Malingering

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Malingering
Classification and external resources
ICD-10 Z76.5
ICD-9-CM V65.2
MeSH D008306

Malingering is not a medical diagnosis.[1] Falling under the broader scope of illness behaviour, it is defined as fabricating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy. Malingering is different from somatization disorder and factitious disorder.[2] Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system, and false attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population.[3][4] According to the Texas Department of Insurance, fraud that includes malingering costs the U.S. insurance industry approximately $150 billion each year.[5] Other non-industry sources suggest it may be as low as $5.4 billion, ironically suggesting that insurance companies are over inflating the seriousness of the problem to divert more law enforcement towards health insurance fraud.[6]

Symptoms[edit]

The symptoms most commonly feigned include those associated with mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. Generally, malingerers complain of psychological disorders such as anxiety. Malingering may take the form of complaints of chronic whiplash pain from automobile accidents. The psychological symptoms experienced by survivors of disaster (post-traumatic stress disorder) are also faked by malingerers.[5]

Many dishonest methods are used by individuals feigning symptoms of malingering.[clarification needed] Some of these include harming oneself, trying to convince medical professionals one has a disease after learning about its details (such as symptoms) in medical textbooks, taking drugs that provoke certain symptoms common in some diseases, performing excess exercise to induce muscle strain or other physical types of ailments, and overdosing on drugs.[5]

DSM-V[edit]

According to the DSM-V, malingering may be suspected:[5]

  • When a patient is referred for examination by an attorney
  • When the onset of illness coincides with a large financial incentive, such as a new disability policy
  • When objective medical tests do not confirm the patient's complaints
  • When the patient does not cooperate with the diagnostic work-up or prescribed treatment
  • When the patient has antisocial attitudes and behaviours (antisocial personality)
  • When a patient who claims to be schizophrenic informs the physician about being confused and is eager to discuss the delusions[7]

Limitations[edit]

A formal assessment of malingering requires the explicit confession of the patient. Even in such cases, clinical guidelines do not exist for interrogation techniques and a physician may elicit a false confession. It is advised to avoid an assessment of malingering. legally the term may be considered prejudicial and excluded on the basis of its probative value.[8] No current research exists regarding the frequency, behaviour or detection of successful malingerers. No neuropsychological inventories exist that can be used to conclusively determine if a patient is malingering; nor are they used to exclude a determination of malingering. Genuine neurological and psychiatric conditions may return false positives. Testing inventories cannot distinguish between exaggeration and fabrication. Psychological inventories rely on naivety. Criminally, an assessment may lead to punishment enhancement and medically; to denial of future treatment. The DSM-V criteria faces scrutiny for providing poor guidelines. As such physicians ultimately rely on their intuition and gut feeling for any assessment which is subject to prejudice and cognitive dissonance and which has been shown to be unreliable in synthetic tests.[9][10][11][12]

Malingering presumes an exhaustive diagnostic procedure has been performed. Exhaustive diagnostics are neither practical nor economically viable or judged to be in the best interests of the patient's health. Radiological and invasive exploratory proceedures can be necessary for an accurate diagnosis yet pose a health risk to the patient. radiographic diagnostics expose the patient to radiation and surgical diagnostic proceedures can carry a high risk of complications and mortality such as a lumbar puncture, the only reliable diagnostic proceedure for diagnosing rare terminal forms of parasitization which the CDC reports as only being diagnosed post mortem 75% of the time.[13] A physician invariably face limitations in the realms of resources, time and liability.[14][15][16] Because an assessment, formal or informal, of malingering ceases the medical process, it may seem an attractive option for the physician and help them to cope with cognitive dissonance over their failure to effectively diagnose and treat a patient within constraints.[17][18][19][20][21][22][23][24][25][26]

Patients with unresolved illness may be adversarial towards physicians, attempting to game the triage system in order to receive specialist care. such cases fit the criteria for malingering yet the patient is still in need of medical care.[27] For example, in a gatekeeper system, primary care physicians may restrict the availability of HIV testing to only patients who report high risk activity.[28] A patient may then falsely report sexual and/or drug history and/or symptoms in order to elevate priority which can then go on to serve as diagnostically relevant history for an inaccurate path of further diagnosis.

