The question naturally arises, What is the reason for this rarity of cases of malingering? Is it because man has reached a state of civilization where he no longer resorts to deception? Decidedly not. The reason lies almost wholly in our changed attitude of today towards this question. As we acquire more real insight into the workings of the human mind we are prone to become more tolerant towards the human weaknesses, and in our study of the malingerer it is the type of individual, his mental make-up, which interests us most, rather than the malingered symptoms. It is for this reason that today the number of authorities is indeed small who do not look upon malingering per se as a morbid phenomenon, as an abortive attempt at adjustment by an individual who is quite incapable of adequately coping with the vicissitudes of life. In my own limited experience of several years with insane delinquents I have yet to see the malingerer who, aside from being a malingerer, was not quite worthless mentally.
Our discussion of malingering,—i.e., of the exhibition of a fictitious mental state by an individual for the purpose of rendering more bearable or more pleasant a particularly painful or difficult situation of life, or for the purpose of entirely annihilating such a situation and of removing it from consciousness by substituting for it a state of affairs wholly created from the individual’s fantasy,—would indeed be incomplete if we were to omit from our consideration at least that much of Freud’s psychology as pertains to this subject.
Thus far we have considered principally the views of what may be termed the descriptive school of psychiatry, though we have briefly touched upon the instinctive biologic roots of this primitive mode of approach to the problems of life, malingering of mental symptoms.
With the consideration of the Freudian psychology we enter upon the interpretative phase of psychiatry and to a very large extent of mental life in general.
Freud holds that a great part of mental life can either partially or entirely be summarized under two principles, which he terms the “pleasure principle” and the “reality principle” respectively.[9] These two opponents are constantly facing one another in our inner life. The former represents the primary, original form of mental activity, and is characteristic of the earliest stages of human development, both in the individual and in the race; it is, therefore, typically found in the mental life of the infant, and to a less extent in that of the savage. Its main attribute is a never-ceasing demand for immediate gratification of various desires of a distinctly lowly order, and at literally any cost. It is thus exquisitely egocentric, selfish, personal, and antisocial. The activities of this “pleasure principle”, however, constantly come into conflict with the “reality principle.” The rigid requirements of our environment, of the social system in which we live, deny us the fulfillment of many, if not most, of our most dearly coveted desires, without, however, being able to abrogate these entirely.
There are two ways in which these forbidden desires may become satisfied. On the one hand, the instinctive striving, finding it quite out of the question to gain expression through the desired channels, may become sublimated into a form which is in accord with our social and ethical requirements, or the forbidden strivings and desires may find gratification in the individual’s fantasy. We are here particularly concerned with the latter mode of psychic adjustment. This mode of adjustment is the usual way in which conflicts with reality are solved by the child and the savage. For them a rigid recognition of reality, such as is necessitated by the normal adult in his struggles for existence, does not take place. In fact, the evolution from childhood to adult life, from savagery to civilization, consists in nothing else than in the progressive recognition of reality and the adjustment thereto. One of the forms of getting away from reality, or a falsification of conditions as they actually exist, was expressed by one of Freud’s patients as the “omnipotence of thought” (Allmacht der Gedanken). It is a state of mind in which the individual believes in the omnipotence of his thoughts; that his mere thinking possesses tremendous power; that no sooner he thinks of a certain deed than the same is accomplished; that an enemy, for instance, is actually harmed by merely wishing him harm. This mode of thinking forms the basis for many magic ceremonials. It is this latter mechanism,—i.e., the endowment of one’s own thoughts with an omnipotent power,—which is also frequently illustrated in malingering. It is sufficient for the type of individual who malingers to merely say the word, and the most fantastic creation of his fancy immediately becomes a reality and is apperceived by him as such. A mere verbal denial of guilt on his part is sufficient to make him believe fully in his innocence and act accordingly. When we inquire into the origin of this facility in transforming fantasy into reality, for this omnipotence of the mere word or thought, we find it in the totally unreasonable overcompensation of these individuals for their feeling of impotence and weakness. This feeling of weakness and helplessness naturally becomes more acute under especially stressful situations of life, and hence it is that the criminal, especially the habitual criminal, who always uses deceit and simulation in his vain attempts at meeting life’s difficulties squarely in the face, regularly resorts to malingering when confronted with a serious criminal charge or when life in prison becomes especially unbearable to him. A good illustration of an attempt at falsification of reality for the purpose of annihilating a particularly stressful situation by means of a mere assertion of a state of affairs such as he would wish them to be, with a total disregard for the real facts which constantly stare him in the face, is furnished by the following case:—
M. came from a good family and led a normal life, earning a substantial livelihood as printer up to the age of about thirty-eight. At this time one of his children died, and this, together with poor physical health, is said to have brought on a severe depression, during which he was actively suicidal and very self-accusatory. Several months later he lost another child by fire, and at this time also claimed to have obtained positive proof of his wife’s infidelity. His mental depression became very much more aggravated; he attempted suicide on a number of occasions, was very suspicious and apprehensive, developed persecutory delusions, feared he was going to be burned to death or suffer some other horrible fate. This condition finally necessitated his admission to the Government Hospital for the Insane on May 28, 1897, at the age of forty. Here he gradually improved, and was discharged into the care of his father on October 22, 1899.
On February 19, 1903, he was readmitted as a D.C. prisoner, having shot and killed a man who seduced one of his daughters. Some idea concerning the type of individual we are dealing with here can be had already when we keep in mind his mode of reaction to the various stressful situations in his life enumerated above. All went well with him so long as he was not called upon to make a difficult adjustment, but with the loss of his child he develops a mental disorder. That he should have reacted to his daughter’s injury with murder is quite in line with his general inability and incompetency for proper adjustment, and the development of a mental disorder which has kept him in an institution for the past twelve years and will in all probability keep him there the rest of his life, in reaction to the committed murder, further emphasizes the general vulnerability of his nervous system. Let us see how he attempts to adjust himself to the situation; how he faces reality in his psychosis.
He does just what primitive man has done and what the child of today does. Not being able to face reality, he annihilates it and substitutes for it a world created out of his fantasy, in which he plays every conceivable rôle but the real one,—i.e., that of a patient accused of murder. We will see that he does this by the mere fiat of his word—that magic dexterity which has served so well primitive man in his struggles with reality.
Let me reproduce some of his letters, of which he hands me at least one daily. Here is one addressed to King George V: