Almost every clinician has had a case of malingering. Just a few years ago, while still an undergrad, I came across a patient who was simply ‘faking it’. Sure, most malingerers trip up at some point, but not all of them. Most malingerers don't fully understand the illness or disability they are trying to portray and, like the actors they see on TV, malingerers can only portray a role as well as they understand it. They often overact their part in the belief that the more bizarre their behavior, the more convincing they will be.
The more astute malingerer will avoid bizarre behavior or claiming exotic symptoms. When presented with a calm and evidently rational patient, even seasoned clinicians would find it hard to deny a patient access to care, even if there was some suspicion.
Clinicians are often reluctant to diagnose malingering for fear of being sued or worse yet, wrong. In audiometry we often deal with malingerers, so let's take a look at the assessments used to detect when someone is ‘faking it’.
What is malingering?
Malingering is the intentional production of false or exaggerated psychological or physically symptoms motivated by external incentives. Individuals usually malinger to avoid pain (such as punishment) or to seek pleasure and benefit (such as compensation). For example, in prison, inmates may malinger psychological or physical illness in order for the security guards to be lenient on them. On the other hand, a patient may fake a hearing loss in order to benefit from the state’s disability grant.
Malingering has a fairly simple definition, but its diagnosis is a veritable can of worms.
Also known as non-organic hearing loss (NOHL) this is a condition in which there is an apparent hearing loss with no evidence of a known disorder or insufficient evidence to explain it. Different terminologies are used for NOHL, including pseudohypacusis, functional hearing loss, malingering and exaggerated hearing loss.
Before functional hearing loss can be detected we must first determine whether or not there is any suspicion of malingering.
Here are some clues that might help:
- Is there discordance between responses to the clinician’s questions.
- Is the patients audiogram atypical, and are there modifications of threshold responses at the same frequencies at repeated examinations?
- Does the patient with a profound functional hearing loss still respond to questions asked with a lower voice, especially when they cannot read your lips?
- Are air conduction thresholds worse than acoustic reflex thresholds?
- In speech audiometry, does the patient repeat only a part of the word presented? For example, half word responses to spondees.
- During consultation, has the patient expressed an obvious interest in obtaining some sort of financial benefit?
- Is there inconsistency between PTA and SRT?
- Are bone conduction results worse than air conduction results?
By no means diagnostic, these clues can be the early warning signs of a malingerer. Functional hearing loss must always be diagnosed by thorough clinical examination and testing.
Several tests have been suggested for assessing and diagnosing functional hearing loss. These tests are generally classified into two groups; special subjective audiometry tests and objective audiometry tests. A few special tests for detecting NOHL are the Stenger test and the Lombard test. Objective tests would include Auditory-Evoked Potentials (AEP) and Otoacoustic Emissions (OAE).
Special Subjective Tests
This well known test is used to determine malingering in the case of unilateral deafness or loss. The principle behind this test is based on Stenger’s discovery, that if two sounds of the same frequency and slightly different intensity are played at the same time in both the patient’s ears, the patient will believe that they only hear the tone only with the ear where the sound is much louder. A 10 dB sound is presented above the threshold in the good ear and a sound of 10 dB below the admitted threshold in the suspect ear (or poor ear).
A malingerer will claim that they cannot hear the tone presented as they are not aware that a sound was actually presented in both the good and the bad ear.
The Lombard test
With this test, a patient is asked to read some text out loud with earphones on. While the patient is reading the text, a sound is emitted in the earphones. A malingering person would generally increase the intensity of their voice because of the loud sound played in the earphones. While a person with a real hearing loss (profound) would not change the intensity of their voice.
While the above tests are theoretically simple, they are not easy to execute and are therefore best handled by audiologists. Of course, this means that any inconsistent test results obtained by technicians or nurses, especially in occupational health, are referred directly to audiologists. Equally apparent is the reason these tests are seldom used to detect NOHL especially when objective tests are available that can detect real thresholds.
Otoacoustic Emissions (OAE)
The principle of OAE is that the normal ear generates sounds that can be recorded. The presence of these sounds indicates whether the cochlear has a normal or near normal functionality. OAEs, especially transient-evoked otoacoustic emissions (TEOAEs), have been shown to be of value in cases of nonorganic hearing loss. However, these tests do not work as well for patients with actual hearing levels greater than 40 dB HL who wish the clinician to believe that their hearing is worse than that.
Auditory-Evoked Potentials (AEP)
Measurement of auditory-evoked potentials (AEP) has long been considered an important test in the diagnosis of non-organic hearing loss as results obtained from this technique and from voluntary pure-tone testing generally agree within 10 dB. Auditory evoked potentials and auditory brain-stem response (ABR) have proven to be more reliable than the auditory middle latency responses or the auditory late responses in detecting non-organic hearing loss.
Using objective measures for testing a malingering patient is based on a battery of tests that do not require the cooperation of the patient, therefore, this is a highly recommended and easy to use way of catching the would be malingerer out.
The problem is that these objective testing methods require specific equipment which do not come cheap. The result is that, while objective testing is clearly the preferred methodology, many practices simply don't have the equipment.
Objective, subjective and affordable
While malingering is not an everyday occurance, it does happen and deserves vigilance. This is especially true in the field of occupational health where patients could stand to benefit from false claims.
Another method of determining a malingerer is through accurate monitoring of patient responses. This is a huge advantage of using a response button for testing as opposed to raising your hand, and something the KUDUwave does very well.
The KUDUwave monitors and tracks patient responses during assessment indicating false and true responses as well as analyses the patient’s response times. With this data attached to every report and available on the live audiogram screen, a clinician is able to make informed decisions to ensure a true representation of the patient's test result and the ability to detect a malingerer on the spot. To find out more about this, click here.
If a thorough investigation indicates that a patient is malingering, you may decide to confront the patient. In this case, avoid direct accusations. A thoughtful approach that asks patients to clarify inconsistencies is more likely to be safer and more productive for the examiner.
As specialists in this field, most of us have experienced a patient “faking it” and if you haven't, it is probably only a matter of time until you do.
Why not share your experience and advice in the comments below?