The M-Word–Malingering











The Definition: Three Requirements

To answer that question, we need to look at the precise definition of the word “malingering.” Here is the definition: “to pretend illness in order to shirk one’s duty or avoid work.”



First, the patient must be pretending or feigning an illness.




Feigning? Or Exaggerating?



So here is the question—was this patient malingering?



Calculated and Deliberate?



Would it be appropriate to say that this patient was malingering?


What is the Goal?


So—was Cory malingering?





What If You Are Wrong?


What is the Goal You Want to Accomplish?









It’s just not worth it—most of the time.



Hello to my new friends, Dr. Nguyen and Dr. Martija! MartijaNguyen

10 thoughts on “The M-Word–Malingering

  1. Hey I really appreciate your blog. You have given me some tools as I go into a new medical environment (beginning June 2016). I too am an emergency physician by training, I have also practiced some low level pain management with a strong emphasis in interventional techniques to help people get off pain pills.
    The words you say regarding the M word are so true in my experience and acknowledging the patients beliefs or story whether valid or not at least demonstrates to them a level of respect which is often disarming.
    Thank you for your work and your articles.

  2. I agree. Using the M-word as a diagnosis or description is counter-productive in correctional settings. It is not very useful in a combat zone either. It is also hard to support in the documentation. I prefer to use whatever symptom is the chief complaint as the assessment; i.e.. back pain = backache, head pain = headache, etc. A comprehensive history and physical exam is needed. The amount of documentation needed is often inversely proportional to the actual illness or injury. If C/C, HPI and ROS is all subjective and the PE is all normal, then I will just make mention that subjective symptoms outweigh physical observations. If I really do suspect offender manipulation for secondary gain, I can note this suspicion along with other less or more likely elements of the differential diagnosis list.

    Back in the Soviet era, the USSR operated numerous large forced labor prison systems. Malingering was such a big problem for the Soviets, that prison physicians had specific limitations in the number of light-duty permits that they could issue. I have often wondered if any good research on malingering emerged from the old Soviet forced labor systems.

  3. Dr. Keller-

    Excellent post as usual. I particularly agree with the notion is their simply is no upside to making this comment and the downsides are huge. My most common expression is “physical or objective findings do not match or are not proportional with subjective complaints”. Or “patient presents subjective complaints that I cannot objectively explain”. It takes out the emotional portion that you discuss. One can also document the possible secondary gain requested by patient without labeling patient Malingering. One doctor I work with got jammed up legally with this word- you are right- a whole lot of headache with very little benefit.

  4. Thank you for this post, especially the case example differentiating fictitious disorder from malingering. I am a psychiatric social worker working with SMI adults as they cycle both in and and out of jail, so I get to see their behaviors in hospitals, jails, clinics, and on the street. When patients are diagnosed as “malingering”, there seems to be a tendency to shut down the clinical thought process, terminating other explanations of what may be going on, why, and what could help. This is ineffective when you cannot fire a patient (reference to another of your posts). One of my clients with PTSD and Borderline PD exhibits off the map self-harm both when he is in locked facilities and custody environments and sometimes in the community. He has thousands of encounters and providers and deputies loathe his complexity (he makes their work very hard). Due to self harm and lack of follow up treatment for different injuries he does have real medical issues that doctors often refuse to treat. He has been labeled as “med-seeking” or “malingering”, but I believe more than these he is addicted to the role of the patient, with its associated care, food, comfort, attention, and finds this preferential to the role of inmate or homeless person. Therefore he harms to assume this role. I labeled his behaviors as secondary to Borderline PD and a factitious disorder. As you indicate, this term carries less stigma with patients and staff, and people seem more willing to consider why he behaves in the ways he does and what can be done about it. This openness to though not only helps the patient but also facility staff, and the county which covers the cost of his care.

    • Wow! Excellent post, Charles! Thank you. I agree with you that if the goal is behavioral modification, you have to understand why the patient does what he does–in other words, what his reward is.

