1. FEIGNING PAIN FOR GAIN: A Guide to Identifying
Exaggerated or Faked Physical Symptoms in Litigation
February 13, 2001
Stuart J. Clayman, Ph.D.
Licensed Psychologist
181 Lake Shore Road
Brighton, MA 02135
Tel. (617) 782-8355
Fax: (617) 254-9053
docstu@psych9.com
Introduction: "Malingering" usually refers to the situation in which an injured
person, motivated by external incentives such as money damages, purposely
exaggerates or fakes psychological symptoms. However, there is a second type
of malingering in which an individual exaggerates or fakes physical symptoms or
pain and simultaneously minimizes or denies psychological symptoms in order to
enhance the credibility of the exaggerated physical complaints. This article will
discuss the second type of malingering.
Composite Case Study: “Bob”, a 35 year old ironworker was injured at work
when he tripped on an I-beam and fell. He was taken by ambulance to a local
hospital and was evaluated in the Emergency Room. He reportedly sustained
significant physical injuries but he was treated and released without being
admitted. He was given discharge diagnoses of severe lacerations on his arms
and legs and neck sprain. He did not return to work after he was injured and filed
a Worker's Compensation claim. His physical injuries healed quite well over the
next two months and his doctors expected him to make a full recovery. Yet, two
years after the accident, he continued to complain of extreme, disabling neck
pain which prevented him from working and from participating in hobbies and
interests. Physicians who examined him several months after the accident were
unable to find any medical explanation for chronic pain.
Malingering: Because large rewards are potentially available to employees in
Worker's Compensation claims, some workers may be motivated to produce
false or greatly exaggerated physical or psychological symptoms in order to
obtain money damages and to avoid work. This behavior, referred to as
“malingering”, is intuitively understood as the deliberate attempt to appear sicker
physically or psychologically than the objective findings would suggest. Perhaps
less intuitive is the situation in which a plaintiff may wish to appear less
psychologically disturbed than is the case. In a Worker's Compensation claim

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involving an allegation of chronic pain, appearing very mentally healthy can be
motivated by the desire to enhance the credibility of exaggerated physical
symptoms. Workers who are exaggerating or faking physical symptoms may be
identified by psychological profiles which possess the following elements:
(1) Claims of moral excellence
(2) Self-portrayal as completely honest and above reproach
(3) Unusually high scores on tests that measure frequency, duration and
intensity of physical symptoms
Rationale for special psychological testing: David Schretlen, who
evaluated the ability of 15 psychological tests to detect malingering, has noted
there is no research proving that interview by itself can reliably identify
malingering. In an article he published in Clinical Psychology Review, Schretlen
stated: "This does not mean that astute clinicians cannot detect malingering by
talking with the patient. But until controlled research validates this application of
the psychiatric interview, it is probably indefensible to render expert testimony
regarding the likelihood of malingering unless one has psychological test data
that bear on the question".1
Even more problematic, Lees-Haley has shown how
surprisingly easy it is for a litigant, motivated to exaggerate or fake, to bamboozle
some commonly administered psychological tests.2
The What and Why of the MMPI: The Minnesota Multiphasic Personality
Inventory (MMPI-2), a 567-item true-false test, is nearly unique among
psychological tests because it contains built in “validity scales” that have been
scientifically demonstrated to be useful in identifying various forms of unusual
responding. Since different scales on the MMPI-2 are comprised of different
numbers of test items, a way was needed to standardize scores for ease of
comparison and interpretation among the various scales. Thus, scores on each
scale are mathematically transformed into “T-Scores”. The average T-Score is
50 while scores above 65T fall within the abnormal range and have a
meaning similar to that of a body temperature above 98.6°. The MMPI-2
scales that can identify exaggerated or faked psychological symptoms are called
"F" and FB". There is ample data showing that F and FB can reliably identify
exaggerated or faked psychological symptoms. But, the tendency to exaggerate
psychological symptoms is not the focus of this article. The tendency to deny
psychological symptoms is the focus of this article and the two MMPI-2 scales
that are used to identify a tendency to minimize or deny psychological symptoms
are called “L” and “K”.

