Understanding Malingering, Feigning and Symptom Validity

What is malingering?

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Malingering is the intentional exaggeration and/or fabrication of symptoms and impairments for an external reward, such as to avoid work, receive compensation, receive welfare payments, and/or access restricted medications (e.g., dexamphetamine, Ritalin, Valium). Malingering can be full or partial. Full malingering is when the person’s presentation is wholly fabricated and/or exaggerated, whereas partial malingering is when the person is genuinely unwell and malingering.

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Intentional and unintentional feigning?

To complicate matters some people intentionally feign symptoms for emotional benefits (e.g., care and sympathy; factitious disorder previously known as Munchausen’s and Munchausen’s by-proxy). This can be contemporaneous with external rewards. It is a fallacy that someone with a factitious presentation cannot be malingering and vice versa.[1] The same behaviour can easily lead to receiving money, avoiding work, and receiving emotional benefit. An additional complexity includes the fact that many people unintentionally feign. Unintentional feigning is when the exaggeration or fabrication is accidental and merely symptomatic of a genuine condition. Further, malingering is context dependent and goal directed, so the behaviour is rarely persistent and pervasive. Discriminating between each of the above is notoriously difficult and requires an advanced, nuanced understanding of the complexities to symptom assessment.

How frequently is malingering assessed in Australia?

Malingering is rarely assessed nor assessed well in Australia. In my research I found that only 19% of fitness to stand trial reports commented on possible malingering and only 4% of reports used a standardised symptom validity test.[2]The tests used were mostly brief screeners with high false positive and false negatives rates. Concerningly, mental health clinicians are meant to consider response style in all medicolegal matters, and any matter where there may be an external incentive to 'unwellness'.[3]There is also an expectation that at least some of the tests used in a malingering evaluation have a false positive rate of less than 10%.[4]

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The tale of the 'Man With No Working Hands'

The scholarly literature provides fascinating insight into malingering too. The infamous ‘Man With No Working Hands’ matter is just one example.[5] In this case the compensation claimant apparently had no working hands for several years after a workplace injury. However, it was discovered that he shook a physician’s hand at an independent review and was observed to have working hands on surveillance footage. The individual was eventually diagnosed with a somatoform disorder and received compensation. The authors’ noted that personal interaction with experts involved with the matter said it was easier for them to diagnose a mental illness rather than call out malingering.

the professionals we expect to be good at detecting deception are usually no better than chance

In my own practice, I have found that mental health clinicians almost never assess response style for their treatment clients, and independent experts infrequently adhere to the Sherman criteria to diagnose malingering. When feigning is assessed, there is often an overreliance on the mental state examination and clinical interview. These methods are essential to a malingering evaluation but are known to lack validity if used alone.[6] Further, it was demonstrated decades ago, and repeatedly since, that the professionals we expect to be good at detecting deception are usually no better than chance.[7] [8] Moral of the story: Malingering and deception are easy.

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Devil in the detail - false positives and negative rate reporting

When validated feigning tests are used in a symptom validity assessment, false positive and false negative rates are almost never reported. This deprives decision makers of the opportunity to critically appraise the expert’s report. False positive rates are especially salient to the diagnosis of malingering and should be reported. Another concern is that some experts misuse and misinterpret tests, perhaps unintentionally, potentially leading to erroneous conclusions.[10]A common test for feigned somatic complaints was described by one research group as “constituting malpractice” if used in motor vehicle accident (MVA)claims.[11]This is because numerous of the ‘feigning’ items on that test overlap with genuine post-concussive and whiplash symptoms.  [9]Another concern is that some experts misuse and misinterpret tests, perhaps unintentionally, potentially leading to erroneous conclusions.[10]A common test for feigned somatic complaints was described by one research group as “constituting malpractice” if used in motor vehicle accident (MVA)claims.[11]This is because numerous of the ‘feigning’ items on that test overlap with genuine post-concussive and whiplash symptoms.

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How do you know the right test has been used?

There are a brilliant range of tests that can be used to discriminate between genuine and feigned cognitive impairments and mental illness. Clever utilisation of multiple tests can help discriminate between full and partial malingering, and between intentional and unintentional feigning. However, no test is determinative and so experts need to understand, and perhaps acknowledge, the strengths and weaknesses of their methods for their clinical, cultural and linguistic relevance.

