Differential Diagnosis of Sensory and Cognitive Malingering

Version	Summary	Created by	Modification	Content Size	Created at	Operation
1		Gesualdo M Zucco	--	1281	2023-07-27 05:30:41	\|
2	format correct	Conner Chen	Meta information modification	1281	2023-07-31 03:15:48	\|

This entry is adapted from the peer-reviewed paper 10.3390/sci5030027

Malingering relates to intentionally pretending or exaggerating physical or psychologic symptoms to gain an external incentive, such as avoiding work, law prosecution or military service, or seeking financial compensation from insurance companies. Accordingly, various techniques have been developed in recent years by the scientific community to address this challenge.

visual malingering auditory malingering olfactory malingering

1. General Introduction

Throughout history, there have been numerous instances of individuals feigning physical or mental illnesses. This practice can be traced back to ancient times with Galeno, ^[1], who recorded cases of malingering in Roman times. In his pamphlet, Quomodo morbum simulantes sint deprehendendi, Galeno reported on two patients who faked illnesses, with one pretending to have colic to avoid a public meeting and the other feigning an injured knee to avoid accompanying his master on a long journey.

The legal setting is a context where malingering behaviours creep in, reaching 25–45% of faking attitudes ^[2]. However, it is difficult to accurately estimate the prevalence of simulation due to several reasons. One of the main challenges is that successful fakers, by definition, remain excluded from the statistics, resulting in an underestimation of the phenomenon but, despite this, the issue of faking should never be denied or overlooked.

Distortions can be of two types: the individual can exaggerate generic symptoms belonging to various psychopathological areas, such as anxiety or depression (generalized malingering), or symptoms related to a particular disease (specific malingering) ^[3].

One of the most useful distinctions to make when discussing deception is between fake-good and fake-bad ^[4]. Fake-bad, known as malingering, refers to a situation where a person feigns an organic/mental disorder, cognitive impairment, or exaggerated physical or psychological symptoms in a legal or civil setting to obtain compensation or a reduction in legal penalty ^[5].

On the other hand, fake-good, known as dissimulation, involves presenting oneself in a more favourable light to hide undesirable traits that could work against them. This could include exaggerating positive qualities or denying common human flaws. While malingering is recognized in DSM-5 ^[6], dissimulation is not explicitly mentioned. However, it can be described as the opposite of malingering, with an individual tending to provide positive self-descriptions.

2. Differential Diagnosis

Like lying, but not deliberate, as such, are certain forms of psychopathology. For malingering to be diagnosed, the following conditions must be ruled out systematically:

Conversion disorder along with other manifestations of somatoform disorders. A conversion disorder is a form of altered voluntary motor or sensory function, in which clinical findings demonstrate incompatibility between the symptom and recognized medical or neurological conditions. It differs from malingering in that motivation is internal rather than external, and intentionality is absent. In contrast, in malingering, intentionality is conscious.
Dissociative disorders. It is possible for the individual affected by the dissociative disorder to report psychic symptoms that are not attributable to a recognizable cognitive deficit or cerebral dysfunction. Dissociative disorders are characterized by a loss of continuity in the typical integration of consciousness, identity, memory, perception, behavior, and/or motor control. As opposed to conversion disorder, in dissociative disorders, symptoms are psychological rather than physical. Also, in this case, the differential diagnosis for malingering requires ruling out intentionality.
Factitious disorder: faking physical or psychological signs or symptoms or inducing injury or disease to oneself to play the sick role, attaining all corollary advantages deriving from the potential benefits. Malingering and factitious disorder are two conditions that involve the intentional creation or exaggeration of symptoms. The primary difference between the two is the motivation behind the behaviour. Malingering is the intentional fabrication of medical symptoms for the purpose of external gain, such as financial compensation or avoiding legal consequences.

Conclusions regarding motivation can be challenging; for this reason, when distinguishing between factitious disorders and malingering, the role of context and a well-documented evidence trail is essential. Moreover, in clinical practice, deception is considered rare, whereas it is considered more common in specific legal contexts or when a patient attempts to evade punishment in the criminal justice system or to obtain something. On the contrary, factitious disorders are generally encountered in clinical settings ^[4].

Other Diagnostic Categories

These are still used today in clinical and psychiatric forensic traditions ranging between descriptions of malingering, dissociative or somatoform conditions, and factitious disorders. Despite that, they lack a formalized and standardized definition. Due to their extensive use in the Italian forensic field.

