Editing Malingering

{{Short description|Faking illness for personal gain}}
{{Use mdy dates|date=January 2016}}
{{Infobox medical condition (new)
| name          = Malingering
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| specialty     = [[Psychiatry]], [[clinical psychology]]
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| differential  = [[Factitious disorder]], [[somatization disorder]]
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'''Malingering''' is the fabrication, feigning, or exaggeration of physical or psychological symptoms designed to achieve a desired outcome, such as personal gain, relief from duty or work, avoiding arrest, receiving medication, or mitigating prison sentencing. It presents a complex ethical dilemma within domains of society, including healthcare, legal systems, and employment settings.<ref name="Gale">{{cite encyclopedia |date=2008 |entry=malingering |url=https://medical-dictionary.thefreedictionary.com/malingering |encyclopedia=Gale Encyclopedia of Medicine |via=[[The Free Dictionary]] |access-date=November 5, 2019|title=Malingering }}</ref><ref name="WHO">{{cite encyclopedia |date=April 2019 |entry=QC30 Malingering |encyclopedia=International Classification of Diseases |edition=11th |url=https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1136473465 |publisher=[[World Health Organization]] |access-date=November 5, 2019|title=ICD-11 for Mortality and Morbidity Statistics }}</ref><ref>{{Cite book |last=Association |first=American Psychiatric |url=http://worldcat.org/oclc/969741924 |title=DSM-5® classification |date=2016 |publisher=American Psychiatric Association |isbn=978-0-89042-566-4 |oclc=969741924}}</ref>

Although malingering is not a medical diagnosis, it may be recorded as a "focus of clinical attention" or a "reason for contact with health services".<ref>{{cite web |url=http://emedicine.medscape.com/article/293206-overview |title=Malingering |last=Bienenfield |first=David |date=April 15, 2015 |website=Medscape |publisher=WebMD LLC |access-date=December 30, 2016 |quote=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. |url-status=live |archive-url=https://web.archive.org/web/20161230090352/http://emedicine.medscape.com/article/293206-overview |archive-date=December 30, 2016 |df=mdy-all }}</ref><ref name="WHO"/> It is coded by both the [[ICD-10]] and [[DSM-5]]. The intent of malingerers vary. For example, the homeless may fake a mental illness to gain hospital admission.<ref>{{Cite web |title=How to distinguish between malingering, genuine psychosis |url=https://www.healio.com/news/psychiatry/20150914/how-to-distinguish-between-malingering-genuine-psychosis |website=www.healio.com |language=en}}</ref> Impacts of failure to detect malingering are extensive, impacting insurance industries, healthcare systems, public safety, and veterans' disability benefits. Malingered behaviour typically ends as soon as the external goal is obtained.<ref name="Alozai 2023">{{Citation |last1=Alozai |first1=Ubaid ullah |title=Malingering |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK507837/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29939614 |last2=McPherson |first2=Pamela K.}}</ref>

Malingering is established as separate from similar forms of excessive illness behaviour, such as [[somatization disorder]], wherein symptoms are not deliberately falsified. Another disorder is [[factitious disorder]], which lacks a desire for secondary, external gain.<ref>{{Cite book |last1=Fogel |first1=Barry S. |url=http://www.oxfordmedicine.com/view/10.1093/med/9780199731855.001.0001/med-9780199731855 |title=Psychiatric Care of the Medical Patient |last2=Greenberg |first2=Donna B. |date=June 2015 |publisher=Oxford University Press |isbn=978-0-19-973185-5 |doi=10.1093/med/9780199731855.003.0037}}</ref><ref name="Alozai 2023"/> Both of these are recognised as diagnosable by the DSM-5. However, not all medical professionals are in agreement with these distinctions.<ref name="Rogers 2008">{{cite book |editor-last=Rogers<!--book cover says edited by--> |editor-first=Richard |date=2008 |title=Clinical assessment of malingering and deception |edition=3rd |location=New York |publisher=Guilford Press |isbn=978-1-59385-699-1 |oclc=175174373 |url=https://www.worldcat.org/oclc/175174373}}</ref>

