The assessment of malingering presents a significant challenge for mental health clinicians. The traditional clinician-patient relationship is based on the assumption that a patient is in genuine need of treatment, so clinicians may feel uneasy about initiating malingering assessment. This uneasiness is understandable given the potential for escalation of an individual's behavior when confronted with the clinician's suspicions of malingering,

 not to mention the rare potential for lawsuits alleging malpractice following a diagnosis of malingering.

Mental health clinicians are nevertheless likely to encounter cases of malingering. Mittenburg and associates

 reported that in a recent study of 33,531 cases seen by members of the 

American Board of Clinical Neuropsychology

 during a 1-year period, probable malingering and symptom exaggeration were found in 30% of disability evaluations, 29% of personal injury evaluations, 19% of criminal evaluations, and 8% of medical cases. This is consistent with earlier studies on base rates of malingering identified during mental health evaluations.

While forensic settings in general harbor higher base rates of malingering, some clinical settings, such as those in which compensation-seeking veterans receive evaluation/treatment for posttraumatic stress disorder (PTSD), may have rates that approach or exceed base rates enumerated in forensic settings.

 Therefore, mental health clinicians should have familiarity with key points in malingering assessment.


Malingering was documented in biblical times. David "feigned insanity and acted like a madman" to avoid a king's wrath (1 Samuel 21:11-16). In 1843, malingering found its way into the English medical literature.

 Four years later, a French surgeon described the use of ether to distinguish feigned from real disease.

 In the late 19th century and early 20th century, the introduction of worker's compensation led to numerous pejorative terms such as 

 During World War II, the British dropped pamphlets over German troops instructing them how to feign injury in order to obtain military leave.

 Recently, a German CD-ROM named the "Sickness Simulator" was available for purchase on the Internet; the program instructed employees on how to malinger in order to obtain sick leave.

 defines malingering as 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." Malingering is not a psychiatric disorder; 

 includes it in the section "Other Conditions That May Be a Focus of Clinical Attention."

 comments on potential subtypes of malingering: 

 involves exaggeration of existing symptoms, and 

 occurs when an evaluee intentionally attributes symptoms to a cause that has little or no relationship to the development of the symptoms.


Malingered psychiatric conditions may include dissociative identity disorder,

 Malingered conditions that cross the spectrum of psychiatry and neurology include acute dystonia,

 In addition, there have been several case reports of "malingering by proxy" in the pediatric setting.

Psychiatric disorders that may be mistaken for malingering


Both malingering and factitious disorders involve feigning of physical or psychological illness. The motivation for feigning associated with factitious disorders is a desire to assume the sick role rather than an obvious external incentive such as disability payments.

 In malingering, external incentive should be tangible. An example is a case in which a criminal defendant feigns mental illness in an attempt to be designated incompetent so as not to be executed.

 On the other hand, a patient with factitious disorder who repeatedly injects insulin to induce hypoglycemia may jeopardize his or her own well-being-a high personal cost just to assume the sick role.

Mental health clinicians should also consider somatoform disorders in the differential diagnosis when a question of malingering is raised.

 Furthermore, clinicians should be careful not to ascribe atypical presentations to feigning before considering a workup to rule out causes for atypical presentations, such as syndromes occurring secondary to drug ingestion or secondary to an occult medical condition. A simplified guide may be helpful in making this differentiation (

 asserts that malingerers engage in a "cost-benefit analysis" during assessment. "Malingering is more likely to occur when (1) the context of the evaluation is perceived as adversarial, (2) the personal stakes are very high, and (3) no other alternatives appear to be viable." In the context of this model, individuals malinger based on their estimate of success in obtaining the desired external incentive.

 malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medicolegal context of presentation; (2) marked discrepancy between the person'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; and (4) the presence in the patient of antisocial personality disorder (ASPD).

 "singling out" of individuals with ASPD is appropriate.

 Research in this area suggests that limiting the consideration of malingering only to those with ASPD will result in significant underdetection.


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.

 One study even proposed a dose-response relationship between the level of financial incentive and the likelihood of malingering or exaggeration.

MALINGERING ASSESSMENT
The clinical interview


The clinical interview is critical in the assessment of malingering, and Cunnien's threshold model for consideration of malingering

 forms the basis for a suggested screening guide (

). 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.

