Handbook of Clinical Neurology, Vol.

139 (3rd series)

Functional Neurologic Disorders
M. Hallett, J. Stone, and A. Carson, Editors
http://dx.doi.org/10.1016/B978-0-12-801772-2.00042-4
© 2016 Elsevier B.V. All rights reserved

Chapter 42

Factitious disorders and malingering in relation to functional

neurologic disorders

C. BASS1* AND P. HALLIGAN2

1
Department of Psychological Medicine, John Radcliffe Hospital, Oxford, UK
2
School of Psychology, Cardiff University, Cardiff, UK

Abstract
Interest in malingering has grown in recent years, and is reflected in the exponential increase in academic
publications since 1990. Although malingering is more commonly detected in medicolegal practice, it is
not an all-or-nothing presentation and moreover can vary in the extent of presentation. As a nonmedical
disorder, the challenge for clinical practice remains that malingering by definition is intentional and delib-
erate. As such, clinical skills alone are often insufficient to detect it and we describe psychometric tests
such as symptom validity tests and relevant nonmedical investigations. Finally, we describe those areas
of neurologic practice where symptom exaggeration and deception are more likely to occur, e.g., postcon-
cussional syndrome, psychogenic nonepileptic seizures, motor weakness and movement disorders, and
chronic pain.
Factitious disorders are rare in clinical practice and their detection depends largely on the level of clin-
ical suspicion supported by the systematic collection of relevant information from a variety of sources. In
this chapter we challenge the accepted DSM-5 definition of factitious disorder and suggest that the tradi-
tional glossaries have neglected the extent to which a person’s reported symptoms can be considered a
product of intentional choice or selective psychopathology largely beyond the subject’s voluntary control,
or more likely, both. We present evidence to suggest that neurologists preferentially diagnose factitious
presentations in healthcare workers as “hysterical,” possibly to avoid the stigma of simulated illness.

A lie is as good as the truth if you can get some-
body to believe it.
INTRODUCTION
Controversial and ubiquitous, deception describes a
common pervasive form of episodic human behavior that
understandably raises concerns and prejudices when
found and/or thought to occur in medical settings
(Conroy and Kwartner, 2006). Considered by some to
be evolutionarily adaptive (Spence, 2004), it is important
from the outset to locate illness deception within a wider
context of human deception. In a study of absenteeism in
Canada of hospital workers who had just returned from a
scheduled day off or an unscheduled day off classified by
the employer as due to sickness absence, 72% admitted
not being sick on their (sick) day off (Haccoun and
DuPont, 1987).
The key issue (and source of much controversy) in
medicine remains the extent to which a person’s reported
symptoms can be considered a product of conscious
choice, a form of psychopathology (beyond the person’s
volitional making), and/or perhaps both. Notwithstand-
ing recent experimental findings using functional
brain imaging, the diagnosis established is frequently

