Chapter 28: Conditions That May Be a Focus of Clinical Attention

The chapter traces the historical context of malingering across medicolegal and forensic settings while establishing critical distinctions between malingering and related presentations including factitious disorder, functional neurological symptom disorder, and authentic psychiatric conditions such as posttraumatic stress disorder and major depression. Understanding response styles including dissimulation, impression management, and strategic presentation of false or exaggerated symptoms requires clinicians to recognize patterns such as improbable symptom combinations, discrepancies between reported experiences and observable behavior, disproportionate symptom severity, and inconsistencies across assessment contexts. Clinical presentations vary widely and may involve somatic complaints like pain or psychogenic nonepileptic seizures, cognitive symptoms such as feigned amnesia or neurocognitive decline, or psychological manifestations including fabricated psychotic or depressive symptoms. The forensic psychiatry context presents heightened diagnostic complexity given the significant legal consequences of malingering determinations in criminal responsibility cases, disability evaluations, and compensation claims. Assessment requires comprehensive methodology integrating longitudinal clinical interviews, collateral information from third parties, standardized neuropsychological testing protocols, and sophisticated clinical reasoning that acknowledges both unconscious psychological mechanisms like projective identification and conscious deception. The chapter emphasizes the ethical tension clinicians face when suspecting deception while remaining mindful that genuine psychiatric illness may coexist with malingering behaviors. Ultimately, the chapter positions malingering as a socially meaningful presentation demanding nuanced, empirically grounded assessment conducted with appropriate clinical skepticism balanced against compassion and diagnostic humility.