The Unexpected Hand Patient

Andrew M. Swiergosz, BS; Morton L. Kasdan, MD, FACS; Bradon J. Wilhelmi, MD, FACS


ePlasty. 2017;17(e16) 

In This Article

Abstract and Introduction


Objective: Physicians should be aware of patients trying to obtain a diagnosis for secondary gain. Malingering is a diagnosis that should be suspected when objective findings do not support the subjective symptoms and there is secondary gain.

Methods: A series of 21 cases are presented that support this position. The charts of 21 patients with a diagnosis of reflex sympathetic dystrophy (chronic regional pain syndrome) and nonanatomic findings were evaluated.

Results: The patients in this series were found to be malingering based on discrepancies between subjective symptoms and objective findings.

Conclusions: The diagnosis of malingering should be based on thorough history, physical examination, electrodiagnostic studies, imaging studies, and evaluation of all medical records.


Individuals have been feigning symptoms of illness to obtain secondary gain for thousands of years. The illusion of an illness to achieve "a consciously desired end" dates back to biblical times. In Samuel I, while David is fleeing from King Saul, he avoided execution by King Achish of Gath through the feigning of a sickness. This instance is described in the following passage.

These words worried David and he became very much afraid of King Achish of Gath. So he concealed his good sense from them; he feigned madness for their benefit. He scratched marks on the doors of the gate and let his saliva run down his beard. And Achish said to his courtiers, "You see the man is raving; why bring him to me? Do I lack madmen that you have brought this fellow to rave for me? Should this fellow enter my house?" [1]

Malingering is described as the willful and deliberate feigning or exaggeration of illness.[2] It was originally described as a means of avoiding military service.[2] The word "malingerer" was introduced in 1785, in a publication titled "Grove's Dictionary of the Vulgar Tongue." The term "malingerer" is said to be derived from the French malingre, meaning sickly or feeble, and was originally used in a military setting to describe persons who pretended to be sick so as to evade military duty.[2] Malingering is defined by the DSM-5 as "the intentional production of false or grossly exaggerated physical or psychological symptoms."[3] It is motivated by external incentives such as avoiding military duty, work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.[3,4] Identifying the reason for secondary gain associated with malingering is crucial in the confirmation of a diagnosis. Typically, the secondary gain is apparent and directly related to the reason for presenting to the physician.[5] This is especially relevant when patients are being evaluated for a disability with the possibility of financial compensation. One study found the incidence of malingering in litigation or compensation-seeking cases related to pain or somatoform disorders to be 33.5%.[6] This is significant because there are more than 38 million Americans classified as disabled, more than 19 million of which are in their working years, from 18 to 64 years.[7] The diagnosis of malingering can be difficult. Many times it is a diagnosis of exclusion. The confirmation of a diagnosis of malingering can be either observed or inferred. An example of an observed confirmation would be covert surveillance, such as a patient being videotaped in his or her natural environment doing something that would not be possible if the symptoms claimed were present. An inferred diagnosis is achieved by data acquisition and collection to see if what the patient is claiming can be proven by objective finding. An example of this would be a depressed patient who complains of poor appetite and sleep yet may be discreetly observed to always finish his meal, have the desserts, sleep soundly, interact appropriately with others, and not lose weight.[8]

We present a case series in which one of the authors (M.L.K.) evaluated 21 patients from 1979 to 1995 in which the patients were found to be malingering in legal cases where they were applying for compensation. Fourteen of the cases were workers' compensation claims and 7 involved tort litigation. The patients arrived for evaluation with a diagnosis of reflex sympathetic dystrophy (RSD), now called chronic regional pain syndrome, and were asking for monetary compensation.