Malingering: The Lord Voldemort of Medicine

Definitions

Malingering occurs when a person feigns symptoms to get something tangible, such as money, time off from work, or food and shelter. This is called secondary gain. Malingering is distinguished from factitious disorder where a person feigns symptoms in the absence of external rewards. This is called primary gain and occurs when people get something intangible from feigning illness, namely attention and sympathy.

Malingering is a “diagnosis of exclusion”, meaning that it can only be made when other conditions have been definitively ruled out. Symptoms such as seizures, chest pain, paralysis, and psychosis are commonly feigned as they take time to evaluate and dangerous diseases cannot be instantly excluded. Malingering itself is not a diagnosis. It is not a psychiatric illness according to The Diagnostic and Statistical Manual of Mental Disorders. As such, it is not clear that people who malinger are really patients any more than someone who pretends to be a doctor is really a doctor.

A controversy

Last year, a psychiatrist, Dr. Derek Tracy, received substantial criticism on Twitter after announcing he was going to lecture students on malingering. In response, he cancelled the talk and released the following statement:

I have cancelled the proposed talk on ‘malingering.” I have seen some of the postings on Twitter about the talk, and reflected on the hurt it has caused, particularly for people who have personal experience of not being believed by mental health professions or services. I am very sorry for this.

Over the past ten years or so, evaluation of malingering has been a relatively small part of academic work that I do. It originated from assessing cognitive testing, and some medico-legal/court work. It is the case that some people have lied and feigned mental illness for various reasons in these environments, and it is important, as in any case of fraud, that the courts try detect this. Professionals, including psychiatrists, have been involved in some such instances.

However, it is also try that this is very much a minority occurrence, and the vast majority of people are doing their best to manage their mental health with or without the support of professional services. It is also the case that many people have felt ignored, marginalized, and disbelieved when engaging with services. The title of the proposed talk, the manner in which was advertised, and the lack of consideration for the wider context has understandingly caused upset.

Where professional discussions on malingering occur, I think that they are best kept to more specialist medico-legal settings and forums. A general medical student conference was not the place for this. The responsibility for giving the talk is mine, and not the medical students- I am the one who should have better anticipated this.

I apologize for the hurt and upset I have cause.

After the cancellation was announced, critics commented that:

  • Malingering is generally accepted to be very rare and should be a fringe interest.
  • Malingering is not common & the discourse on it is toxic for patients.
  • Malingering happens but I think most people who might be mislabeled as malingering are just struggling to express their complex mental health issues in understandable terms.
  • The damage caused by mislabeling and not trusting the narrative of those with mental ill health is immeasurable.
  • Malingering should be a problem for practicing clinicians, not students still only learning.
  • Those of us that do speak out with regard to our chronic mental health conditions are often silenced and not believed and accused of ” faking it”

While these concerns are valid, I believe that not talking about malingering in a formal setting with students is a mistake and more likely to increase these unfortunate outcomes.

“You are calling them a liar”

The word malingering is often quite pejorative in medicine. It conjures an image of someone who lies and fakes symptoms for unethical reasons. This happens occasionally. A decade ago several Long Island Railroad employees were prosecuted after they “falsely claimed to be disabled upon early retirement so they could receive extra pension benefits typically between the ages of 50 and 65”. Doctors, who were often paid in cash, were in on the scheme. According to prosecutors, some doctors “ran disability fraud mills, serving as willing rubber stamps for fraud rather than as independent medical professionals”.

Given its negative connotations, malingering must be discussed with care. As Dr. Jeffrey Keller, who works with inmates, wrote,

The most important consideration of the term “malingering” is not its actual definition. The most important part is its emotional meaning. This is a word that causes others to instantaneously have a strong emotional reaction. When you say that a patient is malingering, whether you are using the term correctly or not, what that patient (and others) understand is that you are calling them a liar.

He’s right.

However, if a clinician is confident that a patient is feigning symptoms, they should not shy away from saying so. Using a diagnosis other than malingering would require clinicians to be dishonest as well. Given that it is such an emotionally laden term, clinicians should recognize that by labeling a person a malingerer, they will likely affect their encounters with future health care providers. People with a documented history of malingering are greeted with suspicion when they present with new symptoms, which is problematic. As such, some doctors have suggested getting rid of the term malingering all together. While I understand the reasons for this, medicine needs some term to describe people who feign illness, and whatever term replaces malingering will soon come to be seen as pejorative as well.

How common is malingering?

