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Malingering in Mental Health Care

Meloncauli is a former nurse and anxiety management therapist. She hopes everyone can take something away from her articles.

Though it may seem obvious to some people that a person has a mental illness, many who suffer from a mental health disorder do not show outward signs. We go about our lives, mingling with the public on a day to day basis, never sure of who is sharing our seat on a coach or is in front of us in a shop queue. We know what these people look like or how they appear to us, but we have no idea if they have a mental illness or not.

The fact is that mental illness can appear invisible but it can also be very apparent. When you visualize a mental health patient, you probably think of:

We all have a perception of what a mentally ill person looks like

We all have a perception of what a mentally ill person looks like

  • Loud and intimidating people
  • Extremely quite and introverted people
  • Wild eyes, staring eyes
  • Unpredictable verbal or physical outbursts
  • Dirty or mismatched clothing
  • Strange facial expressions
  • Alcoholics or drug addicts

A considerable proportion of mentally ill people do not fit those descriptions, but with media encouragement, we have been led to believe that having a mental illness is akin to “madness”. We know well of our image of a “mad” or “deranged” person. If a picture of being mentally ill is so obvious in our eyes, then it is fair to say that there must be a universal image we all relate to. We may have read books, newspaper articles or seen films that depict the persona or outer appearance of people who have a mental health disorder. The problem is that a person with mental illness often doesn’t fit the picture that we paint.

In the late 1800s a journalist actually faked mental illness to do some investigative journalism into mental asylums. She could fake it. (See book on the right).

The shocking but truth is that that some people actually fake mental illness for their own good. Whether it is born from a preconceived image of, or textbook information about mental disorders, these people are willing to pretend they have everything, from an anxiety disorder or depression to schizophrenia. The act is purely intentional and people who feign mental illness are known as malingerers.

What is Malingering?

Malingering is the act of faking illness or exaggerating it, with intent to use the illness for personal gain. It is seen in different circumstances but tends to be for one of the following reasons:

  • To avoid responsibility – work, family, criminal activity
  • To get out of the armed forces
  • To claim insurance
  • To claim disabled benefits
  • To get drugs

It may be that a person has had a bout of depression that has been treated in the past, but they claim that the depression keeps coming back when it doesn’t. They may exaggerate an existing anxiety problem and say that they also have agoraphobia, obsessional behavior or many other anxiety related conditions. As we can’t always see depression visually, or determine someone’s anxiety level throughout the day, we tend to believe them. These mental health issues are easier to fake or exaggerate.

There are some people who fake the more serious mental illnesses such as schizophrenia, and claim to have auditory and visual hallucinations. These kinds of disorders are more difficult to fake, but if these people are desperate, they will attempt to convince the people they need to that they are seriously mentally ill.

Malingerers fraudulently claim benefits

Malingerers fraudulently claim benefits

Work, Disablement Benefits and Malingering

Many people who have a diagnosed mental illness actually work, and to some degree manage quite well. I have known scores of people that have a diagnosis of depression, anxiety disorders, personality disorders, and even some of the more severe mental illnesses who manage to hold down a job. It is still however, not unusual to have to take time off work or not work at all for any mental illness.

What if you don’t like your job any more, or feel under pressure at work? Many people in these circumstances may pretend to be clinically depressed. They go along to their practitioner, say they have a few symptoms related to depression and are signed off sick. This can then develop with a few more feigned symptoms such as anxiety and phobic behavior (anxiety and depression are often seen together). The grand finale is that they are unable to work at all, are discharged from work on medical grounds and then in receipt of long term disablement benefits.

There are also those who recover from mental illness, who pretend to still be suffering with the same symptoms. This kind of exaggeration is often born out of a fear of losing benefits, or a fear of having to work after many years of illness.

Crime and Malingering

The insanity defense brought about by the McNaughton Rules, question a person’s mental competence after a crime has been committed such as murder. A person is deemed liable for the crime committed, if they knew what they were doing at the time, and if they knew that the act was legally wrong. As you can imagine, the insanity plea has been abused terribly over the years.

A famous example of the lengths people will go to in trying to avoid prosecution is that of Mafia mobster Vincent Gigante. Because he was in fear of prosecution, he walked the streets in his pajamas and slippers whilst apparently talking to himself, as though suffering from schizophrenia. This worked for ten years and he was deemed mentally unfit to stand trial. He was caught out in the end however!

 Criminals may use mental illness as an excuse for their behavior

Criminals may use mental illness as an excuse for their behavior

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This is not an isolated case of course, as many criminals from petty thieves to murderers will sometimes try to fake mental illness to avoid the responsibility for their crime. Crime, especially serious crime, can be generally perceived as being closely connected to an underlying mental illness in the eyes of the masses, and this is why it may be considered an easy option for the criminal. We all tend to ask the question “mad or bad” when trying to understand criminal behavior.

Those who are in prison may fake mental illness to receive more lenient care and for attention. Prison life might be considered a little easier with a few drugs thrown in for a mental disorder too! Psychotropic drugs often help calm a person and induce better sleep. A criminal may actually have a drug problem and this is another way to handle that aspect.

Claiming Insurance and Malingering

The most obvious physical illness insurance claim that springs to mind is that of faked or exaggerated whiplash injury after a traffic accident. People do however; fake mental illness after a trauma of any kind. We hear more and more about post traumatic stress disorder (PTSD), and this is an illness that many will try and fake. This is often more about exaggerating the effect that a traumatic event has had on a person. They may indeed be affected, but not to the extent that it interferes with their lives. An exaggeration of PTSD brings with it an attention from professionals and a much needed diagnosis letter for an insurance claim.

The emotions are strongly connected to mental illness and we can not see someone’s emotions; how they truly feel. If a person tells a doctor that he keeps reliving the traumatic event, is anxious, irritable and having a hard time sleeping, it is highly likely that a PTSD diagnosis will be considered, and this is classed as mental illness. This diagnosis will push up insurance claims considerably higher.

Daily Mail Article on Celebrity Mental Illness and Children

Britney Spears is widely known to have mental health disorders

Britney Spears is widely known to have mental health disorders

Celebrity Mental Illness and Young People

Although it sounds unbelievable, it has been found that some children and adolescents can fake mental illness purely because they know of a celebrity that has a disorder. There has been much media coverage of the mental illness of such stars as Britney Spears and Kerry Katona for instance. Faking depression and self harming for example have become “cool” for some children. This could have far reaching consequences for those children, and shows us how little they truly understand about the seriousness of having a mental health disorder. Some of these children may well enter into the psychiatric care services, and be given strong medications to deal with a fictitious mental illness.

Diagnosis of Malingerers in Mental Health Care

Faking or exaggerating mental illness because one actually wants to be mentally ill is recognized as a problem that needs help, but this can be hard to define. Munchausen syndrome is one such factitious disorder that is recognized by mental health professionals. A person with Munchausen syndrome will go to great lengths to assume a sick role because they want to be sick, but there will be no signs of such things as monetary gain or an impending court case. This implies that the person has an emotional problem that is unresolved and is seeking a way to resolve the inner emotional turmoil. Munchausen syndrome can happen within the mental health care service, but is more usually seen first in the medical setting as an attention seeking role. Perhaps this is because it is simply harder to keep up the pretence of a behavior, as opposed to pain.

If a psychiatrist is presented with a suspected malingerer, it is the faker’s purpose or goal that is paramount in diagnosis. There is no internal mental conflict with a true malingerer, and he is faking purely out of a need to gain something such as mentioned above. Many malingerers have not done their homework thoroughly enough, if at all! This is where we come back to how the layman defines the picture of mental illness, and that picture is just not as accurate as we think! A psychiatrist may suspect malingering when:

  • The person has an impending court case
  • The person has an impending insurance claim
  • The person has an addiction to drugs
  • The person talks in a blatant text book fashion about his feigned illness (facts many of us wouldn’t know at the onset of severe mental illness or be in a position to explain)
  • Changing symptoms from time to time
  • The person claims to be confused and behaves irrationally, but has apparent spells of being completely lucid
  • The behavior changes when the person is alone
  • The person has no previous history of any symptoms of mental illness

It can sometimes prove to be a difficult call for psychiatrists and there is always the chance of getting it wrong. In these instances the people who are not faking will not get the treatment they need which is of great concern.

There are sure to be some malingerers that slip through the diagnostic net, but often people will get found out in the end. The impact of malingers on the benefit system, the cost to the health service and the bogus insurance claims, all have an effect on the rest of society. Resources for mental health care are already stretched and this kind of behavior takes valuable services away from those who legitimately need it.


meloncauli (author) from UK on October 21, 2012:

Thanks for your comment to which I fully agree! The benefit system is having an overhaul in the UK, and there are plans for cuts or clamping down on malingerers. I just hope those with genuine mental illness don't suffer because of the actions of those who abuse the system.

