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Factitious disorders 2
Factitious disorders and malingering: challenges for clinical
assessment and management
Christopher Bass, Peter Halligan

Lancet 2014; 383: 1422–32 Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent
Published Online on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient’s
March 6, 2014 medical record. Management of such disorders ideally requires a team-based approach and close involvement of the
http://dx.doi.org/10.1016/
primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important
S0140-6736(13)62186-8
implications for young children, particularly when identified in women and health-care workers. Malingering is
See Online/Comment
http://dx.doi.org/10.1016/ considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded
S0140-6736(13)62640-9 as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can
See Online/Series inform the detection of illness deception, such tests need support from converging evidence sources, including detailed
http://dx.doi.org/10.1016/ interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of
S0140-6736(13)62183-2 abnormal health-care-seeking behaviour is the extent to which a person’s reported symptoms are considered to be a
This is the second in a Series of product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically
two papers about factitious
disorders
sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual,
developmental, and management frameworks to understand and deal with patients whose symptoms appear to be
Department of Psychological
Medicine, John Radcliffe simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs
Hospital, Oxford, UK used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased
(C Bass FRCPsych); and School appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings
of Psychology, Cardiff
University, Cardiff, UK
from social neuroscience, occupational health, and clinical psychology.
(Prof P Halligan DSc)
Correspondence to: Introduction First, although factitious disorders and malingering are
Dr Christopher Bass, Department Abnormal health-care-seeking behaviour covers a both clinically significant, deception is a pervasive,
of Psychological Medicine, multitude of clinical and non-clinical behaviours normal, and ubiquitous social behaviour of human
John Radcliffe Hospital,
ranging from symptom exaggeration to deliberate nature.6 Second, abundant evidence exists to show that
Oxford OX3 9DU, UK
christopher.bass@ feigning.1–4 In this Review, we focus on abnormal health- people (both patients and doctors) frequently engage in a
oxfordhealth.nhs.uk care-seeking behaviours that include simulation range of deceptive behaviours outside medical symptom
(factitious disorders and malingering) and propose that appraisal and for various reasons.4,7,8 Third, the DSM
standard use of these terms in psychiatric classifications diagnosis of a factitious disorder has little clinical validity.9
such as the Diagnostic and Statistical Manual of Mental Precisely what impairment to normal mental functioning
Disorders (DSM)5 has not kept abreast of conceptual justifies defining the intentional fabrication of illness
and psychological advances. In line with our clinical symptoms as a mental disorder in its own right is unclear.
focus, we consider non-medical explanations, in Fourth, evidence that factitious disorders and malingering
particular the neglected part that volitional and behaviours tend to be episodic, situation specific, and
motivational factors can play. As such this Review highly dependent on selective interactions with medical,
departs from previous accounts by not explicitly social, or legal professionals suggests that they are not
endorsing the standard medical glossary definitions of clinical states, but rather discrete “behavior governed by a
factitious disorders, and questions the use and cost–benefit analysis.”10 Fifth, from a clinical and
legitimacy of deception as a special form of mental diagnostic perspective, it seems unlikely that most
disorder for several reasons. clinicians can reliably and consistently extricate the
contributory role of deception and hence distinguish
factitious disorder and malingering.11 Sixth, the diagnosis
Search strategy and selection criteria of factitious disorders (and compensation neurosis)
We searched PsycINFO via Health Databases Advanced Search appear to have been largely created as a way of bridging or
on the UK National Health Service evidence website from linking diagnoses between unconsciously mediated
Nov 11, 2012, with the terms “FACTITIOUS DISORDERS”, OR psychiatric disorder and consciously mediated malin-
“MUNCHAUSEN SYNDROME”, OR “MALINGERING”. We gering.9,12 Seventh, many existing psychiatric accounts of
limited our search to English-language articles published abnormal health-care-seeking behaviour underestimate
from 2000. We did a final search of PubMed on May 30, 2013, the contribution of non-medical deception,13 and without
with the terms “factitious disorder” and “malingering”. explicit consideration or exploration of the potential
part played by volitional choice, meaningful discussion of

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abnormal health-care-seeking behaviour is always going
to be scarce. Eighth, this holistic approach should not
be taken as denying or mitigating the reality or distress
of illness as subjectively experienced by many patients with
medically unexplained disorders, but rather provides a
rationale for alternative explanations and treatments.
When trying to distinguish between factitious disorders
and malingering, we emphasise the role of context and a
well-documented evidence trail. Most research on
malingering takes place within specific legal contexts or
when a patient attempts to evade punishment in the
criminal justice system, seek damages through personal
injury litigation, or gain financial compensation, whereas
factitious disorders are generally encountered in clinical
settings.
