malingering misperceptions: what are we missing?

Jude Bergkamp, Psy.D.

Antioch University Seattle

Ray Hendrickson, Ph.D., J.D.

Western State Hospital

What have you heard about malingering?

How does it impact your work?

How many of you are at this conference to get out of work?

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Definitions & Diagnosis

Clinical Considerations

Alternative Perspectives

Recommendations

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Malingering – the intentional or conscious fabrication or gross exaggeration of mental health symptoms as a means towards gaining a desirable outcome.

Feigning – Fabrication or exaggeration of symptoms without the assumption of motivation/secondary gain.

Other terms include dissimulation, minimization, denial, and distortion

Positive impression management Appear “normal”

Avoid stigma of mental illness

Avoid treatment

Avoid deprivation of liberty (hospitalization, loss of privilege/freedom

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Deceived “the most respected minds in forensic psychiatry” in CST evaluations from 1990 to 1997

The Oddfather and The Enigma in the Bathrobe

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V65.2 Malingering

The essential feature of Malingering is 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. Under some circumstances, malingering may represent adaptive behavior—for example, feigning illness while a captive of the enemy during wartime.

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Malingering should be considered if any combinations of the following is noted:

Medicolegal context of presentation [e.g., if referred by an attorney, or is self-referred while litigation or criminal charges are pending]

Marked discrepancy between the individual’s claimed stress or disability and the objective findings and observations.

Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen.

The presence of antisocial personality disorder.

Problem: The external establishment of internal motivation or volition

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Conscious Feigning

Malingering

Factitious Disorder

Factitious Disorder by Proxy

Unconscious Feigning

Conversion Disorder

Somatization Disorder

Pain Disorder

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Medical/Legal Cases Social Security Disability

Personal Injury

Worker’s compensation

VA Benefits

Treatment Settings Chronic pain

Seeking hospitalization or housing

Forensic Settings Competency

Criminal Responsibility

Sentencing considerations

Correctional Preferable Housing

Protective Custody

Drug seeking

Social Contact

Release Considerations

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Not so fast!

DSM-IV-TR criteria result in a misclassification rate of over 80% (Rogers & Vitacco, 2002).

How did you answer the ”get out of work” question?

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Pathogenic Model Underlying force behind malingering is a mental disorder

This model has fallen out of favor with the changing perceptions of malingering

Criminological Model Malingering as a form or result of antisocial and criminal behavior

The “dishonest criminal” theory

Engaging in dishonesty is a hallmark of ASPD

Adaptation Model Malingering as an adaptive behavior to meet the needs of the

individual at that time

Occurs when the stakes are high and the individual perceives that there is no other viable choice

Adversarial evaluation

Feigning illness while captive

Personal injury suits

Avoiding harm

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We can never truly determine motivation

No psychometric and normed measure to assess motivation/intention

Malingering is a state not a trait

Feigned and genuine symptoms are often present in the same person

Feigning can occur without malingering (secondary gain)

STIGMA!

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Beware of the pitfalls and limitations of malingering (clinical discourse and documentation)

Look for and refer for psychometric testing

Structured Interview of Reported Symptoms (SIRS)

Miller Forensic Assessment of Symptoms Test (M-FAST)

Minnesota Multiphasic Personality Inventory (MMPI-2)

Personality Assessment Inventory (PAI)

Quality consideration will incorporate testing and acknowledge limitations and implications

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Awareness of your emotions (hurt, mistrust, betrayal)

Avoid extracting a confession or playing “gotcha”

Consider the context and possible external/internal gains

Attempt to strategically meet basic human needs

Reinforce alternative coping mechanisms

Balance accountability with alliance/compassion/rapport

Provide face-saving

Firm boundaries

Consistent documentation and consultation

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Present observation in a straightforward and non-judgmental manner

I hear you telling me that everything is “fine,” although when I hear about ______(observation)___, I am having some difficulty understanding what is going on.

I know how much you want people to believe that you have _____(symptoms)___ under control on your own. I see in the chart that ________ may still be going on. Can you help me understand?

I understand how hard it is for some of the people I meet to describe what is going on for them without feeling vulnerable or like it will be used against them. Whenever someone tells me only the good side, I become interested in what is being left out.

According to you today, you are having no difficulties handling _____, but according to the treatment team you look like you are still struggling with ______. Why do you think they might think this?

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Because of the inconsistent or improbable nature of the clinical presentation of someone who is malingering, clinical probes may need to be broader

Some of the problems you describe are rarely seen in patients with mental illness. I am worried that you might be trying to make things seem worse than they are. Can you help me understand why this might be happening?

