THE MALINGERER: A CLINICAL STUDY
I
The following study is undertaken less for the purpose of discussing the
psychology of malingering than with the object in view of illustrating
by means of clinical records the type of individual who malingers. The
opinion is a general one that malingering is a form of mental reaction
to which certain individuals resort in their effort to adjust themselves
to a difficult situation of life. Being a form of human behavior, it
should have been approached, therefore, with the same attitude of mind
as any other type of behavior.
A perusal, however, of the literature on the subject, especially of the
contributions of the older writers, reveals that with certain isolated
exceptions the subject was viewed primarily from the standpoint of the
moralist. Even today one sees in certain quarters a good deal
made--certainly a great deal more than the facts would justify--of the
"insanity dodge" in criminal cases. It is true that today,
notwithstanding the still broadly prevalent tendency to view with
suspicion every mental disorder which becomes manifested in connection
with the commission of crime, the danger of error in this respect has
been reduced to a minimum owing to the more advanced stage of
psychiatry, and therefore the practical importance of the subject of
malingering is not so great as it was formerly. We find, nevertheless,
justification for the further study of this subject in the fact that,
aside from its purely psychiatric importance, the more intensive study
of the malingerer offers a solution for some of the important problems
in criminology. As one of the results of this more intensive study may
be mentioned the gradually-gained conviction that malingering and actual
mental disease are not only not mutually exclusive phenomena in the same
individual, but that malingering itself is a form of mental reaction
manifested almost exclusively by those of an inferior mental make-up;
that is, by individuals concerning whom there must always be
considerable doubt as to the degree of responsibility before the law. As
a result of this recognition cases of pure malingering in individuals
absolutely normal mentally are becoming rarer every day in psychiatric
experience.
The conviction was further gained that malingering as well as lying and
deceit in general, far from being a form of conduct deliberately and
consciously selected by an individual for the purpose of gaining a
certain known end, is in a great majority of instances wholly determined
by unconscious motives, by instinctive biologic forces over which the
individual has little or no control. This is one of the factors which
determines the growing realization among present-day psychiatrists of
the extreme difficulty to state in a given case which is malingered and
which genuine in the symptomatology. That such views should encounter
opposition among our jurists is perfectly natural, threatening as it
does with complete annihilation that wholly artificial concept of the
"freedom of will" upon which our laws are based.
In touching upon the subjects of "responsibility" and "freedom of will"
I incur the danger of adding to the general misunderstanding which still
exists between the physician and jurist concerning crime and the
criminal.
Speaking from personal convictions, I see no real justification whatever
for this misunderstanding, unless it be the difference in the mode of
approach to the subject on the part of the two. The jurist is compelled
by existing statutes to look upon crime largely in the abstract--not as
it concerns the individual who committed the deed, but as it is affected
by the statutes covering it. The physician, on the other hand, sees in
the criminal act a form of reaction to an intrinsic or extrinsic
stimulus by a feeling, willing, and acting human being, and proceeds
accordingly to analyze in a concrete manner the forces which brought
about this particular form of reaction in this particular individual. As
a result of this mode of approach to the subject he is enabled to
conceive of "responsibility" as something fluid, something extremely
variable, and which may be affected by a thousand-and-one things, and
not as something absolutely fixed and invariable and which may be
definitely foreseen by a set of statutes.
Any attempt to bring about this most desirable uniformity of approach to
the subject of criminology between the jurist and the physician must be
based primarily upon intensive study of the personality of the criminal.
Such is the aim of this paper.
II
In the last analysis malingering is to be looked upon as a special form
of lying, and its proper understanding will necessitate a clear insight
into lying in general.
Lying, a very natural and generally prevalent phenomenon, may manifest
itself in all gradations--from the occasional, quite innocent "white
lie" as it occurs in a perfectly normal individual to the pathological
lying exhibited in that mental state known as "pseudologia phantastica."
Its proper understanding, however, no matter under what circumstances
and to what degree it be manifested, will be possible only through a
strict adherence to the theory of absolute psychic determinism.
Lying, like every other psychic phenomenon, never occurs fortuitously,
but always has its psychic determinants which determine its type and
degree.
Naturally many of these determinants are quite obvious and readily
ascertainable. One has only to recall the lying and deceit practiced by
children. But many others, if indeed not most of them, are active in the
individual's unconscious motives and accessible objectively as well as
subjectively only with great difficulty and by means of special
psychological methods.
The degree of participation of unconscious motives in lying will be
determined in the individual case by the extent of repression
necessitated because of social, ethical, and aesthetic considerations. It
is for this reason that lying is most prevalent and exhibited with the
least amount of _critique_ in those individuals who either have never
developed those restraining tendencies which a normal appreciation of
social, ethical, and aesthetic consideration demands, or in whom these
restraining influences have been weakened or abolished by some exogenous
insult to the nervous system--as, for instance, the tendency to
fabrication dependent upon chronic alcoholism or morphinism. A beautiful
illustration of the latter type is furnished by General Ivolgin in
Dostoieffsky's "Idiot."
The child's tendency to lying and deceit is dependent to a large extent
upon the undeveloped state of those restraining forces. To state,
however, that this is the sole mechanism underlying the phenomenon of
lying would be to state only half a truth. For it is an undeniable fact
that, no matter how strongly endowed an individual may be with ethical
or moral feelings, still there comes a time when these are entirely
forgotten and neglected; when, finding himself in a stressful situation,
the instinctive demands for a most satisfactory and least painful
adjustment, no matter at what cost, assert themselves. It is then that
the lie serves the purpose of a more direct, less tedious gratification
of an instinctive demand. The resort to this mode of reaction, to
evasion of real issues for the purpose of gratification of instinctive
demands, is not characteristic of man alone, but is quite prevalent even
in some very low forms of life. We will have more to say about this
later. It is an important tool in the struggle for existence among all
living beings; it is one of the mechanisms by means of which the weaker
inferior being escapes annihilation at the hands of the stronger,
superior being.
Malingering, it will be seen later, appears to certain individuals to be
the only possible means of escape from and evasion of a stressful and
difficult situation of life. The lack of _critique_ which permits such
an abortive attempt at adjustment and the inherent weakness and
incapacity to meet life's problems squarely in the face which drives
them to resort to such a means of defense are some of the traits of
character which serve to distinguish these individuals from what is
generally conceived to be normal man.
