Title Detecting the malingering of psychosis in offenders: No easy solutions.

Authors Fauteck, Paul KarstenFrom Criminal Justice & Behavior Mar95, Vol. 22 Issue 1, p3 Peer

ReviewedDatabase Academic Search Elite

DETECTING THE MALINGERING OF PSYCHOSIS IN OFFENDERS: NO EASY SOLUTIONS

The feigning of a major mental illness is especially likely to occur in criminal forensic contexts. In particular, malingered psychosis is appealing to defendants and often troublesome for examiners. In spite of major improvement in both clinical interviewing techniques and psychological tests (the examiner's main defenses against deception), there is still no foolproof detection method. The author discusses the strengths and weaknesses in common approaches, the most recent innovations, and recommends an eclectic approach to forensic examinations, as well as special sensitivity to the problem of false positives.

Although the behavior currently known as malingering has "from time immemorial . . . attracted the attention of physicians" (Jones & Llewellyn, 1918, p. 8), it was virtually ignored in the literature of psychology and psychiatry until conscription problems of World War II spurred a renewal of interest (e.g., H. Goldstein, 1945; Hunt, 1946; Hunt & Older, 1943). The military service generally was seen as the most likely forum for the playacting of mental disorders (Eissler, 1951; Szasz, 1957).

Early texts (e.g., Jones & Llewellyn, 1918) made no distinction between malingering and what would now be called a factitious disorder. The crucial distinction is whether the objective is (a) a readily identifiable external gain (malingering) or (b) a pathological need to play the patient role (factitious disorder; American Psychiatric Association, 1987). By definition, therefore, malingering is dependent on circumstances and qualifies as a state rather than trait condition, whereas factitious disorders can more reasonably be considered trait conditions.

Bleuler likely was the first theorist of modern times to consider malingering itself to be a sign of serious mental illness (Bash & Alpert, 1980). This view generally was held in the behavioral sciences (Eissler, 1951; Rome, 1970) until as recently

as Hay (1983), who stated that "the simulation of schizophrenia is a prodromal phase of the psychosis occurring in extremely deviant premorbid personalities" (p. 8). In general, however, current opinion holds that malingering behavior is not, in itself, a sign of mental illness and even can be adaptive under some circumstances (American Psychiatric Association, 1987; Rogers & Cavanaugh, 1983), although it can coexist with mental illness (Gorman, 1982). Rogers (in press) found, in fact, that only 3.4% of experienced forensic examiners favored a pathogenic model of malingering. Descriptions of malingering given by the same sample of experts loaded most on an adaptational and a criminologic factor.

Currently, it is in psycholegal contexts, rather than in the military, that malingering is considered most likely to occur. Forensic issues are referred to in virtually every contemporary study of malingering (e.g., Perry & Kinder, 1990; Schretlen & Arkowitz, 1990). The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) referred to a forensic context and the presence of an antisocial personality disorder (APD) as two factors that should heighten an examiner's sensitivity to malingering, although Rogers, Gillis, and Bagby (1990) proposed that it is the adversarial nature of a forensic examination rather than the presence of APD that sets the stage for deceit on the examinee's part.

Fine-tuning our ability to detect malingering through research presents some unique problems. Among these is the fact that, unlike the quintessential schizophrenic or bipolar, the successful malingerer rarely will be identified. Obtaining samples of malingering subjects presents serious difficulties (Hawk & Cornell, 1989). As Grossman, Haywood, and Wasyliw (1992) noted, "forensic patients are not likely to admit to dissembling, and no other 'gold standard' has been devised" (p. 267). In a penal psychiatric unit or a forensic unit of a mental hospital, once the malingerer is positively identified, in most cases he or she is soon thereafter transferred and in any event is not likely to become a cooperative research subject. Most studies use cooperative simulators as stand-ins for (uncooperative) malingerers (Hawk & Cornell, 1989), and "there are likely to be significant differences between normal populations responding under deviant set instruction, and real defendants . . . facing criminal charges" (Heilbrun, Bennett, White, & Kelly, 1990, p. 45).

