Malingering Explained

Many of us have done it. Maybe you called in sick so you could go to that once-in-a-lifetime concert. Maybe you told your parents you were way too nauseated to eat that casserole you hate so much. Or maybe you said you had a headache so you could stay in and catch up on your favorite TV show.

Did anybody accuse you of malingering? If they did, they were right. That’s exactly what you were doing.

Like so many behaviors, malingering is perhaps best described as a spectrum. Occasionally playing hooky or exaggerating a migraine to get out of dinner plans is fairly innocuous. But not all malingering is harmless. It can be deeply hurtful, a violation of trust. And sometimes, it’s a crime.

Psychologist Susan Albers, PsyD, walks us through the basics of malingering: What it is, why it happens and how to spot it.

What is malingering?

Malingering is the intentional fabrication or exaggeration of physical or psychological symptoms for personal gain. It’s an action — and that action may need clinical attention or support. But it’s not a diagnosis.

Examples of malingering include:

• Walking with a limp or using crutches when you don’t need to.
• Pretending to experience chest pain.
• Claiming not to remember your actions or behavior.
• Heating up a thermometer to give the impression of a fever.
• Tampering with a blood or urine sample.
• Feigning a mental health emergency.
• Deliberately underperforming on an assessment to convince someone you have a cognitive deficit.
• Shaving your head and claiming you’re receiving chemotherapy for cancer.

While people with certain psychiatric illnesses or personality disorders might be more likely to engage in malingering behavior, malingering itself isn’t a mental health issue.

Malingering is different from somatic symptom disorder (SSD) and conversion disorder. People with these conditions experience very real symptoms. A person who’s malingering either doesn’t have any symptoms at all or is purposefully overstating their severity.

It’s also easy to confuse malingering with factitious disorder (formerly known as Munchausen syndrome) and factitious disorder imposed on another (FDIA). More on that in a bit.

Causes of malingering

To determine that somebody is malingering, Dr. Albers explains that a healthcare provider has to identify the personal gain that’s motivating the behavior. Examples include:

• Avoiding school, work or personal responsibilities.
• Dodging harmful or stressful situations.
• Being exempted from military service or jury duty.
• Gaining access to prescription medications.
• Receiving charitable donations or disability benefits.
• Winning civil or criminal court cases.

While malingering isn’t a medical condition, it can sometimes be a symptom of an underlying psychiatric issue. Healthcare providers sometimes observe malingering in cases of:

• Substance use disorder (SUD).
• Personality disorders.
• Psychotic disorders.
• Major depressive disorder (MDD).
• Post-traumatic stress disorder (PTSD).
• Complex post-traumatic stress disorder (CPTSD).

Dr. Albers explains that healthcare professionals have to be careful when presented with possible cases of malingering. They don’t want to overlook a genuine health issue or unnecessarily expose themselves to legal liability.

Signs a person is malingering

As malingering isn’t a medical condition, it doesn’t have symptoms. But there are certain common features that healthcare providers look for when assessing a person suspected of malingering. Sometimes, malingering behavior is blatant. Other times, the lies are much harder to detect.

And social media isn’t helping. Most of us have easier access to information about medical conditions and symptoms now than we used to.

“It’s great that so many people feel comfortable sharing their experiences with physical or mental health conditions,” Dr. Albers notes. “But some viewers will misuse that information. It’s easier to describe complex symptoms if you’ve heard somebody who actually has the condition talk about them on social media.”

Dr. Albers has found the single best way to spot malingering when it’s happening is to see it a lot.

“I think it’s a question of time and experience,” she states. “After many years of doing this, I can spot the red flags and identify the patterns a lot faster than I used to.”

Which brings us to an important point: If you’re reading this article because you suspect somebody is malingering, don’t try to confront, accuse or expose them. Leave that work to trained professionals. It’s important not to make (or act on) those assumptions for two reasons:

1. You could be wrong. Determining whether an individual is malingering isn’t something providers do by feel. It’s a complex process that requires information collection, clinical interviews, psychiatric assessment tools and medical review. And depending on the situation, a mistake could have serious consequences.
2. Security concerns. You can’t know how a person who is malingering will respond if they feel threatened. They may take extreme measures to convince you that they’re unwell, up to and including self-injury. There’s also a risk the individual could become violent.

So, don’t think of the red flags that follow as definitive. Think of them instead as signs that it’s time to share your concerns with somebody who has the skills and experience to do a proper assessment.

“Your role as a friend or family member is to join with professionals, help them get the information they need and give your loved one support,” Dr. Albers says.