Controversies and diagnostic dilemmas in
psychiatric classifications
The biomedical justification underpinning many
psychiatric disorders included in DSM and the
International Classification of Diseases still has not been
established.14 The quest for a medically acceptable
diagnosis has resulted in the growth and clinical use of
various aetiologically agnostic, diagnostically ambivalent
descriptors. However, once a diagnosis has entered
general use it tends to become reified and assumed by
many to be a valid entity that need not be questioned.15 In
many cases these disorders are described by what they
are not, rather than as illnesses in their own right.16
Attempts to relocate factitious disorders into more
established psychiatric categories confirm their weak
conceptual underpinnings. Some investigators have
suggested that factitious disorders should be considered
as a variant of somatoform disorders.17 The DSM-5 even
includes the suggestion that factitious disorders be
recategorised as somatic symptom disorders with two
types: factitious disorder imposed on self and factitious
disorder imposed on the other (panel 1). Neither
revisions acknowledge the contribution of an individual’s
consciously mediated choice in the presentation.4
However, in the case of suspected factitious disorder,
some have argued that more objective evidence—eg,
abnormal pathological findings—should be actively
secured.18
The situation with malingering is, if anything, even
more unsatisfactory. Although the neuropsychological
literature on malingering has expanded in the past
30 years, the section describing malingering in the DSM
has barely changed since 1980 and has not been updated
in DSM-5.19 This failure to update the criteria in
DSM-5 ignores relevant research on the topic,20 and led
Berry and Nelson to write that “the evolution of symptom
validity and malingering literature in recent decades has
culminated in a sophisticated conception of malingering
that essentially renders DSM-IV-TR criteria obsolete.”19
This occurrence should come as no surprise to most
psychiatrists because neither of the established medical
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Series
and psychiatric glossaries5,21 presently consider malin-
gering to be a valid diagnostic term and a legitimate
behaviour about which a medical opinion can be
expressed, other than by exclusion.
Detection of malingering consequently remains
difficult, largely because of the late development of an
empirical social neuroscience of deception22 and the
understandable reticence and absence of confidence of
many doctors to consider or explore the possibility that
patients could or would use deceptive behaviours to
influence their clinical presentation. Well publicised
cases have shown how easily the appearance of severe
illness is to simulate.23,24 Evidence suggests that
psychologists and psychiatrists are often no better at
detecting lies than are other professionals or the lay
public,25 and that physicians can be easily deceived—eg,
by patients with chronic pain.26
Evidence also shows that recognition of the frequency
of simulation remains largely a function of experience
and predisposing attitudes of the observer.27 For example,
findings from a study of simulated presentations showed
that neurologists preferentially diagnosed factitious
presentations in nurses as hysterical, presumably to avoid
the stigma associated with the suggestion that symptoms
might have been simulated.28 The disincentives presented
to clinicians to establish a diagnosis of malingering are, if
anything, more stark than those for factitious disorders.29
In dealing with these clinical presentations, key concepts
such as abnormal illness behaviour and the sick role
should be understood, as should the contribution of
societal and motivational factors.
Concept of the sick role and abnormal illness
behaviour
A close association exists between illness behaviour in
some patients and the potential benefits that society
provides for the sick role.30 The sick role is a partly and
conditionally legitimated state, which might be desirable
because of the advantages and potentially socially
mediated secondary gains.31 Notably, “despite a reduction
Panel 1: Diagnostic and Statistical Manual, fifth edition,
criteria for factitious disorder, code 30019 (International
Classification of Diseases-10 code F6810)
Factitious disorder imposed on self
1 Falsification of physical or psychological signs or symptoms,
or induction of injury or disease, associated with identified
deception
2 The individual presents themself to others as ill, impaired,
or injured
3 The deceptive behaviour is evident even in the absence of
obvious external rewards
4 The behaviour is not better explained by another mental
disorder, such as delusional disorder or another psychotic
disorder
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in disease (pathology) and an improvement in our ability
to cure or reduce disease, sickness is rising.”32 In
particular, society more readily accepts physical disorders
as acceptable entries into the sick role than they do
psychological or emotional disorders, or difficulties
coping with and adapting to life’s troubles.32
The determinants of illness behaviour are multifactorial
and are dependent on a person’s previous illness history,
family influences, developmental factors, and present
beliefs about illness and resources.32 A scale for
measuring illness behaviour has been devised,33 and
evidence shows that the way a patient views his or her
illness can have a powerful effect on outcome,34 with
organic causal beliefs being associated with a need for
diagnostic tests and adverse health outcomes.35
Developmental factors
Investigators have argued that chronic somatoform
disorders should be regarded as a disorder of
development, because of the young age of onset, the
enduring nature of the syndrome, and the finding that
more than two-thirds of patients meet the criteria for a
personality disorder.36,37 In a study of 20 patients with
Panel 2: Clinical characteristics that might alert a physician to a diagnosis of fabricated
illness (adapted and modified from reference 48, by permission of American
Psychiatric Press)