 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. 

 includes some characteristics of atypical hallucinations as well as other clinical clues to be considered when malingered psychosis is suspected.

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. Rogers

 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. 

 are valid symptoms that are infrequently reported by psychiatric evaluees. 

 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. 

 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.

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.


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.

 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.


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.

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.


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:

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.

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 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.

Many cases of malingered mental illness are available for review in the literature.

 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.


While malingering may present a challenge for mental health clinicians, those who attend to key points in malingering assessment (

) should be well-equipped to formulate opinions about malingering in either clinical or forensic settings.

Articles

The assessment of malingering presents a significant challenge for mental health clinicians.

Malingering: Key Points in Assessment

A great deal of data exists about the dangers of polypharmacy. Persons with psychiatric disorders experience increased risk for adverse drug interactions because of the great frequency with which multiple medications are used.

 Using multiple antipsychotics concomitantly has been associated with increased mortality in patients with schizophrenia.

 Reports of adverse psychiatric polypharmacy effects are abundant, including increased duration of hospital stay.

In this article we define polypharmacy as the use of 2 or more medications of the same chemical class or with the same or similar pharmacological actions to treat the same condition or separate conditions. For example, prescribing thyroid medication to augment antidepressant response would be polypharmacy, while using thyroid medication to treat hypothyroidism, with concomitant antidepressant therapy for depression would not be considered polypharmacy (

Although the use of multiple medications to treat different conditions is beyond the scope of this paper, it should be realized that there is a potential for problems any time multiple medications are used. As an example, cases of carbamazepine toxicity have been reported when this mood stabilizer is used in combination with protease inhibitors for HIV because of the well-known CYP3A4 inhibition of this antiretro- viral class.

A medication that treats the adverse effects of another agent would not be considered polypharmacy by this definition. For instance, using anticholinergic agents to treat extrapyramidal side effects of first-generation antipsychotics or the use of amiloride to treat lithium-induced polyuria may be empirically based. However, the need for 2 medications might be avoided with the use of second-generation antipsychotics in the first example or valproic acid in the second example.

The term polypharmacy does not in itself suggest whether its use is warranted. Ideally, only one medication would be used to optimally treat a symptom or disorder. However, even a cursory review of the literature suggests that many, if not most, patients show suboptimal response to any one given agent. New medications more specifically target disease state symptoms and have improved side-effect profiles, making combination treatment strategies more attractive and possibly less daunting. The legitimate increase in pressures to help improve patient status has changed the standard for successful treatment in psychiatry; the bar has been raised.

Perhaps the best example of this phenomenon is in the treatment of depression. Response is no longer considered an acceptable goal-remission is now the clear end point for therapy. Multiple lines of evidence show that patients who only respond have a poorer quality of life and are more likely to relapse.

There are certainly some well-researched uses of medication combinations. Even casual reflection shows that the number of possible medication combinations to treat any psychiatric condition is enormous. Surveys have found that the use of 4 or 5 medications simultaneously is not uncommon in the treatment of bipolar disorder

 Given the overwhelming number of possible combinations, it is unlikely that more than a few of these will be researched.

Although double-blind, placebo-controlled trials are considered the standard, relatively few such studies of polypharmacy exist. Therefore, clinicians must venture beyond this evidentiary base. Less firm evidence may be gathered from clinical series and expert opinions, which may not be completely current nor deal with the specific clinical dilemma being faced. Therefore, alternative ways of approaching this problem are needed (


Two polypharmacy strategies may be considered good. The first involves using a combination of 2 medications based on research showing that the combination is more effective than the use of either one alone. Since such studies are in short supply, the second strategy, rational polypharmacy, would be to extrapolate the combined pharmacodynamics of concomitant medications from existing research results, expert opinions, or hypotheses.

Perhaps the largest group of research studies supporting polypharmacy exists for manic episodes in bipolar disorder. The combination use of either lithium or valproate with the second-generation antipsychotics olanzapine, quetiapine, or risperidone has proved to be effective in the treatment of manic episodes.

