Malingering Karen S. Brink 21 February 2008

Content Definitions and Terminology International trends Guidelines for Claims Assessors Guidelines for Occupational Therapists

Definitions Intentional simulation or exaggeration of psychological or physical symptoms for secondary gain (American Psychiatric Association, 1994) Malingering is intentional production of false or exaggerated symptoms motivated by external incentives, such as obtaining compensation or drugs, avoiding work or military duty, or evading criminal prosecution. (DSM:IV-TR V65.2 ) Malingering is not a psychiatric disorder

Terminology Accident neurosis Accident victim syndrome Aftermath neurosis American disease Attitudinal pathosis Compensationitis Entitlement neurosis Functional overlay Greenback neurosis Justice/ Litigation neurosis Neurotic neurosis Profit neurosis Railway brain/ spine Secondary gain neurosis Syndrome of disproportionate disability Traumatic hysteria

The Psychology of Lying Type of Lies White Humourous Altruistic Defensive Aggressive Pathological Secondary gain

Secondary gains Gratification of preexisting dependency or revengeful strivings Attempt to elicit care-giving or sympathy Family anger Entitlement after struggling, dutiful attention to responsibilities Ability to withdraw from unpleasant life roles, activities and responsibilities Adoption of sick role (socially sanctioned) Blame of failures placed on illness beyond one’s own control Maintenance of status in family Holding spouse/partner in relationship Financial rewards (income replacement, settlement, debt protection, subsidized childcare, housing) Protection from legal obligations Job manipulation (promotion/transfer) Secondary losses Economic losses Loss of meaningfully relating to society through work Loss of work social relationships Loss of social support network Loss of meaningful and enjoyable family roles and activities Loss of recreational activities Loss of respect from family and friends Negative sanctions from family Loss of community approval Loss of respect from helping professions New role not comfortable and defined Social stigma Guilt Tertiary gains Gratification of altruistic needs Desired change in role Dependency Gain sympathy from social network Admiration and respect from others Financial gain Tertiary losses Increased responsibilities at home and work Emotional suffering Disturbance and discord within relationship Guilt/obligation to stay in undesirable relationship Stigmatization Financial hardship

Kaplan & Sadock Malingering is different from lying in that it is intended deception about a physical or psychological problem (as opposed to deception about anything else). Obviously, it is possible for an evaluee to both lie and malinger but the two are separate issues to be considered in a criminal forensic evaluation Malingering differs from Factitious Disorder in that the motivation for the symptom production in Malingering is an external incentive, whereas in Factitious Disorder external incentives are absent. Evidence of an intrapsychic need to maintain the sick role suggests Factitious Disorder. Malingering is differentiated from Conversion Disorder and other Somatoform Disorders by the intentional production of symptoms and by the obvious, external incentives associated with it. In Malingering (in contrast to Conversion Disorder), symptom relief is not often obtained by suggestion or hypnosis. (pp. 739-740)

Non-diagnostic terminology Symptom magnification syndrome Symptom exaggeration Abnormal illness behaviour Effort Motivation Effort (sub-maximal/insincere) Illness behaviour/sick role/ psychological overlay

International trends Prevalence: 30% of disability cases Standards (Travis) Use of at least 3 multiple data sources (3) Use multiple data collection methods (>=3) Triangulation of data Consistency Performance across repeated trials, similar tests, expected function, diagnosis Distraction Effort behaviours Self-reported vs observations 30% of disability cases (neuropsyche – Slick et al. 2003) 25-30% of fibromyalgia, chronic fatigue syndrome, depression 40% of chronic pain (Mittenberg, et al. 2002)

Specific FCE tests Test designs not primarily for detection of effort Validity/ Reliability Malingering Blankenship FCE Not published Good, but take care of false positives BTE Work Simulator Moderate Unknown EPIC & SFS Good Isernhagen FCE Good (with use of Borg) Key FCA Unknown* PWPE (Ergoscience) Smith PCE Valpar CWS-Joule Good (Varies between samples) Modapts Test designs not primarily for detection of effort 2004: Five tests were able to discriminate Table not to be misconstrued or used as research

Guidelines for OTs Guidelines needs to be reviewed Malingering guidelines are specific to all diagnoses High prevalence with referrals Comply with international trends Varied approach Take care with terminology (effort, symptom exaggeration, motivation, psychological overlay) Focus should remain on function Varied approach is favoured by all professions in field of disability assessment, incl self-reports, observations, tests, ADL, activities

Guidelines for Claims Assessors Be aware of your own prejudices and feelings Contractual decision and not moral argument Can’t win ‘em all Long-term management of claim Professionalism during interaction with suspected malingerer Consistency assessment part of claims process Use reputable opinions (specialists, OT, forensics) Ask for certain tests, or if second opinion, alternative tests Be specific with forensics Unannounced, follow-up Read between lines of reports 41.7% rarely use terms malingering; 12.5% never use term; More than 80% instead says that the test results are invalid, inconsistent with the severity of the injury or indicative of exaggeration: Detecting malingering – a survey of experts’ practices 2004 (Slick, Tan, Strauss, Hultsch) Use of significant others in detection of malingering 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. 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 typical or atypical of the mental illness in question

The future of malingering Impact on disability claims will not change: Age old practice, psychodynamics remain the same Always a consideration by definition of financial gain Guidelines, training and tests developed as research and experience increases Financial assistance to aid further research 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. Price £10 / 13 Euros / $16 (US)