The extent to which lying and allied behavior depend upon unconscious
motives has never been so well illustrated as in recent psychoanalytic
literature, especially in a paper by Brill.[1] This author is so
thoroughly convinced of the value of conscious lying as an indicator of
unconscious strivings and motives that he frequently asks his patients
to construct--artificially--dreams which he finds to be of valuable aid
in the analysis of the patient's unconscious. After citing a number of
examples Brill states: "These examples suffice to show that these
seemingly involuntary constructions have the same significance as real
dreams, and that as an instrument for the discovery of hidden complexes
they are just as important as the latter. Furthermore, they also
demonstrate some of the mechanisms of conscious deception. The first
patient deliberately tried to fool me by making up what he thought to be
a senseless production, but what he actually did was to produce a
distorted wish. He later admitted to me that for days he was on his
guard lest I should discover his inverted sexuality, but it never
occurred to him that I could discover it in his manner. That his
artificial dreams have betrayed him is not so strange when one remembers
that _no mental production, voluntary or involuntary, can represent
anything but a vital part of the person producing it_."
Were this thesis on malingering to succeed in nothing else than in
bringing home to our legal brethren this important truth of absolute
psychic determinism, that a man is what he is and acts as he does
because of everything that has gone before him--because of ontogenetic
as well as phylogenetic instinctive motives--it will have fully
established its _raison d'etre_. For a realization of this truth would
at once annihilate from our minds that deceptive notion of the "freedom
of will" upon which our laws are based, and will be certain to bring
about a more enlightened solution of the problem of the criminal, all
attempts at which, we are constrained to state, have thus far[A]
undeniably been huge failures.
[A] Intimate contact with members of the legal profession, both
professionally and socially, for some years past has convinced me that
the average lawyer still looks upon the ideas concerning crime and the
criminal expressed by physicians of a forensic bent as totally
unpractical and visionary. It would take only a brief visit to a
criminal department of any modern, well-conducted hospital for the
insane to convince any fair-minded individual that the physician handles
the problem of the criminal not only in a more scientific and rational
manner than does one not possessed of this particular training, but also
in an eminently more practical manner, even so far as dollars and cents
are concerned. I have frequently had patients come under my observation
who for a great number of years had been oscillating between penal
institutions and hospitals for the insane, in whom each additional
sentence did not only fail to bring about the hoped-for reformation, but
served to render them more depraved and criminally inclined, and who
would have undoubtedly continued this checkered career throughout life,
had not their true, unreformable nature been discovered and thus caused
their permanent isolation from society, not by the jurist but by the
physician. Should reformation ever take place in any of these
individuals it is safe to assume that the one who was clear-visioned
enough to discover the cause of their antisocial existence would
likewise be competent enough to know when this cause has disappeared.
The psychic mechanism of lying is the same both in the occasional and in
the pathological liar--in both it is the expression of a wish--but the
difference in the personalities of the two is a very decided one. On the
one hand we have an individual who closely approaches normal man, while
on the other hand one who is closely allied to the mentally diseased.
The difference between the pathological liar and the habitual criminal,
aside from the moral phase of lying, is perhaps but a very slight one,
when we keep in mind that in both instances we are dealing with
individuals who habitually resort to a form of reaction in their
attempts at adjustment to reality which aims at a direct, simple, and
least resistant means for gratification. In both we are dealing with a
type of mental organization which is primarily incompetent to face
reality in an adequate, socially acceptable manner, and therefore has to
resort to constant deceit and lying, and in which those inhibitions
determined by social, ethical, and aesthetic considerations are equally
impotent. The marked egotistic trend which constantly comes to the
surface in the habitual liar when he attempts to play the part of the
hero and central figure in the most fantastic, bizarre, and impossible
adventures is likewise frequently at the bottom of the escapades of the
habitual criminal. The two traits are frequently, though by no means
always, concomitant manifestations in the same individual.
When, in 1891, Anton Delbrueck[2] published the first comprehensive study
of the pathological liar, he not only succeeded in very accurately
delineating a more or less distinct psychopathological entity, but also
furnished additional proof in substantiation of the fact, well known in
psychiatry but as yet unrecognized by the legal profession, that the
transition from mental health to mental disease is not a sudden one;
that any dividing line which would have for its purpose the strict
separation of the mentally sound from the mentally diseased must of
necessity be a purely imaginary one, and one not justified by existing
facts.
The transition from absolute mental health to distinct mental disease is
never delimited by distinct landmarks, but shows any number of
intermediary gradations. Nowhere is this better illustrated than in the
pathological liar. Here one sees how a psychic phenomenon regularly
manifested by perfectly normal individuals may gradually acquire such
dimensions and dominate the individual to such an extent as to render
him frankly insane.
To endeavor, however, to definitely state where normality leaves off and
disease begins would be, to say the least, to attempt something
well-nigh impossible. And yet this is just what the jurist constantly
demands of the alienist. The law as it is laid down in the statutes,
especially in this country, does not permit of any intermediary stages
between mental health and mental disease. An individual, according to
law, must either be sane or insane. This point seems to me to be of very
vital importance, and I shall have occasion to refer to it again in the
consideration of our clinical material.
The part played in lying by disturbances of the apprehensive, retentive,
and reproductive faculties will not be discussed here in detail. These
undeniably have their influence in facilitating the mechanism of lying.
But to attribute this phenomenon wholly to disturbances of this nature
would be to assign to it a purely passive role, whereas experience
teaches that back of every lie are active forces, either conscious or
unconscious, which give birth to it and determine its type and degree.
The following two cases will illustrate better than any formal
description could what is meant by pathological lying, a
psychopathological state for which Delbrueck proposed the term
"Pseudologia phantastica":
E. W. S., a colored male, aged thirty-two years, was admitted to the
Government Hospital for the Insane from Fort D. A. Russell, Wyoming,
on January 29, 1912, on a medical certificate which stated the
following: "Patient is a native of Porto Rico; has been sailor and
soldier; has occasionally used alcoholic beverages, but usually the
light wines or beer; is very good-natured, occasionally melancholy and
lachrymose; gave a history of 'fits', and was previously discharged
from the army on this account. He was thought to be 'queer' in his
organization and had more or less trouble with the men, who made fun
of him. He was sent to the hospital from the guard-house in October,
1911, and his mental condition noted at that time. His present
symptoms were described as delusions of grandeur: 'Queen Victoria was
his instructor in English', 'King Edward of England was his school
chum.' He thinks he was royal interpreter. He does speak a number of
languages fluently and, so far as we can learn, with fair correctness
(?)."
On admission to this hospital the patient was in excellent health
physically; Wassermann reaction with the blood-serum negative.
Mentally he was clearly oriented in all respects and fully in touch
with his immediate environment. He comprehended readily what was said
to him, and his replies, aside from his extreme tendency to
fabrication, were coherent and to the point. Intelligence tests showed
him to be intellectually about on a par with the average negro of his
social and educational status.
