Deception in Clinical Settings Samenvatting
Les 1 – Introduction 13/09/2024
Malingering = lying for certain benefits, there is an intention behind it. A more neutral term is
symptom validity. There are multiple reasons for this, i.e., getting medication, early retirement, etc.
Deception is fundamental to survival in the animal’s kingdom. Video very effective form of
deception, animals playing dead or wounded in dangerous situations. Feigning of death to avoid
predators is common in many animal species (e.g., opossum). So, deception can be functional.
Case report. Frank William Abagnale, Jr. was a cheque con artist, forger and imposter. He claimed to
have many different careers and passed bad cheques worth a lot of money. Interestingly, after lying
that much in his younger years and deceiving many people, after being released, he founded a
company and earned enough money to pay back those he scammed.
Assumption of honesty. In the clinical field, clinicians are usually trained to believe patients. They
often depend on what patients report to them. Consequently, they are often not aware of the
potential for deception in the clinical setting. However, some people do not tell the truth, they
deliberately produce false or grossly exaggerate symptoms. This is what this course is about, if the
symptoms that the patients report do not reflect the truth experiences. It is important not to claim
the intention behind this, there can be many (of which malingering is one). One very important
differentiation is to see if the deception is used to gain external incentives, then it is malingering
(patients want an insurance settlement, medication, early retirement, etc., then there is an external
force). The patients are dishonest to reach certain goals. Malingering is only one reason why people
present dishonesty. Another explanation is the factitious disorder, to assume the sick role. In this
case, there is an internal incentive causing the dishonesty (people want the attention for being so
sick for instance, the desire for spotlight, the questions they get from people, etc.). The difference
between external and internal incentives is hard, however, the internal incentive is about the
internal desire to be pitied, get attention, etc. So, the topic of this course is called
symptom/performance validity, not malingering.
Common psychiatric disorders accompanied by deceptive behaviour.
There are many psychiatric disorders for which we know that people can be dishonest, lie to you,
manipulate you, just for their own good.
- Substance abuse and dependence. Denial and other forms of deception are part of the
disease, in order to minimize consequences of use and ensure continued supply of the
substance.
- Eating disorders. Clinicians are aware that patients with anorexia and bulimia nervosa use
various common deceptive practices. Deception is part of the condition that the people are
suffering from, they have no interest in reporting honestly about their condition. Examples
are dishonesty about body weight or food intake, hiding food, secretive use of laxatives,
body weight manipulation.
- Paraphilias. Sexual deviations or perversions with behaviors or sexual urges focusing on
unusual objects, activities, or situations which are illegal or hurting other people so naturally,
these people are not honest about their desires. Examples are fetishism, exhibitionism,
frotteurism, voyeurism, paedophilia.
- Personality disorders. Common feature: difficulties with impulse control, including
exaggeration or lying. They want to put themselves in a good light. In particular antisocial
personality disorder, borderline personality disorder, histrionic and narcissistic personality
disorder.
,All these psychiatric disorders are associated with a severe form of deception.
Factitious disorders and malingering.
As professionals we need to be sure that patients tell the truth. In the behavioural discipline,
however, there is no biomarker, blood test, or scan that we can use to tell us that people suffer from
a certain disorder. They are behavioural defined disorders; to assess behaviour, we rely on the
information that patients and their relatives tell us. Therefore, we must ensure that the reports are
truthful. Therefore, we need instruments to verify.
- Factitious disorder (FD): a psychiatric condition in which an individual presents with an
illness that is deliberately produced or falsified purpose of assuming the sick role. The child in
the video plays sick only when the parents are looking. This is an internal need.
- Malingering: the intentional production of false or grossly exaggerated physical or
psychological symptoms motivated by external incentives, such as financial motivation.
Both behaviors are intentional, but they are driven by
different motivations. Both people in the videos know that
they don’t actually have the symptoms. They intentionally
show that behavior, but the motivations are different. The
child stops immediately when the parents are out of sight,
it needs attention. This is an internal incentive of being
sick, being the sick role, being cared about by the parents.
The person in court needs attention to get advantages in
court, there might be a benefit in it for her. This is
motivated by an external incentive. There can also be
many things in between, it is not as black and white as it is
described now.
Differential diagnosis. So, there is a differentiation between factitious disorder or malingering; but it
could also be a real medical or mental condition (other than factitious disorder).
Somatic symptom and related disorders. Prominence of somatic symptoms associated with
significant distress and impairment. These are symptoms without any physical cause. There are
various forms (e.g., conversion disorder and illness anxiety disorder):
- Illness anxiety disorder: preoccupation with fears of having a serious illness. They are very
afraid of being sick. This is not malingering; people are really afraid of being sick. The
difference with malingering is that they are really afraid of being sick, they have no intention
to deceive. They are relieved at first when not being sick but after a while will doubt the
assessment, while people that malinger won’t be relieved as they want to be sick to get an
advantage.