Few cases are as famous as Harold Garfinkel's study of Agnes Torres. In the 1950s, Agnes feigned symptoms and lied about almost every aspect of her medical history. Fearing doctors at the UCLA would refuse her access to her desired sexual reassignment surgery, Garfinkel concluded that she had avoided every aspect of her case which would have indicated gender dysphoria so as to avoid being treated as an "effeminate homosexual" and psychiatric patient. She lied that she had not taken hormone therapy and her examining physicians concluded that it would be impossible for someone so young to have stumbled upon a therapy and instituted it at such a young age so as to produce such brilliant feminizing effects. As such they concluded that their patient had testicular feminization syndrome, legitimizing in their professional opinion, the validity of her request for sexual reassignment surgery. While not evaluating the patient, Garfinkel commented that the complexity of the deception was of such intricate construction intended towards the singular goal of seeking the particular desired medical intervention.[29]

Medical practitioners often believe that they can detect deception. In two studies, experienced medical practitioners including psychiatrists failed to perform better than chance when asked to detect lying and simulated patients. In 12 other studies, detection rates ranged between 0 to 25% for the detection of simulated patients.[10][30] It's impossible to detect malingering from a clinical perspective.[31]

History[edit]

In the Hebrew Bible, King David feigns insanity to Achish, king of the Philistines (I Sam. 21:10-15). This is by many supposed not to have been feigned, but a real epilepsy or falling sickness, and the Septuagint uses words which strongly indicate this sense.[32] Odysseus was stated to have also feigned insanity in order to avoid participating in the Trojan War.[33] Malingering has been recorded historically as early as Roman times by the physician Galen (Quomodo morbum simulantes sint deprehendendi), who reported two cases. One patient simulated colic to avoid a public meeting, while the other feigned an injured knee to avoid accompanying his master on a long journey.[34] During the Renaissance, a treatise on feigned diseases (De iis qui morborum simulant deprehensis) by Giambattista Silvatico, was published at Milan in 1595. Various phases of malingering (les gueux contrefaits) are well represented in the etchings and engravings of Jacques Callot (1592–1635).[35] In his social-climbing manual, Elizabethan George Puttenham recommends that would-be courtiers have "sickness in his sleeve, thereby to shake off other importunities of greater consequence" and suggests feigning a "dry dropsy [...] of some such other secret disease, as the common conversant can hardly discover, and the physician either not speedily heal, or not honestly bewray."[36]

General George S. Patton, in what became known as 'the Greek Incident', found a Soldier in a field hospital but with no wounds, claiming to be suffering from battle fatigue. Upon Discovering this and believing that the patient was malingering, Patton flew into a rage, physically assaulted the patient, called him a coward and did not stop until he was physically restrained. The patient was later found to have contracted malaria and to be suffering from dysentery.

Lady Flora Hastings was accused of adultery stemming from court gossip following abdominal pain. Because she refused to be physically examined by a man for reasons of modesty befitting a lady in her position, the physician assumed her to be pregnant. She later died of stomach cancer.

Soviet Union[edit]

Because malingering was widespread throughout the Soviet Union to escape sanctions or coercion, physicians were limited by the state in the number of medical dispensations they could issue.[37]

With thousands forced into manual labour, doctors were presented with four types of patients:

  1. those who needed medical care;[38][39]
  2. those who thought they needed medical care (hypochondriacs);
  3. malingerers; and
  4. those who made direct pleas to the physician for a medical dispensation from work.

This dependence upon doctors by poor labourers altered the doctor-patient relationship to one of mutual mistrust and deception.[37]

United States Armed Forces[edit]

Malingering is a court-martial offense in the United States Armed Forces under Article 115 of the Uniform Code of Military Justice, which provides that:

Any person subject to this chapter who for the purpose of avoiding work, duty, or service–
(1) feigns illness, physical disablement, mental lapse or derangement; or
(2) intentionally inflicts self-injury;
shall be punished as a court-martial may direct.[40]

See also[edit]

References[edit]

