MALINGERINGCTP9 TH EDII

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MALINGERING Ninivaggi
Sadock, Sadock, & Ruiz. 2009. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th
Edition. Vol. 2, Chp. 26.1, pp. 2479-2490. Wolters/Lippincott Williams Wilkens.
[September, 2016: chapter in revision/updating for Kaplan & Sadock’s 2017, 10th edition]
MALINGERING
Frank John Ninivaggi, M. D.
Yale University School of Medicine

frank.ninivaggi@yale.edu
Assistant Clinical Professor of Child Psychiatry, Yale University School of Medicine, New
Haven, Connecticut; Medical Director of Psychiatric Services, Devereux-Glenholme Residential
School, Washington, Connecticut; Attending Physician, Yale-New Haven Hospital, New Haven,
Connecticut.
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The condition termed Malingering as a significant focus of clinical attention was formally
introduced into psychiatry in 1980 in the Diagnostic and Statistical Manual of Mental Disorders
III (DSM III). DSM IV-TR (Text Revision) denotes it as the intentional production of false or
grossly exaggerated physical or psychological symptoms, motivated by external incentives, and
that aspects of it may represent adaptive behavior. The symptoms of Malingering are under
voluntary control. This denotes intentionally contrived statements and behaviors that have both
conscious and unconscious components, all of which are intended to mislead the evaluator.
Emphasis is given to the conscious awareness that the malingerer has of the Malingering
presentation. Malingering as a form of illness behavior suggests dysfunction but not true
psychopathology.
The New Oxford American Dictionary (2001) denotes malingerer as one who exaggerates or
feigns illness in order to escape duty or work. It dates the origin of the term to the very early 19th
Century describing it as “back-formation from malingere, apparently from French malingre,
perhaps formed as mal-‘wrongly, improperly’ + haingre ‘weak,’ probably of Germanic origin.”
The term malingerer is said to have first appeared in 1785 in a French dictionary, and to have
denoted a soldier who feigns himself as sick or who induces or protracts an illness in order to
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avoid his duty. This 200 year history suggests only relatively recent attention to an individual
problem with important social implications. Malingering is socially problematic behavior.
The relative newness of this DSM entity has brought with it a plethora of conceptual difficulties.
In the last twenty five years, the psychiatric, psychological, and sociological literature on this
topic has been increasing. The contributions from these varied sources have been replete with a
wide variety of terms attempting to capture not only core meanings but also attendant nuances. In
an effort to hone down the concept in a relatively lucid fashion and to establish a tentative yet
uniform lexicon for this section, the following definitions will be used. Dissimulation is the
broadest term that encompasses all forms of deception specifically in regard to psychological
symptomatology. Dissimulate denotes concealing, hiding, or disguising perceived truth under a
cover of deliberate, voluntarily controlled pretense. In the vernacular, this concept resembles that
of hoax, an act intended to deceive or to produce a façade of deliberate trickery intended to gain
an advantage. Dissimulation encompasses three principal subcategories: Malingering,
defensiveness or faking good, and markedly inconsistent, evasive responses. Dissimulation in
psychiatry encompasses Malingering, faking good, and Factitious Disorder.
Malingering is medical deception, asserting that one has significantly distressing
symptomatology in the actual absence of such. Its range of shaded meanings all point to a core
denotation of deliberate illness misrepresentation. Some nuances include: to feign, disguise,
deceive, lie, mislead, masquerade, trick, and fake. In a manner of speaking, the malingerer may
be considered to deliberately take on the role of impostor, one whose conscious motivation seeks
to achieve an intentionally fraudulent appearance.

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Malingering has also been termed faking bad, which denotes consciously creating false, untrue
yet apparently distressing symptoms. Faking bad may also include intentionally over-reporting,
embellishing, or elaborating symptoms that are present but not as problematic as the individual
tries to convey in such exaggerated fashion.
Defensiveness or faking good, by contrast, is a dissimulation by way of omission. It denotes
consciously minimizing symptoms that are present and are perceived to have negative
consequences, hence their intentional suppression. Faking good is an attempt to portray oneself
in a better light than is actually the case. For example, pedophiles might use faking good
strategies, referred to as a “dance of denial,” to minimize incriminating behaviors when being
examined. In child custody cases, a parent may also use faking good to intentionally minimize
perceived negative behaviors that might jeopardize that parent’s chances of gaining or
maintaining custody. Since the term defensiveness has been used in the Malingering literature in
a rather loose manner, the author suggests replacing it with the more precise phrase consciously
intended denial of real symptomatology.
The term simulation has been used as a synonym for Malingering, but will not be used in this
way here. Simulation more precisely denotes a consciously contrived pretended situation, an
imitation, or a representation (not a consciously deceptive mis-representation) of one process or
situation by using a different process or situation in an illustrative, perhaps, instructive context.
For example, simulation or analogue research protocols examining dissimulation or contexts in
which faking is being studied use a quasi-experimental design with participants randomly
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assigned to experimental (participants asked to dissimulate and deceive) or to control
(participants asked to be honest) groups.
In the last decade, the condition of Malingering within the field of psychiatry has been a focus of
concern in assessments in several different medicolegal contexts, for example, insurance claims,
disability requests, physical injury litigation, harassment suits, post trauma cases, and criminal
culpability situations. Not only attorneys and courts but also hospital inpatient services request
such assessments and consultations. The forensic evaluator (e.g., psychiatrist, psychologist, or
attorney) especially in criminal contexts acts primarily as fact finder, discovering facts based on
credible evidence, often on a very short-term basis. This consultant role is different from the
therapeutic relationship that the longer- term treater establishes in a clinically-oriented helping
situation. More traditional, forensically-related issues especially faced in general psychiatry in
the past were in the realms of suicide, boundary violations, informed consent, capacity and
competency, civil commitment, confidentiality, domestic violence, and abuse and neglect.
This section emphasizes the psychiatric aspects of Malingering in order to provide a clearer
clinical recognition of such potentially complex and baffling diagnostic presentations of illness
behavior. The primary goal of the psychiatrist in evaluations is first to establish the real presence
of actual disorders, and then to discern whether and in which areas Malingering might exist. The
role of projective identification will be addressed since input from patients, legal systems, and
the psychiatric community may unwittingly and unconsciously act in the coauthoring of
symptoms that influence the psychiatrist’s own mental processes and the optimal goal of striving
for objectivity and fairness. One of the strengths that distinguishes psychiatric assessment and
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the interpretation of complex, often ambiguous, information is an explicit recognition of
unconscious psychodynamics, individual differences, and an appreciation of subtle individual
distinctions. Consideration of the presence of what Malingering connotes in any patient’s
presentation (self-reports, direct observation, and collateral data) will guide the astute clinician in
proper treatment planning, especially the rational prescription of medications.
DEFINITION AND COMPARATIVE NOSOLOGY
The revised fourth edition of the DSM-IV-TR describes the condition of Malingering as follows:
The essential feature of Malingering is 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. Under some circumstances, Malingering may represent adaptive
behavior---for example, feigning illness while a captive of the enemy during
wartime.
Malingering is coded on Axis I as v65.2. DSM IV-TR goes on to say that
Malingering should be strongly suspected if any combination of the