*Correspondence to: Dr. Christopher Bass, MA MD FRCPsych, Consultant Liaison Psychiatrist, Department of Psychological
Medicine, John Radcliffe Hospital, Oxford OX3 9DU, UK. E-mail: c.bass1@btinternet.com
510 C. BASS AND P. HALLIGAN
“influenced by circumstantial factors and the physician’s
opinion of the patient’s personality or background”
(Spence, 2004).
According to Rogers (1997):
If we never investigate dissimulation [e.g., deceit
subterfuge, falsification], then we may never find
it. I believe that our working assumption in
clinical practice should be that an appreciable
minority of evaluatees engage, at some time, in
a dissimulate response style. If we accept this
working assumption, then we also accept the
responsibility to screen all referrals and activity
to consider the possibility of malingering and
other forms of deception.
We have argued elsewhere (Halligan et al., 2003b; Bass
and Halligan, 2014) that illness deception (e.g., factitious
disorder and malingering as defined in DSM-5) is prob-
ably underestimated and is better understood within a
wider biopsychosocial model. At the heart of the
DSM-5 definition is falsification of symptoms and/or
signs associated with deception, in the absence of exter-
nal rewards. The behavior is not accounted for by another
mental disorder such as delusional disorder.
We suggest that the medicalization of illness deception
(such as factitious disorders and compensation neurosis)
arose largely as an attempt to create a way of bridging
or linking diagnoses between unconsciously mediated
psychiatric disorder and consciously mediated malinger-
ing (Bass and Halligan, 2014). Moreover, we believe that
the current DSM diagnosis of factitious disorder has little
clinical validity (Bass and Halligan, 2007).
This is not to argue that medical factors involving
deception are not relevant, but that medical education
needs to provide doctors with a broad conceptual, devel-
opmental, and management framework from which to
better understand and manage deception in patient–
doctor interactions. It is equally important however, to
ensure that medical disorders are not ignored where
symptoms-based illness behavior provides for an alterna-
tive working hypothesis. A study in the Israeli military
showed that two dozen conscripts repeatedly considered
to be malingering were in fact suffering from serious
psychiatric disorders (Witztum et al., 1996).
A growing challenge for dealing with illness decep-
tion is the increasing acceptance that many medical
illnesses cannot be exclusively diagnosed or validated
on the basis of the biomedical model. Medically unex-
plained symptoms (MUS) continue to form one of the
most expensive diagnostic categories in Europe and
are the fifth most common reason for visiting doctors
in the USA (Creed et al., 2011). Interest in functional
neurologic disorders has also grown steadily over the last
decade, and recent conferences on conversion disorders
and psychogenic movement disorders (PMD) have led to
the publication of a number of books (Halligan et al.,
2001; Hallett et al., 2011) and in the UK the formation
of an interdisciplinary Functional Neurology Group
(Carson et al., 2011a). In tandem, there has been a grow-
ing neuropsychologic interest in illness deception and
malingering (e.g., Halligan et al., 2003a; Rogers, 2008;
Bass and Halligan, 2014; Young, 2014), with neuropsy-
chologists and clinicians introducing and refining novel
methods of assessment in patients suspected of simulat-
ing illness.
In addition to a brief historic review, this chapter con-
siders some current themes and outlines the main areas of
clinical practice where deception can complicate the clin-
ical presentation and its subsequent management, with
particular reference to neurologic practice.
HISTORIC CONTEXT
The practice of illness deception by feigning illness has a
long history, with illustrative cases from Greek, biblical
and classic literature. Before the 1880s there are several
isolated reports on malingering (e.g., Gavin, 1838), list-
ing motives such as the need to “to obtain the ease and
comfort of a hospital” and the “avoidance of duties.”
Similar motives were ascribed to the behavior of soldiers
in the American Civil War, including “choosing a career
diversion as a patient rather than a soldier” (Bartholow,
1863). But, as Wessely (2003) argues, a key catalyst
behind the growth in illness deception was the introduc-
tion of the social welfare state and in particular the rise in
workmen’s compensation schemes in the postindustrial
revolution societies of North America and Western
Europe. Fallik (1972) goes so far as to suggest that:
laws of social welfare and work insurance were
made mostly for law-abiding people who really
are in need. Therefore it is not the individual
who causes the problem of simulation and malin-
gering but the society which created the legal
framework for exploitation.
The introduction of social insurance schemes and of
steam-driven train accidents led to an increase in illness
deception and moved from the social, moral, and
political to the medical sphere (Mendelson and
Mendelson, 1993).
In the UK in 1913, Sir John Collie published a book
on malingering and feigned sickness (including hyste-
ria), where the doctor was cast in the role of detective,
utilizing a number of tricks, signs, and traps to detect
the malingering patient.
 FACTITIOUS DISORDERS AND MALINGERING IN RELATION
Malingering and the military have always been closely
linked (Palmer, 2003). The advent of the First World War,
with its focus on “psychotraumatology,” including
“shellshock,” provided a fertile ground for revisiting non-
medical etiologies and diagnostic challenges for psychia-
trists (Crocq and Crocq, 2000). Given that the military and
the governments at the time were ill prepared to accept the
large number of psychiatric casualties, “psychiatrists were
often viewed as a useless burden” (Crocq and Crocq,
2000). This was well illustrated in a memorandum
addressed by Winston Churchill to the Lord President
of the Council in December 1942, where he wrote:
I am sure it would be sensible to restrict as much as
possible the work of these gentlemen [psycholo-
gists and psychiatrists]… it is very wrong to disturb
large numbers of healthy, normal men and women
by asking the kind of odd questions in which the
psychiatrists specialize (Ahrenfeldt, 1958).
In the UK, detecting malingering became part of the war
effort, and when Collie’s textbook was reissued in 1917,
the second edition was nearly twice as long. After the
First World War, the focus of illness deception moved
