INTRODUCTION	Section 2 of 10
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Background: Malingering is intentional production of false or exaggerated symptoms motivated by external incentives, such as obtaining compensation or drugs, avoiding work or military duty, or evading criminal prosecution. Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), malingering receives a V code as one of the other conditions that may be a focus of clinical attention.

Pathophysiology: Malingering is deliberate behavior for a known external purpose. It is not considered a form of mental illness or psychopathology, although it can occur in the context of other mental illnesses.

Mortality/Morbidity: The total cost of health insurance fraud in the United States (including untruthful claims by patients and medical personnel) was more than $59 billion in 1995, resulting in a cost of $1050 in added premiums for the average American family.

	CLINICAL	Section 3 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography

History:

• Strongly suspect malingering in the presence of any combination of the following:

• Medicolegal presentation (eg, an attorney refers patient, a patient is seeking compensation for injury)

• Marked discrepancy between the claimed distress and the objective findings

• Lack of cooperation during evaluation and in complying with prescribed treatment

• Presence of an antisocial personality disorder

• Malingering often is associated with an antisocial personality disorder and a histrionic personality style.

• Prolonged direct observation can reveal evidence of malingering because it is difficult for the person who is malingering to maintain consistency with the false or exaggerated claims for extended periods.

• The person who is malingering usually lacks knowledge of the nuances of the feigned disorder. For example, someone complaining of carpal tunnel syndrome may be referred to occupational therapy, where the person who is malingering would be unable to predict the effect of true carpal tunnel syndrome on tasks in the wood shop.

• Prolonged interview and examination of a person suspected of a malingering disorder may induce fatigue and diminish the ability of the person who is malingering to maintain the deception. Rapid firing of questions increases the likelihood of contradictory or inconsistent responses. Asking leading questions may induce the person to endorse symptoms of a different illness. Questions about improbable symptoms may yield positive responses. However, because some of these techniques may induce similar responses in some patients with genuine psychiatric disorders, exercise caution in reaching a conclusion of malingering.

• Persons malingering psychotic disorders often exaggerate hallucinations and delusions but cannot mimic formal thought disorders. They usually cannot feign blunted affect, concrete thinking, or impaired interpersonal relatedness. They frequently assume that dense amnesia and disorientation are features of psychosis. It should be noted that these descriptions also may apply to some patients with genuine psychiatric disorders. For example, individuals with a delusional disorder can have unshakable beliefs and bizarre ideas without formal thought disorder or affective blunting.

• The most common goals of people who malinger in the ED are obtaining drugs and shelter. In the clinic or office, the most common goal is financial compensation.