Malingering involves the conscious, intentional feigning or exaggeration of a physical or psychological condition, associated with some element of external gain.
The person has more to gain from having a condition than from relinquishing it. External gain may involve:
(1) financial compensation (reward)
(2) drug seeking (reward)
(3) avoidance of school or work (avoidance)
(4) avoidance of military service, criminal prosecution or other unpleasant situation (avoidance)
(5) manipulation of others (control)
(6) manipulation of personal environment to improve conditions (control)
Situations with an increased frequency of malingering:
(1) prison populations
(2) workers' compensation
(3) claims of personal injury
(4) some Emergency Departments
Preferred conditions are those without objective measures of illness, such as:
(1) chronic pain, especially low back pain
(2) headache
(3) vertigo
Suspect malingering with one or more of the following:
(1) medicolegal context of presentation, such as referral by an attorney
(2) marked discrepancy between the person's claimed stress or disability and the objective findings
(3) lack of cooperation during the diagnostic evaluation and in complying with treatment regimens
(4) presence of an antisocial personality disorder or other psychiatric condition
Other indicators:
(1) proven exaggeration of symptoms. An underlying condition may be present, but the person exaggerates any symptoms and complaints.
(2) symptoms that are vague, ill-defined, overdramatized, inconsistent or not in conformity with objective findings
(3) invariable relapse after improvement
(4) self-manipulated worsening of condition
(5) resisting communications with prior health-care providers
(6) poor continuity of care
Confirmation may be difficult or impossible:
(1) Psychological testing may help identify the underlying motives.
(2) It may be necessary to conduct undercover surveillance of the individual.
Differential diagnosis:
(1) factitious disorder
(1a) malingering: external incentive present (although not always immediately obvious)
(1b) factitious disorder: external incentive absent, evidence of an intrapsychic need to maintain a sick role
(2) conversion disorder, somatoform disorder
(2a) malingering: intentional production of symptoms, external incentive, symptom relief not obtained by suggestion or hypnosis
(2b) conversion disorder: symptom relief may be obtained by suggestion or hypnosis, may have some element of gain but symptom production is not intentional