from military to civilian settings, with medical practi-
tioners as the main gatekeepers.
Gavin introduced the term “factitious disorder” in
1838 in a book on military malingering, to delineate a
subtype of malingering where the clinical evidence
was tampered with or faked. The term was used sporad-
ically over the next 100 years, but it was not until Richard
Asher’s paper in 1951 involving 5 cases described as
“Munchausen’s syndrome” that greater awareness of ill-
ness deception was raised. However, factitious disorder
first entered the psychiatric glossaries in 1980
(American Psychiatric Association, 1980) and was used
to describe (diagnose) those patients considered to differ
from hysteria, in whom the symptoms were produced
consciously rather than unconsciously (Hyler and
Spitzer, 1978). In their essay on the origins of factitious
disorder, Kanaan and Wessely (2010a) suggest that the
term developed as a “mediating diagnosis” between hys-
teria and malingering, whilst recognizing that some of
the diagnoses classified as such would have been previ-
ously subsumed within the category of hysteria. One of
the main consequence of the new nosology was appropri-
ating a form of illness deception as a legitimate, medical
diagnosis (Bass and Halligan, 2014).
DIAGNOSIS OF SIMULATED ILLNESS
Despite general acceptance that malingering is not a
medical diagnosis “it is clear from medical literature
and the examination of law reports that many doctors
511
consider detection of malingering as an integral part of
the medical enterprise” (Mendelson, 1995). From a clin-
ical and diagnostic perspective, however, there is also
evidence that most people, including clinicians, are
unable to reliably and consistently detect the contribu-
tory role of deception (Ekman, 1985; Rosen et al.,
2004). Unlike more established medical conditions there
is evidence that factitious disorders and malingering
behaviors are episodic, situation-specific, and dependent
on selective interactions with medical, social, or legal
professionals governed by a cost–benefit analysis
(Rogers, 1990).
Moreover, feigning illness is not as difficult as some
doctors appear to imagine, “The possibility that an indi-
vidual would ever feign illness runs contrary to the empa-
thetic, trusting nature of the physician, so the issue often
never reaches the threshold of consideration” (Lande,
1989). According to Barrow (1971), who developed
the use of “standardized” patient programs in North
America,
A wide range of psychiatric problems can be sim-
ulated, such as depression, agitation, psychosis,
neurotic reactions and thought aberrations, with
little problem. In neurology, the simulated patients
can show a variety: paralysis, sensory losses,
reflex changes, extensor plantar responses, gait
abnormalities, cranial nerve palsy, altered levels
of consciousness, coma, seizures, hyperkinesias,
and so forth.
Even after being warned that these “simulated patients”
were among the examinees, experienced clinicians found
it difficult to detect them (Halligan et al., 2003a).
According to Eagles et al. (2007), “simulated
patients are now deployed for teaching purposes in
almost all areas of medicine where students and health-
care professionals interact with conscious patients.” At
Aberdeen, Eagles and colleagues (2007) employed
professional actors and used live performances in-
formed by detailed life histories and scripts. Psychiat-
ric conditions presented by these actors included
depression, anxiety, alcohol misuse/dependence, hypo-
mania, schizophrenia, psychosis with aggression,
obsessive-compulsive disorder, overdose in adoles-
cence, and early dementia. In their final year, students
have “a week of joint teaching from psychiatrists and
general practitioners, during which actors portray
somatisation, life crisis/depression, the spouse of a
dementia sufferer, adolescent crisis and alcohol
misuse.” With actors portraying a wide range of pre-
sentations with “flair and professionalism,” students
generally found that they could not distinguish them
from “real” patients (Eagles et al., 2007).
512 C. BASS AND P. HALLIGAN
GROWING INTEREST IN ILLNESS
DECEPTION
After World War II medical efforts to detect deception
moved from clinical “intuition” to the more active search
for new techniques to detect it. Understanding deception
in the medical context was further facilitated by the intro-
duction of concepts such as abnormal illness behavior
(Pilowsky, 1969; Mechanic, 1978). The introduction of
quantitative testing by clinical psychologists however
arrived relatively late, with the first modern textbook
on malingering published as late as 1988 (Rogers,
1988), but now in its third edition (Rogers, 2008).
Identifying the number of published papers using
key illness deception terms provides a simple way to
capture the growing interest in the field. A bibliometric
scan (Fig. 42.1) of the published journal papers listing
the terms “malingering” using Scopus (the largest
abstract and citation database of English-language
peer-reviewed literature) over the past 123 years
(accessed December 2014) lists nearly 4000 documents
and shows a slow and relatively modest interest until the
1990s. By 2000 the number of documents pertaining to
malingering was approaching 150 per year (Berry and
Nelson, 2010).
A similar bibliometric scan of the published journal
papers listing the terms “factitious disorder” again using
Scopus (accessed December 2014) showed an under-
standably slower uptake. Since 1891, Scopus listed a
total of nearly 2000 documents but shows a slow but
growing interest, with approximately 50 papers per year
since 1980.
Finally, a bibliometric scan of the published journal
papers listing the specific illness deception term
“Munchausen’s syndrome,” coined by Asher in 1951
(accessed December 2014) lists over 500 documents
demonstrating variable interest, with an average of
15 papers per year since 1997.
PSYCHOSOCIAL CONTEXT
The clinical dilemmas presented by patients with ill-
nesses without definable biomedical causes are well
established (Hatcher and Arroll, 2008; Sharpe, 2013).
In general practice, one-fifth of consultations constitute
medical unexplained symptoms (MUS) (Burton, 2003)
and estimates of those without confirmed disease seen
in hospital outpatient clinics range from 35% to 53%
(Stone et al., 2010; Creed et al., 2011). These figures
are likely to be an underestimate, as many doctors under-
standably remain cautious about excluding physical
disease and presenting a patient with a “psychogenic,”
less than definitive diagnosis (Espay et al., 2009).

