Malingering: Key Points in Assessment

By H. W. LeBourgeois III, MD | April 15, 2007

Dr LeBourgeois is director of the Forensic Psychiatry Fellowship and assistant professor of psychiatry at Tulane University School of Medicine in New Orleans. He was a 2003 Rappeport Fellow of the American Academy of Psychiatry and the Law. He reports that he has no conflicts of interest concerning the subject matter of this article.

Psychological testing
In addition to the availability of validity scales as part of standard personality measurement instruments (eg, Minnesota Multiphasic Personality Inventory-2 and Personality Assessment Inventory), there are a number of psychological instruments and structured clinical interviews that have been developed specifically for evaluating malingering. It is best for clinicians to consult with experienced evaluators to ensure that they use testing that will prove most helpful in the assessment process.

The Structured Interview of Reported Symptoms is a structured clinical interview that takes about 45 minutes to administer. It may be used to differentiate malingered schizophrenia and mood disorders from genuine presentations, and it has been used to investigate the feigning of other conditions, such as PTSD.³⁷

The Test of Memory Malingering (TOMM) is useful in assessing malingered memory deficits. This instrument can help determine whether a subject is intentionally responding in a manner to appear memory-impaired.

Numerous other tests are available, and malingering scales have even been incorporated into competency-to-stand-trial assessment instruments, specifically, in the Evaluation of Competency to Stand Trial-Revised.

Instruments intended to assess malingering are typically designed to minimize the number of false diagnoses of malingering on the principle that a false diagnosis is more harmful than a missed diagnosis. Therefore, some individuals who are malingering may evade detection with psychological testing alone, and clinicians should integrate all available data with test results viewed as one piece of that data set. Also, specific malingering tests may not differentiate a factitious disorder presentation from malingering, so the use of clinical judgment about motivations for feigning is necessary.

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.

The latter is included because some malingerers may respond by escalating their behavior in an attempt to justify their self-reports; in extreme cases, this may take the form of physical aggression or self-injury.²

CASE VIGNETTE
A 19-year-old jail detainee facing a felony charge related to auto theft was evaluated for competence to stand trial by a forensic evaluator in a jail-based setting. The evaluator noted that the evaluee spoke very little and "did not appear to be taking the evaluation seriously." After spending 15 minutes with the evaluee, the evaluator issued a brief report recommending that the defendant be committed to a forensic psychiatric hospital for further evaluation with a "primary rule-out diagnosis of malingering."

The forensic evaluator at the hospital noted that the evaluee was taking moderate doses of haloperidol(Drug information on haloperidol) and that he presented with what appeared to be prominent negative symptoms of schizophrenia. He had a markedly restricted range of emotional expression and very little spontaneous speech, but when he spoke, he did so in a linear fashion. The evaluee denied current hallucinations, did not speak with any delusional material being evident, and denied any history of psychotic symptoms.

A call to the jail's treating psychiatrist, who had prescribed haloperidol for the evaluee, confirmed that he had observed the evaluee in a "genuine" psychotic state about 3 months after his detainment. This included the appearance of "loose associations and neologisms that went away" following antipsychotic administration. A phone call to family members also brought up a pos- sible history of adolescent-onset psychotic symptoms.

Given the collateral information obtained, the current appearance of difficult-to-feign negative symptoms of schizophrenia, and the observation that the evaluee tended to deny all symptoms of mental illness or a history of such (as opposed to calling attention to psychotic symptoms or grossly exaggerating them), the hospital's forensic evaluator determined that the evaluee was not malingering psychosis.

On the other hand, the evaluee presented with cognitive deficits, such as a poor fund of knowledge, poor short-term memory, and a poor ability to calculate and spell. At times he seemed unmotivated to engage in attempts at competency restoration, such as legal rights education. A decision was made to assess the evaluee for feigned cognitive deficits. School records were obtained. This included intellectual testing conducted at the age of 12, before any history of criminal conduct, that revealed an IQ in the mild mental retardation range; intellectual testing repeated at the forensic hospital was consistent with the earlier record.

The TOMM was administered and did not yield evidence of feigned cognitive (memory) problems. After the hospital's treating psychiatrist changed his haloperidol medication to an atypical antipsychotic medication, there was a decrease in negative symptoms, an increase in spontaneous speech, and the evaluee became more cooperative in efforts at competency restoration. He was evaluated for competence to stand trial 10 weeks into his hospitalization, and despite valid cognitive deficits consistent with mild mental retardation, he was recommended competent to proceed. The forensic report addressed the question of malingering, stating that malingered psychosis and cognitive deficits had been assessed and reasonably ruled out. The defendant was found to be competent to proceed, pled guilty to a lesser charge, and was placed on probation under the supervision of the mental health court.


TABLE 3 Key points in malingering assessment


	Consider malingering in the differential, especially in settings where obvious external incentives are at play During the initial interview, be on watch for endorsement of an unusually high number of symptoms that are rare, blatant, absurd, preposterous, and nonselectively endorsed 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 Seek out and review collateral data for consistencies or inconsistencies that help support or refute malingering; note any records that were requested but not received or that the evaluee refused to release for your review Consider use of psychological testing or structured clinical interviews specifically designed to detect malingering when assessment results in a suspicion but is inconclusive in determination of malingering If clarification is sought from an evaluee regarding inconsistencies in self-reports or other evidence of feigning, remember your ABCS: Avoid accusations of lying; Beware of countertransference; Clarification, not “confrontation”; and Security measures Establish or rule out malingering on the basis of an assessment that integrates many sources of information

Many cases of malingered mental illness are available for review in the literature.¹ The case vignette was included to demonstrate that if key points in malingering assessment are adhered to, some cases of suspected malingering will in fact be ruled out.

SUMMARY
While malingering may present a challenge for mental health clinicians, those who attend to key points in malingering assessment (Table 3) should be well-equipped to formulate opinions about malingering in either clinical or forensic settings.

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Bianchini KJ, Curtis KL, Greve KW. Compensation and malingering in traumatic brain injury: a dose-response relationship? Clin Neuropsychol. 2006;20:831-847.
Mittenberg W, Patton C, Canyock E, Condit D. Base rates of malingering and symptom exaggeration. J Clin Exp Neuropsychol. 2002;24:1094-1102.

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Malingering: Key Points in Assessment

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