Journal of Forensic Psychology Practice

ISSN: 1522-8932 (Print) 1522-9092 (Online) Journal homepage: www.tandfonline.com/journals/wfpp20

Factitious Psychological Disorders: The Overlooked

Response Style in Forensic Evaluations

RichardRogersPhD, Rebecca L.JacksonPhD & Patricia L.KaminskiPhD

To cite this article: RichardRogersPhD, Rebecca L.JacksonPhD & Patricia L.KaminskiPhD (2005)
Factitious Psychological Disorders: The Overlooked Response Style in Forensic Evaluations,
Journal of Forensic Psychology Practice, 5:1, 21-41, DOI: 10.1300/J158v05n01_02

To link to this article: https://doi.org/10.1300/J158v05n01_02

Published online: 11 Oct 2008.

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 FULL-LENGTH ARTICLE

Factitious Psychological Disorders:

The Overlooked Response Style
in Forensic Evaluations
Richard Rogers, PhD
Rebecca L. Jackson, PhD
Patricia L. Kaminski, PhD

ABSTRACT. Forensic psychologists face two formidable challenges in

the assessment of feigned mental disorders, not only identifying bogus
presentations but also determining their primary motivation. Regarding
the type of motivation, factitious presentations are largely overshad-
owed in forensic assessments by malingering. The study addresses the
diagnostic conundrums inherent in distinguishing factitial from malin-
gered presentations. As the first analogue research, it examines two fac-
titious conditions (i.e., dependent and demanding interpersonal styles)
and a malingered disability case. Advanced doctoral students in psychol-
ogy were used because of their sophisticated understanding. They were

Richard Rogers is Professor of Psychology, Rebecca L. Jackson is a PhD Candi-

date, and Patricia L. Kaminski is Assistant Professor of Psychology, Department of
Psychology, University of North Texas.
Journal of Forensic Psychology Practice, Vol. 5(1) 2005
http://www.haworthpress.com/web/JFPP
© 2005 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J158v05n01_02 21
22 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

administered the Personality Assessment Inventory (PAI) and Structured

Inventory of Malingered Symptomatology (SIMS) via a simulation de-
sign. Contrary to expectations, few differences were found between
factitial and malingering conditions on these measures. Of conceptual sig-
nificance, results indicated that both factitious groups espoused an acute
need for treatment. Of clinical relevance, the PAI Defensiveness Index
produced moderate to large effect sizes between malingering and facti-
tious presentations. Finally, the SIMS did not differentiate types of
feigned condition, although a new index appears promising. [Article cop-
ies available for a fee from The Haworth Document Delivery Service:
1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Web-
site: <http://www.HaworthPress.com> © 2005 by The Haworth Press, Inc. All
rights reserved.]

KEYWORDS. Factitious disorders, malingering, feigning, response

styles, and forensic evaluations

Clinical and forensic research on the detection of feigned mental dis-

orders has grown exponentially during the last two decades. Recent de-
velopments include the identification of empirically-validated detection
strategies (Rogers, 1997; Rogers & Bender, 2003), refinements in re-
search design (Rogers & Cruise, 1998), and application of meta-ana-
lytic methods (Berry, Baer, & Harris, 1991; Rogers, Sewell, & Salekin,
1994; Rogers, Sewell, Martin, & Vitacco, 2003). Research during this
period is also responsible for the origination of specialized measures of
feigned disorders, including the Malingering Probability Scale (Silver-
ton, 1999), the Structured Interview of Reported Symptoms (SIRS;
Rogers, Bagby, & Dickens, 1992), the Structured Inventory of Malin-
gered Symptomatology (SIMS; Smith, 1992), and the Miller Forensic
Assessment of Symptoms Test (M-FAST; Miller, 2001). These re-
search efforts focus almost exclusively on malingering with virtually no
research on factitious disorders.
Feigned mental disorders are classified by the DSM-IV Text Revi-
sion (DSM-IV-TR; American Psychiatric Association, 2000) as either
malingering or factitious disorders by the source and the type of pre-
sumed motivation. Malingering is characterized by “external incen-
tives” in contrast to the “intrapsychic need to maintain the sick role”
associated with factitious disorders (American Psychiatric Association,
2000, p. 739). This dichotomization based on inferred motivation has
 Full-Length Article 23