When asked to give his family and past personal history, he recited
the following: He knew nothing of his grandparents or parents, and
denied having any living sisters or brothers. One brother died in
Chicago in 1906; thinks he must have been murdered, because he himself
was almost murdered in November, 1911, when they attempted to
assassinate President Taft out in Wyoming. King Mendilic, of Cape
Town, Africa, now dead for seven years, was his cousin. The patient
himself was Prince of Abyssinia, where he reigned for eight years,
having remained in that country from 1896 to 1899, and conducting the
affairs of state the remaining five years by correspondence, with the
approval of Lord King Edward. He stated he was born in Porto Rico in
1876, and calculates his present age as thirty-four, as this is 1912.
About two months ago he received a letter from Queen Alexandra of
England telling him he was thirty-two years, ten-twelfths and two days
old, or thirty-two years, two months, two weeks, and two days. Asked
how much ten-twelfths of a year was, he said: "Three months, three and
two days." When told that ten-twelfths of a year equaled ten months,
he replied: "The calendar of the English era, which is 'our calendar',
does not correspond with the American calendar, but, being in America,
I believe I ought to figure from their standpoint." He left Porto Rico
at the age of six; does not know who took care of him up to this time,
as he never knew his parents, stating that he was just thrown on the
mercies of the country. At the age of six, upon the recommendation and
advice of King Alfonso of Spain, he was taken to England by Queen
Victoria, who came to Porto Rico especially for this purpose. When
asked his opinion as to why Queen Victoria should have taken so much
interest in him he stated that he did not know positively, but it may
have been because he was related to King Solomon of Bible fame.
Requested to explain this relationship to King Solomon, he traces it
in the following manner: He was a cousin of King Mendilic, who in turn
was the "third reigning seed" or stepson of King Solomon. Queen
Victoria, whom he calls "Mother Victor", because she took the place of
his mother, sent him to "Hammenotia School" in Oxford University,
which he attended for four and a half years, received his diploma, and
was transferred to Cambridge College. Here he attended for four years.
At the former school he learned the alphabet, went up to the seventh
grade, learned some medicine about herbs, etc. "I learned some
medicine, not all of it. I didn't practice it much; just practiced it
enough to do the country good. At that time we didn't have any
doctors." At Cambridge he learned "The Reigning of the Thornes", or
the laws of the country. Upon request he described in minutest detail
the city of Cambridge. When asked whether he remembered a large oak
tree which grew on the banks of the river flowing through the city, he
replied: "I should say I do; many a time I sat on the banks of this
river during my student days." Earlier in his student days at
Cambridge he learned German, French, and English. It should be
remarked here that the patient actually did know a few common phrases
in several languages which he picked up during his sailor days. But he
always insisted that he knew thoroughly twenty-two languages, and when
asked to enumerate these he found himself in deep water and was
obliged to invent the languages for the occasion. Nevertheless he
stuck to this story, and was always ready to launch upon the task of
enumerating his twenty-two languages.
After his four years' sojourn at Cambridge, Mother Victoria sent him
to "Saint Palestine", Jerusalem, where he remained for fourteen
months, learning the constitution of the country, by-laws, etc. Mother
Victoria and Father Edward (Queen and King of England) brought him up
so that he could properly reign over Abyssinia. He states that he saw
Queen Victoria frequently, and was at her funeral in August, 1910,
shortly after the death of Pope Leo. Lord King Edward died about three
months later. The Queen died about the age of seventy-six, as did King
Edward at the same age, from grief and senility. Here he adds that his
maternal grandmother was sister to Queen Victoria. While at the
English Court he held the position of "Prince of Escorts." He left
Jerusalem to go to school at Sydney, Australia, for one year. He then
went to sea on Lord Edward's naval reserve boat, which he had
permission to use. Remained at sea for three years and four months,
visiting China, France, Japan, Germany, Austria, Turkey, Italy,
Havana, Archipelago. When asked to repeat these countries, he omits
some of them and adds others.
He then came to the United States for the purpose of electioneering,
stump-speaking, etc., all to benefit the government. He then became a
United States interpreter in the Philippines from 1896 to 1902, at a
salary of $75 per month and expenses. He then returned to Porto Rico,
where he remained until 1910. Following this he attended the funerals
of Queen Victoria, Pope Leo, Lord Edward, and his cousin Mendilic, and
finally came to Chicago, where he enlisted as first-class sergeant in
the United States Army. He was sent to Fort D. A. Russell, Wyoming, to
serve in the Hospital Corps, at a salary of $48 per month and
maintenance. There everything went well until he got to worrying and
crying, so they sent him here. He acted thus because he was
ill-treated, was not treated right for a man of his abilities, was
sworn at too much, and called bad names by the enlisted men. They did
this because they were jealous of his "politicalness", his education;
he never swore, drank, or gambled like the others did. Was robbed of
his every possession in Cheyenne, Wyoming, by members of the Ninth
Cavalry and Eleventh Infantry. Lost $1400 in the past five months in
cash and property. They robbed him of his horse, buggy, clothes, and
jewelry, including chain, watch, finger ring, a pair of jasper
earrings. He could hear them talking about him day and night; feared
to leave his room, for he was continually threatened. They were going
to kill him. On this account he was taken to the hospital and kept
under close guard, because they could protect him. He had to leave at
night. He did so after having received a telegram from the
Surgeon-General of the Army, asking him to report to the Hospital
Corps at St. Elizabeth's Hospital, Washington, D.C. As one of the main
reasons why they had it in for him he gives the following: There was a
car line running from Fort D. A. Russell to Cheyenne, the fare being
ten cents. The men wanted it reduced to five cents. As the one in
charge of the canteen he had it in his power to approve or disapprove
of this reduction. He disapproved of it because he didn't think that
ten cents was an excessive charge for a three-mile ride, especially
since they spent so much money on drink, etc. He had a runabout motor
car, so they thought this was why he disapproved of it. "In
consequence they were on my trail." Part of the way to Washington he
came in a private car, but this they deprived him of at Omaha,
Nebraska. Perhaps they did this because they thought it was too large
for him, but, inasmuch as it was assigned for his private use, they
had no business taking it away from him.
During the recital of the foregoing the patient was bright and alert,
and his attention was easily gained and very well held. He quickly
understood everything that was said to him, and replies were prompt,
relevant, and coherent, though, of course, entirely colored by his
bizarre fabrications.
