History about Malingering, Concept and nosology, Symptom presentation, Interview and observation, Psychological assessment, Diagnostic difficulty and Differential diagnosis.

1. DR. SUBHENDU SEKHAR DHAR & DR. SHIKHA TALATI

2. OUTLINE
• Introduction
• Concept and nosology
• Magnitude of the problem
• When to suspect malingering?
• Symptom presentation
• Interview and observation
• Psychological assessment
• Diagnostic difficulty and Differential diagnosis
• Summary

3. WHAT IS MALINGERING ?
• French malingerer- ‘to suffer’ or ‘pretend to
be ill’
• “Malingering is intentional production of false
or grossly exaggerated physical or psychologic
symptoms motivated by external incentives”
– DSM-5

4. HISTORY
• Feigned madness in Bible
• Ulysses- feigned madness in Trojan war
• 2nd A.D. : Galen- ‘ On feigned disease and
detection of them’
• 1823- Beck’s ‘ Elements of medical
jurisprudence ’
• Landmark study in 1973 by Rosenhan

5. CONCEPT
&
NOSOLOGY

6. DR. ROGERS’ MODELS
• Partial malingering
• Exaggerate pre-existing
symptoms to control experience
PATHOGENIC
• Individual seeking reprieve from
legal consequences
CRIMINOLOGICAL
• Adversarial setting ( stressor)- act
of desperation or poor coping
skills
ADAPTATION

7. RESNICK SUBTYPES
• Based on symptom presentation and
continuum concept
1. Pure malingering- complete fabrication
2. Partial malingering- exaggeration of existing
symptoms
3. False imputation- evaluee intentionally
attributes symptoms to unrelated cause

8. LIPIAN AND MILLS 2000
1. Positive malingering- feigning symptoms
2. Negative malingering- hiding/misreporting
symptoms
3. Data tampering- altering/influencing tests,
records, instruments
4. False imputation- ascribing actual symptoms
to unrelated cause

9. LIPIAN AND MILLS 2000
5. Staging events- careful planning to gain injury
or an explanation for feigning disability
6. Misattribution- ascribe actual symptoms to
cause erroneously believed to have caused it

10. MAGNITUDE OF
THE PROBLEM

11. MAGNITUDE OF PROBLEM
• 1% civilian context
• 5% military context
• 10-20% in medico-legal settings
• 13% patients in emergency settings
• 32% of forensic psychiatry referrals

12. MAGNITUDE OF PROBLEM
33531
30% disability
evaluations
29% personal
injury
19% criminal
evaluations
8% medical
cases
• Mittenburg et al : 33531 cases seen by American
board of clinical neuropsychology in 1 year.

13. WHEN TO SUSPECT
MALINGERING ?

14. SUSPECT WHEN..
1. Marked discrepancy- claimed disability and
objective findings
2. Medico-legal context of presentation
3. Lack of cooperation in evaluation
4. Antisocial personality disorder

15. INCENTIVE/MOTIVATION
• Avoiding work/military duty/prosecution
• Obtaining financial compensation/incentive
• Obtaining narcotic drugs
• Career or work conflicts
• Solution to socio-economic problems
• Documentation purpose/policy requirements
• H/O lying, dishonesty

16. PRESENTATION OF
SYMPTOMS

17. SYMPTOMS
• Unusual/atypical symptoms
• Currently asymptomatic
• Exaggeration of symptoms
• Symptoms incongruent with course of illness
• Bizarre/absurd symptomatology
• Unusual response to treatment
• Atypical fluctuation
• Voluntary control over symptoms

18. COMMONLY MALINGERED SYMPTOMS
• Memory deficits
• Seizure
• Sleep disorders
• Altered identity
• Mood symptoms
• Suicidal ideations
• Hallucinations

19. MALINGERED PSYCHIATRIC
CONDITIONS
• Dissociative disorders- motor, amnesia,
identity
• Amnestic disorders
• PTSD
• Psychosis
• Mood disorders

21. MALINGERED AMNESIA
• Most common
• Easy to feign, difficult to demonstrate
• Neuroimaging, rule out dissociative disorders
and substance use/ intoxication
• No prior history of
• Antisocial traits > histrionic traits
• Spotty episode amnesia rather than global
amnesia

22. MALINGERED COGNITIVE DEFICIT
• TOMM
• Incongruity of vocational, recreational and
social performance with presentation
capabilities
• Striking discrepancy from previous records
and testing
• Lack of perseveration
• Implausible symptom profile given reported
injury

23. MALINGERED PTSD
1. Assertion of inability to work in the face of
unimpaired capacity for pleasurable activity
2. Subscription to more obvious symptoms in
the face of denial of more subtle features
3. Spotty, questionable vocational history;
tendency to drift; fringe member of society
4. Traits common to antisocial, narcissistic,
borderline, or histrionic personality disorders

24. INTERVIEW AND
OBSERVATION

25. HISTORY FROM COLLATERAL SOURCES
• Refute or confirm patient’s information
• Provide additional information
• H/O substance use, antisocial acts or
psychiatric illness
• Prior functioning of patient
• Evidence of claimed disability

26. PATIENT INTERVIEW
INTERVIEW TECHNIQUE
• Long and detailed
• Leading questions for unrelated illness

27. INTERVIEW TECHNIQUE
OTHMER & OTHMER - CROSS EXAMINATION
CLINICAL INTERVIEW-
1. Listen- listen, encourage elaboration
2. Tag- double check for consistency, details,
accuracy
3. Confront- non-threatening way for
inconsistencies
4. Solve -continue interview in yes/no questions
despite resistance
5. Approve- close by approval of evaluee