been questioned on both conceptual and clinical grounds. Because pa-

tients often have multiple motivations, Cunnien (1997, p. 24) affirmed,
“the false dichotomy (factitial versus malingering) in DSM-IV does not
correspond to clinical realities.” Clinically, the task of establishing pre-
cise motivations in deceptive clients may lead to unsubstantiated infer-
ences (Rogers & Neumann, 2003). Clearly, research on psychological
measures is needed to evaluate whether clinical differences can be ob-
served between malingered and factitial presentations.
Cunnien (1997) attempted to catalogue the different types of motiva-
tion underlying factitious disorders. Intrapsychic formulations included
masochism, regression, and repetition compulsion. Cunnien also pos-
ited two key interpersonal dynamics: (a) dependency needs fulfilled by
health care providers, and (b) anger and conflict toward authority fig-
ures, such as health care professionals. These dynamics are exhibited in
treatment in seeking nurturance through unnecessary treatment, yet be-
coming resistive to therapeutic interventions (Eisendrath, Rand, &
Feldman, 1996; Overholser, 1990). The role of these interpersonal dy-
namics in influencing clinical presentation is only known through case
studies and has yet to be formally investigated (Feldman & Smith,
1996).
Despite an extensive literature, the standardized assessment of facti-
tious presentations has been largely neglected in the clinical research.
Focusing on Factitious Disorders with Predominantly Psychological
Signs and Symptoms (subsequently referred to as “Factitious-Psycho-
logical Disorders”), most published research is limited to case reports
(Parker, 1996). As a rare exception, Rogers et al. (1992; see also Rog-
ers, Bagby, & Vincent, 1994) systematically compared SIRS profiles
for 11 patients with factitious disorders to 36 suspected malingerers.
Overall, similar profiles were observed for both groups. However, pa-
tients with factitious disorders exhibited fewer marked elevations on
primary scales.1 Despite extensive research on multiscale inventories and
feigned mental disorders, investigations of Factitious-Psychological Dis-
orders remain conspicuously absent. In conducting PsychINFO searches
for leading multiscale inventories, we found negligible research beyond
case studies that address Factitious-Psychological Disorders on the
MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989)
and no research on the Personality Assessment Inventory (PAI; Morey,
1991).
The lack of any systematic data differentiating factitious and malin-
gered presentations has both diagnostic and forensic implications. Di-
agnostically, practitioners are tempted to make unwarranted inferences
24 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

about underlying motivations that cannot be substantiated by standard-

ized measures (Feldman, Hamilton, & Deemer, 2001). As observed by
Rogers and Neumann (2003), the two current approaches are unsatis-
factory. First, questioning factitious patients about their presentation is
unhelpful because of their demonstrated dishonesty and theorized un-
awareness of intrapsychic motivations. Second, inferential reasoning is
highly suspect, given the perils of equating a possible consequence
(e.g., not working) with a potential motivation (e.g., desire to be a pa-
tient). The fundamental error of inferential reasoning is best demon-
strated by physical illnesses. As an extreme example, would anyone
blithely argue that most cancer patients with poor recovery are uncon-
sciously desiring to be patients?
The forensic implications of this differential diagnosis (factitious
disorders versus malingering) cannot be overlooked. It may profoundly
affect the outcome, especially in disability cases. When an expert con-
cludes that the claimant is malingering, this conclusion is likely to play
a decisive role in the ending of compensation and termination of treat-
ment. Moreover, a malingering determination casts great doubts on the
validity of any future claims. In direct contrast, a factitious disorder is
considered a legitimate diagnosis; it may not result in the same dire con-
sequences found with malingering. Thus, the forensic expert is faced
with conflicting responsibilities in attempting to safeguard the rights of
the claimant (i.e., avoid misclassification of malingering) and the rights
of society (i.e., avoid fraud via malingering).
The current study is seen as the first of many steps in systematically
evaluating differences between factitious and malingered presentations.
Using an analogue design, two factitious presentations are compared to
a malingered disability case.

METHOD

Design

The study uses an analogue design with three experimental and one
control condition. Two experimental conditions address different types
of factitious presentations based on Cunnien’s (1997) formulation: de-
pendency on staff and demandingness on staff. We chose these interper-
sonal motivations because treatment seeking has a strong interpersonal
component, and because they avoid the challenges of simulating intrapsy-
chic motivations. While not mutually exclusive, they also appeared to repre-
 Full-Length Article 25

sent markedly different (i.e., dependency vs. demandingness) interpersonal

styles.
As the first analogue research on factitious presentations, the study is
largely exploratory in nature. However, we have two initial hypotheses.
Because factitial patients are overly invested in treatment, we surmised
that factitial groups would have lower scores on the PAI Treatment Re-
jection (RXR) scale than both malingering and control groups. Low
scores on RXR characterize clients with an acute need for treatment
(Morey, 1991, p. 20). We also hypothesized differences on the Domi-
nance (DOM) scale would be higher in factitious-demanding than fac-
tious-dependent groups based on their interpersonal presentations.

Participants

Doctoral students (N = 65) were recruited for the study from profes-
sional training programs (i.e., clinical, counseling, and health psychol-
ogy) at the University of North Texas (UNT). These students participate
in the same general core of graduate courses. Based on program require-
ments, each participant has graduate coursework in advanced psychopa-
thology and psychological assessment, in addition to supervised prac-
ticum training. To avoid any possible identification of participants, de-
mographic information was collected separately from the psychological
measures.
The sample was predominantly female (48 or 73.8%) with an M age
of 29.37 (SD = 7.43; range from 22 to 54). Based on self-identified eth-
nicity, the sample was composed of 2 (3.1%) African Americans, 1
(1.5%) Asian American, 57 (87.8%) European Americans, 4 (6.2%) His-
panic Americans, and 1 (1.5%) not identified.