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Scale L: Scale L on the MMPI-2 consists of 15 items. These items are often
thought to be "obvious" and present an opportunity for the test-taker to easily
and deliberately portray himself or herself as perfectly mentally healthy by
responding to each item in a certain direction. The following four statements,
though not actual MMPI-2 test items, are similar to the kinds of items that
actually comprise scale L.
• At some time I have told a lie.
• I have been rude to another person.
• I have used offensive language once or twice.
• People have sometimes let me down.
1 point is added to the score for Scale L each time the test-taker answers “false”
to items similar to those above. Scores on this scale can range from 0 to 15.
Research with groups of normal people has shown that the average score for a
male on Scale L is 3.53 out of 15 and for females is 3.56 out of 15. These Raw
Scores translate into T-scores of about 50. Individuals who obtain scores above
60T are "defensive" and are presenting themselves as unusually virtuous. Scores
above 65T are extremely elevated and may invalidate the test because they
indicate that the test-taker is purposely attempting to deceive others.
There is a substantial published scientific literature examining the ability of Scale
L to determine if a test subject is claiming unlikely levels of moral excellence and
honesty. In a study published in the Journal of Personality Assessment, John
Graham3
and others asked 56 students (27 men and 29 women) to take the
MMPI-2 twice: once with standard instructions and once with instructions to
present a very positive impression of themselves and “to try to imagine that you
are graduating from college, are being assessed for a highly desirable job, and
for that reason are trying to appear very well adjusted”. On Validity Scale L,
subjects obtained the following average T-scores (50 is an average score while
scores above 65 are extremely elevated and invalidate the whole test):
Women Men
Standard Instructions: 48.3 48.0
Fake-Good Instructions: 76.5 72.3
These results clearly indicate that male and female subjects who are given
standard instructions for taking the MMPI-2 obtain scores that are very close to
average (50) on Validity Scale L. Subjects given the “fake-good” instructions earn
significantly higher scores which indicate an extreme tendency to claim unusual
levels of moral excellence and honesty. Scale L is successful in identifying
individuals who are trying to appear to be free of psychological symptoms.

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Scale K: Scale K consists of 30 items. The average score on Scale K for normal
men is 15.30 out of 30 and for normal women the average score is 15.03 out of
30. As with Scale L, raw scores on Scale K are transformed into T-scores.
Scores above 65T on Scale K (raw scores above 22) may indicate such severe
deceptiveness on the part of the test-taker that the MMPI-2 is invalidated and
cannot be interpreted. The items comprising Scale K tend to be more subtle than
L Scale items so it is less likely that a "defensive" person will understand the
rationale of the K items and will be less likely to be able to avoid detection. In this
sense, K is a measure of more sophisticated "defensiveness" and seems to
assess "unconscious" attempts to portray oneself as perfectly honest and morally
excellent. The following three statements, though not actual MMPI-2 items, are
similar to the kinds of items comprising scale K; each "false" response given by
the test-taker to these questions will add 1 point to the K Scale:
• Sometimes I have felt like telling another person off.
• Most people exaggerate their accomplishments.
• Sometimes I get annoyed if I can’t have my own way.
Graham and his co-researchers found the following values for Scale K when
students were asked to take the MMPI-2 under "standard" and "fake-good"
instructions:
Women Men
Standard Instructions: 45.1 46.3
Fake-Good Instructions: 60.7 56.6
These results indicate that, given standard instructions for the test, male and
female subjects obtain scores very close to average (50T) on Scale K, a
measure of defensiveness but when the same subjects take the test under “fake-
good” conditions they earn scores that are significantly higher indicating a strong
tendency to portray themselves as very honest and morally excellent.
How Accurate are L and K?: Performing additional calculations on their data,
Graham and his colleagues determined that the Scale L correctly classified 93%
of the fake-good profiles of women, while for men Scale L correctly classified
96% of the fake-good profiles. They also found that Scale K correctly classified
97% of the fake-good profiles of women, while for men, Scale K correctly
classified 93% of the fake-good profiles. These findings indicate that MMPI-2
Validity Scales L and K worked well to separate “fake-good” profiles from honest
profiles for both men and women.
Defensive Responding Profile: Butcher and Harlow (1987)4
noted that
“Individuals who wish to create an impression of having serious physical

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problems tend to produce MMPI profiles that have some common features” (pg
142) including the following:
1. Elevations on Validity Scales L or K or both suggesting exaggerated
personal virtue and honesty with the apparent motivation to appear beyond
reproach so that exaggerated claims of pain or physical symptoms will appear
more credible
2. Elevations on Clinical Scales: An MMPI-2 clinical profile characterized by
exaggerated endorsement of items referring to physical symptoms.
Exaggerated endorsement of physical symptoms can take several forms.
a. One common form is an extreme elevation of Scale 1 (the
Hypochondriasis Scale). An individual who has genuine physical illness
typically obtains a moderate elevation on Scale 1 (a T score of 58 to 64)
while high scorers (T scores of 65 or higher) on Scale 1 have a
psychological component to their symptoms such as a tendency toward
unusual preoccupation with bodily functions or towards endorsing
symptoms which do not co-exist in genuine medical disease.
b. A second form of physical symptom endorsement is characterized by a
combination of elevations on Scale 1 and on Scale 3 (also called Scale
“Hy” or “Hysteria”). The combination of unusual elevations on Scales 1
and 3 is called the “Conversion V” profile. Individuals with elevations on
both Scales 1 and 3 focus on medical explanations for their problems
and avoid acknowledging psychological factors that may contribute to
their difficulties.
c. A third form of physical symptom endorsement that may accompany
elevations on L and K is the significant elevation of Scale 8 (the
"Schizophrenia" scale). This pattern, sometimes manifested by
individuals claiming toxic exposure or poisoning may be accompanied
by "neurological" symptoms such as memory impairment or confused
thinking (Butcher and Harlow, pg 142-143) that may be exaggerated or
faked.
“Bob’s” MMPI-2 Profile: Bob's scores on the basic MMPI-2 scales are as
follows:
L: 64T Scale 1: 67T Scale 4: 47T Scale 7: 60T
F: 52T Scale 2: 59T Scale 5: 51T Scale 8: 44T
K: 63T Scale 3: 71T Scale 6: 55T Scale 9: 53T
Scale 0: 54T
Bob’s MMPI-2 Validity Scale profile indicates that he is claiming very unusual
honesty and virtue (high scores on L & K) while his symptom scales indicate that
he is reporting extreme and chronic pain that disables him (high scores on
Scales 1 & 3). His obvious attempt to portray himself as free from all human