Earlier in the evaluation you said you experienced ________, but you described it differently now. I am having difficulties understanding which is more true for what you go through.

Although you have discussed ______, when I read your chart, you don’t seem to have those difficulties when you are on the unit. What do you think helps you manage your struggles when you are not in session?

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Disengagement is the hallmark of suboptimal effort and irrelevant responses. Inquiries focus on re-engagement and rapport building:

I don’t think we got off on the right foot. Can we start again? Tell me in your words about _____

I may not have asked that question in the most clear way. Getting a clear and honest answer from you is the quickest and best way to get information to move forward with treatment/this case.

What can I do to make you feel more comfortable with this assessment?

I noticed that when you were taking the tests earlier, sometimes it looked like you didn’t pay close enough attention to the questions. Can we go through some of the information so I can have a better picture of what is going on for you?

Do you need a break? Is there a better time of the day for you to be able to concentrate on these questions?

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The Social Nature and Costs of Malingering

Malingering is always a social act. Not a psychiatric disorder. Malingering has

no value or meaning in isolation.

Malingering behavior correlates with social institutions that potentially reward

“sickness behavior.” Rewards can be financial (a gain) or relief from social

responsibility (e.g., military service, criminal responsibility). Social Legislation in

19th Century resulted in industrial compensation. An early notation:

There is evidence that under the operation of the National Health Act the

incidence of sickness, or rather the claims in respect of sickness, will prove

to be considerably above the original estimates…. and it is only too probable

that under the Insurance Act there will be a corresponding rise in the

expenditure… of sickness claims.

Edwin Smith, Editor

The British Medical Journal, April, 1913

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The Social Nature and Costs of Malingering

Some U.S. Financial Costs:

According to Chafetz & Underhill (2013), the Social Security Administration

indicated that in 2011, 11 million workers received SS benefits because of

disabilities, who were paid more than $119 billion out of the Social Security trust

fund. In addition, SSDI payments were made to more than 8 million persons,

84% of whom were disabled, the remainder aged and blind.

From SSDI data, according to Chafetz & Underhill, $32 billion were paid to

mentally disabled individuals in 2011. Using Larabee, Millis, & Myers (2009)

estimates of 40% malingering rate, the costs of SSDI in 2011 was more than $12

billion for malingering individuals. Using the same estimates of malingering,

Chafetz & Underhill calculate a cost of more than $7 billion from SSI (adult)

recipients due to mental disorder malingering. Thus, the total costs in 2011 for

malingered mental illness was more than $20 billion according to Chafetz &

Underhill.

LoPiccolo et al. estimate total U.S. health insurance fraud at $59 billion per year.

Annals of Med, 1999, 13, 166-174.

Chafetz (2011) estimated the total annual costs of malingered disability to be about

$180 billion for all programs. Thus, it is likely that the total costs due to

malingered symptoms across all domains and programs currently to be in excess

of $200 billion annually.

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Malingering in World War I

Between 1914 and 1918, the British Army executed 306 of their own soldiers.

Executed by firing squads from their own units. The German army executed 25 of

their own; the U.S. none. Courts martial included charges of desertion, cowardice,

insubordination, etc. The Generals (e.g., Haig) wanted to make examples of those who

were unable to return to the front.

Private Harry Farr: Fought at Mons and at the Somme, July 1916. Four times

hospitalized 1915-1916 with “shellshock.” Finally refused to return to the trenches;

court-martialed October 1916: The charge: “Misbehaving before the enemy in such a

manner as to show cowardice.” Shot the next morning at age 25. Refused a blindfold.

Not a coward.

Private Herbert Burden enlisted at age 16 by falsifying his age -- to join the

Northcumberland Fusiliers. After the battle of Bellwarde Ridge, he went missing.

Charged with desertion. Executed July, 1915 at age 17—not yet old enough to join the

regiment.

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Malingering in World War I

Private Thomas Highgate: Could not stand the carnage of the Battle of Mons; fled and

hid in a barn after the battle. Was undefended at trial because all of his regimental

comrades had been killed or captured. Executed September 8, 1914 -- the first British

execution of the war.

Highgate’s legacy: His village of Shoreham, Kent struggled for 80 years whether to

include his name on the war memorial in the town. A divided nation.