So, what’s the solution when we know that around 43% of Australian compensation claims might feature some degree of intentional and unintentional feigning?[12]

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What are your options?

First, always ensure that symptom validity is assessed. In my experience complex matters tend to settle quickly after symptom validity is properly assessed. Ensuring that you have a good assessment from the outset maybe essential to swift outcomes for your client.

Second, consult with a shadow expert to craft generic terms of reference for you to repeatedly use in your instructing letters. This will increase the likelihood that the assessment report addresses what it should, or expose the limitations of the report so you can address them before it is too late.

Third, use a shadow expert with advanced knowledge of the relevant issues, such as knowing how to discover the strengths and weaknesses to an assessment method. That individual can examine the reports you receive and provide guidance on how it may or may not be helpful to your case.

Fourth, get educated. Consider requesting supervision or a workshop for you and your team to better understand symptom validity and how it ought to be evaluated.

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References

[1] Rogers, R.,& Bender, S. D. (2020). Clinical assessment of malingering and deception (4th ed.). Guildford Press.

[2] Blake, G. A.,& Ogloff, J. R. P. (2021). The correlates of unfitness to stand trial in Victoria, Australia. The International Journal of Forensic Mental Health,20, 48-62. https://doi.org/10.1080/14999013.2020.1812013

[3] Sherman, E. M.S., Slick, D. J., & Iverson, G. L. (2020). Multidimensional malingering criteria for neuropsychological assessment: A 20-Year update of the malingered neuropsychological dysfunction criteria. Archives of Clinical Neuropsychology, 35 (6), 735-764. https://doi.org/10.1093/arclin/acaa019

[4]Ibid 3

[5] Green, P., &Merten, T. (2012). Noncredible explanations of noncredible performance on symptom validity tests. In S. S. Bush & D. A. Carone (Eds.), Mild traumatic brain injury: Symptom validity assessment and malingering. Springer Publishing.

[6] For example, the notion that feigners will exhibit behavioural signs of anxiety is empirically disputed. See Vrij, A., & Fisher, R. P. (2020). Unravelling them is conception about deception and nervous behavior. Frontiers in Psychology,11, 1377. https://doi.org/10.3389/fpsyg.2020.01377. For a review of the strengths and weaknesses to various malingering detection methods, including the inherent ‘human lie detection’ strategies see Walczyk, J. J.,Sewell, N., & DiBenedetto, M. B. (2018). A review of approaches to detecting malingering in forensic contexts and promising cognitive load-inducing lie detection techniques. Frontiers in Psychiatry, 9,700-714. https://doi.org/10.3389/fpsyt.2018.00700  

[7] Colwell, K.,James-Kangal, N., Hiscock-Anisman, C., & Phelan, V. (2015). Should police use ACID? Training and credibility assessment using transcripts versus recordings. Journal of Forensic Psychology Practice, 15(3),226-247. https://doi.org/10.1080/15228932.2015.1035187

[8] Ekman, P., &O'Sullivan, M. (1991). Who can catch a liar? American Psychologist,46, 913-920. https://doi.org/10.1037/0003-066X.46.9.913

[9] Ibid 3

[10] Cernovsky, Z.,Diamond, D., Mendonca, J., & Ferrari, J. (2020). Inappropriate use of the Modified Somatic Perception Questionnaire (MSPQ) to diagnose malingering. Archivesof Psychiatry and Behavioral Sciences, 3(2), 10-15. https://www.sryahwapublications.com/archives-of-psychiatry-and-behavioral-sciences/pdf/v3-i2/3.pdf

[11] Ibid10

[12] Yoxall, J.,Bahr, M., & O'Neill, T. (2017). Faking bad in workers compensation psychological assessments: Elevation rates of negative distortion scales on the Personality Assessment Inventory in an Australian sample. Psychiatry,Psychology and Law, 24(5), 682-693.https://doi.org/10.1080/13218719.2017.1291295

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‍Disclaimer:

The opinions expressed within the content are solely the author's and do not reflect the opinions and beliefs of LIME Medicolegal, its directors or other affiliates.