Documents by year
175

150

125

100
Documents

75

50

25

0
1871 1889 1913 1926 1938 1947 1953 1958 1963 1968 1973 1978 1983 1988 1993 1998 2003 2008 2013
Fig. 42.1. Number of published papers on malingering (Scopus December 2014).
 FACTITIOUS DISORDERS AND MALINGERING IN RELATION
Whereas disease is typically dependent on objective
abnormalities of physical structure or function, illness
relates to the patient’s experience, including what the
individual reports to be involuntary behaviors. This, in
turn, has led to the growing inclusion of a number of
illness-based conditions such as “functional somatic
symptoms/syndromes,” particularly within psychiatry,
where many of the mental disorders already described
by DSM-5 currently remain biomedically unexplained.
In response to the perceived and growing need to con-
sider more complex, interactional, and contextual para-
digms, “biopsychosocial models” applied to health
sciences emerged in the 1970s (Engel, 1977; White,
2005). These biopsychologic models, however, were
not specifically etiologic but rather argued for a more
holistic process model of illness (Halligan and
Aylward, 2006), where the person, and not the disease,
is the central focus when defining ill health. Acute and
chronic symptoms originating from benign or mild forms
of physical or mental impairment were considered to be
re-experienced as amplified perceptions with accompa-
nying distress which, when filtered through the present-
ing patient’s attitudes, beliefs, coping skills, and
occupational or cultural social context, were seen to
affect patients’ perceptions of their impairment and asso-
ciated disability (Petrie and Weinman, 2006).
FACTITIOUS DISORDERS
Definition
It was recently suggested that factitious disorders should
be considered a variant of somatoform disorders (Krahn
et al., 2008), as both conditions provide patients with the
opportunity to “organize their lives around seeking med-
ical services in spite of having primarily a psychiatric
condition.” This latter model has been adopted by
DSM-5, with factitious disorders recategorized as
somatic symptom disorders with two types: factitious
disorder imposed on self and factitious disorder imposed
on the other. Although the motivation for the behavior
has attracted less emphasis in this definition, which tends
to focus more on observed behavior, there remains little
recognition that patients as people can and do exercise
choices which can, and often includes being influenced
by personal gain or benefit (Bass and Halligan, 2014).
Epidemiology
Factitious disorders are relatively uncommon but, like
many conditions remain largely based on patient feed-
back, and probably remains underdiagnosed. A survey
of referrals to a psychiatric liaison service in a North
American general hospital found that 0.8% had factitious
513
disorder (Sutherland and Rodin, 1990). Surveys of phy-
sicians demonstrate a wide range of prevalence esti-
mates, with a mean estimated prevalence of 1.3%, with
dermatologists and neurologists giving the highest esti-
mations (Fliege et al., 2007).
Recognizing simulation remains largely a function of
experience and the predisposing attitudes of the observer,
especially neurologists (Miller and Cartilidge, 1972). In
a review of factitious disorders in neurology, Kanaan and
Wessely (2010b) found that neurology patients were
strikingly different from those in other specialties in
terms of their demographics. Considering 90 patients
from a total of 45 published reports, they found a wide
range of neurologic presentations, the most common of
which was functional motor symptoms/simulated
strokes, and seizures/blackouts. They found that propor-
tionately more of the patients were male (56%) and only
17% were healthcare workers, which was surprising,
given that the majority of patients with factitious disor-
ders are women and many are involved in the healthcare
professions. The authors speculated that “factitious
nurses” (or, more properly, nurses presenting with facti-
tious disorders) are typically diagnosed with conversion
disorder. They also speculated that there was evidence
that neurologists preferentially diagnosed factitious pre-
sentations in nurses as “hysterical,” presumably to avoid
the stigma of simulated illness.
Factitious disorders: clinical features
Clinical features remain diverse, but the majority of
patients with factitious disorders are nonperipatetic,
socially conforming young women with relatively stable
social networks (Krahn et al., 2003). Evidence of
fabrication can be derived from multiple sources,
e.g., inexplicable laboratory results, an inconsistent or
implausible history, admission of an induced illness
(rare), scrutiny of outside records, observed tampering
with syringes, and finding hidden medications. Deputing
a clinician to construct a medical chronology is
invaluable.
Most patients enact their deceptions in general hospi-
tals, especially Accident and Emergency departments.
In a large case series 72% were women, of whom two-
thirds had an affiliation with health-related professions
(Krahn et al., 2003). In this study the initial presentation