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following is noted:
1. Medicolegal context of presentation (e.g., the person is referred by an
attorney to the clinician for examination)
2. Marked discrepancy between the person’s claimed stress or disability and
the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying
with the prescribed treatment regimen
4. The presence of Antisocial Personality Disorder
Malingering is designated within the v code category. This denotes a condition (not a mental
disorder) that may be a focus of clinical attention. The v code category represents an example of
a clinical situation in which there is insufficient information to know whether or not a presenting
problem is attributable to a mental disorder.
The International Classification of Diseases (ICD-10) lists Malingering in Chapter XXI, “Factors
influencing health status and contact with health services,” block Z00- Z99, as code Z 76.5 in a
section entitled “Persons encountering health services in other circumstances.” It codes the
following: Malingering (conscious simulation)
Person feigning illness (with obvious motivation)
The ICD-10 Chapter which contains Malingering states that these categories are provided
for occasions when circumstances other than disease, injury, or external cause classifiable to
categories A00-Y89 (more clear-cut medical and psychiatric disorders) are recorded as
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“diagnoses” or “problems.” This can arise when a person who may or may not be sick
encounters the health services for some specific purpose or when some circumstance or problem
is present which influences the person’s health status but is not in itself a current illness or injury.
The DSM-IV-TR guidelines used to indicate the condition of Malingering are minimal. There are
no suggestions regarding chronological age range or clear-cut demographic or epidemiological
findings since Malingering has not been studied in the rigorous, scientific manner in which the
mental disorders have been researched. In addition, since Malingering denotes patient deception
and unreliable information, it is difficult, if not impossible, to organize findings in a consistently
coherent fashion. Clinical judgment, especially about motivation, therefore, is essential in
diagnostic evaluations.
History Examples of malingering can be found in the classical literature in stories from
Ulysees feigning insanity to escape the Trojan War to the biblical stories of King David. The
image of the street beggar and vagabond, some of whom feigned disease to gain alms, is a
common one in early Western and Eastern cultures. It was not until about 1880+ in Bismarckian
Germany and about 1910 in the United Kingdom that malingering moved from the political,
military, and social spheres into the aegis of the medical profession. The First World War
appears to have reinforced the phenomenon of what already was known as compensation
neurosis when it added medically prescribed removal from duty to address war fatigue,
shellshock, and war trauma, particularly physical distress. It was at this point that physicians
took or were given a leading role in the management of malingering since it presented as a
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symptomatic picture in the absence of typically associated material causative features. Since
many symptom profiles were strongly suggestive of “mental” and emotional distress,
psychiatrists and psychoanalysts then took a lead in trying to sort out genuine from feigned
illness.
Since its introduction into DSM III in 1980 to about 2005, there has been an almost threefold
increase in the scientific literature on Malingering. Historical accounts have been written, clinical
and empirical case reports have appeared, but evidence-based research is still in its infancy.
Hence, as a scientifically justifiable construct, Malingering remains more in the context of
discovery. The research phase in which evidence is brought to bear on objectively testable
hypotheses remains in statu nascendi.
EPIDEMIOLOGY
The actual incidence, prevalence, and distribution features associated with Malingering are
currently imprecise. This is due to the fact that Malingering has not achieved status as a
psychiatric diagnosis with attendant studies examining validity and reliability in the context of
clinically defined populations. Speculations suggest that base rates can vary from 7.5% to 33%.
In ordinary clinical practice, some have suggested a 1% prevalence; in military populations, a
5% occurrence; and in litigious, criminal situations, up to 20 %. A recent 2002 study of 131
clinicians of the American Board of Clinical Neuropsychology gave the following breakdown of
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base rates for different contexts of Malingering: 29 % for personal injury, 30 % for disability or
worker’s compensation, 19 % in criminal cases, and 8 % in medical or psychiatric cases.
ETIOLOGY
The etiological factors contributing to the spectrum of Malingering presentations are broad and
related to much larger questions concerning the structure of and motivations within human
nature. Issues of cognitive development, cognitive refinement, introspection, insight, accurate
self-analysis, ego defense mechanisms, adaptation and survival, moral development, openness to
self-disclosure, honesty, and the capacity to deliberately lie all play into an assessment of the
mechanisms contributing to Malingering. The label of Malingering moreover may be construed
to carry a pejorative judgment, and so pose significant professional and legal implications for the
doctor if challenged. Hence a diligent, parsimonious, and perspicacious approach to a patient’s
motivations and the carefully considered veracity of a clinical presentation are essential
ingredients leading to fair and reasonable conclusions.
An interesting early 1994 study by Richard Rogers, Ph. D., a recognized leader in the field,
proposed consideration of three explanatory models of Malingering using a prototypical analysis
and subjects who were trained psychologists having extensive experience with actual
malingerers. Etiological determinants showed that adaptational attributes such as rational
decision based on expected rewards, attempts to cope with very difficult circumstances,
weighing their alternatives, trying to make the best of a bad situation, and being faced with an
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unsympathetic or adversarial system, for example, were first rank issues inferred to explain the
behavior of malingerers. Antisocial and criminological factors ranked second, and a
psychopathological model was favored by only 3.4% of the forensic experts. This study
emphasized that the choice of explanatory model may have important implications for treatment
recommendations. For example, the adaptational and pathogenic model carried with it the sense
of a more positive motivation for recommending treatment.
The biopsychosocial model both theoretically and applied to individual cases, perhaps, may be
one of the best ways to consider possible etiological factors until further research reveals more
objectively verifiable causes.
DIAGNOSIS AND CLINICAL FEATURES
For the psychiatrist, the patient’s clinical presentation is the foundation upon which all diagnostic
evaluations and treatment recommendations are made. The clinical presentation includes one or
more interviews with the patient during which an interpersonal and social field is established.
Within this context, all aspects of the patient’s demeanor, not only self-reports, are carefully
observed and explored; some aspects of cognition, memory, social and emotional responsivity,
and behavior may be tested. Issues around the manner in which the patient views and may
express envy and greed have clinically relevant value. Initially, what the patient produces may be
considered raw data that only gradually undergoes an evaluative and interpretive analysis and
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subsequent synthesis. All the patient’s productions are initially taken at face value. Conclusions
can be drawn only after diligent consideration and further collation using collateral information.
Short of the only genuine gold standard for establishing Malingering, which is the patient’s full
disclosure of deliberate intention to malinger, coding for Malingering remains a matter of clinical
judgment and of professional opinion.
Projective identification This fundamental unconscious information processing
mechanism was first described by Melanie Klein in 1946 and expanded by Wilfred Bion during
the 1960’s and -70’s. This theoretical construct denotes the mobilization of partial aspects of an
individual’s unconsciously conflicted emotions, ideation, and wishes that then become split off
and intrusively projected into an unwilling receiver. The astute clinician must parse out this
factor in assessing all Malingering presentations, when formulating clinical judgments, and in
treatment. Further aspects of projective identification will be discussed in the treatment and
management section.
Truth and Malingering In many ways, the consideration of Malingering depends on
the clinician’s conception and assessment of truth---the truthfulness and veracity of the patient’s
clinical presentation, especially verbal descriptions of symptoms. The assessment of Malingering
challenges the trust inherent in the doctor-patient relationship. Detection of true from feigned
symptoms and disorders is made by comparisons to accepted diagnostic standards such as found
in the DSM. Consistency in meeting these standards taken together with understandable atypical
variations reflects the fidelity of clinical assessment. Marked discrepancies, mismatches,

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deceptive shifts of diagnostic frame, and blatant excursions from established norms suggest
deception. When consciously deliberate intention and tangible gain can be assigned to illness
deception, then Malingering can be entertained.
The condition of Malingering, therefore, is not based on whimsy; it is based on comprehensive
considerations of the best evidence available and astute clinical judgment. When reaching
clinical conclusions, particular attention to configurations of factors associated with Malingering
are useful. When psychological testing is used as collateral evidence, neuropsychological
profiles are constructed using multiple tests, each tapping on a different area. There are no
established unambiguous criteria. From the patient’s side, the issue of good faith, openness to
self-disclosure, and well-intentioned honesty are presumed present but are examined for possible
discrepancies. The extent to which such discrepant information is conveyed in what is suspected
to be a deliberately deceitful manner lends itself to a high index of suspicion of Malingering.
Lastly, if Malingering is found to be present, there may be psychiatric disorders that coexist with
it. On Axis I and Axis II, several diagnoses of mental disorders along with the condition of
Malingering may be coded when sufficient evidence is present to justify this.
CONTEXTS IN WHICH MALINGERING MAY PRESENT

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Avoiding Responsibility Some specific contextual situations that surround a psychiatric
assessment also may lend themselves to the suspicion of Malingering. Table 1.1 summarizes
contexts in which Malingering may present itself. The current presence of international unrest
and war makes the context of military service a continuing impetus for some to use malingering
to avoid personal threat. Avoiding responsibility may also appear in child and adolescent
contexts in the frequently encountered condition of school avoidance. Although an Anxiety
Disorder may be the underlying cause of such behaviors, many youngsters also intentionally
feign illness to avoid going to school for other reasons. Malingering may not be an essential
feature in such cases since truancy may be associated with more salient disorders such as
Conduct Disorder, Learning Disorders, or understandable environmentally-based problems such
as an impaired family situation where neglect, abuse, or both may be found.
Criminal and Forensic Contexts Criminal and forensic contexts in which adults as well as
adolescents find themselves are situations within which malingering offers an option to avoid
unwanted legal prosecution or confinement. Feigning psychiatric illness may offer one convicted
of a crime the opportunity to go to a psychiatric hospital rather than to jail. The issues
surrounding criminal behaviors and psychiatric illness are complex and require the skills of those
trained in forensic psychiatry and psychology for appropriate evaluation and recommendations.
In current times, Malingering has been seen in foreigners caught for illegal entry into a country
and threatened with deportation back to their country of origin.

