Malingering – concept and

controversies
Chairperson Swapnajeet Sahoo
Junior Resident Fareed Oomer
Is malingering a psychiatric diagnosis?
• Malingering is a “V code” in DSM – 5
• Identifies conditions other than a disease or injuries
• Used for visits to the healthcare professional for purpose other than
for sickness. Example for annual physical, pregnancy, immunization –
coded as V Code for insurance purposes
Why is malingering important in psychiatry?
• Almost any illness that relies on self-report can be feigned
• Head injury and pain are the most commonly feigned mental
disorders
Overstated pathology
• Malingering – the intentional production of false or grossly exaggerated
physical of psychological symptoms motivated by external incentives
• Presence of malingering does not
Psychological rule
tests canoutbeco-occurrence
used to of internal motivations
• Factitious presentations – “intentional
establish feigning butproduction
not of feigning” of
symptoms that is motivated by the desire to assume a “sick role”
malingering
• Deceptive behaviour is evident even in the absence of obvious external rewards –
therefore – does not rule out external incentives but rather requires some unspecified
internal motivation
• Feigning – deliberate fabrication or gross exaggeration of psychological or
physical symptoms, without any assumption about its goals
• This term has been introduced because standardized measure of response styles (e.g.
psychological tests) have not bene validated to assess an individual's specific
motivations
(Rogers & Bender, 2003, 2013). (Rogers, Jackson, & Kaminski, 2004).
Common misconceptions about malingering
• Malingering is rare Large-scale surveys of more than 500 forensic suggest that
malingering is not rare either in forensic or clinical settings
• Malingering is a static response style On the contrary, most efforts at
malingering appear to be related to specific objectives in a particular context. For
example, descriptive data by Walters (1988) suggest that inmates rarely feign
except when hoping to achieve a highly desired goal
• Malingering is an antisocial act by an antisocial person common misperception
is perpetuated by DSM-5, which attempts to use the presence of antisocial
personality disorder (ASPD) as a screening indicator for malingering
• Deception is evidence of malingering - clients’ marked minimization of
symptoms (i.e., defensiveness) was misreported by a practitioner as evidence of
malingering
• Malingering is similar to the iceberg phenomenon - appears to be based on the
theory that any evidence of malingering is sufficient for its classification
• Syndrome-specific feigning scales measure syndrome-specific malingering –
(examples of how(Rogers,
peopleDuncan,
have&fooled
Sewell, 1994;
the Rogers,
system Salekin, Sewell, Goldstein,
for several years) & Leonard, 1998)
Explanatory models

• Adaptational – individual applies cost benefit analysis

• Pathogenic – underlying disorder is the motivation or means for
malingering
• Criminological – malingering is an antisocial act committed by
antisocial people
Antisocial PD and the DSM
• Suggests that – we should suspect malingering if somebody has antisocial personality disorder
•Study
Two elements that attempt
Sample to link these constructs
Measure Results
•Rogers,
1. medicolegal
1990 context
24of presentation
malingerers DSM indices for ASPD found in
• 2. presence of antisocial
114 personality disordermalingering
bona fide patients 20.8% malingerers
17.7% bona fidefeatures?
Although these are common features in forensic settings – are these distinguishing
patients
Moreover, when using the benchmark of 2 indices or more – high suspiciousness of malingering –
false positive rate 79.9% (4/5 cases)
Although it is seen that people with ASPD are not more sophisticated than others in malingering it is
important to acknowledge that the combination does increase the prevalence, i.e. medicolegal
setting and ASPD

DSM criteria?
There are no criteria but guidelines to expand differentials

(Rogers, 1990)
Function of behavior and symptoms
• Negative expressed emotions in patients with schizophrenia can make
their symptoms worse
• People with depression – characterological judgments – lazy etc. may
make their depression worse
• So if we such judgements about patients may exacerbate the
behavior
• Rogers suggested that the DSM criteria essentially characterizes the
malingerer as a “bad person” (antisocial personality disorder) in “bad
circumstances” (legal difficulties) doing “bad things” (uncooperative
with evaluation and treatment)
Adversarial vs. personalized approach
What drives the negativity towards the malingering patient?
• Moral judgements – the patient is lying
• Personal judgements – the patient is trying to fool me
• Focus on the function of behavior vs. the behavior of manipulation