To complicate matters further, what normally would be considered good research practice may, because of the possible consequences for the examinee, lead to unacceptable results in the diagnosis of malingering in forensic settings (Blau, 1984; Melton, Petrila, Poythress, & Slobogin, 1987). Although at least one behavioral scientist has proposed that malingering, like any other diagnosis, be accepted if it appears to be the most probable explanation of our observations (Ziskin, 1984), in a criminal forensic context this could result in a person not responsible for his or her actions being condemned to prison or perhaps death, or an innocent defendant being sent to trial and convicted because he or she was not mentally competent to stand trial at the time. The most responsible policy,

then, is to follow the advice of Brussel and Hitch (quoted in Davis & Weiss, 1974) that malingering should be the first diagnosis considered but the last to be accepted.

These factors seriously diminish the value of much research. For example, if a study were to find a 75% hit rate with a 20% false positive rate, it might well qualify statistically as an outstanding success. In practice, however, any incidence of false positives is extremely bothersome (Rogers, Bagby, & Dickens, 1992). References to specific studies, below, demonstrate the pervasiveness of this problem.

DETECTION TECHNIQUES

THE CLINICAL METHOD

After police captured serial killer David Berkowitz, alias Son of Sam, the press readily accepted his account of demons commanding him through a neighbor 's dog. Two psychiatrists and one psychologist declared him psychotic and unfit to stand trial. One experienced forensic psychiatrist dissented and presented a compelling argument that convinced the judge. Berkowitz later recanted his story of demons and talking dogs and admitted that these, along with his conveniently timed "psychotic" outbursts, were contrived in the hope of avoiding prison (Abrahamsen, 1985).

Although observation and interview constitute the clinician's default approach for any assessment, Bash and Alpert in 1980 decried the crudeness of this method:

At present, the "state of the art" is such that these suspected malingerers are commonly detected by rather vague clinical intuitions, more or less influenced by observations and interpretations of patient behavior as (perhaps selectively) observed by nursing personnel and by certain exaggerated or incongruous aspects of patient behavior. (p. 86)

In criminal forensic contexts, it is usually the malingering of a schizophrenia-like illness that poses the greatest challenge to evaluators. One reason is that inconsistent behaviors are characteristic of the illness, so the examiner has the unfortunate task of distinguishing between expected and unexpected abnormalities. Furthermore, most other disorders are less opportune. Few malingerers can feign vegetative signs of depression, and mania is virtually impossible to simulate (Quinn & Resnick, 1985). Simulated dementia often can be detected on objective intelligence tests and has been studied longer and more extensively than most forms of simulation (H. Goldstein, 1945; Hunt, 1946; Hunt & Older, 1943). Malingered amnesia has typical earmarks (Quinn & Resnick, 1985), and, in any event, amnesia offers little value in an insanity defense (Parwatiker, Holcomb, & Menninger, 1985). Several recent studies (Frederick & Foster, 1991; Hiscock & Hiscock, 1989) have focused on the relative ease of

identifying fabricated or exaggerated cognitive deficits when examinees perform at worse than chance levels on objective tests.

Forensic examiners sometimes see incidents of malingerers going undetected through repeated interviews (e.g., N. Goldstein, 1989). Many symptoms are easy to fake, and the interview methods required can be complex and time-consuming. During the 1980s, a handful of specialists (e.g., Lees-Haley, 1984; Quinn & Resnick, 1985; Resnick, 1984, 1988; Resnick & Quinn, 1988; Rogers, 1988; Rogers & Cavanaugh, 1983; Rogers & Resnick, 1988) began to provide detailed guidelines for the clinical detection of malingering. With an eye to the various red flags they have pointed out, today's forensic examiners are better equipped to distinguish between true and feigned or exaggerated psychosis, but the problem of lengthy interviews that must be performed by skilled clinicians remains. Hartings (1989) eloquently conveyed the complexity of clinical detection by challenging forensic psychologists to "play sleuth in the labyrinth of the mind" (p. 232).

