Malingering and exaggeration

Malingering (ICD Z76.5, malingerer [conscious simulation]: person feigning illness with obvious motivation) is listed in the ICD not as a mental disorder, but in the little-used chapter, Factors influencing health status and contact with health services Z00-Z99.

Malingering can be defined as the deliberate feigning or exaggeration of illness for external gain. It includes the following:

1. Pure malingering: complete fabrication of symptoms; this is probably rare

2. Partial malingering: exaggerating real symptoms or falsely saying that past symptoms are continuing

3. False attribution: falsely saying that real symptoms are due, for example, to a compensatable accident

DSM-IV lists malingering under 'additional conditions which may be a focus of clinical attention'; that is, not as a mental disorder in itself. It advises that 'malingering should be strongly suspected in any combination of the following:

• medico-legal context

• discrepancy between complaints and objective findings

• uncooperative in examination/treatment

• antisocial personality disorder.'

This sets a fairly low threshold for suspecting malingering, but the DSM gives no further guidance as to how the question should be addressed.

Malingering may occur in an effort to avoid detention or military service; these forms may include apparent drowsiness, together with unusual symptoms such as 'seeing little green men' or coprophagia. (Presumably, the individual considers that these necessarily indicate mental illness.) This group of features, together with so-called approximate answers (for example, question: how many legs has a dog? Answer: three) and apparent mental confusion, were sometimes referred to as the 'Ganser syndrome'. However, there is no unifying pathology underlying the term, which has fallen into desuetude.

Malingering or, more commonly, exaggeration also occurs in civil settings. There are documented examples in the literature of malingered PTSD and chronic pain. There is evidence that it may affect substantial numbers of evaluations (e.g. 40 per cent) (Richman et al., 2006) where a financial outcome depends on the result, such as disability benefit payments or compensation for personal injury. It is assessed by clinical examination, and examination of medical records, looking in particular for consistency and plausibility, or their absence (Gill, 2006). Symptom validity testing (Richman et al., 2006) is a comparatively new technique that may help to elucidate some of these difficult cases.

References

Gill, D. (2006). Faking it London: Solicitors Journal. Expert Witness Update.

Reid, S. et al (2006). Chronic fatigue syndrome. Clinical Evidence (15th edn), pp. 1530-1541.

London: BMJ Books. http://www.clinicalevidence.com/ceweb/conditions/msd/1101/1101. jsp.

Richman, J., Green, P., Gervais, R. et al. (2006). Objective tests of symptom exaggeration in independent medical examinations. J Occup Environ Med 48, 303-311.

Further reading

Sharpe, M. et al. (2006). Bodily symptoms: new approaches to classification. J Psychosom Res 60, 353-356.

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