Malingering: Key Points in Assessment

Figure. Guide to help distinguish malingering, factitious disorders...

The assessment of malingering presents a significant challenge for mental health clinicians. The traditional clinician-patient relationship is based on the assumption that a patient is in genuine need of treatment, so clinicians may feel uneasy about initiating malingering assessment. This uneasiness is understandable given the potential for escalation of an individual's behavior when confronted with the clinician's suspicions of malingering,^1,2 not to mention the rare potential for lawsuits alleging malpractice following a diagnosis of malingering.^3-5

Mental health clinicians are nevertheless likely to encounter cases of malingering. Mittenburg and associates⁶ reported that in a recent study of 33,531 cases seen by members of the American Board of Clinical Neuropsychology during a 1-year period, probable malingering and symptom exaggeration were found in 30% of disability evaluations, 29% of personal injury evaluations, 19% of criminal evaluations, and 8% of medical cases. This is consistent with earlier studies on base rates of malingering identified during mental health evaluations.^7,8

While forensic settings in general harbor higher base rates of malingering, some clinical settings, such as those in which compensation-seeking veterans receive evaluation/treatment for posttraumatic stress disorder (PTSD), may have rates that approach or exceed base rates enumerated in forensic settings.⁹ Therefore, mental health clinicians should have familiarity with key points in malingering assessment.

HISTORICAL BACKGROUND
Malingering was documented in biblical times. David "feigned insanity and acted like a madman" to avoid a king's wrath (1 Samuel 21:11-16). In 1843, malingering found its way into the English medical literature.¹⁰ Four years later, a French surgeon described the use of ether to distinguish feigned from real disease.¹¹ In the late 19th century and early 20th century, the introduction of worker's compensation led to numerous pejorative terms such as compensation neurosis to describe suspected malingering.¹² During World War II, the British dropped pamphlets over German troops instructing them how to feign injury in order to obtain military leave.¹³ Recently, a German CD-ROM named the "Sickness Simulator" was available for purchase on the Internet; the program instructed employees on how to malinger in order to obtain sick leave.¹⁴

DEFINITIONS AND SUBTYPESDSM-IV-TR defines malingering as the "intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs." Malingering is not a psychiatric disorder; DSM-IV-TR includes it in the section "Other Conditions That May Be a Focus of Clinical Attention."

Resnick¹² comments on potential subtypes of malingering: pure malingering involves complete fabrication, partial malingering involves exaggeration of existing symptoms, and false imputation occurs when an evaluee intentionally attributes symptoms to a cause that has little or no relationship to the development of the symptoms.

Malingered conditions
Malingered psychiatric conditions may include dissociative identity disorder,¹⁵ psychosis,¹⁶ suicidality/mood disorders,¹⁷ and PTSD.¹² Malingered conditions that cross the spectrum of psychiatry and neurology include acute dystonia,¹⁸ amnesia,¹⁹ cognitive deficits,²⁰ dementia,²¹ seizure,²² and sleep disorder.²³ In addition, there have been several case reports of "malingering by proxy" in the pediatric setting.^24,25

Psychiatric disorders that may be mistaken for malingering
Both malingering and factitious disorders involve feigning of physical or psychological illness. The motivation for feigning associated with factitious disorders is a desire to assume the sick role rather than an obvious external incentive such as disability payments.²⁶ In malingering, external incentive should be tangible. An example is a case in which a criminal defendant feigns mental illness in an attempt to be designated incompetent so as not to be executed.²⁷ On the other hand, a patient with factitious disorder who repeatedly injects insulin to induce hypoglycemia may jeopardize his or her own well-being-a high personal cost just to assume the sick role.

Mental health clinicians should also consider somatoform disorders in the differential diagnosis when a question of malingering is raised.¹ Furthermore, clinicians should be careful not to ascribe atypical presentations to feigning before considering a workup to rule out causes for atypical presentations, such as syndromes occurring secondary to drug ingestion or secondary to an occult medical condition. A simplified guide may be helpful in making this differentiation (Figure).

Models of malingering behavior

The adaptational model of malingering proposed by Rogers²⁸ asserts that malingerers engage in a "cost-benefit analysis" during assessment. "Malingering is more likely to occur when (1) the context of the evaluation is perceived as adversarial, (2) the personal stakes are very high, and (3) no other alternatives appear to be viable." In the context of this model, individuals malinger based on their estimate of success in obtaining the desired external incentive.