“Soldier’s Heart” had been described during the American Civil War (Dr. DaCosta):

noted elevated blood pressure, pulse, hyper-alert; sometimes called “irritable heart” --

“disrupted neural connections…”

Why call it “Shell-shock”?

SHELL SHOCK AND THE “SHOT AT DAWN CAMPAIGN”: Relatives and supporters

of the executed men campaigned to win posthumous pardon. The campaign asserted

that the men were mostly psychologically traumatized by shell-shock and not cowards.

The campaign went on for decades.

-- In August, 2006 all 306 executed British soldiers were pardoned.

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Society’s Response

U.S. v. Binion, 132 Fed. Appx. 89 (8th Circuit 2005):

Dammeon Binion was arrested for possession of a firearm by a convicted felon.

Representing himself, the defendant filed a pro se motion for a competence to proceed

to trial evaluation, in which psychological tests were administered by a psychologist,

and the evaluating psychiatrist reported the results to the court. Based on the test

results and the discrepancy between these results and the defendant's observed

behavior, the experts concluded that the defendant was most likely feigning mental

illness and had no actual mental disorder. The psychiatrist stated that the defendant's

malingering was a “form of recreation rather than a design to accomplish secondary

material gain.”

Binion pled guilty to the offense, but because of his reported malingering, he was also

charged with obstruction of justice, which enhanced his sentence recommendations.

The court stated that because of the feigned illness, Binion was not accepting

responsibility for his behavior as is normally required in a plea of guilty, and the

normal reduction in sentence for a guilty plea was therefore waived.

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Society’s Response

U.S. v. Batista, 483 F.3d 193 (2007)

Braulio Antonio Batista was charged with conspiracy to distribute 150 grams or more

of crack cocaine. He pled guilty and was sentenced to a 188-month term of

imprisonment. Batista claimed in his appeal that the District Court erred by granting

a two-level enhancement for obstruction of justice, failing to grant a reduction for

acceptance of responsibility, failing to grant a downward departure based on

significantly reduced mental capacity, and failing to apply the “safety valve” provision

of the Sentencing Guidelines. Batista also argued that his sentence was unreasonable

under the factors set out in 18 U.S.C. § 3553(a). The Court stated, “For the reasons set

forth below, we will affirm the District Court’s judgment of sentence.”

The Court stated, “Batista’s actions went beyond the mere exploration or presentation

of a defense of mental incompetence to the feigning of a mental illness in an attempt to

avoid facing trial or punishment for his crime. Batista’s false representation of mental

illness was sufficient for the District Court to find that he had not accepted

responsibility for his action. Batista’s initial admission of guilt is not sufficiently

extraordinary to overcome the later behavior that led to the obstruction of justice

enhancement.”

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Malingering: Why is it sometimes so difficult to ascertain?

Jerry’s case—Possession of Stolen Vehicle

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Malingering: What’s wrong with this picture?

From DSM-5:

Malingering should be considered if any combinations of the following is

noted:

• Medicolegal context of presentation [e.g., if referred by an

attorney, or is self-referred while litigation or criminal charges

are pending]

• Marked discrepancy between the individual’s claimed stress or

disability and the objective findings and observations

• Lack of cooperation during the diagnostic evaluation and in

complying with the prescribed treatment regimen

• The presence of antisocial personality disorder

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Various Models of Malingering

Rogers (Clinical Assessment of Malingering and Deception, 1997) suggests three historical

models for malingering:

• Pathogenic Model: “[T]he underlying force behind malingering is a mental

disorder…[a person] attempts to gain control over emerging symptoms, the patient

creates the symptoms and portrays them as genuine.”

• Criminological Model: Rogers states, “[The] DSM models presuppose that

malingering is likely to occur with (1) persons diagnosed with antisocial personality

disorder (APD), (2) evaluations conducted for forensic purposes, (3) persons

uncooperative with evaluation and treatment, and (4) persons whose claims are

discrepant with objective findings.” Rogers notes that this model “has faltered on

conceptual and empirical grounds…the association between APD and malingering

is likely illusory.”

• Adaptation Model: “[W]ould-be malingerers engage in a cost-benefit analysis

when confronted with an assessment they perceive as indifferent, if not inimical to

their needs. Malingering is more likely to occur when (1) the context of the

evaluation is perceived as adversarial, (2) the personal stakes are very high and (3)

no other alternative appears to be viable.”

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Response Styles

Rogers (2008) suggested that “the most common error appears to be

overspecification of response styles. For instance, criminal offenders are frequently

miscategorized as malingerers simply because of their manipulative behavior, which

may include asking for special treatment (e.g., overuse of medical call for minor

complaints) or displaying inappropriate behavior (e.g., a relatively unimpaired

inmate exposing his genitals).”

