- Let’s first define malingering, this is the production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives.
- Not all lying involves secondary gain, but ALL malingering does involve secondary gain
- Common secondary gains include avoiding military service, avoiding work, financial incentives, avoiding legal actions, and obtaining controlled substances
- Feigning mental illness is not the same as malingering because the reason behind the false production of symptoms is not assumed with feigning symptoms.
- Factitious disorder is the voluntary production of symptoms, but this is with the goal of assuming the sick role or role of a patient, it’s not done for secondary gain.
Consider malingering when….
-Rare symptoms are present
-Improbable symptoms are being reported
-Rare combination of symptoms are present
-Reported Vs observed symptoms are not congruent
-25-30% of patients who claimed major depression in civil litigation were probably malingering
-Pay careful attention to facial expressions
-Pay careful attention to motor function, psychomotor retardation is an important observable sign
-If appetite changes are reported look for actual objective weight change
-symptoms opposite of depression
-blaming others for everything is not the way guilt typically presents in depression, this is externalizing and not taking personal responsibnility
-Often in true psychosis people can describe the voice/s, is it loud, soft, male, female, you have some experience of what you heard. When you ask a malingering patient about a voice, they should have some ability to describe what they are hearing, if not consider malingering.
-If you are suspicious, begin with open ended questions, ask them to describe things in their own words.
-Genuine AH are in words or sentences, drug Hallucinations usually occur as unformed noises.
-The location of the voice inside the head or outside is no longer a good predictor of malingering
-Many times the content of voices are derogatory in nature
-Other signs of malingered psychosis include Vague or inaudible auditory hallucinations, AH not associated with delusions (86% of AH have an associated delusion), no strategies to diminish voices 76% of patients have some coping strategy to diminish the voices. They claim that all instructions are obeyed, the hallucinations are visual alone, seeing little people or giant people for example.