Cornell and Hawk (1989) presented a cataloging of 22 characteristics that differ significantly between defendants diagnosed as psychotic and those diagnosed as malingering by experienced forensic psychologists. Rogers' Structured Interview of Reported Symptoms (SIRS; Rogers, Gillis, & Bagby, 1990) may offer a major improvement over unstructured interviews. The SIRS was able to identify 84.6% of simulators who had been coached on characteristics of psychosis (Rogers, Gillis, Bagby, & Monteiro, 1991) although it should be noted that simulators in this study were college students, not subjects from a forensic sample. But one study found no difference between simulators and diagnosed malingerers on the SIRS (Rogers, Gillis, Dickens, & Bagby, 1991). The interpretation of SIRS scores is relatively complex, and the wording of the items is likely to be a problem for less intelligent subjects. Also, the instructions for the instrument specify the addition of independent corroboration to diagnose malingering (Rogers, Bagby, & Dickens, 1992). Nonetheless, the SIRS clearly represents an improvement over unstructured interviewing.

Numerous problems have been noted with the clinical interview method; space permits only a few examples here. Some people are characteristically nervous and self-conscious or emit atypical gestures, which may be labeled as signs of fabrication (Ekman, 1985). Some people's behavior changes at crucial points because of emotional sensitivity to the subject matter (Quinn & Resnick, 1985). Some emotional discrepancies such as the hysteric's la belle indifference are characteristic of the disorder but may be taken as deception clues. Multiple sclerosis often is mistaken for faking (Gorman, 1981). An examinee changing his account of a past event over time is certain to raise a red flag, but empirical studies indicate that it is normal for memories of emotion-laden events to include fantasies and confabulations and to be inaccurate and easily influenced, and for distortions to increase over time even as subjects become more convinced of their accuracy (Rogers & Cavanaugh, 1983).

The set of behaviors known as Ganser syndrome presents its own unique dilemma. In 1897, Ganser described a phenomenon wherein the subject gives answers that are approximate, that is, almost but not quite right (Epstein, 1991). This obviously smacks of malingering, and is especially likely to be so labeled because of its irritating effect on the examiner. A review of recent literature, however, leads to a conclusion that Ganser's may be a sign of malingering, but also may be associated with neurological impairment, including dementia, psychosis, and dissociation (Heron, Kritchevsky, & Delis, 1991; Kluft, Steinberg, & Spitzer, 1988; Signal, Altmark, Alfici, & Gelkopf, 1992; Weller, 1988).

Another problem is that detection via observation requires a high level of objectivity, but Szasz (1957) called it hypocrisy to maintain that examiners can be unbiased, citing comments dating back at least to Bleuler regarding biases inherent in the examiner's position. In summary, regardless of how sophisticated interview methods become, there continues to be a need for malingering-sensitive psychological tests (N. Goldstein, 1989).

PROJECTIVE TESTS

There is disagreement (Anastasi, 1982; Ziskin, 1984) as to whether projective tests are superior or inferior to objective measures in the detection of malingering. The Rorschach stands, predictably, at the center of this disagreement.

Rorschach declared in 1921 that people could fake content but not structural qualities, according to Fosberg (1938), who also claimed to have demonstrated that the technique was immune to faking. According to Perry and Kinder (1990), however, many researchers have pointed out the serious misuse of statistical analyses in this and other Fosberg studies.

