Epidemiology

There is little systematic information on prevalence, although it is generally agreed that exaggeration of real symptoms is more common than outright faking. Aetiology

Three models of this complex behaviour ('mad', 'bad', 'adaptive') will be discussed. The 'mad' theory conceptualizes subjects trying to make sense of or control incipient genuine symptoms by overemphasizing them and presenting dramatically to clinicians. It predicts that malingering should be followed by the development of genuine disorder, but there is only anecdotal evidence to support this. Criminological ('bad') models appear strongly to have influenced DSM-IV criteria but fail to account for the generality of malingering behaviour. Rogers(38) has proposed 'adaptation' as the simplest model for malingering: 'malingering is more likely to occur when the evaluation is perceived as adversarial, when the personal stakes are very high, and when no alternatives appear to be viable'.

Another perspective is offered by the 'response styles' described by psychologists. Malingering can be conceptualized as one possible response style during assessment; others include honest, defensive (where a patient with real symptoms tries to mislead by concealing them—perhaps a negative counterpart of malingering), irrelevant ('in which the individual does not become engaged in the assessment process' (3.8)), random (especially seen on forced choice measures), and combinations thereof.

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