• The patient has sought treatment at various different hospitals or clinics
• The patient is an inconsistent, selective, or misleading informant; he or she resists
allowing the treatment team access to outside sources of information
• The course of the illness is atypical and does not follow the natural history of the
presumed disease—eg, a wound infection does not respond to appropriate antibiotics
(self-induced skin lesions often fall into this category, when atypical organisms in the
wound might alert the physician)
• A remarkable number of tests, consultations, and medical and surgical treatments have
been done to little or no avail
• The magnitude of symptoms consistently exceeds objective pathology or symptoms
have proved to be exaggerated by the patient
• Some findings are discovered to have been self-induced or at least worsened through
self-manipulation
• The patient might eagerly agree to or request invasive medical procedures or surgery
• Physical evidence of a factitious cause might be discovered during the course of
treatment—eg, a concealed catheter or a ligature applied to a limb to induce oedema
• The patient predicts deteriorations or there are exacerbations shortly before their
scheduled discharge
• A diagnosis of factitious disorder has been explicitly considered by at least one
health-care professional
• The patient is non-compliant with diagnostic or treatment recommendations or is
disruptive on the unit
• Evidence from laboratory or other tests disputes information provided by the patient
• The patient has a history of work in the health-care field
• The patient engages in gratuitous, self-aggrandising lying
• The patient has been prescribed (or obtained) opiate drugs, often pethidine or
morphine, when this drug is not indicated
• While seeking medical or surgical intervention, the patient opposes psychiatric assessment
1424
factitious disorders involved in litigation, 12 (60%) had
suffered a childhood illness and more than half a
childhood loss.38 Accounts of patients with factitious
disorders note that many are motivated by developmental
factors, including a desire to maintain the sick role, to
deceive health-care professionals, and to obtain
attention.39
In terms of developmental theory, deceptive behaviour
becomes evident in non-verbal ways in children younger
than 5 years, and children’s capacity to deceive
subsequently becomes more complex and better
developed. Deception and the development of deception
across the lifespan has been studied with use of an
information-processing methodology,40–42 and more
recently, a social neuroscience approach43 that enables
researchers to assess distortions in information
processing, and to identify the brain systems engaged by
deception.
Deliberate or tactical deception is so common in
human social interactions that some researchers have
suggested that human brains are innately primed to
deceive, and that deception happens early in life in a
predictable way.6 This view is supported by the
developmental psychopathology perspective by which
attachment strategies that use deception are adaptive in
disorders characterised by complexity.42
Factitious disorders
Epidemiology
As traditionally defined, factitious disorders are fairly
uncommon, but likely to be underdiagnosed, with
prevalence estimates ranging between 0·5% and 2%.44,45
Evidence shows that US physicians feel more comfortable
diagnosing conversion disorders than they do other
somatoform and factitious disorders, and that as a result,
the latter disorders are diagnosed far less frequently than
published prevalence and recognition rates suggest.46 In
a survey done in an occupational medicine setting in the
UK, 8% of 400 patients displayed behaviour that was
consistent with illness fabrication.47
Clinical features
Clinical features of factitious disorders remain diverse
(panel 2).48 Most patients are likely to be socially conforming
young women with stable social networks who present to
general hospitals in their mid-30s. In some of these
women, the self-induced illnesses begin in adolescence,49
and prevalence rates in adolescent consultation-liaison
services are similar to those noted for adults.50,51 As many
as one half of these patients work in health-related
occupations.52
Studies including a heterogeneous case series suggest
a typology that includes: (a) a dramatic, deceptive,
hostile, sociopathic wandering type, mostly male
(Munchausen’s syndrome as described by Asher53),
comprising about 10% of cases and becoming
increasingly rare;12 (b) self-induced infections, mainly
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chronic or acute on chronic, largely female; (c) wilful
interference with chronic wounds and cutaneous ulcers;
and (d) a group simulating disorders by falsification of
data and fabrication of signs, symptoms, and
physiological disturbances.54,55 Many patients have had
childhood adversity and have coexisting chronic and
complex somatoform disorders.56,57
Fabricated disorders that include the arm and hand
have been described,58 and a large series included
four clinical categories—psychopathological dystonia,
factitious oedema, psychopathological complex regional
pain syndrome, and factitious wound creation and
manipulation.59 Detailed review of medical notes often
identifies the tell-tale signs of simulation in childhood
and adolescence. Close enquiry and careful examination
of medical records (table) often shows an unexpectedly
large number of childhood illnesses and operations,
high rates of substance abuse, mood disorder, and
personality disorder that collectively confirm complex
histories, which might not be readily disclosed at
interview.38
Some patients exploit the internet to misrepresent
themselves with various diseases.60 So-called electronic
factitious disorder is a term used to describe patients who
falsify their electronic medical records to create a
factitious report (eg, cancer).61 A further group is
encountered in pregnancy, and these cases clearly have
great implications for child protection.62 All clinicians

Attendance or referral Symptoms and precipitants Tests and investigations Outcome and plan Key events
1986 Hospital A admission Right flank pain Normal laparoscopy Non-specific abdominal pain Death of father
(age 12 years)
