Clinical Findings
Even though some physicians overinclusively use the term malingering, it is actually a specific entity. In DSM-IV, malingering is considered one of those conditions that may be a focus of clinical attention and is coded on Axis I as V65.2. The DSM-IV description of malingering is presented in

Table 62-3.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, with the aim of obtaining an external benefit; external in this sense refers to a benefit that is recognizable by an outside observer, regardless of whether the individual acknowledges it. This feature differentiates malingering from factitious disorders; in the latter, there is no observable goal to the production of symptoms except for the individual’s attaining the patient role. The only motivation that an outside observer could reasonably infer for a factitious disorder is some psychological gain.

Both malingering and factitious disorders are produced consciously and voluntarily. Usually, the production of the illness has been identified as being conscious (voluntary) based on the following findings:

1. Direct patient admission of fabrication
2. Outsider observation of fabrication
3. Symptoms that contradict results of laboratory testing
4. A patient’s nonphysiological response to treatment
5. Discovery of physical evidence (e.g., finding pills or syringes)

Some researchers (Ziv et al. 1998) have developed specific tests to identify individuals consciously producing specific physical findings. In general, these tests are related to neurological complaints that can be objectively tested.

The factitious disorder patient voluntarily produces signs or symptoms to obtain a primary gain that solves a psychological problem. Although there may also be some secondary gain (e.g., disability payments), there are also secondary costs (e.g., loss of a fulfilling job, loss of income, loss of function). The primary gain, however, is greater than the secondary costs. However, the secondary costs are often so high that it makes the physician assume the disorder could not have been self-induced; this assumption can lead to substantial delays in diagnosis. In one example, a nurse blinded herself by staring at the sun with atropine-dilated eyes after her husband recovered from a serious automobile accident (Eisendrath 1996). She became permanently disabled, and the etiology of her condition remained confusing until the idea of a factitious disorder was entertained and eventually admitted to by the patient.

In malingering, the secondary gain of some external benefit is usually greater than the secondary costs and is obvious to an outside observer. Winning an award in litigation, obtaining relief from a noxious environment, or escaping from criminal responsibility are common secondary gains. Unquestionably, however, any of these secondary gains may have a primary gain associated with it as well, and this may lead to difficulties in making a clear assessment. Indeed, Bellamy (1997) described the variety of motivations for secondary gain that may make the assessment difficult. In general, however, malingering occurs in response to specific external stressors, whereas factitious disorders are determined more by internal psychological motivations.

Diagnosis
The context of the psychiatric evaluation can often lead to clues to the most appropriate diagnosis. Factitious disorder patients are usually seen in inpatient hospital settings and often are exposed to invasive diagnostic and therapeutic procedures. Malingering patients are more commonly seen in outpatient settings and are less likely to expose themselves to invasive procedures. Pending litigation and criminal prosecutions make the diagnosis of malingering more likely. Overholser (1990) noted that malingering with psychiatric symptoms is more likely to be used in an attempt to avoid criminal liability, whereas malingering with somatic symptoms is typically seen in cases of civil litigation.

It may be extremely difficult for even experienced physicians to detect the malingering of psychiatric disorders. Faust et al. (1988) reported that neuropsychologists’ abilities to identify malingering were quite poor in evaluating children who were instructed to produce fake symptoms; the neuropsychologists failed to discern that any of the children were faking their symptoms and in fact recognized neuropsychological abnormalities in more than 90% of the children. Perconte and Goreczny (1990) found that use of the Minnesota Multiphasic Personality Inventory (MMPI) was not an effective means for differentiating genuine PTSD from feigned cases; in their study, only 43% of the cases were correctly identified with the MMPI. Greene (1988), however, suggested that the MMPI’s F and K scales may be of value in forming a dissimulation index. Ford and Feldman (1996) noted that discrepancies between the validity scales, as well as the clinical subscales graded from obvious to subtle, may help identify individuals who are amplifying symptoms. Keane et al. (1988) developed a useful MMPI scale to identify combat veterans with genuine PTSD, and Frueh and Gold (1997) have continued to investigate this area in individuals seeking compensation for combat-related PTSD. Rogers et al. (1992) reported some success with use of the Structured Interview of Reported Symptoms to identify genuine and feigned mental disorders in correctional facility residents. Resnick (1988) gave some clinical clues to the detection of malingering in forensic settings. For example, he advised asking mental status questions that refer to atypical symptoms to see if the individual endorses them. For example, an individual with a possible diagnosis of PTSD who answers the question “Do yellow lights bother you?” affirmatively may be fabricating symptoms. Building on this approach, Kucharski et al. (1998) described the use of clinical symptom presentations in identifying malingering in criminal cases.

Management
Whenever a physician suspects malingering in patients, the first issue he or she must deal with is his or her countertransference response; recognition of these reactions is important in allowing the physician to make appropriate decisions. Kalivas (1996) made an astute observation in suggesting that individuals with factitious disorder generate pity in their caregivers, whereas individuals who malinger engender a sense of being conned. In general, physicians may be reluctant to identify an individual as malingering. This reluctance may be more prominent in physicians who have not had much experience in the forensic setting and are more likely to accept a patient’s narrative at face value. Physicians like to believe a patient is honoring the doctor-patient contract and being honest. Once the physician realizes that malingering is present, his or her initial reluctance to accuse the patient of malingering can be transformed into a determination to punish the patient (Snowdon et al. 1978).

The physician who has identified a malingering patient in a clinical (as opposed to a forensic) setting should make a tactful but forthright statement to the patient about his or her findings. At that time, the malingering patient may reveal information that sheds further light on his or her motivations for the malingering behavior and other related psychological issues.

In evaluations that take place in a forensic setting, the physician is typically not bound by the normal doctor-patient framework. In these instances, the individual who is being examined should have been informed that the examination was for evaluation and not treatment and that there will not be the usual doctor-patient confidentiality because a report will be generated. In fact, the physician usually has no need to inform the subject of any findings based on the forensic examination. The physician should make a clear report of the findings to the court or attorneys involved. Specific examples of conscious deceit will strengthen the report.

Physicians who give formal testimony regarding cases involving malingering individuals should be aware of the limitations on expert testimony (Ogloff 1990). Psychiatric testimony about the genuineness of an individual’s mental illness is likely to be held admissible. In contrast, evidence about an individual’s credibility (e.g., whether the accused is overtly lying about facts) is rarely admissible. Such a determination is within the purview of the trier of fact (e.g., the judge, the jury).

Conclusions
Factitious disorders and malingering offer unusual challenges for physicians. They represent fascinating aspects of human behavior that must be carefully identified so that specific treatment strategies may be developed. The treatment approaches often must be innovative to be effective with this population. Because these conditions embody marked aberrations from the usual doctor-patient relationship, physicians must be highly aware of their own reactions. Psychiatrists play a central role in helping other physicians understand these conditions and in developing creative treatment plans.

References