of factitious disorders typically began before the age of
30 years, but there is often evidence of simulation in child-
hood and adolescence. Close enquiry and examination of
medical records often reveal an unexpectedly large num-
ber of childhood illnesses and operations, and high rates of
substance abuse, mood disorder, and personality disorder
(Bass and Halligan, 2014). There is also increasing
514 C. BASS AND P. HALLIGAN
evidence to suggest that a high proportion of patients with
factitious disorders have so-called cluster B personality
disorders, in particular borderline personality disorder
(Goldstein, 1998; Gordon and Sansone, 2013). Recent
case reports of suicide suggest that deceptive behavior
does not preclude the presence of serious psychopathol-
ogy (Binder and Grieffenstein, 2012).
There is a suggestion that factitious behavior can be
“communicated” from one generation to another
(Libow, 1995). For example, of children with illnesses
induced by their carers (often the mothers), a proportion
present with pseudoneurologic symptoms such as anoxic
episodes and epilepsy. Examination of their mother’s
medical records reveals that pseudoseizures are often a
key component of their somatoform presentation (Bass
and Jones, 2011). This is an important observation,
and neurologists should be alert to it, especially as sei-
zures have been reported to be the most common presen-
tations of fabricated and induced illness in children
(Barber and Davis, 2002).
Management
Management of simulated disorders can be divided into
two phases: the acute management in the hospital, which
could be an emergency room or an inpatient infectious
diseases unit, or the chronic process of engaging the
patient in outpatient management with some form of psy-
chotherapy (McCullumsmith and Ford, 2011). Manage-
ment in both phases must focus on negotiating the
diagnosis with the patient and then engaging the patient
into treatment.
The initial diagnosis of factitious disorder (in hospi-
tal) is nearly always made by a nonpsychiatrist, who
may wish to involve a psychiatric college in a supportive
confrontation of the patient. This process requires careful
preparation (Table 42.1).
There is no robust research evidence to support the
effectiveness of any management strategy for factitious
illness (Eastwood and Bisson, 2008). Despite this, the
authors of this chapter recommend supportive confronta-
tion, which should always involve at least two members
of staff, with an emphasis on the patient being a sick per-
son in need of help. For some patients a more nuanced
approach may be preferred, with nonconfrontational
approaches. Face saving is a key element, and it is impor-
tant for patients to subsequently explain their disclosures
to other people as “recoveries,” without admitting that
their original problems were fabricated.
Course and prognosis
Recovery from factitious disorder is extremely rare as
few patients agree to comply with treatment. In the
93 patients described by Krahn et al. (2003), three-
Table 42.1
Supportive confrontation: preparation and process
(for nonpsychiatrists)
● Collect firm evidence of fabrication, e.g., catheter, syringe,
ligature
● Discuss with psychiatrist (or member of hospital legal team if
no psychiatrist is available)
● Arrange meeting to marshal the facts, discuss strategy,
discuss with primary care doctor
● Confrontation with the patient should be nonjudgmental and
nonpunitive, and include a proposal of ongoing support and
follow-up
● Discuss the outcome of the confrontation with the primary
care doctor
● If the patient is a healthcare worker, the doctor should discuss
with a member of his/her defense organization
● Document a full record of the meeting and its outcome in the
patient record
quarters were confronted with their diagnosis; however,
only 17% acknowledged that their illness was self-
induced or simulated, and a small number agreed to have
psychiatric treatment, but the outcomes were not pub-
lished. Despite this, recent accounts of patients wishing
to engage in treatment have demonstrated that, with
appropriate management, these individuals can be
helped (Avignal and Hall, 2012; Bass and Taylor,
2013). In a fascinating study using a novel method of
accessing first-hand experiences of an online community
of factitious disorder sufferers, Lawlor and Kirakowski
(2014) found that members were aware of their motiva-
tions, were upset by their behavior, and claimed to want
to recover, but were deterred by fear. The enormous cost
to the healthcare system has been extensively documen-
ted (Hoertel et al., 2012).
MALINGERING
Conceptual and definitional problems
Rogers (1990) considers malingering to be a behavior
governed by a cost–benefit analysis. Psychiatric glossa-
ries have struggled to define malingering, and the short-
comings of the DSM-5 definition have been described
elsewhere (Bass and Halligan, 2014). In essence, the
diagnostic glossary presents malingering as a categoric
condition (“the intentional production of false or grossly
exaggerated physical or psychological symptoms, moti-
vated by external incentives” and where this external
