![]() Mental health clinicians should also consider somatoform disorders in the differential diagnosis when a question of malingering is raised. 27 On the other hand, 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. An example is a case in which a criminal defendant feigns mental illness in an attempt to be designated incompetent so as not to be executed. 26 In malingering, external incentive should be tangible. The motivation for feigning associated with factitious disorders is a desire to assume the sick role rather than an obvious external incentive such as disability payments. Psychiatric disorders that may be mistaken for malingering Both malingering and factitious disorders involve feigning of physical or psychological illness. 23 In addition, there have been several case reports of "malingering by proxy" in the pediatric setting. 12 Malingered conditions that cross the spectrum of psychiatry and neurology include acute dystonia, 18 amnesia, 19 cognitive deficits, 20 dementia, 21 seizure, 22 and sleep disorder. Malingered conditions Malingered psychiatric conditions may include dissociative identity disorder, 15 psychosis, 16 suicidality/mood disorders, 17 and PTSD. Resnick 12 comments on potential subtypes of malingering: pure malingering involves complete fabrication, partial malingering involves exaggeration of existing symptoms, and false imputation occurs when an evaluee intentionally attributes symptoms to a cause that has little or no relationship to the development of the symptoms. 14ĭEFINITIONS AND SUBTYPES DSM-IV-TR defines malingering as the "intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs." Malingering is not a psychiatric disorder DSM-IV-TR includes it in the section "Other Conditions That May Be a Focus of Clinical Attention." 13 Recently, a German CD-ROM named the "Sickness Simulator" was available for purchase on the Internet the program instructed employees on how to malinger in order to obtain sick leave. 12 During World War II, the British dropped pamphlets over German troops instructing them how to feign injury in order to obtain military leave. 11 In the late 19th century and early 20th century, the introduction of worker's compensation led to numerous pejorative terms such as compensation neurosis to describe suspected malingering. 10 Four years later, a French surgeon described the use of ether to distinguish feigned from real disease. In 1843, malingering found its way into the English medical literature. David "feigned insanity and acted like a madman" to avoid a king's wrath (1 Samuel 21:11-16). ![]() HISTORICAL BACKGROUND Malingering was documented in biblical times. 9 Therefore, mental health clinicians should have familiarity with key points in malingering assessment. While forensic settings in general harbor higher base rates of malingering, some clinical settings, such as those in which compensation-seeking veterans receive evaluation/treatment for posttraumatic stress disorder (PTSD), may have rates that approach or exceed base rates enumerated in forensic settings. This is consistent with earlier studies on base rates of malingering identified during mental health evaluations. Mittenburg and associates 6 reported that in a recent study of 33,531 cases seen by members of the American Board of Clinical Neuropsychology during a 1-year period, probable malingering and symptom exaggeration were found in 30% of disability evaluations, 29% of personal injury evaluations, 19% of criminal evaluations, and 8% of medical cases. Mental health clinicians are nevertheless likely to encounter cases of malingering. This uneasiness is understandable given the potential for escalation of an individual's behavior when confronted with the clinician's suspicions of malingering, 1,2 not to mention the rare potential for lawsuits alleging malpractice following a diagnosis of malingering. The traditional clinician-patient relationship is based on the assumption that a patient is in genuine need of treatment, so clinicians may feel uneasy about initiating malingering assessment. The assessment of malingering presents a significant challenge for mental health clinicians.
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