== History ==
===Antiquity===
According to [[1 Samuel]] in the [[Old Testament]], [[King David]] [[feigned madness]] to [[Achish]], the king of the [[Philistines]]. Some scholars believe this was not feigned but real [[epilepsy]], and phrasing in the [[Septuagint]] supports that position.<ref>{{cite encyclopedia |editor-last1=McClintock |editor-first1=John |editor-link1=John McClintock (theologian) |editor-last2=Strong |editor-first2=James |editor-link2=James Strong (theologian) |entry=Madness |title=[[Cyclopaedia of Biblical, Theological and Ecclesiastical Literature]] |volume=5 |publisher=[[Harper & Brothers]] |year=1894 |pages=628b–629a}}</ref>

[[Odysseus]] was said to have feigned insanity to avoid participating in the [[Trojan War]].<ref name="Apollodorus">{{cite book |author=Apollodorus |author-link=Pseudo-Apollodorus |translator-last=Frazer |translator-first=James George |translator-link=James George Frazer |orig-year=c. 100–200 CE|title=Epitome |section=E3.7 |url=https://www.perseus.tufts.edu/hopper/text?doc=urn:cts:greekLit:tlg0548.tlg002.perseus-eng1:e.3.7 |series=[[Loeb Classical Library]] |publisher=[[Harvard University Press]], [[W. Heinemann]] |publication-date=1921 |isbn=0-674-99136-2}}</ref><ref name="Hyginus">{{cite book |author=Hyginus |author-link=Gaius Julius Hyginus |translator-last=Grant |translator-first=Mary |orig-year=c. 40 BCE–15 CE |title=''Fabulae'' (The Myths of Hyginus) |url=https://www.theoi.com/Text/HyginusFabulae2.html |location=Lawrence, KS |publisher=[[University Press of Kansas|University of Kansas Press]] |publication-date=1960 |section=95 |archive-url=https://web.archive.org/web/20130209204358/http://www.theoi.com/Text/HyginusFabulae2.html#95 |archive-date=February 9, 2013 |via=[[Theoi Project]]}}</ref>

Malingering was recorded in Roman times by the physician [[Galen]], who reported two cases: one patient simulated [[colic]] to avoid a public meeting, and another feigned an injured knee to avoid accompanying his master on a long journey.<ref name="Lund">{{cite journal |author-last=Lund |author-first=Fred Bates |date=1941 |title=Galen on Malingering, Centaurs, Diabetes, and Other Subjects More or Less Related |journal=Proceedings of the Charaka Club |volume=10 |location=New York |publisher=[[Columbia University Press]] |pages=52–55}}</ref>

===Renaissance===
In 1595, a treatise on feigned diseases was published in [[Milan]] by Giambattista Silvatico.

Various phases of malingering ({{lang|fr|les gueux contrefaits}}) are represented in the etchings and engravings of [[Jacques Callot]] (1592–1635).<ref>{{cite book |first=Fielding H. |last=Garrison |author-link=Fielding H. Garrison |title=History of Medicine |edition=3rd |publisher=W. B. Saunders |year=1921 |pages=[https://archive.org/stream/3edintroductiont00garruoft#page/201/mode/1up 201], [https://archive.org/stream/3edintroductiont00garruoft#page/312/mode/1up 312] |url=https://archive.org/details/3edintroductiont00garruoft |via=[[Internet Archive]] |df=mdy-all }}</ref>

In his [[Elizabethan]]-era social-climbing manual, [[George Puttenham]] recommends a would-be courtier to have "sickness in his sleeve, thereby to shake off other importunities of greater consequence".<ref name="Puttenham">{{cite book |author-last=Puttenham |author-first=George |author-link=George Puttenham |editor-last1=Wigham |editor-first1=Frank |editor-last2=Rebhorn |editor-first2=Wayne A. |year=1589 |title=The Art of English Posey: A Critical Edition |url=https://books.google.com/books?id=FZ89DQAAQBAJ&pg=PA379 |location=Ithaca, NY |publisher=[[Cornell University Press]] |publication-date=2007 |isbn=978-1501707414 |pages=379–380}}</ref>