 Therefore, since research supports using 3 of the second-generation antipsychotics in combination with mood stabilizers for mania, it would seem reasonable to generalize these findings as applicable to the other 2 second-generation antipsychotics, aripiprazole and ziprasidone. Moreover, they too are approved for the treatment of manic episodes in bipolar disorder, so combining them with a mood stabilizer would be rational polypharmacy.

Various algorithms exist reflecting both research and clinical experience from authorities and panels of experts. These guidelines frequently suggest rational approaches to the concomitant use of more than 2 drugs. Post and colleagues

 report on the complexity and sophistication necessary for such combinations, particularly in the treatment of bipolar disorder.

Knowledge about the biology of a disorder and the pharmacodynamic properties of medications can be foundations on which rational polypharmacy regimens can be built. For example, the addition of bupropion, which possesses norepinephrine and dopamine reuptake inhibition, to an SSRI would appear rational in the treatment of depression, despite the lack of firm double-blind, placebo-controlled evidence that this combination is effective.

It should be realized that regardless of the rationale or quality of the research, the combination chosen might not be effective for a given patient. Therefore, it is incumbent upon the clinician to carefully monitor the effects of such combinations. Although the use of detailed research scales would be ideal, time constraints in most practices mitigate against this. However, the use of selected items from such scales or the use of a clinical global impression scale would be helpful in avoiding long-term use of additional medications that provide little or no benefit.

Schizophrenia is one area where such monitoring is necessary because polypharmacy research is either lacking or contradictory. For example, although there are case studies suggesting that the addition of risperidone may augment response to clozapine, the only double-blind studies of this combination report contradictory results.

Since some positive results exist, using risperidone and clozapine together may be beneficial, but the combination requires monitoring for symptom improvement to ensure the adequacy of such treatment. We have often been consulted about cases of schizophrenia in which patients are taking several antipsychotics simultaneously and the clinician is seeking to add another. When asked whether they had considered a trial of clozapine alone for the patient, the answer is invariably no.


For the purposes of this article, bad polypharmacy will refer to the combination of 2 or more medications without attention to pharmacodynamic properties. Inattention to pharmacokinetic properties will be discussed in the next section.

Several reasons for bad polypharmacy have been described.

 One example is clinicians' fear of "rocking the boat," so they refrain from discontinuing any current medications that are partially effective. An additional medication is then added to the existing regimen in an attempt to achieve full therapeutic effects. In these cases, the additional medication may be sufficient as monotherapy, which would make a medication switch more appropriate than a combination approach.

Another cause of bad polypharmacy deserves mention: following fads. For example, we have frequently seen the addition of low-dose quetiapine for sleep to suboptimal doses of antipsychotics or mood stabilizers. Although clearly more expensive, it is unclear whether the use of low-dose quetiapine provides any greater benefit than a pure antihistamine agent. Another recent example we observed was the addition of gabapentin to a large variety of medications in the hope of augmenting response in schizophrenia, bipolar disorder, depression, and other conditions despite an absence of sound evidence for its efficacy.

We have unfortunately observed plentiful inattention to the combined pharmacodynamic properties of medications. An example is the use of 2 SSRIs, both at suboptimal doses. Another is the addition of a serotonin- norepinephrine reuptake inhibitor (SNRI), such as venlafaxine, to an SSRI when the serotonin reuptake inhibition of the SNRI alone may be sufficient.

Another recently observed example was the combined use of an anticholinergic agent with donepezil. Obviously, the cholinergic antagonist should cancel out any benefits of a cholinesterase inhibitor. This, again, shows inattention to the combined pharmacodynamic effects.


In contrast to polypharmacy that is mostly wasteful or ineffective, as described in the previous section, the "ugly" refers to polypharmacy that may be harmful. Two major errors may lead to harm: inattention to pharmacokinetic interactions and inattention to side-effect profiles of medication combinations.

Much has been learned in recent years about the cytochrome P-450 (CYP450) system as well as medications that may induce or inhibit specific isoenzymes. We have repeatedly observed patients taking a number of medications receive an additional medication with potent CYP450 induction or inhibition properties, which potentially leads to adverse effects or decreased effectiveness of the original medications. Conversely, we have observed detrimental effects following the removal of a medication that was inducing or inhibiting concomitant medications. As simple examples, although the potent CYP450 inhibition of paroxetine and fluoxetine are well known, less attention is typically paid to the metabolism of medications used with them.