During his sojourn at this hospital he was a model patient in every
respect, worked diligently with a farm gang, though frequently
dilating upon the fact of having the responsibility of the whole gang
on his shoulders. On several occasions he gave evidence of being of a
highly sensitive make-up, becoming readily insulted, but he always
reacted to these real or imaginary insults in a mild and kind sort of
way, always preferring to go out of people's way rather than
retaliate. Hallucinatory disturbances were never manifested.
The story of his past life was gone over with him on a number of
occasions, but on each occasion he gave a different, highly fantastic
recital of his past adventures, always using high-sounding words and
phrases and high-sounding names, many of which he mispronounced. Many
of the words used by him were of his own coinage, if one were to judge
by the sound of them. He was always very pleasant and agreeable, and
enjoyed reciting his past immensely. In all these bizarre and
marvelous adventures he played the chief role and occupied the center
of the stage.
He was finally induced to give an explanation of his extreme love for
lying, which he gave as follows: "_It isn't because I don't know
better, doctor, but because I think it will make me feel better,
that's all. When I tell of all these big things it makes me feel that
I am a little above the common herd of negroes, and then I never tell
anything to hurt anybody._"
He stated that he couldn't really separate the true from the false in
his stories, and that he seemed to have little or no control over this
tendency to exaggerate things and to weave into real occurrences all
sorts of manufactured detail. "I know one thing, doctor; that it's
been a habit of mine all my life. I have always tried to exaggerate a
bit. It makes me feel, for the time being, that I'm above the other
negroes, that's all. I know I always try to make an honest living, and
this habit of mine never interfered with me."
A good deal more could be furnished from the records of this man's case
in illustration of his pathologic disposition to lying. An ordinary
negro soldier, he succeeds in projecting himself, by means of his ready
and very fertile fantasy, into the most wonderful situations and in
rubbing shoulders with royalty. If we inquire into the causes operative
here we first of all see in the fabrications of this individual an
unbounded craving for compensation for a natural deficiency--in this
instance a racial deficiency. What this man lacks in reality he
endeavors to substitute in his fantasy. There can be no doubt that the
tendency to lie has reached such dimensions and intensity in this man's
mental make-up as to make him absolutely believe in his own impossible
fabrications, to render him absolutely helpless in the mazes of his
fantastic creations. He is assisted in this by his craving for
self-esteem, by his extreme need of compensation for a real deficiency,
by his ready and fertile fantasy, one absolutely devoid of _critique_,
by his extreme suggestibility, and, lastly, what is of great importance,
by his extremely defective apperceptive faculties and consequent
falsifications of memory.
The latter defect was particularly well illustrated in the following
note from my records of the case. He was asked, in the course of my
examination, to repeat a simple story known as the "Shark Story", which
I shall reproduce here in full for the sake of making clear my point:--
"The son of a Governor of Indiana was first officer of an Oriental
steamer. When in the Indian Ocean the boat was overtaken by a typhoon
and was violently tossed about. The officer was suddenly thrown
overboard. A life preserver was thrown to him, but on account of the
heavy sea difficulty was encountered in launching a boat. The crew,
however, rushed to the side of the vessel to keep him in sight, but
before their shuddering eyes the unlucky young man was grasped by one
of the sharks encircling the steamer and was drawn under the water,
leaving only a dark streak of blood."
In reproducing it he said:--
"The son of a Governor of an Oriental steamer was the captain. Now,
doctor, I can't think of those little stories. It isn't because I
haven't brains enough; it's because I'm so poor a scholar at reciting.
I always was." "What happened to the captain?" "That I can't
recollect, neither." "What happened to the ship?"
Here, instead of answering my question, he said: "Doctor, I suppose you
have heard about the big wreck that happened out on the ocean." (This
was when the terrible _Titanic_ disaster was on everybody's lips and the
papers were full of the tragedy.) The patient regularly read the papers.
"Tell me about this wreck."
"Well, the steamer was 1200 miles from the land--north-northerly
course. It was first reported that 1800 lives were lost; afterwards
they found out for certain, through the communication with General
Wood, that it was only 1300. Mrs. Zelia Smith, she was on the vessel."
(Patient's name is Smith.) "She is Commissioner Hodges's daughter. She
was counted lost, for instance, and was found alive. I knew her well;
I knew a good many other people on that boat." "About how many people
did you know?" "Well, I just only remember some. For instance, Major
B----; I knew him well, of course. I dare say I knew all the others,
but I knew him best. The boat was in charge of E. C. Smith." "Did you
know Captain Smith?" "Yes, sir; I knew him. I didn't know him
personally; I only made one voyage with him from Angel Island." "When
was that?" "In 1907." "What was the name of the wrecked ship?" "I
can't recall that, neither; _Tripoli_, I think it was; she is close on
1500 feet long." "How much money was she supposed to be worth?" "I
don't know, sir; there were several heirs who had charge of the ship.
She was called the sister-ship _Trinic_ and was worth about $25,000.
That, perhaps, may not cover her upper-deck cabins." "Did you ever
travel on her?" "No, sir; I never was on her. I was on the _Trinic_,
the sister-ship. The White Star people own these boats. I used to run
a transport between the White Star Line and the Yellow Star Line."
Here he was told that the examiner did not know of the existence of a
Yellow Star Line, and he replied: "Oh yes, doctor; you heard of the
Flying Squadron that reports all these disasters and signals the other
ships."
Thus we see that with partial truths, with facts only partially and
imperfectly recalled as a framework, he builds his fantastic tales. He
read the newspapers regularly, but could not even recall the name of the
ill-fortuned ship, or any particulars about the accident. But what of
that?--he could readily fill in the hiatuses with his fabrication. He
failed entirely in the attempt to reproduce the story given him, and
used the talk about the _Titanic_ disaster as a subterfuge--as a ready
means of escape from the difficulty in which he found himself.
He himself threw some light upon the part played by his craving for
self-esteem in his statement: "When I tell of all these big things it
makes me feel that I'm a little above the common herd of negroes." He
unquestionably believes in these tales, if they are real enough to make
him feel above the common herd of negroes. His suggestibility was well
illustrated by the suggested river at Cambridge, "on the banks of which
he sat many a time during his student days."
The facility with which his imagination, his fantasy, works was
demonstrated by the "ink-blotch" test to which he was subjected. This
test, in brief, consists of a series of ink blotches which are shown the
patient, with the request to describe them as they appear to him. The
following are several of his replies: (1) "A woman sitting on a man,
seems like she's got a little weaving in her hand; a little stick,
sticking out from the weaving, seems like the man's elbow is sticking
out back of the shawl." (2) "It seems to me I have seen a volcano that
looks like that. I think it is a ship out at sea. I can see the
lifeboats lashed to the side, several ripples of water behind." (3) "A
figure of a woman with a hand purse or a disfigured arm near the wrist.
