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Malingering of mental illness has been studied extensively; however, malingered medical illness has been examined much less avidly. While in theory any ailment can be fabricated or self-induced, pain--including lower back pain, cervical pain, and fibromyalgia--and cognitive deficits associated with mild head trauma or toxic exposure are feigned most frequently, especially in situations where there are financial incentives to malinger. Structured assessments have been developed to help detect both types of malingering; however, in daily practice, the physician should generally suspect malingering when there are tangible incentives and when reported symptoms do not match the physical examination or no organic basis for the physical complaints is found.
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Malingering in the Medical Setting
Barbara E. McDermott, PhD
a,b,
*, Marc D. Feldman, MD
c
a
University of California, Davis School of Medicine, Department of Psychiatry
and Behavioral Sciences, Division of Psychiatry and the Law, 2230 Stockton Blvd, 2nd Floor,
Sacramento, CA 95817, USA
b
Clinical Demonstration/Research Unit, Napa State Hospital, 2100 Napa Vallejo Hwy, Napa,
CA 94558, USA
c
The University of Alabama, Tuscaloosa, 2609 Crowne Ridge Court, Birmingham,
AL 35243–5351, USA
‘‘Malingering’’ is defined as the conscious feigning, exaggeration, or
self-induction of illness (either physical or psychological) for an
identifiable secondary gain [1]. In the medical setting, that sec-
ondary gain can be diverse, including the receipt of monies (legal settlements
or verdicts, worker’s compensation, disability benefits); the procurement of abus-
able prescription medications, such as opioids or benzodiazepines; the avoidance
of unpleasant work or military duty; or simply access to a warm, dry hospital bed.
In other cases, the incentives can be more subtle, such as avoidance of onerous
household responsibilities. Malingering is distinguished from factitious disorder
by its motivation: in clear-cut cases, the malingerer consciously falsifies or induces
illness or symptoms for a specific purpose that is identifiable, once details of the
malingerer’s life are known. In contrast, in factitious disorder, symptom produc-
tion is conscious for a primary gain: the assumption of the ‘‘sick role’’ [2]. The rea-
sons that the individual desires the sick role are presumably primarily
unconscious [3]. In psychiatry, malingering of mental illness is often suspected
in both criminal and civil cases, where the secondary gain can be substantial
[4,5]. As noted, malingering in the medical setting has not been studied as exten-
sively. This article discusses the various disorders most commonly malingered in
the medical setting, the frequency of such malingering, methods for detection,
and finally, recommendations for intervention.
CLASSIFICATION
Diagnostic confusion between malingering and mental disorders, particularly
factitious disorder, can be traced to Asher’s [6] original description of
*Corresponding author. University of California, Davis School of Medicine, Department of
Psychiatry and Behavioral Sciences, Division of Psychiatry and the Law, 2230 Stockton
Blvd, 2nd Floor, Sacramento, CA 95817. E-mail address: bemcdermott@ucdavis.edu
(B.E. McDermott).
0193-953X/07/$ – see front matter ª2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.psc.2007.07.007 psych.theclinics.com
Psychiatr Clin N Am 30 (2007) 645–662
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Munchausen syndrome. Asher attributed several possible motives to Mun-
chausen syndrome, including ‘‘a desire to escape from the police’’ and ‘‘a desire
to get free board and lodgings for the night’’ (339), motives that would now
clearly be classified as malingering. The tendency to include malingering within
the factitious disorder spectrum was further reinforced by Spiro [7], who rec-
ommended that in individuals with Munchausen syndrome, ‘‘malingering
should only be diagnosed in the absence of psychiatric illness and the presence
of behavior appropriately adaptive to a clear-cut long-term goal’’ (569). Thus,
according to Spiro, an individual with a psychiatric disorder of any type cannot
be deemed a malingerer. There are, however, many examples of patients with
factitious disorder who also malinger [8]. Eisendrath [9] described three such
individuals, all of whom entered into civil litigation as a result of their feigned
physical illnesses. In each case, it appeared that the feigned illness was intended
to allow the individual to assume the sick role and only later was used to pur-
sue financial incentives.
The term ‘‘malingering by proxy’’ has been suggested [10] for those cases
in which illness is fabricated in a child for secondary gain—for example, for
the purpose of obtaining social assistance benefits [11]. The literature con-
tains several case reports of parents who report, or induce their children
to report, disability for the purpose of litigation and ultimately remuneration
[12,13].
Various types of malingerers have been identified. As described by Resnick
[14], their behaviors can include pure malingering, partial malingering, and
false imputation. In pure malingering, the individual is fabricating a condition
that does not exist and has never existed. In partial malingering, the individual
is exaggerating symptoms that actually exist. False imputation refers to an in-
dividual’s ascribing symptoms to a cause that is actually unrelated. For exam-
ple, in personal injury litigation, an individual might claim pain from a motor
vehicle accident when in fact the pain is secondary to an unrelated fall. Most
detection methods target either pure or partial malingering, as the presumption
in false imputation is that the symptom is real; only the source of the symptom
is in question.
The Diagnostic and Statistical Manual, 4th edition text revision (DSM-IV-
TR) [15] classifies malingering with a ‘‘V’’ code, indicating, ‘‘Other conditions
that may be the focus of clinical attention.’’ In this nomenclature, malingering is
not considered to be a mental disorder. Instead, by definition it is ‘‘the inten-
tional production of false or grossly exaggerated physical or psychological
symptoms motivated by external incentives’’ (739). The DSM provides four
guidelines for when to suspect malingering, including (1) the evaluation occurs
in a medico-legal context, (2) a discrepancy exists between the person’s claims
and objective findings, (3) the individual is uncooperative during the diagnostic
evaluation and is noncompliant with the prescribed treatment regimen, and (4)
antisocial personality disorder is present. However, many experts consider this
definition overly broad and inclusive, leading to the risk of overidentification of
patients as malingerers. For example, Rogers [16] noted that use of these
646 MCDERMOTT & FELDMAN
guidelines as criteria for detecting malingering (ie, an individual who meets two
of the four criteria) leads rather impressively to the correct classification of ap-
proximately two-thirds of true malingerers. However, he determined that this
strategy led to the overclassification of true psychiatric patients as malingerers.
