By Brian L. Grant, MD

This excellent article from Slate addresses the popular but incorrect notion that folks can easily fake illness, including insanity. In truth, insanity is a rare defense and even rarer to be successful due to the stringent legal criteria of such a defense – that few defendants qualify for, though many may indeed have a mental illness. A mental illness is necessary but not sufficient for a successful insanity defense.

Additional requirements depending upon jurisdiction, include the inability to refrain from the act, the inability to appreciate the immorality of the act and other criteria. Furthermore, a finding of insanity may serve to alter the location of confinement to a locked psychiatric unit, but not eliminate removal of the accused from society.

The article, “Can you Fake a Mental Illness? How forensic psychologists can tell whether someone is malingering,” focuses on psychiatry, but in any setting where factors such as compensation, avoidance of responsibility, acquisition of narcotics, and other factors beyond the desire to obtain necessary diagnosis and treatment come into play, malingering must be considered. Malingering is a big word for lying or faking it. It is willful on the part of the perpetrator and goal directed. Detection of malingering requires a combination of a willingness to consider the possibility, skills appropriate to one’s specialty, and enough information in the context of the examination, along with external evidence including medical and other records, investigation and other factors to allow one to reasonably conclude that one is malingering.

Most or all who enter the medical profession while young, are aware that there are a group of individuals they may encounter in the course of their practice who have less than admirable goals which include deceiving clinicians and others. Detection of malingering is not a typical part of the training of young clinicians. It generally takes experience, on the job training, and continuing education seminars to develop the necessary skills. Needless to say, any forensic medical reviewer must have a working knowledge of the subject in their specialty.