intentional
  3. The symptom production is motivated by an external incentive (eg, avoiding work or military duty or criminal prosecution, or obtaining financial compensation or drugs)

Both DSM-IV-TR and DSM-5 provide 4 conditions under which malingering “should be strongly suspected. These include

  1. medicolegal context,
  2. discrepancy between self-report and medical findings,
  3. poor patient cooperation, and
  4. antisocial personality disorder.

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

Factitious disorder

Similar to malingering, a diagnosis of factitious disorder also requires conscious and intentional falsification of physical or psychological symptoms. 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.  

While the main tenets of factitious disorder remain fairly similar across DSM-IV-TR and DSM-5, a prior criterion that required that the motivation for deceptive behavior be “to assume the sick role” is now absent from DSM-5.

Factitious disorder imposed on another

Factitious disorder imposed on another (formerly factitious disorder by proxy) occurs when one volitionally falsifies the psychological or physical signs or symptoms of another person in the absence of an external incentive.

In some instances this may take the form of an individual falsely reporting or exaggerating another’s symptoms to receive sympathy or attention. In more deleterious instances, individuals may actually induce physical or psychological harm or injury to another.

Differentiating malingering and factitious disorder from related somatic disorders

A number of substantive changes to the diagnostic labels and criteria for somatoform disorders appear in DSM-5

These disorders are now referred to as somatic symptom and related disorders

This DSM diagnostic category includes factitious disorder as well as conditions such as

  • somatic symptom disorder,
  • illness anxiety disorder, and
  • conversion disorder (functional neurological symptom disorder).

This makes it sound like any kind of “somatic symptom” (without a known source over which a patient shows some concern) or “functional neurological symptom disorder” or anxiety of illness is a pathological mental disorder

The latter disorders can be difficult to clinically differentiate from malingering and factitious disorder because patients with these disorders also report symptoms that are in excess of, inconsistent with, or incompatible with known manifestations of true medical illness

This assumes we already know all the possible medical illnesses, that no new syndromes will ever be seen.

Such inexplicable symptoms used to be regarded as hints of an unknown disease or syndrome, now they are simply disregarded as malingering.

This whole article is based on current medical arrogance:

If you cannot explain the cause, it doesn’t exist.

a diagnosis of conversion disorder is appropriate when patients present with a clearly neurologically incompatible loss or alteration in motor or sensory function that cannot be attributed to an intentional act of deception

DSM-5 does not require clinicians to determine that symptoms are unintentionally produced to diagnose conversion disorder.

Standardized assessment of excessive illness behavior

In many cases, psychiatric providers can determine that symptoms are excessive, exaggerated, or feigned based on clinical history and examination findings.

When feigning or exaggeration of symptoms is suspected but not confirmed or in cases where differential diagnosis of these conditions is still questionable, psychiatric providers may consider referring patients to a clinical neuropsychologist or psychologist for additional workup

Clinical neuropsychologists assess cognitive functioning to detect true cognitive changes. At the same time they often employ standardized and well- validated tests that are sensitive to patient attempts to exaggerate or feign cognitive impairment.   

Common validity tests administered by neuropsychologists include

  • Test of Memory Malingering,
  • Word Memory Test,
  • Medical Symptom Validity Test, and
  • Rey 15 Item Test

These tests were designed to appear challenging to an examinee but, in actuality, are easily performed even by individuals with rather severe cognitive impairment.

Such standardized assessment provides an objective approach for helping to determine the veracity and nature of a patient’s reported symptoms.

There is NOTHING objective about any psychological symptom, even if it is discovered by “standardized assessments”.

It’s common knowledge that people are very different psychologically and also that we cannot “see into” anyone else’s intentions, yet here they claim that a “standardized test” can determine if it is someone’s intent to exaggerate their symptoms. 

Treatment and management

A major hurdle in diagnosing and treating patients with disorders characterized by medical and psychiatric deception is that key distinguishing features of the disorders––those relating to intent and motivation––are not readily observed in most clinical settings

Because differential diagnosis of malingering, factitious disorder, and related somatic disorders is often difficult even when there is documentation of symptom exaggeration, it is recommended that clinicians try to extend beyond categorical thinking about the conditions and instead try to understand the function of the deceptive behavior (eg, avoiding work to avoid stress caused by a difficult co-worker) when treating and managing individuals with such presentations.

However, this assumes that the behavior has already been classified as “deceptive”.

This approach may allow for a bridge to treatment in patients whose deception is rooted in poor coping or potentially remediable psychological problems.

Patients may find discussions regarding stress and coping strategies to be more palatable than confrontations about their deception or assertions that “it’s all in your head.”

When you suspect malingering, true symptoms may sometimes exist.

If falsified symptoms can be disentangled from non-falsified symptoms, treatment of true symptoms may be possible in some cases. 

Even if “some” symptoms do exist, the patient is still not absolved of malingering with other symptoms. I’m sure that with enough effort,  wouldn’t be too difficult to find some vague, slightly exaggerated, complaint by the patient to pounce upon.

That a patient might be truthful about their currently unrecognised symptoms (which might be recognized as a new disease/syndrome years later as so many others have), that medical knowledge might not be perfect and complete is never considered.

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