Malingering
Scene 1. The Ekta Kapoor blockbuster serial “Kyonki Saas Bhi Kabhi Bahu Thi” is being aired and the character of Mihir Virani who has lost his memory following an accident is the topic of hot discussion.
Scene 2. Another Ekta Kapoor serial on Star Plus “Kahani Ghar Ghar Ki” has another central character Om Agrawal suffering from amnesia following an accident.
Scene 3. The factory of Ramesh Patel who manufactures dyestuffs and chemicals. One of the workers Shivaji got a minor electric shock while operating the machines. He became unconscious for a while and was admitted to the hospital. On his regaining his consciousness, he could not remember who he was or what he was doing in the hospital. He remembers where he is living, who his wife and children are and how to get around his house. When faced with a doctor he is unable to do calculations or talk about his work. He has employed a lawyer to look after his concerns. He has been like that for 3 months now. Ramesh Patel suspects that Shivaji is just playing a role to get compensation. What should he do?
In the medical field, the tension between truth and lies has found expression in the domain of malingering and its detection. Mental illness, because it is difficult to verify objectively and is dramatic and emotional subjectively, is an age-old favorite. The fundamental characteristic of malingering is intentional falsity with an underlying incentive of gain of some kind. There is a marked discrepancy between the person’s claimed stress or disability and the objective findings. There is often a lack of cooperation and in complying with the prescribed treatment. Most doctors would find it distasteful and a violation of the doctor-patient relationship to call a patient a liar. They are also concerned about the anger and outbursts of the patient if his conscious attempts at deception are foiled and his scheme to manipulate the system for reward is dismantled. Nevertheless, several clues exist to detect malingering. You have to look into the personality of Shivaji. He would have excessively favorable and capable self-depiction prior to the alleged trauma and behavioral collapse. He would have an energetic and concerted pursuit of legal claim in the face of alleged debility caused by the trauma. There is often a history of unusually frequent absences from work. The general presentation is of sullenness, suspicious guardedness, uncooperativeness and resentment. In the case of Shivaji, there is no prior history of memory problems. He has spotty, episode-specific amnesia than global memory difficulties. To detect the problem, a thorough medical and laboratory examination is mandatory. In the talks that you have with him, you should be looking for several things. Shivaji will tend to overact his part, often mistakenly believing that the more bizarre he appears, the more convincing he will be. He may sometimes attempt to take control of the conversation behaving in an intimidating and blustery manner. He is more likely to repeat questions or answer questions slowly, working to give himself more time to fabricate convincing responses. He is more likely to contradict himself in his account and the contradictions may multiply as the conversation proceeds for a longer time. Intentional malingering is difficult to maintain in the longer run because of the basic fatigue and a pull towards reality. He may be led astray by asking questions that you know are absurd and he may make mistakes when questioned rapidly or directly confronted. The absence of variation, angry irritability and a lack of depressive withdrawal from enjoyable domains in the face of apparent total incapacity are in the favor of malingering. He may also be more impressive with the expressionistic, flamboyant features of amnesia rather than the emotional numbness, indifference and social withdrawal that often accompany memory loss. There is an eagerness to call attention to the memory difficulties rather than a reluctance to acknowledge them. The behavior is inconsistent with the memory loss rather than reflective of the memory problems. Planning a lie before the fact allows Shivaji to rehearse more carefully. Then he requires fewer pauses for words, has more control over the tone of voice and is able to be confident. Then it becomes difficult to detect the lie. Videotaping the patient’s activities throughout the day can often be helpful to detect the difference between true anguish and malingered one.
Shivaji would never want to be treated; the last thing he desires is to have his condition diagnosed. He is consciously gaming the system, manipulating it in the hopes of achieving the gain of compensation. The appropriate stance is to confront him tactfully but firmly. Do not abruptly shun him; instead elicit the underlying reasons for the ruse and possible alternative pathways to the desired outcome. If he is unwilling to interact with you under any terms other than manipulation, the possibility of an ultimate, positive outcome should be abandoned. You should then go ahead with not giving in to his demands and instead let him pull any tactics whatsoever. You may need to ignore him till he comes to the negotiating table. The initiative lies with Shivaji. The malingering will persist as long as Shivaji thinks it to be productive of the desired rewards. The more the malingering is reinforced, it will recur. Make it clear to him that the malingering is futile. It often happens that the achievement of the objective results in a quick clearance of the problems with a return to the original level although in a new place. You might also think of giving in at this moment with an undercover investigation later on.