According to DSM-IV-TR, malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medicolegal context of presentation; (2) marked discrepancy between the person's claimed stress or disability and the objective findings; (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen; and (4) the presence in the patient of antisocial personality disorder (ASPD).

There has been debate about whether DSM-IV-TR's "singling out" of individuals with ASPD is appropriate.^29,30 Research in this area suggests that limiting the consideration of malingering only to those with ASPD will result in significant underdetection.¹

Financial incentive and Malingering
Individuals who are seeking some form of compensation are commonly believed to be more likely to exaggerate symptoms. Four recent studies found a positive correlation between financial incentive and the likelihood of malingering or exaggeration.^9,31-33 One study even proposed a dose-response relationship between the level of financial incentive and the likelihood of malingering or exaggeration.³³

MALINGERING ASSESSMENT
The clinical interview
The clinical interview is critical in the assessment of malingering, and Cunnien's threshold model for consideration of malingering³⁴ forms the basis for a suggested screening guide (Table 1). If certain factors trigger suspicion of malingering, clinicians should be cautious in how they frame questions, avoiding leading questions that might give evaluees clues about how a genuine syndrome manifests itself.³⁵ Rather, clinicians should rely at first on open-ended questions. After evaluees have been given a chance to report symptoms in their own words, clinicians can ask specific, detailed questions that help to characterize symptoms as typical or atypical. Table 2 includes some characteristics of atypical hallucinations as well as other clinical clues to be considered when malingered psychosis is suspected.

Clinicians should be aware that malingering often takes great effort on the part of the evaluee; therefore, some malingerers will tire the longer the interview lasts. Clinicians should be prepared to set aside the time it takes to conduct a thorough interview, while taking particular note of discrepancies between claimed deficits and actual abilities exhibited during the interview or as reported by collateral informants. For instance, in malingered cognitive deficits, an evaluee may spontaneously name items in a room, such as a clock, a fan, or a cell phone, but then appear perplexed upon direct presentation of a task requiring them to name a pen or a watch. Clinicians should have a heightened awareness for such discrepancies, because this information, along with other data, may later support an opinion of malingering.

Clinicians should further rely on clinical experience with genuine patients to recognize an abnormal pattern of self-reported symptoms. Rogers³⁶ also encourages clinicians to be on the watch for endorsement of an unusually high number of symptoms that are rare, blatant, absurd, and nonselectively endorsed. Rare symptoms are valid symptoms that are infrequently reported by psychiatric evaluees. Blatant symptoms are immediately recognized by nonprofessionals as indicative of severe psychopathology. An example of such is an individual who presents to an emergency department reporting that he is suicidal, homicidal, and hearing voices telling him to kill himself and other people. Improbable or absurd symptoms are almost never reported or affirmed, even in severely disturbed evaluees. An individual who endorses the belief that "honeybees are involved in a plot to kill the president" is demonstrating an improbable and absurd symptom. Nonselective endorsement of symptoms refers to a strategy used by malingerers based on the belief that the more symptoms endorsed, the more likely they are to be assessed as ill.¹

After the clinical interview, some clinicians may feel they have ruled out malingering. Others may find clues that heighten their suspicion. Those clinicians should consider proceeding further using the following techniques.

Collateral information
Clinicians should search for collateral information that supports or refutes the evaluee's self-reports. Such data may include previous treatment records and forensic evaluations, interviews of collateral informants familiar with the evaluee (including nurses, other clinicians, or family), personnel files, information gathered by an insurance agency to investigate a claim, depositions, surveillance tapes, police reports, and witness statements. Clinicians who have access to these data are at a great advantage when coming to conclusions about malingering.¹ Clinicians should document the records reviewed, records requested but not received, as well as records that the evaluee or other agencies refused to release for review.

Psychological testing
In addition to the availability of validity scales as part of standard personality measurement instruments (eg, Minnesota Multiphasic Personality Inventory-2 and Personality Assessment Inventory), there are a number of psychological instruments and structured clinical interviews that have been developed specifically for evaluating malingering. It is best for clinicians to consult with experienced evaluators to ensure that they use testing that will prove most helpful in the assessment process.

The Structured Interview of Reported Symptoms is a structured clinical interview that takes about 45 minutes to administer. It may be used to differentiate malingered schizophrenia and mood disorders from genuine presentations, and it has been used to investigate the feigning of other conditions, such as PTSD.³⁷

The Test of Memory Malingering (TOMM) is useful in assessing malingered memory deficits. This instrument can help determine whether a subject is intentionally responding in a manner to appear memory-impaired.