1987 Hospital A admission Overdose of analgesics .. Referred to social worker; patient stealing Arguments with
(age 13 years) money from mother mother
1990 Hospital B admission Inhalation of smoke from fire Normal blood tests Self-discharged Set fire to house;
(age 16 years) after fire setting pregnant
1991 Neurology outpatient Episodes of loss of consciousness Normal EEG and CT scan; Reassured no organic cause ..
(age 17 years) services (B) and muscle twitching normal blood tests
1991 Emergency admission to Right-sided abdominal pain Normal radiograph Admitted for observation; self-discharged ..
(age 17 years) general surgery (A) against medical advice
June,1992 Gynaecology outpatient Claims to be pregnant Normal pregnancy test “She lied to the registrar, saying that she had ..
(age 18 years) clinic a positive pregnancy test when she had been
told by the GP [general practitioner (family
doctor)] that she was not pregnant”
October, 1992 Emergency admission (A) Overdose of paracetamol in Noted abscess on right breast Worried about scarring on right breast; Grandfather ill
(age 18 years) context of excess alcohol dermatologist considered possibility of
artifactual skin disorder
1993 Ear, nose, and throat Episodes of haemoptysis Normal direct laryngoscopy Followed up in psychiatric outpatients clinic; ..
(age 19 years) outpatient clinic (C) possibility of personality disorder considered
1993 General medicine outpatient Unexplained septicaemia Isolated blood culture of “Given these findings we feel that there has Boyfriend of 2 years
(age 19 years) clinic (B), with subsequent saprophytic organisms not usually been deliberate introduction into the body has left her
admission associated with the cause of sepsis of material from an environmental source”
in the immunocompetent patient
1994 Gynaecology outpatient “Told me she had been sterilised” Fallopian tubes patent “When I obtained her notes and showed ..
(age 20 years) clinic (B) her this she decided to self-discharge”
1995 Neurology outpatient clinic Recurrent blackouts and odd All investigations normal Diagnosis of psychogenic non-epileptic ..
(age 21 years) on second opinion (C) movements since age 17 years (video telemetry) seizures
1995 Psychiatric outpatient clinic Patient denies that non-epileptic Cognitive behavioural therapy Demands to be kept on carmazepine despite Drinking a bottle of
(age 21 years) seizures are related to emotional not helping advice to taper drug vodka every day
problems; attends clinic with
crutches
1996 Emergency admission Pain in right forearm after Substantial soft tissue injury with Currently an inpatient on local psychiatric Child born
(age 22 years) orthopaedics repeatedly punching wall swelling but no fracture ward; follow-up by mental health team
1996 Admission orthopaedics (D) Infection right wrist; demanding No positive cultures; “Birefringent Planned supportive confrontation; patient ..
(age 22 years) oromorph particles found consistent with self-discharged; family doctor and psychiatric
foreign material in a distribution team informed
incompatible with wound-care
procedures”
1996 Paediatric outpatient Worried about 1-year-old son Investigations unable to detect Patient requesting disability living allowance Case conference
(age 22 years) clinic (B) with 3 month history of any relevant organic cause for son; asking how to hire a wheelchair for convened by social
“shaking episodes” herself services at surgery of
family doctor

Data anonymised for patient confidentiality. A, B, C, and D represent four different hospitals.