=== Modern period ===
Although the concept of malingering has existed since time immemorial, the term for malingering was introduced in the 1900s due to those who would feign illness or disability to avoid [[military service]].<ref>{{Citation |title=Why questions regarding effort and malingering are always raised in forensic neuropsychological evaluations |date=2008-11-19 |url=http://dx.doi.org/10.4324/9780203890042-8 |work=Neuropsychology of Malingering Casebook |pages=27–38 |access-date= |publisher=Psychology Press|doi=10.4324/9780203890042-8 |isbn=9780203890042 |url-access=subscription }}</ref> In 1943, US Army General [[George S. Patton]] found a soldier in a field hospital with no wounds; the soldier claimed to be suffering from [[combat stress reaction|battle fatigue]]. Believing the patient was malingering, [[George S. Patton slapping incidents|Patton flew into a rage and physically assaulted him]]. The patient had [[Malaria|malarial parasites]].<ref name="Axelrod">{{cite book |first=Alan |last=Axelrod |author-link=Alan Axelrod |year=2006 |title=Patton: A Biography |publisher=[[Palgrave Macmillan]] |location=[[London]] |isbn=978-1-4039-7139-5 |url=https://archive.org/details/patton00axel/page/115 |pages=[https://archive.org/details/patton00axel/page/115 115–116] }}</ref>

[[Agnes (case study)|Agnes]] was the first subject of an in-depth discussion of transgender identity in sociology, published by [[Harold Garfinkel]] in 1967. In the 1950s, Agnes feigned symptoms and lied about almost every aspect of her medical history. Garfinkel concluded that fearing she would be denied access to [[sexual reassignment surgery]], she had avoided every aspect of her case which would have indicated [[gender dysphoria]] and hidden the fact that she had taken hormone therapy. Physicians observing her feminine appearance therefore concluded she had [[testicular feminization syndrome]], which legitimized her request for the surgery.<ref>{{cite book |last=Garfinkel |first=Harold |author-link=Harold Garfinkel |date=1967 |chapter=Passing and the Managed Achievement of Sex Status in an Intersex Person, Part 1 |title=Studies in Ethnomethodology |publisher=[[Blackwell Publishing]] |pages=116–185 |isbn= 978-0745600055}}</ref>

==Types==
Classifying malingering behaviour into different categories allows for an easier assessment of possible deception, as created by [[Robert J. Resnick|Robert Resnick]].<ref name="Rogers 2008" />
As individuals within institutions grapple with the challenges posed by malingering, a critical examination ethical duties emerges as imperative. Balancing compassion for those genuinely in need with the responsibility to uphold integrity and fairness, ethical obligations in addressing malingering extend beyond mere detection to encompass considerations of empathy, justice, and the broader implications for trust and societal welfare. 
* '''Pure malingering:''' feigning a disorder or illness that is nonexistent. It is arguably the most simple to detect. This is because malingerers of this type tend to provide unreliable, additional symptoms when describing their supposed disorder, since they have to create an entire story from scratch. It is, therefore, difficult to entirely accurately mimic real-world scenarios.<ref name=":1">{{Cite web |title=Know the 3 Categories of Malingering |url=https://www.cuddiganlaw.com/blog/3-types-of-malingering.cfm |access-date=2023-03-29 |website=Cuddigan Law |language=en}}</ref><ref name=":2">{{Cite journal |last1=Wooley |first1=Chelsea N. |last2=Rogers |first2=Richard |date= 2015|title=The Effectiveness of the Personality Assessment Inventory With Feigned PTSD: An Initial Investigation of Resnick's Model of Malingering |url=http://journals.sagepub.com/doi/10.1177/1073191114552076 |journal=Assessment |language=en |volume=22 |issue=4 |pages=449–458 |doi=10.1177/1073191114552076 |pmid=25268016 |issn=1073-1911|url-access=subscription }}</ref>
* '''Partial malingering''': purposefully exaggerating symptoms for an existing disorder or illness. This may be particularly difficult to detect, because those who partake in this would be building on their own genuine traumatic experiences, rather than completely falsifying claims.<ref name=":1" /><ref name=":2" />
* '''False imputation:''' attributing of existing symptoms to a cause that the patient knows is unrelated to their illness. Identifying this type of malingering is less difficult than partial malingering, as patients may inaccurately transpose symptoms from their real experience to the supposed cause of their disorder. This entails inaccurate storytelling and would indicate deliberate deception.<ref name=":1" /><ref name=":2" />

