By Moritz Krömer

It was a typical day on the construction site when the accident happened: A microwave fell from an old cupboard and hit Mr S. on the head. Mr S. had a cut above his right eye but luckily showed no signs of a concussion. However, after coming home from work, he claimed to have experienced severe headaches and blurred vision. Even worse, two weeks later, Mr S. alleged to have lost sight on both eyes, which made it impossible for him to continue his job as a painter and decorator. Mr S. was diagnosed with functional blindness as neither neurologists nor psychiatrists could find any deviations from the norm in ophthalmic and mental state investigations. He filed a compensation claim within six months from the accident. Consequently, he was registered blind and able to receive disability living allowance. He was also equipped with a mobility cane.

Be that as it may, shortly after his diagnosis, Mr S. was seen on CCTV footage running a half-marathon. Without assistance, he picked up water bottles from refreshment stations, avoided obstacles and traffic, and raced against the other competitors toward the finish line (Bass & Wade, 2019). Miracle healing or dealing with malingering?

In the case of Mr S. the diagnosis was revised to malingering. Malingering is the intentional production or exaggeration of physical or psychological symptoms motivated by an external incentive (DSM-V, American Psychiatric Association, 2013). An external incentive could be gaining disability pensions and avoiding work, as was the case with Mr S. Other incentives might be related to injury compensation claims, evading criminal prosecution, or receiving medication (Walczyk et al., 2018; Boskovic & Merckelbach, 2018). The true prevalence of malingering varies per population (i.e., forensic context or injury compensation claims etc.) and can only be estimated approximately. However, research suggests alarmingly high numbers, ranging from 10% to 50% (Freeman et al., 2008; Larrabee, 2003; Mittenberg et al., 2002). In that, malingering causes significant ramifications for society. Luckily there are specific tests designed to screen for malingering: Symptom Validity Tests (SVTs). Many SVTs have high diagnostic accuracy and are successfully applied by forensic psychologists. Hence, SVTs are considered in the following diagnostic criteria for malingering (which is not considered a disorder): (a) the presence of an external incentive; (b) evidence of feigning or exaggeration from invalid presentation on examination or psychometric tests (e.g., SVTs); (c) discrepancies in self-reported symptoms and collateral reports/media-recordings (e.g., see the case of Mr S.); (d) and the absence of psychiatric, neurological, or developmental disorders that could account for meeting criterion (b) or (c) (Sherman et al., 2020).

Unfortunately, this is only the tip of the iceberg. Malingering can co-exist with genuine symptoms and not meeting the proposed diagnostic criteria does not necessarily exclude the possibility that a patient is malingering. Furthermore, psychologists must consider other reasons for symptom exaggeration. Patients with the factitious disorder, for example, feign to stay in the role of a patient (Schlesinger, 2007). Similarly, whether symptom exaggeration arises from conscious or unconscious mechanisms is impossible to say with certainty. In cases of somatoform disorder, patients experience physical symptoms in response to psychological distress (Bass & Wade, 2019). All the above make diagnosing malingering a complicated matter.

Does that mean that any attempt to diagnose malingering is a lost cause. No, but it is essential to carefully assess for evidence of inconsistencies between reported and observed symptoms, watch out for external incentives, use SVTs and consider alternative explanations for symptom exaggeration (see table 1).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Bass, C., & Wade, D. T. (2019). Malingering and factitious disorder. Practical Neurology, 19(2), 96–96. https://doi.org/10.1136/practneurol-2018-001950

Boskovic, I., & Merckelbach, H. (2018). Fake posttraumatic stress disorder (PTSD) costs real money. The Inquisitive Mind, 36. https://www.in-mind.org/article/fake-posttraumatic-stress-disorder-ptsd-costs-real-money

Freeman, T., Powell, M., & Kimbrell, T. (2008). Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder. Psychiatry Research, 158, 374-380. https://doi.org/10.1016/j.psychres.2007.04.002

Larrabee, G.J. (2003). Detection of malingering using atypical performance patterns on standard neuropsychological tests. The Clinical Neuropsychologist, 17, 410-425. https://doi-org.mu.idm.oclc.org/10.1076/clin.17.3.410.18089

Mittenberg, W., Patton, C., Canyock, E. M., & Condit, D. C. (2002). Base rates of malingering and symptom exaggeration. Journal of Clinical and Experimental Neuropsychology, 24(8), 1094–102. https://doi-org.mu.idm.oclc.org/10.1076/jcen.24.8.1094.8379

Schlesinger, L. (2007). Explorations in criminal psychopathology: Clinical syndromes with forensic implications (2nd ed.). Springfield, Ill.: Charles C. Thomas.

 Sherman, E. M., Slick, D. J., & Iverson, G. L. (2020). Multidimensional malingering criteria for neuropsychological assessment: A 20-year update of the malingered neuropsychological dysfunction criteria. Archives of Clinical Neuropsychology, 35, 735-764.

Walczyk, J. J., Sewell, N., & DiBenedetto, M. B. (2018). A review of approaches to detecting malingering in forensic contexts and promising cognitive load-inducing lie detection techniques. Frontiers in Psychiatry, 9, 700–700. https://doi.org/10.3389/fpsyt.2018.00700