Malingering

OVERVIEW

malingering is an odd condition and not a true psychiatric diagnosis

it reflects more badness than madness

the historic methodology of psychiatry listening to and observing one's patients is oddly ineffective in detecting malingering

Mental illness is an age-old favorite of the malingerer.

HISTORY

issues of malingering appear to be as old as civilization.

Paolo Zacchias, wrote of madness, there is no disease more easily feigned, or more difficult to detect.

DEFINITION

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 should be strongly suspected if:

(1) medicolegal context of presentation (2) evident discrepancy between the individual'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

(4) the presence of antisocial personality disorder.

concept of a continuum

(1) degree of intentionality

(2) degree of symptom exaggeration

(3) degree of actual impairment (if any)

various degrees of malingering

Pure malingering

Partial malingering

False imputation

Misattribution

several forms of malingering

Simulation (referred to as faking bad and positive malingering).

Dissimulation (faking good, negative malingering, and defensiveness)

Staged events Data tampering Opportunistic malingering Symptom invention

EPIDEMIOLOGY

1 percent presence of malingering has been estimated among mental health patients in civilian clinical practice

rising to 5 percent in the military.

In a litigious context, during interviews of criminal defendants, the estimated prevalence of malingering is much higher between 10 and 20 percent

EPIDEMIOLOGY

malingering does appear to be highly prevalent in:

certain military, prison, and litigious populations

in Western society in men from youth through middle age

Associated disorders

Conduct disorder and anxiety disorders in children

antisocial, borderline, and narcissistic personality disorders in adults

Beck

Diseases are usually feigned from one of three causes:

Fear shame the hope of gain

patterns of malingering

Avoidance of CriminalResponsibility, Trial, and Punishment

Avoidance of Military Service or of Particularly Hazardous Duties

Financial Gain Avoidance of Work, Social Responsibility, and Social

Consequences Facilitation of Transfer from Prison to Hospital Admission to a Hospital Drug-Seeking Child Custody

The psychiatric conditions most likely to be malingered are:

mental retardation organic impairment amnesia psychosisposttraumatic residua, including

depression and posttraumatic stress disorder (PTSD).

DETECTION OF MALINGERING

every effort should be made to interview the criminal shortly after the event

the clinical interview should be long and detailed

Detecting Deception

liars often speak in high-pitched voices, make errors of grammar, and make slips of the tongue ; hesitatation or pause while lying and tend to make irrelevant, rambling, and negative comments

The passive voice is more common than the active, discrepancies between verbal and nonverbal expression

answers may appear rehearsed, overly facile, and rote many spontaneous assurances of veracity, such as

Would I tell you a lie? or To be perfectly honest facial expression and eye contact are generally poor

indicators of truthfulness

Malingered Mental Deficiency or Mental Retardation

1. Striking discrepancy between level of education and level of intelligence

2. Striking discrepancy between military and employment records and presenting behavior and test performance

3. Striking discrepancy between adult test performance and prior pattern of test performance

4. Failure on easy items and success on difficult items during evaluative testing

5. Incongruity of vocational and social performance with presentation capabilities

Malingered Cognitive Disorders

1. Lack of marked perseveration

2. Implausible symptom profile given reported injury

3. Psychotic symptoms confused with cognitive impairments

4. Unimpaired function in social and recreational realms in the face of gross disability

Malingered Amnesia

At least six possible causes have been suggested for amnesia:

(1) conversion disorder (2) psychosis (3) alcoholism (4) head injury (5) epilepsy (6) malingering

Malingered Amnesia

1. No history of amnestic episodes2. Antisocial personality traits more

prominent than histrionic personality traits

3. Spotty, episode-specific amnesia rather than global amnesia

4. Recent, widely publicized, suspiciously familiar cases involving amnesia

Malingered Psychosis

Malingerers tend to overact their part, often mistakenly believing that the more bizarre they appear, the more convincing they are

Schizophrenic patients tend to be reluctant to discuss their symptoms

malingerers may be anxious to call attention to their illnesses

The form of schizophrenic thinking (a formal thought disorder) is far more difficult for malingerers to imitate than is its content

Unsophisticated malingerers often confuse madness with dumbness ; silly or childlike responses

