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mental health mondays :: sadly, it does happen

one of the worst things that a person with a mental disorder can hear from friends and loved ones is that what they're going through isn't real, or the close cousin of that accusation, that it isn't serious. the fear that they might be disbelieved, or the idea that they're somehow weaker or less capable people are among the chief reasons why people who have disorders seek help to begin with. but here's the bad news: some people do exaggerate or outright fake mental illness. the reasons behind this can vary, but it happens, and it's one of the hardest things for even a seasoned professional to diagnose.

the official term for faking/ exaggerating an illness [mental or otherwise] is malingering, a word of old french origin that, as you might have guessed, also gives us the english word malign. the reasons for malingering range from gaining financial benefit to avoiding legal responsibility to mental illness. wait, what? yes, you read that right. people who are faking mental illness can be suffering from a mental illness. we'll get to that shortly.

to meet the official definition of malingering, there needs to be some tangible benefit to doing so. one of the most obvious is to gain disability benefits. a one year study conducted by the american board of clinical neuropsychology found that cases of malingering constituted up to 30% of mental health claims. that's a horrifying statistic, but it does warrant a further breakdown of the numbers: the areas where faking illness was most prominent were the ones with the highest financial rewards, i.e., coverage from private insurance plans. it's also worth considering that that's where psychiatric evaluators are most prone to suspect malingering, especially those who are employed by insurance companies, which means that the number of cases may be exaggerated by findings biased against patients. the second highest percentage of fake or exaggerated illness [about 19%] was in legal context, where, again, there is a clear and tangible benefit to be gained. looking at cases of people hospitalised for mental illness, and the figure drops to an average of 8%. that's a lot less than 30% but, at just under 1 in 10, still a bit disturbing.

what should be equally disturbing, however, is the idea that 1 in 10 people with mental illness will fake or exaggerate symptoms to such an extent that they will allow themselves to be hospitalised, without any other marked benefit to them. yes, you could argue, it gives them free room and board, access to free food and access to some pretty funky drugs, but in return, they have to consent to be cut off from everything else and to allow themselves to be completely controlled by others.

this is where we enter a fuzzy area between pure malingering [where the individual is fully aware of the fact that they're putting on a show] and something called factitious disorder. this is the mental disorder that i mentioned earlier.

people who have a factitious disorder are partially unaware that they are being disingenuous, but may believe that they need to embellish in order to get what they need. the benefits they derive from their feigned illness are generally more abstract, or less valuable, than those who engage in pure malingering. for instance, someone with a factitious disorder may seek to be perceived as a victim in order to elicit sympathy or to be treated as helpless. the reasons behind the disorder aren't understood, although they can be related to past trauma. the important thing to note is that a factitious disorder is not the same as malingering; people with factitious disorders can and will harm themselves, sometimes severely, in order to perpetuate the narrative of their illness.

detecting either malingering or factitious disorder is a clinical nightmare. many doctors shy away from it out of fear of making a legitimate disorder even worse, or because they might be wrong. and if it's a difficult call for a professional to make, it's nigh on impossible for the rest of us. and parsing between the two conditions is as complicated as... well, brain surgery.

both malingering and factitious disorders share some features that can serve as red flags:


  • bizarre or inconsistent symptoms. mental disease, like any other, may not be completely predictable, but the group of symptoms and the course of the disease is roughly consistent. 
  • too-consistent symptoms. on the other hand, we all have access to wikipedia and webmd, so if a person's list of symptoms conforms exactly to the ones that are given on popular websites, that's surprising as well. [malingerers in particular are known to be much too precise and detailed in their evaluation of symptoms.]
  • adapting or adopting symptoms to suit a diagnosis. i'm guessing that's pretty clear.
  • failure to show any improvement. neither malingerers nor those with factitious disorders want to get better. malingerers may show improvement if it suits their needs ["i was legally insane when i committed that crime, but i'm fine now!"], but a person with a factitious disorder will not only refuse to admit improvement, but will go to some lengths [such as skipping medication or engaging in activity they've been advised can be harmful to their condition] in order to keep up their story. 
  • sudden onset of symptoms. a tricky area, because there are lots of people who have a mental disorder, but who only come to realise it, much less talk about it, after a long time. nonetheless, there should be some evidence of symptoms being present well before diagnosis. 

the key driving factor with malingerers is tangible gain. there is a reason why they are behaving in a certain way, and the reason is usually pretty obvious.

factitious disorders are also characterised by a dramatic, but inconsistent, medical history. these people can seem like the unluckiest people in the world, because they've had kidney stones, bone cancer, and heart problems in the last two years. when one diagnosis doesn't "work out", they move on to get another, or their symptoms shift in order to point doctors in another direction. in fact, it's fairly common for people with this disorder [or from this spectrum of disorders, since there's a considerable range] to have switched doctors often, even going to see doctors in other cities in order to avoid "detection".

the above paragraph can make people with factitious disorders seem quite devious, and there is a certain element of that, but it's important to keep in mind that these people are really sick, just not in the way[s] that they think they are. even between factitious disorder and malingering, there's room for confusion. some will act to gain advantages most people would find unworthy, and can make themselves quite miserable in the process. that sort of person can fall on either side of the "line", or shift from one side to the other.

so what to do if you suspect someone is malingering or has a factitious disorder? well, for starters, remember that identifying mental disorders is always tricky business. it's not like cancer or hiv, where there's a diagnostic test [yet], so, just as doctors fear they could be wrong, so should you. straight up confrontation a recipe for disaster more often than not and, in the case of a belligerent malingerer, could possibly put you in danger yourself.

in the case of malingering, keep in mind that the problem may well resolve itself over time. insurance companies are aggressive about weeding out such cases, and even public health care plans require significant clinical evidence and regular updates in cases of disabilities claimed for mental health. legal defenses of insanity in the united states have a success rate of under 1%, which, given the prevalence of serious mental illness in the general population, is not too high, but alarmingly low.

if you suspect someone you care about is suffering from a factitious disorder, assuming you don't mind engaging in a little deception, your best course might be to try to talk to their doctor[s] about your concerns. be prepared for the fact that the doctor may not agree with you; just as you see things the doctor doesn't, the doctor sees things you don't. no matter how confident you are, there are parts of the story you don't possess and parts of the path to a cure that you might not be aware of.

none of this makes you any less of an arsehead if your first inclination to someone telling you they have a mental illness is to say that it's not real, that they're playing it up, or that it's not that serious. take the time yourself to look at what the illness is, how it's dealt with, what the prognosis is, and what the best things you can do as a non-professional observer are. if you still think that there's reason to be suspicious, think about it and study it some more, then talk to someone who knows more about it than you do. 

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