Rogers suggests that practitioners try to determine which response style best fits the

clinical data, by asking two questions:

(1) Do the clinical data support a nonspecific (e.g., “unreliable informant”)

description?

(2) If yes, are there ample data to determine a specific response style?

Rogers presented some examples of nonspecific terms:

• Unreliability is a very general term that raises questions about the accuracy of

reported information…makes no assumption about the individual’s intent or the

reasons for the inaccurate data.

• Nondisclosure describes a withholding of information (i.e., omission). It makes

no assumptions about intentionality. An individual may choose to not disclose or

be compelled by internal demands to withhold information. 29

Rogers (2008) Nonspecific terms

• Self-disclosure refers to how much individuals reveal about

themselves; high self-disclosure when the person evidences a

high degree of openness. A lack of self-disclosure does not imply

dishonesty, but simply unwillingness to share personal

information.

• Deception is an all-encompassing term used to describe any

consequential attempts by individuals to distort or misrepresent

their self-reporting. As operationalized, deception includes acts

of deceit, often accompanied by nondisclosure.

• Dissimulation is a general term used to describe an individual

who is deliberately distorting or misrepresenting psychological

symptoms. This may be a useful term, as it would include

difficult clinical presentations that do not clearly represent

malingering or any specific response style.

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Overstated Pathology

Rogers (2008) stated that important distinctions must be made between

malingering and other terms used to describe overstate pathology, and

presented three recommend terms below:

• Malingering has been defined by the DSM as “the intentional

production of false or grossly exaggerated physical or psychological

symptoms, motivated by external symptoms” (APA, 2000). Rogers

notes that this presentation must be the fabrication or gross

exaggeration of multiple symptoms. Minor exaggerations or isolated

symptoms do not qualify as malingering. The requirement of external

incentives does not rule out the co-occurrence of internal motivations.

• Factitious presentations are characterized by the “intentional

production or feigning” of symptoms that is motivated by the desire to

assume the “sick role” (APA, 2000). This diagnosis must be excluded if

any external incentives are present, and this categoric exclusion can be

problematic “because most patient roles also involve concomitant

modifications of work and family responsibilities.”

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• Feigning is the deliberate fabrication or gross exaggeration of psychological

or physical symptoms without any assumptions about its goals. Rogers states

that this term “was introduced because standardized measures of response

styles (e.g., psychological tests) have not been validated for assessment of any

individual’s specific motivations. Determinations can be made for feigning

but not their underlying specific motivations.

Rogers suggests there are three terms that should be avoided in clinical and

forensic practice, as they “lack well-defined and valid descriptions.”

• Suboptimal effort (also referred to as “incomplete” or “submaximal”

effort) is sometimes used as a proxy for malingering. Rogers notes that

the “best” efforts by an individual may be affected by a variety of internal

and external factors.

• Overreporting simply refers to an unexpectedly high level of item

endorsement, especially on multiscale inventories. These are often

erroneously identified as feigning; however this descriptive term lacks

clarity with respect to content.

• Secondary gain, on the other hand, does have clear definition. It may be

part of an unconscious defense process motivated by intrapsychic needs, a

need perpetuated by social context, or the deliberate use an illness to gain

special attention. 32

Simulated Adjustment

Rogers (2008) described other closely related terms used to present response styles

associated with simulated adjustment:

• Defensiveness refers to the deliberate denial or gross minimization of physical

and/or psychological symptoms.

• Social desirability is the pervasive tendency for an individual to “present

themselves in the most favorable manner relative to social norms and mores.”

Rogers suggests this should be carefully distinguished from defensiveness.

• Impression management refers to deliberate efforts to control others’ perceptions of

an individual, it may range from maximizing social outcomes to the portrayal of a

desired identity.

Rogers includes other response styles that are not as well understood as malingering,

defensiveness, and described response styles:

• Irrelevant Responding: Individual does not become psychologically engaged in the

assessment process…the responses are not necessarily related to the content of the

inquiry.

• Random Responding: A subset of irrelevant responding…most frequently observed

when subjected to forced choice format.

• Role assumption—the individual may occasionally assume the role of another person

responding to psychological measures.

• Hybrid responding—an individual’s use of more than one response style in a

particular situation, and for example may include honest responding and

defensiveness.