Similarly, inattention to the use of multiple medications with similar side-effect profiles may lead to greater problems than the use of either alone. For instance, many psychiatric medications may lead to weight gain. Nevertheless, several such medications are often freely combined without considering alternatives that are more weight-neutral.


As more therapeutic agents are introduced with varying pharmacological profiles, it becomes increasingly important for practitioners to be familiar with existing research, the mechanisms of action of medications, and metabolic pathways in order to use rational polypharmacy. Various interventions have been described that lessen irrational polypharmacy, including peer review processes, continuing education on rational polypharmacy approaches, and clinical pharmacy involvement in patient care.

If future trends in psychiatric disease management follow along their current route, polypharmacy will continue to be necessary in order to obtain optimal therapeutic goals. With this in mind, it becomes imperative for providers to remain judicious when using polypharmacy strategies in the treatment of psychiatric disorders.

Dr Kingsbury is chief of outpatient mental health at the VA Southern Nevada Healthcare System in Las Vegas and clinical professor of psychiatry in the department of Psychiatry and Behavioral Science at the University of Nevada. Dr Lotito is a clinical pharmacy specialist in psychiatry and director of the PGY1 pharmacy residency program at the VA Southern Nevada Healthcare System in Las Vegas. She is also assistant professor of pharmacy practice at the University of Southern Nevada College of Pharmacy. Dr Kingsbury reports that he is on the speakers' bureau for AstraZeneca, Bristol-Myers Squibb, Forest, Janssen, and Pfizer. Dr Lotito reports that she has no conflicts of interest concerning the subject matter of this article.

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Psychiatric Polypharmacy: The Good, the Bad, and the Ugly

Just 2 minutes before an episode of the television show Boston Legal aired, Roger Pitman, MD, professor of psychiatry at Harvard Medical School, received a telephone call from his sister-in-law informing him that the show would include a segment on propranolol, a drug he was researching for the prevention and treatment of posttraumatic stress disorder (PTSD).

After watching the "Selling Sickness" episode,

 Pitman was amazed at how quickly his research, albeit substantially embellished, had made it to a popular television show viewed by more than 10 million people.

The episode included a fictional story about a 16-year-old girl, Michelle, who had recently been molested by a rabbi, and about the ensuing conflict between her divorced parents over whether Michelle should take the "forgetting pill." Michelle's psychiatrist father sought a court order to permit her to take the pill, while her mother opposed it. The pill was propranolol (Inderal), a Ã-blocker, which is FDA-approved for the treatment of hypertension and angina pectoris, among other disorders.

In the courtroom drama, the father's attorney described the drug as essentially blocking "adrenaline from entering the nerve cell, and adrenaline attaches emotion to memories. If you take the drug quickly enough, it can prevent you from remembering and being scarred by the trauma." He then added that it had been used "with soldiers suffering from PTSD with good results."

Opposing the drug's use, Michelle's mother argued: "You just can't erase the bad parts of life," and "our best artists are informed by their pain. . . . Certainly, if the trauma affects your life, treat it, either behaviorally or with medication. But some miracle amnesia pill, so you have no memory of bad things-what kind of brave new world are we entering into?"

The episode segment ends with the judge ruling against Michelle being given the drug.

 writers "used artistic license to make more out of this than there currently is," Pitman said. "I thought the [drug's] effects that were portrayed in the show were beyond what we know the effects to be, but . . . the discussion of the ethical issues was fairly good."

 segment aired November 26, 2006, in which correspondent Lesley Stahl interviewed him, other researchers, and study participants with PTSD who had received propranolol.

 show indicated that this research was experimental and that there were not any firm results yet," Pitman said. "Now, in . . . Boston Legal, the plaintiffs were portraying it like it was this miracle drug. On the other hand, the defendant's lawyer did say that it hadn't even been shown to be effective yet."

Summarizing his reaction to the episode, Pitman said, "It was an interesting show, but what we need is more data rather than more interest. . . . At this point, the most important thing for us to do is to continue our research and see what there really is to this drug."

