MALINGERING A DIAGNOSTIC DILEMMA

Malingering

Abstract

INTRODUCTION

The deliberate and voluntary production of false and or psychological symptoms is referred to as malingering. Factitious disorders on the other hand are characterized by feigned physical or psychological symptoms and signs presented with the aim of receiving medical care [1]. They are therefore different from functional symptoms. A distinction should be made between factitious disorders and malingering. Malingerers deliberately feign symptoms to achieve a goal. Military authorities have always been suspicious that doctors attest disability on psychiatric grounds at the cost of discipline and promote malingering resulting in excessive war pension liabilities [2].

The concept of malingering is as old as history of mankind itself. Central to philosophical moral thought has been debate of the rightfulness or wrongfulness of a person's deliberate employment of the capacity to deceive [3].  

In medicine, the dichotomy between truth and lies has found expression in the domain of malingering and its detection. Mental illness, because it is difficult to verify objectively and is dramatic and emotional subjectively, is an all-time favorite of the malingerers [4].

In the second century AD Galen wrote a treatise, “On Feigned Diseases and the Detection of Them”, in which he described Roman conscripts who cut off thumbs or fingers to evade dangerous duties. In the sixteenth century Paolo Zacchias, considered to be the father of forensic medicine, wrote of madness, "There is no disease more easily feigned, or more difficult to detect [3].

According to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) the essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Under some circumstances, malingering may represent adaptive behavior - for example, feigning illness while a captive of the enemy during wartime [5].

In his 1823 Medical Jurisprudence, Beck described the three contexts that have mostly stimulated malingering behavior throughout history. Diseases are generally feigned from one of three causes - fear, shame, or the hope of gain. Thus the individual ordered on service will pretend being afflicted with various maladies to escape the performance of military duty; the mendicant, to avoid labour, and to impose on public or private beneficence and the criminal, to prevent the infliction of punishment. The spirit of revenge, and the hope of receiving exorbitant damages, have also induced some to magnify slight ailments into serious and alarming illness [6].