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Etiology
Malingering has no specific etiology, but the causes include socio-economic
conditions. It is commonly reported among prisoners avoiding trial, students avoiding
school, workers avoiding work, homeless hoping for economic compensation/rations.
Drug abusers commonly fake sickness, painful conditions, or insomnia to receive
drugs of abuse including opioids such as nalbuphine, benzodiazepines, among others.
Malingering is reported in people trying to avoid military service. It has a close
association with an antisocial personality disorder and histrionic personality trait.
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Epidemiology
The prevalence of malingering is difficult to determine. In an estimate of malingering
in forensic populations, prevalence reached 17%. In another study conducted
by Department of Psychology, the University of New Orleans, 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. There have been
efforts to determine the frequency of malingering in populations, but the reliability of
those sources is questionable. Although it is presumed that the frequency of
malingering is higher in females than males, there is no data to back up this
presumption.
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Pathophysiology
Malingering is associated with an anti-social personality disorder and histrionic
personality trait. To get an external (secondary) gain, the individual fakes an illness
that can be of physical or psychological nature. The patient consciously lies about his
or her condition to get a benefit, and upon achieving the benefit, they stop
complaining. No medicine or intervention can cure malingerers. Upon detailed
history, the malingerer may exhaust their excuses and give up.
DSM-5 states that if any combination of the following 4 complains is present in a
patient, then malingering should be considered.
1. The medicolegal context of the presentation, for example, a lawyer sending his
client for evaluation or patient presents with an illness while facing trial
2. Marked discrepancy between the individual's "claimed stress or disability" and
"objective finding and observation"
3. Lack of compliance with diagnostic evaluation, treatment regimen and follow
up care
4. Presence of anti-social personality disorder
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Evaluation
The diagnosis of malingering is based on history, physical exam, and psychological
tests. No diagnostic laboratory tests are available to diagnose malingering. Laboratory
studies are, however, useful to exclude organic cause and genuineness of illness.
These laboratory studies might include the following:
Complete blood cell (CBC) count
Serum electrolytes.
Renal function tests
Liver function tests (LFTs)
Blood alcohol level
Blood and urine toxicology screen (may also rule in malingering in case of
drug abusers seeking opioids)
Computed tomography (CT) scanning or magnetic resonance imaging (MRI)
of the brain should be considered to rule out organic brain disorders
Other tests:
The Minnesota Multiphasic Personality Inventory (MMPI)
The F-scale
Test of memory malingering
The negative impression management scale
Rey 15-item test
The temporal memory sequence test
Symptom and Disposition Interview (SDI)
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Treatment / Management
Do not confront the patient directly. Do not question the beliefs of the patient. Do not
accuse the patient of feigning his or her illness. Patient-doctor conflict, a lawsuit
against the doctor, and violence may result. Rather confront the patient
indirectly. Offer a scientific explanation but do not deny the beliefs of the patient.
Invasive diagnostics and interventions ought to be avoided as their harm outweigh
benefits. The physician can help by encouraging:
Behavioral therapy
Psychotherapy
Counseling
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Differential Diagnosis
1. Organic cause of the disease. Organic disorder, any physical illness must be
ruled out before considering malingering.
2. Conversion disorders. Look for stressors and incentive.
3. Factitious disorder, for example, Munchausen syndrome; Differentiate
between primary and secondary/external gain.
4. Hypochondriasis
5. Somatic symptom disorder
6. Psychosis, schizophrenia (thought disorders)
7. Depression, mania (mood disorders)
8. Dissociative disorders
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Prognosis
Prognosis is unpredictable. Generally, the malingerer keeps on malingering until his
incentive/external gain is fulfilled.
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Complications
If the demands of a malingerer are denied, then the subject may show aggressive
behavior which may result in an offensive conflict. The doctor may face a lawsuit.
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Consultations
Malingerer usually avoids psychiatric consultation. Referral to another physician is
not advised.
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