28. INTERVIEW TECHNIQUE
CAUTION- ABCS
A- avoid accusations of lying
B- beware of countertransference
C- clarification; not confrontation
S- security measures

29. OBSERVATION DURING INTERVIEW
SPEECH
• High- pitched
• Frequent grammatical errors
• More hesitations and pauses

30. OBSERVATION DURING INTERVIEW
FACIAL EXPRESSION
• More reliable as difficult to rehearse
• False affect deliberate, prolonged without the
natural crescendo-decrescendo
• Timing of affective display late or early

31. OBSERVATION DURING INTERVIEW
BODY GESTURES
• Good source of leakage
• Illustrators ( gestures accompanying speech)
less frequently used
• Emblems ( specific meaning gestures)
discordant with spoken language
• Manipulators ( movements and props )
prolonged and frequently used

32. CLAIMANT INTERVIEW PRESENTATION
• Admission of malingering
• Lack of cooperation/ non- compliance
• Discrepancy between history report and
documentation
• Inconsistent reporting

33. OBSERVATION ACROSS TIME AND
SITUATIONS
• Different settings and different professionals
at different cross sections- consistency of
symptoms
• IPD admission- daily monitoring and
recording- difficulty in feigning uniformly for
prolonged periods

34. PSYCHOLOGICAL
ASSESSMENT OF
MALINGERING

35. PRINCIPLES
• Attempt to magnify illness- perform less
adequately than predicted
• Validity scales to check-
1. Exaggeration
2. Defensiveness
3. Untruthfulness
4. Consistency over time
5. Tendency to respond excessively

36. PSYCHOLOGICAL TESTS
1. MMPI-2 (Minnesota Multiphasic Personality
Inventory-2)
• F- scale( malingering index) – stereotypic and
serious symptoms rarely found in patients
• Fake bad scale ( FBS )- evaluating fake physical
complaints
2. SIRS (Structured Interview Of Reported Symptoms)
• Evaluate exaggerated, atypical or absurd symptoms
• Good sensitivity and specificity
• Screening in correctional setting

37. PSYCHOLOGICAL TESTS
3. Miller- forensic assessment of symptoms test
(M-FAST)
4. Victoria symptom validity test- compares
errors and reaction time on easy vs. difficult
items
5. Personality assessment inventory- 6 response
distortion indicators
6. Personality inventory for youth- inconsistency
scale

38. PSYCHOLOGICAL TESTS
7. Structured inventory of malingered
symptomatology - detect manipulative and
antisocial personality
8. Rorschach test
9. Rey auditory verbal learning test
10. Wisconsin cart sorting test

39. PSYCHOLOGICAL TESTS
11. Test of memory malingering (TOMM)
Pts are given a memory test, which looks
difficult, but is in fact known to be easy.
Someone making good effort: scores well on
tests which are actually easy and lower on more
difficult tests.
Someone making a poor effort: score low on test
which look hard but are in fact easy. May not
score low on more difficult tests.

40. LIMITATIONS
• 40% will not be identified
• 30% will be identified by standard cognitive
testing
• 40% can be identified by psychological
assessment

41. DIAGNOSIS AND
MANAGEMENT

42. DSM AND ICD
• Not a psychiatric disorder
• DSM-5- in other conditions that may focus on
clinical attention
• ICD-10- V code & Z code

43. DIFFICULTY IN DIAGNOSIS
• ROSENHAN 1973
• Challenging despite high index of suspicion
because of-
1. Ethical dilemma
2. Difficulty in proving
3. Fear of legal suit
4. Pejorative term- stigmatization
5. Easy to feign psychiatric symptoms in absence of
objective testing

44. DIFFERENTIAL DIAGNOSIS
• Factitious disorder
• Somatoform disorder
• Dissociative disorder

46. FACTORS AIDING DIFFERENTIATION
WITH DISSOCIATIVE DISORDER
DISSOCIATIVE MALINGERING
ATTITUDE friendly, cooperative,
appealing, dependent, and
clinging
suspicious, uncooperative,
aloof, and unfriendly
HISTORY report historical gaps,
inaccuracies, and vagaries
detailed and exacting
descriptions of events
precipitating their illness
EVALUATION welcome evaluation and
treatment, searching for an
answer
avoid diagnostic
evaluations and refuse
recommended treatment
EMPLOYMENT accept opportunities refuse employment
opportunities designed to
circumvent their disability

47. MANAGEMENT
• Understand the function of deception
• Stress and coping strategies
• Disentangle true symptoms and their
treatment
• Conservative approach minimizing iatrogenic
effects and unnecessary expenditure

48. SUMMARY
• Malingering is common & very difficult to
detect.
• Due to the nature of the disorder, the
literature on malingering is largely confined to
case reports and case series, limiting the
information available.
• Sensitive legal and ethical issues involved.

49. SUMMARY
• The medical expert's role is to assess a
clinical presentation, evaluate reported
symptoms, render diagnoses based on the
best evidence possible, and suggest a
treatment plan.
• This approach to malingering clearly gives the
physician a medical rather than a legal or even
a moral role.

50. REFERENCES
• Forensic Psychiatry, An Indian Perspective.
• Mittenberg W, Patton C, Canyock EM, Condit
DC (2002) Base Rates of Malingering and
Symptom Exeggeration. Journal of Clinical and
Experimental Neuropsychology 24: 1094–
1102. doi: 10.1076/jcen.24.8.1094.8379
• Singh J, Avasthi A, Grover S. Malingering of
psychiatric disorders: A review. German
Journal of Psychiatry. 2007;10(4):126-32.

51. THANK YOU