Monday, July 9, 2012

Is "Malingering" a Pelagian concept?

As a psychiatrist at a university-affiliated teaching hospital, I spend part of my week in my hospital’s emergency department supervising psychiatry residents and evaluating patients who present in psychiatric crisis.  It is unpredictable and sometimes difficult work:  patients who present to a psychiatric emergency service are representative neither of the general population nor of those who seek outpatient mental health treatment.  We see people who are not doing well:  many are intoxicated with and/or withdrawing from alcohol and other drugs; many have no relationship either with a mental health clinician or with any other significant community of support; many are off any prescribed medications; some are agitated, belligerent, and even assaultive.  I try, though not always with success, to keep my trainees from becoming bitter and cynical about “frequent flyers” who present repeatedly in crisis. 

This emergency psychiatry work has made me increasingly attentive to the work done by the clinical term “malingering.”  It is not uncommon at my institution for patients to present to the emergency department intoxicated, disheveled, and homeless, stating unequivocally to a triage nurse that they are “suicidal,” thus virtually guaranteeing at least a multi-hour stay in a secure section of the emergency department and, quite possibly, an inpatient psychiatric admission.  These patients tend to provoke feelings of revulsion and dismissal among emergency department clinicians – including me, if I am not careful – and I frequently hear residents and others complain that such patients are “playing the system” and “probably malingering.”

Malingering is not, properly speaking, considered a mental disorder; but it does appear in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as an “additional condition that may be a focus of clinical attention.”  The DSM-IV-TR defines malingering as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs” (APA, 2000).  The DSM-IV-TR distinguishes Malingering from Factitious Disorder (which also involves the “intentional” production of symptoms but which is a “mental disorder”) by the criterion that the malingerer is motivated by external incentives while the person with factitious disorder is motivated by the desire (or “intrapsychic need”) to maintain the sick role.  Both of these conditions, in turn, are distinguished from Conversion Disorder and other Somatoform Disorders by the fact that symptoms are intentionally produced in the former and not in the latter. 

You don’t have to work long in an emergency department to know that these distinctions are woefully oversimplistic.  Let us return to the intoxicated, homeless, “suicidal” patient.  Could he or she be “malingering” threats of suicide in order to gain (at least temporary) food and housing?  Well, sure.  But what does it mean for an action to be “intentional” when one’s blood alcohol level is several times the legal limit, or for that matter when the alcohol is gone but one’s body is craving one more drink?  Does “intention” refer to a certain type of mental state, in a way that the Christian philosopher G.E.M. Anscombe refuted nearly a half-century ago? (Anscombe, 2000).  Do the DSM-IV-TR authors mean to suggest that persons with Factitious Disorder pursuing the sick role are not eo ipso pursuing external gain, given that the sick role is fundamentally a description of the various privileges (and expectations) which modern western culture accords to the sick person?  In truth, the intoxicated, suicidal patient may not know much about what he or she wants, other than to stay safe and to get away from the complex hell that awaits him beyond the perimeter of the hospital grounds.  He is doing the best he can with what he has learned to get what he thinks that he needs, which is to say both a great deal and very little about his “agency.”

I worry that clinicians who are quick to diagnose “malingering” often assume too much about the degree to which patients are unconstrained moral agents.  “I can’t make sense of this help-seeking behavior other than by recourse to the external gains which might accrue from it,” such clinicians might say, “and so this patient must be intentionally ‘malingering’ these symptoms.”  But this is a mistake which can be named in multiple ways.  Social psychologists would perhaps recognize this as a variant of the fundamental attribution error, but Christians know it by another name:  Pelagianism.

Although its fourth-century origins are still debated, Pelagianism refers most generally to the denial of original sin and to the belief that humans, aided at most by the grace of creation and by Christ’s worthy example, can live free of sin.  Such views, articulated by Pelagius and others, provoked the ire of St. Augustine, who argued that such optimism about sinlessness eviscerates the Christian doctrine of grace.  Augustine taught that humans sin “in Adam” not through simple imitation but rather through participation; because humans are weighted by original sin, humans lose the ability consistently to recognize and to pursue the good and therefore require God’s grace even to desire that which is good (St. Augustine). 

The Augustinian theological tradition, it seems to me, provides a “both/and” approach to human agency which can usefully critique the “either/or” Pelagian assumptions about agency which dominate both our common language and our clinical diagnostic categories.  The homeless, substance-dependent patient in the psychiatric emergency room, in other words, is not either malingering or “really” sick; rather, he or she is both acting as an agent, with the responsibility entailed by that action, and caught like all of us in certain structures of brokenness, which limit his or her ability to see and to act clearly.  In this way, I would argue, a proper Christian account of agency – about which much more could and must be said – can pave the way not only to a more humane and appropriate response to “frequent flyers” in the emergency department but also to a robustly nuanced appreciation of clinical psychiatry and psychology.


American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. with text revision (p. 739). Washington, D.C.:  American Psychiatric Association.

Anscombe, G.E.M. (2000). Intention.  2d. ed.  Cambridge, Mass:  Harvard University Press.

St. Augustine (412). De peccatorum meritis et remissione et de baptismo parvulorum I.27.

Warren Kinghorn MD
Assistant Professor of Psychiatry and Pastoral and Moral Theology
Duke University

No comments:

Post a Comment