Motivation and emotion/Book/2021/Malingering motivation

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Malingering motivation:
What motivates malingering and what can be done about it?

Overview[edit | edit source]

  • This chapter explores:
  • What malingering is
  • What motivates malingering
  • Plus how malingering can be managed

Focus questions:

  • What is malingering?
  • What motivates malingering?
  • How can malingering be managed?

What is Malingering[grammar?][edit | edit source]

  • Malingering is when a person fakes, or significantly exaggerates physical or psychological symptoms in order to gain external benefits[factual?].
  • While malingering isn't an everyday occurrence, it has dire consequences. These consequences include: costs of financial compensation, the draining of resources that would otherwise being going towards other people that need them, the relationship between the physician and the patient being damaged, criminal charges for the malingerer (e.g., malingering to avoid a military draft), and the malingerer undergoing potentially harmful surgeries and medication[factual?].
  • Malingering is not classified as a mental disorder, however, it is included in the DSM-V under a V-code, also known as Other Conditions That May Be a Focus of Clinical Attention.
  • This is because malingering can affect the diagnosis and treatment of a patient, whether the malingering is an indicator of other underlying psychological conditions; or the malingering is motivated by purely external benefits.

Aetiology of Malingering[edit | edit source]

  • Unlike [[wikipedia:Factitious_disorder|facetious[spelling?] disorder]], where the patient fakes or significantly exaggerates their symptoms in order to be seen as sick by other people, malingerers fake their symptoms in order to gain external benefits.
  • Malingering is not classified as a mental disorder, however, it is included in the DSM-V under a V-code, also known as Other Conditions That May Be a Focus of Clinical Attention.(Alozai & McPherson, 2021)
  • This is because malingering can affect the diagnosis and treatment of a patient, whether the malingering is an indicator of other underlying psychological conditions; or the malingering is motivated by purely external benefits.

Common Motives for Malingering[edit | edit source]

  • Financial compensation, whether it be through civil lawsuits, or disability benefits.
  • Revenge
  • Avoiding or reducing criminal charges.
  • Obtaining medication or illegal substances.
  • Avoiding military draft.
  • Avoiding distressing environments and situations, (e.g., school) (Alozai & McPherson, 2021)

Case Study: The Mysterious Rash

  • A 14 year old girl was referred to a hospital for a possible case of chronic fatigue. At the time, she was experiencing fatigue, reduced appetite, nausea, and a pink rash under her cheeks. These symptoms had begun a fortnight before the visit, and was also accompanied by conjunctivitis at the time. At this point, she had missed school for a month.
  • Except for the conjunctivitis and her rash, the physical examination was unremarkable. However, the doctor noticed that her rash could be wiped off with alcohol.
  • At first she denied applying makeup, however, she ended up tearfully confessing that she applied makeup to her cheeks and eyes so that she could avoid school.
  • This was because a classmate was spreading a rumour that he had sex with her, and because of this, she was feeling harassed, and embarrassed.
  • The family was then referred to counselling to resolve this issue, and she was able to return to school. Since then, she has continued to do well with no further episodes. (Peebles et al., 2005)

Personality Traits and Conditions Associated with Malingering[edit | edit source]

  • Fantasy proneness (Peace & Masliuk, 2011)
  • Antisocial personality disorder, because people with antisocial personality disorder are more likely to use malingering as a tool to achieve their goal.
  • It is hard to make generalisations about malingerers as the demographics and motivations of malingerers are incredibly diverse, and recent research suggests that malingering is not a trait, rather, it is a situation-specific tool whose use is influenced by adaptational factors rather than criminological factors. (Sahoo et al., 2020)

Psychological Theories[edit | edit source]

  • The pathogenic model is a theory that suggests that the motivation for malingering stems from when an individual who is already experiencing some form of illness, feigns and reports further symptoms in an attempt to control their experience of it and also gain external benefits. This theory however has been disregarded due to lack of replication.
  • The criminological model suggests that the motivation to malinger is caused by socially deviant individuals who use malingering as a tool in court. While this theory bears some weight, it however is not applicable to all cases of malingering.
  • The adaptational model stems from the humanistic school of psychology, and it proposes that malingering is an individual's method of coping with extreme stress. There are several assumptions that accompany this model; one, the patient sees the diagnostic process as involuntary, or antagonistic; two, the patient cannot see any alternative ways of achieving their goal; three, the patient believes that there no other ways of achieving their goal. (Sahoo et al., 2020)

Detecting Malingering[edit | edit source]

  • There are several ways of detecting malingering. These include tests, reviewing the patient's medical history, and looking for indicators of malingering in the patients behaviour. The best approach is using a combination of the above methods as this will ensure a richer understanding of the patient.

