Tests for malingering
When time permits, there are psychometric tests that can assist in the detection of malingering. For example, the Minnesota Multiphasic Personality Inventory-2 is the most validated test for detecting malingering in the psychiatric setting. The Structured Interview of Reported Symptoms was specifically designed for the detection of malingered psychiatric symptoms. The Test of Memory Malingering is used to detect faked memory deficits.5 The Rey 15-Item Memory Test is used as a screening test; it has low sensitivity but high specificity.6
When psychological testing is not an option, unobtrusive observation is crucial in detecting malingering because the fallacy is often revealed when the physician is out of sight. Ancillary staff can be crucial in the detection of inconsistent behavior. The patient who is tearful and suicidal may expose himself by joking with staff when believed to be out of view of the physician. A patient demonstrating what appears to be psychomotor retardation in the interview might move rapidly to a smoking break. Winning at card games is inconsistent with the distractibility of psychosis or other cognitive impairments.
Course of action
The contradictions inherent in the malingerer can manifest in an unlimited number of ways, but what should clinicians do once malingering has been confidently diagnosed? A framework for formulating a disposition is needed. Rogers and colleagues7,8 describe 3 motivational models of malingering: pathogenic, criminological, and adaptational. These models can be used to assist in formulating a reasonable disposition. The pathogenic model contradicts our current conceptualization of malingering because it attributes malingering to an underlying mental illness that will eventually become apparent and has fallen out of favor. The criminological model addresses malingering in the context of personality traits, such as antisocial personality disorder, and is more frequently applicable or useful in the forensic setting. Finally, the adaptational model proposes that the malingerer is using cost-benefit analysis. The malingerer has weighed the benefits and risks and decided that "being sick" can yield what he wants or needs.
Mr M, a 41 year old, presented to the VA Medical Center stating that he was going to kill himself by walking in front of a car. He had been seen 5 times in 4 days. He went to the mental health walk-in clinic once and the rest of the visits were to the emergency department. Each time, he claimed to be suicidal. He was admitted to the inpatient unit twice but each time spent only one night before being discharged. There were multiple notes from the nursing staff reporting that he was laughing and joking with them and other patients once in the ward.
For most clinicians outside the forensic setting, the motivational model that is most useful is the adaptational model. The adaptational model can uncover the tools needed to successfully create a disposition that is safe and satisfactory to both the malingering patient and the clinician. After Mr M's chart was reviewed, collateral information was received from previous on-call physicians, and the assessment itself was complete, malingering was at the top of the differential diagnosis.
However, this is still a patient who is homeless and clearly verbalizing that he will attempt suicide if not admitted to the hospital. The key to a successful disposition is not proving that this patient is lying. It can be accomplished by asking him what he really wants or feels he needs--that is, what are the components of his adaptational model?
After discussing the information gathered with the patient, Mr M admitted that he understood from a social worker in another city that the only way to get the specific benefits he wanted was to be admitted to the inpatient psychiatric facility. Once the inaccuracy of this information was conveyed, the patient was happy to be directed toward more appropriate services. He then readily admitted that he had never been suicidal and expressed his irritation that he had to waste so much time at the VA Medical Center pretending to be depressed.
Although the criminological model first comes to mind, viewing this case through the adaptational model allows physicians to understand the patient and give him a means of fulfilling at least some of his needs while saving face. This method allows the clinician to avoid a more confrontational approach in situations that are already volatile. It is usually much more productive to give a malingerer a way out than to confront him directly about the deception.5
There are many incentives for malingering in different psychiatric settings. Clinicians must balance a desire to treat with a low threshold for suspicion of feigned symptoms. A malingering assessment must be comprehensive, including a thorough clinical interview, a review of all records, examination of collateral information, and psychological testing when available. A diagnosis of malingering delivers a powerful stigma, so psychiatrists must carefully weigh all the evidence before drawing that conclusion. By understanding the types, motivations, and presentations of malingering, a clinician can systematically and empathetically diagnose and respond to the intentional feigning of psychiatric symptoms.