Discrepancies

Constructing an elaborate lie is harder than you might think. That’s why clinicians who are evaluating a potential malingering case gather so much information. Chances are they’ll find differences in the way the individuals represent their situation over time. The police report won’t list the same injuries as the insurance claim, and neither will jive with their medical records or their testimony at trial … that kind of thing.

Symptom variability

It’s common (and legitimate) for symptoms of health conditions to vary based on the season, time of day, activity and other factors. But when a person is malingering, they don’t really have symptoms. As a result, their ailments tend to be worst when it’s most convenient. For example, right before the test, as the in-laws arrive or the day before that three-day weekend.

Having every symptom

Most of the time when we get sick, we experience some telltale signs of an illness, but not others. Our throat’s sore but we don’t have muscle aches. We have a stiff neck, but no rash. People who are malingering have something to prove, so they often say they have every symptom, including the rarest ones.

Negative exam findings

When evaluating a person to determine whether they’re malingering, clinicians go through a lot of medical records and may even reach out to other physicians to get their perspective. If they find that their patient has gone to multiple providers and none have identified a problem — or that all of their lab work came back clear — that might raise concerns.

Note the word “might.” It’s important here. Not all inconclusive tests or negative findings are created equal. Lots of people with chronic conditions have to wait years, sometimes even decades, to get a diagnosis. And far too many people with disabilities get accused of faking or overstating their condition as they go about their daily lives … oftentimes, by complete strangers.

If you aren’t a medical professional, don’t try to distinguish between a medical mystery and a fabrication. Leave that to the experts.

A clear external benefit

You can’t find that a person is engaging in malingering without establishing the personal gain that’s motivating the behavior.

Remember: Malingering isn’t a diagnosis; it’s an action. If a person is fabricating a medical condition without benefiting from it in any meaningful way, something else is going on. That something else might be factitious disorder.

Factitious disorder vs. malingering

If you’re a fan of movies and television, you may be wondering if malingering is the same condition you saw represented in The Sixth Sense, Sharp Objects or Law and Order. If true crime’s more your thing, you may have Gypsy Rose Blanchard on your mind. But you may be surprised to learn that none of those stories are actually about malingering.

It’s common to confuse malingering with factitious disorder and factitious disorder imposed on another (FDIA). These conditions used to go by the names Munchausen syndrome and Munchausen syndrome by proxy. People with these conditions are pretending to be ill (in the case of factitious disorder) or are claiming somebody they care for is ill (in the case of FDIA). But that’s not all: They’re actually creating those symptoms by harming themselves or their loved one.

Here’s an example that illustrates the difference between the three conditions.

A person who’s malingering might claim they have a serious leg injury. To sell the story, they wear a cast or walk with a cane. A person with factitious disorder, on the other hand, would actually cut their leg — and then rub dirt or feces in it to ensure it gets badly infected. A person with factitious disorder by proxy would do the same thing, except they’d do it to their child, partner or parent.

While factitious disorders and malingering may seem similar at first glance, Dr. Albers says there are several important distinctions between them:

• Unlike malingering, factitious disorder and factitious disorder imposed on another are diagnosable mental health disorders.
• People with factitious disorder or FDIA don’t gain anything from harming themselves or another person besides attention and sympathy.
• Both factitious disorder and FDIA, unlike malingering, can be deadly.

How to address malingering

If somebody you care about has been assessed and found to be malingering, you may be wondering, What now? It depends on the circumstances.

“My next step as a provider is understanding what’s driving that person to need or want that external gain — and figuring out if there are healthy ways to get what they want,” Dr. Albers explains.

If your child is malingering to avoid going to school because they’re being bullied, it’s time to schedule a meeting with their teacher. If your partner is feigning a painful injury because they’re struggling with opioid use disorder (OUD), they may need to join a support group or enter a treatment facility. If you’re pretending to be sick to get out of that performance review at work, you may need to work with a therapist on stress management techniques.

“Trying to understand the behavior is important because it’s so often negatively perceived,” Dr. Albers clarifies. “But if it’s happening, it’s happening for a reason.”

Depending on the situation, you may need to seek mental health support, too. While not necessarily the goal, malingering is a violation of trust. In some cases, it’s part of a larger pattern of abuse and victimization. In other cases — like with children — it’s important to address the problem appropriately. Instead of yelling or punishing, get together with your kid to brainstorm ways to make chores more fun, talk to their teacher about their test anxiety or make an appointment with a pediatric behavioral health professional.

Whether you’re dealing with lingering trauma as a result of somebody else’s deception or just need some advice, reach out for help. Providers are all too aware of the effects malingering has on individuals and the people in their lives. And they’re prepared to support you moving forward.