The Assessment of malingering with the M-FAST

1. The Assessment of malingering with the M-FAST Holly A. Miller, Ph.D. College of Criminal Justice Sam Houston State University

2. Overview • Malingering • Theory and assessment • Miller Forensic Assessment of Symptoms Test • Development of the M-FAST • Utility of the M-FAST • Brief overview of studies • Administration and scoring of the M-FAST • Practice administration • Interpretation • Questions

3. Malingering • The DSM-IV-TR defines malingering as: • Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives (APA, 2000) • Why might someone malinger? • Prevalence of malingering • Around 8% of general evaluations • Around 20% of forensic evaluations • Miller, 2000; Rogers & Cruise, 2000; Rogers, Salekin, Sewell, & Goldstein, 1996

4. malingering • When to assess for malingering • Rogers suggests under these circumstances • Atypical presentation of symptoms • Unusually high number of unusual or obvious symptoms • Nonselective endorsement of symptoms • Discrepancies between reported and documented history of mental illness

5. malingering • Why not just use clinical judgment? • DSM criteria • Marked discrepancy between reported impairment and objective findings • Lack of cooperation during evaluation or treatment • Medico-legal context presentation • Presence of APD • What research reports on accuracy of clinical judgment • Utilizing DSM criteria results in high false-positive rates • Studies strongly support that objective assessment instruments are significantly more accurate than clinical judgment (Miller, 2005; Rogers 1984; Ziskin, 1984)

6. malingering • Miller, H. A. (2005). The Miller-Forensic Assessment of Symptoms Test (M-FAST): Test generalizability and utility across race, literacy, and clinical opinion. Criminal Justice & Behavior, 32 (6), 591-611. • Study 1 – initial M-FAST items (79 items) • 280 forensic patients; 5 psychiatrists; 8 psychologists • M-FAST; SIRS; Mtest; MMPI-2 • Study 2 – final M-FAST (25 items) • 50 forensic patients; 5 psychiatrists; 8 psychologists • M-FAST; SIRS; Mtest; MMPI-2

7. malingering • Study 1 Clinical opinion v. M-FAST results • Psychiatrist Opinion • AUC = .72 (SE = .05) • CI = .62 - .81 • 19 FP; 17 FN • Psychologist Opinion • AUC = .80 (SE = .04) • CI = .72 - .88 • 15 FP; 11 FN • M-FAST (79 items) • AUC = .89 (SE = .02) • CI = .85 - .93

8. Malingering • Study 2 Clinical opinion v. M-FAST results • Psychiatrists • AUC = .65 (SE = .09) • CI = .47 - .83 • 7 FP; 7 FN • Psychologists • AUC = .73 (SE = .08) • CI = .57 - .89 • 9 FP; 4 FN • M-FAST (final version) • AUC = .95 (SE = .03) • CI = .88 – 1.00 • 6 FP; 1 FN

9. malingering • How to catch a malingerer • Previous research has indicated important areas of assessment: • Certain response styles • Certain interview strategies • Several instruments include assessment of response styles or were specifically designed to assess malingering • MMPI-2 • PAI • SIRS • However, there remains a need for a brief screen for malingered mental illness

10. Development of the M-FAST • M-FAST items were developed to operationalize the response styles and interview strategies that have been validated for identifying individuals who are malingering • Reported vs Observed symptoms (RO) • Extreme Symptomatology (ES) • Rare Combinations (RC) • Unusual Hallucinations (UH) • Unusual Symptom Course (USC) • Negative Image (NI) • Suggestibility (S)

11. Development of the m-fast • M-FAST is a structured interview of 25 items representing the “proven” detection strategies • Administration is approximately 5-10 minutes • Scoring is approximately 10 minutes • Does not require the ability to read (examinee) • Has been translated into Korean and Spanish • M-FAST was developed using both known- group and simulation studies

12. Administration and scoring • Materials include manual and 8-page interview booklet • Validated on people 18 yrsand older • Validated with different ethnic/race groups • Validated across gender • Validated with varied populations • In prison • On probation • In forensic hospital • In civil hospital • Outpatient disability assessment

13. Administration and scoring • Appropriate populations and limitations • Malingered psychopathology (not neuro) • Examinee must be able to understand items • Adults 18 yrsor older • Screening instrument and was not developed to be the sole determinate of malingered mental illness • Professional requirements • Mental health clinician with formal training in diagnostic interviewing and assessment

14. Administration and scoring • M-FAST should be preceded by a clinical interview • To gather both symptom information and observable behavior (RO assessment help) • Read aloud instructions for administration to client • Suggestibility item • 1st response dictates how you ask last part of item • Read items and possible responses of each item • May repeat once – but offer no explanation

15. Administer m-fast • With partner, practice administration • Partner role play a malingerer • Want to appear mentally ill, without elevating M-FAST score • Then reverse roles

16. Administration and scoring • Scoring instructions provided on last page of interview booklet • Score individual items • Score scales • If more than 2 items missing, not considered valid administration

17. interpretation • Malingering is distinct from most forms of psychopathology; however the presence of malingering does not rule out a psychiatric disorder • Significant consequences for malingering diagnosis • Choosing of a cut score for M-FAST • More acceptable to have false positives than false negatives • Cut score of 6 utilized

18. interpretation • Three levels • Total scale • Provides an estimate of the likelihood that the examinee is malingering • Interpretive statement: The examinee’s total score on the M-FAST was significantly elevated, indicating that this individual may be malingering mental illness. • Scales • Provides information on how the individual is malingering • Can make interpretive statements about scale elevations, but utilize total score for overall assessment • Each scale has own “cut score” • Suggestibility item (scale) • Manual provides interpretative statement examples • Items

19. interpretation • Next step • Further malingering assessment is warranted if client elevated M-FAST

20. M-FAST articles by topic • Competency to stand trial – forensic inpatients • Jackson, R., Rogers, R., Sewell, K. W. (2005). Forensic applications of the M-FAST: Screening for feigned disorders in competency to stand trial evaluations. Law and Human Behavior, 29(2), 199-210. • Vitacco, M. J., Rogers, R., Gabel, J., Munizza, J. (2007). An evaluation of malingering screens with competency to stand trial patients: A known-groups comparison. Law and Human Behavior, 31(3), 249-260. • Miller, H. A. (2004). Examining the use of the M-FAST with criminal defendants incompetent to stand trial. International Journal of Offender Therapy and Comparative Criminology, 48(3), 268-280.

21. M-FAST articles by topic • Validity Studies • Vitacco, M. J., Jackson, R. L., Rogers, R., Neumann, C. S., Miller, H. A. Gabel, J. (2008). Detection strategies for malingering with the M-FAST: A confirmatory factor analysis of its underlying dimensions. Assessment, 15(1), 97-103. • Miller, H. A. (2005). The Miller Forensic Assessment of Symptoms Test (M-FAST): Test generalizability and utility across race, literacy, and clinical opinion. Criminal Justice and Behavior, 32(6), 591-611. • Veazey, C. H., Hays, J. R., Wagner, A. L., & Miller, H. A. (2005). Validity of the Miller Forensic Assessment of Symptoms Test in psychiatric inpatients. Psychological Reports, 96(3), 771-774. • Guy, L. S., & Miller, H. A. (2004). Screening for malingered psychopathology in a correctional setting: Utility of the Miller Forensic Assessment of Symptoms Test (M-FAST). Criminal Justice and Behavior, 31(6), 695-716.

22. M-FAST articles by topic • