DSM-5: Malingering.

My DSM-5 group has lost its pre­vi­ous vital­ity for the same rea­sons my blog has lost its pre­vi­ous verve (pend­ing job change, ongo­ing fam­ily health con­cerns). But! The DSM-5 group has had a few updates; the most recent edi­tion is below. If you’re inter­ested in sub­scrib­ing to the DSM-5 e-mail group, you can sign up here.

Malin­ger­ing in DSM-5, like in DSM-IV, is a “V code”. “V codes” (in ICD-9) will turn into “Z codes” (in ICD-10) and these are con­sid­ered “other con­di­tions that may be a focus on clin­i­cal atten­tion”. This means two things:

(1) Con­di­tions listed as “V codes” are not diag­noses because

(2) Con­di­tions listed as “V codes” are not men­tal disorders.

There­fore, malin­ger­ing is not a men­tal disorder.

In crass terms, malin­ger­ing means that peo­ple are fak­ing or *really* embell­ish­ing phys­i­cal or psy­cho­log­i­cal symp­toms. Peo­ple who are malin­ger­ing do this “con­sciously” (hat tip to the ana­lysts) because there is an exter­nal incen­tive to do so. These exter­nal incen­tives might include:

a) avoid­ing mil­i­tary duty
b) avoid­ing work
c) obtain­ing finan­cial com­pen­sa­tion
d) evad­ing crim­i­nal pros­e­cu­tion
e) obtain­ing drugs

Malin­ger­ing can be hugely adap­tive: If you were home­less and the tem­per­a­tures out­side are below freez­ing and a win­ter wind is whip­ping the frost off of the trees and there are no open shel­ter beds and you are hun­gry because the last time you ate was two days ago and that was a soggy, half-eaten sand­wich you found in the trashcan–

–wouldn’t you con­sider going to the hos­pi­tal and say that you want to kill your­self so you could be in a warm place for a few hours and get some non-soggy food?

DSM-5 argues that if “any com­bi­na­tion” of the fol­low­ing four items is present in a patient, you should con­sider the con­di­tion of malingering:

(1) Medicole­gal con­text of pre­sen­ta­tion (a lawyer sends the client for eval­u­a­tion or the patient presents for care in the midst of crim­i­nal charges)

(2) There is a “marked dis­crep­ancy” between the individual’s “claimed stress or dis­abil­ity” and “objec­tive find­ings and observations”

(3) “Lack of coop­er­a­tion dur­ing the diag­nos­tic eval­u­a­tion and in com­ply­ing with the pre­scribed treat­ment reg­i­men” (some tired clin­i­cians would sum­ma­rize this as “a dif­fi­cult patient”, though I much pre­fer DSM-5’s description)

(4) The pres­ence of anti­so­cial per­son­al­ity disorder

I applaud DSM-5’s efforts in keep­ing the descrip­tion of malin­ger­ing neu­tral. Some peo­ple have strong reac­tions towards (trans­la­tion: self-righteous fury at) peo­ple who present with malin­ger­ing. Keep­ing the focus on the behav­iors helps tem­per the emo­tional reactions.

DSM-5 then clar­i­fies the dif­fer­ences between malin­ger­ing and fac­ti­tious dis­or­der, con­ver­sion dis­or­der, and related con­di­tions. Malin­ger­ing is the only con­di­tion here where symp­toms appear solely because there is an exter­nal incentive.

On a some­what related note, the con­di­tion that fol­lows malin­ger­ing in DSM-5 is “wan­der­ing asso­ci­ated with a men­tal dis­or­der”. This is appar­ently lim­ited to walk­ing (where the “desire to walk about leads to sig­nif­i­cant clin­i­cal man­age­ment or safety concerns”).

The next post will hope­fully show up less than one month away.