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A 15-year-old male was referred by the court to a juvenile justice psychiatric evaluation clinic. He was being held at
a detention center for multiple charges: possession of Cannabis and crack cocaine, setting fire to his family’s mobile
home, violence toward a parent, and resisting arrest. The arresting officers described him as uncooperative, at times
belligerent, and communicatively unclear. They had known this adolescent since they had been involved with him
and his mother alleging physical abuse by one of mother’s live-in boyfriends several years ago. At the point of
arrest, he was brought to a local Emergency Department where he was examined and found to be in good health; he
became quiet and did not appear to exhibit any clear-cut psychiatric symptomatology. Shortly thereafter he was
brought to the clinic on a daily basis for a series of psychiatric and psychosocial examinations along with
psychological testing. The patient was reticently compliant and demonstrated minimal expressive communication.
He did admit to illicit substance use over a period of several years, a history of school avoidance and failure, and a
chronic history of family conflict. When asked about the fire setting, he did not reply. Family interviews revealed a
chaotic household with biological father being incarcerated, mother having multiple male companions and a history
of depression with suicidal attempts, and overall lack of structure and home supervision. Psychological testing
showed a full scale IQ of 65, pervasive deficits in academic functioning, and projective tests suggesting possible
psychosis but no depression. Mother and the patient wanted to avoid incarceration and emphasized a history of
abuse. The patient then claimed to be depressed; mother vociferously supported this. From all the available past
history, current interviews, and psychological testing, diagnoses of Psychotic Disorder NOS, Borderline Intellectual
Functioning, and possible PTSD were made. Although both mother and son intentionally tried to establish a
diagnosis of clinical depression, the evaluator did not concur. Adding malingering to the diagnostic profile,
moreover, was thought to be unhelpful in the particular context of this already complex group of psychiatric
disorders. Recommendations for long-term therapeutic residential placement and consideration of psychotropic
medication were made.
Medicolegal Contexts Medicolegal contexts can suggest Malingering when issues of financial
compensation are at stake. This may involve personal injury cases as well as disability claims for
psychiatric or developmental problems. Since these complex cases have salient medical features,
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their assessment requires the combined efforts of medical specialists to assess neurological and
musculoskeletal features as well as psychiatric and psychological evaluation.
A 16-year-old male was brought to the Emergency Department by police. He was wildly out of control, moving
about in a disorganized, hyperkinetic fashion and speaking incoherently. Initial physical examination was
unremarkable but laboratory investigations showed elevated liver function tests; drug screening was negative. The
patient’s mother said that he had no prior medical or psychiatric history, and that she was unaware of any indication
of substance abuse or cigarette smoking. The patient was admitted to the psychiatric unit where he was moderately
agitated and demonstrated a catatonic-like excitement. Atypical neuroleptics were begun; after several days, his
motor behavior began to normalize and he was more coherent. His cognitive functioning cleared but was slow. He
denied the use of illicit substances but said that he had recently begun a summer job in a small paint factory; this
appeared to coincide with his symptoms. A tentative diagnosis of Inhalant-Induced Psychotic Disorder was made.
The patient was discharged on no psychotropic medication, and seen one week later. He appeared stable and in no
acute distress. Sleep, appetite, and energy level were normal. Blood work was within normal limits at this time. He
returned to school in the Fall and was reported to be doing as well as he had been doing prior to his decompensation.
Mother then requested that the hospital physicians support her contention that her son was currently disabled,
thereby certifying him to be eligible for financial compensation. After further interviews, no evidence of changed or
limited functioning from pre-hospital baselines could be found to support disability claims. Mother’s attorneys
brought the matter to a hearing. It was agreed upon that a small settlement by the paint factory would be made. This
case demonstrates how patients may try to intentionally shift evidence of a real disorder and its resolution toward
exaggerated claims of continued impairment.
Emergency Facilities Emergency Departments and Primary Care facilities may be the only
resource to which those who are socially and occupationally impaired have relatively easy
access. Such persons may have complex chronic medical and even psychiatric illnesses, which
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nonetheless do not warrant immediate hospitalization even though they ask to be admitted.
Careful diagnostic assessment of emergent, urgent, and longer-term needs is critical. The
assistance of social services, particularly if immediate shelter is needed, can be an important
resource. Whether or not Malingering, in addition to other problems, is believed to be present,
clinical judgment must dictate the appropriate disposition of these cases.
Outpatient Settings A commonly encountered situation wherein Malingering may present
itself is in typical outpatient practice. This obtains not only for the psychiatrist but for all
physicians. Patients may malinger about pain symptoms that are either untrue or deliberately
exaggerated. The request for controlled substances such as narcotics in excess of what the
physician deems reasonable always needs careful attention. Patients also may be habituated to or
dependent on benzodiazepines and so ask for, sometimes demand, ongoing prescriptions or
excessively high daily dosages. The physician’s clinical judgment again must weigh reasonable
risks and benefits, especially if Malingering is suspected. A not infrequent request by adolescents
and by some adults is for psychostimulant medications such as methylphenidate and its
derivatives, and dextroamphetamine and its derivatives to treat a reported case of Attention-
deficit/ hyperactivity disorder (ADHD) or Attention Deficit Disorder (ADD). Since these
disorders are frequently diagnosed, careful clinical assessment is needed to discern legitimate
cases from those persons that wish to obtain controlled substances for purposes such as weight
loss or non-medically justified stimulation and abuse. It has been almost commonplace for
adolescent females, and even many males, to be overly concerned about body weight and to
request psychostimulant medications under the ruse of suffering from ADHD when, in fact, the
underlying intent is to use the psychostimulant drug for effective weight loss. Child and
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adolescent psychiatrists face this issue on an almost daily basis. In addition, careful histories and
assessments of the family context, particularly members with illicit drug histories or criminal
backgrounds, are essential to rule out unwarranted, abusive use or diversion into the street for
illicit drug trade.
A 35-year-old attorney requested a psychiatric evaluation for treatment of what he claimed was his adult Attention
Deficit Disorder (ADD). This was the third such consultation he requested in the last 6 months. The patient was a
middle class, Caucasian male, married with two children, and a practicing attorney for the last six years. He had a
reported past history of intermittent, moderate depressions since age 20 for which he received periodic brief
psychotherapy and antidepressant medication. He stated that he had not felt depressed for the last five years,
although he described himself in terms he said his wife used: “a man who fears success.” This, he explained, was
related to multiple attempts at jobs in various law firms that quickly ended with his impulsive resignation. He now
felt that he was troubled with difficulties concentrating, staying focused, and completing tasks that required
attention, concentration, and perseverance. He said he was able to diagnose himself, and believed that he suffered
from ADD. He sought a prescription for a stimulant medication.

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After several sessions of careful history taking, diagnoses of anxiety and mild mood instability were suggested,
especially based on past history. After agreeing with the psychiatrist’s “skillful insights” as he described them, he
proceeded to assert that the assessment was essentially wrong, and missed understanding the core of his dilemma.
He said that, although partly right, the assessment was “perfectly flawed.” He insisted, however, that he would come
for further sessions to “show the doctor” how wrong he was, and that the putative ADD required a prescription that
“only the doctor had the power and authority to order. Whether or not I meet criteria for ADD, I feel I can benefit
from the drug.” Axis II personality disorders were considered, but such diagnoses were deferred.
During the course of about six sessions, he behaved in a similar and repetitive fashion.
When it became clear that no psychostimulant medication would be prescribed, he said: “You just won’t open up
and listen to me. It’s really very clear, I know myself better than you do. Even though I didn’t go to some fancy
medical school, I’m competent enough to see things as they are.” He would then add, “I guess we’re on different
wavelengths.” Any sort of interpretive attempt was thwarted, and the patient declared that an “impasse” was reached
and that he would not return.

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Characterological issues were principal. Envy of the therapist is an obvious feature of this brief clinical vignette. The
nature of the patient’s motivation is complex. He certainly intended to persuade the psychiatrist both of his ADD
and his need for drugs, but the extent to which he feigned or believed these to be true is unclear. His almost arrogant
insistence on his independently arrived at, correct self-diagnosis and his inability to consider another opinion along
with the constant comparisons he made between himself and the psychiatrist evidenced rigidity and a quality of
recalcitrance that in this context suggested pathological, unconscious envy. His partial acknowledgement of skill, yet
his insistence on the assessment as ultimately being “perfectly flawed” point to his attempt at envious spoiling of
what was sensed to be partially skillful and insightful, that is, ideal to some degree. This patient’s aggressive attempt
to influence the psychiatrist can be viewed as a display of omnipotence and the use of projective identification as a
way to aggressively gain active control in order to ward off and defend against feelings of inferred inadequacy and
helplessness. His choice to leave the therapeutic field due to what he called an “impasse” further attests to the usual
blocking of forward progress that results when excessive envy, in fact, is a major underlying factor in the therapeutic
impasse. The boundary between Malingering and Factitious Disorder as seen in this case is thin.
CLINICAL PRESENTATIONS OF MALINGERING
Physical Symptomatology
Pain Presentations Malingered symptomatology may take various forms. Table 1.2
summarizes clinical presentations of malingered symptomatology. They may be divided into