Features of Malingered Delusions

1. Abrupt onset and termination rather than gradual development and hesitant abandonment

2. Eagerness to call attention to delusions and symptoms rather than reluctance to acknowledge them

3. Behavior inconsistent with delusional content rather than reflective of delusional content

4. Thought content grossly disturbed in the face of conventional and goal-directed thought process

True hallucinations

tend to be associated with delusions frequently report that voices speak directly to them or

pass judgment on them tend to be intermittent rather than continuous more than 50 percent of schizophrenic individuals

eventually acknowledge that they may have imagined their hallucinations

The visual hallucinations almost always accompany the auditory hallucinations

Visual hallucinations tend to be in color and of normal-sized people

olfactory hallucinations are of unpleasant odors and are extremely rare

True hallucinations

Eighty-eight percent of schizophrenic individuals report that auditory hallucinations come from outside the head, and 75 percent report that they hear both male and female voices.

The message is usually clear is accusatory approximately one-third of the time Approximately 30 percent of schizophrenic individuals

answer the voices they hear Most truly psychotic individuals have developed

strategies for coping with hallucinatory episodes

Malingered Auditory Hallucinations

1. Continuous rather than intermittent2. Vague, inaudible, or unintelligible rather than distinct3. Free-standing rather than associated with delusions4. Stilted in language and specific in tone rather than

basic and general5. Reported in the first person rather than in the third

person6. Uncontrollable rather than susceptible to strategies

for containment7. Irresistible rather than susceptible to indifference

Malingered Posttraumatic Symptoms

Much more common are claims of depression and, now that it has become widely publicized, of PTSD

Factors Suggesting Malingering of Psychological Distress after Trauma

1. Assertion of inability to work in the face of unimpaired capacity for pleasurable activity

2. Subscription to more obvious symptoms of widely publicized disorders in the face of denial of more subtle features

3. Refusal to comply with recommended diagnostic or treatment procedures; avoidance of direct examination

4. Traits common to antisocial, narcissistic, borderline, or histrionic personality disorders

5. Energetic and concerted pursuit of legal claim in the face of alleged debility caused by depression and posttraumatic stress disorder

6. Self-depiction in excessively favorable and capable terms before alleged trauma and behavioral collapse

Objective Testing

Polygraph: is not foolproof; at best, it is 80 to 90 percent reliable

Amobarbital and hypnotic techniques: Approximately 50 percent of tested persons are able to maintain a lie under either of these relaxation techniques

Psychological testing

MMPI-2 :the F K scale is a significant indicator Higher scores on the F K index suggest a

greater likelihood that the subject is malingering overall.

With an F K index of +10, one would be correct approximately 97.5 percent of the time to assume that the entire MMPI-2 profile was malingered.

Psychological testing

the Personality Assessment Inventory (PAI)

The Validity Indicator Profile (VIP) The Structured Interview of Reported

Symptoms (SIRS)Neuropsychological testing ( the

Halstead-Reitan)

DIFFERENTIAL DIAGNOSIS

actual physical or psychiatric illness It should also be remembered that a real psychiatric disorder and

malingering are not mutually exclusive

partial malingering

factitious disorder external incentives are absent Evidence of an intrapsychic need to maintain the sick role somatoform disorders lack the volitional component of malingering an underlying emotional conflict No external environmental outcome or reward is consciously sought

COURSE AND PROGNOSIS

In the absence of concurrent diagnoses, once the rewards have been attained, the feigned symptoms disappear

In some structured settings, such as the military or

prison units, ignoring the malingered behavior may result in its disappearance

In children, malingering is most likely associated with a

predisposing anxiety or conduct disorder; proper attention to this developing problem may alleviate the child's propensity to malinger.

COURSE AND PROGNOSIS

Malingerers are unlikely to comply with disorder-specific treatments

they are confronted with their malingering directly, they are likely to seek out other doctors

the more the malingering has been reinforced, the more likely it is to recur.

Successful malingerers are apt to malinger repeatedly throughout their lives

TREATMENT

a careful differential investigation should ensue the patient should be tactfully but firmly confronted

with the apparent outcome

the reasons underlying the ruse need to be elicited and alternative pathways to the desired outcome explored

Coexisting psychiatric disorders should be thoroughly assessed