Abstract
DSM-IV-TR defines malingering as the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as obtaining financial compensation or evading criminal prosecution.[1] It is coded as an ‘additional condition’ (V code), rather than as a defined Axis I mental disorder and has pejorative connotations. Factitious disorder also involves the intentional feigning of symptoms but the motivation is to assume the sick role.
Patients who feign psychiatric illness may have a valid psychiatric diagnosis but also malinger. The term ‘instrumental psychosis’ has been coined to describe patients, most of whom have a history of previous psychosis, who deliberately feign symptoms for purposes such as receiving accommodation or living allowances.[2] Individuals who simulate psychosis may also go on to develop a genuine illness with the passage of time. Hay[3] described a case series of six patients who were thought to be feigning schizophrenia. All but one became overtly psychotic on followup and he argued that the simulation of schizophrenia was a prodromal phase of the psychosis occurring in extremely deviant premorbid personalities. In a cohort of nine patients with factitious psychosis, Pope et al.[4] failed to identify schizophrenia after 4 to 7 year follow-up but similarly noted high psychiatric comorbidity due to personality disorder.
There is little published data about psychiatric malingering outside of forensic settings. In a study of psychiatrists providing emergency services at an urban general hospital, 13% of patients seen were strongly or definitely suspected of feigning symptoms.[5] None of these patients received a primary diagnosis of malingering and less than half were confronted. Experienced clinicians may be reluctant to challenge patients due to fears of damaging the therapeutic relationship and potentially ignoring important risk factors. Furthermore, general psychiatrists rely heavily on the patient's accurate self report of internal mental states and may have less objective measures than those available in forensic settings.
CASE REPORT
Mr, B., a 40-year-old unemployed man, was brought to hospital by police following an alert raised by a psychologist from a local social security office. According to the police conveyance form, Mr B had informed the staff member that he was hearing voices telling him to kill an employee and he was unsure whether he could resist acting on this instruction.
On initial assessment, Mr B stated that he had been diagnosed with schizophrenia 20 years ago and admitted to several interstate hospitals. He said that he had received treatment with numerous antipsychotic medications, most recently olanzapine which he had ceased of his own accord because of perceived ineffectiveness. The hospital records detailed past presentations with reflux oesophagitis and alcohol abuse but no documentation of any psychiatric history.
Mr B said that there was a microchip implanted in his shoulder through which he received messages from the government. He also described people in his house who were trying to harm him and said as a safety precaution he had spent the last few months living in a cupboard in the back shed. He spoke of hearing three voices telling him to kill people. He stated that he was so distressed by his predicament that he would suicide by overdose if he could obtain heroin. Mr B was detained under the Mental Health Act in view of the risk of violence to others and possible self-harm. He then became very hostile and aggressive, insisting he had to go home and that he presented no danger. Intramuscular olanzapine and lorazepam were required for sedation and he was admitted to a locked ward of the hospital psychiatric unit.
On examination, he was a thin, dishevelled man with tattoos, who was hypervigilant and hostile. He paced around the room for the duration of the interview and refused to answer any questions in detail. He accused the hospital staff of abusing his human rights and threatened legal action. He stated that he would refuse to eat or drink because his food might be poisoned. There was no evidence of thought disorder and he did not appear to be preoccupied by hallucinations. His insight and judgement were assessed to be poor. Despite his hostility, he signed a consent to release medical information and agreed to his girlfriend being contacted. Given his high level of arousal and agitation and his refusal to accept oral medication, further parenteral medications (zuclopenthixol acetate and clonazepam) were given.
On later review, he was more behaviourally settled and described hearing voices that were constantly present but easily resisted. He reiterated his concerns about a government conspiracy to kill him but denied having ever been admitted to psychiatric hospitals before. He reported the loss of his mother at age 6 years and described a very abusive childhood during which his father subjected him to physical and sexual abuse. As an adult, he had led an itinerant lifestyle and experienced protracted periods of unemployment.