Table: Chronology of a 22-year-old composite female patient with factitious disorder

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Panel 3: Constructive confrontation—preparation and
process (for non-psychiatrists)
• Collect firm evidence of fabrication (eg, catheter, syringe,
ligature)
• Discuss with psychiatrist (or member of hospital legal team
if no psychiatrist available)
• Arrange meeting to collate the facts, devise strategy, and
discuss with primary care doctor
• Confrontation with the patient should be non-judgmental
and non-punitive, and should include a proposal of ongoing
support and follow-up
• Discuss the outcome of the confrontation with the primary
care doctor
• If the patient is a health-care worker the doctor should
discuss with a member of their defence organisation
• Document a full record of the meeting and its outcome in
the patient record
should be alert to the potential onward effect when such a
diagnosis is made in women with young children.63
Assessment
Medical notes should, ideally, be always read in advance
of interview, and any apparent inconsistencies noted for
specific enquiry. General practice notes can be crucial,
and should be obtained, if possible, and read in detail.64
Longitudinal contemporaneous medical records provide
a substantial resource in assessment of such patients,
and documentation of a chronology with dates,
complaints, and medical outcomes proves invaluable
(table), particularly when a team approach is involved.
Management
Management of factitious disorders includes acute
management in inpatient settings, which could be an
emergency room or an inpatient infectious diseases unit,
or the longer-term process of attempting to engage the
patient in some form of psychotherapy or at least harm
reduction.18 The key to successful management in both
phases requires negotiation and agreement of the
diagnosis with the patient and engagement of that patient
with treatment. No robust research evidence is available to
support the effectiveness of a management strategy for
factitious illness; however, a systematic review recom-
mended the establishment of a central reporting register
to aid development of evidence-based guidelines.65
Initial concern about the possible presence of factitious
disorders is typically raised by non-psychiatrists, who
might wish to involve a psychiatric colleague in a
discussion of the diagnosis with the patient, a process
sometimes described as supportive confrontation.66 This
process needs careful preparation (panel 3). Supportive
confrontation should involve at least two members of
staff, with an emphasis on the patient being a person
who needs help, with the assurance that care will
1426
continue.49 Some patients will interpret confrontation as
humiliating and seek care elsewhere, or will lodge
complaints or escalate their self-destructive behaviour; as
such, a more nuanced approach might be preferable.18
However, saving face and harm minimisation are key
management elements. Improved outcomes have been
reported with a multidisciplinary team incorporating
elements of both medical and psychological support.67
Diagnosis of a factitious disorder in a health-care worker
will have important implications for their future
employment, and the person’s registering body might
need to be contacted. This contact is best made after
consultation with the hospital legal department.
Course and prognosis
Patients often drop out of follow up, especially after the
diagnosis of a factitious disorder has been raised as a
possibility. Consequently, prospective studies are rare and
the course of the disorder is difficult to ascertain. Evidence
from large case series suggests that, typically, patients are
first identified in their mid-30s,49,52,54,55 and that the course
is variable and can include a chronic and enduring
pattern of fabrication or a life punctuated by episodes that
might or might not progress to a more chronic pattern.55
These groups might include unfortunate victims of
fabricated or induced illness maltreatment in childhood68
who continue their simulations into adult life. Findings
from a published series52 showed that three-quarters of
the patients were confronted, but only one in six acknow-
ledged that their illness was self-induced; 12% agreed to
have psychiatric treatment, but the outcomes were not
published.
Recovery from chronic factitious disorder is rare69,70 and
largely unknown because many patients understandably
drop out of follow-up. Furthermore, factitious disorders
are associated with substantial morbidity and mortality,
and this risk seems to be increased when litigation is
involved, whereby the need to obtain judicial
endorsement of the presence of an illness might be
increased.71 Case reports of suicide have confirmed that
deceptive behaviour does not preclude the presence of
serious psychopathology.72 The enormous economic
burden these patients impose on the health-care system
has been extensively documented.73
Ethical and legal matters
Obtaining clinical notes is crucial, but if the patient does
not sanction this request, doctors are left with a dilemma.
Such access difficulties further prevent the optimum
management of these patients. Physicians who disclose
information to third parties without patient consent might
have to justify the decision to their licensing body, and for
this reason, doctors should have a low cutoff point for
contacting their defence organisations.
Evidence has shown that indication of simulation can
be identified by doctors using electronic searches of
health records.74,75 Although legal and ethical questions
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can arise from such searches,76,77 such a search might be
warranted to establish a diagnosis of deception when
done within the ethical guideline of beneficence (ie, to
prevent iatrogenic disease), preferably in conjunction
with a colleague from the hospital legal department.