Rogers concluded that persons meeting two of the four DSM-IV-TR criteria
have only a one in five chance of being true malingerers. An 80% false positive
rate is inordinately high and generally considered unacceptable.
Rogers [17] described three models to explain the underlying motivation of
an individual who malingers: the pathogenic model, the criminological model,
and the adaptational model. Although the pathogenic model no longer re-
ceives general support [18], it warrants an historical discussion. In this model,
the malingerer’s motivation is based on true pathology. The production of
symptoms is postulated to be an effort to gain control over real symptoms.
The eventual outcome is the replacement of feigned symptoms with real
ones. However, research has not shown this prediction to hold true [19].
The criminological model presumes an underlying ‘‘badness’’ of the malin-
gerer and is based on the DSM suggestions for when to be suspicious of ma-
lingering. As Rogers [20] noted, ‘‘a bad person in bad circumstances (legal
difficulties) who is performing badly (uncooperative)’’ (7) is considered highly
likely to malinger in the criminological model. Finally, the motivation can be
understood within the adaptational model, wherein the malingerer evaluates
the cost-benefit of his or her options. In this model, malingering may be more
likely under three circumstances: (1) when the context is adversarial, (2)
when the personal stakes are high, and (3) when there are no viable alterna-
tives. An individual feigning mental illness when faced with a life sentence is
an example of this model. It is important to note that these models only pro-
vide explanations for the behavior; they are not intended as prescriptions for
the detection of malingering.
In a study evaluating the correlates of malingering, Sierles [21] asked 172
Veterans Administration patients and 160 medical students, a control group,
to complete a questionnaire designed to assess the frequency and potential
indicators of malingering in various types of patients. The sample included
patients from acute medical, surgical, psychiatric, substance dependence, and
alcohol detoxification services. The questionnaire contained a list of 59 prob-
lems; the individuals were asked if they had ever reported any of these as
problems for which a physician could find no organic basis, and a malinger-
ing index score was calculated. An individual was considered to have a pat-
tern of medically unexplained symptoms if 20 or more items from the list
were endorsed. In addition, Sierles included items that were indicative of
the respondent’s being sociopathic. He found that being a sociopath and
having a drug or alcohol diagnosis increased the likelihood of malingering.
The study revealed that, of the individuals evaluated, medical and surgical
patients were the least likely to admit ever to having malingered; they re-
ceived a malingering index score even slightly lower than that of the med-
ical students.
647MALINGERING IN THE MEDICAL SETTING
DIFFERENTIAL DIAGNOSIS
There are five conditions from which malingering must be differentiated: un-
detected physical pathology, three of the somatoform disorders, and factitious
disorder.
Undetected or Underestimated Physical Illness
Malingering, like somatoform disorders and factitious disorder, is a diagnosis
of exclusion. Patients who present with unexplained somatic complaints may
actually have an illness that is not detected during an initial evaluation, or
even with subsequent testing. Physicians may be inclined at that point to pre-
sume the patient is malingering. While it may be nearly impossible to rule out
every conceivable occult physical pathology that is responsible for the presen-
tation of a patient who might be malingering, physicians should reasonably
consider whether the evaluation has been adequate. Further testing must be
balanced with the possibility of a nonorganic etiology, as physicians can engen-
der serious iatrogenic problems by overtesting and overtreating. A rule of
thumb is to seriously consider and evaluate malingering before advancing to
highly esoteric physical diagnoses.
Pain Disorder and Somatization Disorder
Cases of pain disorder involve persistent complaints of pain that are not ac-
counted for by tissue damage. Somatization disorder cases involve chronic, un-
pleasant symptoms (often including pain) that appear to implicate multiple
organ systems. In both, it is presumed that the patient actually experiences
the pain he or she is reporting. The pain complaints may covary with psycho-
logical stressors. Unlike malingering, the pain reported in these disorders is not
under conscious control, nor is it motivated by external incentives. However,
there are no reliable methods for affirmatively establishing that pain and other
complaints are unconscious and involuntarily produced [22].
Hypochondriasis
Hypochondriasis is diagnosed in patients who unconsciously interpret physical
sensations as indicative of serious disease. The patient may present with minor
pains that he or she fears indicate some unrecognized, potentially life-threaten-
ing illness. These patients are eager to undergo diagnostic evaluations of all
kinds. In contrast, the malingerer is often uncooperative with the diagnostic
process and, unlike those with hypochondriasis, is unlikely to show any relief
or pleasure (albeit temporary) in response to negative test results. When hypo-
chondriac patients do simulate or self-induce illness, the deceptions reflect a des-
perate need to convince physicians to perform further tests [22].
Factitious Disorder with Predominantly Physical Signs and Symptoms
As in malingering, factitious physical disorders involve the feigning, exaggera-
tion, or self-induction of medical illness. However, the fraudulent complaints
cannot be adequately explained by external incentives. Rather, the factitious
disorder patient will welcome the chance to undergo medical and surgical pro-
cedures—including those that most people would seek to avoid—because they
648 MCDERMOTT & FELDMAN
find the sick role intrinsically gratifying. Malingerers, conversely, seek to min-
imize medical contacts through which their deceptions might be uncovered.