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physical symptomatology (pain and incapacity) and psychological symptomatology. Whereas
Factitious Disorders often present with physical symptomatology and signs, Malingering appears
in psychiatric settings to present with psychological symptomatology suggestive of psychiatric
disorders. Perhaps, the presentation of pain and distress in suspected Malingering is most often
encountered in contexts wherein financial or disability compensation is at stake. This can be
related to physical injury or degenerative disease states. If pain is malingered, it may typically
take the form of an embellishment of the severity of pain, and subsequently what appears to be
significantly impaired functional capacity. Ordinarily, some degree of real pain is present, but the
excessive degree to which it is intentionally exaggerated may suggest Malingering. Since this is
an extremely complex area, and one wherein Malingering has been shown to be less prevalent
than once thought, such presentations need careful consideration. When physical symptoms are
in question, medical specialists are needed to rule out neurological, infectious, musculoskeletal,
and other primarily somatically-based complaints. In addition, one must carefully discern the
presence or absence of the following: Pain Disorder or the condition of Pain Associated With a
General Medical Condition whose code is specifically selected based on the associated medical
condition or the anatomical site.
Pseudoseizures Pseudoseizures (psychoseizures, hysteroepilepsy) resemble epileptic seizures.
Patients exhibiting pseudoseizures are unusually suggestible. They may also have true seizure
disorders or a family history of epilepsy. Although resembling tonic-clonic convulsions, no tonic
phase is present; there is an asynchronous thrashing of the limbs typically lasting more than a
few minutes unlike in true seizures. Consciousness may be normal or lost, and there is no typical
postictal phase or loss of continence. Laboratory studies show no electrocerebral changes. Serum
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prolactin, ordinarily increased between 15 and 30 minutes after a true tonic-clonic seizure,
remains unchanged from baseline. Resistance to epileptic drugs is common. Pseudoseizures have
been determined to be due either to Malingering or, in some cases, to hysterical conversion
reactions associated with acute emotional stress or chronic physical and sexual abuse.
Psychological Symptomatology
Clinical Presentations Psychological symptomatology and the suggestion of mental disorders
are presentations that the psychiatrist encounters, often by referral or consultation, in ruling out
suspected malingering. A high index of suspicion is raised when symptoms are clearly atypical,
grossly unusual, non-traditionally bizarre, extraordinarily exaggerated, embellished or
elaborated, or alleged to occur in the future if some incentive or personal gain in the present is
not met. Lay persons, for example, may decide to exhibit dramatic symptoms or to portray some
florid clinical picture based on what has been seen in the popular media. Professionals who
malinger might consult psychiatric texts and attempt to feign a bona fide mental disorder by
using every feature and criteria listed as well as their precisely given timeframes. Such direct
textbook presentations rarely present in day to day clinical contexts. Detection strategies include
close attention to the patient’s description of when and how symptoms arose as well as to their
sequence. Clinical incongruities in symptom presentation, as, for example, an individual
describing an Anxiety Disorder in a calm and composed manner at every interview suggests
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feigning. Lastly, markedly atypical juxtapositioning of symptoms may suggest Malingering.
Some examples of psychological symptomatology are the following.
Posttraumatic stress disorder Posttraumatic stress disorder (PTSD), after pain presentations,
is a common presentation in which malingering needs to be ruled out. In addition to alleged
traumas associated with military service and combat, personal injury and automobile accident
trauma may present with features of PTSD. Combat-related and civilian PTSD need to be
differentiated. The most common motivation for malingering PTSD is financial gain. Feigned
PTSD diverts care from those military personnel who genuinely have suffered trauma and
require services. Symptom presentations in feigned cases often appear dramatic and highly
embellished. Dramatic positive symptoms such as flashbacks and nightmares are emphasized.
These are reported in ways that are inconsistent with DSM IV-TR definitions; by contrast, they
reflect unrealistic caricatures seen in the media. Subtle features and generally incapacitating
anxiety are often absent. For example, in an effort to avoid occupational duties, psychological
and physical incapacity may be claimed. Often, upon further examination, this incapacity does
not extend to other more pleasant activities such as social activities, recreation, travel, vacation,
or sports. A thorough history may reveal past occupational difficulties or frequent job changes.
The general demeanor of uncooperativeness, withholding information, belligerence, or
personality disorders (Antisocial, Borderline, or Histrionic) may also suggest Malingering. A
bland refusal to undergo treatment and to consider future re-employment is also implicating.
Depression Depression may be malingered. Since Depressive Disorder and depressive
variations (Melancholic, Atypical, and Bipolar, for example) have been so extensively
24
researched, the psychiatrist is usually keen to spot faking in this area. For example, the
malingerer may be extremely fluent in descriptions of “feeling depressed” and “not sleeping” but
may not report the typical details of impairment (diminished specific hobbies; dysfunctional
interpersonal relationship issues such as envy, jealousy, and guilt; limitations in everyday
activities of daily living; and altered vegetative functions) that the genuinely depressed person
may report. Appetite and weight remain constant. The very loquaciousness that often attends
such presentations is inconsistent with depression. In addition, malingered depressions may not
pervade all aspects of the person’s life and functioning. For example, the malingerer may
continue to engage in going out to dinner, hobbies, and in regular sports activities.
Amnesia Amnesia may be a form of Malingering seen in forensic settings and is usually
related to alleged crimes. It has been suggested that up to 1/3 of homicide perpetrators claim
amnesia. Since this is a grave situation, specialists in forensic psychiatry in collaboration with
other specialists are best suited to discern such presentations. Head injury after accidents also
presents with degrees of amnesia. Such cases have historically been referred to in the literature as
accident neurosis or compensation neurosis and seen in a negative light until recent research has
suggested that genuine cognitive deficits may be present in large numbers of these cases. In
assessing amnesia, highly selective, localized memory deficits, especially in the areas where the
patient’s motivation and liability are in question, may suggest feigning. Typically, amnesic
patients demonstrate impaired new learning and short-term memory but procedural memory and
premorbid semantic memory are preserved. If deficits are produced in immediate recall, digit
span, autobiographical/self memory, procedural memory, and new learning, this may suggest
feigning if the wider context is also corroborative. In genuine Amnestic Disorders with
25
pathophysiologic concomitants, disorientation may be to place and to time. There may be lack of
insight into memory deficits and the patient may explicitly deny the presence of severe memory
impairment. This is often accompanied by apathy and emotional blandness. Chronic substance
abuse and alcoholism need to be ruled out. Dissociative states and Histrionic Personality
Disorder tend to lessen the probability of Malingering. In Dissociative Amnesic disorder, the
patient does demonstrate inability to recall important personal information usually of a traumatic
or stressful nature. Patients with true Dissociative Amnesia usually score high on standard
measures of hypnotizability unlike the case with malingerers. Antisocial Personality Disorder is
a feature of Malingering according to DSM IV-TR guidelines and needs to be considered in
forensic contexts. Of course, neurological examination and appropriate radiographic studies
should be considered.
Psychosis Psychosis can be malingered, for example, in criminal defendants attempting to
avoid trial or to alter prison sentences, in the homeless who present to the Emergency
Department in an effort to gain entry into the hospital for temporary food and shelter, or in those
whose motivation is to avoid some clear-cut responsibility, which they find undesirable such as
conscription into military service. This may be a more common malingered presentation in less
sophisticated persons. For the experienced clinician, it may not be very difficult to differentiate
true psychosis, as, for example, in Schizophrenia, or Bipolar Mania, from deceptive illness.
Persons with schizophrenia are often withdrawn and minimally verbal, not open to fluent
descriptions of their symptoms. Those feigning psychosis often produce reports of very dramatic,
perhaps melodramatic, hallucinations with bizarre content that is more characteristic of sci-fi
media than that which is ordinarily reported by those with genuine psychosis. Hallucinations
26
may be uncharacteristically not accompanied by associated delusions. Hallucinations are
reported to be constant not intermittent, irresistibly commanding to action, always terrifying
rather than at times manageable, and, if visual, they are said to be seen in dramatic colors in
cinematic, film-like fashion. Malingerers may speak of delusions in a forthright, open manner
unlike the guardedness often accompanying descriptions of genuine delusions. These persons
may describe their delusions as having all or none features rather than the more subtle and
continuous tone characteristic of truly psychotic delusions. In addition, malingerers feign only
the contents that accompany psychotic states and often demonstrate no irregularities in the form
of their thinking processes, which is an important characteristic of psychosis.
A 35-year-old male pharmacist was referred to an outpatient clinic by his internist for medication evaluation of his
long standing Bipolar disorder. He was in apparently good health and working over 60 hours per week but
experiencing anxiety, dysphoria, and increasing disorganization. He reported a one year history of a turbulent
relationship with a girlfriend of 3 years. Sleep, appetite, and job performance were beginning to suffer. The patient
had been on lithium and an atypical neuroleptic for 4 years with good control of symptoms. When recently
escalating symptoms appeared, the patient suggested to his internist that his ADHD in addition to his Bipolar was
not being properly addressed. A once per day, long acting psychostimulant was then added. Although the patient
stated that he felt that he could function more efficiently on the stimulant, his observable behaviors deteriorated.
When he demanded benzodiazepines for anxiety and insomnia, his prescribing physician made the referral. Upon
interview, the patient was a thin, agitated male who appeared highly intelligent and articulate. He at first asked for
increases of his lithium and neuroleptic, but then demanded increases in his stimulant and also the addition of a
benzodiazepine. At that time, it was apparent that he was hypomanic and that his judgment was becoming
progressively impaired. After several sessions of attempting to target the escalating Bipolar presentation and obtain
blood work (which the patient failed to procure), a recommendation for inpatient hospitalization was made. He
27
protested and reiterated that his ADHD was his primary problem and that stimulant medication was the only answer.
A second psychiatric opinion was obtained and it confirmed Bipolar disorder with little or no evidence of ADHD.
Again, hospitalization was strongly recommended at which point the patient abruptly left the clinic. Attempts to
contact him failed. After several weeks, it was discovered that he had left the state; and his whereabouts were
unknown. Six months later a family member contacted the clinic to request records stating that the patient had been
found dead in suspicious circumstances and that an investigation was in progress.
Intellectual Disabilities Intellectual Disabilities connote substantially reduced cognitive
capacities, that is, a significantly limited age-appropriate capacity and use of thinking skills,
memory, reasoning, abstraction, judgment, and decision making. Such intellectual limitations
have traditionally been referred to as ranging from the extreme of Mental Retardation to
Borderline Intellectual Functioning. Dementia with its apparent decrease in expressive language
and marked perseveration might also be considered to represent a significant intellectual decline,
although it is usually not a malingered condition. It is also not very common for an adult to feign
such conditions as Mental Retardation since past history, especially of academic performance,
vocational functioning, activities of daily living, and social adaptation ordinarily appear in quite
distinct ways as substantially impaired over long periods in genuine cases. These impairments
pervade all sectors of the personality, and often require obvious caregiving whether in childhood,
adolescence, or adulthood. The clinician may be presented with a case of malingering by proxy,
which suggests that the real malingerer (usually a parent) is alleging that their child has
substantial intellectual disabilities that demand financial and other compensation. In these cases,
careful assessment of the past history of both child and caregiver is essential.
28
The single mother of an 18-year-old just graduating from a residential school for adolescents with academic and
behavioral problems requested documentation verifying that her son was disabled on the grounds of learning
disabilities. Mother was an immigrant from Europe living in America for over 10 years; father died in an automobile
accident 5 years previously. There were no other children and mother was unable to work due to disability
secondary to depression. The boy had been enrolled in the school about 3 years ago because of school failure. At
that time, psychological testing showed intelligence to be slightly below average and there was no evidence of
primary attentional problems or learning disorders. His academic failure was deemed due to primary situational
conflicts between him and mother. For the last 3 years, his school performance and behavior were within normal
limits, but his relational situation did not improve. After comprehensive retesting and assessment of psychological
and social factors, it was judged that he was not disabled. Attendance at a college away from home was suggested.
Borderline Intellectual Functioning Borderline Intellectual Functioning is a condition that
denotes intellectual quotient (IQ) between about 70 and 85 accompanied by significantly
impaired adaptive functioning. Such persons often present as slow learners who may appear to
be feigning their cognitive limitations in an effort to achieve an external gain---needed help from
others. The oftentimes genuine needs of these persons should be differentiated from the
deceptions of Malingering. In addition, persons of any intelligence level may innocently attribute
an unlikely causative factor (e.g., allergies, job stress, or Lyme disease) to what they genuinely
believe is a disorder. Such innocent misattributions should be distinguished from consciously
motivated Malingering. Cognitive decline, however, after head injury, toxin exposure, or chronic
substance abuse would suggest a clear traumatic precipitant. Past history, medical examination,
and laboratory screening for illicit substances and liver functions would help rule out
29
legitimately understandable causes of true illness even if the patient misattributes cause and
effect.
Ganser’s syndrome Ganser’s syndrome is classified as a DSM IV-TR Dissociative Disorder
Not Otherwise Specified. It is denoted as the giving of approximate answers (Vorbereiden) to
questions when not associated with Dissociative Amnesia or Dissociative Fugue. Dissociative
Disorders connote disruptions in the integration of consciousness, memory, identity, or
perception of the environment. Ganser’s syndrome was originally described in prisoners who
presented as confused. Although the utility of this diagnostic classification has been questioned,
such presentations require ruling out genuine intellectual disabilities, Borderline Intellectual
Functioning, forms of Delirium, as well as Malingering. Assessments of inferred motivation and
the prospect of external gain need to be considered.
Attention-Deficit/Hyperactivity Disorder Attention-deficit/hyperactivity disorder is a
common diagnosis. It is characterized by significant inattention, hyperactivity, impulsivity,
beginning before age 7, and showing functional impairment in two or more settings such as in
school and at home. Task avoidance and low motivation, which may be primary in such
presentations, must always be ruled out in attentional difficulties presentations. Since one aspect
of the comprehensive educational, psychosocial, and psychopharmacological treatment of
ADHD requires Class II controlled psychostimulant medication, the adolescent and adult
population have been known to malinger symptomatology in order to gain these drugs for their,
at times, perceived pleasurable and excitatory effects. In malingering by proxy, a caregiver might
30
attempt to persuade the physician that the child or adolescent has ADHD symptomatology in the
known absence of such in order to procure these controlled substances for personal use or for
illicit diversion.
An 8-year-old boy was brought to the clinic by his mother for medication management of his 2 year history of
ADHD, which had been medicated by the family pediatrician until now. The referring physician reported that he
was unwilling to continue to prescribe controlled substances since mother up to now had been unwilling to involve
the child or herself in psychosocial interventions that included psychotherapy, parent management skills, and
adjunctive school interventions. Mother and child were interviewed both together and alone on several occasions.
Mother reluctantly agreed to the release of school records. Previous psychological and academic testing showed the
child to have a low but within normal limits IQ and adequate performance in all subjects except a clear-cut problem
with reading. School personnel regarded this as probable dyslexia, not ADHD; and appropriate remediation was in
place. The child was significantly below average for height and weight. He had multiple facial grimaces and tics,
and a history of insomnia and difficulty awakening in the morning. His medication regimen included
dextroamphetamine in high doses and clonidine at night for sleep. Mother also requested that the clinic verify the
child’s need for disability compensation based on his ADHD. The multidisciplinary clinic team assessment included
