Malingering

“ Whatever convictions I possess concerning the subject of malingering were gained from a fairly extensive experience with insane delinquents at the Government Hospital for the Insane, and when I assert that I have yet to see a malingerer who, aside from being a malingerer, was likewise normal mentally, I do so with the full consciousness that my experience has been a more or less one-sided one. ”

“ The first question which the psychiatrist is called upon to decide in many instances is that of malingering. To the lay mind and to the minds of many of our eminent—but psychiatrically uninformed—jurists the question of malingering suggests itself at once. To them it is perfectly evident that this development of a mental disorder, in the wake of a criminal act, is nothing but a timely preparation for the “insanity dodge.” The clinical pictures presented by the acute prison psychosis are especially apt to awaken suspicions of malingering in the minds of the untrained. ”

“ Re malingering, see discussion concerning simulateurs de création and simulateurs de fixation under Case 453.
[655]
Deafmutism: Explained by patient as malingering.
Case 463. (Myers, September, 1916.)
A pure malingerer, of set purpose, initiates a quasipathological condition which he will discard when he has gained his end or when he is assured that he is unobserved. Malingering in the field of speech is rare. A private, 26, one year in service, three months in France, entered a base hospital, deafmute for nine weeks. He wrote: “I should be very happy if you can do anything for me. ”

“ It would simply substantiate the truth of our contention that in the malingerer we see a type of individual who is far from normal, and in whom malingering as well as frank mental disease is not at all a rare phenomenon. ”

“ In malingering we see the application of deceit and lying to a definite situation. That which is a habitual type of reaction in some individuals, as was illustrated in the foregoing cases, comes to the fore in others only under certain stressful situations of life. While in the habitual fabricator the most prominent motives are those of an egotistic nature, a craving for self-esteem as compensation for an inherent defect, in the malingerer we see a resort to this form of reaction as a means of self-preservation, as a means of escape from a particularly painful situation. ”

“ Why then should we question at all the genuineness of a mental disorder developing in an individual who faces the gallows or a life-long imprisonment? As a matter of fact cases of pure malingering are among the rarest things which the psychiatrist observes. Wilmanns, [1] in his study of 277 cases of insanity of prisoners, found but two cases of simulation, and in a later review of the diagnoses of the same series of cases, the two cases of malingering do not appear at all. ”

“ Because a few tips may make it possible for the interrogator to distinguish between the malingerer and the person who is genuinely ill, and because both illness and malingering are sometimes produced by coercive interrogation, a brief discussion of the topic has been included here.
Most persons who feign a mental or physical illness do not know enough about it to deceive the well-informed. Malcolm L. Meltzer says, "The detection of malingering depends to a great extent on the simulator's failure to understand adequately the characteristics of the role he is feigning.... ”

“ Bonhoeffer, [6] in a study of 221 cases, found only 0.5 per cent of malingering. Knecht, [7] in an experience of seven and a half years at the Waldheim Prison, did not observe a single case of true malingering. Vingtrinier [8] claims not to have found a single case of true malingering among the 43,000 delinquents observed by him during his experience at Rouen. Connolly, Ball, Krafft-Ebing, Jessen, Siemens, Mittenzweig, and Scheule are quoted by Penta as having expressed themselves that pure malingering is extremely rare. ”

“ The other form in which malingering may be so intertwined with actual mental disease as to render accurate differentiation quite impossible is where the individual may be suffering from a psychosis at one time, and at some later period, finding himself in a stressful situation, malinger a psychotic state. In these cases the danger of ever committing a habitual criminal to a hospital for the insane is especially apparent. ”

“ Re malingering, Moore states that no diagnosis of malingering should be made without the most careful examination and consideration of the individual as such, on account of the fact that the erroneous diagnosis dejects the patient and postpones recovery. It is particularly unwise to term the trouble “imaginary,” or to talk about “suggestion” or use similar terms in the presence of the patient. ”

“ In the last analysis malingering is to be looked upon as a special form of lying, and its proper understanding will necessitate a clear insight into lying in general.
Lying, a very natural and generally prevalent phenomenon, may manifest itself in all gradations—from the occasional, quite innocent “white lie” as it occurs in a perfectly normal individual to the pathological lying exhibited in that mental state known as “pseudologia phantastica.” ”

“ It is of no particular value to add more cases illustrative of the type of mental make-up which leads to malingering, especially since there exists a more or less complete unanimity of opinion on the subject among present-day psychiatrists. ”

“ It is perfectly natural that he should resort to malingering of mental disease in his last attempt at evading a stressful situation. Malingering is frequently the only means of escape for such as he, unable as they are to meet life’s problems squarely in the face. ”

“ This view, thus baldly put, shows a relation between hysteria and malingering, and, returning to the case of the prentice engineer, we can see his work in the shop becoming more and more distasteful whilst his anxiety tended to become a means of escape; then in the army the neurosis took a more determined form which might be confounded with malingering by an observer who assumed that all actions were the result of conscious motives.
My present opinion is that the theory of repression offers the only explanation of many cases of hysteria. ”

“ A number of them are either insane when sent to prison or potentially so, and when thrown into a more or less difficult situation, such as imprisonment, readily develop a mental disorder. We see this illustrated very well in the highly beneficial effect which transfer to a hospital for the insane has upon these individuals. I am convinced that one would not be wrong in agreeing with the opinions quoted below, that malingering, as such, is a morbid phenomenon and always the expression of an individual inferior mentally. ”

