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ULY CLINIC

26 Septemba 2025, 00:38:49

Malingering

Malingering is the intentional exaggeration, feigning, or simulation of symptoms for secondary gain, such as avoiding an unpleasant situation, obtaining financial compensation, gaining attention, or evading responsibilities. It is not a psychiatric disorder, but a behavior observed in various settings.

Pathophysiology

Normal physiology:

Individuals typically experience and report genuine symptoms in response to illness or injury.

Abnormal physiology (malingering):

The individual consciously fabricates or exaggerates symptoms for personal benefit.
Motivations may include:
- Avoiding work, military duty, or legal consequences
- Gaining financial compensation or drugs
- Attracting attention or sympathy
Physical findings are often inconsistent with known pathophysiology, and symptoms may resolve when incentives are removed.

Associated findings: May include inconsistent history, disproportionate complaints, or contradictions between reported and observed abilities.

Examination Technique

Patient history: Carefully evaluate consistency, timing, and plausibility of symptoms.
Observation: Compare reported symptoms with objective findings, functional abilities, and diagnostic tests.
Testing: Utilize psychometric testing, functional assessment, or surveillance when appropriate.
Documentation: Record specific discrepancies, observed behaviors, and any objective evidence suggesting feigned symptoms.

Clinical Features

Feature	Manifestation
Symptom exaggeration	Symptoms disproportionate to objective findings
Inconsistency	History or physical exam varies between visits
Motivation	Obvious secondary gain (financial, legal, avoidance, attention)
Functional behavior	Performance better when unobserved or incentives removed
Onset/Pattern	Symptoms may appear suddenly, often linked to gain

Differential Diagnosis

Condition	Key Feature	Notes
Factitious disorder	Symptoms intentionally produced but for primary psychological gain	Desire to assume sick role, not external reward
Somatic symptom disorder	Genuine distress without conscious fabrication	Patient truly experiences symptoms
Conversion disorder	Neurologic symptoms incompatible with medical findings	Symptoms arise subconsciously
Psychiatric illness	Mood, anxiety, or psychotic disorder	Symptoms may be real, not intentionally feigned

Special populations

Adults:

Most commonly observed in legal, occupational, or compensation contexts.

Children/Adolescents:

May simulate symptoms to avoid school, chores, or punishment.
Careful evaluation is needed to differentiate from normal attention-seeking behavior.

Limitations

Malingering is difficult to prove definitively; requires careful, objective assessment.
Risk of mislabeling genuine patients; always corroborate with evidence.
Ethical and legal implications exist; must document findings accurately.

Patient counseling

Direct confrontation should be avoided unless evidence is clear.
Emphasize assessment and treatment of actual conditions, while monitoring for secondary gain behaviors.
Encourage honest reporting of symptoms and discuss consequences of fabrication in appropriate contexts.

Conclusion

Malingering is the intentional fabrication or exaggeration of symptoms for external gain. Careful observation, objective testing, and corroboration are required for identification, enabling appropriate management and preventing unnecessary interventions.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.
Resnick PJ. Malingering: Theoretical and clinical overview. Psychiatr Clin North Am. 1997;20:179–195.
Rogers R. Clinical Assessment of Malingering and Deception. 4th ed. New York: Guilford Press; 2020.
Bianchini KJ, Schacter DL. Behavioral and cognitive markers in malingering. J Forensic Psychol Pract. 2018;18:53–72.