Measures

Personality Assessment Inventory (PAI). The PAI (Morey, 1991) is a

344-item multiscale inventory designed to assess clinical syndromes rele-
vant to “contemporary diagnostic practice” (p. 1). With easily-read items
(Flesch-Kincaid = 4th grade), diagnostically relevant information is or-
ganized into 11 clinical scales, 5 treatment scales, and 2 interpersonal
scales. Four validity scales are also available for the assessment of re-
sponse styles. Of relevance to the current study, Morey (1996) supple-
mented the validity scales with the Malingering Index (MAL) and the
Defensiveness Index (DEF). The PAI was selected because (a) its non-
overlapping scales enhance discriminant validity, and (b) its feigning re-
26 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

search has incorporated both simulation designs and known-groups com-

parisons (Rogers, Sewell, Cruise, Wang, & Ustad, 1998).
Structured Inventory of Malingered Symptomatology (SIMS). The
SIMS (Smith, 1992) is a 75-item, true-false screen for feigned psycho-
pathology and cognitive impairment. With an easy reading comprehen-
sion (Flesch-Kincaid = 5.3 grade), the SIMS was chosen as an estab-
lished screen for feigned mental disorders with five scales covering
broad domains: Psychosis (P), Affective Disorders (AF), Low Intelli-
gence (LI), Amnesia (A), and Neurological impairment (N). Simu-
lation research (Edens, Otto, & Dwyer, 1999; Lewis, Simcox, & Berry,
in press; Rogers, Hinds, & Sewell, 1996; Smith & Burger, 1997) sug-
gests promise for the SIMS in identifying potential feigners, although
no research is available on its use for patients with factitious disorders.

Methodological Issues

Analogue research on response styles has raised important method-

ological concerns (Rogers, 1997). To ensure that the instructional set re-
garding clinical presentation was clearly understandable, doctoral
students with advanced training in professional psychology were se-
lected as participants. Because past research (Rogers & Cruise, 1998)
has demonstrated the need for participants to be familiar with scenarios,
we created a scenario (i.e., outpatient setting) with which the partici-
pants could closely identify.
A fundamental component of analogue research is to offer partici-
pants some incentive to parallel, even symbolically, the potential
real-world gains for feigning. Toward this end, a modest financial in-
centive was provided for completing the experimental conditions. We
realized this incentive was “external” (i.e., analogous to malingering)
but concluded that the need (participant recruitment and involvement)
outweighed this methodological constraint. Our assumption is that
many factitious patients are motivated by their patient roles but still re-
ceive some external benefits (e.g., worker’s compensation or decreased
parental responsibilities).
One challenge for simulation research is approximating the factitial
motivation to assume the patient role. Factitious patients are aware of
their motivation to feign but have only an incomplete awareness of the
underlying reasons. In developing the instructions for the factitial con-
ditions, we described in detail the patient’s perceived needs for much
more professional care and treatment. In order to parallel the modest
 Full-Length Article 27

level of insight reported with factitious patients, we carefully avoided

any diagnostic terms or clinical interpretations in the instructional sets.
An additional issue in analogue research is whether the study is mea-
suring the effects of role-playing per se (i.e., adopting an outpatient sta-
tus) or the factitious condition (e.g., factitious-demanding vs. control).
To address this issue systematically, all participants including controls
were asked to assume the same basic role of an outpatient at a private
clinic. This modification minimizes any “patient-role” effects for the
subsequent analyses (see Kroger & Turnbell, 1975; Rogers, 1997).

Procedure

In accordance with the University of North Texas Institutional Re-

view Board, all participants gave informed consent prior to their in-
volvement in the study. A quasi-random procedure was used for the
assignment of participants to experimental or control conditions. Single
sets of instructions were placed individually in unmarked packets with
test materials and intermixed. These packets were consecutively distrib-
uted to qualified participants. Under supervision, participants were
tested in small groups at the end of an organized practicum or their labo-
ratory training.
Participants were provided with a packet of materials including a de-
scription of the study, their control or experimental instructions, the
PAI, and the SIMS. Participants were free to choose which measure
they completed first. Following their completion of the two measures,
they replaced the materials in an unmarked envelope. The total partici-
pation time typically was less than one hour.
A cumulative list of participants was kept entirely separate from the
research packets. Participants in the control condition were paid $20.00
for their time. Participants in the experimental conditions were told they
would be remunerated $20 for successfully role-playing their instruc-
tions. In the absence of empirical data on Factitious-Psychological Dis-
orders, we did not attempt to operationalize success; therefore, each
participant was paid $20 at the conclusion of data collection.
Because their anonymity was guaranteed, we did not interview par-
ticipants individually about their role-playing condition following data
collection. Participants retained their instructions throughout the entire
study. We deemed it very unlikely that doctoral students intentionally
failed2 to follow simple instructions, given the brevity of the study, the
ongoing availability of the instructions, and the financial incentive.
28 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

Instructional Sets

Prior to receiving specific instructions, all participants were asked to

role play an outpatient at a private clinic receiving weekly individual ther-
apy from his or her psychologist for the past six months. Participants were
also asked to assume that they are financially comfortable and clinically
stable with no mental health crises.
Factitious-Dependent Condition. Participants in this condition were asked
to role-play outpatients adulating their psychologists and wanting more ser-
vices as needy patients, immersed in the sick role. Participants were given the
following description:

You quietly admire your doctor and her clinical abilities. You feel ac-
cepted and cared for in her presence. Although you have friends and
family, nothing fulfills you like seeing your psychologist and being
involved at the clinic. You are hoping to be seen for at least 2 or 3
therapy sessions per week. If only you could be seen daily. You also
wonder about whether private inpatient treatment would fulfill your
needs to feel accepted. You are worried that your psychologist and
other health care providers do not realize fully the importance of their
help to you.

