This is not a medical or psychiatric diagnosis. It refers to willful production of a physical or psychological symptom with the intent of deceiving others and gaining some privileges. The difference from factitious disorder is that here the malingerer is after material gain or escape from punishment. Usually this occurs in forensic settings (when some public figure is arrested!) and in prisoners. The doctor has to examine the patient at different times to check for consistency if the symptoms. If the symptoms are changing in an inconsistent manner it is conclusive proof. The patient’s behavior has to be observed when he is unaware of this. A person with limping may be found to walk normally when alone in his room. Subjective complaint like insomnia may be reported to get hypnotic drugs. Here also observation is important.
It is not correct to ill-treat or insult a malingerer. He has no valid reason to be in the hospital. But he may be having other difficulties. After ensuring that this is ‘genuine’ malingering, the doctor has to report this to concerned authorities. He has to be handled by appropriate social, legal or government agencies.
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1 week ago
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Hi friends,
Another excellent piece of writing from Dr.Harish! We have no other ways but to appreciate his hard work and effort to present socially relevant topics. Problems like malingering are calling for the necessity of a more objective diagnostic criterion in mind-brain disorders. The experiments of Rosenhan are still possible today. His first experiment has a problem of ‘conscious lying’ but his second experiment of ‘detecting non existent fake patients’ deserves serious attention. Different psychiatrists may diagnose different disorders in the same cases. The accuracy of identifying fake disorders or malingering is doubtful. Not all people do malingering or crimes. Capgras delusion was an act of lying many years ago, nobody doubted the role of biological dysfunction. It was same for hallucinations and delusions, experts of ancient times considered it as either an act of lying or an act of supernatural powers. Who knows that how many psychotics are punished for their abnormality? There are reports of criminals using mental illness as an excuse for crime in courts. It can not be allowed. Modification of laws or diagnostic criteria may not solve this problem but I think it is more rational to dedicate time to find objective diagnostic methods. Imaging studies can show significant changes in the brain of some psychotic patients but it is too expensive to use as a routine tool. Still doctors need to use it as a more common diagnostic tool to identify new patterns and also to obtain large samples of brain images. People may fake insomnia or stress to get anxiolytics but we should also note that healthy people in the developed countries consume too much food supplements, enriched foods or vitamin tablets. Everybody has a desire to feel better and human beings are not evolved in conditions like this to accumulate small biological changes necessary to cope with the day to day stress of modern civilization has given to us. US Citizens are more mentally disturbed than people who live in undeveloped countries and it is evident from daily news reports. American delusion of biological weapons in Iraq led to the destruction of a country, its people and civilizations. Both communists and religious governments are also not bad in enforcing strange pathological regulations to citizens. Madness is considered relative and who is madder is an interesting question for me.
Thank you.
hi all, i have had tales from lawyer friends about many cases of successful malingering, mainly in breach of contract cases where the party that breaches proves in court that he was of unsound mind when entering into the contract. Can brain mapping indicate malingering, and if so, can it not be used in such cases ? Is there any independent aid that a pschiatrist can call for to bolster his diagnosis, at present ? The range of psychiatric illnesses is so wide that i doubt if an objective method can be developed, apart from setting up a broad range of criteria. There might be a marker for some specific disease, but for all psychiatric patients, i sincerely think not. I wonder what type of objective method Ajeesh is aiming for. Thank you'
Hi all!
Both sashi and Ajeesh have rightly pointed to the dangers that can occur when people start to feign psychological disorders. Our western text books quote several stories of people who received huge amounts as compensation following road traffic or work related accidents. A follow up after few years showed that a huge number of them were living quite free of any disability, obviuosly richer. It is not very common for people to feign mental illnesses in this part of the world, but in this age of globalization of everything, one has to be cautious. Malingering is not uncommon in the context of crimes. Again we are lucky because presentation with psychological symptoms are not common. It is true that we do not have any objective tests for confirming the diagnosis in psychiatry, but skillful use of observation and interviewing helps in many cases. But it will be ideal if there is a test for diagnosing at least major disorders.
Psychological tests are nothing more than extensions of mental status examination. Both are based on analysing a sample of observed behavior. Most tests are based on theories without any empirical evidence. Difference of opinion is frquent in the interpretation of the same test protocol. Again things are difficult because there is no onjective gold standard.
