Malingering
Anthony Cozzolino, M.D.
I. Objectives
A. To understand how malingering is defined
B. To differentiate various forms of malingering
C. To review basic strategies in detecting malingering
D. To gain an understanding of objective tests used for detection of malingering
II. Definitions
A. Webster’s: To pretend incapacity so as to avoid work or duty
B. DSM III: Classified as Condition Not Attributable to a Mental Disorder that is Focus of Clinical Attention or Treatment
C. DSM IV: 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
1. strongly suspect if:
a. medical-legal context of presentation
b. marked discrepancy between reported symptoms and objective findings
c. lack of cooperation with evaluation or treatment regimen
d. presence of Antisocial Personality Disorder
III. Differential Diagnoses
A. Actual Illness
B. Factitious Disorders
C. Somatoform Disorders
IV. General Considerations
A. Underreported
1. hesitation to label
2. concerns over liability
3. fear of generating anger in accused
4. traditional reliance on truthfulness in clinical practice
B. Most commonly malingered disorders
1. psychosis
2. cognitive deficits/amnesia
3. depression with suicidality
4. PTSD
V. Prevalence
A. Unclear due to underreporting
B. Criminal Defendants: 10-20%
C.
VI. Subtypes/Forms of Malingering
A. Simulation/Pure Malingering
1. “Faking bad” or “positive malingering”
2. attempting to deceive or manipulate in a pathological direction
3. feigning symptoms that do not exist or are grossly exaggerated
B. Dissimulation
1. attempting to manipulate in a non-pathological direction
2. “Faking good”
C. Partial malingering - conscious exaggeration of existing symptoms
D. Staged events – planning an event with desired result of actual injury
E. Data tampering – manipulating records to simulate a disorder (e.g. adding substance to lab test)
F. Opportunistic malingering – exploiting naturally occurring event or pre-existing condition for secondary gain
G. Symptom invention – consciously complaining of symptoms not caused by actual injury or pre-existing condition
H. Ganser’s Syndrome – providing approximate answers to questions
VII. Evaluation of Malingering – General
A. Clearly understand genuine illness characteristics
B. Ascertain motivations to malinger
C. Distinguish motivation to malinger from actual illness
D. Obtain objective tests if possible (e.g. labs)
E. Obtain collateral information
F. Observations when individual unaware (e.g. dayroom on unit)
G. 3-question framwork:
1. Does individual exhibit “classic signs” of malingering?
2. Does individual have foreseeable motive motive or believe would gain from illness?
3. Could actual illness be present which appears consciously produced? If so, is it exaggerated?
VIII. General Clinical Indicators of Malingering
A. Abnormality occurs in particular context
B. Changes in speech
1. may be more accurate than facial expressions
2. basis of Voice Stress Analysis
3. higher pitch
4. errors of grammar
5. “slips of the tongue”
C. Overacting, overly dramatic
1. abrupt onset and offset of symptom
2. distinguish from Cluster B personality
D. Eager to call attention to symptoms
E. Symptoms do not fit particular diagnostic category, span multiple diagnoses
F. Pausing before responding, answer slowly
IX. General Interview Techniques
A. May require being cunning, allowing individual to abandon role
B. Interview should involve frequent changes in direction and pace
C. Longer interviews more conducive to detecting malingering
D. In forensic settings, see defendant shortly after incident
X. Specific Disorders - Psychosis
A. Psychosis (hallucinations, delusions)
1. critical to ascertain details
2. determine if uses mechanisms to diminish symptoms: exercise/walking, listening to music, watching TV, contacting others
B. Actual hallucinations
1. generally intermittent
2. both male and female voices
3. both familiar and unfamiliar
4. more commonly outside of head
5. clear rather than vague
6. worse in isolation
7. unaffected by eyes open or closed (visual)
C. Malingered symptoms
1. unlikely to show negative symptoms: blunted affect, concrete thinking, poor relatedness
2. rarely demonstrate tangentiality, neologisms
3. more often dramatic/grandiose, less often self-deprecatory
4. sudden onset and offset
5. respond to all commands
XI. Specific Disorders – Amnesia
A. cognitive impairment common following actual head injuries/accidents- commonly malingered
B. malingered symptoms show apparent self-serving timing and recovery of symptoms
C. amnesia specific for particular incident/offense rather than global- may recall events following and prior
XII. Specific Disorders – PTSD
A. emphasize more dramatic symptoms – nightmares, flashbacks, hyperarousal
B. less commonly demonstrate avoidance, social withdrawal
C. may report inability to work but demonstrate normal social functioning
D. may call attention to previous high functioning to reported injury
E. poor compliance with treatment recommendations
XIII. Assessment Tools
A. MMPI-2
1. F-K scale – higher value = increased likelihood of malingering
2. F score alone – valid if score >100
B. Rey 15-item test
C. Structured Interview of Reported Symptoms (SIRS)
1. systematically assesses deliberate distortion of symptoms
2. high sensitivity and specificity
3. 156 questions: No Answer, No, Sometimes, Definite Yes
4. Results in profile: honest, indeterminate, probably feigning, definite feigning
5. scores <71 = honest, >76 definite feigning
D. Amytal Interview (“Truth Serum”)
1. most commonly used in catatonia, hysteria with mutism or stupor, to recover memories in dissociative/fugue states
2. often used in conjunction with hypnotherapy
3. allows individual to talk about repressed memories
4. considered unreliable in detecting malingering – can maintain lie under amytal effect
E. Polygraphy
1. used by law enforcement including FBI
2. based on emotional and physiological effects of lying (hyperarousal)
3. requires extensive preparation of test questions
a. relevant questions (related to specific offense)
b. control questions
c. irrelevant questions (“are you sitting in a chair”)
d. not admissible in most jurisdictions– does not meet standards for presentation of evidence
XIV: Case presentation
XV. Conclusions