==Society and culture==
=== Post-traumatic stress disorder ===
{{main|Malingering of post-traumatic stress disorder}}
Veterans may be denied [[disability benefits]] if their doctor believes that they are malingering, especially regarding [[post-traumatic stress disorder]]. In navigating these ethical dimensions, it becomes essential to foster a nuanced understanding that acknowledges the complexities inherent in distinguishing genuine suffering from deceptive behavior, while also safeguarding against the misuse of resources and the erosion of trust in systems designed to support those in need. PTSD is the only condition for which the DSM-5 explicitly warns clinicians to observe in case of malingering. Distinguishing malingered PTSD from genuine symptoms is challenging due to the range of the nature and severity of the disorder. An assessment showed that in over 10% of cases, veterans were falsifying or exaggerating their service history.<ref name=":3">{{Cite journal |last1=Tracy |first1=Derek K. |last2=Rix |first2=Keith J. B. |date= 2017|title=Malingering mental disorders: Clinical assessment |journal=BJPsych Advances |language=en |volume=23 |issue=1 |pages=27–35 |doi=10.1192/apt.bp.116.015958 |issn=2056-4678|doi-access=free }}</ref><ref>{{Cite news |last=Townsend |first=Mark |date=2016-01-23 |title=Many military veterans' PTSD claims 'fabricated or exaggerated' |language=en-GB |work=The Guardian |url=https://www.theguardian.com/uk-news/2016/jan/23/many-military-veterans-ptsd-claims-fabricated-or-exaggerated |access-date=2023-03-29 |issn=0261-3077}}</ref>

=== Attention deficit hyperactivity disorder ===
Research that focuses on malingering [[attention deficit hyperactivity disorder]] are largely centred around university or college students. This is because of the significant benefits that may be gained if the student is successful, including [[student financial aid]] and exemptions for academic work. Medicinal treatments of ADHD may also be [[nootropic]]s, which would enhance [[Cognition|cognitive]] performance in examinations.<ref name=":3" />

=== Legal issues ===
Malingering is a [[court-martial]] offense in the United States military under the [[Uniform Code of Military Justice]], which defines the term as "feign[ing] illness, physical disablement, mental lapse, or derangement."<ref name="10USC">{{UnitedStatesCode2|10|883|Article 83. Malingering}}</ref> According to the [[Texas Department of Insurance]], fraud that includes malingering costs the US insurance industry approximately $150 billion each year.<ref name="Garriga">{{cite journal |last=Garriga |first=Michelle |date=March 2007 |title=Malingering in the Clinical Setting |url=http://www.psychiatrictimes.com/display/article/10168/55286 |url-status=live |journal=Psychiatric Times |volume=24 |issue=3 |url-access=registration |archive-url=https://web.archive.org/web/20091119211858/http://www.psychiatrictimes.com/display/article/10168/55286 |archive-date=November 19, 2009 |df=mdy-all}}</ref><ref name="geom-malingering">{{cite encyclopedia |editor-first=Laurie J. |editor-last=Fundukian |first=Robert Scott |last=Dinsmoor |entry=Malingering |encyclopedia=The Gale Encyclopedia of Medicine |volume=4 |edition=4th |publisher=Gale |year=2011 |pages=2737–2739 |isbn=978-1-4144-8646-8}}</ref> Other non-industry sources report it may be as low as $5.4 billion.<ref>{{cite journal |url=https://www.researchgate.net/publication/5242163 |via=[[ResearchGate]] |title=The vulnerability to coaching across measures of effort |last1=Brennan |first1=Adrianne M. |last2=Meyer |first2=Stephen |last3=David |first3=Emily |last4=Pella |first4=Russell |last5=Hill |first5=Ben D. |last6=Gouvier |first6=William Drew |date=February 2009 |journal=The Clinical Neuropsychologist |volume=23 |issue=2 |pages=314–328 |pmid=18609324 |doi=10.1080/13854040802054151 |s2cid=6771846 |access-date=December 29, 2016 |quote=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). |url-status=live |archive-url=https://web.archive.org/web/20161229034222/https://www.researchgate.net/publication/5242163_The_Vulnerability_to_Coaching_across_Measures_of_Effort |archive-date=December 29, 2016 |df=mdy-all }}</ref>

