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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
 psychosis
 posttraumatic 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
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
1.
Malingered Cognitive Disorders
1.
2.
3.
4.
Lack of marked perseveration
Implausible symptom profile given
reported injury
Psychotic symptoms confused with
cognitive impairments
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.
2.
3.
4.
No history of amnestic episodes
Antisocial personality traits more
prominent than histrionic personality
traits
Spotty, episode-specific amnesia rather
than global amnesia
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
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
1.
True hallucinations






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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 normalsized 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
Continuous rather than intermittent
2. Vague, inaudible, or unintelligible rather than distinct
3. Free-standing rather than associated with delusions
4. Stilted in language and specific in tone rather than
basic and general
5. Reported in the first person rather than in the third
person
6. Uncontrollable rather than susceptible to strategies
for containment
7. Irresistible rather than susceptible to indifference
1.
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