gain may take the form of financial rewards, or evading
criminal responsibility), while much of the evidence sup-
ports the view that it is a dimensional construct. As
Lipman (1962) pointed out, the behavior is not a binary
 FACTITIOUS DISORDERS AND MALINGERING IN RELATION
Table 42.2
Malingering – best viewed as a continuum disorder
1. Exaggeration: symptoms and/or disabilities magnified
or embellished
2. Dissimulation (concealment): patient denies the existence
of problems that would account for the symptoms
(e.g., presenting to doctors repeatedly with gastric bleeding
whilst deliberately withholding the fact that he/she is
prescribed nonsteroidal anti-inflammatory drugs)
3. Symptom feignings only (subjective states, e.g., abdominal
pain)
4. Misattribution/false imputation of cause: attributing real
symptoms to a false cause (e.g., patient reports symptoms
that were formerly present and ceased, but are alleged to
continue; alternatively, genuine symptoms are fraudulently
attributed to a particular injury)
5. Invention: creating symptoms and signs when none exist
(e.g., smash fist on wall and present to Accident and
Emergency, stating that hand was damaged in a road traffic
accident)
characteristic of being “present” or “absent”: an indi-
vidual might, for example, be exaggerating genuine
difficulties (Table 42.2).
Epidemiology
A frequently cited study (Mittenberg et al., 2002) found
that experienced neuropsychologists estimate the preva-
lence of malingering in patient referrals from civil
(i.e., personal injury cases) and criminal legal settings
to be in the 10–30% range. Further evidence to support
the nontrivial prevalence of malingering comes from
studies that have administered symptom validity tests
(SVTs) to patients involved in litigation or disability-
related evaluation (discussed further below). Many of
these studies concluded that the prevalence of suspicious
performance on SVTs exceeds the 10–30% range in
those seeking compensation who report a diverse range
of clinical disorders, e.g., mild traumatic brain injury,
whiplash neck injury, and psychogenic nonepileptic sei-
zures (PNES). The feigning of disabling illness for the
purpose of disability compensation has been reported
to occur in 45–59% of adult cases, with an estimated cost
of $20 billion for adult mental disorder claimants
(Chafetz and Underhill, 2013).
Assessment
The clinical cornerstone of detection as opposed to
diagnosis of malingering is the well-prepared clinical
interview, having reviewed available documents and
incorporating available forensic materials. Further evi-
dence includes lying from differing accounts to people,
515
evidence of tampering with wounds, and avoiding inves-
tigations that might confirm their stated diagnosis.
Typically, diagnosis requires collating evidence from
multiple sources over time, including both structured
and unstructured clinical interviews, psychometric test-
ing, and information collected from third parties
(Iverson, 2007).
A longitudinal health record is invaluable, as medical
records provide objective evidence of reported com-
plaints and clinic attendances that help illuminate the
relationship between an accident/injury/life event and
any subsequent symptoms attributed by the patient to
the putative causal event. A chronologic summary or
“chronology” often pays dividends in the assessment
of health documents.
SPECIAL INVESTIGATIONS
Probably the most widely encountered is video surveil-
lance and evidence from social media sites, typically
provided by the insurance companies/lawyers. Usually
this provides information about both the reported and
observed physical abilities of the claimant. Marked or
unexpected differences between the claimant’s reported/
observed behaviors and what he/she claims not to be able
to do can understandably raise serious doubts as to the
credibility of a claimant’s report.
PSYCHOLOGIC APPROACHES
Clinical psychologists and neuropsychologists have
developed tests that claim to provide for a more precise
assessment of the credibility of verbally claimed symp-
toms. In this context symptom validity refers to the accu-
racy or veracity of a person’s behavioral presentation,
self-reported symptoms, or performance on neuropsy-
chologic tests (Larrabee, 2012; Tracy, 2014). SVTs
typically comprise a simple memory or recognition task
in which a wide range of people with neurologic or
psychiatric problems can achieve near-perfect perfor-
mance (Guidotti Breting and Sweet, 2013). The basic
premise behind this approach is establishing a finding
of “below-chance” (i.e., less than 50%) performance
on a forced-choice test. Here voluntary endorsement
of incorrect answers (Bush et al., 2005) is taken by some
as “tantamount to confession of malingering” (Larrabee,
2004), but by others to help the expert to differentiate
between credible and noncredible symptom presenta-
tions (Merten and Merckelbach, 2013). Professional
bodies and guidelines have stressed the importance of
SVTs (Heilbronner et al., 2009).
When patients present with dissociative and somato-
form disorders or MUS, clinicians may administer SVTs