Factitious-Demanding Condition. Participants in this condition were

asked to role-play outpatients feeling hurt, frustrated, and neglected because
their treatment needs were not being met. Participants must seek actively the
care that they needed and deserved. Participants were given the following
description:

You are increasingly frustrated that your doctor is not providing you
with the treatment you need. She acts like you should be satisfied with
your weekly appointments. You are tired of being treated like an ordi-
nary client with ordinary problems. You need lots of therapy. You
want to be treated seriously with at least several therapy sessions per
week. You might even need inpatient treatment. You feel good after
therapy sessions. You deserve to feel good each day. While not pushy
in other parts of your life, you realize that you will have to act differ-
ently to get the treatment, care, and attention you deserve.

Malingering Condition. Participants in this condition were asked to

role-play outpatients in danger of losing their positions as high-paid profes-
sionals in a company that is downsizing. Participants were presented with
 Full-Length Article 29

an alternative to job termination, namely the feigning of a disability claim

that would bring generous compensation. Participants were given the follow-
ing description:

You know that a second round of job cuts is inevitable. As a highly

paid professional, you know you will be on the chopping block. You
see a way out. If you could appear disabled, the firm would have trou-
ble firing you without looking like they were violating the Americans
With Disabilities Act. Anyway, you deserve some time off at their ex-
pense after all your work. Plus, you have your private disability insur-
ance that would pay you generously. Naturally, you are stressed and
upset by your current circumstances, but are not really disabled. If you
are going to succeed, you have prove that you are unable to function at
your profession (i.e., 100% disabled). Obviously, you have to be credi-
ble in your presentation if you want to secure your financial future.

Control Condition. Participants in this condition were asked to role-play

outpatients that were being evaluated simply to document their progress in
therapy. Participants were given the following description:

Please complete the following tests as honestly as possible. You have

no vested interest in making your current problems or symptoms any
better or any worse than they are for you in your actual life as a UNT
graduate student. Your answers are entirely anonymous.

Statistical Comparisons

A methodological constraint on the current study is the absence of a large

clinical comparison sample. To address this issue, we conducted selected
analyses that incorporated PAI data from Rogers, Sewell, Morey, and Ustad
(1996) on 221 patients. For the SIMS, we computed a new variable (AF-N,
see Table 1) on Lewis et al. (in press) data from a forensic sample.

RESULTS

Differences in Clinical Presentation

Differences were examined via ANOVAs between factitious presen-

tations, malingering, and control conditions. We sought to minimize
Type I error via Bonferroni corrections for family-wise error (.05/18
30 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

TABLE 1. Differences in Clinical Presentation on SIMS Scales for Factitious

Disorders, Malingering, and Controls

Factitious Presentation Effect sizes

Scale Dependant Demanding Malingering Control d1 d2 d3 d4 d5 F

N 2.93ab 3.24ab 5.63a .63b 1.74 7.00**
3.22 3.50 3.86 1.26
AF 8.14a 9.41a 7.13ab 5.06b .98 1.57 6.54**
3.23 2.48 2.87 3.04
P .93a .65a 1.00a .25a 1.14
1.64 1.22 1.41 .58
LI .88a 1.29a 1.69a .94a 1.79
.86 .85 1.66 .85
AM 2.21a 2.18a 2.56a .69a 1.48
3.45 3.05 2.92 .87
a
Total 15.07ab 16.76 18.00a 7.56b 1.35 1.45 5.33*
score 10.03 8.13 8.81 4.97
AF-N 5.21a 6.18a 1.50b 4.44a 1.13 1.39 1.00 6.75**
3.19 3.40 3.35 2.45

Note. The M for each scale is presented in the first row, followed by the SD in the second row. SIMS = Structured Inven-
tory of Malingered Symptomatology; For SIMS scales, AF= Affective Disorders, P = Psychosis, N = Neurological
Impairment, LI = Low Intelligence, and AM = Amnesia. For effect sizes (Cohen ’s d), d1 = Dependent vs. Malingering;
d2 = Demanding vs. Malingering; d3 = Dependent vs. Control; d4 = Demanding vs. Control; d5 = Malingering vs Control.
Using Tukey HSD, groups with the same subscripts are not significantly different.
*p < .01; **p < .001

comparisons = .003). As summarized in Table 2, three clinical scales

produced significant group differences with feigned conditions (i.e.,
factitious and malingering) generally producing higher elevations than
the control group. Interestingly, these scales evidenced mostly mild ele-
vations (e.g., 60T) for the feigned conditions.
Several important findings emerged from the ANOVAs. First, the
two forms of factitious presentations appeared to be very similar, based
on Tukey HSD post-hoc comparisons (i.e., all ps > .50). Second, the
malingering group obtained significantly lower elevations on the Bor-
derline Scale than either factitious-dependent (Cohen’s d = 1.24) or fac-
titious-demanding (d = 1.22) groups. Inspection of Borderline subscales
revealed that the major difference occurred on the Identity Problems
(BOR-I) subscale. Specifically, Tukey post-hoc comparisons indicated
a high likelihood of significance (i.e., ps < .001); large effect sizes were
also observed between malingering and (a) factitious dependent (d =
2.43) and (b) factitious demanding (d = 1.51) groups.
As a supplementary analysis, we computed effect sizes for BOR and
BOR-I comparing our current experimental conditions to data on 221
bona fide patients in Rogers, Sewell et al. (1996). We found moderate to
large effect sizes on the BOR scale with genuine patients lower than
factitious-dependent (d = .79), factitious-demanding (d = .69), and malin-
 Full-Length Article 31

