Malingering is a diagnosis of exclusion. Because it is not a true clinical illness, the differential diagnosis can include a variety of disorders. The key component of malingering is intentional misrepresentation, which requires the realization that the patient may have a secondary gain by feigning an illness. The authors present the case of a prisoner who came to the emergency department with the chief complaint of cough and fever but who had normal physical examination and laboratory findings. The patient managed to have confused the prison physicians in an unusual way.

Malingering is defined as pretending to be ill, usually for the purpose of attaining financial or another self-serving goal.¹ According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the individual voluntarily controls the production of symptoms and is in pursuit of a goal that is obviously recognizable.² External incentives include avoiding military conscription or duty, avoiding work, obtaining financial compensation, evading criminal prosecution, obtaining drugs, gaining hospital admission for purposes of free room and board, or securing better living conditions.³ The single variable that is essential to establishing the conscious misrepresentation of an illness inherent to malingering is the presence of secondary gain.

Illustrative Case
A 42-year-old man was transferred from Prison Health Services for evaluation of 1-week duration of cough and subjective fever. He denied any difficulty breathing, chest pain, sore throat, congestion, weight loss, or malaise. He had no risk factors for immunosuppression and had no significant medical history. He also denied ever having smoked. A single posteroanterior (PA) chest radiograph that accompanied the patient from Prison Health Services was interpreted as a left lower-lobe infiltrate (Figure 1). The patient was referred for a presumptive diagnosis of pneumonia and was treated with intravenous (IV) antibiotics.

Physical examination showed the man was alert and oriented and in no apparent distress. Vital signs were: temperature, 37°C; pulse, 64 beats/min; blood pressure, 110/70 mm Hg; respiratory rate, 12 breaths/min; oxygen saturation, 98% on room air. Examination of the head, eyes, ears, neck, and throat were unremarkable, as was the evaluation of the heart. Lung examination showed no evidence of rales, rhonchi, or wheezing. His lung sounds were symmetric. The remainder of the physical examination was normal.

Repeat PA and lateral chest radiographs were obtained, now clearly revealing that the patient not only had no active pulmonary processes but also had his arm over his left chest (Figure 2). When presented with the new evidence, the patient admitted that he was attempting to avoid prison and obtain the benefits of being a hospital patient. He was diagnosed with malingering and subsequently referred back to prison.

Characteristics of Malingering
Evidence to support malingering includes historical inconsistencies, contradictions in the physical examination, and symptoms that exceed the expected response to an injury. Although malingering was categorized as a mental disease in the past, this is no longer consistent with current beliefs. Malingering should be suspected in patients with any combination of the following presentations²:

• Medicolegal context of presentation
• Marked discrepancy between the claimed symptoms and the medical findings
• Lack of cooperation during the evaluation and noncompliance with treatment
• Presence of antisocial personality disorder.

Differential Diagnosis
Malingering may be a difficult diagnosis to confirm and may be confused with several other conditions in the differential diagnosis (Table).

Conversion disorder
Possibly the most difficult differentiation to make is between conversion disorder and malingering. The former is based on unconscious motivation and represents a true psychiatric disorder, whereas the latter is volitional.

Conversion disorder occurs more frequently in women than in men and in younger than in older age-groups, although persons of all ages and socioeconomic backgrounds may be affected.⁴ The condition is associated with high rates of neurologic and psychiatric comorbidity, including head injury, schizophrenia, manic depression, psychosis, epilepsy, alcoholism, and drug abuse.⁴ Therefore, the presence of organic disease does not exclude a diagnosis of conversion disorder and vice versa.⁵ Common examples of conversion symptoms include paralysis, seizures, anesthesia, unexplained blindness, diplopia, aphonia, amnesia, difficulty walking, and generalized pain.⁴

The diagnoses of conversion disorder and malingering are established by the history, physical examination, and negative laboratory test results and radiography findings. Hypnosis with IV amobarbital sodium (Amytal Sodium) has often been used to diagnose conversion disorder, but it also can be used to diagnose malingering. The procedure usually involves slow IV injection, at no greater than 50 mg/min, until drowsiness, slurred speech, and horizontal nystagmus appear. The maximum total dose is 500 mg. The patient is then interviewed and will often achieve a dramatic recovery if the interviewer predicts recovery during the interview.⁵ It is usually unsuccessful in the malingerer but can act as conclusive proof of conversion disorder with successful removal of the defect.