Collateral history from the psychologist at social security revealed that Mr B had recently been referred for psychiatric review in order to determine his eligibility for a disability pension, but he had failed to attend. Prior to this, Mr B had been working at a hotel and had received a collection of money from his workmates after he had informed them of the death of his girlfriend. When it was discovered that the story was fabricated, he was fired. On the day of his admission, Mr B had not appeared unwell or threatening in the office until the recommendation for hospital assessment had arisen. Mr B's general practitioner had no record of him suffering from schizophrenia.
Mr B's girlfriend was oblivious to the supposed history of schizophrenia and had not observed any unusual behaviour over their 12 year relationship. According to her history, Mr B had no paranoia or hallucinations and had never lived in a cupboard. She was unable to explain his motivation for these assertions and seemed genuinely surprised to discover that he had been admitted to a psychiatric facility.
Forty-eight hours after presentation, when confronted with this conflicting information, Mr B divulged that he had fabricated his symptoms. He explained that his claim of having schizophrenia was a deliberate attempt to receive a pension. He had used accounts from friends who suffered from schizophrenia to elaborate his story but had never expected to be hospitalized. During this acknowledgement, Mr B was self-possessed and cooperative, in marked contrast to his previous interactions. He was subsequently transferred to the open ward of the unit, antipsychotic medication was ceased and he remained in hospital for further observation. This failed to reveal any psychotic symptoms or the development of extrapyramidal side-effects. His story
remained consistent and he was discharged, refusing the offer of a follow-up appointment.
DISCUSSION
Clinicians should suspect malingering most strongly when atypical or bizarre presentations are found in the context of obvious personal gain. In this case, the claim of living in a cupboard was certainly unusual and implausible and the desire for a disability pension was a clear external motive. Mr B was eager to call attention to his illness, in contrast to many patients with schizophrenia who are guarded about discussing their diagnosis. In keeping with oft quoted characteristics of malingerers, Mr B faked positive symptoms rather than negative symptoms, he was controlling and intimidating during interviews, he was unable to elaborate on his symptoms and there was no evidence of thought disorder.[6] Given his adverse developmental experiences and history of deceiving workmates, he may have had a comorbid personality disorder, which is consistent with other identified cases of malingerers.[3], [4]
When a person is suspected of malingering psychosis, detailed knowledge about actual psychotic symptoms and open-ended questions which avoid giving clues about the nature of true psychopathology, are invaluable tools.[6] Inconsistencies in the presentation should also be noted as they can be suggestive of malingering. In the case of Mr, B., there was a discrepancy between his reported symptoms and our clinical observations. First, Mr B reported hearing voices continuously, but did not appear distracted or preoccupied during the interview or when observed on the ward. Studies of patients with schizophrenia have also shown that hallucinations tend to be intermittent, rather that continuous.[7] Second, Mr B's behaviour did not match his alleged delusions. He described being too frightened to leave the safety of his cupboard, yet had attended the social security office unaccompanied. In addition, despite his apparent distrust of the treating team, he agreed to the collection of collateral data and signed a consent to release information without hesitation. Third, details of his history and symptoms changed over time. He gave inconsistent accounts to different doctors of his past treatment and his ability to resist the violent instructions of the ‘voices’.
Once contradictory information was obtained from multiple sources, Mr B was able to be confidently approached about the lack of evidence to support a diagnosis of schizophrenia. This resulted in his disclosure that he had fabricated his symptoms, the gold standard for diagnosis in malingering.[6]
Mr B was admitted to an acute psychiatric unit, consuming considerable police, medical and nursing resources. He received medication that carries a significant risk of side-effects and was exposed to the potentially traumatic aspects of involuntary hospitalization. The probable social and economic problems associated with his presentation were unable to be addressed and it is unlikely he will seek psychiatric help of his own accord in the future if required. This case highlights the need for a comprehensive assessment process, with consideration of malingering in atypical presentations. This will not only reduce inappropriate admissions but may also enable the needs of this disadvantaged group to be adequately addressed.