Malingering and Illness Deception Edited by Peter W. Halligan, Christopher Bass & David A. Oakley. Oxford: Oxford University Press. 2003. 370 pp. £35 (pb). ISBN 0 19 851554 5

The territory of malingering and illness deception is one of the last ‘no go’ areas in medical practice: few doctors tread there with any degree of confidence, and little is taught about it to medical students or postgraduate trainees. The authors of this book have therefore taken on a difficult challenge. Malingering has been neglected in the medical literature, probably because it is not regarded as a medical diagnosis in the broadest sense of the term. Neither of the widely used medical and psychiatric classifications regard malingering as a valid diagnosis. It is, essentially, a conclusion that is reached after relevant medical and psychiatric disorders have been excluded. Although it is therefore not a medical condition, malingering impinges on medical practice in most areas of clinical medicine. It implies deliberate deception and in this context the clinician has to make judgements about the level of conscious awareness, the degree of free will and the motivation that accompanies the spurious symptoms of ill-health. The conclusion that someone is malingering carries highly pejorative judgements. There are serious implications for the doctor if the diagnosis is incorrect, with medico-legal consequences and professional reprimands.

The book makes it clear that malingering is on the increase. The contributors cite various examples, including including sickness absence, early retirement on grounds of ill-health, health insurance fraud and bogus personal injuries compensation. The assessment of malingering is complicated by observations that suggest that even within the same individual conscious awareness is not an all-or-none phenomenon. It varies over time and its assessment is highly subjective. Only when there is direct, recorded observation that an individual is able to perform activities that he or she has claimed not to be able to perform can malingering be concluded with a reasonable degree of certainty.

In their opening chapter the authors provide a helpful definition of malingering, which they describe as a conscious voluntary act or set of actions made with the intention of obtaining personal advantage by securing benefits and/or lack of responsibilities that society and the legal system have bestowed upon the sick role. Several of the subsequent chapters approach malingering from a sociological viewpoint. Others attempt to define the boundary between malingering and psychiatric illness, particularly dissociative disorders (hysteria) and functional somatic syndromes. There is a very useful section on the medico-legal and occupational perspectives. Particularly intriguing are two chapters that review attempts to distinguish malingering from dissociative disorder, using functional brain imaging. This work is at a preliminary stage and remains inconclusive, but it does open up the possibility of obtaining objective criteria to distinguish symptoms associated with loss of free will from those that appear to be consciously determined.

Doctors, whatever their specialty, like to believe that patients who consult them are honest, distressed and in need of medical help. The notion that some people wilfully set out to deceive doctors sits uncomfortably with this assumption. This book provides an illuminating glimpse into the hinterland between illness and fraudulent behaviour. It is a book that should have relevance to clinicians whatever their background, to the legal profession and to those who have an interest in understanding human behaviour in relation to health.