social work home visits and an intensive assessment of mother’s history. It was found that she was on probation for
a history of financial scams, writing bad checks, and involvement with the illicit drug trade. She gave informed
consent for the release of her probation records. It was also discovered that State social services were in the process
of an investigation of alleged child neglect. Before the psychiatric evaluation was completed, the clinic was
informed that mother had been arrested for possession of and dealing illicit substances, some of which included
stimulant medications. The child was put in custody of his grandparents. Recommendations were made for
comprehensive psychosocial services for the child and grandparents. Grandparents were in agreement that all
medications should be tapered so that a new baseline of overall functioning could be obtained.
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Child and Adolescent Illness Falsification
The importance of taking into account the developmental characteristics of the child or
adolescent when considering whether or not genuine illness is present cannot be
overemphasized. Since individuals under the age of eighteen fail to meet some of the guidelines
used to code for Malingering (e.g., Antisocial Personality Disorder), the phrase illness
falsification is best used to denote situations in which youth appear to deliberately feign a
medical or psychiatric illness having some ulterior personal gain as a goal. Often, such illness
falsification is associated with symptomatic lying in this age group.
Does illness falsification present differently at different developmental stages?
In childhood, up to about 12 years of age, separation anxiety, school avoidance, and PTSD may
be the leading disorders associated with a child’s feigning illness (e.g., stomach ache, headache,
forgetfulness/intentional suppression of information of abuse, pseudoseizures) to obtain a desired
goal such as staying home from school, avoiding consequences for negative behaviors, or the
wish to receive presents or increased attention for being sick. Children who are bullied in school
might also use illness falsification to avoid the context of trauma. Symptom coaching, sometimes
a consideration when a child falsely attributes illness to a parent, may occur in the context of an
acrimonious divorce and child custody dispute. One parent coaches the child to describe the
other parent in an unfairly negative light. This is an example of illness falsification by proxy.
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In adolescence, about age 13 to 18 years of age, the emotions of anxiety, fear, and guilt typically
prompt the teenager toward illness falsification. Anxiety and fear of attending classes may be
related to Anxiety Disorders, Social Phobia, and Asperger’s Syndrome. School avoidance may
result. As is discussed in the section on attentional problems, it is not uncommon for adolescents
to claim ADD and ADHD as an excuse to rationalize both poor motivation and intentional task
avoidance and so excuse excessively poor school performance. Juvenile offenders, often carrying
a diagnosis of Conduct Disorder, which strongly connotes the presence of lying and deception,
have been noted to use illness falsification to avoid sentencing to jail, to lighten sentencing
severity, or to divert their adjudication from jail to the mental health system for rehabilitation and
treatment.
Antisocial Personality Disorder and Malingering
The criminological model as described by Richard Rogers in 1990 and again in 1997 proposes
that this DSM articulated framework is used, perhaps inaptly in Rogers’ view, to explain the
primary motivations underlying Malingering. It includes the diagnostic variable of Antisocial
Personality Disorder, the contextual variable of a medicolegal evaluation, and two presentational
variables, uncooperativeness and discrepancies with objective findings. The strong association
between Antisocial Personality and deceptiveness is emphasized in this implied risk model.
Although there are obvious correlations between these, some studies have questioned their
validity. The prejudicial role of confirmatory bias must be taken into account in all assessments.
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The non-Malingerer’s Dilemma
A very important consideration in any assessment of Malingering is an abiding awareness of the
patient whose symptomatic presentation is real, that is, genuine and not intentionally feigned.
Ordinarily such patients have genuine disease processes, bone fide diagnoses, obvious
impairments, limitations, and restricted functioning. Such functional incapacity typically affects
all areas of their life including home, occupational, and social spheres. Their biopsychosocial
functional capacity is significantly diminished and true disability leaves them handicapped. The
context in which this appears may be work-related, injury-related, associated with degenerative
disease, or a mental disorder, to name just a few.
In the process of assessing a patient’s genuine functional incapacity and current needs, the
extensive and rigorous interviewing, at times perceived as an interrogation, and the implicit level
of accusation that questions the patient’s credibility and forthrightness are often sources that
strain the patient’s already compromised emotional resilience. The integrity of the working
relationship between examiners and caregivers may become unduly encumbered. In such cases,
iatrogenic factors may appear in the patient’s presentation and confound correct evaluation and
management. It is here that the adaptive component of the individual’s resources may be
mobilized. Considerations of these factors are useful guidelines to help temper any tendencies to
conduct evaluations in an inappropriately aggressive manner which, in itself, may be experienced
as a trauma.
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CODING MALINGERING
When Malingering is considered present, it is useful to indicate its inferred type. Full
malingering denotes complete fabrication. Pure malingering denotes the feigning of disease
when it does not exist. Positive malingering denotes the feigning of symptoms that do not exist.
Partial malingering denotes the exaggeration of currently existing symptoms, or stating that
extinct symptoms are still present. A more nebulous type of malingering is termed false
imputation. The malingerer deceptively shifts the frame of the diagnostic focus by ascribing
actual symptoms to a cause consciously recognized to have no relationship to those symptoms.
Such obfuscation darkens and obscures diagnostic clarity, yet may be often overlooked.
It may also be helpful to place malingering in a context that connotes degree of certainty:
indeterminate, strongly suspected, provisional, probable, or deemed likely present. Indeterminate
cases show findings that suggest the possibility of Malingering but whose findings are currently
too ambiguous, insufficient, and unsupported by collateral evidence. Strongly suspected cases
show findings that are consistent with DSM IV-TR guidelines but lack typically associated
features and contexts and whose collateral support is equivocal. Provisional cases show findings
that are consistent with guidelines although currently incomplete or of too brief a duration, yet
suggest a strong presumption that more complete indicators will be found over time. Probable
cases show findings that are consistent with basic DSM IV-TR guidelines, associated features
and contexts, but there is a lack of strong confirmation from collateral sources, especially
psychological testing. Malingering may be considered present when findings are clearly
consistent with DSM IV-TR guidelines, associated features and contexts, and are reasonably
35
supported by a preponderance of evidence from most collateral sources. It must be emphasized
that the American Medical Association (2001) has stated that confirmation of Malingering is
extremely difficult. Table 1.3 summarizes a range of degrees of certainty in coding for
Malingering. Lastly, the inadvertent misattribution of linking symptoms with unrelated causes,
as, for example, found in the reports of persons with cognitive limitations or in those who do so
because of educational or cultural variations, should not be considering malingering.
Table 1.4 summarizes DSM IV-TR guidelines indicative of Malingering as described earlier and
provides a clinical decision model for coding Malingering. Although the presence of all of these
threshold screening indicators is not essential, factors 1 (the intentional production of false or
grossly exaggerated physical or psychological symptoms) and 2 (motivations arising from
external incentives) are fundamental and should be accompanied by some of the other typical
features. While DSM IV-TR does list the presence of Antisocial Personality Disorder in these
coding guidelines, some have questioned the strength of this association. Others have called
attention to the connection between the clinical findings of deliberate misrepresentation and
lying, for instance, commonly seen in persons with Antisocial Personality as well as Borderline
Personality and similar findings of intentional deception in Malingering.
The final conclusions one arrives at should derive from five foundations. They are
36
1. Is the clinical evaluator acting as a short-term consultant in a setting that implies a
medicolegal, perhaps, adversarial, context?
2. Is the patient’s presentation reasonably consistent with the presentation of genuine
illness or not?
3. Is there a medical or psychiatric disorder that plausibly explains the signs and
symptoms presented?
4. Are the final diagnostic conclusions based on evidence of consistency or on
marked inconsistency?, and
5. What is the best professional opinion about the nature and goals of the patient’s
intention?
COLLATERAL DIAGNOSTIC DATA
The finding of Malingering may also be supported by obtaining information from collateral
sources that include data from interviews with those who know the patient, relevant records, and
psychological testing. Informed consent issues need to be considered. Interviews with family
members and significant others, employers, past therapists, jail or prison personnel, and
probation or parole officers may provide important information. Past medical records,
psychiatric records, occupational and educational reports, court evaluations and prior disability
claims are also useful. There are no physical examination techniques that have been
37
demonstrated to objectively prove the presence of Malingering. Internists and family practice
physicians stress, however, that warning flags include persistent noncompliance, striking
inconsistency between physical findings and stated symptoms, and a referral from an attorney or
an insurance company. Although the psychiatrist has an important clinical role in an overall
assessment, the collaborative efforts of a team of medical, psychological, and legal specialists
may be needed to provide corroborative evidence and hence a consensus to support psychiatric
findings.
Psychological testing involves the use of standardized psychometric instruments by a trained and
experienced clinical psychologist. Such tests are often used in the assessment of competency to
stand trial, child custody evaluations, criminal responsibility, violence risk assessments, and
personal injury litigation. To be admissible in legal contexts, tests must show validity and
reliability, and adequate sensitivity to identify true positives and adequate specificity to identity
true negatives. These federally recognized criteria are known as the Daubert standard and derive
from the 1993 United States Supreme Court case Daubert v. Merrell Dow Pharmaceuticals, Inc.
Some of the more commonly employed tests with these features used to detect Malingering will
be reviewed. It is acknowledged that there is no one gold standard that is considered definitive.
The use of multiple test measures and other collateral data aids in providing converging
supportive evidence.
The Minnesota Multiphasic Personality Inventory-2 is one of the most commonly employed
instruments used in detecting Malingering of mental illness. Some of its subscales are
38
particularly useful. The F scale detects symptom exaggeration or severe psychological
disturbance. It is considered to be the best available discriminator of honest versus malingered
symptom profiles. It, however, is not sensitive to detecting neurocognitive dysfunction. The K
scale is considered good at detecting faking good or minimizing what the respondent perceives as
incriminatingly negative symptomatology; this is mildly negative symptomatology that an
ordinary person would openly admit to experiencing. The F-K scale indicates a tendency to
exaggerate symptoms. The F-psychopathology scale detects truly rare symptoms, and the D scale
and FBS scale expose erroneous stereotypes of illness.
The Wechsler Intelligence Scales also are used to determine strengths and weaknesses in areas of
intellectual functioning from verbal and performance perspectives. Gross abnormalities in
intellectual level such as forms of Mental Retardation and striking discrepancies in subtest areas
can be detected. Wechsler Memory Scales are also frequently used. Results are supplementary to
the other tests of Malingering described in this section.
The Structured Inventory of Reported Symptoms (SIRS), a very popular instrument substantially
gaining in use, is employed to test for feigned mental disorders and truly rare symptoms. The two
underlying dimensions in this test are the Spurious Presentation used to assess symptom
constellations that are unlikely true under any circumstances, and the Plausible Presentation used
to assess some symptoms that genuine patients are likely to endorse. Another instrument is the
Personality Assessment Test (PAI) also used to test for truly rare symptoms and unlikely patterns
of psychopathology. It can be completed in under one hour. The Validity Indicator Profile (VIP)
is a psychometric instrument employing verbal and nonverbal items to test for cognitive
39
malingering; it takes less than one hour. VIP contains very easy as well as difficult items.
Malingered profiles show easy items, which non-malingerers pass, missed and difficult items
responded to at chance levels by malingerers. It should be noted that such tests are not suitable
for those with significant intellectual disabilities or mental retardation since such cognitively
limited persons may not try as hard or may give up easily and produce what are recognized to be
careless and invalid profiles. Task avoidance and low motivation also must always be considered
in assessing the results of psychometric tests.
The Test of Memory Malingering (TOMM) is a newer, more sophisticated malingering test. It is
becoming very popular and is widely used. It assesses exaggerated memory complaints, the
dissimulation of cognitive impairment, and detects subtle forms of malingering. Its classification
is based on the “floor effect,” which is a testing strategy that relies on the nonmalingering
individual’s easily passing most test items. Studies of its validation indicate excellent specificity
and modest sensitivity. It has a very high accuracy rate and its validity has been supported in a
forensic psychiatric population. The Millon Clinical Multiaxial Inventiory (MCMI-III) is a test
of malingering that detects tendencies to overstate emotional and personal problems. The Fifteen
Item Test (FIT) is a test of recall; it evaluates malingered neurocognitive deficits. The Miller
Forensic Assessment of Symptoms Test (M-FAST), a relatively new instrument, uses a
structured interview and is considered most efficient at distinguishing feigned from bona fide
schizophrenia. This tool is a screening device with highly validated studies confirming that it has
sound psychometric properties. The majority of its items represent psychotic or highly unusual or
improbable symptoms.
40
The use of the polygraph or lie detector, drug-assisted (e.g., amobarbital) interviews, and
hypnosis are not considered standardized in an adequately scientific fashion and so are not
ordinarily used to detect Malingering. Ultimately, the only acknowledged gold standard that is
undisputed in confirming Malingering is full disclosure by the subject’s stating a deliberate
intention to malinger.
DIFFERENTIAL DIAGNOSES
The condition of Malingering may coexist with true mental disorders such as, for example,
Major Depressive Disorder, Anxiety Disorders, Bipolar Disorders, and Personality Disorders.
Careful assessment must discriminate genuine mental disorders and Personality Disorders from
the pretense of Malingering. Presentations are usually complicated and typically not
straightforward. Often more than one diagnosis and condition may exist together. In addition,
one must screen for intact cognitive status and rule out Dementias and intellectual disabilities
since these may inadvertently cause the patient to incorrectly describe what seem to be
symptoms. Such mistaken beliefs do not carry the motivation of intent to deceive and so must be
distinguished from Malingering.
Malingering traditionally has been contrasted primarily with two classes of mental disorders:
Factitious Disorders and Somatoform Disorders. Table 1.5 summarizes the differentiation of
Malingering from Factitious and Somatoform Disorders. Factitious Disorders are characterized
by physical, psychological, or mixed symptoms plus signs of illness that are intentionally
41
produced or feigned secondary to an unconscious psychological need to assume the sick role.
This Axis I diagnosis always implies psychopathology. Its prevalence is uncertain but said to be
about 1%. Individuals with Factitious Disorder present their history in a dramatic fashion, but
tend to be vague regarding details. Pathological lying (i. e., pseudologia fantastica) may be
present. Intentionally feigned symptoms may include depression, amnesia, Posttraumatic Stress
Disorder caricatures, infections, pain, fevers, or neurological symptoms. Pain and requests for
analgesic medications are very common. The most severe and chronic form of Factitious
Disorder has been referred to as Munchausen’s syndrome, which includes recurrent
hospitalizations, peregrination (traveling), and pseudologia fantastica. Munchausen by proxy
refers to a form of maltreatment in which an individual in loco parentis fabricates or produces
physical, psychological, or combined illness in another to assume the vicarious sick role. Other
actual mental disorders and Borderline Personality Disorder may also accompany this.
Malingering differs from Factitious Disorders in that the malingerer’s intentionally feigned
symptom presentation is secondary to a conscious motivation regarding a recognizable external
incentive and not to an unconsciously motivated need to assume the sick role. The malingerer
seeks a tangible external incentive, which is usually material, not an abstract satisfaction
motivated by unconscious needs. The patient with Factitious Disorder unlike the malingerer is
often significantly self-injurious. Feigned symptoms are often accompanied by dangerous, self-
handicapping signs. Malingering and Factitious Disorders may not be diagnosed together. In
psychodynamic terms, the intentionally feigned signs and symptoms of Factitious Disorder
satisfy the unconscious need that the primary gain from an illness serves, that is, the
unconsciously determined transformation of conflict into symptomatology. By contrast, the