Plastic surgeons should be aware that they can be sued
for malpractice by patients with factitious disorders.78
Malingering
Definition and conceptual issues
Malingering is not a formal medical diagnosis and there
continues to be little agreement about its definition.79
Additionally, many neuropsychologists conceptualise
malingering in probabilistic rather than dichotomous
terms,80 and perceive feigning of physical symptoms as
dimensional and episodic rather than categorical.81
Although the DSM makes clear that malingering is not a
psychiatric disorder, the most commonly quoted
definition of malingering is probably from the American
Psychiatric Association,82 namely that the disorder
involves “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”. We have described the shortcomings of
this definition above.19,20
One issue with malingering is that despite falling
outside the remit of all recognised psychiatric
authorities, many clinicians have difficulty avoiding the
temptation to medicalise the illness. In an effort to
retain medical involvement in the growing number of
medically unexplained disorders, new disorders such as
compensation neurosis”83 and factitious disorders were
introduced into mainstream psychiatric nosologies in
the 20th century. Common to both malingering and
factitious disorders is the requirement of doctors to
ascertain, during a clinical interview, the motivations
and level of conscious awareness that accompany
symptoms reported by patients.4 As a neuropsychological
concept, the assessment of malingering generally
involves both exaggeration and poor effort, although it
has been claimed to be present with only one of these
being accurately detected.80
In recognition that all such disorders are best viewed as
existing on a continuum, the conceptual overlaps and
potential for confusion are evident when considered in
terms of motivation and symptom exaggeration83 or
between attributed intention and subject responsibility.8
The figure shows both models. Malingering has been
conceptualised in three categories: pure, when non-
existent clinical problems are feigned; partial, when
actual symptoms are exaggerated; and false imputation,
which refers to the deliberate misattribution of actual
symptoms to the compensable event. Exaggeration of
symptoms is generally assumed to be more common
than outright faking.84
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Epidemiology
Prevalence estimates of symptom exaggeration are
understandably difficult to estimate and vary according
to the setting and criteria adopted.85 In social security
disability examinations undertaken in the USA, the
prevalence of symptom exaggeration in claimants has
been estimated to be between 46% and 60%, with use of
symptom validity tests.86 Members of the American
Board of Clinical Neuropsychology reported rates of
symptom exaggeration in 29% of cases of personal injury,
in 30% of disability or workers compensation referrals,
in 19% of criminal cases, and in 8% of medical or
psychiatric cases (statistically adjusted to remove for the
effect of referral source).87 The same rates categorised by
diagnosis showed that 39% of cases were for mild head
injury, 35% were fibromyalgia and chronic fatigue, 31%
were chronic pain, 15% were depressive disorders, and
11% were dissociative disorders. Prevalence of symptom
exaggeration is highest in compensation or litigation
settings, but notably, most compensation claimants
(75–90%) respond well to treatment, recover from illness
or injury, and return to work.85
A
Choice
Deception
Intentional
Malingering
Exaggeration
Psychiatric or
psychosocial
disorder
Non-
intentional
Exculpated
Responsibility
B
Change in motivation going from internal
at the bottom to more external at the top
Malingering
Compensation
Conversion disorder neurosis
(DSM-5 functional Factitious disorder
neurological disorder)
Range of level of intentional symptom production increasing from left to right
Figure: Two models of illness deception (A)8 and compensation neurosis (B)83
Reproduced by permission of Sage Publications (A) and American Psychiatric Press (B). Diagrams show the
potential roles of patient choice, intentions, and motivation in symptom production and, ultimately, diagnosis.
DSM-5=Diagnostic and Statistical Manual of Mental Disorders, fifth edition.
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Assessment
The cornerstone of detection as opposed to diagnosis of
malingering is the well-prepared clinical interview, having
reviewed available documents and, when available,
forensic materials. A conclusion of malingering typically
needs multiple sources of converging evidence and the
systematic ruling out of probable alternative explanations.88
For the interview, plenty of time and a neutral and
supportive attitude are essential. A biographical and
developmental approach is recommended, starting from
childhood and working through the personal history to
the index event and thenceforward to the present time.
Most UK residents are registered with a primary care
doctor, which allows for a longitudinal health record.
Medical records potentially constitute an invaluable
resource and provide objective evidence of reported
complaints and clinic attendances that help to elucidate
the association between an accident or injury and any
subsequent symptoms attributed by the patient to the
putative causal event. For example, doubts could arise if
there was a very long gap between an accident and the
start of consultations for a health problem (ie, the
symptoms did not materialise logically from the incident
in question). A chronological summary often pays
dividends in the assessment of health documents (table).
Special investigations are another method of detection.