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frailties, even those human weaknesses to which most people will admit, is
apparently motivated by his desire to convince others of the credibility of his
exaggerated physical complaints).
DSM-IV Criteria of Malingering: “Malingering” is the term psychologists and
other mental health professionals use to describe “the intentional production of
false or grossly exaggerated physical or psychological symptoms, motivated by
external incentives such as avoiding military duty, avoiding work, obtaining
financial compensation, evading criminal prosecution or obtaining drugs” 5
. The
individual engaging in malingering is thought to be consciously aware that he or
she is exaggerating or minimizing symptoms.
There should be a strong suspicion of malingering if any two or more of the
following are identified: 6
1. Medicologal context of presentation (e.g. the person is referred by an
attorney to the clinician for examination)
2. Marked discrepancy between the person’s claimed stress or disability
and the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying
with the prescribed treatment regimen
4. The presence of Antisocial Personality Disorder
Confirmatory data: Various pieces of data, obtained during interviews of the
injured worker by the defense's psychological expert, and from a review of the
medical records, were consistent with DSM-IV criteria of malingering and indicate
that "Bob" was most likely exaggerating or faking his chronic pain complaint. The
following are some examples of these findings:
(Consistent with Malingering criterion #1:“medicolegal presentation”)
• He was given a preliminary diagnosis of "Mixed Anxiety and Depression"
when he was evaluated in an emergency room on the day of the work
accident, but he did not seek treatment for emotional distress until he
retained counsel and his attorney referred him to a psychiatrist
(Consistent with Malingering criterion #2: marked discrepancy)
• The emergency room physician said: “his pain is not consistent with anything
I learned in medical school about nerve injury”
• The plaintiff’s neurologist wrote in his report that “the patient’s pain does not
conform to any known anatomical pattern and cannot be explained by nerve
damage”

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• The defense neurologist said “There is no objective evidence consistent with
the limitation in daily activities he is describing”
• The defense orthopedic doctor said: “There is evidence of symptom
magnification”
• The employee repeatedly completes Pain Scales (as a part of treatment)
and, on a scale from 1 to 10 (with 1 being no pain at all and 10 being the
most pain imaginable), he complains that his current pain is a “10” and his
average pain is a "10" and that there has little change in pain intensity since
the day of the work injury
(Consistent with Malingering criterion #3: lack of cooperation)
• His medical doctor recommended several times that he attend a Pain Clinic,
but he failed to set up an appointment for an initial evaluation at the Pain
Clinic
• He failed to complete hourly pain ratings which he was asked to do by the
psychologist who was treating him for pain
• He was prescribed a specific exercise in order to reduce neck pain, but he
did not perform this exercise
• He failed to complete a “negative thoughts” worksheet
• He refused to participate in some neurological tests used to evaluate pain
• Bob failed to show up for two scheduled visits with the defense’s mental
health expert; evidence in his diary indicated he decided in advance not to
keep one of these appointments and didn’t let the examining doctor know
• He was one-half hour late for one visit with the defense’s psychological
expert
• He was reluctant to complete tests conducted by the defense's psychologist
Conclusions: Pain that is exaggerated or faked within the context of litigation
can often be identified by a combination of careful history-taking, scrutiny of
medical records and personality evaluation utilizing specialized psychological
tests.
Assembling strong evidence that identifies pain and psychological symptoms as
exaggerated or faked will significantly reduce the credibility of such claims.
1
Schretlen, David. The use of psychological tests to identify malingered symptoms of mental disorder. Clinical
Psychology Review, 1988, 8, 451-476.
2
Lees-Haley, Paul. Malingering traumatic mental disorder on the Beck Depression Inventory: cancerphobia and
toxic exposure. Psychological Reports, 1989, 65, 623-626.
3
Graham, J.R., Watts, D. & Timbrook, R.E. Detecting fake-good and fake-bad MMPI-2 profiles. Journal of
Personality Assessment, 1991, 57, 264-277.
4
Butcher, J.N. & Harlow, T.C. Personality Assessment in Personal Injury Cases, In Handbook of Forensic
Psychology, (A. Hess and I. Weiner, Eds.), New York, Wiley.

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5
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), American Psychiatric
Association, 1994, pp. 683
6
DSM-IV, pp 471