42
symptoms feigned in Malingering are consciously motivated by the secondary gain or
environmentally recognizable advantages that they are intended to procure.
Somatoform Disorders are characterized by the presence of physical symptoms that are not
intentionally produced and are not under voluntary control. These complaints suggest a medical
condition but cannot be fully explained by a general medical condition, by the direct effects of a
drug substance, or by another mental disorder. Psychological factors, inferred to be dynamically
unconscious, are judged to have an important role in regard to the physical symptoms. In this
mental disorder, the patient appears to believe that their symptoms are real. Complaints are either
in excess of what would be expected from history, physical examination, or laboratory findings
or there may be the absence of objective findings to fully explain the clinical presentation. Other
mental disorders and genuine medical disorders may coexist with Somatoform Disorders.
Malingering differs from Somatoform Disorders in that the malingerer’s intentionally feigned
presentation of physical and psychological symptoms is under voluntary control. In Somatoform
Disorders only physical symptoms are present and they are not intentionally feigned and are not
under the patient’s voluntary control. Conversion Disorder within the Somatoform category is
susceptible to symptom relief by suggestion and by hypnosis unlike the situation in Malingering.
Malingering and Somatoform Disorders may exist together. Somatoform Disorders may also
exist with Factitious Disorders. If Factitious Disorder is diagnosed, Malingering may not be
added to Axis I as an additional condition.

