Book of the Month: Malingering and Illness Deception
Authors: Jason Warren
Journal: Journal of the Royal Society of Medicine (2004)

Here is a true story.1 A 35-year-old war veteran with depression and headaches complains of hearing voices and music in his head. The symptom is relieved only if he lies supine on the floor of his garage. One day, one of his psychiatrists notices that his voices and music seem to match the 560 kHz AM broadcast band on the local radio station. It turns out he is receiving radio signals via shrapnel fragments in his left parietal lobe.

If nature can dupe us like this, is it any wonder our fellow humans sometimes do so as well? In Malingering and Illness Deception,2 Peter Halligan, Christopher Bass and David Oakley present a taxonomy and analysis of clinical duplicity in its many forms. The 'infinite categories of dishonesty', their sources, phenomenology and management, form the subject of their book. In the course of its 370-page journey through the dark wood of human deceit, 42 experts drawn from fields as diverse as sociology, military history, clinical psychology, primate behaviour, the law, medical ethics, insurance, child psychiatry, occupational medicine and functional brain imaging describe the view from their own corner. In the process we stumble into some very dense thickets indeed—free will, the limits of knowledge, theories of mind, and the human condition. There are epistemological conundra here that would have delighted Epimenides ('Doctor, can you tell me how many times you have failed to detect a lie?'). The book suffers from the usual unevenness of a multiauthor work; however, to the editors' credit, it is scrupulously objective and scholarly throughout. Doctors will be relieved to find that the legal contributions, in particular, are (by and large) models of lucidity.

Malingering and Illness Deception is sure to generate heat as well as light. To trim the rich panoply of clinical deception to the more serviceable trappings of scientific and social reductionism is a daunting exercise. Intriguing as they are, the chapters on 'unintentional malingering' among apes and monkeys and the functional neuroanatomy of lying in humans only serve to demonstrate how little we really understand about the biological roots of human deceit. As one author acknowledges, 'even liars get sick': they also come in many different shades of mendacity, ranging from half-conscious exaggeration to out-and-out treachery. It would be an ambitious neurobiological or ethological model that sought to embrace all of them. The book resoundingly conveys the inexhaustible inventiveness with which we deceive one another: the examples span the gamut of human endeavour, and some are quite breathtaking. Presumably the reason humans lie with such fluency is that it is socially highly adaptive; the average dinner party would end in catastrophe if the injunction to tell the truth were strictly enforced. No surprise, then, that a social skill of such delicacy should engage the high-level prefrontal mechanisms that mediate other executive functions, though it is fascinating to consider that functional brain imaging just might be able to distinguish hysterical from feigned paralysis (thereby affirming the secret suspicions of the inconsolably paranoid that the scanner really is a mind-reading tool, after all).

Doctors will find it hard not to be a little mortified by the book's exposition of their clinical frailty: we are bad both at recognizing malingerers and at categorizing them. We may even be guilty of the sin decried by Thomas Szasz —the medicalization of social woes to suit our own ends. In defence of the hapless clinician, one might add that most doctors are neither trusting naifs nor unredeemed narcissists but simple pragmatists. Every neurologist, for instance, will have a complement of 'tricks' to expose factitious complaints, but such manoeuvres, when they must be employed, occasion no frisson of triumph or exasperation; like testing the visual fields or tapping the reflexes, they are (or should be) simply a means to a diagnostic end. Whatever our existential reservations, a patient still presents a problem to be solved, and most of us would prefer to grant the benefit of the doubt. Human motivation is at best a murky subject; and doctors make bad policemen. It is surely no accident that the lawyers here endorse a similarly pragmatic approach, in their own contribution to the debate.

This brings us to another recurring theme of the book: what makes an illness a disease? If we define it as a clinical syndrome for which we can demonstrate tissue pathology, we are already on shaky ground, since that will disqualify most of psychiatry (and a good deal of neurology). On the other hand, it clearly won't do to sanction all human foibles with a medical label. The grey middle is a shifting quicksand for the unwary, as is amply shown by the new brain imaging modalities and by the ever-growing litany of misdiagnoses on both sides of the Great Divide. We can propose as many socio-legal models as we like, but if moral torpor can change to post-traumatic stress disorder (for example) in the space of two generations, and if (as several authors controversially suggest) this metamorphosis should be endorsed in a minority of cases, then in the individual case there seems little alternative to a ruthless pragmatism and a healthy tolerance of uncertainty. The unlucky few among us may actually live long enough to witness the turn of the tide.

There is a further dimension to the culture of clinical deceit that might bear closer examination than it receives in this book—our curiously ambivalent attitude to malingerers. Difficult as they are, under some circumstances we may become rather fond of them. Perhaps this is not very surprising; after all, our species has always had a soft spot for rogues. Achilles is more forthright than Odysseus, but who would you rather have to dinner? While the latter's factitious madness receives due attention here, we are left to wonder what Homer's surgeons made of the chronic pain syndrome of Philoctetes;3 you can bet he was regarded as a problem patient. I was heartened to find a chapter devoted to the lost souls that appear in hospital emergency departments, apparently bereft of both past and future: here we have an authentic intimation that illness deception really can be a symptom of the human condition (or at least, a pervasive social malaise), and not always a coldly calculated exercise in benefit fraud.

At various places in the book much is made of the dichotomous characterization of malingerers as 'mad' or 'bad'. Clinicians might suggest an equally resonant third possibility—'sad'. Perhaps we should ask ourselves how appealing the much-discussed sick role really is. When I was a brand-new intern working the night-shift I saw a young woman whose presenting complaint was an inability to move her left hand. My meticulous and over-inclusive neurological examination disclosed no objective signs other than a chipped nail. When questioned, she admitted that the nail injury was the first thing she had noticed, and added that she thought the hand was already returning to normal. I am sure she had a very good reason to sit in casualty for three of the wee small hours with such a plainly non-organic problem. I was too callow to discover it, and I would guess that the necessary wisdom is not to be found in books.