1. Malingering

2. 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.

3. 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.

4. 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

5. 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.

6. concept of a continuum (1) degree of intentionality
(2) degree of symptom exaggeration
(3) degree of actual impairment (if any)

7. various degrees of malingering
Pure malingering
Partial malingering
False imputation
Misattribution

8. 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

9. 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

10. 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

11. Associated disorders
Conduct disorder and anxiety disorders in children
antisocial, borderline, and narcissistic personality disorders in adults

12. Beck Diseases are usually feigned from one of three causes: Fear shame
the hope of gain

13. 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

14. The psychiatric conditions most likely to be malingered are:
mental retardation
organic impairment
amnesia
psychosis
posttraumatic residua, including depression and posttraumatic stress disorder (PTSD).

15. DETECTION OF MALINGERING
every effort should be made to interview the criminal shortly after the event
the clinical interview should be long and detailed

16. 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

17. Malingered Mental Deficiency or Mental Retardation
Striking discrepancy between level of education and level of intelligence
Striking discrepancy between military and employment records and presenting behavior and test performance
Striking discrepancy between adult test performance and prior pattern of test performance
Failure on easy items and success on difficult items during evaluative testing
Incongruity of vocational and social performance with presentation capabilities

18. Malingered Cognitive Disorders
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

19. 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

20. Malingered Amnesia 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

21. 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

22. Features of Malingered Delusions
Abrupt onset and termination rather than gradual development and hesitant abandonment
Eagerness to call attention to delusions and symptoms rather than reluctance to acknowledge them
Behavior inconsistent with delusional content rather than reflective of delusional content
Thought content grossly disturbed in the face of conventional and goal-directed thought process

23. 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

24. 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

25. Malingered Auditory Hallucinations
Continuous rather than intermittent
Vague, inaudible, or unintelligible rather than distinct
Free-standing rather than associated with delusions
Stilted in language and specific in tone rather than basic and general
Reported in the first person rather than in the third person
Uncontrollable rather than susceptible to strategies for containment
Irresistible rather than susceptible to indifference

26. Malingered Posttraumatic Symptoms
Much more common are claims of depression and, now that it has become widely publicized, of PTSD

27. 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

28. 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

29. 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.

30. Psychological testing
the Personality Assessment Inventory (PAI)
The Validity Indicator Profile (VIP)
The Structured Interview of Reported Symptoms (SIRS)
Neuropsychological testing ( the Halstead-Reitan)

31. 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

32. 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.

33. 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

34. 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