Boo McCourt from Washington MI on October 20, 2012:

It is a shame that treatment goes to the ones who are faking their illness while those with a real mental illness suffer to get treatment. I don't want to believe that there are those who fake something so horrific as mental illness, however I have seen it first hand, it is even worse when they end up on disability for that faked illness. It is sad. Your hub brings the truth into the light about this horrible fact of pretending. When real people with a true diagnosis are fighting to stop stigma, we have pretenders giving those that suffer a bad rap.

meloncauli (author) from UK on October 20, 2012:

Very interesting comments here so thanks for taking the time to respond.

I agree with almost all you say actually. There is conforming within society and there is conforming within psychiatry. We are at the mercy of the very idea that psychiatry is a science and treatment should be prescribed by way of medication first and therapy second. I wonder...are we talking "mind" or brain" disorders ? There is little proof scientifically for the latter.

I look forward to your debate on the forums!

Best wishes

Dr. Gary L. Sidley from Lancashire, England on October 20, 2012:

Hi meloncauli

Thanks for sharing your detailed thoughts. As always, I do very much respect your point of view. You have stimulated a really interesting debate that touches on most of the controversies associated with western psychiatric services. In the future (if I’m feeling a bit masochistic!) I might try and trigger a similar debate on the forums.

Although I suspect we will have to agree to differ, I would suggest the following in response to your comments:

1. Apart from giving us a descriptive language in which to converse, it is difficult to see any positive contribution that diagnostic labels make to helping service-users overcome their problems. Diagnoses of a “depressive illness” or “schizophrenia” are poor predictors of treatment outcome, induce passivity (by wrongly suggesting there is some primary biological cause for the problem – like insulin deficiency in diabetes) and tend to stigmatise.

I don’t believe it should be the professionals deciding who needs help, but the service-users themselves. Throughout the general population at any one time there will be many people suffering varying degrees of low mood, anxiety, voice-hearing, unusual beliefs etc. and these experiences will be having widely varying impacts on their lives. As a society what (in my humble opinion!) we should be concentrating on are:

- comprehensive public health programmes, starting in the schools and colleges, describing how to maintain positive mental health, deal with low mood, reduce anxiety, manage unusual experiences etc;

- massively expand change-enablers of all modalities (peer group support, psychological therapy, access to a medication prescriber) all supported by balanced information (not the psychiatry/pharmaceutical industry hype) about the pros and cons of each of these approaches.

Maybe I’m describing a utopia that we will never realise, but I believe this is the kind of service we should be aspiring to.

2. I have worked with many people over the years that have been trapped in the DLA trap, where the prospect of overcoming their fears and mood problems and being financially penalised is a major threat that adds further to their psychological problems. I don’t blame the service-users here, I blame the system. Fundamentally, I do struggle to see how paying someone additional money to compensate for their reversible (non-organic) mental health problems can do anything other than act as a significant disincentive to putting themselves through a treatment programme that often involves increased discomfort in the short term.

It would probably be unfair to change the system of DLA for those already caught within it, but I would certainly abolish it for new sufferers.

3. But people with mental health problems currently face an unfair criminal justice system. The Mental Health Act is fundamentally discriminatory – for example how can it be right that you or I could make an advance decision preventing life-saving treatment for a medical decision (and rest assured knowing that it would have to be respected) but we could not, through the same means, refuse a specific treatment for “mental illness” (if a psychiatrist disagrees and sections us that would trump any advance decision). Also there is clear evidence that people who commit serious crime (e.g. murder) and are deemed to have “mental illness” will suffer much longer periods of incarceration. The common “mad vs bad” fiasco within the Court system is an embarrassingly meaningless debate.

Anyway, I’ll get off my soap-box now. Sorry for the very long response.

Best wishes.

meloncauli (author) from UK on October 20, 2012:

Hi gsidley

Your comments are understandable and I see the validity of those points, however I would like to respond to those points.

1. I do wonder how we would change the help for people with mental health problems, if there was no acceptance or recognition of diagnosis in the first place ! Where would we draw the line about who needed help and who did not? Who would decide? I hate the labels, but without them, all people with problems (emotional, spiritual etc), would be added to the equation in their masses. Do we not need definition?

2. I don't believe that the people who receive DLA for very valid reasons should go without it because of the minority who abuse it. Anxiety problems are reversible, but some people suffer so badly that they cannot function properly without extra monetary help e.g. paralyzing agoraphobia and the expense of taxis which DLA is useful for. These people who need to get from A to B quickly, are usually unemployed for quite some time but have mobility issues. Just an example and I am sure there are many others

3. Because there is still so much stigma around and misunderstanding about mental illness on the part of Joe Public, I would doubt anyone with a valid mental health issue would be fairly treated by a lay-person jury.