- Conversion disorder: sensory or motor symptoms without any physiological cause. The
difference is that they really experience symptoms. It is not intentional. Only because we
don’t know the cause, doesn’t mean there is none. The symptoms are hard to believe, and
we don’t have an explanation for them, but the people really experience them. The
symptoms are very strange and there is no explanation, but they really experience them like
this, it is not intentionally produced. An example is of glove anaesthesia, you even have
physical reasons that speak against the symptoms, so it is hard to believe. However, only
because we don’t have an explanation, doesn’t mean there is none. The bottom line is, in
conversion disorder, it is not intentional (contrary to malingering and FD).
, - Determining existence of an external incentive can be difficult (malingerers usually don’t
trumpet their external incentives).
- Voluntariness and intentionality are more likely dimensions rather than discrete entities.
So, there are many reasons for why people are dishonest. It can be because of the condition, maybe
they have an external incentive (malingering), an internal incentive (desire to play the sick role, FD), it
can also be a conversion disorder (a true experience of symptoms for which we don’t have an
explanation, but they truly experience a physical symptom), or the illness anxiety disorder (no
symptoms present, but they are so preoccupied with potentially being sick that it impairs their life).
So, the bottom line is, there are many patients who don’t present their symptoms truthfully.
However, there is no monopoly on distortion for patients. Also, clinicians are not always honest.
What about the clinicians? An example is that clinicians can lie about his or her skills. In this case, it
is likely to be malingering (e.g., for a good salary). The same accounts for clinicians as for patients,
they are dishonest for the sake of money, evading prosecution, etc.
An example of an imposter is Gert Postel, he successfully applied as a medical doctor several times
without ever having received medical education. Also, it is estimated that around 30% of all sick
notes by students are bogus. Another example is that physicians can use deception in the interest of
their patients. They are prepared to lie in the interest of their patients (e.g., to secure insurance
payment). So, it doesn’t just affect patients, but also clinicians, attorney’s, etc. Eventually, we all
make advantage of it. We know that certain medication is not as beneficial as we hope. They are only
beneficial with the addition of a placebo effect. Medication also works better if the effects are
explained by an authority figure. Deception is not only negative, sometimes you try to take
advantage of deception to increase the effectiveness of certain treatments.
Why do people malinger? There are three different models that explain this behavior:
1. Adaptation model: cost-benefit analysis results in a deliberate decision to feign psychological
impairment. This is a rational decision and based on the analysis, you make a decision to
deceive or not.
o Substance abuse: explained by this model as escaping and avoiding responsibilities.
2. Pathogenic model: underlying disorder discloses in malingered symptomatology (i.e.
malingerers “can’t control their behavior”).
o Eating disorder: explained by this model as rigidity, distorted body image, the need
of people to maintain control. These patients need to malinger because they are sick.
o Substance abuse: I am sick, so I need to take drugs for self-medicating reasons.
o Paraphilias: the own abuse history leads to poor boundaries (assumes that
somebody has had an abnormal development and therefore, needs to act this
behavior because he or she is sick themselves).
3. Criminological model: malingering is a sign of antisocial behavior committed by antisocial
persons (unfortunately, the DSM relies on this model, which is questioned by research data).
o Conduct disorder: explained by this model as poor impulse control, they are
impulsive and dangerous people.
o Substance abuse: secondary to antisocial personality disorder (taking drugs because
of the bad personality).
o Paraphilias: luring victims/maintaining offending (the antisocial personality type
commits these crimes).
, What do laypeople think about malingering? A survey of 975 citizens from the Dutch community.
They asked about what people think about malingering. They asked: what percentage of all Dutch
people, do you think, would malinger symptoms in order to obtain an advantage? The mean
estimation was 31.2%. Then they asked per context. These percentages ranged from 25% to 50%.
Their beliefs were quite clear, people would malinger if it gave them an advantage. Then they asked,
what about yourself? 25% - 39% of participants having had contact with people malingering. 14%
admitted having feigned symptoms themselves at some point in the past. This gave a clear image of
how prevalent this issue is believed in the general public. They also asked about the explanation of
malingered behavior, and which model is most likely?
- It is an act of fraud committed in a cool and unscrupulous manner (criminological model)
- The behavior of the person in question reveals a mental disorder, because a healthy person
would not do something like this (pathogenic model)
- The person in question is in a situation in which this appears to be the best behavioural
option (adaptational model)
The results were more or less evenly spread, there was no clear choice of which model explains it the
best.
So, it happens all over the place. There are different motivations behind deception. It may be
intentional or not, and internal or external.