Her mouth is open and she is looking around. The wind carried her hat
off; she has a muff on her right hand. Seems like there is a neck-piece
around the muff."
Notice the detail with which he describes the blotches. In this one
ordinary speech seemed to have been insufficient to describe the blotch,
and he had to resort to a neologism. "Is that supposed to be a
'perpendicament'? It's got a head like a sea devil; the upper part seems
like a peacock trying to peck him in the back of the head."
There remains one other thing to be inquired into in this case, and that
is the history of epilepsy which accompanied the patient. He was never
observed in an epileptic seizure at the military post from which he came
to us, and no seizures were observed in this hospital. His own
statements concerning this are, like everything else he said, quite
totally unreliable. But in repeated examinations he persisted in his
statement that he had had but one "spell" in his life, but that he
frequently suffered from fits of melancholy. In all probability this one
seizure was hysterical in nature, phenomena of which type not
infrequently manifest themselves in the pathological liar, as will be
seen in the next case.
Here one sees how lying, a mental phenomenon which is looked upon as
quite a normal manifestation in a great many people, has reached such
dimensions in this individual and has succeeded in dominating his
personality to such an extent as to definitely remove him out of the
pale of normality and place him within the sphere of the mentally
diseased.
There is, of course, no question here about the genuineness of his lying
as a symptom of mental aberration; _i.e._, the fabrication as manifested
by this individual is something over which he has no more control than
the dementia praecox patient has over his delusions. In both instances
the symptoms are spontaneous and genuine expressions of a pathological
mentality. And yet when such pathological phenomena become manifest in
association with some concrete difficulty in the individual's life, say
in connection with a threatened punishment for a crime committed, the
genuineness of the symptoms is frequently doubted.
One, of course, can readily see with what facility an individual of the
type under discussion could malinger mental symptoms. Reality and
fiction have about identical values in this type of mental make-up, and
it is frequently impossible to separate the genuine from the fictitious
in their mental productivity.
It is likewise quite easy to divine why an individual of this sort would
resort to malingering in his effort to extricate himself from a
difficult situation which he is organically unable to meet squarely in
the face. On the contrary, it would be strange indeed were an individual
of this type to refrain from resorting to this form of defense. Of
course, even the man whose history we have just quoted may still be
considered mentally responsible before the law were we to judge him by
the legal standards of responsibility. But as physicians we need not on
this account refrain from attempting to delineate these mental types in
their true colors.
The situation is well illustrated in the following case. Here the
symptom of pathological lying is associated with pathological swindling
and criminality and offers a fertile field for seeds of malingering.
E. D. C., a white male, aged thirty-four, came to us on April 16,
1914, from the penitentiary at Stillwater, Minn., where he was serving
a sentence of ten years for white slavery. He was admitted on a
medical certificate which stated that his father was supposed to have
died from pulmonary tuberculosis. The patient gave a history of
epilepsy until fourteen years of age, likewise of having been a
patient in a Vienna hospital for the insane for one and a half years,
in 1900 and 1901. So far as was known to the prison authorities, he
was mentally depressed and had delusions since his arrival at the
Minnesota State Prison on October 11, 1913. The present symptoms were
described as mental depression; says that everybody is persecuting
him; also has the delusions that he has or can invent a wonderful
electric machine which he wants to sell to the government for a
hundred million dollars; said he would shoot himself and die in
prison. Physical condition was not good. Patient suffered from
obstinate constipation, peculiar shuffling gait, suggesting partial
loss of control of legs and feet. Complained of constant headache on
the top of his head. No fever.
On admission to this hospital the patient was in poor physical health
and very anaemic. He was quite slender in stature and somewhat
effeminate in manners and speech. He walked with a very marked limp of
the right leg, stating that he had been afflicted in this manner ever
since his first attack of mental trouble at the age of nineteen.
Patellar reflexes were markedly exaggerated on both sides, the left
more so than the right, and ankle clonus was present on the left side.
Babinski phenomenon was absent. While the reflexes were being tested
he volunteered the information that his left patellar reflex was very
much stronger than the right. He was a very glib talker and spoke
fluently in five foreign languages. He gave his name as E. J. B.,
Count de C., the son of the chamberlain to the Austrian Emperor and of
a famous Austrian countess. In the official papers which accompanied
him to the hospital the above name was followed by several aliases. He
talked in an affected, whining manner, constantly complained of
various bodily ailments, and showed a marked tendency to
hypochondriasis. He spoke of himself as a poor, down-trodden, and
persecuted unfortunate who is being constantly misunderstood. The
whole "white slavery" episode for which he is unjustly made to suffer
ten years' imprisonment was a trumped-up affair on the part of the
sheriff, who was bound to make a case out of it. He married the girl
with the best of intentions, and when arrested was with her on the way
to the Atlantic coast, preparatory to sailing for Paris, where he
intended to give her a splendid time. She testified against him at the
trial because she was scared into it by the officials, and, being
naturally of a weak nervous organization, she gave in. He was certain
he was going to die if he had to serve out his sentence, because
prison life is so different from the life he has led in the past. He
is entirely too refined to be able to stand the rough life of
imprisonment. Referred the examiner to the Austrian Embassy, which
could readily establish his noble descent and get him out of this
terrible predicament. When, later in his sojourn here, he was
interviewed by several gentlemen from the Austrian Embassy he
maintained the same attitude of wronged innocence, notwithstanding the
fact that these gentlemen confronted him with an undoubtedly genuine
photograph of himself, obtained from the Austrian police. It seems
that he was quite a famous character in Austria, and had served a
sentence there under a different name for a similar offense (white
slavery). Soon after his arrival at the Government Hospital for the
Insane he began to scheme for his escape, and on one occasion
attempted to saw the guards in his room with an improvised saw. He
likewise began to associate freely with the more dangerous element of
the criminal department of this hospital, quite likely with a view
towards getting assistance for his escape. He spoke with reluctance of
his ideas concerning the inventions, adding that he had decided to
quit talking about these things, because, although he is quite
convinced of the extreme value of these original ideas of his, people
have told him he was crazy wherever he expressed them. As an
illustration of some of these extremely valuable original ideas the
following may be mentioned. It concerns a bed-bug trap which he
invented, and which he described as a paper pocket which is placed in
the bed and scented with oil of pine so as to attract the bed-bugs.
These make their home in this paper pocket and lay their eggs there,
after which it is removed and burned. In the course of time (about two
months) he fully recovered from that serious leg affliction from which
he stated he had been suffering since the age of nineteen.