  5. I was with you 100% until you described the solution as “just stop complaining”.

    In the example of “I have cancer” guy, you described the diagnosis as “persistent psychiatric delusion”.
    He honestly believed he had cancer. This belief wasn’t a switch that could simply be flipped on and off. It persisted even after multiple locations had assured him he was fine.
    People with psychiatric disorders can not erase their disorder simply by keeping quiet about it.

    In fact, telling psychiatric patients to “stop complaining” seems extremely counterproductive and detrimental to the communication/treatment process.

    Would you tell patients with PTSD, Manic-Depressive Disorder, or Pyromania to “just stop complaining”?

    Honestly I mean no offense; I’ve enjoyed your site.
    I’ve enjoyed all the other articles you’ve written, and honestly I enjoyed the majority of this one as well, but the overly-simplistic solution of “just quit complaining” really struck a bad chord.

    • Thank you Jann! I agree with you that the word “complaining” was not the best and I removed it. The main point I was trying to make here was that using the word “malingering” will not help the patient who erroneously believes that he has cancer. Labeling him a malingerer will more likely make this delusion even more fixed.

  6. I really appreciate that you brought up such a delicate discussion on surface. I have been working as Prison GP for the last 15 years in Scotland UK. Before that I was surgeon in Hospital. My take on this discussion is that, there is a very fine line between Malingering and other close conditions like Factitious or conversion or dissociation or Hysterical disorders. Further could be seen in DSM-5 and ICD-10. The only thing which keep malingering out standing of other list of conditions is that, patient is 100% aware what he is doing and also he knows that he is wrong. Most of the time the agenda behind is fraudulent and and has grievous medical and financial gains. Drug diversion and overdose are frequent outcomes of it. If we take malingering lightly and not to high light it clearly we will be promoting cases of drug overdose, drug related deaths and increased threats to doctors and medical staff in Prisons. In many states of America Drug seeking behavior is a criminal Offense and and peoples are prosecuted.
    You may find my comments offensive but malingering is very common in Prisons and insurance claim cases. It should be dealt robustly and and carefully.

  7. Exaggerating an illness qualifies as malingering so long as the motive is secondary gain. For example, a kid who has a mildly upset tummy but pretends to be writhing in pain to avoid going to school is malingering. A man with a broken femur who exaggerates his pain as 10/10 instead of 7/10 to make sure he’s not given Advil is not malingering. He’s exaggerating his condition for the purpose of ensuring he is taken seriously. This isn’t my opinion—it’s straight from the DSM: the symptoms can be feigned or grossly exaggerated, but the defining feature is secondary gain, an external incentive.

    That point aside, I think the examples used are somewhat facile and only helpful for the uninitiated. Sure, delusions aren’t malingering, and neither is factitious disorder, and neither is symptom exaggeration for the purpose of ensuring timely care for a real condition. People need to learn the correct application of these terms. The problem is, those who’ve worked in community and correctional settings might get the sense that the aversion to malingering goes far beyond a desire for correct diagnosis. In my opinion, it is a sort of political correctness, and one that comes from a good place. Social workers and psychiatrists are generally progressive people who see inmates not as sociopaths but as victims of society, driven to crime by unjust life experiences, and to call them malingerers is to salt that wound, to doubly victimize them.

    There’s a noble logic to this, but it’s also somewhat naive and devoid of nuance. Ideological positions tend to be that way. It’s possible to diagnose a manipulative antisocial with malingering and still treat him with dignity. To withhold the diagnosis when it is obvious and supported by a mountain of evidence over multiple encounters is professional dishonesty, often in the lofty service of social justice. Perhaps it protects the patient from stigma, but it is a disservice to others who may benefit from that data. I can’t tell you how many times I’ve seen multiple evaluations on a patient who was malingering who was “diagnosed” with adjustment disorder to avoid the obvious conclusion that they were serially malingering. I’m experienced enough to read the tea leaves, but younger docs are not, and they end up confused and learn to doubt their instincts.

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