TABLE 2. Differences in Clinical Presentation on PAI Clinical, Treatment, and

Interpersonal Scales for Factitious Disorders, Malingering, and Non-Clinical
Controls

Factitious Presentation Effect Sizes

Scale Dependent Demanding Malingering Control
(n = 14) (n = 18) (n = 17) (n = 16) d1 d2 d3 d4 d5 F
SOM 55.14a 57.67a 61.29a 47.63b 1.31 1.76 1.98 11.31***
7.23 6.90 8.81 3.95
ANX 57.79ab 54.17a 51.48ab 48.13b .94 2.60
6.17 8.16 6.26 3.48
ARD 47.64ab 57.72b 43.76ab 40.25a 1.97 4.95*
10.58 11.18 8.39 5.08
DEP 60.07a 59.56a 58.76a 52.00b 1.17 1.15 1.08 3.93*
9.32 8.33 7.97 3.58 1.11
MAN 35.14a 38.06a 37.94a 34.88a
5.90 6.35 9.15 4.16
PAR 61.64a 59.78a 56.18ab 52.81b 1.83 .99 5.82***
4.52 6.72 6.41 7.34
SCZ 52.58a 50.67a 51.06a 47.56a 1.43
7.19 6.62 8.88 3.86
BOR 54.21a 55.67a 46.88b 44.56b 1.24 1.22 2.10 1.75 12.56***
4.50 7.50 6.83 4.72
ANT 45.79a 48.28a 47.82a 45.50a .86
4.84 4.88 9.25 3.92
ALC 51.29a 53.17a 51.88a 49.94a .77
. 5.97 7.90 6.52 3.66
DRG 56.14a 56.00a 56.47a 55.50a .13
4.19 4.90 4.33 4.41
AGG 49.14a 51.00a 49.35a 49.56a .39
6.90 3.79 6.24 5.33
SUI 57.36a 58.39a 54.59a 50.19a 2.62
10.51 11.88 8.44 3.06
STR 48.79a 49.28a 45.12a 43.75a 2.73*
7.95 7.95 4.18 5.90
NON 69.36a 66.17a 65.53a 60.88a 1.94
10.57 9.26 8.66 10.76
RXR 38.71ab 36.83a 44.47bc 49.88c .95 1.43 1.88 9.10***
6.88 5.20 10.22 8.50
DOM 28.21a 31.17ab 35.29b 33.63ab 1.33 3.82
4.89 6.32 5.62 7.44
WRM 28.36a 26.28a 27.76a 31.88a 1.75
6.20 8.33 8.21 5.77

Note. The M for each scale is presented in the first row, followed by the SD in the second row. For PAI scales, SOM =
Somatic Complaints; ANX = Anxiety; ARD = Anxiety-Related Disorders; DEP = Depression; MAN = Mania; PAR = Para-
noia; SCZ = Schizophrenia; BOR = Borderline Features; ANT = Antisocial Features; ALC = Alcohol Problems; DRG =
Drug Problems; AGG = Aggression; SUI = Suicidal Ideation; STR = Stress; NON = Nonsupport; RXR = Treatment
Rejection; DOM = Dominance; WRM = Warmth. Effect sizes (Cohen=s d) are reported for significant post-hoc comparisons:
d1 = Dependent vs Malingering; d2 = Demanding vs. Malingering; d3 = Dependent vs. Control; d4 = Demanding vs. Con-
trol;d5 = Malingering vs Control.
Using Tukey HSD, groups with the same subscripts are not significantly different.
For tests of significance, *p < .05 (nonsignificant trend), **p < .003 (significant with Bonnferoni correction), ***p < .001.

gering (d = 1.35) conditions. In contrast, BOR-I produced only modest ef-

fect sizes with factitious-dependent (d = .24) and factitious-demanding (d =
.56) conditions, but yielded a large effect size with malingering (d = 1.50).
Regarding the treatment scales, the primary motivation for factitious
disorders is the embracement of the patient role. As hypothesized, we
expected that participants in the factitious conditions would score low
on the Treatment Rejection (RXR) scale. This expectation was con-
32 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

firmed (i.e., RXR < 40T) for both factitious groups indicating an acute
need for professional interventions. In particular, the factitious-de-
manding group was significantly lower than malingering (d = .95). In-
terestingly, genuine patients also tend to score low on RXR; as a
supplementary analysis, we compared these factitious groups to genu-
ine patients in Rogers, Sewell et al. (1996). These comparisons re-
vealed negligible effect sizes for both factitious-dependent (d = .00) and
factitious-demanding (d = .16) conditions.