EPIDEMIOLOGY
While almost any medical illness can be malingered, there is evidence that cer-
tain types of medical problems are more likely to be malingered than others. In
a study of over 30,000 cases referred to 144 neuropsychologists, the most likely
ailment to be malingered was mild head injury, followed by fibromyalgia or
chronic fatigue syndrome, pain, neurotoxic disorders, electrical injury, seizure
disorders, and moderate or severe head injury [23]. In another report, malin-
gerers more commonly presented with cervical pain and repetitive strain in-
juries, accessing general practitioners, rheumatologists, neurologists, and
orthopedic and hand surgeons [22]. These differences are likely reflective of
the types of individuals surveyed: neuropsychologists are more likely to eval-
uate individuals referred for head trauma, while general practitioners are more
likely to be contacted for pain complaints.
Just as the frequency of malingered mental illness varies depending on the
context (ie, criminal, civil, or military evaluations), estimates of malingering
in the medical setting vary considerably. For example, in a study surveying
105 board-certified orthopedic surgeons and neurosurgeons from six states, es-
timates of the percentages of their patients with low back pain who were ma-
lingering varied widely, from a low of 1% to a high of 75% [24]. However,
the majority of the surgeons made low estimates, with 78% indicating that
10% or fewer of their patients malingered their pain. Factors that surgeons
most strongly considered in making their estimates were not in fact related
to secondary gain, but were more closely associated with inconsistencies in
the medical examination. The two inconsistencies most frequently cited as sug-
gestive of malingering were weakness in the exam not seen in other activities,
and disablement disproportionate to the objective findings. Other studies sug-
gest that the incidence of malingered pain is significantly higher. For example,
estimates of malingering range from 25% to 30% for fibromyalgia cases [25],
with similar results found for patients malingering chronic pain [26].
The literature also contains inconsistencies regarding the incidence of malin-
gering in mild head trauma, with some authors suggesting that malingering is
common [27–29] and others suggesting that it is rare [30]. Rogers [31] estimated
that approximately half of the individuals evaluated for personal injury claims
were feigning all or part of their cognitive deficits. In a meta-analysis of the
effect of financial incentives on neuropsychological symptoms, Binder and
colleagues [32] reaffirmed that compensation is critical. Their results indicated
that more abnormalities and disabilities were reported in patients with financial
incentives, even if injuries were less severe. The highest rates of malingering of
medical illness appear related to personal injury litigation, worker’s compensa-
tion, or disability claims [23]. For example, Greiffenstein and colleagues [33]
found a 37% base rate of malingering in individuals with mild head injury
who were seeking compensation of some sort. Along these lines, several studies
649MALINGERING IN THE MEDICAL SETTING
have indicated that patients with milder injuries or fewer symptoms were more
likely to seek compensation [34,35]. Symptoms appearing long after the alleged
injury—which have been shown to be less likely to have an organic etiology
[36]—occurred more frequently in patients pursuing financial compensation.
Similarly, a shorter duration of amnesia was correlated with failure to return
to work. Larrabee [37], in a review of 11 studies, found a prevalence rate of
malingering of 40% in 1,363 patients who were seeking compensation for
a mild head injury. Various signs were suggested as indicative of the possibility
of malingering, including a severity of impairment that is inconsistent with mild
trauma, discrepancies in the records, inconsistencies in self-report versus ob-
served behavior, and implausible self-reported symptoms. In support of these
detection strategies, Binder and colleagues [38] found that 95% of authentic
mild head trauma cases evidence no impairment three months after the trauma.
In the aforementioned study of 144 neuropsychologists [23], estimates of ma-
lingering varied by referral type. When the referral was made secondary to
a personal injury claim, estimates of malingering were 30%; for disability or
worker’s compensation cases, estimates were as high as 33%. Malingering
was estimated in 23% of individuals facing criminal cases. In contrast, the esti-
mate was only 8% for cases without any known external incentive. When pa-
tients were in litigation, the neuropsychologists estimated that 41% referred for
mild head injury were malingering, as compared with 37% for fibromyalgia
and 33% for pain. They also determined that when patients were referred by
defense attorneys for civil cases, estimates for malingering were even higher.
These results suggest that, in contrast to malingered mental illness, which
more often occurs in the context of criminal charges to reduce or eliminate sen-
tencing, the malingering of physical illness is substantially related to financial
incentives.
DIAGNOSIS
In addition to the office or hospital, malingerers also often present to emer-
gency departments or urgent care centers, generally ‘‘doctor-shopping’’ if their
initial efforts to procure secondary gain (ie, abusable medications for their own
use or for resale) are unmet by the physicians seen initially. When pursuing
drugs, they may report an unusually large number of drug allergies to steer
the physician toward prescribing their drug of choice, or simply insist on a
specific product, such as meperidine (Demerol).
The malingerer who seeks to avoid an immediate predicament might feign
an acute problem, while those seeking a permanent disability judgment will
feign a subacute medical problem that is recognizable to the examiner when
the malingerer’s stressors are known [22].
Physicians are trained to assess and treat individuals who actually have med-
ical or mental health symptoms. A health care provider’s natural inclination—
one reinforced by education and training—is to accept the person’s reported
symptoms at face value. Rosenhan [39] conducted a famous study that dem-
onstrated clinicians’ tendency to blindly accept reported mental health
650 MCDERMOTT & FELDMAN
symptoms. In this study, eight nonmentally ill individuals presented to a psy-
chiatric hospital alleging that they were hearing very atypical voices. Based
on this one reported symptom, every person was admitted to the hospital
and given a diagnosis of schizophrenia, even though each person ceased re-
porting any symptoms after admission.