Numerous other tests are available, and malingering scales have even been incorporated into competency-to-stand-trial assessment instruments, specifically, in the Evaluation of Competency to Stand Trial-Revised.

Instruments intended to assess malingering are typically designed to minimize the number of false diagnoses of malingering on the principle that a false diagnosis is more harmful than a missed diagnosis. Therefore, some individuals who are malingering may evade detection with psychological testing alone, and clinicians should integrate all available data with test results viewed as one piece of that data set. Also, specific malingering tests may not differentiate a factitious disorder presentation from malingering, so the use of clinical judgment about motivations for feigning is necessary.

The clarification process
Some clinicians may wish to speak directly to the evaluee regarding evidence of feigning to further the assessment or to give the evaluee a chance to explain discrepancies. The statement, "Remember your ABCS" may be useful to clinicians who decide to seek clarification from evaluees:

• Avoid accusations of lying.
• Beware of countertransference.
• Clarification, not "confrontation."
• Security measures.

The latter is included because some malingerers may respond by escalating their behavior in an attempt to justify their self-reports; in extreme cases, this may take the form of physical aggression or self-injury.²

CASE VIGNETTEA 19-year-old jail detainee facing a felony charge related to auto theft was evaluated for competence to stand trial by a forensic evaluator in a jail-based setting. The evaluator noted that the evaluee spoke very little and "did not appear to be taking the evaluation seriously." After spending 15 minutes with the evaluee, the evaluator issued a brief report recommending that the defendant be committed to a forensic psychiatric hospital for further evaluation with a "primary rule-out diagnosis of malingering."

The forensic evaluator at the hospital noted that the evaluee was taking moderate doses of haloperidol and that he presented with what appeared to be prominent negative symptoms of schizophrenia. He had a markedly restricted range of emotional expression and very little spontaneous speech, but when he spoke, he did so in a linear fashion. The evaluee denied current hallucinations, did not speak with any delusional material being evident, and denied any history of psychotic symptoms.

A call to the jail's treating psychiatrist, who had prescribed haloperidol for the evaluee, confirmed that he had observed the evaluee in a "genuine" psychotic state about 3 months after his detainment. This included the appearance of "loose associations and neologisms that went away" following antipsychotic administration. A phone call to family members also brought up a pos- sible history of adolescent-onset psychotic symptoms.

Given the collateral information obtained, the current appearance of difficult-to-feign negative symptoms of schizophrenia, and the observation that the evaluee tended to deny all symptoms of mental illness or a history of such (as opposed to calling attention to psychotic symptoms or grossly exaggerating them), the hospital's forensic evaluator determined that the evaluee was not malingering psychosis.

On the other hand, the evaluee presented with cognitive deficits, such as a poor fund of knowledge, poor short-term memory, and a poor ability to calculate and spell. At times he seemed unmotivated to engage in attempts at competency restoration, such as legal rights education. A decision was made to assess the evaluee for feigned cognitive deficits. School records were obtained. This included intellectual testing conducted at the age of 12, before any history of criminal conduct, that revealed an IQ in the mild mental retardation range; intellectual testing repeated at the forensic hospital was consistent with the earlier record.

The TOMM was administered and did not yield evidence of feigned cognitive (memory) problems. After the hospital's treating psychiatrist changed his haloperidol medication to an atypical antipsychotic medication, there was a decrease in negative symptoms, an increase in spontaneous speech, and the evaluee became more cooperative in efforts at competency restoration. He was evaluated for competence to stand trial 10 weeks into his hospitalization, and despite valid cognitive deficits consistent with mild mental retardation, he was recommended competent to proceed. The forensic report addressed the question of malingering, stating that malingered psychosis and cognitive deficits had been assessed and reasonably ruled out. The defendant was found to be competent to proceed, pled guilty to a lesser charge, and was placed on probation under the supervision of the mental health court.

Many cases of malingered mental illness are available for review in the literature.¹ The case vignette was included to demonstrate that if key points in malingering assessment are adhered to, some cases of suspected malingering will in fact be ruled out.

SUMMARY
While malingering may present a challenge for mental health clinicians, those who attend to key points in malingering assessment (Table 3) should be well-equipped to formulate opinions about malingering in either clinical or forensic settings.