Even if we suspect the patient is malingering – we need to think about

What function is this serving?
What other options can we provide to the patient so that they do not
malinger?
Problems in setting
• Clients perceive this as an adversarial process because
1. Experts work for others
2. Confidentiality is circumscribed
3. External criteria set the framework of the consultation
• Clients are less inclined to be open in such interviews and this is equated with
uncooperativeness or manipulation of the compensation case.
• A more moderate view of this situation regarding lack of openness may be attributed to
poor rapport where the responsibility is shared between the expert and client.
• In some cases lack of rapport building is defended by experts with claims that such
efforts assume a therapeutic role and mislead the client. The distinction between
forensic and therapeutic role should be maintained. But rapport is a necessary
precondition to all professional relationships. And rapport should help in clarifying rather
than obscuring the nature of the forensic consultation.
Prevalence of malingering
- Around 8% of general evaluations
- Around 20% of forensic evaluations
(Miller, 2000; Rogers & Cruise, 2000; Rogers, Selekin, Sewell, Goldstein)
Problems in diagnosing
• It is categorical when it should be dimensional
• It relies on judgements of character as opposed to looking at the function
behind the reported symptoms
• The criteria for malingering has not changed significantly since the DSM-III
even though the research and understanding of it have increased
dramatically
• Exceptionally difficult to arrive at an objectively based discrimination
between externally motivated malingering and internally motivated
somatoform disorder
• Example – undifferentiated somatoform (vague symptoms) comorbid with
PTSD, some may assume due to vague symptoms that person faking PTSD
(Boone, 2007)
Response styles
• Way in which responses are given to questions or physical exam tasks
• Conscious decision to disclose information or deceive
• Not trait like characteristics, can be flexible
• Modified by circumstances and motivations
• Inconsequential responses may not be relevant to determine
response styles
Response styles
Nonspecific terms
• Unreliability – raises questions regarding accuracy of information – no
assumption about individuals' intent
• Nondisclosure – withholding information – no assumptions about intent
can be made
• Self-disclosure – high – evidence of high degree of openness but lack of
self disclosure does not imply dishonesty
• Deception – any consequential attempts by individuals to distort or
misrepresent their self-reporting. Deceit + nondisclosure
• Dissimulation – wide range of deliberate distortions or misrepresentation
of psychological symptoms
Response styles
Overstated pathology
Feigning
• Psychological tests can determine feigned symptoms, but they cannot determine
malingering because they cannot establish external gain or motivation
Defensiveness
• Opposite of malingering – masking of symptoms or denial of symptoms
• Consequences can be equal of malingering
Social desirability
• People present themselves in the most socially appropriate way
Impression management (concealment)
• Effort to control others perceptions
• Stronger relation to situation than social desirability
Response styles
Terms to avoid due to multiple/conflicting definitions

• Suboptimal effort – maybe due to several external or internal factors

• Over reporting – high level of endorsement; sometimes erroneously
reported with feigning
• Secondary gain – due to unclear definition
Malingering Subclassification
• Pure malingering – feigning a nonexistent disorder
• Partial malingering – consciously exaggerating actual symptoms
• False imputation – assigning actual symptoms to unrelated cause