Clinicians should be aware that malingering for compensation of various
types may be unplanned. The patient may seize upon an incidental workplace
or motor vehicle accident as a fortuitous opportunity for financial gain. It also
appears, at least anecdotally, that there is an increased frequency of disability
claims in families in which a family member has already been declared
disabled.
Citing Hamilton and Feldman [22], ‘‘it is against [the malingerer’s] interests
to acknowledge any improvement in their condition or even any palliative ef-
fects of medicine, corrective surgery, or physical therapy. The one exception to
this may be in cases of sophisticated patients who admit to partial or temporary
relief of pain to enhance their credibility’’ (448).
Eisendrath, Rand, and Feldman [40] offered a list of potential correlates of
illness deception (Box 1). However, their validity and reliability have not
been formally researched.
DETECTION OF MALINGERED PAIN
The detection of malingered pain is often extremely difficult, in large part be-
cause the experience of pain is so subjective [41,42]. Additionally, as is so often
cited for malingered mental illness, it is much easier to malinger that with
which you have had experience.
1
It is relatively easy to malinger pain because
everyone has had the experience of pain and therefore knows how it should
appear to others. Hamilton and Feldman [22] note that the malingerer’s pain
complaint ‘‘will vary according to the medical sophistication of the patient;
they may present with diffuse pain, or patterns of pain that are not consistent
with known medical conditions or with the anatomy of the peripheral nervous
system’’ (444-5). In particular, these cases may present as specific maladies,
such as repetitive strain injury or variable limb pain (ie, in reflex sympathetic
dystrophy, fibromyalgia, or chronic fatigue syndrome), though the bulk of
the literature has focused on low back pain or pain related to the cervical
and thoracic spine (especially whiplash injuries). The malingerer commonly
knows the characteristics of the pain associated with the condition he or she
is feigning. One unfortunate result of the wide availability of high quality med-
ical information on the Internet is that malingerers now have abundant guid-
ance on how to convincingly display pain and disability [22].
There are no objective laboratory tests that allow examiners to indepen-
dently quantify pain without the use of patient self-report. Although initially
thermography was considered to be promising as an independent method
for evaluating pain, it has fallen out of use because it was shown to be
1
Although technically, Resnick would describe this phenomenon as partial malingering.
651MALINGERING IN THE MEDICAL SETTING
Box 1: Potential indicators of malingering
1. The signs and symptoms do not improve with treatment. There is escalation of
symptoms, relapse, or new complaints apparently in the service of keeping
the caregivers engaged.
2. The magnitude of symptoms consistently exceeds what is usual for the dis-
ease or there is evident dishonesty about the presentation of symptoms.
3. Some findings are determined to have been self-induced, or at least wors-
ened through self-manipulation.
4. There are remarkable numbers of tests, consultations, and treatment efforts,
to no avail.
5. The individual disputes test results that do not support the presence of authen-
tic disease.
6. The individual accurately predicts physical deteriorations.
7. The individual ‘‘doctor shops’’ and has sought treatment at an unusual num-
ber of facilities.
8. The individual emerges as an inconsistent, selective, or misleading source of
information.
9. The individual refuses to allow the treatment team access to outside informa-
tion sources.
10. There is a history of so many medical treatments for secondary problems that
the impression is created that the individual must be astonishingly unlucky.
(This ‘‘black cloud’’ phenomenon may strain credulity to the breaking point.)
11. Deception is explicitly considered by at least one health care professional, if
evidenced merely by a brief chart entry.
12. The individual does not follow treatment recommendations and is intensely
disruptive.
13. The individual focuses on his or her self-perceived ‘‘victimization’’ by medi-
cal personnel and others.
14. There is consistent evidence from laboratory or other tests that disproves
information supplied by the individual.
15. The individual has had exposure to a model of the ailment they are falsifying
(eg, a relative with a similar ailment).
16. Even while pursuing medical or surgical assessment, the individual
vigorously opposes psychiatric assessment and treatment.
17. During interviews, the individual makes statements to strengthen his or her
case that nevertheless contradict the records.
18. There is evidence for external incentives for illness or incapacity.
Adapted from Eisendrath SJ, Rand DC, Feldman MD. Factitious disorders and litigation. In
Feldman MD, Eisendrath SJ editors. The spectrum of factitious disorders. Washington (DC):
American Psychiatric Press, Inc., 1996. p. 65–82; with permission.
652 MCDERMOTT & FELDMAN
nonspecific [43]. While the self-report Minnesota Multi-Phasic Personality In-
ventory, 2
nd
edition (MMPI-2) [44] has been used with considerable success
in identifying malingering of mental illness [45], it is less effectively used
with malingered medical illnesses. However, in one study [46], MMPI-2 pro-
files were compared between pain patients who were and were not involved
in litigation. The investigators found that pain patients in litigation endorsed
more obvious and fewer subtle items. They found inconsistent support for us-
ing the ‘‘Conversion V’’ as an identifier of litigants. These results provide mod-
est support for the use of the MMPI-2 in the detection of malingered pain.
However, although many patients in litigation are also malingering, the two
groups may not be identical in regards to psychological profiles.
The Symptom Checklist-90-Revised (SCL-90-R) [47], a self-report checklist
containing 90 items targeting a wide range of psychological problems, also
has been used to identify genuine pain patients. In a simulation study, Wallis
and Bogduk [48] found that, consistent with research on the simulation of men-
tal illness, patients who malinger pain frequently ‘‘overendorse’’ symptoms.
Simulators scored significantly higher than true whiplash patients on all
SCL-90-R subscales.