Detection of Factitious Presentations

PAI. We tested via ANOVAs the potential usefulness of PAI validity

scales for the detection of factitious simulators. Contrary to our expec-
tations, NIM was relatively ineffective (see Table 3) with the only sig-
nificant difference being between factitious-demanding and control
conditions. Moreover, the factitious-dependent and malingering groups
averaged in the normal range suggesting a lack of utility for NIM with
sophisticated simulators. Based on extensive simulation data and
known-groups comparisons, Rogers et al. (1998) had established that a
NIM < 77T indicated a high likelihood of nonfeigned responses. This
cut score was successful only 50% of the time with Negative Predictive

TABLE 3. Differences in Clinical Presentation on PAI Validity Scales for Facti-

tious Disorders, Malingering, and Non-Clinical Controls

Factitious Presentation Effect sizes

Scale Dependent Demanding Malingering Control d1 d2 d3 d4 d5 F
ICN 69.79a 65.33a 69.12a 67.31a .48
10.09 6.61 6.60 19.42
INF 65.21a 62.11a 63.65a 61.50a .78
7.63a 6.94 8.84 5.63
NIM 57.50 63.56a 56.00a 45.25b 2.22 10.06***
13.64 11.07 8.92 2.46
PIM 50.07ab 45.44a 57.47b 56.38b 1.26 1.30 5.28
13.08 8.37 10.61 8.50
MAL .36a .67a .29a .31a 1.47
.50 .69 .59 .60
RDF 69.36a 64.44a 66.18a 64.19a 1.13
6.93 8.83 10.01 8.27
DEF 1.50a .83b 2.53c 2.56c .91 1.73 1.11 2.16 13.14
1.16 .86 1.10 .73

Note. The M for each scale is presented in the first row, followed by the SD in the second row. For PAI validity scales,
ICN = Inconsistency; INF = Infrequency; NIM = Negative Impression; PIM = Positive Impression; MAL = Malingering In -
dex; RDF = Rogers Discriminant Function; DEF = Defensiveness Index. For effect sizes (Cohen=s d), d1 = Dependent
vs. Malingering; d2 = Demanding vs. Malingering; d3 = Dependent vs. Control; d4 = Demanding vs. Control; d5 = Malin-
gering vs. Control.
Using Tukey HSD, groups with the same subscripts are not significantly different.
**p < .005; ***p < .001
 Full-Length Article 33

Power (NPP) estimates ranging from .47 to .55. Likewise, MAL pro-
duced raw scores for the three feigning groups that were remarkably
unelevated (Ms < 1.00).
An unexpected finding was the notable absence of defensiveness for
the factitious-demanding group. Its scores on PIM (M = 45.44T) aver-
age more than 10 points lower than either the malingering or the control
conditions. Similarly, the factitious-demanding group’s Defensiveness
Index (M = .83) is substantially lower than the other groups and the pub-
lished national norms (Morey, 1996) for community (M = 2.81; SD =
1.52) and clinical (M = 1.66; SD = 1.54) samples. The factitious-depend-
ent group (M = 1.50) is lower than the malingering and control conditions
but comparable to the national clinical norms. Subject to cross-validation,
a DEF cut score ⱕ1 for factitious cases may have some clinical useful-
ness in discriminating factitious from malingering cases. For the current
data (see Table 4), this cut score produced moderate sensitivity (.59) and
an excellent PPP (.90).
We were interested in whether PAI validity and treatment scales
might differentiate between factitious and malingering presentations.
As a preliminary step, we conducted two stepwise discriminant analy-
ses that were limited to two independent variables in order to achieve an
adequate (20:1) subject-to-variable ratio. With the factitious groups col-
lapsed, the first analysis was limited to PAI clinical scales and resulted
in a significant discriminant function (Wilks’ lambda [2, 46] = .594, p <
.001) with standardized canonical coefficients for BOR (.846) and DOM
(⫺.698). With a hit rate of 81.6%, the discriminant function appeared po-
tentially useful in identifying possible factitious cases with a sensitivity
of .78 and PPP of .93 (see Table 4). The second discriminant function,

TABLE 4. Selected Utility Estimates for Differentiating Factitious from Malin-

gered Presentations

Scale/Index PPP NPP Sensitivity Specificity Hit rate

PAI DEF ⱕ 1 .90 .54 .59 .88 .69
PAI Discrim #1 .78 .88 .93 .68 .82
PAI Discrim #2 .97 .84 .91 .94 .92
PAI Discrim #3 .89 .67 .78 .82 .80
SIMS Af-N ⱖ 1 .78 1.00 1.00 .31 .77

Note. Utility estimates are based on the classification of factitious presentations. For PAI discriminant analyses, #1 = clinical
scales (BOR and DOM entered); #2 = PAI clinical subscales (BOR-I and SOM-C entered); #3 = validity and clinical scales
(BOR and DEF entered). For SIMS, AF-N = arithmetic difference between AF and N.
34 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

limited to PAI subscales, explained the majority of the variance (56.1%)

with a Wilks’ lambda (2, 46) = .439, p < .001. The discriminant function
coefficients (BOR-I = .937; SOM Conversion [SOM-C] = ⫺.698)
achieved a high hit rate of 91.8%. For factitious cases, the sensitivity (.88)
and PPP (.97) are very promising.
We conducted a third stepwise discriminant analysis, limited to two
steps, that allowed both validity and clinical scales to enter. Two scales
(DEF = .704; BOR = ⫺.715) produced a significant discriminant func-
tion with Wilks’ lambda (2, 46) = .586, p < .001. With a hit rate of
79.6%, this function proved moderately successful at identifying facti-
tious cases with a sensitivity of .78 and a PPP of .89. However, the addi-
tion of the PAI validity scales did not appear to add incremental accuracy
to the discriminant function.
SIMS. Participants in the feigning conditions were unrestricted in the
type of disorders that they simulated. Despite this latitude, only two scale
differences were observed (see Table 3): (a) malingerers scored higher
than nonclinical controls on the N scale, and (b) factitious conditions (de-
pendent and demanding) scored higher than controls on the AF scale. Un-
fortunately, no differences were found between factitious and maling-
ering conditions. Based on the first two findings, we computed a new
variable AF minus N (i.e., AF-N), which resulted in a much lower score
for the malingering condition (1.50) than both factitious conditions (5.21
and 6.18). Clearly, AF-N may capitalize on chance variation, especially
given our limited sample and the analogue design. Therefore, we com-
puted AF-N on Lewis et al. (in press) SIMS data for suspected malinger-
ers (M = 0.50) and genuine patients (M = 2.60) in a forensic setting. All
factitious participants and nonclinical controls scored ⱖ 1 on AF-N. In
differentiating factitious from malingered presentations (see Table 4), a
cut score ⱖ 1 was indicative of factitious presentation (sensitivity = 1.00
and NPP 1.00) for the current data but yielded only a modest specificity
of .31.