43
COURSE AND PROGNOSIS
Malingering when deemed present needs to be assessed in the overall biopsychosocial context of
the person’s life. The presence of diagnosable mental disorders, their histories, and their response
to psychotherapy and medications must be addressed. Any acute or chronic medical or surgical
problem(s) and its impact on the patient’s overall functioning need to be considered. In forensic,
hospital-related settings, or in military cases, Malingering may be context specific and change its
presentation or even disappear if circumstances change. Since malingerers do not usually comply
with treatment recommendations, the Malingering status often remains unaffected. Research in
this area is limited but shows that if reinforced, Malingering may continue; if malingered goals
are met, symptoms sometimes abate; if the malingerer becomes frustrated with current care,
other providers are sought.
TREATMENT AND MANAGEMENT
Since Malingering is regarded as a condition that may be a focus of clinical attention, no routine
or standardized interventions have been devised and recommended. A range of suitable
management approaches having clarification as a primary goal includes the following. (1) A
clear diagnostic delineation of any medical or psychiatric disorders, if present, in addition to
Malingering. (2) A mindful consideration of legal and ethical issues, especially reflected in the
medical record since Malingering is unlikely to be proved conclusively. (3) If the psychiatrist is
44
the treater, a non-threatening approach of concerned neutrality and the avoidance of any abrupt
confrontation or accusations of lying. Clear recognition of issues of countertransference reactions
and prescience for the subtle impact of projective identification on all parties can minimize
inordinate distortions. The psychological boundary violations that result typically stir up adverse
and negative emotional responses that are counterproductive. Such unconscious information
transfers have important communicational value. They often act as defensive maneuvers whose
aim is to aggressively control and force the recipient to think and feel in ways the sender wishes.
The clinician might discuss that all findings indicate that no medical basis for the patient’s
symptoms can be found, and hence no medical or psychiatric diagnoses can be established.
Suggesting that the patient’s history appears incomplete or that something very important has
been left out may offer the patient a last opportunity to reveal the illness deception or, perhaps,
devise an explanation to save face. With tactful clarification, alternative strategies that are
healthier might emerge. Parsimonious, sensitive feedback might then encourage the patient to
shed further light on motivational impetus. In some cases, the patient may become angry,
respond defensively, and decide to go elsewhere. It is not often that a patient will openly admit to
malingering. (4) If the psychiatrist is a consultant, recommendations and management strategies
as suggested above can be provided directly to the referring party for implementation.
FUTURE DIRECTIONS
The introduction of Malingering into DSM III in 1980 brought about a vociferous reaction by
many non-medical specialists in a vigorous effort to question and to examine the validity of this
45
attempt to medicalize deceptive illness behavior. What had seemingly been in the realm of an
orphan condition was and is now becoming the subject of intense debate. This is in contrast to an
alternate view, which emphasizes the person in terms of surgency, agency, having free will and
choice, and being able to make consciously planned decisions. From this perspective,
malingering as illness deception is said to be better regarded within the context of individual
responsibility, conscious choice, and social action. In such a framework, then, the emphasis in
malingering, it is advocated, should eschew an uncritical adoption of the medical model and take
into consideration legal issues and those having to do with social deviance. It has been stated by
those who advocate this position that patterns which are, in fact, “bad behavior” are incorrectly
being redefined as bona fide illnesses.
Many have debated the extent to which malingering has clear-cut legal implications as, for
example, its being equated with criminal fraud. It may be argued that the function of a medical
expert is not principally to make a judgment on an individual’s honesty since issues relating to
conscious and unconscious motivational factors are clearly involved and at best are ambiguous.
The medical expert’s role is to assess a clinical presentation, evaluate reported symptoms, render
diagnoses based on the best evidence possible, and suggest a treatment plan. This approach to
malingering clearly gives the physician a medical rather than legal or even moral role.
The effort to introduce more objectivity into the field of detecting malingering has produced
sophisticated test measures from the medical field. Detecting deception has shown some success
46
by mapping brain correlates of lying. Functional magnetic resonance imaging (fMRI) has
demonstrated specific neurocircuitry in brain regions under conditions of simulated, mock crime
such as stealing. Truthful from deceptive responses, for example, were correctly identified in
90% of the model testing group. Similar brain imaging studies have shown that different cerebral
activation processes are involved when a symptom is subjectively experienced as real compared
to when it is intentionally feigned. Such objective data are intriguing but far from conclusive.
The entire area of malingering and all that it implies is complex. Obvious psychological,
psychiatric, monetary, social, legal, and philosophical issues, to mention merely a few, are at
play. Although it is laudatory to attempt to understand malingering in an objectively valid
manner as many in specialized fields are attempting to do, the explosion of research, conjecture,
simulation studies, and psychological testing has raised serious ethical questions. At this time,
there is no generally agreed upon consensus. In the author’s opinion, the psychiatric approach
with its relatively straightforward and non-judgmental guidelines, dedicated capacity for
examining multiple sources of information, and nosological reserve appears as a rational, if not
essential, player in the field.
SUGGESTED CROSS-REFERENCES
Factitious disorders are discussed in Chapter 16. The Somatoform disorders and pain are
discussed in Chapter 15; further differentiation of those disorders from malingering may be
found in those chapters. Chapter 8 outlines the clinical manifestations of psychiatric disorders.
47
Schizophrenia is discussed in Chapter 12; Dementia, Delirium, Amnesic disorders, and other
disorders of cognition are discussed in Chapter 10. Intellectual disabilities such as Mental
Retardation and Borderline Intellectual Functioning are discussed in Chapters 34, and 26.3,
respectively. Dissociative amnesia is addressed in Chapter 17. Depressive disorders are reviewed
in Chapter 13. Anxiety and Posttraumatic stress disorder are discussed in Chapter 14. Attention-
deficit disorders are discussed in Chapter 39. Various personality disorders and traits, including
borderline, narcissistic, histrionic, and antisocial personality disorder, are elucidated in Chapter
23. Examination of the psychiatric patient and psychological and neuropsychological testing are
addressed in Chapter 7. Consultation-Liaison psychiatry is discussed in Chapter 24.11. Ethical
and forensic psychiatry are reviewed in Chapter 54.
REFERENCES
Bion WR. Learning from Experience. London: Heinemann; 1962.
Bion WR. Attention and Interpretation. London: Tavistock; 1970.
Clark C: Sociopathy, malingering, and defensiveness. In: Rogers R, ed. Clinical Assessment of
malingering and deception. 2nd ed. New York: Guilford; 1997.
Cocchiarella L, Andersson G. Guides to the evaluation of permanent Impairment. 5th ed.
Chicago: AMA Press; 2001.