Signs of Malingering[edit | edit source]

In the DSM-V, indicators of malingering are:

  • The medicolegal context of the presentation (eg. a lawyer sending a client due for trial to an evaluation to try and reduce their sentence).
  • Inconsistencies between the client's claimed symptoms, and observed behaviour and symptoms.
  • Lack of compliance with diagnosis, treatment, and follow up.
  • They have antisocial personality disorder. (Alozai & McPherson, 2021)

Other indicators of malingering include:

  • Abnormal presentation, however, abnormal presentation can also be an indicator of a dual diagnosis in genuine patients.
  • Atypical symptoms, however, this alone is not an indicator of malingering as there are genuine patients with atypical symptoms.
  • A willingness to talk about embarrassing or distressing symptoms with the practitioner, even in the absence of a close relationship.
  • The use of specific terminology, however, a patient using specific terminology is also an indicator that a genuine patient is well-educated on the matter.
  • They describe symptoms vaguely.
  • Can't describe what they do to mitigate the symptoms. (Schnellbacher & O’Mara, 2016)

Finding Evidence of Malingering[edit | edit source]

  • Ask the patient about improbable symptoms in order to catch them out. These improbable questions can be asked in between several genuine questions in order to make the questions seem more realistic.
  • Review the patients medical records and history. (Sahoo et al., 2020)
  • If necessary, conduct lab tests to rule out physical symptoms.
  • Conduct malingering tests on the patient. (Alozai & McPherson, 2021)
This image is titled, 'The Floor Effect in Action'. It contains three individuals who are falling, and a floor. The floor is labelled 'baseline passing standards of the test'. Two of the individuals are falling above the floor. They are labelled, 'participants with cognitive issues', and 'participants without cognitive issues'. One of the participants has fallen through the floor. They are labelled, 'participants who are malingering'. End Description.
Figure 1. A diagram of the floor effect in action.

Tests for Detecting Malingering[edit | edit source]

  • A common strategy malingering tests employ in their design is The Floor Effect. This is when a cognitive test designed so that individuals with cognitive impairments can easily complete it, however, it is designed to look harder than it actually is, so that when a participant fails the test, this is an indicator of malingering. (Walczyk et al., 2018)
  • MMPI-2, also known as the Minnesota Multiphasic Personality Inventory 2, this test is a frequently used personality and psychopathology test. There are also versions of the MMPI-2 that are used to detect malingering. A study conducted by De Marchi and Balboni (2018) found that the MMPI-2 was effective in detecting malingerers.
  • SIMS, The Structured Inventory of Malingered Symptomatology is a true-false inventory designed to measure malingering. The SIMS was found to more sensitive than other tests designed to identify malingerers, however, SIMS had issues with specificity.
  • NIM (Negative Impression) scale of the PAI (Personality Assessment Inventory) is a scale that measures the extent that participants describe themselves in a negative manner. The NIM can also be used to measure malingering. The NIM was found to be an effective tool to detect malingering. (De Marchi & Balboni, 2018)
  • SIRS-2, also known as the Structured Interview of Reported Symptoms, and it's abbreviated version, the Miller Forensic Assessment of Symptom Test (M-FAST), are tests used to assess deliberate distortions in the self report of symptoms. A study conducted by Guriel-Tennant and Fremouw (2006), have found both tests to be effective at detecting malingering. This result has also been validated by Zubera et al. (2014) in the context of the emergency department.
  • While these tests are good at detecting malingering, the results are unfortunately vulnerable to being manipulated, whether its through a client being coached by their attorney, or a person who has done extensive research on symptomology. (Brennan et al., 2009)
  • These tests also aren't culturally valid. An example of this can be seen with how people from Hispanic or Mediterranean cultures are more inclined to answer in extremes (e.g., strongly agree, or strongly disagree), which leads to their results indicating malingering, even when they're genuine patients. (Merten & Rogers, 2017)