You raise valid and interesting points, but I see problems arising from them.

Dr. Gary L. Sidley from Lancashire, England on October 19, 2012:

A very interesting hub with some equally pertinent responses.

I think my views are somewhat radical on this topic. In my opinion three changes to the current system would be of great value:

1. Recognise and accept that a mental illness diagnosis is virtually meaningless - invalid and unreliable. That way there would be fewer people striving to achieve the label for ulterior motives.

2. Get rid of additional benefits (e.g. Disability Living Allowance) for anyone suffering a disorder that is potentially reversible i.e. all mental health problems.

3. Get rid of the insanity plea within criminal proceedings. If some one commits a crime lets show them the respect of prosecuting them like anyone else, irrespective of whether there have mental health issues. I would trust the lay-people on a jury (rather than psychiatrists) to take into account mitigating circumstances and sentence accordingly.

Before everyone starts accusing me of insensitivity or lack of compassion, I can assure them that this couldn't be further from the truth. I believe we should hugely increase the availability of change-orientated help for people with mental health problems(the savings from the DLA budget would go along way to funding this).

Best wishes.

meloncauli (author) from UK on October 19, 2012:

Thanks for your comment. I think it is sad that mental illness seems to be divided into severe and less severe, but it is. Anxiety disorders and depression are very debilitating illnesses. Both can leave you housebound, wreck relationships and even cause suicide. The only thing I would say is that a lot of anxiety problems can be manageable given the right help and support. I recovered from mine, but from my observations, I'd say it is far less likely that a person will recover from bipolar disorder or schizophrenia for example. But then these can be managed also.

I know how hard it can be for someone suffering a long-term anxiety disorder and my heart goes out to those people. The people who fake it or stretch the truth for monetary gain, drugs etc, anger me because I know how much resources are at breaking point in some areas.

catgypsy from the South on October 18, 2012:

I see your point and it is a good one. I actually know a person who I suspect is using her mental issues as an excuse for all sorts of things, but that's a whole other hub! The only thing I cringe at a little here is that so many people think anxiety disorders and depression are a lot of baloney, "all in your head", a way to get attention, etc. They don't give the proper support to people who are truly suffering from these. So, I hope that people don't take this as a way to suspect anyone they know who says they are suffering from one of these is just faking it. But you make a good point and those that do "fake" it should be punished in some way if caught. They are hurting those that truly need help.

meloncauli (author) from UK on October 18, 2012:

Absolutely! It is as if the system protected them to such a degree that they don't know how to manage without it.

Mary Kelly Godley from Ireland on October 18, 2012:

Yes thank you too I understand what you are saying, treatment needs to go to people who truly need it as resources are always so limited, that's a very valid point too and I know there can be instances where people are capable of going back to work but they may just have become too used to their crutch and that's not good for anybody especially not them in the longer term.

meloncauli (author) from UK on October 18, 2012:

Thanks for your comment and your interesting reply. I fully understand what you are saying because we too have less psychiatric in-patient beds than ever before, and getting the help can be difficult. Here it appears to be more of an increasing divide for treatment between those with the less severe illnesses such as anxiety disorders and depression, and those with severe mental illness such as schizophrenia and psychosis.

Attention seeking can be part of the malingering, but there can be several reasons for this:

Scared to go back to work in case of a mental illness relapse

Not worked in such a long time that a person is afraid of the workplace or mixing socially

This means that some people who could be deemed "recovered" may feel the need to further act out or exaggerate their illness in order to maintain support. It's sad really because some of these people may be seen as "attention seekers".

Mental illness is such that we have no lab tests as such in diagnosis. Malingering in the medical health care sector can be ascertained much more easily I think!

There are not enough places for mental health care treatment as it is, so true malingering needs to be weeded out.

Thanks again for your comments.

Mary Kelly Godley from Ireland on October 18, 2012:

Interesting article and viewpoint. Here in Ireland we are trying to raise more awareness of Mental Health issues because each year suicide rates are rising especially among the young male population. The problem here is that many go undiagnosed because many GP's are not all that adept or willing to diagnose Mental Health issues such as Depression, Bi-Polar or even conditions such as ADHD and Autism. Here I think even if you are Mentally unwell it is a battle to convince the Health Services that you need help at all and there is still also a lot of stigma attached to revealing a Mental Health issue here in Ireland too although I think that has begun to change in recent years. So I dunno if we have too many people faking it here yet but probably it will increase over the next few years.

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