When an attempt was made to obtain his past history it was soon
discovered that it was so fantastically colored with fabrications as
to be entirely worthless, so far as a reliable account of his past
life is concerned. As an instance of pathological lying, however, it
was a masterpiece. He was requested to write out briefly his past life
history, and in this abbreviated form it covered twelve
closely-typewritten pages. We will not burden the reader with a
complete reproduction of his story, although I assure you it makes
very interesting reading material, but will simply review it briefly.
He speaks of the confession made to him several years ago by the lady
whom he had always looked up to as his mother. She told him that she
was only his foster-mother, and that in reality he was the son of the
Austrian chamberlain and a famous countess. The latter turned him over
into this lady's care when he was quite young, following her divorce
from the chamberlain. She furnished him with the authenticated proof
of the fact that he was entitled to a fabulous fortune left by his
parents. Unfortunately the lady died after a brief illness, during
which he practically sacrificed his life to save her, and thus his
most important witness is forever inaccessible. The papers which could
readily prove his noble descent were, most unfortunately, taken from
him when he was arrested and are probably destroyed by this time.
His foster-mother, he states, was regularly supplied with funds by his
real mother, gave him an excellent education and traveled with him
extensively. In a plea for clemency he dwells upon the fact that his
father died insane, that he himself suffered from epilepsy in his
youth, and that at the age of twenty he spent a year in an insane
asylum in Austria.
As an instance of his tendency to dramatization, of the part his ego
plays in the recital of his past exploits and of the tendency to crave
sympathy and compassion, a characteristic quite common to these
pathological swindlers, the following, his own description of the
circumstances which brought about his admission to the Vienna Insane
Asylum may be quoted:--
"While on vacation, I met at Wertersee, which is a fashionable summer
resort, a girl with the name L. Adle von D. I had left my tutor
behind. She was the first girl I met, and my romantic character, my
easily-excited nervous system, overpowered me and I fell in love, in
love as deep as a man can fall. A few months after that I was engaged
to her, and we should have been married on the 23d of April, 1899. On
the 22d of April my beautiful beloved bride was riding horseback with
me in the park, when at once her horse frightened, threw her off,
dragged her for a distance and then left her behind, a motionless,
bleeding mass. I saw right away that she was dead, lost to me, lost
forever; there was but one way not to lose her, and that was to follow
her soul, and that as quickly as possible. There in the park beside
her I took my pistol and shot myself. The public had gathered and
stopped me, and then I don't know what happened. I only remember that
I was ill for a long time, and then I was ill again, and they told me
L. was alive, and then I found out that she was not alive and I was
ill again."
Of course, the entire episode is a fabrication. The patient admitted
quite as much, but the interesting thing in this episode is the fact
that it illustrates how rigidly dependent lying is upon unconscious
motives. Had this episode really taken place, the patient, because of
his particular make-up, would have acted, in all likelihood, just the
way he behaved in his fantastic adventure.
After his year's confinement in the insane asylum his foster-mother
traveled with him in France, England, Egypt, and Turkey, in order to
divert his mind. Finally arriving at Transylvania, he became infatuated
with a poor girl named P., whom he christened L. in memory of his former
love, and married. The highly dramatic adventures of this second
matrimonial venture are altogether too numerous to describe in detail.
He describes in a very dramatic style how this lady was kidnapped from
him by a family of New York artists and spirited away across the ocean;
how after awakening from his unconsciousness, induced by some dope
administered to him in a tea which he had with these artist-friends the
night before, he at once made for the dock, arriving there just as the
ship carrying his wife was disappearing from sight; how he pursued them
across the Atlantic, to England, the continent, and so on, finally
locating them in Cape Town, South Africa; how upon arriving there he was
mortally wounded to find his beloved wife performing upon the stage of a
cheap, dirty place. An excerpt from his description of this eventful
voyage is as follows: "We passed Las Palmas, Asuncion, and St. Helena.
Christmas and New Year's were celebrated on board the ship, but I did
not care much for it. I was too much in distress. Would I find her
there? Would I reach her in time? How would I find her? Would she be
alive? My excitable fantasy awakened in me the most terrible suspicions.
I suffered dreadfully, and it seemed to me we would never arrive. But we
did at last, and some time in the beginning of January, 1906, I landed
in Cape Town." This is how he discovered her: "I knew I was going to see
something terrible, but I remained there--I had to. There were the rope
dancers, the clowns, and the music, but I had no interest in them. I was
waiting for L., my wife, and she came. On a small, mean stage L., my
beloved wife, appeared with painted cheeks and shining eyes, dressed up
in tights. She was dancing a mean dance and singing an obscene song
before an audience consisting mostly of drunken sailors. So I found my
wife L. and the music played. It was surely wonderful that I could
control myself at such a moment. At once it seemed to me that I had no
reason to be astonished. I was quiet and decided and waited until the
show was over, and after the show I went behind the stage, and when my
wife came out, laughing and happy, with a couple of other girls, I
stepped near her and said simply 'L.' She gazed at me and fainted." Thus
he finishes another tableau in his adventurous career. Several other
similarly dramatic adventures follow in his history, the last of which
landed him, wholly unjustifiably, in prison for ten years. When asked
why all his love adventures ended so disastrously, he replied: "Doctor,
all my life I have been suffering from a 'superaltruistic monomania to
help girls in distress,' and that is how I'm repaid."
Any discussion on "freedom of will" and responsibility in connection
with an individual of this type is, of course, quite futile and really
of no practical importance. This man ought to be permanently isolated
from the community, but not because he happens to have violated a given
statute, but because his grave mental defect--in all probability an
incurable defect--tends to express itself in criminal traits.
Back of this fantastic lying we see again that instinctive craving for
compensation by means of a resort to the imagination and fantasy, a
subterfuge rendered easy by those inherent defects enumerated in
connection with the preceding case.
All the frankly psychotic manifestations, such as his delusional ideas
and his grave affection of the lower extremity which served to put him
in a hospital for the insane, were, of course, entirely malingered.
This brings us to the subject of malingering proper.
III
In malingering we see the application of deceit and lying to a definite
situation. That which is a habitual type of reaction in some
individuals, as was illustrated in the foregoing cases, comes to the
fore in others only under certain stressful situations of life. While in
the habitual fabricator the most prominent motives are those of an
egotistic nature, a craving for self-esteem as compensation for an
inherent defect, in the malingerer we see a resort to this form of
reaction as a means of self-preservation, as a means of escape from a
particularly painful situation.
