Instrumental psychosis: the Good Soldier Svejk syndrome

Malingered psychosis leading to involuntary psychiatric hospitalization

OBJECTIVE

To describe a patient with feigned psychosis who was admitted to an acute psychiatric unit under the Mental Health Act, and to discuss the clinical features of malingering in this treatment setting.

METHOD

Case report.

RESULTS

A 40-year-old man with no known past psychiatric history was brought by police to the Emergency Department. He gave a history of paranoia, hallucinations and bizarre behaviour and was admitted to a secure ward. Treatment with parenteral medication was required due to hostile and aggressive behaviour. Collateral history was inconsistent with his reported symptoms and, when confronted with this information, he acknowledged fabricating his symptoms in order to obtain a disability pension.

CONCLUSIONS

It is important to consider malingering as a differential diagnosis in patients who present with atypical features and have clear external incentives for their behaviour. With improved health literacy and access to health information, individuals who are marginalized in society and have limited social and occupational opportunities may malinger symptoms for obvious personal gain. Inconsistency between reported symptoms and clinical observations, as well as contradictory collateral information from multiple sources, are helpful tools in diagnosing malingering. It is important for clinicians to identify malingerers early and limit unnecessary admissions.

A cognitive neurobiological account of deception: evidence from functional neuroimaging

An organism may use misinformation, knowingly (through deception) or unknowingly (as in the case of camouflage), to gain advantage in a competitive environment. From an evolutionary perspective, greater tactical deception occurs among primates closer to humans, with larger neocortices. In humans, the onset of deceptive behaviours in childhood exhibits a developmental trajectory, which may be regarded as 'normal' in the majority and deficient among a minority with certain neurodevelopmental disorders (e.g. autism). In the human adult, deception and lying exhibit features consistent with their use of 'higher' or 'executive' brain systems. Accurate detection of deception in humans may be of particular importance in forensic practice, while an understanding of its cognitive neurobiology may have implications for models of 'theory of mind' and social cognition, and societal notions of responsibility, guilt and mitigation. In recent years, functional neuroimaging techniques (especially functional magnetic resonance imaging) have been used to study deception. Though few in number, and using very different experimental protocols, studies published in the peer-reviewed literature exhibit certain consistencies. Attempted deception is associated with activation of executive brain regions (particularly prefrontal and anterior cingulate cortices), while truthful responding has not been shown to be associated with any areas of increased activation (relative to deception). Hence, truthful responding may comprise a relative 'baseline' in human cognition and communication. The subject who lies may necessarily engage 'higher' brain centres, consistent with a purpose or intention (to deceive). While the principle of executive control during deception remains plausible, its precise anatomy awaits elucidation.