Probably the most widely encountered technique is video
surveillance, which is typically provided by the insurance
companies or lawyers. Video surveillance usually
provides information about the physical abilities of the
claimant. Marked or unexpected differences between the
claimant’s observed behaviours and what they claim not
to be able to do can raise doubts as to the credibility of
their report. Experience and tradition in various
specialties have resulted in different clinical techniques
being used to help to assess the validity of clinical
presentations. Patterns of muscular weakness might be
used by neurologists and orthopaedic surgeons and
others as indicators of the genuineness or otherwise of
clinical presentations.89,90 Several motor tasks have been
examined and grip strength measured with a hand
dynanometer seems to be a good indicator of poor effort.91
A finger-tapping task has also provided useful
information in personal injury claimants.92
In the past two decades, clinical psychology and
neuropsychologists have developed psychological tests
that have been claimed to provide a more precise
assessment of the credibility of verbally claimed symptoms
than other assessment methods. In this context symptom
validity refers to the accuracy or veracity of a person’s
behavioural presentation, self-reported symptoms, or
performance on neuropsychological tests.93,94 Symptom
validity tests typically comprise a simple memory or
recognition task on which a wide range of people with
neurological or psychiatric problems can achieve near-
perfect performance.95 The basic premise underlying this
approach is that a finding of below-chance (ie, <50%)
1428
performance in a forced-choice test suggests a voluntary
endorsement of incorrect answers,96 and considered by
some as tantamount to confession of malingering.97 The
importance of these tests has been stressed by professional
bodies and guidelines.98
Among the best-studied self-reported symptom validity
tests used in chronic pain populations is the test of
memory malingering,99 the word memory test,100 and the
Portland digit recognition test.79 When several symptom
validity tests are used in combination, the likelihood that a
malingerer will go undetected is greatly reduced.101 Other
techniques that allow for the objective detection of feigned
symptoms include validity scales from the Minnesota
Multiphasic Personality Inventory-2,79 the Personality
Assessment Inventory,98 and the Psychological Screening
Inventory.19 The structured interview of reported
symptoms has been used in samples of patients with
mental disorders.102 Investigators have persuasively argued
that no evidence exists to support the view that psychiatric
disorders, such as somatoform and dissociative disorders,
lead to failure on symptom validity tests per se, and in
view of this point, the patient’s self-reported symptoms
and life history can no longer be accepted at face value.103
Types of clinical presentations
Post-traumatic stress disorder
Many clinical disorders can be simulated,4 but in this
section, we discuss three of the more common disorders:
post-traumatic stress disorder, brain injury, and chronic
pain. Well attested examples of non-genuine post-
traumatic stress disorder have been published,104–106
possibly because the diagnosis is based almost entirely on
the individual’s subjective report of symptoms.107 Striking
positive symptoms such as nightmares and flashbacks are
more readily elaborated than are more subtle features,
such as depression.108 Evidence from the USA suggests
that malingering of post-traumatic stress disorder in the
military is a huge problem.104
Comprehensive assessment is crucial. In a prospective
study of patients claiming post-traumatic stress disorder,
70% showed negative response bias on at least one
symptom validity test, and 25% did in all three tests.109
Neuropsychologists stress the importance of use of
various methods for assessment of possible response
distortion, and of the establishment of whether the
trauma reported satisfies a proportional reaction.110
Brain injury
Brain injury is a common subject in personal injury
litigation, and 15–30% of patients with mild traumatic
brain injury report the presence of continuing non-
specific symptoms such as distress, headache, and
cognitive problems, collectively described as post-
concussional syndrome.111 There is also the complication
of an association between patient concern (ie, expectations)
that symptoms will have adverse consequences, and the
reporting of major and enduring complaints.112,113
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In medicolegal settings, clinical neuropsychologists
have been encouraged to assess motivation and effort
with use of both separate and embedded effort measures
throughout an assessment of a patient with a mild
traumatic brain injury.96,98,114 A frequent finding in the
scientific literature on symptom validly tests is that
patients with mild traumatic brain injury (especially
those seeking compensation) do worse on cognitive tests
than do those with moderate or severe brain injury.115
This finding confirms Miller’s formative finding that
many patients’ fabricated memory and other cognitive
symptoms are in inverse proportion to injury severity
and only resolve with receipt of compensation.27
Somatoform disorders, chronic pain, and whiplash
neck injury
Chronic pain is common and 10% of people surveyed
report some disability associated with chronic pain.116 In
the UK, whiplash neck injury is regarded as a public
health problem, accounting for double the proportion of
personal injury claims as other countries in Europe.117
Research in whiplash has shown the importance of
patient beliefs and expectations,118 and the role of
perceived injustice in the establishment of occupational
disability,119 suggesting that a patient’s expectations about
getting better and negative psychological outlook are just
as important as the physical symptoms.120
In medicolegal settings the proportion of patients with
a diagnosis of somatoform, dissociative, or pain disorders
who show negative response bias is substantial and can
amount to at least a third.87 The clinical practice of
diagnosis of medically unexplained symptoms or
