Malingering [muh-ling-ger-ing] is a medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of ‘secondary gain’ motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy. A common form of malingering in legal procedure prosecution is sometimes referred to as fabricated mental illness or feigned madness.
Malingering remains separate from somatization disorders and factitious disorders in which primary and secondary gain, such as the relief of anxiety or the assumption of the ‘patient role,’ is the goal. The symptoms most commonly feigned include those associated with mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system, and false attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population.
In the Hebrew Bible, David feigns insanity to escape from a king who views him as an enemy. Odysseus was stated to have also feigned insanity in order to avoid participating in the Trojan War. Malingering has been recorded historically as early as Roman times by the physician Galen, who reported two cases. One patient simulated colic to avoid a public meeting, while the other feigned an injured knee to avoid accompanying his master on a long journey. In his social-climbing manual, Elizabethan George Puttenham recommends that would-be courtiers have ‘sickness in his sleeve, thereby to shake off other importunities of greater consequence’ and suggests feigning a ‘dry dropsy […] of some such other secret disease, as the common conversant can hardly discover, and the physician either not speedily heal, or not honestly bewray.’
Because malingering was widespread throughout the Soviet Union to escape sanctions or coercion, physicians were limited by the state in the number of medical dispensations they could issue. There is a rich and diverse array of methods for feigning illness. Physical methods reported include trying to deceive measuring devices such as thermometers, inducing swelling, delaying wound healing, over-exercise, drug overdose, self-harm, or directly reporting diagnostic signs of disease, learnt from a medical textbook. Patients may report a fictitious history, such as describing epileptic seizures or a heart attack, sometimes supplementing this with the use of agents which mimic disease, such as taking neuroleptic drugs to mimic tremor.
Detection is made more difficult in those who do have a diagnosed, organic disease already, sometimes called ‘partial malingering.’ In these cases, malingering is sometimes described as a ‘functional overlay’ on an existing disease. Persons who have an intermittent disorder may feign a return of symptoms in order to gain some benefit. The indigent homeless may do this in cold weather, in order to obtain indoor lodgings. Some conditions are thought to be easier to feign than others. For example, everyone has experienced pain and knows how a person in pain should appear to others. The medical literature, especially in psychiatry, has become keenly aware of the complex issues related to malingering.
Ganser syndrome was once thought to be a form of factitious disorder, or malingering psychiatric symptoms for psychological gain. This was seen when prisoners were released from extreme solitary confinement, often involving the inability to communicate with anybody, and perpetual darkness. However, the symptoms were different from other mental illness, but consistent from one prison to another, where the affected individuals did not know one another. It has since been determined to be a genuine syndrome, resulting from the stress of isolation. Münchausen syndrome by proxy involves feigning illness of another person, or even causing their illness, in order to appear heroic in reviving the person, or to appear long-suffering to a sympathetic audience.
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