In a study designed to evaluate the effectiveness of three scales in identifying
malingerers, Larrabee [49] found that one instrument, the Modified Somatic
Perception Questionnaire; [50], distinguished malingerers from nonmalingerers
with a sensitivity and specificity of 0.90. In a series of simulation studies,
McGuire and colleagues [51] evaluated the effectiveness of using the Pain Pa-
tient Profile (P3); [52] in identifying malingerers. The P3 contains three clinical
scales: depression, anxiety, and somatization, as well as a validity scale. They
found that simulators were more likely to score above a t-score of 55 on all
three scales, although the depression scale had the highest positive and negative
predictive power. The investigators concluded that this instrument shows
promise in the detection of malingered pain, though the inventory and its
use require more study.
Several studies have been designed to evaluate whether facial expressions of
pain are useful in identifying simulators. Various investigators have found that
judges consistently ascribed higher levels of pain to simulators, even when given
feedback or advance warning [53,54]. Thus, attempting to detect malingering by
evaluating the degree of the patient’s pained expression appears fruitless.
Regarding physical examinations, expected signs of injury or disease will be
absent or inadequate to account for the patient’s reported degree of pain. Be-
cause they are still commonly applied, ‘‘Waddell signs’’ will be mentioned.
In the 1980s, Waddell indicated that certain signs were suggestive of nonor-
ganic pain or ‘‘illness behavior’’ [55,56]. These signs were divided into five gen-
eral categories, including tenderness, simulation, distraction, regional, and
overreaction. Table 1 presents the complete list of signs. Since being published,
these signs of illness behavior have often been viewed as suggestive of malin-
gering. However, in a review of the literature on this point, Fishbain and col-
leagues [57] found inconsistent evidence. In one study, Waddell signs were
653MALINGERING IN THE MEDICAL SETTING
associated with poorer outcomes, but the signs did not discriminate organic
from nonorganic pain [58].
In a review examining various physical tests of malingering [58], including
Waddell signs, the investigators found support for using two (of the seven de-
scribed) for detecting nonorganic symptoms. The two for which the investiga-
tors found consistent support were both for detecting nonorganic paralysis.
The Hoover’s test [59] and the abducter test [60], both of which involve manip-
ulation of the legs, show promise in detecting malingered leg paresis. In an ar-
ticle written for family physicians, Kiester and Duke [61] offered additional
suggestions for detecting malingered pain including, for example, checking
shoes for uneven wear in patients limping into the office; manual laborers
claiming inability to work but having callouses, dirt, or lacerations on their
hands; and patients who do not injure themselves upon fainting or collapsing.
The reader is also referred to the groundbreaking and colorful books on ma-
lingering by Gavin [62] and Collie [63], in which other clues to malingering,
many still viable, are presented.
DETECTION OF MALINGERED HEAD TRAUMA
While pain is ubiquitous, fortunately head trauma and subsequent cognitive
deficits are relatively uncommon. As a result, the associated patterns of test re-
sults expected from certain central nervous system injuries may be less well
known to the casual observer. Thus, standard neuropsychological assessments
can be useful in identifying individuals who exaggerate such deficits. Various
instruments have been developed to detect this type of malingering.
Table 1
Waddell signs
Category Sign
Tenderness Superficial skin tender to
light touch
Nonanatomic deep
tenderness not localized
to one area
Simulation Axial loading on skull
induces lower back pain
Shoulder and pelvis rotated
in same plane induces
pain
Distraction Difference in straight leg
raising in supine versus
sitting position
Regional Many muscle groups
evidence weakness
Sensory loss in stocking or
glove distribution
Overreaction Disproportionate facial or
verbal expressions
654 MCDERMOTT & FELDMAN
The assessments of malingered head trauma and related cognitive deficits fall
into six general types of detection strategies [31]: the floor effect, performance
curve, magnitude of errors, symptom validity testing, atypical presentation,
and psychological sequelae. The floor effect refers to the inability of individuals
to perform extremely simple tasks. The Rey 15-item memory test [64] is an ex-
ample of such an assessment. This test requires that individuals remember a set
of 15 letters, numbers, and geometric shapes that are in fact quite simple. Indi-
viduals attempting to malinger memory deficits often miss more than truly im-
paired individuals do because of their efforts at deception. The performance
curve strategy is based on the supposition that malingerers do not distinguish
between easy and difficult items. Thus, their performance curve can be com-
pared with those of individuals with true deficits and discrepancies noted.
The Validity Indicator Profile [65] is an example of this strategy. The magni-
tude of errors method is derived from research indicating that malingerers
give larger numbers of near misses and grossly wrong responses to standard-
ized tests [66]. Symptom validity testing requires a forced choice assessment
(ie, the patient must choose between two or more responses). Response rates
below chance are indicative of malingering. The Victoria Symptom Validity
Test [67] is an example of this type of assessment. Atypical presentation occurs
when the response patterns exhibited are significantly different from those of
true patients. The primary limitation of this method of detection is that nonma-
lingerers can sometimes exhibit this pattern. For example, in a simulation study
using the Bender Gestalt [68], standard scoring did not identify malingerers from
nonmalingerers. However, in this study, a forensic psychologist was able to iden-
tify simulators with 100% accuracy. The final method is psychological sequelae
and is based on research that suggests that individuals malingering medical
illnesses are likely to exaggerate psychological symptoms as well [69–71].
Recently, response time has been proposed as an additional strategy. Re-
snick [72] theorized that increased response latency may occur for two reasons:
simulators may overestimate the response time in individuals with a true trau-
matic brain injury, and latency may be increased secondary to the time it takes
a malingerer to decide on an appropriate (wrong) response. Several investiga-
tors have examined this strategy with inconsistent results. For example, Rees
and his colleagues [73], on the Test of Malingered Memory (TOMM), found
that simulators have longer reaction times on correct responses. Strauss and
colleagues [74,75] found that reaction time was longer on a symptom validity
task in simulators (as compared with controls) and that this difference was
more pronounced with more difficult items. In contrast, Rose and colleagues
[76] found that controls and simulators had the same reaction time to a digit
recognition test. However, the combination of response latency and number
of correct responses improved the discriminating ability of the test.