48
Crossman A M, Lewis M: Adult’s ability to detect children’s lying. Behavioral Sciences and the
Law. 2006; 24:703-715
Daubert v. Merrell Dow Pharmaceuticals, Inc., 113 S. Ct 2786 (1993).
Farkas M R, Rosenfeld B, Robbins R, van Gorp W: Do tests of malingering concur?
Concordance among malingering measures. Behavioral Sciences & the Law. 2006; 24:659-671.
Geller JL, Erlen J, Kaye NS, Fischer WH: Feigned insanity in nineteenth-century America:
Tactics, trials and truth. Behavioral Sciences and the Law. 1990; 8 (1):3-26.
Greer S, Chambliss L, Mackler L, Huber T: What physical exam techniques are useful to detect
malingering? Journal of Family Practice. 2005; 54 (8):719-722.
Guy L S, Kwartner P P, Miller H A: Investigating the M-FAST: Psychometric properties and
utility to detect diagnostic specific malingering. Behavioral Sciences and the Law. 2006; 24:
687-702.
*Halligan P W, Bass C, Oakley D A, eds. Malingering and Illness Deception. London: Oxford
University Press; 2003.

49
*Iverson G L: Ethical issues associated with the assessment of exaggeration, poor effort, and
malingering. Applied Neuropsychology. 2006; 13 (2):77-90.
Klein M: (1946). Notes on some schizoid mechanisms. In: Envy and Gratitude and Other Works,
London: Hogarth Press, 1975, pp. 1-24.
Klein M: (1957). Envy and Gratitude. In: Envy and Gratitude and Other Works, London:
Hogarth Press, 1975, pp. 176-235.
Kozel A , Johnson K A, Mu Q, Grenesko E L, Laken S J, George M S: Detecting deception
using functional magnetic resonance imaging. Biological Psychiatry. 2005; 58 (8):605-613.
Kucharski TL, Duncan S, Egan SS, Falkenbach DM: Psychopathy and malingering of
psychiatric disorder in criminal defendants. Behavioral Sciences and the Law. 2006; 24:633-644.
Libow JA: Child and adolescent illness falsification. Pediatrics. 2000; 105 (2):336-342.
McCann JT. The Significance of Malingering and Deception in Adolescents: Assessing
Credibility in Clinical and Forensic Settings. Washington, DC: American Psychological
Association; 1998.
McPhee SJ, Papadakis MA, Tierney LM: Current Medical Diagnosis and Treatment-2007.
NY,NY: McGraw Hill Publisher; 2007, p. 1007.

50
Mendelson G: ‘Compensation neurosis’ revisited: outcome studies of the effects of litigation.
Journal of Psychosomatic Research. 1995; 39:695-706.
Miller H A. M-FAST: Miller Forensic Assessment of Symptoms Test and professional manual.
Odessa, FL: Psychological Assessment Resources. 2001.
Mittenberg W, Patton C, Canyock EM, Condit DC: Base rates of Malingering and symptom
exaggeration. J Clin Exp Neuropsychol. 2002; 24 (8): 1094-1102.
*Mittenberg W, Aguila-Puentes G, Patton C, Canyock EM, Heilbronner RL.
Neuropsychological profiling of symptom exaggeration and malingering. Journal of Forensic
Neuropsychology. 2002; 3(1-2):227-240.
Ninivaggi, Frank J. Biomental Child Development: Perspectives on Parenting and Psychology
(Lanham, 2013).
Ninivaggi, Frank J. Envy Theory: Perspectives on the Theory of Envy (Lanham, MD: Rowman &
Littlefield, 2010).
51
Oakly DA, Ward NS, Halligan PW, Frackowiak RSJ: Differential brain activations for
malingered and subjectively ‘real’ paralysis. In: Halligan P, Bass C, Oakley DA, eds.
Malingering and Illness Deception. London: Oxford University Press. 2003, pp.267-284.
Poythress N , Edens J , Watkins M M: The relationship between psychopathic personality
features and malingering symptoms of major mental illness. Law and Human Behavior. 2001; 25
(6):567-582.
*Reynolds CR (ed.). Detection of Malingering During Head Injury Litigation. New
York:Plenum; 1998.
Rogers R: Models of feigned mental illness. Professional Psychology: Research and practice.
1990; 21:182-188.
Rogers R, Sewell KW, Goldstein AM: Explanatory models of Malingering: A prototypical
analysis. Law and Human Behavior. 1994; 18 (5): 543-552.
*Rogers R. Clinical Assessment of Malingering and Deception. New York: Guilford Press; 1997.
Sanders M J: Symptom coaching: factitious disorder by proxy with older children. Clinical
Psychology Review. 1995; 15(5): 423-442.

52
Wechsler D. Wechsler Adult Intelligence Scale---Revised. San Antonio, TX: Psychological
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TABLE 1.1 Contexts in Which Malingering May Present
1. Avoiding responsibility: military service; child or adolescent school avoidance

53
2. Criminal forensic contexts: avoiding punishment, criminal liability, or seeking
transfer from prison to hospital (base rate incidence in criminal cases about 19%)
3. Medicolegal Contexts: to obtain financial gain, compensation cases (personal
injury 29%; disability 30%)
4. Emergency Department or Primary Care outpatient clinic visits to gain admission
to hospital as may be found in homeless persons seeking shelter
5. Outpatient settings: Medical requests to obtain drugs such as controlled
substances, narcotics, minor tranquilizers, or psychostimulants
TABLE 1.2 Clinical Presentations of Malingered Symptomatology

54
1. Physical: Pain and incapacity due to injury or chronic medical condition;
Pseudoseizures
2. Psychological:
PTSD
Depression
Amnesia
Psychosis
Intellectual disabilities, MR, Borderline Intellectual Functioning, Dementia
Miscellaneous disorders: Attention -Deficit/Hyperactivity disorder
TABLE 1.3 Degrees of Certainty for Coding Malingering

55
1. Indeterminate Findings suggest the possible presence of Malingering according
to DSM IV-TR guidelines but are currently too ambiguous,
insufficient, and unsupported by collateral evidence
2. Strongly Suspected Findings are consistent with basic DSM IV-TR guidelines
but lack typically associated features and contexts; collateral
support is equivocal
3. Provisional Findings are consistent with basic DSM IV-TR guidelines although
currently incomplete or of too brief a duration, yet a strong presumption
exists that more complete indicators will be found over time
4. Probable Findings are consistent with basic DSM IV-TR guidelines,
associated features and contexts are present, but there is a lack strong
confirmation from collateral sources, especially psychological testing
5. Present Findings are consistent with basic DSM IV-TR guidelines,
associated features and contexts, and are supported by a
preponderance of evidence from most collateral sources
TABLE 1.4 Clinical Decision Model for Coding Malingering on Axis I

56
1. Intentional production of false or grossly exaggerated physical or psychological
symptoms.
2. Motivation by external incentives:
A. avoiding military duty
B. avoiding work
C. obtaining financial compensation
D. evading criminal prosecution
E. obtaining drugs
F. adaptive behavior (e.g., feigning illness while a captive of the enemy during
wartime)
3. Medicolegal context
4. Marked discrepancy between a person’s claimed stress or disability and the objective
findings
5. Lack of cooperation during the diagnostic evaluation or in complying with treatment
6. The presence of Antisocial Personality
TABLE 1.5 Differentiating Malingering from Factitious and Somatoform Disorders

57
Malingering Factitious Somatoform
Presentation: Psychological/Physical Psychological/Physical Physical
Symptoms Signs and Symptoms Symptoms
Deliberate Feigning: Yes Yes No
Inferred Motivation: Cs desire for tangible gain Ucs need to assume sick role Ucsly
determined

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1

Edition. Vol. 2, Chp. 26.1, pp. 2479-2490. Wolters/Lippincott Williams Wilkens.

Frank John Ninivaggi, M. D.

Yale University School of Medicine

Haven, Connecticut; Medical Director of Psychiatric Services, Devereux-Glenholme Residential

grossly exaggerated physical or psychological symptoms, motivated by external incentives, and

Century describing it as “back-formation from malingere, apparently from French malingre,

perhaps formed as mal-‘wrongly, improperly’ + haingre ‘weak,’ probably of Germanic origin.”

problem with important social implications. Malingering is socially problematic behavior.

symptomatology. Dissimulate denotes concealing, hiding, or disguising perceived truth under a

an advantage. Dissimulation encompasses three principal subcategories: Malingering,

defensiveness or faking good, and markedly inconsistent, evasive responses. Dissimulation in

psychiatry encompasses Malingering, faking good, and Factitious Disorder.

Malingering is medical deception, asserting that one has significantly distressing

denotation of deliberate illness misrepresentation. Some nuances include: to feign, disguise,

to achieve an intentionally fraudulent appearance.

tries to convey in such exaggerated fashion.

Defensiveness or faking good, by contrast, is a dissimulation by way of omission. It denotes

strategies, referred to as a “dance of denial,” to minimize incriminating behaviors when being

intended denial of real symptomatology.

imitation, or a representation (not a consciously deceptive mis-representation) of one process or

situation by using a different process or situation in an illustrative, perhaps, instructive context.

For example, simulation or analogue research protocols examining dissimulation or contexts in

assigned to experimental (participants asked to dissimulate and deceive) or to control

(participants asked to be honest) groups.

situation. More traditional, forensically-related issues especially faced in general psychiatry in

the interpretation of complex, often ambiguous, information is an explicit recognition of

unconscious psychodynamics, individual differences, and an appreciation of subtle individual

distinctions. Consideration of the presence of what Malingering connotes in any patient’s

proper treatment planning, especially the rational prescription of medications.

DEFINITION AND COMPARATIVE NOSOLOGY

The essential feature of Malingering is 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. Under some circumstances, Malingering may represent adaptive

behavior---for example, feigning illness while a captive of the enemy during

Malingering is coded on Axis I as v65.2. DSM IV-TR goes on to say that

Malingering should be strongly suspected if any combination of the

1. Medicolegal context of presentation (e.g., the person is referred by an

attorney to the clinician for examination)

2. Marked discrepancy between the person’s claimed stress or disability and

the objective findings

3. Lack of cooperation during the diagnostic evaluation and in complying

with the prescribed treatment regimen

4. The presence of Antisocial Personality Disorder

problem is attributable to a mental disorder.

following: Malingering (conscious simulation)

Person feigning illness (with obvious motivation)

no suggestions regarding chronological age range or clear-cut demographic or epidemiological

and unreliable information, it is difficult, if not impossible, to organize findings in a consistently

coherent fashion. Clinical judgment, especially about motivation, therefore, is essential in

Hence, as a scientifically justifiable construct, Malingering remains more in the context of

hypotheses remains in statu nascendi.

In ordinary clinical practice, some have suggested a 1% prevalence; in military populations, a

5% occurrence; and in litigious, criminal situations, up to 20 %. A recent 2002 study of 131

worker’s compensation, 19 % in criminal cases, and 8 % in medical or psychiatric cases.

nature. Issues of cognitive development, cognitive refinement, introspection, insight, accurate

mechanisms contributing to Malingering. The label of Malingering moreover may be construed

doctor if challenged. Hence a diligent, parsimonious, and perspicacious approach to a patient’s

ingredients leading to fair and reasonable conclusions.

proposed consideration of three explanatory models of Malingering using a prototypical analysis