Doctors have wildly different perceptions of how common malingering is. My career has afforded me relatively unique perspective on this topic, I believe. I’ve worked on hospital wards at both Bellevue, a public hospital with a jail ward, and New York University, a private hospital up the street. I’ve worked in outpatient clinics at both hospitals. For over a decade, I worked the Sunday overnight shift in the Bellevue psychiatric emergency room.

My impression is that the frequency of malingering varies greatly based on the location, time of day, and season. I’ve only clearly seen it once in my outpatient neurology clinics, in a man who was suing an airline. In contrast, I encounter it often in the ER at 2AM on a snowy night. Often times it is easy to detect, such as a person who comes to the ER for the fourth time that week calmly reporting “voices telling me to hurt myself and others”, and later requests to leave with their symptoms completely resolved after a hot meal and a night’s sleep. Occasionally, these individuals will admit to feigning symptoms so they are not retained in the hospital against their will.

Determining the true rate of malingering is obviously difficult as patients are unlikely to respond to questions asking them if they are lying about their symptoms. One study found:

Twenty-nine percent of personal injury, 30% of disability, 19% of criminal, and 8% of medical cases involved probable malingering and symptom exaggeration. Thirty-nine percent of mild head injury, 35% of fibromyalgia/chronic fatigue, 31% of chronic pain, 27% of neurotoxic, and 22% of electrical injury claims resulted in diagnostic impressions of probable malingering.

Another study found “the prevalence of malingering in patients suffering from chronic pain with financial incentive was found to be between 20% to 50% depending on the diagnostic system used”. Yet another study of psychiatric patients in the correctional setting, found that 66% were malingering. In certain settings at least, malingering is not rare.

However, a corollary to this is that malingering occurs only in a very small minority of medical encounters. Several of Dr. Tracy’s critics worried that his lecture would encourage students to detect malingering where it does not exist. While this is a valid concern, a well-done lecture would instead teach students that the overwhelming majority of people do not feign illness to get something tangible in return. The very small number of people who do malinger tend to do so in limited, predictable circumstances. Malingering almost never occurs outside these situations. Even the majority of people with a with personal injury claims, for example, are not malingering. Doctors should know this.

Why is malingering worth talking about?

Unfortunately, malingering is almost never formally discussed as part of the medical curriculum. There are lectures and discussions on all manners of disease, including those that occur in literally one-in-a-million people. Even though it is not rare in certain settings, I’ve never heard any talk on malingering. As Dr. Tracy found out, clinicians who attempt to lecture on this subject may face withering criticism. It is truly the Lord Voldemort of medicine. Everyone knows it exists, no one likes it, and those who try to talk about it are silenced.

Yet, malingering is worth talking about because it happens, and not talking about it doesn’t make it go away. If students don’t learn about malingering in a lecture, they will instead learn about it informally in work rooms and on rounds, almost certainly without the wisdom and compassion Dr. Tracy would have brought to the topic. Indeed, some informal rules in medicine assume patients will lie. For example, clinicians are often taught to automatically double the amount of alcohol a patient says they consume. This “informal curriculum” of medical school is not the ideal place to learn about a sensitive topic such as malingering.

Not talking about malingering in a formal setting may increase the chances that patients will be “ignored, marginalized, and disbelieved”, the outcome Dr. Tracy rightly wants to avoid. Dr. Tracy was right when he said that malingering “is very much a minority occurrence, and the vast majority of people are doing their best to manage their mental health with or without the support of professional services”. However, I disagree when he said that “a general medical student conference was not the place” to learn about this. In my opinion, a general medical student conference is the ideal place for students to learn that malingering is generally rare. They won’t learn this anywhere else.

Students also need to be learn about potential pitfalls in treating these individuals. Depending on the feigned condition, malingering can be dangerous. Not uncommonly, I see patients who feign symptoms and then receive multiple unnecessary tests and procedures, including radiation from CT scans. Occasionally, I have seen them receive medications with potentially devastating side effects, such as thrombolytic medications for strokes. Although malingering is a diagnosis of exclusion, once a clinician is convinced a person is malingering, care must be taken not to hurt them through iatrogenesis.

