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Malingering & Clinician Tricks

by | Nov 1, 2020 | Manuscripts | 0 comments

Solanki Lala, B.Optometry

Intern Optometrist, Dr. Shroff’s Charity Eye hospital, Delhi, India

 

Malingering, a term used to imply condition where patients pretend to have certain symptoms which they do not experience. In a clinical setting it can falsely impact the diagnostic process. The most popular definition of malingering is:

 

“International production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.” Malingering is not considered to be a psychiatric disorder. (1)

Pathophysiology of Malingering: Malingering is a careful demeanour of an individual to bogus an ailment of physical/psychological cosmos for a noted cause. The patient sensibly lies about their state to get a benefit and after achieving it they stop complaining. No medical interventions can cure this condition. (2)

Malingering Epitome –

  1. Pure Malingering: Involves total creation of a disorder that does not exist.
  2. Partial Malingering: This involves an overemphasis of existing symptoms.
  3. False Imputation: Occurs when a person deliberately attributes symptoms to a cause having little or no relationship to the evolution of symptoms.(3)

Malingering Hits:-

Psychitric conditions like Dissociative identity disorder, (4) psychosis, suicidality/mood disorders, Post traumatic stress disorder(3) & other condition like sleep disorder. (5)

Malingering & Patient Motive:-

Models of malingering behaviour have been proposed by different research papers to understand the patient’s motive behind malingering. Two such the important models are discussed below –

  1. Adaptation Model: The model proposed by Roger(6)avouch that malingering engage in “cost benefit analysis” during assessment which includes circumstances of assessment is discerned as antipathetic, Personal post is high & No alternatives appear to be applicable.
  2. Financial Incentive: Individuals who are pursuing different reparation are usually considered to be more likely to inflate symptoms. Recent study indicated positive correlation between financial incentive and the likelihood of malingering or exaggeration(7).

Following are the most common problems(8) with malingering seen especially in a clinical scenario:

  • Medico legal factors of appearance
  • Distinct incongruity between the person’s claimed disability and the clinical findings
  • Lack of cooperation during diagnostic examination
  • Complying with prescribed treatment regimen
  • Presence in the patient of antisocial personality disorder

Scrutinization of a Malinger:–

In an ophthalmic practice, a clinician should master the knowledge of stimulation to avoid misdiagnosis or to delay the diagnostic process. Malingerers imitate disorder/disease, or disaffirm enduring pathology.

The two essential examination strategies for malingering are confounding and fogging. It can sometimes be a combination of the two. The tests hinge on either subjective or objective evaluation. Some of the other tests can be cylinder and prism test for visual acuity, pupil test for hemianopia, Ishihara plates for colour vision, dark room test for nyctalopia and stereo test for amblyopia. Examiners can also consider hospitalising the patient to have a close follow up also perform other sophisticated tests like OCT, electro diagnostic test (9).

Both malingering and psychiatric disorders involve pretence of physical or psychological illness. Originating psychiatric disorders is a tendency to postulate the sick role in lieu to distinct external provocation. In malingering, external provocation should be definite(10). Ailing fallaciously, struggling diligently leads to eradication & lesson to Malingers. Clinician may consider speaking directly to the individual about evidence of feigning after a few clinical assessments.

References 

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder; DSM-IV-TR . 4th ed. Jaypee; 2000.
  1. Ubaidullah Alozai; Pamela K. McPherson Malingering; June 27, 2020
  1. Perry, B. Harris Waish K, et al. Change in psychotropic prescribing patterns among youths. in foster care associated with a peer-to-peer physician consultation program. J Am Acad Child Adoles Psychiatry. 2019; 58:1218-1222

4 . Owens JA, Mindell JA. Pediatric insomnia. PediatClin N Am. 2011;58:555-569

  1. Fuermaier, A.B.M., Tucha L, Becke,M. &Tucha O., Journal of Sleep Medicine and Disorders, 2014.
  2. Rogers R, Sewell KW, Goldstein AM. Explanatory models of malingering. Law and human behavior. 1994;1;18(5):543-52.
  1. Sege RD, Amaya-Jackson L, et al. Clinical considerations related to the behavioral manifestations of child maltreatment. Pediatrics. 2017; 139:e20170100
  1. Ross CA. Problems with Factitious Disorder, Malingering, and Somatic Symptoms in DSM-5. Psychosomatics. 2019 Jul- Aug; 60(4):432-433.
  1. Ali IhsanIncesu., Tests for malingering in ophthalmology, Int J Ophthalmol. 2013; 6(5): 708-717.

10. H. W. Lebourgeois lii, MD, Malingering: Key Points in Assessment; April 15, 2007

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