Consider magnitude of dishonesty

• Minor exaggerations or isolated symptoms do not qualify but
important to remember – if the patient thinks that they will benefit
significantly – this does qualify as malingering
Psychological assessment
Strategy Explanation Scales
Rare symptoms
Quasi-rare symptoms
Improbable symptoms
Miller Forensic Assessment of Symptoms Test
(Miller 2001)
• M-Fast was developed to operationalize and standardize measurement of
the response styles and interview strategies that have been validated for
identifying malingering
- Reported vs. observed symptoms (RO)
- Extreme symptomology (ES)
- Rare combinations (RC)
- Unusual hallucinations (UH)
- Unusual symptom course (USC)
- Negative Image (NI)
- Suggestibility (S)
Miller Forensic Assessment of Symptoms Test
(Miller 2001)
- Structured interview of 25 items representing the empirically
supported detection strategies
- Administration about 5-10 minutes
- Scoring takes about 10 minutes
- Does not require ability to read (examinee)
- Was developed using both known- group and simulation studies
(asking people to fake illness to see if the test can pick up on it)
Structured interview of reported symptoms
(SIRS; Rogers et al.1992)
• Initial development based on an exhaustive review of potential detection strategies for
feigned mental disorders
• Developed based on the likely effectiveness of the underlying detection strategy and the
adaptability of each strategy to interview-based assessments
• Pitfalls
• A lot of checking and re-checking and repeated asking of questions that can cause
suspiciousness – also seen with the MMPI
• Final item selection was based on independent judgements by eight experts in
malingering and was subsequently refined to improve scale homogeneity
• Composed of 173 items that are organized by eight primary and five supplementary
scales
• Primary scales consist of – Rare symptoms (RS), Symptoms combination (SC), Improbable
and Absurd symptoms (IA), Blatant symptoms (BL), Subtle symptoms (SU), Selectivity of
symptoms (SEL), Severity of symptoms (SEV) and Reported vs Observed symptoms (RO)
Validity of the SIRS
• Major focal point of the SIRS is its discriminant validity. The critical
issue is whether each of the primary scales systematically
differentiates between genuine and feigned psychopathology
• Combining across studies, effect sizes can be computed for the critical
distinctions (a) simulators versus clinical honest and (b) suspected
malingerers versus clinical honest
• Both groups produced large effect sizes, providing robust support that
the instrument can distinguish between those who are malingering
and those who are faking
• There is now a SIRS-2 and it continues to maintain the benchmark for
other instruments for malingering
Minnesota Multiphasic Personality Inventory
– 2 (MMPI – 2)
• 567 item personality inventory that utilizes various validity scales to
ensure the results are a valid representation of an individual’s clinical
diagnostic function and personality structure
• First 370 questions give us
• Cannot say score
• Infrequency scale also known as the Fake Bad Scale
• Lie Scale or L Scale
• VRIN – Variable Response inconsistency
• TRIN – True Response Inconsistency
Minnesota Multiphasic Personality Inventory
– 2 (MMPI – 2)
• Where the MMPI – 2 gets interesting for detecting malingering is
often with the F scores. Along with the aforementioned F scale, there
are the following:
• Fb or F back, which measures infrequent answers on the second half
of the test past question 370
• And Fp – The Psychopathology Infrequency Scale
Categorical vs. dimensional approach to
feigned presentations
• Rogers et al. (2010) established a multi-categorical decision model in
their revision of the SIRS-2.
• model is composed of four categories: feigning, indeterminate
evaluate, indeterminate-general, and genuine responding.
• The indeterminate-evaluate group indicates a likelihood of feigning
that exceeds 50%; it signifies that this issue should be thoroughly
investigated. In contrast, the indeterminate-general group raises no
particular concern about feigning. However, its scores are not
sufficiently low as to accurately classify its group members as genuine
responders.
Single point cut scores
• First, what is a single point cut score? It occurs when a single difference in response is used to
change the classification of response styles. For example, a PAI NIM raw score of 13 (92 T) may be
considered evidence of feigning, whereas a raw score 12 (88 T) would be interpreted differently
(Morey, 2007).
• Rogers et al. (2012) described the single point cut scores as a cardinal example regarding the
“laser accuracy myth of cut scores”
• Rogers et al. (2012) examined measurement error for NIM =11 (> 84 T) as a cut score for feigning.
For an estimated 21.2% of examinees, an NIM of 11 represents false-positives (i.e., the“true”
score for NIM actually being < = 10 because of measurement error alone.
• If we inspect a narrow range of scores (± 5 T) around the cut score, it becomes very obvious that
these scores are “too close to call.” Using the same study (Rogers et al., 2012) and the same cut
score 84 T), 80% of those with 88 T are false positives (genuine patients incorrectly categorized as
feigners), whereas 50% at 81 T are false negatives (feigners incorrectly categorized as genuine).
• Rather than disclose to the court that error rates are likely to exceed 50% for the occasional too-
close-to-call case, we submit that the use of well-defined cut scores represents the best practice
in clinical and forensic settings.
Assessment of feigning with ethnic minorities
• In both North American and northern European countries, there is a lot of informal
discussion about a presumed elevated occurrence of distorted symptom presentation
among members of ethnic minorities.
• Difficulties may arise in the context of culturally distinct illness expression, which may be
perceived as alien or invalid by health care professionals (for a sound discussion of this
issue, see Hausotter & Schouler-Ocak, 2007) One such issue based on erroneous
stereotyping involves the so-called “Mediterranean back” (e.g., Pearn, 2000).
• Only a few studies address the question of how performance validity tests work in
minority groups, and some attempts to develop specific norms for particular groups (e.g.,
Burton, Vilar-López, & Puente, 2012; Robies et al., 2015; Salazar, Lu, Wen, & Boone,
2007; Strutt et al., 2012). Salazar et al. (2007) concluded that “in the absence “of more
robust data, clinicians assessing minority populations are often forced to infer the
validity, and justify the use, of common malingering instruments, based largely on their
own unique experience and expertise with a specific cultural group” (p. 406)
Criticisms of clinical and research traditions
• When reaching clinical conclusions combine all data
• If we rely on valid but weaker variables, or if we allow weaker variables to
override stronger variables, our overall accuracy will not increase and quite
possibly will decline
• Instead, focus on methods that provide incremental validity
• Studies for optimization of methods to combine data are needed
• Nothing can substitute experience in learning how to detect malingering
• Over-reliance on experience is likely to lead to inder-weighting or disregard
of research
• One bearing the cost of such an error is the subject – patient
• Research is the most important in the context of verification
Criticisms of clinical and research traditions
• Malingering is a category or taxon is of little practical use
• If one can identify an individual as “a hard-core sociopath” this would
permit reasonably trustworthy judgement about certain things
• Usually best to identify it as such and assume multi-dimensional ratings do
not provide comparable benefits or information
• Determination of taxonicity is not arbitrary
• Research requires gold standard to make progress
• If we had established a GS, research on assessment methods would not
need to go ahead – if a GS was required to progress – we couldn’t progress
• The ones that are caught may not represent the GS
• Impure groups are not fatal