to determine whether or not the patient exhibits negative
response bias. Although some authors have argued that
516 C. BASS AND P. HALLIGAN
psychologic problems (e.g., unconscious conflicts and
depression) and life circumstances (e.g., a cry for help)
may explain such bias, Merten and Merckelbach
(2013) have argued that there is no empiric evidence to
support the view that psychiatric disorders such as soma-
toform and dissociative disorders lead to SVT failure.
These authors have argued that it is not unreasonable
to conclude that the patient’s self-reported symptoms
and life history can no longer be accepted at face value.
CLINICAL PRESENTATIONS RELATING
TO NEUROPSYCHIATRIC PRACTICE
Malingered cognitive deficit
(e.g., postconcussional syndrome)
A significant proportion (15–30%) of patients with mild
traumatic brain injury seem at risk of developing post-
concussional syndrome, with symptoms such as head-
ache, distress, cognitive problems, and dizziness (Hou
et al., 2012). It has also been shown that there is an asso-
ciation between patient concern (i.e., expectations) that
symptoms will have adverse consequences, and the
reporting of major and enduring complaints (Whittaker
et al., 2007; Ferrari, 2011).
In their influential paper, Miller and Cartilidge (1972)
suggested that many patients malingered their memory
and other cognitive symptoms and those symptoms were
in inverse proportion to injury severity and were only
resolved with receipt of compensation. Recent findings
tend to support the authors’ original observations that
embellishment rises as injury severity decreases in a
compensable context (Greiffenstein and Baker, 2005).
The American Academy of Neuropsychologists recently
published a consensus statement which concluded that
“Symptom exaggeration or fabrication occurs in a size-
able minority of neuropsychological examinees, with
greater prevalence in forensic contexts,” and that the
use of effort testing is mandatory in neuropsychologic
assessments (Heilbronner et al., 2009). By contrast, in
individuals with moderate to severe brain injury,
Gouse et al. (2013) found no evidence that subjects
malingered or delivered suboptimal effort during neurop-
sychologic testing in the context of litigation.
Silver (2012) has recently argued against excessive
reliance on the results of effort testing as evidence of
malingering. He pointed out that poor effort and exagger-
ation are not categoric values, but are complex and multi-
determined and have a differential diagnosis of their
own. Some factors, he suggests, are intrinsic to the cir-
cumstances of the injury or the assessment process, such
as expectations and beliefs about illness duration and
consequences, the pressure to perform well under
“threat conditions,” and anger and revenge.
Similar views have been expressed by Bender and
Matusewicz (2013), who cited work suggesting that
deception in the medicolegal arena may not be a one-
dimensional construct but instead involves at least two
dimensions: self and other. Each separate dimension
may involve varying degrees, such that high self-
deception and low other-deception would reflect pure
MUS, and vice versa for pure malingering (Merckelbach
and Merten, 2012). Further research is needed to describe
this paradigm and how it applies to the boundaries bet-
ween somatoform disorders, factitious disorders, and
malingering.
Somatoform and dissociative disorders
It is well established that approximately one-third of all
referrals to outpatient services in neurology have symp-
toms unexplained by disease (e.g., conversion symptoms
such as paralysis or blackouts; Carson et al, 2011b). Fur-
thermore, follow-up studies of these patients have shown
that two-thirds had a poor outcome after 1 year (Sharpe
et al., 2010). Significantly, illness beliefs and receipt of
financial benefits were more useful in predicting poor
outcome than the number of symptoms, disability, and
distress.
It has recently been demonstrated that, in nonlitigant
patients presenting to neurology outpatients, 11% failed
effort tests (Kemp et al., 2008). It is possible that some
patients with somatoform disorders are likely to fail
effort testing due to consciously feigning or symptom
exaggeration (i.e., factitious disorder or malingering)
and that, if this is the case, then the patient’s self-report
can no longer be taken at face value (Merten and
Merckelbach, 2013). An alternative explanation is that,
for various nonspecific reasons, such as fatigue, pain,
general malaise, or the presence of medical symptoms
(regardless of etiology), patients could have underper-
formed on effort tests in the absence of intention to feign
or exaggerate. The authors of this paper urged clinicians
to acquire the tools to identify patients who do exagger-
ate and base rate data that assist them in making judg-
ments that do not prejudice patients in genuine clinical
need. In an accompanying commentary to this paper,
Stone (2008) pointed out that cognitive effort testing is
only a proxy measure of the degree of motoric “effort
failure” that may underlie other physical symptoms, such