Importantly, feigning or exaggerating symptoms is often not an all-or-nothing phenomenon, something that students need to learn as well. Doctors have several tricks to help determine who is feigning a symptom such as leg weakness. Earlier in my career, I might have dismissed a patient if I “caught” them with one of these tricks. I still use them occasionally, but I’ve learned to do so with care. Some people with legitimate illness may exaggerate their symptoms so they are not ignored or to communicate their discomfort to clinicians, though this is not malingering of course. A clinician who feels a patient is exaggerating some symptoms should be very careful not to then discount everything else the patient says. Moreover, someone who malingers chest pain on a Saturday is not protected from having a heart attack on a Sunday. Doctors must try to balance this fact while not subjecting patients to repeated batteries of expensive, potentially harmful diagnostic tests. This is a difficult task, but it is not made easier by forbidding discussions of malingering.

Additionally, clinicians should try to understand how malingerers make them feel and how this may impact their care. Like the existence of malingering in the first place, its effect on clinicians is almost completely ignored. Yet, malingering can have a corrosive effect on clinicians, leading them to believe everyone is lying to them. As obstetrician Dr. Amy Tuteur wrote,

The patients who are deliberately deceptive seem to have an outsize influence on the practice of medicine. During internship and residency, young doctors are repeatedly fooled, and therefore embarrassed, by patients. Drug addicts are notorious for presenting themselves as model citizens with serious pain problems. After several episodes of unwittingly giving an addict a fix, or a prescription for drugs that will be sold, young doctors begin to listen to a patients’ stories with increasing cynicism. The subtext for many physicians, consciously or unconsciously, is that they must be convinced that the patient is telling the truth.

Clinician surveys bear this out. In a Medscape survey from 2016, malingerers were rated among as those that most were likely to trigger bias. This is not a surprise. No one likes to be deceived. As such, clinicians should be encouraged to talk about how malingering make them feel, rather than allowing negative feelings to fester undiscussed and unexamined, impacting the care of future patients.

I know for example that I am often distrustful of prisoners. I am not proud of this fact, but after seeing wheelchair-bound prisoners suddenly regain the ability to walk after being bailed out, it is an involuntary association at this point. I know I am not alone. Patients will not be well served by doctors who deny their feelings and never introspect about how this may impact their decisions. Knowing my biases, I try to go the “extra mile” for patients of whom I am automatically suspicious to make sure I don’t miss anything. After all, a prisoner who says that can’t walk may actually have a spinal cord disorder. I’ve seen that many times too. Almost every doctor will have the experience of disbelieving a patient who turns out to have a genuine illness. It’s terrible when this happen, and frank discussions of malingering may lessen the frequency of such events.

Additionally, doctors should learn how to manage people who malinger, though this is difficult. Confronting them is usually counterproductive, as they may feel required to “prove” the clinician wrong and maintain the sick role. Instead, clinicians should do their best to maintain an alliance with them and express optimism about their condition, so there is no shame when they get “better”.

“Understanding isn’t advanced with acquiescence and silence”

Most importantly, clinicians should be sensitive to the fact that most people have perfectly legitimate reasons to malinger. The railroad employees who feigned illness as a scam are outliers. Almost every patient I have seen malinger has done so for a very valid reason, and I’ve become much more sympathetic to most of them as a result.

Faking a seizure may be a rational response for a prisoner who is housed with rival gang members. A woman who feigns chest pain may be doing so to escape an abusive partner. Patients with substance dependence may feign an injury to stave off withdrawal, a violently unpleasant experience. I’ve seen all of this and more. Most commonly in my experience, patients malinger simply to get food and a safe place to sleep. This is an entirely adaptive response for a hungry, vulnerable, homeless person on a freezing cold night.

As such, people who malinger should treated with kindness and respect. Most are marginalized and suffering. They usually have nothing and nobody to help them. Even if the hospital is not the right place for them to get food and a bed night after night, they deserve our sympathy. Too often they do not receive it. Clinicians who quickly dismiss malingerers may not bother to learn what motivated them to feign symptoms in the first place, and they may miss other ways they can help the person. A referral to a domestic violence shelter or a suggestion that corrections officers transfer an endangered inmate to a safer jail unit can be life-altering. I wish I had been more attuned to this early in my career.

Not everyone agreed with Dr. Tracy’s decision to cancel his talk. A physical therapist named Cameron Tudor wrote,

The reasons you give for cancelling seem to be exactly the reasons why you should give this talk. We need people with specific expertise to help others understand, to shift paradigms. Understanding isn’t advanced with acquiescence and silence.

This is exactly why Dr. Tracy should proudly teach students about malingering.

  • Dr. Jonathan Howard is a neurologist and psychiatrist based in New York City who has been interested in vaccines since long before COVID-19.

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Malingering:  The Lord Voldemort of Medicine