The issue of abusing drugs and using fake prescriptions is real. But medical professionals are helpless. Many pharmacists also give drugs based on symptoms reported by public. Some even venture to advice on the use of psychotrpoics. As in many other issues, we have excellent laws, but there is no agency to check on how these are implemented in real world. Many teenagers abuse sedative / hypnotic drugs without knowing the dangers. I have come across a few who use up to 30 tablets of Proxyvon. Thank You.
hi.... I think, like ajeesh observed, some knowledge of psychiatric presentations is necessary for successive psychological malingering. Probably it's low in our country because most eccentricities are tolerated in our country, which would attract the psychiatrist's attention in western countries. Only the more florid and dramatic forms of abnormal behaviour was considered as genuine insanity. It is difficult for people to enact such extreme symptoms and still walk around to commit crimes. Once people, nowadays, start to learn about psychiatric symptoms form the net, and it's subtle features,we can expect an increase in malingering. And with increasing education, the ability to malinger will only improve., as harish anticipates. But hopefully such individuals may use it only for attaining purely private aims, not for crimes. As ajeesh said, a mental fitness certificate is very useful in breach of contract cases. He has come up with a very useful suggestion which can save a lot of the court's time in useless litigation. But usually a clause is added, at the end of malor contracts, that ' i make this agreement under my own will and in full possession of my faculties, and not under any duress ' .will that suffice as a declaration of sanity for legal purposes, i guess we will have to ask a lawyer for that. Otherwise 1000s of contracts are signed everyday, no psychiatrist will ever be able to treat anybody, he will be busy issuing mental fitness certificates !......thank you
Hi
I just heard today that the supreme court has sais in a recent judgement (on 23rd October) that medical insanity is not the same as legal insanity. Details of this are not available yet to me. I dont know what implicatios it may have on psychiatric practice.
Hi friends,
It is better to consider mentally disturbed people as normal people in legal proceedings otherwise they have serious mind-brain disorders that make them disabled to make proper judgment, at least till we get a biological model of diagnosis. A good percentage of mentally disturbed persons are capable of making crucial decisions or understanding legal implications of their actions. Almost all people have at least one phobia. One percentage of people has schizophrenia. Another one percentage has bipolar disorder. More than five percentages of people are troubled with OCD. But it is obvious that more than 99% of people are able to take proper decisions or understand the importance of their actions. I think mild to moderate cases of mind-brain disorders should be considered ‘normal’ in legal proceedings. They should be treated like all others due to some practical problems. It may help prevent excessive malingering. The situation may change when we have enough objective models of diagnosis of mind-brain disorders.
I do not know if my observation is right but I like to put it here for your evaluation. I have seen that popular doctors (doctors with a lot of patients) use more drugs than others. The use of antibiotics in viral fever is a habit. People get around 7 drugs from small village clinics for their common cold and light fever. Popular cough and cold remedies contain 4 or 5 drugs. The trick is that one of the drugs may click. Some guys are super smart that they give a good brand of pantoprazole and a low quality brand of omeprazole at the same time. They keep both deals intact and patient is safe because only the good brand acts.Small private clinics seen in our area do not provide the details of the drugs they use. We have to move the patients to Medical Colleges when the problems get worse and nobody knows that what drugs or injections the patients already got. It is dangerous, unethical and the patient has all the right to know what he gets. Some drugs are needed for life long and it is very nice if the patient/guardian knows about the economical and potential effects and side effects of the drug. The doctor is the right person to give this information. I do not know how many doctors are interested in patient education. I am afraid that the side effects of the commonly used antidepressants are underestimated. They cause sexual dysfunction in approximately 70% of men. Significant weight gain / loss are also common. Other problems may include decreased ability to enjoy art forms, decreased sensitivity to emotions, altered perceptions or behavioral patterns etc… So a search for optimum doses are important, not the recommended maximum doses. Patient or the guardian (in severe cases) should be informed of this. Drug company’s claims of restoring chemical balance in the brain are over simplified and misleading. Some of the drugs are unnecessarily expensive. A radical change in the current practice of medicine is required. Patient education is necessary to avoid patients falling into the traps of pseudo sciences. A good percentage of people treated under Homeopathy or Naturopathy recover to complete health means nothing but the same percentage of people do not need any drug therapy, in my opinion. I consider Homeopathy as a pseudoscience and their drugs are placebos. There should be an initiative from health professionals.
Thank you.
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