Writers draw on life experience As with the Boston Legal episode, many story lines of television series and films are increasingly imitating life. But is the information accurate? The importance of this question is highlighted by a 2001 Healthstyles Survey that found more than half (57%) of regular viewers reported learning something about a disease or how to prevent it from a daytime/ prime time drama.

Certainly, when mobster Tony Soprano sought treatment for panic attacks in 

s, the process and purpose of psychotherapy received wide exposure. The television series provided one of the best depictions of psychotherapy "to ever appear on film or television," according to Glenn Gabbard, MD, Brown Foundation Professor of Psychoanalysis at Baylor College of Medicine and author of a book about 

Increasingly, writers, directors, and producers of prime time shows or feature- length films, along with actors, are shifting away from mental illness stereotypes and seeking the input of psychiatrists, psychologists, other mental health experts, family members of the mentally ill, and those suffering from the disorders.

 episode called "Wishin' and Hopin'," Joan Rater, one of the episode's writers, explained that the episode was "really about Alzheimer disease. How devastating it is to families, how it turns spouses and children into caretakers, how it robs people of their memory, their identity."

 In the episode, Ellis, mother of one of the main characters, Meredith Grey, suffers from middlestage Alzheimer disease. But on this one day, she has a lucid moment, recognizes her daughter, and remembers everything up until the last 5 years, when she has been in a supervised living facility.

"The concept of someone with this disease having a lucid day is real," Rater said. "The disease varies for everyone, but experts we talked to said that patients have bad days and good days, and then sometimes they have great days where it seems like they are their old selves."

, a drama about the ruthless editor of a celebrity tabloid, actor Ian Hart portrays Don Konkey, a paparazzo who suffers from schizophrenia and who is often reluctant to take his medication. To research his part, Hart said he relied on his memories of distant relatives who have schizophrenia, some reading materials about the disorder, and BBC radio documentaries that featured conversations with individuals who have schizophrenia.

One of the most thorough investigations of schizophrenia is in a new independent film, 

, starring Academy Award-winner Marcia Gay Harden as Mary, a woman suffering from schizophrenia who paints her dreams on canvas; 

 Joe Pantoliano as her husband, John, a construction foreman; and newcomer Devon Gearhart as Chris, their 10-year-old son.

In the story, Chris attempts to conceal his mother's illness, but her bizarre public behavior alienates him from his schoolmates and widens the rift between him and his father. When Mary's illness leads her to violence, endangering her family and herself, John hospitalizes the woman he adores and tries to cope by building a large sailboat in his driveway. When Chris is suspended from school for fighting with bullies, John punishes him. A pivotal confrontation follows between father and son, ending in a reconciliation during which they come to terms with Mary's illness.

The film, an award winner at several film festivals even before going into general release, is a fictional narrative. Yet, its story is inspired by real childhood experiences of writer/director Joseph Greco, whose mother has schizophrenia.

"She was actually hospitalized for several months when I was a child. That's where the idea for the story came from," he told 

"That is how we were able to cope as a family, by him taking me sailing," he said. "I'm lucky, because I had a really great father. In some instances, he was both the father and the mother, while she was away in treatment. We leaned on each other and that is really what the movie is about-how a family ultimately can overcome problems if given the right opportunity."

"My goal first and foremost was to tell a good story and make a good movie to entertain people, but I would also like people to learn about mental illness and if we can combat stigma in the process, then all the better," he added.


Beyond relying on his own experiences for the plot, Greco told Psychiatric Times that he did some research about schizophrenia.

"I wanted to be sure that I portrayed mental illness accurately and sensitively, so I enlisted the support of the mental health community. In particular, there is a script consultant that I worked with, Susan Dempsay, who founded a rehabilitation center [for individuals suffering from severe and persistent mental illness] called Step Up on Second. Her son, unfortunately, has schizophrenia, so she has a personal connection to mental illness and first-hand experience. More than that, she has consulted on other movies."