Münchhausen syndrome ^[6]. This term was coined to describe those cases, predominantly in male individuals, that feigned physical symptoms and disorders. In this case, the aim is to perpetuate a pattern of hospital and care-related experiences, such as hospitalization, surgery, or quarrelsome relationships with medical professionals. It is distinguishable from factitious disorder because it is adopted to address more chronic and severe manifestations, less prone to recovery and where symptoms are legitimately auto-induced (with injury or medications) rather than purely feigned or merely lamented.
Münchhausen syndrome by proxy. Like Münchhausen syndrome, this term is applied to the more severe cases. However, in this syndrome, the symptoms are induced by the perpetrator to another person (the victim). This term is ambiguous and sometimes is used to malingering by proxy. Still, it differs from the latter because it is not motivated by external gains (e.g., keeping a son sick for financial gain).
Ganser syndrome ^[7] is typically observed in carceral environments and was initially noticed in convicts awaiting execution who would manifest a generalized plunge in superior cognitive functioning (with severe amnesia, absurd speech, failed logical reasoning) with preserved understanding, orientation, and consciousness instead. These symptoms are interpreted as signs of a dissociative disorder due to a highly stressogenic situation.
Compensation neurosis ^[8] describes an exaggeration of symptoms that occur due to the unique stressor of seeking legally awarded compensation. Motivation in these cases is primarily internal, coupled with less anticipation of secondary gain. The financial reward may be a part of the condition and may influence the course, but the overall pattern of symptoms is more than just the pursuit of money. Again, in malingering, exaggeration occurs solely or primarily for external incentives, while internal incentives in compensation neurosis are equal to or larger than external ones. Moreover, the diagnosis of compensation neurosis requires determining the conscious and unconscious motivation (frequently made in distinguishing factitious disorder from conversion disorder).

To sum up, the parameters to be considered are ^[1]:

-: subject’s conscious intentionality making psychic symptoms not based on a genuine dysfunction of the nervous system.
-: presence of external incentives.

In addition, malingering should be strongly suspected when any possible combination of these factors is presented: (1) symptoms occur in a medico-legal setting; (2) is noted by a marked discrepancy between the individual’s claimed impairment and the objective findings; (3) there is a lack in collaboration during the assessment and low compliance with the prescribed treatment regimen; and (4) the presence of antisocial personality disorder.

In the forensic context, particularly in forensic neuropsychology, it is good practice to identify the conscious intentionality of the subject and the existence of external incentives. If in a clinical setting, it is usual to go along with the symptoms that the patient reports; instead, in the forensic context, it is crucial first to take into account the two points listed above. Considering these parameters help the clinician to become a wiser expert. Depending on the form of simulation, intentionality may be absent or accentuated. The presence of consciousness about the planning of the disorder (challenging to ascertain) should be a criterion for identifying the symptoms of deception (see, however, ref. ^[9] for an unconscious, psychoanalytic interpretation of malingering). Moreover, in most cases, the external advantage may not be immediately recognizable. When doubt exists, it is essential to look in the case history for economic benefits that are not evident at first glance.

References

Ganis, G.; Keenan, J.P. The cognitive neuroscience of deception. Soc. Neurosci. 2009, 4, 465–472.
Greve, K.W.; Ord, J.S.; Bianchini, K.J.; Curtis, K.L. Prevalence of malingering in patients with chronic pain referred for psychologic evaluation in a medico-legal context. Arch. Phys. Med. Rehab. 2009, 90, 1117–1126.
Regier, D.A.; Kuhl, E.A.; Kupfer, D.J. The DSM-5: Classification and criteria changes. World Psychiatry 2013, 12, 92–98.
Ellingson, J.E.; McFarland, L.A. Understanding faking behavior through the lens of motivation: An application of VIE theory. Hum. Perform. 2011, 24, 322–337.
Monaro, M.; Mazza, C.; Colasanti, M.; Ferracuti, S.; Orrù, G.; di Domenico, A.; Roma, P. Detecting faking-good response style in personality questionnaires with four choice alternatives. Psychol. Res. 2021, 85, 3094–3107.
Abeln, B.; Love, R. An overview of Munchausen syndrome and Munchausen syndrome by proxy. Nurs. Clin. 2018, 53, 375–384.
Dieguez, S. Ganser syndrome. In Neurologic-Psychiatric Syndromes in Focus-Part II; Karger: Basel, Switzerland, 2018; Volume 42, pp. 1–22.
Hall, R.C.W.; Hall, R.C.W. Compensation neurosis: A too quickly forgotten concept. J. Am. Acad. Psychiatry 2012, 40, 390–398.
Eissler, K.R. Malingering. In Psychoanalysis and Culture; Wilbur, G.B., Muensterberger, W., Eds.; Essays in Honor of Géza Róheim; International Universities Press: Madison, CT, USA, 1951; pp. 218–253.

© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license; additional terms may apply. By using this site, you agree to the Terms and Conditions and Privacy Policy.

Upload a video for this entry

Information

Subjects: Medicine, General & Internal

Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :

Gesualdo M. Zucco

Giuseppe Sartori

View Times: 386

Update Date: 31 Jul 2023

Table of Contents

Video Upload Options

Confirm

1. General Introduction

2. Differential Diagnosis

Other Diagnostic Categories

References