  1. ^ Bienenfield, David (April 15, 2015). "Malingering". medscape. medscape. Retrieved December 30, 2016. malingering receives a V code as one of the other conditions that may be a focus of clinical attention. 
  2. ^ R. Rogers. Clinical Assessment of Malingering and Deception. 3rd Edition, Guilford, 2008. ISBN 1-59385-699-7
  3. ^ "Malingering in the Clinical Setting" Garriga, Psychiatric Times. Vol. 24 No. 3, 2007
  4. ^ Shapiro, AP; Teasell, RW (March 1998). "Misdiagnosis of chronic pain as hysteria and malingering". Current Pain and Headache Reports. 2 (1): 19–28. doi:10.1007/s11916-998-0059-5. Archived from the original on July 14, 2011. 
  5. ^ a b c d Robert Scott Dinsmoor (2011), "Malingering", in Laurie J. Fundukian, The Gale Encyclopedia of Medicine, 4 (4th ed.), Gale, pp. 2737–2739, ISBN 978-1-4144-8646-8 
  6. ^ Gouvier, Drew (2009). "The vulnerability to coaching across measures of effort". researchgate.net. The Clinical Neuropsychologist. Retrieved December 29, 2016. combined medical and legal costs approach five billion dollars annually 
  7. ^ Phillip J. Resnick, MD, James Knoll, MD Faking it: How to detect malingered psychosis, Current Psychiatry, November 2005
  8. ^ Conroy, Mary (2006). "MALINGERING" (PDF). Applied Psychology in Criminal Justice. Sam Houston State University. Retrieved December 30, 2016. pg31. "Courts can exclude relevant evidence if its probative value is substantially outweighed by the danger of unfair prejudice. Use of the term “malingering” can be highly prejudicial." 
  9. ^ Rosen, Gerald (2004). "A Cautionary Lesson from Simulated Patients" (PDF). Journal of Psychiatric Law. Retrieved December 29, 2016. 
  10. ^ a b Palmieri, John (2009). "Lies in the Doctor-Patient Relationship". NIMH. Primary Care Companion Journal of clinical Psychiatry. Retrieved December 29, 2016. 
  11. ^ Webber, Miriam (2000). "A Clinical Approach to Evaluating Malingering in Forensic Neuropsychological Evaluations" (PDF). University of Albany. Retrieved December 30, 2016. 
  12. ^ Conroy, Mary (2006). "MALINGERING" (PDF). Applied Psychology in Criminal Justice. Sam Houston State University. Retrieved December 30, 2016. 
  13. ^ "Naegleria fowleri — Primary Amebic Meningoencephalitis (PAM) — Amebic Encephalitis". Centre For Disease Control and Prevention. May 22, 2014. Retrieved December 28, 2016. " Because of the rarity of the infection and difficulty in initial detection, about 75% of diagnoses are made after the death of the patient. 
  14. ^ Srivastava, Ranjana (September 7, 2016). "Do I really need 'the test'? Too many tests could do patients more harm than good". The Guardian. 
  15. ^ Duckett, Stephen (September 30, 2015). "Removing overused treatments from Medicare isn't the answer". ABC News. Retrieved December 28, 2016. 
  16. ^ Graber, Mark (May 28, 2013). "The hidden problem of medical misdiagnosis – and how to fix it". The Conversation. Retrieved December 28, 2016. 
  17. ^ williamson, diane (September 27, 2009). "Finally heard, but too late". Worcester Telegram. Retrieved December 30, 2016. when they told her to leave. So adamant was her insistence on staying that UMass Memorial police were called to escort the sick woman from the hospital. One month later, Ms. Chapman was dead. When doctors finally admitted her to UMass Memorial Sept. 3, metastatic cancer was found in her lungs, liver and spine. 
  18. ^ Croy, Liam (August 29, 2016). "Perth baby dies after being sent home from two hospitals". Yahoo 7 News. Retrieved December 30, 2016. She claimed a nurse laughed at her when she asked if the symptoms could be connected. 
  19. ^ Devlin, Amanda (May 25, 2016). "Teenager, 16, died from meningitis 'after being sent home from hospital with a suspected migraine'". The Sun. Retrieved December 30, 2016. Izzy’s symptoms were not typical of meningitis at the time of first presentation and we believe that both the assessment and treatment were appropriate. 
  20. ^ O'Connor, Brendan (December 20, 2016). "Alabama Inmate Commits Suicide Just Weeks After Testifying in Federal Mental Health Trial". Jezebel. Retrieved December 30, 2016. The state’s attorneys, Borden said, “went to great lengths to try to portray his suicide attempts as faking. It is tragic and devastating that it took a fatal hanging to perhaps finally make it clear that he wasn’t just faking. Jamie’s case is emblematic of the utter neglect and mistreatment of people with serious mental illness in ADOC prisons. 
  21. ^ Boodman, Sandra (December 6, 2016). "5 simple steps to avoid becoming a medical mystery". Chicago Tribune. The Washington Post. Retrieved December 30, 2016. Local doctors had variously attributed his pain to a mental illness, malingering, drug-seeking behavior or a dental problem. An expert at a major teaching hospital in another state rapidly diagnosed and successfully treated him for a neurological disorder. 