dissociative disorders without attempts to exclude
malingering (or factitious disorders) as alternative
explanations could result in gross overdiagnosis,
especially in litigating populations and in patients
seeking other forms of external gain.103
The challenge of pain assessment in contexts of
secondary gain is formidable, and malingered pain-related
disability has been described.101,121 Fibromyalgia and
chronic regional pain syndrome type 1 have attracted
attention in the past few years, especially because
psychological factors or so-called yellow flags122 have been
shown to be key determinants of pain intensity and
disability. Many patients with fibromyalgia who seek
disability benefits fail effort tests.123 Moreover, performance
on validity testing and disability status is associated with
exaggeration of non-cognitive symptoms such as pain,
sleep, and fatigue in people with fibromyalgia.124
The phenomenon of complex regional pain syndrome
type 1, once known as reflex sympathetic dystrophy, can
arise after injury to a limb.125 The disorder is diagnosed
on the basis of non-specific, often subjective, criteria,
some of which, including skin temperature, weakness,
and colour differences between limbs, can be produced
and maintained by short-term immobilisation and
dependency of the limb.126 Diagnosis of complex
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Series
regional pain syndrome type 1 is controversial, in view
of claims of overdiagnosis in medicolegal settings,127
and in the UK this disorder seems to have displaced
another non-specific disorder—repetitive strain
injury.128 Iatrogenic complications129 and self-induced
symptoms have been reported,130 and in a survey of
73 patients with complex regional pain syndrome
type 1, incentivised by disability-seeking contexts, at
least three-quarters failed one performance validity
indicator.131 Doctors need to be especially cautious when
they encounter this diagnosis.132
Management
Patients with mild traumatic brain injury are most likely
to present with symptom validity failure, exaggeration,
or malingering, or all three,87 and feedback of test results
has been most systematically studied in this group.133 A
feedback model has been described that involves
building of rapport with the patient, exploring of the
reasons for poor effort and acknowledgment of possible
task disengagement, establishment of the potential
reasons for exaggeration, and discussion of other factors
that can underlie symptom persistence. Evidence has
shown that after confrontation two-thirds of patients
from a non-forensic sample produced valid scores on
subsequent re-examination, suggesting that this inter-
vention can be helpful.134
Prognosis and outcome
The prognosis for malingering in personal injury
litigants is unknown, but clinical experience suggests
that patients with longstanding disability, even if partly
or wholly non-organic, do not always recover after
settlement.135 Improvement after settlement can take
place for many reasons, including less stress and
uncertainty in the litigant’s life because they are no
longer involved in an adversarial system in which their
reputation is under scrutiny and they have to prove their
injury.82 However, convincing evidence exists to show
individuals involved in litigation for financial rewards to
compensate pain and suffering after a road traffic
accident do not recover as quickly as those with similar
injuries who are not litigating.136
Conclusions
Although specialists generally agree that malingering
and factitious disorders describe a cluster of illness-
related symptoms that include differential degrees of
simulation, controversy and debate continue about the
best way to frame, explain, and manage these behaviours.4
Central to this debate is the model of illness adopted.137
Unlike the traditional biomedical model, the expanded
WHO International Classification of Functioning model
should be considered in view of its focus on the person
and not the disorder as central to defining health and ill
health.138 Consequently, if illness as an experience is
attributable to the person, and not just to their body, then
1429
 Series
key characteristics of being a person might contribute to
the emergence and adoption of a sick role.138
Doctors should consider competing explanatory models
to help them and their patients to better understand the
interaction of potential psychological causes and reasons,
and should appreciate the capacity of individuals to
influence and control their own actions.139,140 Consideration
of non-medical aspects moves the discussion from the
traditional reliance on medical or psychological causes to a
consideration of the reasons, psychosocial determinants,
and potential incentives that help explain why some people
engage in these socially deviant behaviours.4 Even in
patients with established and well recognised psychiatric
and neurological illnesses, it might be unclear whether all
the abnormal illness behaviour is exclusively derived from
their medical disorder. Many patients with medically
unexplained physical symptoms do not have psychiatric
disorders; rather, the symptoms might be the consequence
of minor pathological changes, physiological perceptions,
and factors such as the previous experience of illness.141
Finally, there is clearly scope for increased inter-
disciplinary collaboration between social neuroscience and
neuropsychology, as well as clinicians involved in the
assessment of patients with somatoform disorders,142 in
particular liaison psychiatrists, clinical psychologists,
neuropsychiatrists, neurologists, pain clinicians, and
occupational health physicians.
Contributors
CB did the literature search, wrote the first draft of the Review,
and coordinated subsequent revisions. PH reviewed the relevant
neuropsychological literature and contributed to later refinements
and additions to the final draft. Both authors contributed figures and
approved the final submitted version.
Conflicts of interest
We declare that we have no conflicts of interest.
Acknowledgments
David Gill commented on an earlier draft of the section about
malingering, but did not contribute to parts about fabricated illness.
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