== Detection ==
[[Richard Rogers (psychologist)|Richard Rogers]] and Daniel Shuman found that the use of DSM-5 criteria results in a [[True positive|true-positive]] rate of only 13.6% to 20.1%; that is, among persons whom the criteria indicate to be malingering, only 13.6% to 20.1% are actual malingerers.<ref>{{Citation |title=Malingering and Deception in Criminal Evaluations |date=2005 |url=https://doi.org/10.1007/0-387-25227-4_2 |work=Fundamentals of Forensic Practice: Mental Health and Criminal Law |pages=21–55 |editor-last=Rogers |editor-first=Richard |access-date=2023-03-29 |place=Boston, MA |publisher=Springer US |language=en |doi=10.1007/0-387-25227-4_2 |isbn=978-0-387-25227-8 |editor2-last=Shuman |editor2-first=Daniel W.|url-access=subscription }}</ref> The remaining 79.9% to 86.4% whom those criteria indicate to be malingering are in fact [[False positives and false negatives|false positives]], ''i.e.'', non-malingerers erroneously classified as malingerers. Being falsely accused of malingering may cause adverse reactions, some of which lead to violence. Thus, the accurate detection of malingering is a pressing societal issue.<ref>{{Cite web |title=Malingering {{!}} Psychology Today |url=https://www.psychologytoday.com/us/conditions/malingering |access-date=2023-03-29 |website=www.psychologytoday.com |language=en-US}}</ref>

=== Tests ===
There are multiple methods to evaluate malingering, such as the [[Minnesota Multiphasic Personality Inventory|Minnesota Multiphasic Personality Inventory-2]], which is the most validated test. Other tests include the Structured Interview of Reported Symptoms, which is used for [[Mental disorder|psychiatric symptoms]], and the [[Test of Memory Malingering|Test of Memory Malingering (TOMM)]], intended for [[false memory]] deficits.<ref name=":1" /> Culture and education also likely affect overall performance in these tests. Research found that [[Colombia]]n adults with low [[literacy]] skills perform significantly worse on the Test of Memory Malingering, so there are concerns with the impact of education levels on malingering assessments.<ref>{{Cite journal |last1=Nijdam-Jones |first1=Alicia |last2=Rivera |first2=Diego |last3=Rosenfeld |first3=Barry |last4=Arango-Lasprilla |first4=Juan Carlos |date=2019-11-26 |title=The effect of literacy and culture on cognitive effort test performance: An examination of the Test of Memory Malingering in Colombia |url=https://doi.org/10.1080/13803395.2019.1644294 |journal=Journal of Clinical and Experimental Neuropsychology |volume=41 |issue=10 |pages=1015–1023 |doi=10.1080/13803395.2019.1644294 |issn=1380-3395 |pmid=31322039|url-access=subscription }}</ref>

Existing criteria for one malingered disorder may not be applicable to a different disorder. For example, tests for malingered PTSD may not work for malingered [[neurocognitive disorders]]; therefore, there is a need for newer criteria to be created.<ref name=":3" />

=== Indicative behaviour ===
Although there is no singular test that definitively discerns malingering,<ref name=":1" /> medical professionals are told to watch out for certain behaviours that may indicate deliberate deception.

Signs that illustrate malingering include:<ref name=":3" /><ref>{{Cite web |title=How to distinguish between malingering, genuine psychosis |url=https://www.healio.com/news/psychiatry/20150914/how-to-distinguish-between-malingering-genuine-psychosis |access-date=2023-03-29 |website=www.healio.com |language=en}}</ref>

* providing contradictory statements about symptoms;
* dramatic or peculiar behaviour that is meant to be convincing;
* behaviour that is inconsistent with described symptoms;
* acting adverse to accepting treatment for their supposed disorder;
* overenthusiasm about negative symptoms through going into extensive detail;
* sudden termination or onset of symptoms

== See also ==
{{Portal|Medicine}}
{{Wiktionary|malingering}}
* [[Doctor shopping]]
* [[Drug seeking behaviour]]
* [[Falsifiability]]
* [[Ganser syndrome]]
* [[Hypochondriasis]]
* [[Insanity defense]]
* [[Münchausen syndrome]]
* [[Ocular malingering]]
* [[Structured Inventory of Malingered Symptomatology]]
* [[Syndrome K]], illness fabricated by doctors to protect Jews from Nazis

== References ==
{{Reflist}}

{{Medical resources
|  ICD10       = {{ICD10|Z76.5}} 
|  ICD9        = {{ICD9|V65.2}} 
|  eMedicineSubj = article 
|  eMedicineTopic  = 293206 
|  MeshID      = D008306
}}
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[[Category:Forensic psychology]]
[[Category:Malingering| ]]
[[Category:Medical law]]