Several authors have provided guidelines for when to suspect malingering of
cognitive deficits. Greiffenstein and colleagues [77] indicated that the examiner
should suspect malingered memory deficits under the following circumstances:
(1) poor performance on two or more standard neuropsychological
655MALINGERING IN THE MEDICAL SETTING
assessments, (2) complete disability in a social role, (3) inconsistency between
reported symptom history and other sources of information, and (4) remote
memory loss. Pankratz and Binder [78] suggested seven behaviors that are in-
dicative of malingering and require further exploration. The first and foremost
is dishonesty: if patients misrepresent details of their lives, they may also be
misrepresenting their symptoms. Additionally, the following six are suggestive
of malingering: (1) inconsistency between reported and observed symptoms,
(2) inconsistency between physical and neuropsychological findings, (3) resis-
tance to or avoidance of standardized tests, (4) failure on measures designed
to detect malingering, (5) functional findings on medical examination, and
(6) delayed cognitive complaints following trauma.
Faust and Ackley [79] also suggest six behaviors that are indicative of feigned
cognitive deficits: (1) poor effort, (2) exaggerated symptoms, (3) production of
nonexistent symptoms, (4) distortion of history regarding symptoms, (5) distor-
tion of premorbid functioning, and (6) denial of strengths. Slick and colleagues
[80] have proposed a much more complicated schema for the detection of ma-
lingered cognitive deficits, which includes four criteria, designated as Criteria A
through D. Criterion A is the presence of financial incentive. Criterion B in-
cludes evidence of exaggeration on neuropsychological tests. Criterion C in-
cludes evidence of false or exaggerated self-report, and Criterion D is that
both criteria B and C cannot be accounted for by psychiatric, neurological,
or developmental factors. An individual can be considered a ‘‘probable malin-
gerer’’ when Criterion A is met and two or more items (of a list of six) are met
from Criterion B or one from B and one from C (of a list of five). Possible ma-
lingering is defined as the presence of Criterion A plus two (or more) items
from Criterion C. More simply put, these investigators believe that self-report
evidence (other than an admission of malingering) is only suggestive of ma-
lingering; evidence of malingering on standard neuropsychological testing is
necessary to be more definitive.
In a recent survey of neuropsychologists who consistently practice in the
area of compensation claims [81], more than 45% indicated that they routinely
use the TOMM [82], and more than 33% indicated that they use the Rey 15-
item Test [64]. As suggested, both instruments were designed specifically for
the detection of malingering. Other specialized tests were used with less fre-
quency. An exhaustive list of instruments developed for the purpose of detect-
ing malingered cognitive deficits is beyond the scope of this article. However,
Table 2 provides a list of the more commonly used assessment tools and many
more are discussed by Pope at http://www.kspope.com/assess/malinger.php.
Most of these instruments require administration by a psychologist with spe-
cific training.
OTHER MALINGERED ILLNESSES
While pain (ie, lower back pain, cervical pain—primarily from whiplash injur-
ies—and fibromyalgia) and mild head injury (including associated cognitive
656 MCDERMOTT & FELDMAN
Table 2
Selected memory and cognitive tests
Memory tests Ease of administration Brief description
Victoria Symptom Validity
Test
Requires training Computer administered,
forced choice; 24 easy,
24 difficult items,
response time also
recorded
Rey 15-item Simple 15 different items shown,
told to reproduce as
many as can
Test of Memory
Malingering (TOMM)
Requires training 2 alternative forced choice,
50 target pictures,
recognize from
50 presentations
of 2 pictures
Portland Digit Recognition
Test
Requires minimal training 72 items, 26 easy, 36 hard;
verbal presentation of
5-digit number, 5, 10 &
30 sec. delay
Digit memory test Requires minimal training 3 blocks of 24 5-digit
numbers; forced choice
with 5, 10 & 15 sec.
delay
Reliable digit span Requires training on
Wechsler Adult
Intelligence Scale (WAIS-
III)
Based on WAIS-III digit
span subtest; sum longest
string of digits passed on
both trials forward and
backward
Word Completion Memory
Test (WCMT)
Requires training 2 subtests: Inclusion
(30 items), Exclusion
(30 items); copies and
rates words; is a priming
task
Word Memory Test
(WMT):
Requires minimal training 20 linked word lists; oral
and computerized
version
Other cognitive deficits Ease of administration Brief description
Validity Indicator Profile Requires training 100 problems assessing
nonverbal abstraction;
78 word definition
problems; 2 alternative
forced choice
Cognitive behavioral
driver’s inventory
Requires training 10 tasks in part adapted
from other instruments;
requires specialized
equipment
Computerized assessment
of response bias
Requires training Computer administered;
25 trials of 5-digit
string; response time
also recorded
657MALINGERING IN THE MEDICAL SETTING
deficits and memory loss) are the most common medical illnesses feigned, the
literature reveals various other illnesses that may be malingered. For example,
both cognitive deficits and psychological sequelae are frequently attributed to
toxic exposures, especially because the injuries related to such exposure may
be ambiguous [83]. Psychogenic seizures are another ailment identified in
some malingering investigations. In a study of psychogenic seizures, Abubakr
and colleagues [84] found that almost 22% of the patients were malingering and
all but one had financial incentives to do so. Similar results were found by
Cragar and colleagues [85]. Huang [86] even reported a case of an individual
malingering HIV illness to obtain housing.