  22. ^ Back, Alexandra (September 29, 2016). "Convicted killer refused bail after alleged breach of parole in Canberra". the Canberra Times. Retrieved December 30, 2016. A parole officer told the court a doctor at Canberra Hospital had made an unsolicited call to the board, and said she believed he was using the condition to avoid his responsibilities. His condition could be managed in the AMC, the officer said. 
  23. ^ Orstroff, Jamie (June 1, 2016). "Family seeks justice after inmate at Tuscaloosa County Jail dies". CBS WIAT. Retrieved December 30, 2016. Attorney David Schoen says Anderson had an ulcer that had perforated, causing his intense pain at the jail and leaving his stomach distended, classic symptoms of a duodenal ulcer that should have been obvious as such to jailers and medical staff. 
  24. ^ White, Tracie (May 23, 2016). "Stanford scientist's mission to help solve the mystery of CFS brings hope to patients". Stanford Medicine. Retrieved December 30, 2016. Hillenbrand and so many others like her — including Dafoe — often get labeled as malingerers. Doctors refuse to treat patients... 
  25. ^ McFarling, Usha (November 21, 2016). "Wanted: Women's brains — to jump-start lagging research on female concussions". Stat News. Boston Globe News. Retrieved December 30, 2016. “When a girl says she still needs to go to the nurse four weeks after a concussion,” she said, “she gets judged as a malingerer or someone with a mental health problem.” 
  26. ^ Thompson, Angela (October 13, 2016). "Brain tumour survivor Trudy Davis wrongly discharged from Shellharbour Hospital, Professional Standards Committee finds". Illawarra Mercury. Retrieved December 30, 2016. Last week the committee ordered Dr Chimpanda to undergo further training, concluding he had acted “significantly below the standard reasonably expected of a practitioner of his level of training and experience” by sending Ms Davis home.  
  27. ^ Donnelly, Laura (April 14, 2016). "NHS reconsiders 'self-check in' after patients fake symptoms to jump queue". The Telegraph. Retrieved December 28, 2016. Whilst the majority of people use the kiosks responsibly, they do contain trigger questions which patients may use to mis-report the seriousness of their condition. 
  28. ^ "STI SCREENING". Melbourne Sexual Health Centre. May 1, 2015. Retrieved December 28, 2016. The type of tests required to screen individuals for STI depends on the sexual history and risk behviour of the individual. 
  29. ^ Garfinkel, Harold (1967). Polity Press, ed. Studies in Ethnomethodology, Chapter Five: Passing and the Managed Achievement of Sex Status in an Intersex Person, Part 1. Blackwell Publishing. pp. 116–185. ISBN 978-0-7456-0005-5. 
  30. ^ Rosen, Gerald (2004). "A Cautionary Lesson from Simulated Patients" (PDF). Journal of Psychiatric Law. Retrieved December 29, 2016. 
  31. ^ Morgan, Joel (2009). "Neuropsychology of Malingering Casebook". google books. Psychology Press. Retrieved December 29, 2016. Unless individuals confess to malingering, neuropsychologists cannot really know whether invalid test performance is conscious and deliberate or a reflection of other factors. 
  32. ^ John McClintock; James Strong, eds. (1894), "Madness", Cyclopaedia of Biblical, Theological and Ecclesiastical Literature, 5, Harper & Brothers, pp. 628b–629a 
  33. ^ Hyginus Fabulae 95. Cf. Apollodorus Epitome 3.7.
  34. ^ "Galen on Malingering, Centaurs, Diabetes, and Other Subjects More or Less Related", Proceedings of the Charaka Club, X (1941), p52-55
  35. ^ Fielding H. Garrison (1921), History of Medicine (3rd ed.), W. B. Saunders, pp. 201, 312 
  36. ^ "The Art of English Posey: a Critical Edition." George Puttenham. Ed. Frank Whigham & Wayne A. Rebhorn. (2007) 379-380.
  37. ^ a b Structured Strain in the Role of the Soviet Physician, Mark G. Field, 1953 The American Journal of Sociology, v.58;5;493-502
  38. ^ "Skumin V A Borderline mental disorders in chronic diseases of the digestive system in children and adolescents.". Zhurnal nevropatologii i psikhiatrii imeni SS Korsakova Moscow Russia 1952. 91, (8): 81–84. 1991. PMID 1661526. 
  39. ^ Skumin, VA (1982). Непсихотические нарушения психики у больных с приобретёнными пороками сердца до и после операции (обзор). [Nonpsychotic mental disorders in patients with acquired heart defects before and after surgery (review)]. Zhurnal nevropatologii i psikhiatrii imeni S.S. Korsakova (in Russian). 82 (11): 130–5. PMID 6758444. 
  40. ^ United States Code Title 10, Subtitle A, Part II, Chapter 47. "Article 115 — Malingering". 

External links[edit]

  • The dictionary definition of malingering at Wiktionary