as weakness and fatigue, and furthermore that the study
did not reveal whether patients with weakness, for exam-
ple, had “effort failure” when attempting to move their
weak limb.
It is possible that the emergence of effort testing may
cast new light on the area of unexplained physical symp-
toms. For example, the concept of somatoform disorders
assumes that the symptoms are not consciously produced
 FACTITIOUS DISORDERS AND MALINGERING IN RELATION
(Creed et al., 2011). However, to date studies of patients
with functional neurologic disorders have yielded equiv-
ocal results. Heintz et al. (2013) compared patients with
PMD and those with Gilles de la Tourette syndrome
using an SVT to measure noncredible test performance.
No evidence of neuropsychologic impairments was
found in the PMD sample: the only differences to emerge
were noncredible cognitive symptoms in the PMD
patients. The authors concluded that noncredible
response might help to differentiate PMD from other
movement disorders.
Psychogenic nonepileptic seizures
Drane et al. (2006) first raised the possibility that patients
with PNES performed poorly on effort tests, especially
when compared to patients with epilepsy. These findings
were not replicated by Dodrill (2008), whose patients
were recruited over a consecutive period, none of whom
had received epilepsy surgery. In keeping with the find-
ings of Cragar et al. (2006), these authors founds a high
failure rate on effort test scores for the epilepsy patients,
and point out that the failure rate in unselected epilepsy
patient samples may be much higher than is commonly
believed.
In a recent study of 91 participants with PNES,
Williamson et al. (2012) found a relationship between
failure rates on SVTs and reported histories of abuse,
but, contrary to expectation, was not associated with
the presence of financial incentives or severity of
reported psychopathology. This finding was unexpected,
and the extent to which SVT failure is related to reports of
abuse in other groups of patients with MUS is unclear. It
has been argued that large-scale studies that dissect
incentive, motivation, and effort (as opposed to effort
tests) are needed to answer these questions (Bender
and Matusewicz, 2013).
Complex regional pain syndrome
The phenomenon of complex regional pain syndrome
type I (CRPS I) can arise after an injury to a limb
(Goebel, 2011). It is often diagnosed on the basis of non-
specific, often subjective observations, and in 85% of
patients the symptoms resolve within 18 months
(de Mos et al., 2009). It has been shown that certain
“diagnostic” features, such as skin temperature and color
differences between limbs, can be produced and main-
tained by short-term immobilization and dependency
of the limb (Singh and Davis, 2006). Iatrogenic compli-
cations are common and can lead to amputation in some
cases (de Asla, 2011). Self-induced symptoms have been
reported (Mailis-Gagnon et al., 2008) and, in a recent sur-
vey of 73 patients with CRPS, potentially incentivized by
517
disability-seeking contexts, at least 75% of the sample
failed one performance validity indicator and over half
showed at least one positive symptom validity score
(Grieffenstein et al., 2013). These findings suggest that
doctors need to be vigilant when confronted with this
diagnosis, especially in medicolegal settings (Ochoa
and Verdugo, 2010; Crick and Crick, 2011; Bass, 2014).
Prognosis and outcome
The levels of physical disability and psychologic comor-
bidity in follow-up studies of patients with functional
motor symptoms (weakness and movement disorder)
are generally high (Gelauff et al., 2014). The prognosis
for malingered neurologic disorders, however, is
unknown, but clinical experience suggests that patients
with longstanding disability, even if partly or wholly
nonorganic, do not always recover after settlement
(Mendelson, 1995). Outcomes following the completion
of litigation require more systematic evaluation.
CONCLUSIONS
Sensitivities surrounding the nature of illness deception
will no doubt continue to be a challenging issue for mod-
ern medicine given the growing recognition that many
medical illnesses are not exclusively diagnosed or vali-
dated on the basis of the biomedical model. Given the
personal, financial, and social benefits provided by sick
role and the low risk of detection (Halligan et al., 2003b),
it seems reasonable that illness deception is more preva-
lent than previously presumed or detected. Much of the
controversy surrounding illness deception reflects the
conflict of strongly held beliefs regarding human nature
and the motivation of people seeking medical attention.
Unlike the traditional biomedical model, the expanded
World Health Organization International Classification
of Functioning model, which highlights the role of the
person when defining illness (Wade and Halligan,
2003), provides a more comprehensive and pragmatic
model that includes the capacity for people as patients
to knowingly engage in deception for the purpose of per-
sonal gain or avoidance of responsibility.
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