DISCUSSION

The discussion examines the clinical presentation of factitious pa-

tients and the clinical usefulness of available detection methods. The
implications for forensic practice are considered in light of the current
findings and past research.
 Full-Length Article 35

Clinical Presentation

The clinical presentation of Factitious-Psychological Disorders on

multiscale inventories and other psychological measures remains virtu-
ally unresearched. In current analogue research, inspection of clinical
scales for both factitious groups suggests a similar pattern with mild ele-
vations (60T) on DEP and PAR. Using the clinical validation sample
(Morey, 1991, p. 139) as a reference point, this pattern of mostly
unelevated scores is similar to Cluster 1. This cluster occurs frequently
(22.3%) with its modal clinical scales ranging from 47T to 55T (Morey,
1991, p. 23). For DEP, the main contributions for the factitious presen-
tations appear to be negative thoughts about inadequacy and low
self-worth with an elevated Depression-Cognitive subscale (combined
factitious M = 66.00T). For PAR, the primary contributions appear to be
bitterness and resentment toward others with an elevated PAR-Resent-
ment subscale (combined factitious M = 65.22T). While useful on a de-
scriptive level, these simulated factitious profiles do not appear to
constitute a unique pattern that can be discriminated from other disorders
in the clinical validation sample (Morey, 1991).
Factitious-Psychological Disorders are distinguished from malinger-
ing by their predominant motivation to adopt the patient role. As ex-
pected, both factitious groups scored low on RXR indicating an acute
need for psychological treatment. Pending further research, this finding
may have important forensic implications in differentiating between
factitious and malingered presentations. For example, we found most
(87.5%) factitious participants had below average scores with RXR ⱕ
45⌻.
Attempts to differentiate subtypes of Factitious-Psychological Disor-
ders based on interpersonal style (i.e., dependent vs. demanding)
proved unsuccessful. With our analogue design, the factitious groups
produced highly similar clinical profiles with no significant differences
in post-hoc comparisons. In particular, we were surprised not to find the
hypothesized differences on the Dominance (DOM) scale (see Table 1).
We had expected low scores for the factitious-dependent group and
high scores for the factitious-demanding group. Contrary to our expec-
tations, both groups yielded very low scores (combined M = 29.88T);
scores in this range suggest submissive persons unlikely to get their needs
met. One possible explanation is that moderate elevations on DOM are
also associated with self confidence and self reliance. Whether dependent
or demanding, factitious participants likely would want to avoid any per-
ceptions of self efficacy in their efforts to secure more treatment.
36 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

Detection Methods

Our assessment of validity scales relied on an empirical analysis

(Meehl, 2000), given the lack of any theoretical basis for differentiating
factitious-psychological and malingering presentations. Nonetheless,
we were surprised that the absence of defensiveness provided the best
differentiation between the two groups. This finding is partially consis-
tent with Greene’s (2000) bipolarity hypothesis suggesting that defen-
siveness should decrease as feigning increases. However, we are unable
to explain why this finding applies differentially to factitious disorders.
As noted in Table 2, the factitious-demanding condition yielded low-av-
erage scores on PIM (45.44T) and very low scores on DEF (.86). Specifi-
cally with DEF, our preliminary data suggest some promise for a cut
score ⱕ 1 for differentiating factitious and malingering cases.
The substantial overlap on PAI scales between factitious and malin-
gering conditions militated against the establishment of traditional cut
scores. Preliminary results of a stepwise discriminant analysis suggest
some promise for the use of BOR-I and SOM-C, which yielded impres-
sive utility estimates. Unlike traditional studies of malingering, differ-
ences in clinical scales and subscales appear to be a central component in
any differentiation between factitious and malingered presentations. In-
deed, the addition of validity indicators did not improve the discriminant
function. As an important caution, single-stage discriminant analyses may
capitalize on chance variation and often produce spuriously high classifica-
tion rates. In addition, this finding may not extend to different experimen-
tal conditions (e.g., scenarios) or other measures.
Beyond the PAI, we investigated the usefulness of the SIMS as a
clinical screen for feigned mental disorders. In the analogue design, the
SIMS scales and total score did not differentiate between the facti-
tious-psychological and malingering conditions. However, the use of
AF-N produced large effect sizes between these feigning conditions. As
partial cross-validation, AF-N produced even lower scores when ap-
plied to the Lewis et al. (in press) data. For the current data, negative
scores appeared indicative of malingering. One possible explanation is
that malingerers may be less discriminating than factitious cases in their
presentations endorsing substantial levels of mood and neurological
symptoms. Alternatively, the observed difference may be an artifact of
the instructional sets that emphasize purported disabilities for the ma-
lingering condition. Clearly, this finding deserves further investigation.
 Full-Length Article 37

