Malingering Treena Klassen – Regional Educator – Mental Health December 2004

Malingering Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives (DSM IV-TR)

Adaptive Malingering Malingering may represent adaptive behavior under some circumstances…

Suspect Malingering When… 1.Medico legal presentation 2.Marked discrepancy 3.Lack of Cooperation 4.Presence of Antisocial Personality Disorder

Differentiating Malingering

Assessing Response Styles Suspect Genuine Psychiatric Illness When: Defensive Honest Suspect Malingering When: Irrelevant Responding Random Responding Hybrid Responding

Clinical Assessment of Malingering A.Psychological or physical symptoms are clearly under voluntary control as manifested by one or more indicators: 1.Patient acknowledgment 2.Inconsistent symptoms 3.Illness production 4.Paraphernalia or substances 5.Laboratory testing

Clinical Assessment of Malingering Con’t B.Clinical certainity that illness production occurs in response to: 1. Pursuit of financial gain, shelter, or drugs, etc. 2. Avoidance of work, military duty, prosecution or legal consequences

Clinical Assessment of Malingering Con’t C. Another disorder, if present, cannot explain current symptoms D. Evidence of desire to assume the sick role, if present, cannot explain the totality of current symptoms

Interview Methods 1.Open-ended questions 2.Questions about hallucinations 3.Do not let your irritability show 4.See client quickly 5.Good rapport 6.Suspect malingering

Interview Methods 7.Gather as much data as possible 8. Ask questions about a different illness than the one the malinger is portraying. 9.Ask questions about improbable symptoms.

Clues to Malingered Psychoses Malingerers may overact their part Malingerers are eager to call attention to their illnesses in contrast to schizophrenics, who are often reluctant to discuss their symptoms It is more difficult for malingerers to successfully imitate the form, than the content of schizophrenic thinking

Clues to Malingered Psychoses (2) Malingerers may claim the sudden onset of a delusion Behavior is unlikely to conform to his alleged delusions; acute schizophrenic behavior usually does.

Clues to Malingered Psychoses (3) May tell a far-fetched story to fit the facts of his crimes into a mental disease model Tend to present themselves as blameless within their feigned illnesses More likely to repeat questions or answers slowly Absence of any active or subtle signs of psychosis at the time of the evaluation

Examples of Feedback with Malingering 1.“Some of the problems you describe are rarely seen in psychiatric patients. I am worried that you might be trying to make thinks seem worse than they are.” 2.“Earlier in the evaluation you told me…, now you are telling me …I am having trouble putting this together.” 3.“Although you have told me about … (I.e., description of current problems), when I observed you, you have not appeared …”

Examples of Feedback with Malingering (2) 4.“I don’t want to hurt your feelings, but I just don’t think things are quite as bad as you tell me they are.” 5.“According to you, you have … (I.e., current problems), but according to … (I.e., reliable information) you are… Can you help me understand this?”

Negative Feedback “You haven’t told me the whole truth.” “You are lying.” “Your wasting my time.”

Conclusion If in doubt you must assume the patient is not a malingerer. All efforts must be made not stigmatize the genuinely mentally ill as this further impedes treatment measures.