Identifying Reverse Malingering in the Civilian Occupational Setting

Abstract

Malingering is a common phenomenon in the workplace. However, reverse malingering can be just as common, but may have greater negative consequences for employees and employers. The only research on reverse malingering has been conducted in the military; however, little is known about this phenomenon in the civilian setting.

Reverse Malingering in the Civilian Workplace

Malingering is familiar to most occupational health providers. Malingering is claiming signs and symptoms for personal gain, which may include avoiding military service or securing disability (Killinger, 1946). However, beginning in World War II, the military experienced a phenomenon referred to as “reverse malingering” (Hulett, 1941; Hunt & Older, 1943). Reverse malingering is an intentional withholding of health-related information that could potentially disqualify military recruits from military service; however, no formal definition could be found in the literature. It was noted that young men concealed conditions that could disqualify them from military service. Disqualifications from the military during that time and currently include previous head injuries, diabetes, seizures, or sleepwalking (Killinger, 1946). Two common reasons for reverse malingering by military recruits were to obtain unique positions in the military (e.g., Special Forces or aviation assignments) and to avoid psychiatric diagnoses (Budd & Harvey, 2006).

Military recruits practiced “concealment” which began during the interview process and pre-entrance physical examination. Upon arrival at the training station, concealment was difficult because recruits were under 24-hour observation in unfamiliar working and living environments. For example, experiencing sleep deprivation during military training could provoke a seizure disorder; the recruit could not hide medications because military barracks were constantly searched for contraband. Psychological disorders also surfaced during training, due in part to stressful experiences and living conditions (Killinger, 1946).

Since the 1940s, only one study was found regarding reverse malingering. The Air Force focused on aviation crews who withheld health-related information or memorized the Snellen Eye Chart to avoid losing flight status (Lollis, Royden, Marsh, & Thompson, 2009). To stop aviation crews from memorizing the Snellen Eye Chart or Ishihara Color Plates, these tests are now computerized and the numbers and letters routinely changed.

Reverse malingering may be easier to identify in military service than in the civilian sector. Due to close living quarters, 24-hour observation, a change of lifestyle, and exposure to new stressers (e.g., intense exercise, changes in diet), health conditions, such as insulin-dependent diabetes, may be identified early and the recruit could be medically discharged to protect the military recruit and other military members from negative health consequences (i.e., a pilot suffering from hypoglycemia).

In the civilian sector, a reliance is placed on the honesty of employees to report health concerns because they are not under observation 24 hours a day. Careful attention must be provided during interviews and physical examinations.

Case Study

JF, a 25-year-old male, was hired by a paper company and presented for a pre-placement examination; no driving was involved, but heavy lifting, pushing, pulling, and the operation of machinery were required. During the interview, JF denied any health concerns and stated that he “never takes any medications, not even acetaminophen for a headache.” It was noted that his mother drove him to this appointment.

During the physical examination, abnormalities were noted. JF exhibited bilateral nystagmus, positive Romberg sign, loss of balance with tandem walking (heel to toe), and tremors with arms outstretched. When presented with these abnormal findings, JF stated that he had been awake all night and that maybe he should come back another day to complete the physical examination. It was explained that these symptoms could be reflexive of a more serious health issue and that this physical examination would have to be postponed until he was cleared for employment by a primary care provider, preferably a neurologist. JF was also provided with a job description for review by a primary care provider to determine whether he was medically qualified for the position.

JF never returned to the clinic for re-evaluation. However, JF did find work at another company that did not require a pre-placement physical because the position entailed only sitting and filing.

A year after first meeting JF, the same provider evaluated and treated JF for a head contusion at the same occupational health clinic. One of the employees stated that JF was “acting funny,” and fell, hitting his head. Upon reviewing JF’s health history, it was noted that he had been diagnosed with a seizure disorder as a child and was taking Dilantin.

Implications for Occupational Health Nurses

A thorough history and physical examination is essential prior to placement in the workplace. If any abnormalities are noted during the physical examination, the provider must investigate further. In the case of JF, the abnormal neurological examination resulted from side effects of Dilantin. If JF had been cleared to work at a job for which a seizure disorder was a disqualifying condition, it could have been disastrous for all involved.

Upon further questioning, JF was asked why he did not disclose this information during his pre-placement examination for the original job. JF stated that he “needed a job, any job.” JF said that it was difficult to find work because he had a high school education and a job he had applied for several years ago disqualified him because of his seizure disorder; as a result, he thought it best not to disclose this health information. JF also did not think that anyone would know that he had a seizure disorder because when he was examined by his neurologist, he was told, “everything is okay, just take your medication.” The provider emphasized the importance of honesty; any negative consequences that occurred as a result of his seizure disorder could generate liability for JF as well as his employer.

Further studies about reverse malingering should be conducted in the civilian sector to increase awareness and develop practice guidelines. Currently, occupational physicians, certified in flight medicine, are aware of this phenomenon because aviation crews are known to withhold health information; the consequences of these actions could result in massive loss of life.