Subsequent Rorschach studies produced a mixed bag of results, and generally employed test-retest designs with nonpsychotic subjects; similarity of faked profiles to those of a criterion group largely was untested. Carp and Shavzin (1950) used a modification of Fosberg's test-retest studies and found that only Z-scores differed. Feldman and Graley (1954) found that fake-bad groups produced elevated scores on Rorschach m, CF+C, and FC indices, increased sex and anatomy content, and decreased frequency of popular responses. In interviews, their subjects reported specific strategies, such as avoiding the obvious responses and stressing aggressive and gory concepts. Later Rorschach studies usually compared experimental fakers with diagnosed psychotics, typically using orthodox Exner scoring. Seamons, Howell, Carlisle, and Roe (1981) concluded that form quality and Lambda within normal limits, in combination with a high number of special scores and theatrical responses, suggest faking bad. The generalizability of their study, however, is questionable because it involved only one judge. The most devastating study was conducted

by Albert, Fox, and Kahn (1980), who found that reputed Rorschach experts performed worse than chance at distinguishing faked from psychotic protocols. The authors concluded that their judges may not have used standard scoring procedures. Exner (1978, 1991) claimed to have demonstrated that making Rorschach responses appear superficially bizarre is relatively simple, but that elevation via simulation beyond a score of 4 on the Exner Schizophrenia Scale is next to impossible.

On the other hand, Kahn, Fox, and Rhode (1988, 1990) reported limited evidence that even a properly scored Rorschach can be faked. In their simulation study, the only protocol labeled clearly invalid by a computerized assessment came, in fact, from a diagnosed schizophrenic. Perry and Kinder (1990) have pointed out intrinsic research problems with the Rorschach, including the fact that a reduction in the number of responses, which typically occurs in malingering, affects many other variables, and that the hallmark of the test, the great latitude in response style it permits, complicates systematic differentiation between faked and psychotic profiles.

The Bender-Gestalt has seen limited use in malingering research, for example, by Bash and Alpert (1980), who employed Bender's original malingering indices and, more recently, by Schretlen and Arkowitz (1990) with modifications of the same indices. The latter study identified five Bender-Gestalt scores sensitive to faking, two of which contributed (along with a specially designed malingered retardation scale and two MMPI validity indices) to a discriminant function for the faking of both psychosis and retardation.

Although projective drawings make up one of the most common diagnostic techniques currently in use, except for his own study (Fauteck, 1994), the author found no studies using the Draw-a-Person test (DAP) in the detection of malingered schizophrenia. Rogers' (1988) very thorough book did not contain a single reference to the DAP, although, because of the subtlety of its indices, one would expect it to be fertile ground for exploration. A single faking study found by the author included the DAP among other tests involving aggressiveness in an offender population (Posey & Hess, 1984).

Both Anastasi (1982) and Stermac (1988) reviewed studies that found examinees could alter Thematic Apperception Test (TAT) stories at will. Nevertheless, neither Rogers (1984) nor the present author could find any TAT malingering studies. This should serve as a caution to forensic examiners who use the TAT. Stermac (1988) conducted a study on the ability of college students to fake good or bad on the Group Personality Projective Test (GPPT), whose premises are similar to those of the TAT, but offered few firm conclusions.

Possibly the oldest projective technique, word association (WA), was described by Galton in 1879 (Anastasi, 1982) and discussed extensively in Jung's famous book, Studies in Word Association (1918). Normative responses have been

amazingly durable (Bowles, Williams, & Poon, 1983; Kent & Rosanoff, 1910). Given the salience of associative processes in schizophrenia and the continuing use of WA in research (e.g., Gordon, Silverstein, & Harrow, 1982; Mefford, 1979), it is surprising that the author could find no studies employing WA in the detection of malingering prior to Fauteck (1994).

OBJECTIVE MEASURES

Objective tests offer the obvious advantage of less ambiguous results, demanding fewer judgment calls by the examiner. Anastasi (1982) observed, however, that self-report inventories, which probably comprise the majority of objective tests, are particularly subject to faking and response set. Gorman (1981) told of a popular book from a few years ago that, he reported, included a chapter on how to cheat on such tests. Although the foremost of self-report inventories, the MMPI (and by inference the MMPI-2), has been described by Rogers (1983, p. 100) as "nearly perfect" in the detection of malingering, he based this opinion mostly on research performed in 1949. Lees-Haley (1989) also called the MMPI the most effective test to detect malingering, contending that the Rorschach is more vulnerable. The confidence evoked by the MMPI is due largely to the fact that it leads the field in the number and type of validity indices it incorporates (Anastasi, 1982; Greene, 1980). These include the well-known L, F, and K scales, the Dissimulation scale, F-K, and Subtle-Obvious scales.