There was a time in the history of psychiatry when malingering was a
frequent subject of discussion in psychiatric literature. This was due
not so much to any inherent practical importance of the phenomenon of
malingering as such as to the faulty conception that this phenomenon was
something which by its very existence ruled out the existence of mental
disease. More scientific studies of personality which led to a direction
of our attention to the malingerer rather than to malingering as an
isolated mental phenomenon brought with it a complete change of attitude
towards the entire subject.
Today, far from harboring the notion that malingering and mental disease
are mutually exclusive, we are beginning to look upon malingering itself
as the expression of an abnormal psychic make-up. Furthermore, far from
believing, as of old, that the proverbially insane is supposed to be
totally devoid of discretion in his conduct, we know that there may be a
good deal of method in madness, and that even the frankly insane
malinger mental symptoms when the occasion requires it. No experienced
psychiatrist would today, for instance, consider the oft-quoted story of
the alleged madness of Ulysses as evidence of malingering.
The story is told that Ulysses, in order to escape the Trojan war,
feigned insanity. He yoked a bull and a horse together, plowed the
seashore, and sowed salt instead of grain. Palamedes detected this
deception by placing the infant son of the King of Ithaca in the line of
the furrow and observing the pretended lunatic turn the plow aside, an
act of discretion which was considered sufficient proof that his madness
was not real. Without attempting to pass upon the case of Ulysses, we
may say without fear of contradiction that no one would today depend
upon such criteria. Experience teaches us that an individual may be very
seriously mentally affected and at the same time show sufficient
discretion of conduct to avoid threatening danger and to seek those
means which best subserve his immediate needs and wants. Not only is
this true, but we have arrived at a stage where we are prone to look
upon a great many of the psychoses as the direct expressions of the
individual's wish--as a haven sought out by himself within which he
seeks shelter from the tempests of life. One of my patients tells me
that the gun which he used in the alleged homicide was not loaded with
bullets, but with paper wadding put there by his enemies, hence his
alleged victim could not have been killed; in fact, he knows that this
man is alive and having a good time on the money furnished him by his,
the patient's, enemies. Another instance is that of a colored man who is
serving a life sentence for murder. Among the many symptoms which this
fairly advanced dementia praecox case shows is the one that he considers
himself a white man; that his dark color is due to some paint which he
used in order to disguise himself; and that, inasmuch as the murder with
which he is charged was supposed to have been committed by a colored
man, he is not guilty of it. The motives here are quite obvious. Both
these individuals find life much more bearable believing, as they do, in
their innocence of the crimes imputed to them. Many other examples could
be cited to prove that symptoms in mental disease do serve a definite
purpose; that there may be indeed considerable method in madness.
Nevertheless, the observation is not uncommon that whenever such method
is detected under circumstances where some ulterior motive may be ascribed
to it the lay mind, and not infrequently psychiatrically-trained
physicians, are at once ready to question the genuineness of the
symptoms. It is the more curious that the so-called "insanity dodge" cry
is frequently raised under circumstances where it would seem to be the
least justifiable, as, for instance, in the case of an individual
battling for his life before the bar of justice.
A little inquiry, however, into this phenomenon will help us to
understand it better. It has its root primarily in that very common
tendency of man to impute to his neighbor a type of behavior, a form of
reaction, of which he would gladly avail himself were he in his
neighbor's place, and the weapon he would use under the circumstances
would very likely be that exquisitely human trait, deceit, malingering.
It is a weapon which has played a tremendous part in the evolutionary
struggle, not only of man but of all living things; in a broader sense,
it may be looked upon as an organic function, as an endowment, thanks
to which the weak, inferior being is able to avoid the danger of
becoming the prey of the stronger, superior being. This function is very
well illustrated in those animals which are able to acquire the color of
their immediate surroundings in order to render themselves more
difficult of detection. It is common among various insects, reptiles,
and amphibians. The chameleon may be especially mentioned in this
connection. Even the eggs acquire, in the process of natural selection,
the color of the place where they are deposited, and the cuckoo which is
about to cheat a couple of another species by placing her eggs in their
nest for them to hatch selects that species the color of whose eggs most
closely resembles that of her own, in order to assure herself of the
success of the deception. The simulation and malingering practiced by
the fox is common knowledge. Malingering, an instinctive function
originally, has, in the process of evolution, become an act of reason
with certain animals. One is forced to believe, from a survey of
mythological writings, that primitive man must have had recourse to
simulation and all else that this term stands for whenever he was
confronted with an especially difficult problem in his struggles for
existence. To the gods was attributed, among other special propensities,
the ability to assume any shape or form, else how could they have
performed all those miraculous escapades? Thus we are told that Jove
transformed himself into an eagle when he carried off Ganymede.
Achilles, the son of a goddess, sought to avoid the iniquitous fate
which drove him to Troy by disguising himself as a woman. Deception is a
common weapon of defense with the savage and with the inferior races of
today. It is the tool by means of which these individuals render things
as they want them to be; it is with them the means for a more direct,
less difficult, less tedious solution of the problems of life.
The child in whose development the various steps of phylogeny are
recapitulated shows this tendency to deception, to simulation, and
dissimulation in a very pronounced degree. Lombroso, who was the first
to demonstrate that so-called moral insanity is but a continuation of
childhood without the adjunct of education, cites many facts, not
excepting his own example, to show that the child is naturally drawn to
fraud, to deception, to simulation. The child simulates either because
of fear of injury and punishment or because of vanity or jealousy.
Ferrari,[3] in his excellent work on juvenile delinquency, discusses the
various motives for deception and malingering in the child. According to
him, deception is, first of all, instinctive with the child. It
malingers because of weakness, playfulness, imitation, egotism,
jealousy, envy, and revenge. Deception frequently forms for it the only
available weapon of defense against the parents and teachers.
Penta[4] cites many well-authenticated cases of malingering of mental
symptoms in children. Of special interest is Malmstein's case of a girl
of eight years who, in order to deceive her father and render him less
severe in his treatment of her, and in order to gain the sympathy of
those in the house who were in the habit of giving her sweets, feigned
complete muteness for five months, after which time, no longer able to
resist the desire to speak, she went into the woods, where, believing
herself unobserved, she began to sing. St. Augustine, in his
confessions, speaks of his childhood in the following manner: "I cheated
with innumerable lies my teachers and parents from a love of play and
for the purpose of being amused."[B] Penta, after a thorough discussion
of the subject of malingering in children, comes to the conclusion that
children use all the diverse forms of fraud, from simple lying to
simulation, much more frequently than is believed or known. It may with
them as with some lower animals simply be an instinctive playfulness, a
habit or a necessity, as a weapon consciously and voluntarily wielded.