Implications for Forensic Practice

The differential diagnosis between Factitious-Psychological Disor-

ders and malingering, while controversial, has profound implications
for forensic practice, especially with disability cases. Non-empirical
methods, such as further inquiry or inferential reasoning, lack even the
conceptual basis for their continued use in forensic evaluations. Unfor-
tunately, our empirically-based knowledge of Factitious-Psychological
Disorders is very limited.
Available data from Rogers et al. (1992) suggest that factitious pa-
tients do not typically provide extreme presentations with respect to
spurious symptomatology. The present findings do not contradict Rog-
ers et al. (1992); however, the lack of any marked elevations for either
malingering or the two factitious groups is difficult to interpret. It is
quite possible that the level of sophistication among doctoral students
allowed them to suppress PAI scale elevations and thereby minimized
the likelihood of differences based on response styles.
Forensic psychologists are likely to be divided on the potential uses
of the current data. Clearly, the analogue data are preliminary and lack
cross-validation. For many psychologists, the current findings represent
an important stimulus for further research. Alternatively, some psychol-
ogists may pragmatically adopt the “best-available practices” perspec-
tive and consider preliminary data better than no data at all. From this
perspective, negative scores on the PAI Defensiveness Index or positive
scores on the SIMS AF-N would help to inform the forensic expert in
distinguishing factitious from malingered presentations. In no case
should past data (Rogers et al., 1992) or the current findings be viewed
as definitive.
In the absence of extensive research, forensic guidelines for the as-
sessment of Factitious-Psychological Disorders are difficult to estab-
lish. We suggest the following ideas for further consideration:

1. Forensic psychologists may wish to use the term “feigning” or

“dissimulation” (see Rogers, 1997) as generic terms for fabrica-
tions or exaggerations. They avoid the murkiness in attempting to
distinguish different motivations. In many forensic cases (e.g., in-
sanity evaluations), the fundamental issue is the genuineness of
the presenting disorder, and not distinctions between different
types of feigning.
2. In disability cases, forensic psychologists may wish to be forth-
coming about the limitations of their clinical methods. Given the
38 JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE

paucity of empirical data, experts cannot systematically rule-out

either response style.
3. Some forensic psychologists present their findings about response
styles to the client so as to hear his or her perspective. If the client
discloses an external motivation (e.g., financial gain), should the
experts include this admission in the forensic report? Because
Factitious-Psychological Disorders can only be diagnosed in the
absence of external motivation, a credible admission would assist
in the differential diagnosis. However, other psychologists may
be reluctant to use these admissions out of concern for potential
bias. If the clients’ statements can only be used for determinations
of malingering but never for genuine disorders (e.g., diagnoses of
factitious disorders), then their conclusions appear one-sided.
4. Forensic psychologists may be tempted to apply base-rates to
their determinations of malingering versus factitious disorders.
The forensic literature appears consistent in describing substantial
numbers of malingering cases (see Rogers, Salekin, Sewell,
Goldstein, & Leonard, 1998) in comparison to relatively few fac-
titious patients. We caution against the use of base rates. Because
Factitious-Psychological Disorders have been virtually ignored in
both forensic and clinical research, we cannot simply assume its
base-rate is negligible. Moreover, base-rates for malingering vary
markedly across forensic settings (Rogers & Salekin, 1998).

Final Commentary

We took considerable care in planning the first analogue study of fac-

titious disorders. Despite this care, the study has several important
methodological limitations. First, the study operationalized Cunnien’s
two interpersonal motivations but does not address intrapsychic mecha-
nisms. The use of an analogue design is likely to be a poor match for
intrapsychic dynamics. Nonetheless, the current results do not attempt
to capture the full complexity of factitious motivations. Second, the ap-
parent rarity of factitious-psychological disorders prevents researchers
from making a key comparison in examining the differences between
the current simulators and patients independently diagnosed as facti-
tious disorders via a known-groups comparison. Even with their clinical
sophistication, however, the current simulators may differ from true
factitious patients. Third, the construction of scenarios and instructional
sets are especially challenging for factitious presentations. Further re-
 Full-Length Article 39

search with varied scenarios and experimental conditions is definitely

needed.
In conclusion, the current study represents one of the first systematic
attempts to differentiate factitious presentations from malingering. Sur-
prisingly few differences were found between types of factitious pre-
sentations. Consistent with our hypothesis, treatment needs were very
salient for both factitious groups. Pending cross-validation, several
indices evidence considerable promise for differentiating types of
feigned presentations. Based on past and current findings, forensic issues
regarding Factitious-Psychological Disorders were examined with prac-
tical suggestions regarding terminology, limitations of assessment meth-
ods, potential bias, and misapplication of base-rates.

NOTES

1. Using optimized cut scores for four primary scales, few patients (12.3%) with
factitious disorders reached these cut scores as compared to malingerers (37.8%).
2. Our implicit assumption is that advanced doctoral students have the cognitive
abilities to comply with simple instructions and complete psychological measures re-
quiring less than a 6th grade education.

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RECEIVED: 10/15/03
REVISED: 12/12/03
ACCEPTED: 12/12/03