Malingering: Key Points in Assessment

Published on Psychiatric Times

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Malingering: Key Points in Assessment

April 15, 2007 | Forensic Psychiatry [1], Dissociative Identity Disorder [2], Munchausen Syndrome [3],
Risk Assessment [4], Somatoform Disorder [5]
By H. W. Lebourgeois Iii, MD [6]

The assessment of malingering presents a significant challenge for mental health clinicians.

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 SUBTYPES
DSM-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

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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-beinga 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.

TABLE 1
Guide to screening for
malingering

Atypical
presentation in
the presence of
tangible external
incentive or
noxious
environmental
conditions
Suspicion of
voluntary control

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over symptoms
as demonstrated
by: Bizarre or
absurd sy
mptomat
ology
Unusual s
ymptoma
tic
response
to
treatment
Atypical
symptomatic
fluctuation
consistent with
external
incentives
Complaints
grossly in excess
of clinical
findings
Substantial
noncompliance
with assessment
or treatment

Adapted from Cunnien AJ.

Clinical Assessment of
Malingering and Deception.
1997.35

TABLE 2
Clinical clues to malingered
psychosis*

Evaluee reports
hallucinations
and/or delusions,
but objective
signs of
psychosis (eg,
negative
symptoms,
distraction due to
hallucinations,
derailment,
thought blocking,
clang-bang
associations,
loose
associations,

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neologisms,
incoherence, or
perseveration)
are minimal or
absent
Auditory
hallucinations are
continuous rather
than intermittent,
vague, or
inaudible,38 or
spoken in stilted
language (overly
formal and not
paralleling the
normal
syntactical
structure used by
the evaluee)16
Evaluee has no
strategies to
diminish auditory
hallucinations16
Visual
hallucinations are
seen in black and
white38
Hallucinations
are not
associated with a
delusion39
Evaluee claims
that a delusion
suddenly
developed or
disappeared16
Content of a
delusion is
bizarre, but
evaluee does not
exhibit
disorganized
thinking16
In the context of
criminal
responsibility
evaluations, the
presence of a
rational,
alternative
motive for a
criminal act, an
extensive
previous pattern
of similar
criminal
behavior, or a
partner in crime
suggest

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malingering16

*No single factor listed

above is pathognomonic of
malingered psychosis.
Clinicians should consider
the above factors along
with the rest of the data set
and consider causes of
atypical presentations of
psychosis (eg,
substanceinduced
psychosis or psychosis
secondary to a general
medical condition).

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

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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 VIGNETTE
A 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

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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.

TABLE 3
Key points in malingering
assessment

Consider
malingering in
the differential,
especially in
settings where
obvious external
incentives are at
play
During the initial
interview, be on
watch for
endorsement of
an unusually high
number of
symptoms that
are rare, blatant,
absurd,
preposterous,
and
nonselectively
endorsed
Be cautious in
the use of
leading questions
when
interviewing
evaluees
suspected of
malingering; use
open-ended
questions at the
outset of the
interview and
later ask detailed
questions that
help characterize
symptoms as

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typical or
atypical of the
mental illness in
question
Seek out and
review collateral
data for
consistencies or
inconsistencies
that help support
or refute
malingering; note
any records that
were requested
but not received
or that the
evaluee refused
to release for
your review
Consider use of
psychological
testing or
structured
clinical interviews
specifically
designed to
detect
malingering
when
assessment
results in a
suspicion but is
inconclusive in
determination of
malingering
If clarification is
sought from an
evaluee
regarding
inconsistencies in
self-reports or
other evidence of
feigning,
remember your
ABCS: Avoid
accusations of
lying; Beware of
countertransfere
nce; Clarification,
not
confrontation;
and Security
measures
Establish or rule
out malingering
on the basis of an
assessment that
integrates many
sources of

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information

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.

Source URL:
http://www.psychiatrictimes.com/forensic-psychiatry/malingering-key-points-assessment

Links:
[1] http://www.psychiatrictimes.com/forensic-psychiatry
[2] http://www.psychiatrictimes.com/dissociative-identity-disorder
[3] http://www.psychiatrictimes.com/munchausen-syndrome
[4] http://www.psychiatrictimes.com/risk-assessment-0
[5] http://www.psychiatrictimes.com/somatoform-disorder
[6] http://www.psychiatrictimes.com/authors/h-w-lebourgeois-iii-md

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