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What to Know About Malingering

Medically Reviewed by Dan Brennan, MD on June 15, 2021

‌Malingering is pretending to have an illness in order to get a benefit. The feigned illness can be mental or physical. Malingering is also when someone exaggerates symptoms of an illness for the same purpose. Malingering is an act, not a condition. 

Malingering was first used to describe soldiers who tried to avoid military service in the 1900s. The meaning has expanded to include those who feign illness for other reasons. But it is easier to define malingering than it is to identify it. 

Malingering v. Factitious Disorder

It's important to distinguish malingering from factitious disorder, another type of feigning behavior. Those with factitious disorder also pretend to have illnesses, but they don't do it on purpose. It is different from malingering because they don't hope to gain benefits from being ill. Instead, they enjoy the attention they get from being ill. 

Experts consider factitious disorder a mental illness. Malingering is not. The fifth edition of the Diagnostic and Statistical Manual of Mental Disease, commonly known as the DSM-5, gives malingering a "V" code. That means it is a condition that may require "clinical attention" although it is not a mental illness.  

Reasons for Malingering

Malingerers can have a variety of reasons for their deception. These include:

  • Getting drugs such as pain medications
  • Seeking attention
  • Avoiding military service
  • Getting leave from school or work
  • Avoiding legal action

What Are the Signs of Malingering?

It can be hard to tell whether a person's symptoms are real or made up. Those in the health and legal professions often have to make the call. The DSM-5 gives some guidance in this area.

Malingering is possible if two of the following four signs are present.

  • The person is in a medical or legal situation that could be improved with a certain diagnosis.
  • Observers can see a difference between what the person claims to be feeling and physical signs of illness.  
  • The subject doesn't follow treatments or go for follow-up care.
  • The subject has an anti-social personality disorder.

Some health professionals feel these criteria are flawed.

They say the criteria have several flaws, including:

They are out of date. These descriptors are basically the same as when they were formulated around 40 years ago.  A great deal of research has been done since then.

They aren't accurate. According to one researcher, using this standard results in a 20% accuracy rating. 

They don't allow for degrees of seriousness. This approach puts all malingerers into one category, although some cases involve mild exaggeration and others are outrageous falsehoods.

They make a moral judgment. All malingering behavior is described as bad. Another approach would be to see malingering as a person's adaptation to an unacceptable situation.

Other Tests for Malingering

Professionals have many other methods for investigating possible malingering.

Other tests may include:

  • Laboratory tests can help rule out physical disorders.
  • They may use questioning techniques that make it difficult for a malingerer to stay consistent. For example, they may use rapid-fire questions, extended interviews, and open-ended questioning. 
  • The Minnesota Multiphasic Personality Inventory may show when a person is faking a psychiatric disorder.
  • Other tests use a principle called cognitive load. They require the subject to do two mental tasks at once, which makes it harder to feign symptoms consistently. 

Before deciding that a person is malingering, doctors and other professionals must rule out physical causes that could be causing the behavior. They must also rule out other conditions that can look like malingering.

Besides factitious disorder, these conditions include:

  • Schizophrenia, a mental disorder where a person may have hallucinations, disoriented thinking, and interpret reality abnormally.
  • Psychosis, when mental conditions affect a person's mind and there is loss of contact with reality.
  • Hypochondria, also known as illness anxiety disorder, when people have a constant fear that they have a serious illness despite having few or no symptoms.
  • Depression

Malingering in Institutions

Although malingering can arise in many settings, it is a special concern in jails and prisons. One study found that 32% of those in a medium-security prison were malingering.

Inmates may feign symptoms for many reasons, including:

  • They want to receive medications to take themselves, sell, or trade to others.
  • They want to receive a diagnosis that may help their legal defense.
  • They seek a diagnosis that could get them placed on disability when they are released.
  • They would like to be placed in alternate housing.
  • A diagnosis of mental illness may keep them from being punished when they break the rules. 

Malingering is also a problem in mental health institutions. Some people try to gain admission to avoid the legal system. Others may be looking for food and shelter.

Costs of Malingering

Successful malingerers have a negative impact on society. They divert funds and resources from those who really need them. They put a burden on the health care system. A person who has committed a crime can escape punishment.

On the other hand, great harm comes from accusing sick people of malingering. They may be denied the treatment they need. They may be labeled a malingerer for the rest of their lives.

Psychiatrists and others who must diagnose malingering also put themselves at risk. They can be sued for slander or malpractice — even if the diagnosis was made in good faith.

WebMD Medical Reference

Sources

SOURCES:

Alozai, U., McPherson, P. StatPearls: Malingering. StatPearls Publishing, 2020.

Cleveland Clinic: "Factitious Disorders," "Illness Anxiety Disorder (Hypochondria, Hypochondriasis)."

Frontiers in Psychology: "A Review of Approaches to Detecting Malingering in Forensic Contexts and Promising Cognitive Load-Inducing Lie Detection Techniques." 

Jefferson Journal of Psychiatry: "The Malingering of Psychotic Disorders."

Journal of Forensic Sciences: "Defining Malingering." 

Journal of the American Society of Psychiatry and the Law: "Liability for Diagnosing Malingering."

Mayo Clinic: "Schizophrenia."

National Institute of Mental Health: "What is Psychosis?"

Psychological Injury and Law: "DSM-5 and Malingering: a Modest Proposal." 

Scott, C. Encyclopedia of Mental Health (Second Edition): Correctional Mental Health. ScienceDirect, 2016.

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