A clinical approach to the malingering patient

Malingering presents special challenges to the practicing clinician, including diagnostic uncertainty, the confrontation of potentially criminal conduct, and countertransference and personal reactions. Maintaining a traditional clinical approach to the patient suspected of malingering enables the therapist to draw analogies to other disorders and utilize customary diagnostic and therapeutic skills. Malingering has long been recognized in the military, and has predictably come to the forefront of clinical practice during a time of war. The art in military medicine is to find a way to make our ethical and fiduciary responsibility to act in the best interest of the patient coincide with the needs of the system. In this context, malingering can also be viewed as an immature or primitive defense in a very stressful situation, and approached accordingly. This article discusses key elements of the history and mental status examination in the clinical assessment of malingering, and therapeutic analogies that offer the possibility of a positive outcome for an otherwise potentially negative encounter.