Faust, 2012
Distinguishing malingering from psychiatric
illness
• Characteristics of malingering
• Unexplained by disease – symptoms or disability are not adequately
explained by objectively defined disease
• Gain – there is a tangible external gain from presenting as ill
• Intention – deliberate and conscious intent to deceive the doctor or
other persons
• Context and value – a situation where the genuineness of illness is
scrutinized
Distinguishing malingering from psychiatric
illness
• Inconsistency
• Within history
• Between history and observation
• Between symptoms and diagnostic criteria
• Between history from patient and informant
• Between patients history and medical records
• Over time
• Between history and other sources of information
Distinguishing malingering from psychiatric illness
Conscious deliberate intention to deceive
• Rule out factitious disorder – Malingering for primary gain?
• Primary gain was a decrease in anxiety brought about through a defensive
operation that had resulted in the production of the symptom of the illness
• Secondary gain was defined as the gain achieved from the conversion
symptom in avoiding a activity that was noxious to the patient or enabled
the patient to get support from the environment that might not otherwise
be forthcoming, or both
• Tertiary gains were first described and defined by Dansak. These were
gains sought or attained from a patient's illness by someone other than the
patient, usually a family member. Since then, this type of gain has been
noted in chronic pain patients and cancer cases
Problems with concept of secondary gain
Somatoform Malingering

Unconscious Factitious Conscious

Psychodynamic Nomenclaturists
theorists
Motivation Conscious
Intrapsychic Material gains
needs and
defenses
Malingering equated with secondary gain
Presence of financial rewards = malingering
Suspicion interferes with treatment and results in loss of empathy
Secondary losses?
Secondary gain an excuse for treatment failure
Chronic pain patient sick only for a short period then attains
disability role
Distinguishing malingering from psychiatric
illness
• The context
• 1. stands to gain substantially
• 2. previous history of similar behavior
• 3. history or repeated deception or even diagnosis of ASPD

Note: Probably increase the risk but cannot be assumed

Distinguishing malingering from psychiatric
illness
History
• Open ended questions

Factors which should invoke doubt

• Overly dramatic presentation

• Symptoms do not match accepted symptom patterns
• Internal inconsistency
• Endorsement of proffered symptoms
Distinguishing malingering from psychiatric
illness
• Mental status examination
Identify patterns of symptoms and compare it to descriptions
An opportunity to compare history and observation
• Physical examination
Waddell’s sign
• Other sources of information
History from informant
Investigations and psychometric tests
Observation over time
Further considerations in the detection of
malingering
• Bias
• Overestimation of illness
Established long-standing relationship with patient – disposed to
believing
Greater error to miss a diagnosis than over-treat
If patient thought to be exaggerating this is viewed sympathetically
• Underestimation of illness
This may result from a personal attitude of scepticism toward suffering
and disability of patients who have illnesses that are defined only by
symptoms
Why are clinicians hesitant to diagnose
malingering?
• Must rule out many other disorders
• Mistaking malingering can stigmatize the patient and can lead to poor care in the future
• Legal action for defamation of character – but for this to happen you have to release the
information to a third party
• Also patient may assault the patient for calling him a liar
(Rogers, 2018)
“the doctor’s primary role is to help his orher patients with their subjectively voiced needs,
not to determine their ‘genuineness’”
Some psychiatrists may even regard malingering as an expression of a psychological need
that they should help the patient to address in a way that was more socially acceptable

(Sharpe, 2012)
How should doctors address the issue of
malingering?
• Why do I want to determine the genuineness of this patient’s
symptoms?
• What is your precise aim?
• What evidence do I have for inconsistency?
• How should I express an opinion?

“The consideration of whether and why patients’ complaints may

appear inconsistent is an important medical task; the detection of
malingering is arguably not”
(Sharpe, 2003)
Chronic pain