Before the film was finished, Greco invited Stella March, national coordinator of StigmaBusters for the National Alliance on Mental Illness (NAMI), to attend a rough-cut screening in Beverly Hills. She urged Greco to send the movie to NAMI's headquarters in Arlington, Va. Last July, it was shown at NAMI's national convention, received 2 standing ovations, and was praised by NAMI's executive director Michael Fitzpatrick, MSW, as "one of the few dramatic films that can be considered authentic in its portrayal of schizophrenia- presenting both heart-breaking and heart-warming dimensions and even touches of humor." The film has since received enthusiastic reviews from entertainment industry critics, including John Anderson writing for 

Not only Greco, but also Harden and Pantoliano researched schizophrenia. At Greco's request, they spent a day visiting Fountain House in New York City, a self-help program operated by individuals recovering from mental illness, in collaboration with a professional staff.

Before the film goes into general release, Greco said, "We are doing our best to give people in the mental health community a first look at the film."Greco and Pantoliano recently screened the film at a gathering of psychiatrists and other mental health professionals at Tufts University.


When viewed as a whole, mental health issues are being portrayed more accurately in recent movies than in the past, said psychotherapist Birgit Wolz, PhD, MFT, author of

 E-Motion Picture Magic: A Movie Lover's Guide to Healing and Transformation

. The improvement in accurate portrayals parallels an improvement in psychiatric diagnoses, she told 

In her own work,Wolz uses movies as a catalyst for the psychotherapeutic process and for educating mental health professionals. Currently, she is developing an online continuing education program for psychologists and others that will utilize specific movies to illustrate diagnoses cited in 

It is a way to learn about fairly dry material in an entertaining format, she explained. For example, the movie 

 can be helpful in diagnosing obsessive-compulsive disorder, while 

 presents a useful picture of bipolar disorder.

With Ofer Zur, PhD,Wolz has written an online CE course, "Therapeutic Ethics and the Movies-What Films Can Teach Psychotherapists About Ethics and Boundaries in Therapy."

 The course uses movie vignettes to discuss such ethical dilemmas as confidentiality, self-disclosure, touch, and out-of-office experiences.

"We looked at several movies where therapists are portrayed and in just about every one there is a boundary violation, so it is easy to portray ethical issues," Wolz said, adding that she and Zur are collaborating on a second course on ethics and the movies. Examples Wolz provided include Basic Instinct and Mr Jones, in which sexual relationships occur between therapist and client; Antwone Fisher, in which a client is invited to a family dinner with his therapist; and What About Bob? in which a client follows his analyst on his vacation.

Wolz also has developed an online course on cinema therapy. In the course description, she explains the power of films: "Movies affect us powerfully because the synergistic impact of music, dialogue, lighting, camera angles, and sound effects enables a film to bypass our ordinary defensive censors. They draw us into the viewing experience and at the same time-often more easily than in real life-afford a unique opportunity to retain a perspective outside the experience, the observer's view."

Just 2 minutes before an episode of the television show Boston Legal aired, Roger Pitman, MD, professor of psychiatry at Harvard Medical School, received a telephone call from his sister-in-law informing him that the show would include a segment on propranolol, a drug he was researching for the prevention and treatment of PTSD.

Mental Illness on the Screen: No More Snake Pit

What is comorbidity? Psychiatric comorbidity refers to the occurrence of 2 or more mental or substance use disorders within a certain period. Research shows that comorbidity of substance use and other psychiatric disorders is common and often worsens the prognosis for each disorder; increases the personal disease burden; increases the frequency of hospitalization (revolving-door effect); increases the risk of other medical and psychosocial consequences, including suicide; and makes treatment more difficult. What follows is a brief review of the epidemiology of comorbidity of illicit drug use disorders and major mental disorders, summarizing the results of several large epidemiologic studies conducted in the United States over the past 2 decades.

In order to maximize the ability to compare findings and draw conclusions across these studies, this review focuses on comorbidity of illicit drug use disorders and several mental disorders that have been consistently associated with them: antisocial personality disorder (ASPD), mood disorders, and anxiety disorders. Following a brief review of the published literature, we offer some interpretations and clinical implications of such comorbidity. Readers are directed elsewhere for reviews of the comorbidity of psychiatric disorders with alcohol use disorders in adulthood,

 and substance use disorders in childhood and adolescence.