While malingering can occur in any setting for multiple reasons, malingering
in the medical setting is often associated with financial incentives. As indicated,
the detection of malingering can be complex and may involve specialized test-
ing. However, the hallmark of malingering is the inconsistency between re-
ported symptoms and collateral reports, observed behaviors, and physical
and psychological assessments.
TREATMENT
When a determination of malingering is made, the clinician is faced with the
dilemma of how to ‘‘treat’’ a nondisorder. Depending on the situation, the cli-
nician may elect to confront the individual with the assessment. Pankratz and
Erickson [87] emphasize the importance of permitting the malingerer to save
face. Kiester and Duke [61] recommend explaining to patients that they do
not have a serious problem and that deterioration is not expected. They also
recommend assisting in replacing the patient’s illness behavior with other,
more psychologically healthy behaviors. However, these interventions are
predicated on a certain level of psychological health. When there are substan-
tial secondary gains, such as large sums of money, such interventions may well
be ineffective. In these cases, referral to a mental health professional also may
be fruitless. In some cases, though, such a referral facilitates an exploration of
some of the psychological or social deficits for which the patient compensates
through his or her malingering.
Any attempted management of malingering must first be based on an under-
standing of the motivations for symptom production [88]. Blatant malingering
may arise from the same types of enduring personality traits that are observed
in antisocial personality disorder (ASPD), such as a tendency to manipulate
others for personal gain. A number of other psychological problems—some
viewed as treatable and others as refractory, such as ASPD—may contribute
to the drive to malinger. These problems include anxiety, depression, and
other personality disorders more amenable to intervention. Treatment of these
underlying or coexisting mental disorders may reduce the patient’s self-
perceived need to malinger.
Overall, management of milder forms of malingering may benefit from the
kinds of interventions advocated for factitious disorder [89]. They are beyond
the scope of this article. It is important to note, however, that caregivers’
658 MCDERMOTT & FELDMAN
aversion to malingering can translate into overly harsh confrontations and dis-
missals from further care. Consistent with the face-saving strategies noted,
a nonconfrontational approach can allow the patient to relinquish the com-
plaints without admitting that symptoms have been falsified.
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... The markers included were selected among those that showed the greatest discriminatory capacity in the study of Akehurst et al. [1], from the cognitive dimensions of Leventhal (Commonsense Self-Regulation Model [CS-SRM]; [29,30]), and from the publications of Ferrari [21], McDermott, and Feldman [34], Resnick [39], and Vrij [52], among others. The complete list of indicators and their source are included in Appendix 1. ...
... Dimension 5, "Inconsistencies," had the second most discriminative capacity. The results obtained indicate that malingerers often confirm the existence of many symptoms (I9), which is known as a trend towards symptom over-endorsement [34]. On most occasions, they described the symptoms inconsistently (I11) or they claimed suffering from symptoms that did not belong to the pathology (I10). ...
... When synthesizing the above evidence, it can be observed that instructed malingerers tend to overestimate the severity of WAD and offer a much more negative and catastrophic view of the pathology than the genuine patients. These results are compatible with the malingerer profile that has been commonly presented in the bibliography (see [18,34,42]). Despite this, the fact that the instructed malingerers included in the present study were medical students should be considered. ...
Article
The objective of this work is to evaluate the ability of a series of possible feigning indicators, extracted from relevant literature in the field, to discriminate between clinical patients with genuine symptomatology and instructed malingerers. A sample of 273 participants divided into two groups was used for this study: 153 whiplash associated disorder patients who were evaluated at a multidisciplinary medical center in the region of Murcia (Spain), between December 2017 and March 2019 and 120 healthy controls with malingering instructions, students of the Faculty of Medicine of the University of Murcia. In order for researchers to evaluate the indicators included in the study, a 22-step checklist (CDS) was developed, consisting of 22 criteria divided into 5 dimensions. Our results show that 18 of 22 indicators could discriminate between groups. Dimension 2 “Attitude toward the situation of illness” presented the greatest capacity for discrimination. In general terms, malingerers express a much more negative experience of the condition than the clinical patients.
... In settings such as psychiatric emergency departments, it is paramount that, before diagnosing a patient, a clinician considers the possibility that the patient is feigning their complaints (Hong et al., 2019;McDermott & Feldman, 2007). People might engage in symptom feigning for a variety of reasons, including financial, legal, or medical benefits (e.g., obtaining drugs). 1 There is no consensus on the prevalence of feigning (Young, 2015), with estimates ranging from 0% to 40%, but researchers agree that rates are higher in forensic settings (e.g., litigation) than in clinical settings (Bianchini et al., 2005;Greve et al., 2013;Mittenberg et al., 2002). ...
... Some clinicians have argued that a highly variable, that is, inconsistent symptom presentation is a red flag of feigning, but this practical guideline has not been researched very well (Bianchini et al., 2005;McDermott & Feldman, 2007). The idea that intraindividual variability in symptom reports points in the direction of feigning, whereas consistent presentations reflect genuine illness, aligns with the medical model, according to which symptoms are signs of underlying problems that are stable and permanent unless treated (Blaney, 2014). ...
Article
Full-text available
Practitioners always want to exclude the possibility that a patient is feigning symptoms. Some experts have suggested that an inconsistent symptom presentation across time (i.e., intraindividual variability) is indicative of feigning. We investigated how individuals with genuine pain-related symptoms (truth tellers; Study 1 n = 32; Study 2 n = 48) and people feigning such complaints (feigners; Study 1 n = 32; Study 2 n = 28) rated the intensity of their symptoms across a 5-day period. In both studies, feigners reported on all 5 days significantly higher symptom intensities than people with genuine complaints, but the two groups did not differ with regard to symptom (in)consistency. Thus, persistently inflated, rather than inconsistent, reports of symptom intensity over time are suggestive of feigning. The implications and limitations of our work are discussed.