This inherent tendency is, of course, modified to a considerable extent
by the environment under which the child was brought up. Finally, the
independence which the growing human being acquires from this form of
reaction is in direct proportion to the ability he has acquired through
education and precept to meet life's problems squarely in the face. We
will see, later on, how the type of individual who is most likely to
malinger has in reality never fully outgrown his childhood; that his
reactions to the problems of everyday life are largely infantile in
character.
[B] Cited by Penta.
Thus we see that malingering has its _raison d'etre_; that, after all,
it is not at all strange that the suspicion of its existence should be
so frequently raised by our legal brethren--yes, and medical brethren,
too; that in reality it ought to be a very common manifestation.
Nevertheless, paradoxical though it may seem, cases of pure malingering
of mental disease are comparatively rare in actual practice.
Wilmanns,[5] in a report of 277 cases of mental disease in
prisoners, cites only two cases of pure malingering, and in a later
revision of the diagnoses of the same series of cases the two cases of
malingering do not appear at all. Bonhoeffer,[6] in a study of 221
cases, found only 0.5 per cent of malingering. Knecht,[7] in an
experience of seven and a half years at the Waldheim Prison, did not
observe a single case of true malingering. Vingtrinier[8] claims not to
have found a single case of true malingering among the 43,000
delinquents observed by him during his experience at Rouen. Connolly,
Ball, Krafft-Ebing, Jessen, Siemens, Mittenzweig, and Scheule are quoted
by Penta as having expressed themselves that pure malingering is
extremely rare. Penta, on the contrary, observed about 120 cases during
his four years' service in the prison in Naples. He gives as the reason
for this unusually high percentage of cases observed by him the fact
that two-thirds of the inmates of the prison belonged to the Camorra, an
organization whose members are gleaned from the lowest and most
degenerate stratum of society, and in whom the tendency for deception
and fraud in any form is highly developed.
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 role 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:
DEAR SIR: I wish to return at once to England to the Cissel Hotel. You
told me not to take my wife back after the courts here had granted me
a divorce, so I look to you to just please come on here in person and
have me released, as the United States Senate has given permission for
you to come and release me. I am the young man that rescued you from
drowning at River View, and after telling you my case you advised me
to get a divorce. The guests from the hotel were wishing for me to
return when on here, as also my family.
Please find enclosed check for your expenses and give prompt action.
Very respectfully,
(W. H. M.) HOWARD HALL,
Washington, D.C.
The check:--
U. S. Treasury,
Pa. Ave. and 15th Street.
WASHINGTON, D.C., October 1, 1914.
Please pay to King George of England Ten Thousand Dollars for
professional services.
$10,000 W. H. M.
Thus by the mere stroke of the pen he, a poor mortal accused of murder
and indefinitely confined to an institution, succeeds in putting himself
in touch with King George, in drawing _ad libitum_ upon the United
States Treasury, in ridding himself of the wife whom he accuses of
infidelity, and in annihilating old age by styling himself "The young
man," when in reality he is fifty-seven years of age at present.
His belief in these statements is absolutely unshakable, notwithstanding
the fact that he retains a clear orientation concerning his immediate
environment, and thus has the actual state of his affairs constantly
forced to his attention.
His grandiose compensation has such dimensions as to gratify every
imaginable wish of his. He came here because he was divorced from his
wife, not because of any crime he had committed. He is the son of the
supervisor in charge of this building. He owns this institution and
built it for a place in which he could count his money. He had forty-six
wagon-loads of this. He will live 250 years, because he has taken the
severest punishment to secure this. He refuses to assist with the ward
work, because he pays $1.50 a day for board and is not supposed to do
any work. He was brought here to select a woman for his wife. They
brought him a lot of blue-eyed blondes and also a lot of Baltimore and
St. Louis beauties, etc.
W. H. M., Owner, Washington Asylum, 5000 Branch Hospitals, five
million employees.
ANACOSTIA, D.C., Fri., Nov. 6, 1914.
DEAR MR. PRESIDENT:
I came over here to take out forty-six wagons loaded with greenbacks.
I respectfully had it arranged to have the Senate hold me here on
account of so much wealth until I thought it safe to return. Please
sign this and return it by mail. The Senate ordered me to write it to
you, as there is no crime against me.
WASHINGTON, D.C., Fri., Nov. 6, 1914.
DR. W. AND STAFF OFFICERS OF WASHINGTON ASYLUM:
Please allow Mr. W. H. M. to pass out the gate at once free.
Very respectfully,
W. W.
Please don't delay this one minute.
Thus we see that the entire content of this man's delusional fabric is
intended, first, to serve the purpose of annihilating the painful
reality, and, second, to substitute for it a beautiful world in which he
finds himself free and young again, enjoying his fabulous riches and
many blue-eyed beauties. It is the only compromise possible for him, and
the fact that it is nothing but a day-dream does not in the least
detract from its compensating possibilities for this individual's
painful reality. This man's mental disorder has been so obvious ever
since its inception that the question of malingering never suggested
itself to anyone, and yet the underlying mechanism in this case differs
in no particular essential from the cases usually considered as
malingerers. In both instances the psychosis represents an attempt to
get away from a painful reality by individuals who are quite incapable
of meeting such reality face to face.
A more detailed consideration of Freudian psychology, especially such as
concerns the subjects of determinism, defense, and compensation, would
give one a still clearer insight into the subject under discussion, but
to do so would lead us considerably beyond the scope of this paper. From
what has been said thus far it will be seen that the mental processes
underlying the mental state of malingering differ in no essential from
those operative in the human mind generally; that man in his endeavor to
reach a satisfactory compromise between the two underlying principles of
his conduct,--_i.e._, that of pleasure and reality,--frequently resorts
to his fantasy; that malingering in its broader sense,--_i.e._, the
attempt to evade reality,--is a common mode of reaction in primitive
man, the child of today and in the undeveloped mind, in all of these
instances signifying an inability to meet stern reality in the face, and
that, therefore, malingering, when it does occur, should at least not be
looked upon as an aggravating circumstance, which is not infrequently
the case when the malingerer happens to be facing a court of law.
That this mode of reaction is at times resorted to by individuals who
had always been looked upon as being far from incompetent only proves
that under special stress, especially mental stress, man readily sinks
to a lower cultural level and resorts to the defensive means common at
this level.
Clinically, malingering is to be considered from three distinct
viewpoints:--
1. Malingering in the frankly insane;
2. Malingering in those apparently normal mentally; and
3. Malingering in that large group of border-line cases which should
rightly be looked upon as potentially insane and as constantly verging
upon an actual psychosis.