Overlooking Feigning Behavior May Result in Potential Harmful Treatment Interventions: Two Case Reports of Undetected Malingering

Abstract

Clinicians tend to overestimate their ability to recognize feigning behavior in psychiatric patients, especially if it concerns patients who have been admitted for observation. Feigning can be either externally motivated (e.g., for financial compensation, known as malingering) or internally motivated (e.g., to assume the “sick role,” known as factitious disorder). Persistent presentation of severe symptoms is usually associated with the factitious disorder. We present two patients with strong external incentives who consistently and convincingly feigned severe psychiatric symptoms during a protracted period of inpatient observation in a specialized center; both were engaged in a procedure for medical asylum. The first case presented with the clinical picture of a psychotic depression with severe motor symptoms, and the second case showed symptoms of a chronic post‐traumatic stress disorder with secondary psychotic symptoms. Both cases were thoroughly investigated but feigning was overlooked, and unnecessary and harmful treatment interventions were given. To prevent iatrogenic damage, we recommend a critical attitude that takes malingering as an option into account in settings where patients are often involved in high stake legal procedures. A clinical sign that might indicate feigning is therapy‐resistant symptoms. To rule out feigning a comprehensive, multimethod approach is required, but an active stance toward collateral information is essential. Specialized psychological tests may be useful for preliminary screening, but for their use in culturally diverse populations as in refugee mental health more research is needed.

Replicating a Meta-Analysis: The Search for the Optimal Word Choice Test Cutoff Continues

“…Therefore, assessors may decide to apply more conservative cutoffs than the one that produces the optimal overall classification accuracy. However, such legitimate concerns about false positives should be balanced against the societal and individual cost of false negatives (e.g., awarding large personal injury settlements or disability payments for fraudulent claims, misdiagnosis, and resulting unnecessary treatment for a neuropsychiatric condition that the patient does not have; Chafetz & Underhill, 2013; van der Heide et al, 2020).…”

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“…This is often the case in patients with factitious disorder, to name the most obvious constellation of potential harm unnecessarily caused to mental health patients. Thus, van der Heide et al (2020) published two case vignettes in which nondetected feigned symptomatology resulted in potentially harmful interventions. The detrimental effects of false diagnoses in cases of claimed ADHD and other incentivized nonvisible disabilities, their medicalization and overpathologizing have more recently been discussed by Suhr and Johnson (2022) and Harrison (2022).…”

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