Article summary of Feigned medical presentations by Granacher & Berry - Chapter

What is the difference between feigning and malingering?

In the medical context, the term feigning is used more broadly than malingering, and includes exaggeration, magnification, or faking of symptoms. Feigning can include unawareness of behavior for the production of simulated symptoms without clear evidence of external gain. Malingering is a conscious choice to intentionally exaggerate or fabricate a medical or psychological condition for external gain. Feigned presentations can be classified in three general domains, namely physical (somatic), cognitive, and psychological (emotional). 

What types of malingering are there?

Three categories of malingering have been identified: 

• In pure malingering the person entirely fabricates a psychological or medical condition that does not exist and has never existed. 

• In partial malingering the person is exaggerating symptoms of a condition that actually exists. 

• False imputation refers to an individual ascribing symptoms to an unrelated cause. Here, the symptoms are genuine, only the source of the symptoms is in question.

Which differential diagnoses exist with regards to malingering?

When malingering is a clinical consideration, the following five conditions should be considered in the differential diagnosis:

• Undetected physical pathology. Any person with unexplained physical complaints may actually have an illness that is not detected during an initial evaluation (or even with subsequent testing). 

• Somatization disorder. This refers to a pattern of recurring polysymptomatic somatic complaints resulting in medical treatment or impaired daily functioning. 

• Hypochondriasis. This refers to the preoccupation with the fear of having, or the idea that a person has, a serious disease based on the person’s misinterpretation of bodily symptoms. 

• Pain disorder (pain disorder with related psychological factors or pain disorder exclusively related to psychological factors).

• Factitious disorder with predominantly physical signs and symptoms. This refers to a category of physical or psychological symptoms that are intentionally produced in order to assume the sick role, which the patient finds very gratifying. 

How common are feigned medical presentations?

Almost any medical illness can be feigned or malingered. Some types of medical problems are more likely to be feigned or malingered than others, namely personal injury, disability, criminal injury, or medical matters. Within medical cases there are high percentages of probable malingering and symptom exaggeration. Malingering is often supported by evidence in severity or pattern of cognitive impairment inconsistent with the condition. There are also discrepancies among records, self-report, and observed behavior, and implausible self-reported symptoms in interviews. Finally there were implausible changes of test scores across repeated examinations and validity scales on objective personality tests. 

How prevalent is physical feigning and malingering?

The prevalence rates of physical feigning and malingering vary and studies often have very few participants. To determine the base rates for physical medical malingering multiple factors are involved, such as the clinical setting, the individual practitioner, the practitioner's specialty, whether psychological measures are added to physical examination, and clinical patients versus examinees seeking compensation. The two discrepancies in self-presentation most frequently mentioned as suggestive of malingering involved muscular weakness in the examinations not seen in other personal activities and claimed disablement disproportionate to the objective physical findings. 

How prevalent is cognitive feigning and malingering?

The most alleged neurocognitive impairment in a litigation setting is traumatic brain injury, with a combined rate of probable and definite malingered neurocognitive dysfunction of 54%. Examinations of traumatic brain injury in compensation-seeking circumstances should be looked at carefully, with attention paid to premorbid and postinjury psychological status, insufficient effort, and symptom exaggeration. 

How prevalent is psychological feigning and malingering?

Different feigning measures and detection strategies should be used for each different domain of psychological feigning (malingered psychosis, malingered PTSD, feigned psychological impairment). 

How can medical feigning and malingering be detected?

All cases of medical examination that include a significant incentive should include the services of a psychologist or a neuropsychologist to provide assessment of feigning/malingering. Motivation needs to be evaluated. Malingerers may complain of a mental, behavioral, or physical disorder (or all). The possibility of avoiding responsibility and/or getting a monetary award increases the likelihood of exaggeration and/or malingering. Nonspecific symptoms that are difficult to verify are often overrepresented (e.g. headache, lower back pain, vertigo). 

• There are no direct measurements of physical malingering available. Physicians will have to use fairly simple tests while performing a physical examination to detect symptom exaggeration/malingering. 

• Performance validity tests are very important when an examinee is claiming cognitive/neuropsychological deficits in a compensation-seeking context. Practitioners have multiple, well-validated procedures suitable for detection of such deficits, such as the Test of Memory Malingering, the Medical Symptom Validity Test, and the Word Memory Test. 

• The two most important measures for feigned mental disorders are the Miller Forensic Assessment of Symptoms Test and the second edition of the Structured Interview of Reported Symptoms.