Several large epidemiologic studies have directly examined the comorbidity of mental and illicit drug use disorders among adults in the United States. Major studies with published comparable data on this topic include the Epidemiologic Catchment Area(ECA) study, the National Comorbidity Survey (NCS), and the National Epidemio- logic Survey on Alcohol and Related Conditions (NESARC). These studies survey individuals from the general population, apply advanced sampling strategies to maximize generalizability and case yield, use standardized assessment instruments, define psychiatric disorders according to 

 and administer structured interview schedules by carefully trained interviewers. A snapshot of the methods of these studies is presented in 

From a statistical perspective, the probability of co-occurrence of mental and drug use disorders is indicated most commonly by the odds ratio (OR), which is an estimate of the likelihood that a certain event is the same for 2 groups. The OR is a convenient and widely used index of comorbidity that is readily interpretable and comparable across different epidemiologic studies.

 An OR of 1.0 means that the event is equally likely to occur in both groups of individuals; an OR exceeding 1.0 means that the event is more likely in the first group; an OR that is less than 1.0 means that the event is less likely in the first group.


Epidemiologic studies report extensive lifetime psychiatric comorbidity among people who have drug use disorders. Some of the most extensive and consistent findings have been reported among drug use disorders and ASPD, mood disorders, and anxiety disorders. 

 presents the associations between drug use disorders (separately for drug abuse and drug dependence) and these mental disorders according to published reports from the ECA study, NCS, and NESARC.

Several observations are apparent from the pattern of results in 

. First, the 3 studies show that drug use disorders are highly comorbid with ASPD, mood disorders, and anxiety disorders. The ORs are nearly universally greater than 1.0 and are statistically significant.

Second, the risk of ASPD, mood disorders, and anxiety disorders is notably greater for individuals with drug dependence than for those with drug abuse. The association between drug dependence and ASPD, for example, is 3 to 5 times greater than the association between drug abuse and ASPD. Regarding internalizing disorders, the association between drug dependence and any mood or anxiety disorder is 2 to 3 times greater than the association between drug abuse and any mood or anxiety disorder.

also shows higher ORs for drug dependence than for drug abuse across nearly all subtypes of mood and anxiety disorders, although it is particularly evident for bipolar disorder, mania, and panic with agoraphobia. Other findings from the NESARC show greater associations for dependence than for abuse across 8 specific drug use disorders.

Third, ASPD is the mental disorder most strongly associated with drug abuse or dependence. Across the 3 studies, the ORs between drug abuse or dependence and ASPD are consistently much higher (range, 2.5 to 16.7) than between drug abuse or dependence and any mood disorder (range, 1.7 to 7.1) or any anxiety disorder (range, 1.4 to 4.9).

Fourth, there is mixed evidence that mood disorders are more highly associated with drug use disorders than are anxiety disorders. The ECA study and the NESARC report ORs between drug use disorders and any mood disorder that are greater than the corresponding ORs for any anxiety disorder. Recent findings from the NESARC also show greater associations for mood disorders than for anxiety disorders across 8 specific drug use disorders, with the greatest associations between each of the specific drug use disorders and comorbid mood and anxiety disorder, followed by pure mood disorder, and then pure anxiety disorder.

 In contrast to the findings from the ECA study and the NESARC, the NCS reported associations between drug dependence and any anxiety disorder that exceed that for any mood disorder, whereas the OR for drug abuse and any mood disorder exceeded that for any anxiety disorder.

 presents additional findings from the NESARC indicating that certain pairwise associations between 

 drug use disorders are greater than others.

 This level of matching is made possible for the first time by the large sample size of the NESARC study. Results show that although nearly every specific mental disorder is positively and significantly associated with each specific drug use disorder, the magnitude of the associations is inversely related to the prevalence of the specific drug use disorder. That is, marijuana use disorder is by far the most prevalent drug use disorder, followed by cocaine use disorder, yet these drug use disorders generally show the weakest associations with mood, anxiety, and antisocial personality disorders. Conversely, low-prevalence drug use disorders (eg, sedative, opioid, and tranquilizer abuse or dependence) are more strongly associated with those mental disorders. Regarding the specific mental disorders, the largest ORs are seen for mania and panic disorder with agoraphobia. These mental disorders are most strongly associated with several less prevalent drug use disorders involving sedatives, tranquilizers, and opiates. The ORs for these associations range from 6.2 to 8.4.