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Definitions: Conceptual Clarity, Occasional Muddlement

Rogers suggests that there are gradations of malingering and

defensiveness, including response styles such as unreliability,

malingering, and defensiveness.

Dissimulation: Any deliberate distortion or misrepresentation of

psychological symptoms (in some places used to denote defensive

distortion). Dissimulation can include malingering, defensiveness,

irrelevant responding, or random responding (DeClue, 2002).

Feigning: The deliberate fabrication or gross exaggeration of

psychological or physical symptoms without any presumption

about goals, purpose, or intent (DeClue, 2002). Often cannot

discern goal or conscious purpose.

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Common Misconception of Malingering

Rogers (2008) presents some common misconceptions about malingering:

• Malingering is very rare. Studies suggest it is not rare in either forensic or

clinical settings.

• Malingering is a static response style, i.e., “Once a malingerer, always a

malingerer.” Research indicates efforts at malingering are related to specific

objectives.

• Deception is evidence of malingering, i.e., “malingerers lie; therefore, liars

malinger.” Deceptions by manipulative patients may be mistaken for

malingering.

• Malingering precludes genuine disorders. The analysis of a diagnosis begins

with a genuine disorder, and then upon discovering malingering, the genuine

disorder disappears.

• Malingering is an antisocial act by an antisocial person. A perpetuated myth by

the DSM, and confuses common characteristics (e.g., criminality in criminal

settings).

• Malingering is analogous to the iceberg phenomenon, i.e., any evidence of

malingering is sufficient for its classification.

• Malingering has stable base rates. Rogers (1998) noted that there are marked

base rate variations (i.e., SD=14.4%) for malingering across forensic settings.

Overall base rates are low (e.g., 10-30%), but with standardized assessments,

base rates may exceed 50%. 35

Feigning versus Malingering

The problem of inferring the patient’s conscious aims: Which kind of mistake

would we prefer to make?

Not every instance of feigning is easily classified: patient’s aims can be both

(not always so clear re motive: “sick role” also includes practical factors in

patient’s life – e.g., a dependent patient wants to be in sick role, but now is

relieved of responsibility for housework, shopping, child care, elder care, etc.).

Malingering is not either/or, black and white.

Malingering can be by patients with actual psychiatric disorder.

Malingering can be partial, some exaggeration of actual symptoms; report of

symptoms that no longer exist.

“False imputation” is when the patient ascribes symptoms to an unrelated

cause (e.g., ADHD vs drug use…).

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Detection Strategies

Common characteristics versus discriminating characteristics, e.g.,

DSM-5.

Experience with real patients; detailed inquiry, e.g., mental status

examination

Test Protocols:

Structured Interview of Reported Symptoms (SIRS) (2nd edition, SIRS-2)

• Rare Symptoms

• Unusual Symptom Combinations

• Improbable Symptoms

• Blatant Symptoms

• Subtle Symptoms

• Severity of Symptoms

• Selectivity of Symptoms

• Observed Symptoms

37


Miller-Forensic Assessment of Symptoms Test (M-FAST)

• Reported versus Observed Behavior

• Extreme Symptomatology

• Rare Combinations

• Unusual Hallucinations

• Unusual Symptom Course

• Negative Image (self-perception)

• Suggestibility

Structured Inventory of Malingered Symptomatology (SIMS)

• Unusual Psychotic Symptoms

• Atypical Neurological Symptoms

• Memory Impairment

• Cognitive Incapacity

• Affective Disorders

38


Validity Indicator Profile (VIP): Both verbal and non-verbal

sections

• Inconsistent Response Style versus Compliant Style

• Irrelevant Response Style versus Suppressed Style

• Compliant: high effort to perform well

• Inconsistent: willingness to respond correctly to some

items, but is incomplete, intermittent, or minimal

• Irrelevant: responses are not related to item content

• Suppressed: efforts to answer items incorrectly

39


Minnesota Multiphasic Personality Inventory, 2nd Edition

(MMPI-2)

• Markedly elevated L scores could suggest pervasive test-

taking orientation (portraying oneself as overly positive)—

would depress clinical scales

• Markedly low L scores –may suggest efforts to exaggerate

emotional symptoms

• Elevated F scores may be due to random answering, poor

reading skills, deliberately exaggerating difficulties

• Elevated K scores may indicate efforts to slant their

responses to minimize poor emotional control and poor

personal ineffectiveness

•VRIN and TRIN are imbedded validity indicators (e.g.,

inconsistency or contradictions)

40


Personality Assessment Inventory (PAI)