Case Study: The Collegno Amnesiac

  • In March 1926, a man was admitted to the Collegno Asylum, Turin, Italy, after being arrested for stealing from a Jewish Cemetery. During his arrest, he was uncooperative and violent, refusing to give his name, and even attempting to throw himself down the stairs and beat his head against a wall. The man was approximately 45 years old and he had no autobiographical memories.
  • He spent about a year in the asylum where his mental health improved considerably, save for his memories. During this time, he established good relationships with the nurses, doctors, and other patients.
  • He was later identified as Guilio Canella, a philosophy professor who disappeared during World War 1, by Renzo Canella, his brother. The Amnesiac was welcomed back into the family and began to recover his memories.
  • However, a while later, an anonymous letter was sent to the police, identifying 'Guilio Canella' as Mario Bruneri, a typesetter who was wanted for fraud. This lead to multiple controversial court cases with split verdicts until the Turin High Court ruled that The Amnesiac was Bruneri.
  • This verdict was influenced by the results of many cognitive tests conducted on The Amnesiac by medical experts, as well as inconsistencies in character.
  • A major contributor to these assessments was Prof Alfredo Coppola.
  • Coppola's assessments are noteworthy because not only was he the only expert to diagnose The Amnesiac with malingered retrograde amnesia, but his approach to assessment was rather modern, as he used a combination of cognitive tests, close observation of behaviour, and a review of Canella and Bruneri's personal histories to arrive at the diagnosis.
  • Firstly, Coppola tested The Amnesiac's attention with Bourdon's Test, where the subject has to underline the target letters in a short test. Here, The Amnesiac claimed to have problems with attention, and even forgot underline a few of the target letters. However, his scores indicated that his attention was mostly intact, and interestingly, he vertically struck a few of the letters rather than underlining them. This behaviour was common in typesetters.
  • Coppola then tested visual recognition, mental calculation, and language in The Amnesiac, whose results were normal.
  • Short term memory (then classified as simply 'memory') was extensively tested with Ziehen's Test, which is where the participant has to repeat the numbers the tester has said in the same order. Interestingly, even participants with severe intellectual disabilities or participants with severe brain injuries are able to repeat at least three numbers accurately. The Amnesiac failed to do that, which indicated that he was feigning.
  • Semantic memory was also assessed, with Coppola conducting The Flag Test to detect malingering. During this test, The Amnesiac's errors in his answers were extremely exaggerated.
  • Interestingly, his 'memories' as Canella were coming back, however, all of the memories that he 'recalled' were memories that he was told about.
  • Canella was a skilled piano player, and Coppola used this as an opportunity to test The Amnesiac's procedural memories by evaluating his piano skills alongside two expert piano players, because Coppola understood that motor skills would be retained in people with amnesia. The Amnesiac was unable to play the piano and his technique suggested that he had never played the piano until the evaluation. This confirmed Coppola's diagnosis of malingered retrograde amnesia. (Zago et al., 2004)

Treating Malingering[edit | edit source]

  • Malingering cannot be cured by medicine or psychological interventions
  • Malingers only stop when they either achieve their goal, or give up because pursing their goal is futile.
  • Malingers cannot be directly confronted as this can lead to lawsuits, and other negative consequences. (Alozai & McPherson, 2021)
  • However broader terms such as 'unreliable' and 'inaccurate' should be used before 'malingerer' is used as the term 'malingerer' is stigmatising. (Shapiro & Teasell, 1998)
  • It is also important to note that while a patient's malingering can also be an indicator of other underlying issues which should be monitored.

