There are definitions.
When a person feigns symptoms to get something tangible, such as money, time off from work, or food and shelter, it's called secondary gain. There is a difference between Malingering and factitious disorder. When people feign illness, they get attention and sympathy, which is called primary gain.
Malingering is adiagnosis of exclusion, meaning that it can only be made when other conditions have been ruled out. Symptoms such as seizures, chest pain, paralysis, and psychosis can be faked as they take time to evaluate and dangerous diseases cannot be immediately excluded. Malingering is not a diagnosis. According to the Diagnostic and Statistical Manual of Mental Diseases, malingers are not a mental illness.
There is a controversy.
Last year, a psychiatrist received a lot of criticism after announcing he was going to lecture students on malingering. He released a statement after cancelling the talk.
I have cancelled the proposed talk on ‘malingering.” I have seen some of the postings on Twitter about the talk, and reflected on the hurt it has caused, particularly for people who have personal experience of not being believed by mental health professions or services. I am very sorry for this.
Over the past ten years or so, evaluation of malingering has been a relatively small part of academic work that I do. It originated from assessing cognitive testing, and some medico-legal/court work. It is the case that some people have lied and feigned mental illness for various reasons in these environments, and it is important, as in any case of fraud, that the courts try detect this. Professionals, including psychiatrists, have been involved in some such instances.
However, it is also try that this is very much a minority occurrence, and the vast majority of people are doing their best to manage their mental health with or without the support of professional services. It is also the case that many people have felt ignored, marginalized, and disbelieved when engaging with services. The title of the proposed talk, the manner in which was advertised, and the lack of consideration for the wider context has understandingly caused upset.
Where professional discussions on malingering occur, I think that they are best kept to more specialist medico-legal settings and forums. A general medical student conference was not the place for this. The responsibility for giving the talk is mine, and not the medical students- I am the one who should have better anticipated this.
I apologize for the hurt and upset I have cause.
Critics commented after the cancellation was announced.
I believe that not talking about malingering in a formal setting with students is a mistake and more likely to increase these unfortunate outcomes.
You are referring to the person as a Liar.
In medicine, the word malingering is often used negatively. It conjures up an image of a person who is faking symptoms. Several Long Island Railroad employees were prosecuted a decade ago after they lied about being disabled to get extra pension benefits.
Malingering must be discussed with care. Dr. Jeffrey Keller works with inmates.
The most important consideration of the term “malingering” is not its actual definition. The most important part is its emotional meaning. This is a word that causes others to instantaneously have a strong emotional reaction. When you say that a patient is malingering, whether you are using the term correctly or not, what that patient (and others) understand is that you are calling them a liar.
He is correct.
If a clinician is confident that a patient is faking symptoms, they should say so. If clinicians used a diagnosis other than malingering, they would have to be dishonest as well. When people with a documented history of malingering present with new symptoms, it is problematic. The term malingering has been suggested as a way to get rid of people who feign illness.
How common is Malingering?
Doctors have different opinions on how common malingering is. My career has given me a unique perspective on this topic, I believe, as I have worked on hospital wards at both New York University and a public hospital.
The location, time of day, and season all have an effect on the amount of malingering. I have only seen it once in my outpatient clinics, in a man who was suing an airline. It's easy to spot it when a person comes to the ER for the fourth time in a week. Occasionally, these individuals will admit to faking symptoms so they don't have to go to the hospital.
It's difficult to determine the true rate of malingering as patients are unlikely to respond to questions about their symptoms.
Twenty-nine percent of personal injury, 30% of disability, 19% of criminal, and 8% of medical cases involved probable malingering and symptom exaggeration. Thirty-nine percent of mild head injury, 35% of fibromyalgia/chronic fatigue, 31% of chronic pain, 27% of neurotoxic, and 22% of electrical injury claims resulted in diagnostic impressions of probable malingering.