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Background: Malingering is a common and challenging clinical presentation in emergency departments (EDs). Objective: This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service. Methods: Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses. Results: Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01). Conclusions: No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.
Chapter
In malingering and factitious disorders, the patient pretends to be ill and intentionally causes his or her own symptoms. Physicians, who are trained to trust what patients tell them, have difficulty assessing and treating patients who lie. This chapter will review the diagnosis, assessment, and management of these difficult patients and provide practical advice to the emergency department (ED) clinician.
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Introduction Malingering, defined as a deliberate attempt to lie or deceive in connection with an illness or disability, exaggerating the symptomatology, with the aim of obtaining a personal benefit, is a complex phenomenon, seldom studied in our professional context. The objective of this study was to analyse the way in which this phenomenon manifests itself in the forensic field. Material and methods An incidental sample of 190 subjects attended in the Psychology Unit (IMLCFC) over 16 months was selected. The Structured Inventory of Malingered Symptomatology (SIMS) was administered to them, while assessing certain clinical indicators of malingering and other psychometric results. A descriptive statistical analysis of the sample was performed, focusing on the correlations between clinical and psychometric suspicion, and on specific vs. generic test sensitivity. Results The structured clinical criterion to detect malingering correlates moderately with the result obtained in the SIMS; the total score in this test presents a positive, albeit attenuated, correlation with the exaggeration indicators from the main psychopathology test; malingering is a highly prevalent response style in subjects seeking work-related sickness compensation, with a pattern of significantly increased responses compared to that observed in criminal samples. Discussion The assessment of malingered psychological symptoms in the forensic context requires a multi-method strategy that includes structured clinical diagnosis, specific detection instruments, and other complementary psychometric tests, in order to generate convergent validity that contributes to the detection of this phenomenon.
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Factitious gastrointestinal bleeding (GIB) is a manifestation of factitious disorder (FD) wherein patients feign GIB in the absence of external gain. As it can be a challenging diagnosis to make, factitious GIB often leads to multiple tests, exposure to contrast agents and radiation, invasive endoscopic and surgical procedures, an increased risk of iatrogenic complications, and increased healthcare costs. Patients who feign GIB often demonstrate characteristic behaviors that may go unnoticed unless they are explicitly addressed. We report a series of patients admitted to our institution for further evaluation of obscure overt GIB with an eventual diagnosis of factitious GIB and review of the epidemiology and development of FD, a diagnostic approach to factitious GIB, and current management strategies.
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Malingering, or intentional feigning of impairment for an external incentive, has been the topic of extensive psychological research in recent decades. The emphasis on symptom validity assessment in training, practice, and research in clinical psychology is not echoed across other health professions. While past surveys of clinical psychologists revealed positive beliefs and attitudes toward validity assessment, much less is known about physicians in this area, particularly in regard to how they identify suspected malingering. To address this gap, we surveyed a sample of demographically similar clinical psychologists (n = 57) and physicians (n = 54) regarding their beliefs and practices about malingering. Unique to this study was the use of a mixed survey and mixed methods approach to analyzing quantitative and qualitative data. Broadly, survey findings indicated that more clinical psychologists reported documenting malingering in their careers compared with physicians (65.0% vs. 33.0%). Consistently, more clinical psychologists endorsed “always” or “often” being able to recognize malingering compared with physicians (73.7% vs. 22.2%). Clinical psychologists indicated that they ask patients or evaluees about potential external incentives (e.g., current involvement in litigation) much more often than physicians (70.0% vs. 16.0%). On average, clinical psychologists estimated higher base rates of malingering in six high-risk malingering diagnostic categories compared with physicians, with greatest estimation difference noted for mild traumatic brain injury (19.9% vs. 5.9%). Qualitative examination of respondent data generally converged with quantitative findings and provided additional insights to how conceptualizations of malingering differ across healthcare disciplines. Implications for practice and study limitations are discussed.
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Factitious Disorders typically involve patients who feign physical and/or psychological symptoms for the sake of psychological benefits rather than external gain. This chapter illustrates ways that people who exhibit this type of pathology, usually in medical settings, may transfer their proclivity for elaborate deceptions to the legal arena. These individuals may present as highly believable to attorneys, judges, law enforcement and child protection personnel who are unfamiliar with the dynamics of Factitious Disorders.
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The utility of various measures of malingering was evaluated using an analog design in which half the participants (composed of three groups: naive healthy people, professionals working with head-injured people, individuals who suffered a head injury but not currently in litigation) were asked to try their best and the remainder was asked to feign believable injury. Participants were assessed with the Reliable Digit Span (RDS) task, the Victoria Symptom Validity Test (VSVT), and the Computerized Dot Counting Test (CDCT) on three separate occasions in order to determine whether repeat administration of tests improves prediction. The results indicated that regardless of an individual's experience, consideration of both level of performance (particularly on forced-choice symptom validity tasks) and intraindividual variability holds considerable promise for the detection of malingering.
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A large sample of chronic postconcussive patients with and without overt malingering signs was compared with objectively brain-injured patients on common episodic memory and malingered amnesia measures. Probable malingerers and traumatically brain-injured Ss were not differentiated on popular episodic recall tests. In contrast, probable malingerers performed poorly on the Rey 15-item, Rey Word Recognition List, Reliable Digit Span, Portland Digit Recognition Test, and Rey Auditory Verbal Learning Test recognition trial. These findings validated both commonly cited malingering measures and newly introduced methods of classifying malingering in real-world clinical samples. The base rate for malingering in chronically complaining mild head injury patients may be much larger than previously assumed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)