Today, benzodiazepines are used more frequently than amobarbital to provide sedation and to distinguish conversion disorder from malingering. In most instances, outpatient psychiatric and/or neurologic follow-up is warranted for conversion disorder. If the diagnosis is in question, which is often the case, further testing and/or admission to the hospital may be required. Research suggests that malingerers can easily fool clinicians into diagnosing emotional or cognitive abnormality.⁶ In such cases, collateral information can be very revealing. For example, the psychiatrist or neuropsychiatrist can administer the Minnesota Multiphasic Personality Inventory, which probably has the largest body of supportive literature among malingering detection methods, and its malingering indices have demonstrated validity.⁶ Of the 4 situations described in the DSM-IV-TR that raise suspicion of malingering, the discrepancy between claimed symptoms and those observed by the physician is the most reliable.⁷

Somatization disorder
Another diagnosis of exclusion is somatization disorder, which is characterized by the presence of multiple physical symptoms without underlying physical or psychiatric disease. The symptoms recur over a period of several years and cannot be attributed to an underlying physical or psychiatric disorder. Onset of the disease is usually before age 30 years, and more women than men are affected. Patients have a variety of symptoms, including pain; gastrointestinal, cardiopulmonary, and neurologic complaints; and sexual problems or other symptoms related to the reproductive system.⁸

The DSM-IV-TR definition of somatization disorder requires that the patient have a history of at least 8 symptoms that cannot be fully explained by a known medical condition or the direct effects of a drug or medication. The symptoms must result in treatment being sought or in significant impairment in social, occupational, or other important areas of functioning.² As with malingering, there is a risk of iatrogenic complications in somatization disorder because of the patient’s continuing search for medical care. This often results in frequent visits to several physicians, making it difficult to keep a complete record of the patient’s history.⁸ Such patients are usually difficult to treat, and the disease often runs a chronic course.

Undifferentiated somatoform disorder is a milder form of somatization disorder and is treated similarly to somatization disorder.^2,9 Patients who do not meet the full criteria of somatization disorder but have suggestive symptoms for 6 months or longer may be classified as having it.² Undifferentiated somatoform disorder is defined as:

• 1 or more physical complaints lasting more than 6 months and causing significant distress
• Symptoms that either cannot be explained by a known general medical condition or drug or are in excess of what would be expected from physical findings
• The symptoms are not feigned and cannot be accounted for by another mental disorder.^2,9

The medically unexplained symptoms and concern about illness may have a cultural basis, constituting what is referred to as culturally shaped “idioms of distress” that are used to express concerns about a variety of personal and social issues.

The physician should take a careful history and perform a thorough physical examination while providing reassurance to the patient. This approach is better than performing a battery of tests that may be harmful to the patient, unless objective signs indicate the need for further investigation.¹⁰ Of note, physicians may not recognize that the patient with apparent somatization disorder may also have anxiety disorder or depression, or may have an actual organic process, which may go undiagnosed.¹¹

Hypochondriasis
Hypochondriasis is characterized by the following²:

• Physical symptoms disproportionate to demonstrable organic disease
• Fear of disease and conviction that one is sick
• Preoccupation with personal health and physical appearance
• Repeat visits to physicians with a history of numerous procedures and surgeries, with return of symptoms.

Patients with hypochondriasis are apprehensive about having a physical illness, often to the point where they may be preoccupied with normal physiologic events, such as bowel sounds or pulses. In contrast to the malingerer, hypochondriacs are not deliberately feigning illness; they are exhibiting unconscious behavior.²

Factitious disorder
Another important differentiation is between factitious disorder and malingering. The malingering patient’s symptoms are under voluntary control, but for an obvious goal. In contrast, a patient with a factitious illness has no apparent goal other than to assume the role of a patient.³ As with malingering and conversion disorder, true psychological or physical symptoms may coexist with a factitious disorder.¹² Commonly associated features include substance abuse, self-induced physical illness, and a history of incarceration. Diagnostic features include a history of many hospitalizations and an eagerness to assume the patient role.^2,12 The patient may present with complaints that suggest psychiatric, medical, or surgical illness.