Nevertheless, the MMPI and MMPI-2 cannot completely plug every possible malingering leak. For example, the MMPI is considered questionable for examinees with IQs of less than 80 (Greene, 1980); this takes in a large portion of the United States prison population. In a typical population of young offenders, about a third fall below this level (Quay, 1987), and one study (DeCato & Husband, 1984), using a sampling of psychiatrically hospitalized prisoners that excluded those with histories of brain damage, found the mean IQ score to be 79.4. Cornell and Hawk (1989), in fact, found that 50% of their MMPI profiles were unusable. Among the remaining 50%, the various indices they employed would have misidentified 18% of psychotics as malingerers. The problems of intelligence and reading ability may be somewhat less severe with the MMPI-2 (Greene, 1991).

Rogers (1983) reported that a random answer pattern on the MMPI would approximate closely a malingering profile on the Subtle-Obvious scales. Cut-off scorns recommended for the F-K index have ranged from 4 (Gough, 1947) to 20 (Cofer, Chance, & Judson, 1949), which would still mislabel about a third of nonmalingerers. Much more recently, Schretlen and Arkowitz (1990) found that Hunt's traditional F-K cut-off of 11 would mislabel 40% of a psychiatric population. Lees-Haley (1989) referred to F and F-K as questionable indices, and Berry, Baer, and Harris (1991) found that F alone was better than F-K. Rogers et al. (1990), though, found that APDs who were not malingering produced elevated

F scale scores, and Anastasi (1982) pointed out that the mentally ill also tend to have elevated F scores. A study by Roman, Tuley, Villanueva, and Mitchell (1990) found that 41% of psychotics obtained T scores of 80 or more on the F scale, while 22% had T scores above 100 percent.

The present author found no criminal malingering studies employing the Millon Clinical Multiaxial Inventory (Millon, 1983), although this instrument employs three validity scales as correction factors. The only relevant study with the 16-PF involved only validation against the MMPI (Grossman, Haywood, & Wasyliw, 1992), rather than comparing fakers with nonfakers.

Two objective instruments (to the author's knowledge) have been constructed specifically for the detection of malingering. One of these, the Hidden Schizophrenia Attitude Scale (HSAS; Audubon, 1986), is intended to detect schizophrenia that the examinee is attempting to disguise, as well as simulated psychosis. The HSAS employs an unusual design. Each item consists of two statements, and the examinee must choose which is closest to true for him or her. Although promising, the HSAS appears to duplicate some of the MMPI's difficulties, such as vocabulary level and the problem of random responses.

The other such instrument, the Malingering Test (M-Test; Beaber, Marston, Michelli, & Mills, 1985) includes a Confusion scale to detect random answer patterns, but instructions provided with the instrument describe high scores on this scale as indicative of malingering. Gillis, Rogers, and Bagby (1991) found, however, that the Confusion scale did load highest on a confusion factor, and Rogers, Gillis, Dickens, and Bagby (1991) found agreement between the M-Test and the SIRS. This instrument clearly holds some promise, although it also presents the problem of 100% of items on the Malingering and Schizophrenia scales being framed so that true is the deviant response.

The following section describes a relatively novel approach intended to combine the best characteristics of objective and projective tests for malingering detection.

