When assessing for malingered psychosis, Resnick's categories are particularly helpful. A patient feigning psychosis as described by pure malingering will often think that the more fantastic and bizarre the claim (eg, describing little people or Martians), the "crazier" he will seem. Because he has never experienced an actual hallucination, he may keep descriptions of the voices vague. He may not give the number of voices, sex, or exactly what is being said in the hallucinations.4 Among suspicious auditory hallucinations, Resnick lists commands that are always obeyed, are unassociated with delusions, are continuous rather than intermittent, occur in stilted language, or are voices seeking information.
Real delusions have an insidious onset and the patient is often hesitant to call attention to them. Malingering should be suspected in a delusion that presents acutely, is spotlighted by the patient, or is particularly bizarre without associated thought disorganization. Resnick describes suspicious visual hallucinations as those reported in black and white, miniature or giant, and again, bizarre without disorganization.4 Visions that change when the eyes are closed or those that occur alone are also suspect.
In partial malingering, thought disorganization becomes the most useful clue. A patient with a psychotic illness can often convincingly describe hallucinations and may actually have negative symptoms or be able to fake them, but disorganized thought processes are difficult to fake and are even more difficult to maintain.
For the same reason, mania is infrequently feigned. Pressured speech is a unique phenomenon, which for those not suffering from an affective disorder is nearly impossible to keep up. Merely extending the interview will expose a patient who is faking a manic episode, because the patient will tire. The pretense of mania is more often manifested in a reported history of past manic episodes in the context of a current presentation of depression. Again, the clinician must look for the lesser-known and atypical symptoms of depression. Hypersomnolence and hyperphagia are portrayed in popular culture as the usual presentation of depression. Most people do not realize that, more frequently, those suffering from depression lose weight and have difficulty in sleeping and that the former symptoms occur more in atypical depression. Malingerers who claim to be depressed may report having difficulty in falling asleep instead of the usual early morning awakening or frequent awakening. Open-ended questions provide security against giving the malingerer the clues he needs to be successful.
False imputation often manifests as pretended depression, posttraumatic stress disorder (PTSD), or other anxiety disorders. All these diagnoses are frequently the focus of disability claims, workers' compensation claims, or other civil litigation scenarios. Here, collateral information and detective work are essential. A thorough evaluation includes searching for past trauma and past symptomatology to determine the most likely cause of symptoms. The above disorders are particularly vulnerable to malingering because of the importance of patient-reported symptoms in the diagnosis.
Again, the length of the interview can wear down the deceptive patient. Asking the same question repeatedly in different contexts will often expose inconsistencies in the account of a patient who is malingering. Look for divergence in self-reported symptoms and behavior. It is not logical that a patient with PTSD reports avoidance of situations or things relating to an accident to an evaluating clinician but will repeatedly rehash the accident when the purpose is to direct blame or liability.
1. Texas Department of Insurance: Consumer. Insurance Fraud. August 2006. Available at: http://www.tdi.state.tx.us/consumer/cb044.html. Accessed January 11, 2007.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
3. Resnick PJ. Malingering of posttraumatic stress disorders. In: Rogers R, ed. Clinical Assessment of Malingering and Deception. 2nd ed. New York: Guilford; 1997:130-152. 4. Resnick PJ. Malingering. In: Rosner R, ed. Principles and Practice of Forensic Psychiatry. 2nd ed. New York: Arnold; 2003:543-554.
5. Thompson JW Jr, LeBourgeois HW III, Black WF. Malingering. In: Simon RI, Gold LH, eds. Textbook of Forensic Psychiatry. Arlington, Va: American Psychiatric Publishing; 2004:427-448.
6. Reznek L. The Rey 15-item memory test for malingering: a meta-analysis. Brain Inj. 2005;19:539-543.
7. Rogers R. Development of a new classificatory model of malingering. Bull Am Acad Psychiatry Law. 1990;18: 323-333.
8. Rogers R, Sewell KW, Goldstein A. Explanatory models of malingering: a prototypical analysis. Law Hum Behav. 1994;18:543-553.