Strategies for Addressing Malingering[edit | edit source]

  • The patient should be indirectly confronted, so that they are encouraged to stop malingering, but are also allowed an opportunity to save face. (Alozai & McPherson, 2021)
  • A script for this strategy can follow as, "There is good news and bad news, the good news is we reviewed your symptoms and you do not have [condition that patient was claiming to have], however, the symptoms you're presenting with are still concerning, and I would like to help you with them".
  • This strategy also allows the practitioner to address the motive of the patient's malingering, so that the patient can receive help, and they can still be monitored for any other conditions they may have.
  • Another strategy for addressing malingering is the Double Blind technique, which is where the patient undergoes treatment, and is informed that their symptoms will improve with the treatment. However, this strategy can lead to the patient undergoing unnecessary procedures which could be potentially harmful.
  • Managing negative reactions from the patient
  • While indirect confrontation can lead to a positive outcome, it can also lead to a negative reaction from the patient, agitation, threats of escalation, and possible violence. This can be managed through:
  • Maintaining a calm demeanour, which will help prevent further escalation.
  • If the patient threatens to escalate their complaint to relevant authority figures, help facilitate this request by providing them with necessary contact details.
  • Negative patient reactions can also be minimised by proving a patient advocate or a second opinion for the patient.
  • The above options help minimise negative reactions as they demonstrate that the physician is following procedure, and is also willing to support further evaluation. (Schnellbacher & O’Mara, 2016)

Differential Diagnoses[edit | edit source]

Differential diagnoses to consider when a patient is presenting with signs of malingering include:

  • Factitious Disorder, which is where a patient fakes, or significantly exaggerates symptoms in order to gain the role of being a sick person. Factitious disorder is also an indicator of other underlying issues, especially when children are presenting with it.
  • Conversion Disorder, which is when a patient experiences neurological symptoms (e.g., paralysis) which are explained by psychological symptoms rather than physical symptoms.
  • Somatic Symptom Disorder, which is when a patient experiences physical symptoms whose origins cannot be explained by medical disorders, substance abuse, or other psychological conditions. (Alozai & McPherson, 2021)
  • Physical diagnoses such as chronic illnesses can be an explanation for the symptoms a patient is experiencing. Lab tests can assist in determining whether this is the case or not. (Shapiro & Teasell, 1998)
  • Thought disorders such as Psychosis and Schizophrenia can be an underlying cause of malingering behaviours, as a study conducted by Humphreys and Ogilvie (1996) found that 3 out of 10 patients who were initially diagnosed with malingering met the criteria for schizophrenia at the 20-year follow up. (Zubera et al., 2014)

Avoiding Misdiagnosis[edit | edit source]

  • When dealing with patients who are suspected malingerers, there is always the possibility that this diagnosis is in fact, a misdiagnosis. (Shapiro & Teasell, 1998)
  • This is especially prevalent with genuine patients from marginalised groups (e.g., women, ethnic minorities, disabled people), who have been misdiagnosed as malingerers due to the physician's own prejudices.
  • Misdiagnosis can lead to the patient's health being neglected, which can leave the physician liable to whatever consequences follow, whether it be the patient's poor health or a lawsuit.
  • Misdiagnosis also damages the patient-physician relationship. (Shapiro & Teasell, 1998)

Misdiagnosis can be avoided by:

  • Conducting lab tests to determine whether the symptoms have a physical cause.
  • Considering differential diagnoses.
  • Watching for underlying causes of behaviour. (Shapiro & Teasell, 1998)
  • As a physician, evaluate any implicit biases you may hold.

Working notes[edit | edit source]

include more stuff on chronic illnesses and avoiding misdiagnosis

as well as more detail on motivation

include more diagrams

include tom of bedlam trope as a case study for adaptational tools

use Roald Dahl as an example of a malingerer

Conclusion[edit | edit source]

