Dealing with these people who fake or exaggerate their physical injury is a disheartening experience. But are are these the most difficult cases to manage.
I would rank them second in difficulty. Whether they are malingering with regard to their physical complaints and/or psychological complaints, careful examination will most often reveal their motives? Do not forget that a person with a valid injury can also be malingering. This is called partial malingering and occurs when the complaints far exceed the objective findings.
The most difficult patients to assist are those who live in an environment/culture in which they hear the bragging of malingering individuals, yet their own complaints are sincere. They feel quite accurately that they are often lumped with those who fake or exaggerate symptoms are, therefore, not believed by their doctors, employer or insurer.
They often come from a background where work within their limitations is not likely available from their employer and/or the employer truly does not wish them to return. They have increasing financial despair and yet they are certain (and often accurately so) that the insurer believes that they could mobilize if they wished to do so.
Concurrently, they have neighbors/acquaintances who boast of their _milking the system._ The one case I most often site was a woman with a failed fusion, sitting in the waiting room of a pain clinic and listening to the enthusiastic discussion of the other patients regarding the ability to amplify their symptoms for probable financial gain._