FORCED-CHOICE PROJECTIVES

The antecedents of forced-choice projectives date to group Rorschach studies in the 1940s (Buckle & Cook, 1943; Harrower & Steiner, 1951), in which some objective methods of responding and scoring were incorporated. Several personality tests based on projective principles and dating to the 1950s and 1960s offered multiple-choice administration methods. Among those still commercially available are the Group Personality Projective Test (Cassel & Kahn, 1961), the Proverbs Test (Gorham, 1956), and the Famous Sayings Test (Bass, 1958). More recently, forensic psychologists have employed multiple-choice Rorschach tests in malingering simulation studies (e.g., Pettigrew, Tuma, Pickering, & Whelton, 1983). The present author (Fauteck, 1994) found that forced choices of Rorschach responses, human figures, and word associations

all discriminated between experimental fakers and diagnosed schizophrenics in an offender population, but to date the instrument exists only in experimental form. In recent studies, the forced-choice principle has been used successfully in detecting malingering of cognitive and memory deficits, respectively (Frederick & Foster, 1991; Hiscock & Hiscock, 1989).

THE PROBLEM OF PSYCHOSIS AND MALINGERING COMBINED

It would be extremely useful for a malingering test to also permit the independent detection of psychosis, because the two are not mutually exclusive (Gorman, 1982; Rogers & Resnick, 1988). Practically speaking, this is problematic given the present state of the art, because if we had an instrument that could simply detect schizophrenia and not be influenced by malingering attempts, then a malingering test per se for schizophrenia would be superfluous. Although Roman et al. (1990) contended that "whether subjects with genuine psychiatric disturbances exaggerate their psychopathology . . . is irrelevant if the objective is to differentiate them empirically from malingerers" (p. 188), in practice the identification of a true psychosis is not sufficient to answer crucial forensic questions (e.g., Melton et al., 1987). As noted above, the HSAS test was intended to detect faking good as well as faking bad (Audubon, 1986), but the present author was unable to find any published corroboratory studies.

In fact, some of the aforementioned experimental instruments have incorporated schizophrenia scales. These generally are composed of responses that diagnosed, nonmalingering schizophrenics had given in free association (e.g., Harrower & Steiner, 1951; Pettigrew et at., 1983). The effects were weak at best, however, and may have been due more to schizophrenics' difficulties in concentration, i.e., to a degree of randomness in their answers, than to systematic choice of the expected responses.

Given the foregoing, it is surprising that so few studies have examined the differences in performance between nonfaking and faking schizophrenics, rather than simply between nonfaking schizophrenics and normals faking psychosis.

FUTURE DIRECTIONS

The author suggests that the ideal malingering test would incorporate certain specific characteristics: It would have the ability to detect schizophrenia and malingering independently; it would distinguish between random and faking answer patterns; it would be "quite unstructured for the subject but fairly well structured for the examiner" (Thurston, quoted in Bass, 1958); it would present a variety of challenges; there would be no severe limitations with regard to the intelligence or reading ability of subjects; it would be fast and easy to administer; and it could be used by appropriately supervised paraprofessionals. Furthermore, it would be validated with the sort of population most likely to be examined in a criminal forensic context, that is, accused offenders.

There is a widely accepted principle (Anastasi, 1982; Schretlen & Arkowitz, 1990) that the most valid tests are those that sample more than one mental process, but most tests employed for the detection of malingering limit themselves to a single kind of challenge. The obvious inference to be drawn from this is that psychologists always should consider the advisability of employing a battery, rather than a single instrument, in any given case where malingering is suspected.

Until the ideal instrument is developed and validated, it behooves forensic examiners to be familiar with the various instruments that have been used in the detection of malingering, to know the strengths and weaknesses of each, to be careful observers of behavior, to take the time and effort to explore apparent contradictions, and, above all, to be intimately acquainted with psychotic symptom patterns. As clinicians, we must be open to any possibility, but as scientists, we must take nothing at face value.

AUTHOR'S NOTE: Address all correspondence to Paul Karsten Fauteck, Psychiatric Institute of the Circuit Court of Cook County, Suite 1001, 2650 S. California Avenue, Chicago, IL 60608.

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By PAUL KARSTEN FAUTECK

Circuit Court of Cook County, Illinois

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Source: Criminal Justice & Behavior, Mar95, Vol. 22 Issue 1, p3, 16p.

Item Number: 9503130705