“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”
― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook
According to the DSM-5, malingering is characterized by "intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives." Reasons that one might malinger include "avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs." It is these external incentives that differentiate malingering from factitious disorder. Malingering is further differentiated from conversion disorder and other somatic symptoms by the intentional production of symptoms. Clear evidence of feigned symptoms may be taken as support of either factitious disorder or malingering depending on the motivation (American Psychiatric Association, 2013).1
The DSM-5 lists the following indicators as strong warning signs of malingering:
"1. Medicolegal context of presentation (e.g., the individual is referred by an attorney to the clinician for examination, or the individual self-refers while litigation or criminal charges are pending).
2. Marked discrepancy between the individual's claimed stress or disability and the objective findings and observations.
3. Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen.
4. The presence of antisocial personality disorder" (American Psychiatric Association, 2013).1
The most important indicator of malingering may be a marked discrepancy between the symptoms that a patient reports and the symptoms that the patient actually displays as well as inconsistency within symptoms. Bizarre or unusual presentation coupled with flamboyancy or eager over-sharing can also indicate malingering (Adetunji et al., 2006).2 Individuals who malinger often have a history of lying, making claims of unbelievable symptoms, or refusing to allow collateral sources to be used in order for additional information to be obtained (Brand, McNary, Loewenstein, Kolos, & Barr, 2006).3
Malingering can be differentiated into "pure malingering", in which symptoms are entirely fabricated, "partial malingering," in which existing symptoms are exaggerated or extended in continuity, and "false imputation," in which existing symptoms are deliberately misattributed. Malingering by proxy also exists when dependents are forced to feign illness or injuries in order for the perpetrator to gain money from legal settlements, access to controlled substances, or other such external incentives (Adetunji et al., 2006).2
Malingering should be differentiated from non-purposeful distortion. Simple unreliability is not cause enough to label an individual as malingering. As well, it should be remembered that individuals who malinger may actually experience the symptoms that they exaggerate or may genuinely suffer from other conditions. Because of the stigma associated with the term and concept of malingering, it may not be productive to overtly apply such a label to an individual. However, notes of the individual's unreliability must be made, as the costs associated with malingering are high. Malingering can increase insurance premiums, divert resources away from those who truly need them, and hamper justice (Conroy & Kwartner, 2006).4 Malingering can also contribute to the spread of misinformation and false public perceptions of conditions.
One study by Yates et al. found that 13% of emergency room attendees were malingering while other studies have found that 10-12% of psychiatric inpatients are malingering (Adetunji et al., 2006).2 A study of forensic populations estimated a rate of malingering of 17%. Estimates may be lower than the actual rate of malingering due to the ability of successful malingerers to escape detection (Conroy & Kwartner, 2006).4
It has been claimed that "in nonforensic settings, malingered conditions are more likely to include dissociative identity disorder, psychosis, suicidality, posttraumatic stress disorder (PTSD), amnesia, acute dystonias, and sleep disorders, whereas in forensic settings, malingered conditions are more likely to include malingered PTSD, malingered amnesia, and malingered cognitive deficits" (Adetunji et al., 2006).2
1 American Psychiatric Association. (2013). Other Conditions That May Be a Focus of Clinical Attention. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.VandZcodes
2 Adetunji, B. A., Basil, B., Mathews, M., Williams, A., Osinowo, T., & Oladinni, O. (2006). Detection and management of malingering in a clinical setting. Primary Psychiatry, 13(1), 61-69.
3 Brand, B. L., McNary, S. W., Loewenstein, R. J., Kolos, A. C., & Barr, S. R. (2006). Assessment of genuine and simulated dissociative identity disorder on the Structured Interview of Reported Symptoms. Journal of Trauma & Dissociation, 7(1), 63-85. doi:10.1300/j229v07n01_06
4 Conroy, M. A., & Kwartner, P. P. (2006). Malingering. Applied Psychology in Criminal Justice, 2(3), 29-51.