“ Such things occur in the history of malingering, and what the consciousness can do the dissociated stream is equally capable of doing: the only difficulty is the very practical one of believing that the patient can carry out the necessary action without being fully aware of what is happening, unless we assume an abrupt dissociation with the main personality temporarily abolished. ”

“ Neurosis has an absolute genius for malingering. There is no illness which it cannot counterfeit perfectly. ”

“ The psychoses which these individuals develop are in the great majority of instances purely psychogenetic in character, one of the many distinguishing features of which is a marked susceptibility of the symptoms to be influenced by external occurrences. This tendency of the symptoms to shape themselves in accordance with occurrences in the immediate environment frequently leads to the suspicion of malingering, because there seems to be altogether too much discretion displayed by these alleged insane. ”

“ Even today one sees in certain quarters a good deal made—certainly a great deal more than the facts would justify—of the “insanity dodge” in criminal cases. It is true that today, notwithstanding the still broadly prevalent tendency to view with suspicion every mental disorder which becomes manifested in connection with the commission of crime, the danger of error in this respect has been reduced to a minimum owing to the more advanced stage of psychiatry, and therefore the practical importance of the subject of malingering is not so great as it was formerly. ”

“ When, as is so common now, women are accused of malingering, I often wish that complainants would accompany me on my investigation of cases of accident or poisoning at the workers’ homes, for I know that, like me, these people would return in a humbled frame of mind, recognising courage and [Pg 289] endurance under circumstances which would break many of us. ”

“ Knowing his vindictive nature, I was perfectly certain that he would come to look upon his handiwork.”
“But your appearance, Holmes—your ghastly face?”
“Three days of absolute fast does not improve one’s beauty, Watson. For the rest, there is nothing which a sponge may not cure. With vaseline upon one’s forehead, belladonna in one’s eyes, rouge over the cheek-bones, and crusts of beeswax round one’s lips, a very satisfying effect can be produced. Malingering is a subject upon which I have sometimes thought of writing a monograph. ”

“ Re malingerers, Glueck remarks that a malingerer, besides being a malingerer, is a worthless sort of person in any event, and calls attention to the fact that special stresses may reduce men to lower cultural levels, to which lying and deceit may be more appropriate. ”

“ The feigned psychosis often contains many contradictory and inconsistent symptoms, rarely existing together. The malingerer tends to go to extremes in his portrayal of his symptoms; he exaggerates, overdramatizes, grimaces, shouts, is overly bizarre, and calls attention to himself in other ways....
"Another characteristic of the malingerer is that he will usually seek to evade or postpone examination. A study of the behavior of lie-detector subjects, for example, showed that persons later 'proven guilty' showed certain similarities of behavior. ”

“ But the true Manling, however it may have pleased and profited him heretofore to confuse himself with another, is now exposed in his proper colors as the ordinary, low, and brutal villain. Our police cannot too soon abandon their absurd persecution of those whom they have been holding under surveillance. Instead of being one of the gentle class pursuing this remarkable course in refined crime for some obscure purpose, the man is too clearly of the repulsive, cruel, criminal type which sticks at nothing. ”

“ This would be a God, this hermaphroditic prostitute who fondles himself at night. Mallare ... weep. Whips will not rid you of this monster. Mallare, the plaything.
“But there is a way to be rid of her. Hate will darken the gleam of her body. She will vanish. But do I hate her? My madness is infatuated since it makes her so radiant. And who am I that I laugh at my madness? It is I who am insane. Not this other Eden maker whose mania I applauded. I, Mallare, tear at my hair. ”

“ The word, among other acceptations, has that of mal [evil] , a substantive that signifies, in aesthetics, the opposite of good; of mal [pain, disease, complaint] , a substantive that enters into a thousand pathological expressions; then malle [a mail-bag] , and finally malle [a trunk] , that box of various forms, covered with all kinds of skin, made of every sort of leather, with handles, that journeys rapidly, for it serves to carry travelling effects in, as a man of Delille's school would say.
For you, a man of some sharpness, the Sphinx displays his wiles ”

“ And how above all can it not serve as an exhibition again of the manner in which all my benevolent backer's inveterate original malaise in face of betrayed symptoms of the impulse to "narrow down" on the part of his young found its solution always, or its almost droll simplification, as soon as the case might reach for him a personal enough, or "social" enough, as he would have said, relation to its fruits? Then the malaise might promptly be felt as changed, by a wave of that wand, to the extremity of active and expatiative confidence. ”

“ Malice is found in a sense in every formal sin, inasmuch as every sin is committed out of choice. But malice in the strict sense, as here understood, is a choice of sin made, not on account of preceding ignorance or passion, but on account of some corrupt disposition of the sinner which makes sin pleasing or acceptable to him, such as a vicious habit or inclination which he cultivates, or willful despair or presumption which he entertains. ”

“ How shall I earn it?' 'By service to God,' says Moling. 'Woe is me!' says the Devil, 'I cannot bring it.' 'Even a trifle of study.' 'Thine own study is not greater, and yet it helps me not.' 'Fasting, then,' says Moling. 'I have been fasting since the beginning of the world, and not the better thereof am I.' 'Making genuflexions,' says Moling. 'I cannot bend forward,' says the Devil, 'for backwards are my knees.' 'Go forth,' says Moling ”

“ A pest, a mendicant, a croaking idiot—I cursed him out roundly and refused him further attention. This is the wisest course sometimes. It is dangerous to humor too carelessly these sprawling Mallares. They are slyly at war with my omnipotence. I can understand the anger of God. Sacrilege confuses Him. And We are all alike—We Gods. We are forced into an attitude of indifference in order that We may keep Ourselves intact. ”