Across major epidemiologic studies of adults living in the United States, there is a strong consensus that drug use disorders co-occur at higher-than-chance levels with ASPD, mood disorders, and anxiety disorders. The accord across the ECA study, NCS, and NESARC is particularly impressive given the nontrivial methodological differences across studies presented in 

The extensive comorbidity among these psychiatric disorders can be interpreted in several ways, although more fine-grained research is needed to understand the complexity of these co-occurring disorders. First, comorbid disorders are independent disorders with distinct courses that co-occur either by chance alone or because of methodologic issues that overestimate comorbidity. Large epidemiologic studies can be especially prone to overestimation if they focus only on lifetime diagnoses in mixed-age samples and use assessments that include subthreshold conditions as diagnoses.

 Yet, it is noteworthy that significantly elevated ORs are reported throughout the literature despite important methodological variations, including epidemiologic sample, assessment tools, diagnostic system, and time for estimating comorbidity (eg, lifetime, past year, past month).

A second interpretation poses that one disorder may influence the onset and/or course of the other disorder. On the one hand, comorbid mental disorders may increase the risk of progression from heavy misuse of drugs to addiction. The plausibility of this interpretation is supported by order-of-onset information from both epidemiologic studies and longitudinal studies that show that the first onset of a mood, anxiety, or conduct (the precursor to ASPD) disorder usually precedes the first onset of the comorbid drug use disorder.

Individuals with mood or anxiety disorders may use drugs to self-medicate, whereas individuals with externalizing problems may, by virtue of their deviant behavior, increase their opportunities to use drugs. Of interest, mania and panic disorder with and without agoraphobia were most strongly related to specific drug use disorders involving sedatives, tranquilizers, and opiates-perhaps suggesting a preference for substances that suppress CNS activity. On the other hand, drug use may influence the onset or course of mental disorders by mediating biologic and environmental factors.

Habitual drug use alters neuroanatomy in long-lasting ways, and these changes may increase vulnerability to psychiatric disorders.

 A recent review suggests that substance-induced mood and anxiety disorders are fairly common and that substance-induced psychopathology may necessitate treatment approaches that differ from disorders that are independent of drug addiction.

Third, drug use disorders and mental disorders co-occur because of shared causes that give rise to both disorders. Regarding the association between drug use disorders and ASPD, for instance, numerous researchers propose that neurobehavioral disinhibition is a common underlying vulnerability factor of both drug use disorders and antisocial syndromes.

Coupled with evidence linking self-regulatory deficits and substance use disorders to certain mesocorticolimbic brain circuits,

 it is plausible that disinhibited individuals are prone to chronically misuse drugs and engage in deviant behavior because of a lack of inhibitory mechanisms to appropriately modify their conduct. The notion of a shared cause for comorbid conditions is supported by evidence from longitudinal studies

 as well as twin studies implicating common genetic factors for all externalizing syndromes, including alcohol, drug, conduct, and antisocial personality disorders.


The clinical impact of comorbidity is substantial. Comorbid disorders are more serious and chronic than single disorders,

 and increase use of services and health care costs.

 Substance use can have a significant impact on the course of a comorbid mental disorder and the effect may vary depending on the type of drug misused, route of administration, severity of addiction, and the presence of physical dependence. Similarly, mental disorders can impact the outcome of the addiction depending on the severity of the mental disorder, level of cognitive impairment, and availability of internal resources to develop motivation to quit.

 In particular, several studies have shown that co-occurring depression or ASPD worsens the course of treatment in persons who have drug use disorders.

What is comorbidity? Psychiatric comorbidity refers to the occurrence of 2 or more mental or substance use disorders within a certain period. Research shows that comorbidity of substance use and other psychiatric disorders is common and often worsens the prognosis for each disorder.

Psychiatric Times Vol 24 No 4

Malingering: Key Points in Assessment

Psychiatric Polypharmacy: The Good, the Bad, and the Ugly

Mental Illness on the Screen: No More Snake Pit

Lifetime Psychiatric Comorbidity of Illicit Drug Use Disorders