Feigning a medical condition or mental illness can pay off in many ways. Malingering is the intentional production of false or exaggerated physical or psychological complaints with the goal of receiving a reward.These rewards are referred to as secondary gains, which may include attention, money, an insurance settlement, narcotics (sedatives, tranquilizers, or stimulants), as well as the avoidance of work, punishment, incarceration, responsibility, etc.
Malingering is not a benign activity; it is deliberate and damages society in several ways. Malingering reduces productivity by labor lost. It also depletes Social Security, disability, workers compensation, and insurance funds. Malingering has been estimated to occur in 7.5% to 33% of all disability claims. The Texas Department of Insurance reports fraud that broadly includes malingering costs the insurance industry $150 billion annually, increasing the cost of insurance by $1800 per family. Additionally, malingerers tie up medical personnel, emergency departments, psychiatric wards, etc. To rule out a malingerer's obscure complaints, money is lost doing expensive and detailed testing.
The incarcerated malingerer
The motives for an incarcerated inmate include avoiding or delaying legal proceedings or to support a defense of insanity or an incompetency to stand trial. Another motive is to obtain a more preferred housing unit which may have more privileges, or where it would be easier to escape (such as a hospital, the infirmary or psychiatric ward). Additionally most incarcerated malingerers crave medications. Prescriptions like narcotics, stimulants and sedatives can certainly make hard time seem much easier. Meds can also be sold to other inmates. Finally, some inmates want to have evidence of a psychiatric diagnosis to obtain Supplemental Security Income (SSI) benefits after release from jail. The most common thread among malingerers is that they have an antisocial personality disorder; they have a pervasive pattern of disregarding and violating the rights of others. Deceit and manipulation are considered essential features of an antisocial personality, and malingering.
Factors that suggest the presence of malingering include:
- motivation for reporting a mental illness
- circumstances of the claim of mental illness (incarceration)
- atypical or exaggerated symptoms
- inconsistencies in the claimant's reports
- activity and behavior that is incongruent with the claims or symptoms
- history of an antisocial or borderline personality disorder
- history of substance abuse or dependence
Malingered psychiatric symptoms
The most typical malingered mental illness symptoms are psychosis, dementia/amnesia, or a traumatic head injury. An individual who is trying to avoid responsibility or punishment generally fakes psychosis, or reports memory blackouts. Someone who wants to get money from a lawsuit or insurance settlement more frequently fakes a brain trauma. Individuals who are seeking narcotics or stimulants exaggerate symptoms of severe anxiety, posttraumatic stress disorder, insomnia, pain, adult attention-deficit/hyperactivity disorder (ADHD), or narcolepsy.
The malingerer usually chooses very dramatic symptoms that they have probably seen in the media (movies and television). Frequently their symptoms are simply preposterous. However identifying a malingerer who is faking psychiatric illness is extremely difficult. This is because diagnoses of mental illness are based on specific signs and symptoms provided by the patient during a psychiatric interview. For example, a person is diagnosed with a psychotic disorder if they claim hallucinations, or are delusional or paranoid. There is no scientific way to guarantee that an individual is not experiencing the symptoms he/she is reporting, even if a psychiatric expert believes he/she is being fraudulent. Clinicians who are trying to assess for malingering should use all additional sources of information available. Talking with the individual, treatment providers, family members, co-workers, etc. will help determine if the reported symptomology and observed behaviors have been consistent. Psychological testing, such as the Minnesota Multiphasic Personality Inventory-2, may also help to identify a malingerer. If you are a corrections officer and notice discrepancies, note them and talk to your supervisor and psychiatric staff about your observations. Depressed and psychotic individuals don't snap out of it the minute a clinician leaves the room.
Trained psychiatric clinicians can sometimes identify inconsistencies with reported symptoms. Even a good malingerer can make mistakes. For example, malingerers tend to exaggerate hallucinations. Their description of a hallucination(s) will change frequently. Visual hallucinations are not typical symptoms of mental illness, auditory hallucinations are. True visual hallucinations are in color and involve normal sized items. Malingerers will claim to constantly hear voices, but cannot understand what they are saying. True auditory hallucinations are transient and clear, usually a repeated word, name, or sentence. A malingerer can offer no way that they have tried to decrease their symptoms, a schizophrenic can. Malingerers also often add symptoms that are not consistent with a specific disorder. For example, disorientation and amnesia are not characteristics of psychosis. While they may be able to bluff about complaints and experiences, it is much harder to fake the blunted affect or the concrete thought process associated with an acute psychotic disorder. These are all indications of malingering.
Malingerers tend to be excessively needy and demanding. Most will have a prior history of substance abuse. They aren't stupid; they have done their homework online or in a library. They know the disorder they are faking quite well, as well as examination methods to detect the disease and those designed to check for deception. If confronted about their deception they frequently threaten suicide. Their mood is usually irritable or hostile.
There are many malingering inmates, pretending to have mental illness in order to meet personal goals. Unfortunately this depletes the psychiatric services and resources from the incarcerated mentally ill who truly need services.
Drug seeking behavior
Malingerers invariably want to trick the corrections system into providing psychotropic drugs. The prudent jail psychiatrist will determine if medication is appropriate, if it will be effective, if it is safe, and if the cost of the med is within department budgets. Additionally, the possibility for abuse must be thoroughly assessed. Benzodiazepines (Valium), stimulants (Ritalin), and narcotic pain medications (Vicodin) are usually not prescribed. However, a new drug is becoming a favorite of inmates: Seroquel is also known as "quell," "Susie Q," and "baby heroin." Seroquel is prescribed for bipolar disorder and schizophrenia. The medication is sedating and has an anti-anxiety effect. A 2004 study found that up to 30% of the inmates in the Los Angeles County Jail seen by psychiatric clinicians malingered psychotic symptoms in order to obtain Seroquel. It can be injected or snorted for more impact. Seroquel does have a street value.
Malingering, insanity, and competency to stand trial
Insanity is a legal term, not a medical one. The premise is based on a defense of diminished capacity. Did the individual lack the capacity to conform his behavior to the law at the time the crime was committed? Does he have the capacity to appreciate the criminal charges for his behavior? Criminal responsibility standards vary by state. There is no constitutional right to an insanity defense.
The insanity defense is only raised in about 1% of all felony crimes. However, the reported success rate is 25%. 80% of the successful cases are successful because the prosecution agrees to the insanity plea. The criminal justice system typically frowns on malingering, and may lead to increased charges such as obstruction of justice.
The financial extent of what malingering costs society cannot be underestimated. Malingerers can also monopolize mental health services, jeopardizing available treatment for those who need it most.