The Assessment of Malingering
“There were no real demons, no talking dogs, no satanic henchmen. I made it all up via my wild imagination so as to find some form of justification for my criminal acts against society” [“Son of Sam” serial killer David Berkowitz].
Deception is a frequent behaviour that occurs in day to day life. In the setting of the doctor-patient or lawyer-client relationship, self-disclosure is rarely complete and accurate and individuals are selective about how much they share with others.
Malingering has been defined by the American Psychiatric Association as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives”. Malingering itself is not considered to be a form of mental illness or psychopathology but although it can occur concurrently with mental illness.
According to DSM-IV-TR, malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medico-legal context of presentation; (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 the prescribed treatment regimen; and (4) the presence in the patient of antisocial personality disorder (ASPD). However, criticism has been levelled against this criteria and some have suggested that they result in a misclassification rate of over 80%.
The distinction between malingering, factitious presentations and feigning is not always well understood. In contrast to malingering, factitious presentations are characterised by the intentional production or feigning of symptoms that is motivated by the desire to assume a “sick role”. Feigning is the deliberate fabrication or gross exaggeration of psychological or physical symptoms without any assumptions about its goals.
Malingering is important from a clinical and medico-legal perspective. In my own clinical practice, it is not uncommon to [...]