  • Malingering is when a patient fakes, or significantly exaggerates their symptoms in order to gain external benefits.
  • It is a situation-specific tool whose use is mostly influenced by adaptational factors where the patient feels there is no other way to achieve their goal.
  • This can be seen in circumstances such as, a kid pretending to be sick in order to avoid school because they're being bullied, or a person who has been drafted into the military attempting to leave.
  • The use of malingering can however be influenced by criminological factors.
  • This can be seen in circumstances such as, a person malingering to avoid criminal charges, or a person malingering to gain financial compensation.
  • Malingering can be detected through a combination of tests, observation of behaviour, and a review of their medical history.
  • Malingering cannot be treated with traditional therapy or medication as malingering is not a mental condition, and, malingerers will only stop malingering when they either achieve their goal or give up because pursing it is futile.
  • However, it is important to still treat malingerers with empathy as malingering can be the result of other underlying issues.
  • When confronting malingerers, it is important to do so in an indirect manner. This way, the malingerer is able to stop, while also saving face, and the physician is still able to offer help that is better suited to their needs.
  • Though before diagnosing a patient as a malingerer, it is important to consider other possible diagnoses as there are diagnoses such as factitious disorder and physical diagnoses such as chronic illnesses whose symptoms can present in a manner that would be indicative of malingering.
  • This is because misdiagnosis can lead to the patient's health being neglected, and the patient-physician relationship being damaged.

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See also[edit | edit source]

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References[edit | edit source]

Alozai, U., & McPherson, P. (2021). Malingering. From

Brennan, A., Meyer, S., David, E., Pella, R., Hill, B., & Gouvier, W. (2009). The Vulnerability to Coaching across Measures of Effort. The Clinical Neuropsychologist, 23(2), 314-328.

De Marchi, B., & Balboni, G. (2018). Detecting malingering mental illness in forensics: Known-Group Comparison and Simulation Design with MMPI-2, SIMS and NIM. Peerj, 6, e5259.

Guriel-Tennant, J., & Fremouw, W. (2006). Impact of trauma history and coaching on malingering of posttraumatic stress disorder using the PAI, TSI, and M-FAST ∗. Journal Of Forensic Psychiatry & Psychology, 17(4), 577-592.

Humphreys M, Ogilvie A. Feigned psychosis revisited-A 20 year follow up of 10 patients. Psychiatric Bulletin. 1996;20:666–9.

Mason, D. (2014). Tom of Bedlam. American Journal Of Psychiatry, 171(12), 1257-1258.

Merten, T., & Rogers, R. (2017). An International Perspective on Feigned Mental Disabilities: Conceptual Issues and Continuing Controversies. Behavioral Sciences & The Law, 35(2), 97-112.

Peace, K., & Masliuk, K. (2011). Do Motivations for Malingering Matter? Symptoms of Malingered PTSD as a Function of Motivation and Trauma Type. Psychological Injury And Law, 4(1), 44-55.

Peebles, R., Sabella, C., Franco, K., & Goldfarb, J. (2005). Factitious Disorder and Malingering in Adolescent Girls: Case Series and Literature Review. Clinical Pediatrics, 44(3), 237-243.

Reese, C., Suhr, J., & Riddle, T. (2012). Exploration of Malingering Indices in the Wechsler Adult Intelligence Scale-Fourth Edition Digit Span Subtest. Archives Of Clinical Neuropsychology, 27(2), 176-181.

Sahoo, S., Kumar, R., & Oomer, F. (2020). Concepts and controversies of malingering: A re-look. Asian Journal Of Psychiatry, 50, 101952.

Schnellbacher, S., & O’Mara, H. (2016). Identifying and Managing Malingering and Factitious Disorder in the Military. Current Psychiatry Reports, 18(11).

Shapiro, A., & Teasell, R. (1998). Misdiagnosis of chronic pain as hysteria and malingering. Current Review Of Pain, 2(1), 19-28.

Walczyk, J., Sewell, N., & DiBenedetto, M. (2018). A Review of Approaches to Detecting Malingering in Forensic Contexts and Promising Cognitive Load-Inducing Lie Detection Techniques. Frontiers In Psychiatry, 9.

Zago, S., Sartori, G., & Scarlat, G. (2004). Malingering and Retrograde Amnesia: The Historic Case of the Collegno Amnesic. Cortex, 40(3), 519-532.

Zubera, A., Raza, M., Holaday, E., & Aggarwal, R. (2014). Screening for Malingering in the Emergency Department. Academic Psychiatry, 39(2), 233-234.

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