The prevalence of malingering in patients with chronic pain with financial incentive was found to be between 20% and 50%. Malingering is not uncommon in certain settings.
Malingering occurs in a very small minority of medical encounters, and Dr. Tracy's critics worried that his lecture would encourage students to detect it. A well-done lecture would teach students that the majority of people do not feign illness to get something tangible in return. The majority of people with personal injury claims are not malingering. Doctors should be aware of this.
Malingering is worth talking about.
Malingering is rarely discussed in the medical curriculum. There are discussions on all manners of disease, including those that occur in one-in-a-million people. I've never heard anyone talk about malingering. Everyone knows that it exists, no one likes it, and those who try to talk about it are silenced.
Malingering is worth talking about because it happens and not talking about it makes it go away. If students don't learn about malingering in a lecture, they will learn about it informally in work rooms and on rounds, almost certainly without the wisdom and compassion Dr. Tracy would have brought to the topic. Informal rules in medicine assume patients will lie. For example, clinicians are taught to double the amount of alcohol a patient says they consume. The informal curriculum of medical school is not the best place to learn about malingering.
Not talking about malingering in a formal setting may increase the chances that patients will be ignored, marginalized, and disbelieved. They will not learn this anywhere else.
Potential pitfalls in treating these individuals need to be learned by students. Patients who feign symptoms and then receive unnecessary tests and procedures can be dangerous. I have seen them receive potentially devastating side effects, such as thrombolytic medications for strokes.
Students need to learn that faking or exaggerating symptoms is not an all-or-nothing phenomenon. If I caught a patient with one of the tricks, I might have dismissed them. Some people with legitimate illness may exaggerate their symptoms so they are not ignored or to communicate their discomfort to clinicians, though this is not malingering of course. It's not easy, but it's not made easier by forbidding discussions of malingering.
The effect of malingering on clinicians is almost completely ignored. Malingering can cause clinicians to believe everyone is lying to them.
The patients who are deliberately deceptive seem to have an outsize influence on the practice of medicine. During internship and residency, young doctors are repeatedly fooled, and therefore embarrassed, by patients. Drug addicts are notorious for presenting themselves as model citizens with serious pain problems. After several episodes of unwittingly giving an addict a fix, or a prescription for drugs that will be sold, young doctors begin to listen to a patients’ stories with increasing cynicism. The subtext for many physicians, consciously or unconsciously, is that they must be convinced that the patient is telling the truth.
In a Medscape survey from 2016 malingerers were rated as the most likely to cause bias. No one likes to be deceived, so clinicians should be encouraged to talk about how malingering makes them feel.
I am often distrustful of prisoners. I am not proud of this fact, but after seeing wheelchair-bound prisoners suddenly regain the ability to walk after being released, it is an association at this point. Knowing my biases, I try to make sure I don't miss anything for patients who I am automatically suspicious of. I've seen that many times and it's terrible when it happens.
It is difficult to manage people who malinger. Confronting them is counter productive as they may feel like they have to keep the sick role. Instead, clinicians should do their best to maintain an alliance with them and express optimism about their condition, so there is no shame when they get better.
Understanding is not advanced with Acquiescence and Silence.
Most people have legitimate reasons to malinger, and the railroad employees who pretended to be sick are outliers.
A prisoner who is housed with rival gang members may be faking a seizure to escape. I've seen all of this and more and most patients just want to get food and sleep. This is an adaptive response for a homeless person on a cold night.
People who malinger should be treated with respect and kindness. Most of them are marginalized. They usually have no one to help them. They deserve our sympathy even if the hospital is not the right place for them to get food and a bed.
A physical therapist wrote that he didn't agree with Dr. Tracy's decision to cancel his talk.
The reasons you give for cancelling seem to be exactly the reasons why you should give this talk. We need people with specific expertise to help others understand, to shift paradigms. Understanding isn’t advanced with acquiescence and silence.
Dr. Tracy should teach students about malingering.
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