• Inconsistency (ICN)—records inconsistent responses

• Infrequency (INF)—indications of careless or random

responses

• Negative Impression (NIM)—indications of

exaggerated unfavorable impression or malingering

• Positive Impression (PIM)—suggest presentation of

favorable impression or a reluctance to admit to minor

flaws

41


Evaluation of Competency to Stand Trial-Revised (ECST-

R) (Rogers)

• Protocol has Atypical Presentation Scale as one of the

sections

• 28 questions to elicit atypical responses

• Rogers suggests three common motivations for

feigning responses

• To present as incompetent to proceed to trial

• Concern for one’s safety—to escape real or

imagined threats

• Exaggerating or feigning symptoms to receive

treatment 42


Competence Assessment for Standing Trial for Defendants

with Intellectual Impairment (CAST-MR)

• This test has been used “off label” as a screening tool

for persons without evidence of developmental disability

• Three parts:

• Basic Skills

• Skills to Assist Defense

• Understanding Case Events

• Extremely low scores suggest feigning

43

Memory Impairment

Test of Memory Malingering (TOMM)

• 50 item recognition test

• Administered twice

• Optional third administration after delay

Rey Fifteen Item Test (FIT)

• Screening test

• Low discrimination

• Can screen out faking

44

Malingering: Taxon or Dimensional?

Rogers’ levels of exaggeration/fabrication model

Strong et al (2006): F and Fp scales taxonomic (e.g., dichotomy) model of

malingering

Walters, et al (2008): Factor analysis of SIRS, MMPI F , Fp and Ds scales:

Conclusion: That “Malingering is more accurately conceptualized as levels of

exaggeration or fabrication rather than as a response style that is categorically

distinct from honest responding”

“feigned psychopathology forms a dimension… rather than a taxon

(malingering-honest dichotomy), and that malingering is a quantitative

distinction rather than a qualitative one”

_________________________

Malingering of psychiatric symptoms is not inconsistent with the presence of

actual psychopathology. Psychotic patients are fully capable of exaggerating

and fabricating.

The problem of how to report findings; caveats. 45

So—without these somewhat sophisticated protocols,

what can we do to measure feigned symptoms?

Let’s look at some strategies that may help (Rogers, 2008):

Strategy Explanation

Rare symptoms Symptoms rarely reported by genuine patients

Quasi-rare symptoms Symptoms rarely reported by normals

Improbable symptoms Symptoms that are fantastic or absurd

Symptom combinations Symptoms that are common but rarely occur

together

Indiscriminant Endorsement of excessive proportion of symptoms

endorsement of symptoms

Severity of symptoms Excessive number of symptoms endorsed as

unbearable or extreme

Obvious symptoms Excessive number of clear symptoms of mental

disorder endorsed

Reported versus Discrepancies between self-reported symptoms and

observed symptoms observed symptoms

Erroneous stereotype Endorsement of symptoms erroneously thought to

symptoms be reported by patients with mental disorders 46

Berry and Nelson (2010) suggest the following

after a review of available literature:

1. Focus on objective identification of feigned symptom

reports, without attempting to infer volition or

motivation.

2. Systematically review literature on techniques for

detecting feigned symptoms or recommendations for

clinical identification.

3. Employ multiple strategies for identifying false

symptom reports.

4. Focus on minimizing false-positive rates for any single

detection strategy to allow adequate sensitivity to

feigning. 47

Motivation for symptom feigning

What are some possible motivating factors?

•Trying to look mentally ill to avoid criminal responsibility

•Feigning incompetency to proceed to trial

•Feigning psychotic condition at time of crime to

support a mental state defense

•Trying to present emotional symptoms to support a

personal injury claim

•Trying to present emotional symptoms in conjunction with

physical injuries in L&I claims

•Trying to get the attention of mental health or medical

providers

48

What about feigning no mental illness or minimizing symptoms?

What would motivate someone to minimize symptoms?

•Attempting to appear “normal”

•Avoid involuntary hospitalization

•Problems recalling symptom presentation

•Others?

49

How can we minimize our false positive rates?

•Do not ask “leading questions,” i.e., Do you have [this

symptom]?

•Ask open-ended questions, i.e.,

•Tell me how you are feeling.

•What makes you feel that way?

•Tell me how your day has gone.

•Tell me how you are sleeping.

•Tell me how your work is going.

•Tell me where you plan to stay tonight, get food.

•Tell me about your family, your friends.

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malingering misperceptions: what are we missing?

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