Munchausen syndrome, the most dramatic of the factitious disorders, was first described in 1951.13 This rare syndrome takes its name from Baron Karl F. von Munchausen (1720–1797), a noted raconteur who amused his friends with fantastic and entertaining, but untrue, personal stories. The diagnosis is applied to individuals who repeatedly gain hospital admission or medical attention by simulating illness with dramatic but false complaints.¹⁴ The diagnosis is applied to only 10% to 20% of patients with factitious disorders.¹⁵ The prognosis for cure remains poor. Psychiatric treatment is the mainstay. Prognosis is much better for patients who have factitious illnesses without having true Munchausen syndrome.¹²

Establishing the Diagnosis
If the suspicion remains high that the patient is malingering based on the 4 criteria outlined above, the diagnosis should be given indirectly, by gradually and subtly implying that the physician is aware of the absence of medical illness, and that the patient’s symptoms are not consistent with a medical disease. The physician may also deprive the patient of the benefits of the sick role if the physician is certain that a medical or psychiatric disorder does not coexist with the malingering. No treatment exists for malingering.

Is Malingering an Illness?
One view holds that malingering is not a disease or a disorder; it simply needs to be detected. Malingerers do not want to be treated since they are “gaming the system” for personal advantage. The last thing they want is an accurate identification of their behavior and appropriate intervention. The physician should maintain clinical neutrality and offer reassurance that the symptoms and examination findings are not consistent with any serious disease.³

Because of the legal implications and obligation to the patient, physicians tend to err on the side of presuming dysfunction. In addition, for many clinical conditions, it is far worse to overlook a disorder than to overdiagnose it.⁶ However, the patient may be less likely to suffer iatrogenic illness, undergo unnecessary and costly tests and procedures, and repeatedly visit doctors when the diagnosis of malingering or a somatoform disorder is presented to the patient in an empathetic manner. Hospital administrators and risk management staff may be of assistance if difficulties arise.³ Clandestine searches are inadvisable, and patient confidentiality should always be respected.¹⁶

Conclusion
In the illustrative case, the only tests needed to ascertain the diagnosis of malingering were the PA and lateral radiographs. The additional views detected the patient’s left arm as the abnormality that had originally been described as a left lower-lobe infiltrate.

This case also demonstrates the importance of having 2 views on standard chest radiographs to detect a disease process. Since only a single chest radiograph view was obtained from Prison Health Services, the patient was able to fool the prison physicians into thinking that he was ill.

Self-assessment test
1. Which of the following features is NOT a characteristic of malingering?
A. Medicolegal context of presentation
B. Marked discrepancy between claimed symptoms and clinical findings
C. Desire to play the role of a patient
D. Antisocial personality

2. All these features are characteristic of conversion disorder, except:
A. More common in older than in younger adults
B. More common in women than in men
C. High rates of neurologic comorbidity
D. High rates of psychiatric comorbidity

3. In which of these conditions are symptoms preceded by conflicts or other stressors?
A. Factitious disorder
B. Conversion disorder
C. Hypochondriasis
D. Somatization disorder

4. Which of these conditions is characterized by intentional feigning of symptoms?
A. Factitious disorder
B. Conversion disorder
C. Hypochondriasis
D. Somatization disorder

5. Which of these features is most characteristic of somatization disorder?
A. Numerous physical complaints lasting more than 6 months
B. Many psychological symptoms lasting more than 6 months
C. Comorbid anxiety
D. Disease onset after age 30 years

References
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10. Purcell TB. The somatic patient. Emerg Med Clin North Am. 1991; 9:137-159.

11. Walker EA. Medically unexplained physical symptoms. Clin Obstet Gynecol. 1997;40:589-600.

12. Folks DG, Freeman AM III. Munchausen’s syndrome and other factitious illness. Psychiatr Clin North Am. 1985;8:263-278.

13. Asher R. Munchausen’s syndrome. Lancet. 1951;1:339-341.

14. Kwan P, Lynch S, Davy A. Munchausen’s syndrome with concurrent neurological and psychiatric presentations. J R Soc Med. 1997; 90:83-85.

15. Sutherland AJ, Rodin GM. Factitious disorders in a general hospital setting: clinical features and a review of the literature. Psychosomatics. 1990;31:392-399.

16. Wise MG, Ford CV. Factitious disorders. Prim Care. 1999;26:315-326.