Financial incentive and Malingering
Individuals who are seeking some form of compensation are commonly believed to be more likely to exaggerate symptoms. Four recent studies found a positive correlation between financial incentive and the likelihood of malingering or exaggeration.9,31-33 One study even proposed a dose-response relationship between the level of financial incentive and the likelihood of malingering or exaggeration.33
MALINGERING ASSESSMENT
The clinical interview
The clinical interview is critical in the assessment of malingering, and Cunnien's threshold model for consideration of malingering34 forms the basis for a suggested screening guide (Table 1). If certain factors trigger suspicion of malingering, clinicians should be cautious in how they frame questions, avoiding leading questions that might give evaluees clues about how a genuine syndrome manifests itself.35 Rather, clinicians should rely at first on open-ended questions. After evaluees have been given a chance to report symptoms in their own words, clinicians can ask specific, detailed questions that help to characterize symptoms as typical or atypical. Table 2 includes some characteristics of atypical hallucinations as well as other clinical clues to be considered when malingered psychosis is suspected.
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TABLE 1 Guide to screening for malingering |
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Adapted from Cunnien AJ. Clinical Assessment of Malingering and Deception. 1997.35 |
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TABLE 2 Clinical clues to malingered psychosis* |
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*No single factor listed above is pathognomonic of malingered psychosis. Clinicians should consider the above factors
along with the rest of the data set and consider causes of atypical presentations of psychosis (eg, substanceinduced
psychosis or psychosis secondary to a general medical condition).
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Clinicians should be aware that malingering often takes great effort on the part of the evaluee; therefore, some malingerers will tire the longer the interview lasts. Clinicians should be prepared to set aside the time it takes to conduct a thorough interview, while taking particular note of discrepancies between claimed deficits and actual abilities exhibited during the interview or as reported by collateral informants. For instance, in malingered cognitive deficits, an evaluee may spontaneously name items in a room, such as a clock, a fan, or a cell phone, but then appear perplexed upon direct presentation of a task requiring them to name a pen or a watch. Clinicians should have a heightened awareness for such discrepancies, because this information, along with other data, may later support an opinion of malingering.
Clinicians should further rely on clinical experience with genuine patients to recognize an abnormal pattern of self-reported symptoms. Rogers36 also encourages clinicians to be on the watch for endorsement of an unusually high number of symptoms that are rare, blatant, absurd, and nonselectively endorsed. Rare symptoms are valid symptoms that are infrequently reported by psychiatric evaluees. Blatant symptoms are immediately recognized by nonprofessionals as indicative of severe psychopathology. An example of such is an individual who presents to an emergency department reporting that he is suicidal, homicidal, and hearing voices telling him to kill himself and other people. Improbable or absurd symptoms are almost never reported or affirmed, even in severely disturbed evaluees. An individual who endorses the belief that "honeybees are involved in a plot to kill the president" is demonstrating an improbable and absurd symptom. Nonselective endorsement of symptoms refers to a strategy used by malingerers based on the belief that the more symptoms endorsed, the more likely they are to be assessed as ill.1
After the clinical interview, some clinicians may feel they have ruled out malingering. Others may find clues that heighten their suspicion. Those clinicians should consider proceeding further using the following techniques.
Collateral information
Clinicians should search for collateral information that supports or refutes the evaluee's self-reports. Such data may include previous treatment records and forensic evaluations, interviews of collateral informants familiar with the evaluee (including nurses, other clinicians, or family), personnel files, information gathered by an insurance agency to investigate a claim, depositions, surveillance tapes, police reports, and witness statements. Clinicians who have access to these data are at a great advantage when coming to conclusions about malingering.1 Clinicians should document the records reviewed, records requested but not received, as well as records that the evaluee or other agencies refused to release for review.
