Feigning Symptoms to Obtain Prescription Stimulants: A Vignette-Based Study on Its Conditions

• Author: Sebastian Sattler,Floris van Veen,Guido Mehlkop,Fabian Hasselhorn
• Published date: 01 April 2022
• Date: 01 April 2022
• DOI: 10.1177/00220426211055433
• Subject Matter: Articles

Article

Journal of Drug Issues

2022, Vol. 52(2) 225–249

© The Author(s) 2021

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DOI: 10.1177/00220426211055433

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Feigning Symptoms to Obtain

Prescription Stimulants: A

Vignette-Based Study on Its

Conditions

Floris van Veen

1

, Sebastian Sattler

2,3,4

, Guido Mehlkop

1,5

, and

Fabian Hasselhorn

3

Abstract

This vignette-based study examined the willingness to feign symptoms to obtain a prescription

following an analysis on who might use prescription stimulants to enhance performance (N=

3,468). It experimentally manipulated three factors: the social disapproval of prescription

stimulant use for enhancement purposes, the physicians’diagnostic efforts, and the medical

condition (attention-def‌icit/hyperactivity disorder and narcolepsy); respondent characteristics of

self-control, personal morality, and self-eff‌icacy were also measured. Our results showed that

social disapproval of prescription drug use, a personal morality that disapproves of drug use, high

self-control, and high self-eff‌icacy were negatively associated with the willingness to use. Will-

ingness increased especially in situations of social approval when there was a stronger personal

approval of drug use, or surprisingly when physicians’diagnostic efforts were higher. The feig ning

willingness was lower in situations of social disapproval and when personal morality disapproved

of feigning. Thus, personal and situational characteristics are relevant to understand both

behaviors.

Keywords

feigning symptoms, nonmedical use of prescription stimulants, injunctive norms, personal

morality, cognitive enhancement, factorial survey design, attention-def‌icit/hyperactivity

disorder, narcolepsy, malignering

1

University of Erfurt, Germany

2

Bielefeld University, Germany

3

University of Cologne, Germany

4

Institut de Recherches Cliniques de Montr´

eal, Montreal, QC, Canada

5

University of Erfurt, Germany

Corresponding Author:

Sebastian Sattler, Institute of Sociology and Social Psychology, University of Cologne, Universitaetsstrasse 24, Koln 50931,

Germany.

Email: sebastian.sattler@uni-bielefeld.de

Introduction

Prescription drugs are an indispensable resource for curing illnesses and injuries and for the relief

of chronic symptoms. However, there is also a growing demand for the nonmedical use of such

drugs, for example, to get high, lose weight, or increase cognitive performance (Faraone et al.,

2020;Fuermaier et al., 2021;Hurst, Eassey, Baldwin, & Ten Bensel, 2021;Maier, Ferris, &

Winstock, 2018;Teter,DiRaimo, West, Schepis, & McCabe, 2020). Next to buying these drugs on

illegal markets, users try to obtain medications by feigning symptoms to get a prescription. Here,

feigning is def‌ined as the intentional production of “false or grossly exaggerated physical or

psychological symptoms”to gain external benef‌its, such as obtaining a prescription for desired

medications (American Psychiatric Association, 2000 p. 739). Although the exact prevalence of

malingering

1

or symptom exaggeration is diff‌icult to determine (ullah Alozai & McPherson, 2019;

Williamson et al., 2014), it was estimated to occur in 38.5% of mild head injury cases, 30.1% of

disability assessments, and 28.7% of personal injury cases (Mittenberg, Patton, Canyock, &

Condit, 2002). A Dutch study on college students found that the majority (57.1%) believed that

feigning attention-def‌icit/hyperactivity disorder (ADHD) symptoms is simple, while 2.2% had

already considered feigning them (Fuermaier et al., 2021). In the US and Canada, 15–48% of

college students that underwent an ADHD assessment showed signs of feigning symptoms

(Fuermaier et al., 2021;Harrison & Edwards, 2010;Marschall, Nolting, Hildebrandt, & Sydow,

2015;Sullivan, May, & Galbally, 2007;Williamson et al., 2014). Some authors argue such

feigning behavior may even be associated with the surge in stimulant prescriptions for adults

(Quinn, 2003;Williamson et al., 2014).

Individuals who have feigned symptoms and take the drugs without medical necessity risk

adverse side effects and long-term health consequences, such as addiction. These risks also occur

for other individuals who buy these drugs on the black market from feigners (Musso, Hill, Barker,

Pella, & Gouvier, 2016). This abuse of the health-care system dissipates the physicians’scarce

time needed for treating unhealthy individuals and often insurances cover the expenses for such

unnecessary treatment, summing up to several billion dollars per year in the United States alone

(Chafetz & Underhill, 2013). Feigning warrants further investigation because lying to physicians

can also complicate accurate diagnoses of individuals requiring treatment for actual ADHD

(Quinn, 2003).

Research found that motivations to feign symptoms include to obtain medical certif‌icates (e.g.,

to certify that one is unf‌it for school or work) or to obtain drugs to share and to use nonmedically

(Bass & Wade, 2019;Clegg-Kraynok, McBean, & Montgomery-Downs, 2011;Harrison, 2006;

Musso et al., 2016;Robitaille & Collin, 2016). Here, we focused on prescription stimulant drugs

developed to treat ADHD and narcolepsy, which are frequently misused nonmedically to enhance

cognitive functions (e.g., concentration or wakefulness) in school, university, at work, or during

leisure activities (d’Angelo, Savulich, & Sahakian, 2017;Leon, Harms, & Gilmer, 2019;Racine,

Sattler, & Boehlen, 2021;Racine & Forlini, 2009;Singh, Bard, & Jackson, 2014). The psy-

choactive properties of these stimulant drugs (such as modaf‌inil and methylphenidate) make them

attractive for enhancement purposes (Battleday & Brem, 2015;Robitaille & Collin, 2016).

This misuse of prescription stimulants has received much attention in research, ethics debate s,

and the media (Greely et al., 2008;Partridge, Bell, Lucke, Yeates, & Hall, 2011;Racine et al.,

2021). Researchers have frequently discussed the implied moral issues and potential increases in

prevalence rates (Baum, Sattler, & Reimann, 2021;Caviola & Faber, 2015;Maier et al., 2018;

Sahakian et al., 2015;Sattler, Sauer, Mehlkop, & Graeff, 2013, p. 20; Schelle et al., 2014). The

sources for obtaining enhancement drugs, however, need to be better researched—especially the

prevalence and conditions of obtaining such drugs through feigning symptoms while at the

physician’soff‌ice (Aikins, 2011;Faraone et al., 2020;Novak, Kroutil, Williams, & Van Brunt,

226 Journal of Drug Issues 52(2)