Techniques for the Malingering Patient

As you begin to put more and more years of practice under your belt, you will increasingly begin to recognize that some of your patients are faking their symptoms for secondary gain. Nobody knows how common this is, and it probably is pretty uncommon, but you will need to know how to recognize such patients and to “smoke them out.” This chapter provides you some helpful techniques.

But before proceeding, make sure not to confuse malingering with “factitious disorder,” or Munchausen’s syndrome. Munchausen’s involves the self-infliction of actual pain or injury with no clear secondary gain being served. Such patients may be motivated by unconscious psychodynamic motivations, and while they, like malingerers, lie about their symptoms, the ultimate treatment approach is different, because Munchausen’s represents a recognized psychiatric syndrome unto itself, while malingering is just lying, plain, and simple.

CLINICAL VIGNETTE

A 34-year-old single man presented to me after having been referred by employee health at his manufacturing company. He appeared somewhat disheveled and launched into a narrative about a work situation, saying that “It all started on June 6, when this foreman called me into his office.” As he began describing the episode, I reached over for my pen and clipboard. He responded to my movement with a dramatic startle response, and then explained, “I don’t know what that is, it’s been happening ever since that day in June.” On my prompting, he described in great detail a series of events leading to
his current short-term medical disability, including precise dates and names of all parties involved. During the review of psychiatric symptoms, when asked about his memory and concentration, he said, “I can’t remember a single thing since June, I can’t even read.”

Obviously, there are a number of clues to malingering here. The “startle response” was exaggerated to the point of looking like a convulsion and his self-described concentration problems were undermined by his masterful ability to describe the “traumatic” event at work. Over time, he failed to respond to any of the medications usually helpful for PTSD, and once he was approved for long-term disability he stopped coming to appointments. The coup de grace was failure to pay his bill because of bankruptcy!

The first step in correctly diagnosing malingering is to have a high index of suspicion that it exists. All of the following patient categories are red flags for possible malingering:

Any patient on any form of disability, whether through work or public insurance
Any patient involved in litigation having to do with the psychiatric illness
Any patient who, early on in the appointment, indicates that they are hoping to leave the appointment with a prescription for a controlled medication

I don’t mean to sound heartless; in my experience the majority of patients on disability are genuinely disabled, and litigation is often legitimate. But if you raise your malingering antennae with these types of patients, you’ll rarely find yourself duped.

INTERVIEWING CLUES TO MALINGERING (AND STRATEGIES FOR RESPONDING)

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