Dr. David B. Adams – Psychological Blog

Psychology of Injury, Pain, Anxiety and Depression

Disorder – Why Lie

why lieBeginning with cases in which an individual believes that he/she has a disorder, we can then discuss those who consciously emulate a disorder for complex reasons.

An individual who continues to believe that s/he has a disorder despite repeated medical reassurance to the contrary may be suffering from Illness Anxiety Disorder. This is one of several Somatic Symptom Disorders, and such disorders do not yield their beliefs to negative diagnostic findings.

Regardless of negative tests, they continue to believe that the disorder is present.

In the past, we used “hypochondriac” to label such people, complete with the derogatory connotations of that term. In cases of work-related injury, the Disorder can arise in response to more serious/valid findings in a similarly injured coworker. In one case, a workers’ son had a motorcycle accident with consequent seizure. The worker later sustained a minor head injury on the job and began to exhibit seizure like activities in the absence of any positive brain findings.

In this and similar cases, the goal is not seeking financial (benefits) gain; the goal is seeking treatment for a problem that they believe truly exists despite negative tests. These patients have a valid and treatable condition arising from anxiety; they are not attempting to fool someone, cheat the system or manipulate a situation.

There is an entirely different situation that is not a disease, disorder or condition. It is merely voluntary behavior which we refer to as malingering, but in this case it is a unique form of malingering. Malingering is not a mental disorder. It is a voluntary behavior most often attributed to anti-social (i.e. “psychopathic”) personality. Such individuals are feigning their symptoms (assimilation) while, for example, denying drug abuse (dissimulation) or seeking a diagnosis (Eg. post traumatic stress disorder) in order to be remunerated for their “problem” as well as, in some cases, avoiding prosecution.

It is important to be aware that there is one more variant that appears in workers’ compensation: those who are, indeed, feigning their symptoms and disease not in order to receive tangible/financial gain but because they are afraid. Thus, these individuals are malingering/faking/feigning; they are consciously aware that they are doing so. They have been asked diagnostic questions (for example regarding post concussive disorder, post traumatic stress disorder, severe major depressive disorder, etc.) and even though they do not have the condition, they are fearful that someday that condition may emerge. They may be worried that they will develop delayed onset PTSD, that their mildly depressed mood may be a harbinger for a significant major depressive episode or that they do have a brain injury that is merely defying diagnosis. They feign symptoms to maintain medical care that may someday be needed.

The distinction between Illness Anxiety Disorder, anti-social malingering and pathological malingering is crucial to understanding and treating only those who will benefit from work-related care.

Differentiating between the three goes beyond the ken of an EAP (which is beneficial for mild situational anxiety or occupational crises) or the physician to whom all three have the same presentation. Nonetheless, it is a critical distinction that will govern case management and resolution or lack thereof.

American Psychological Association

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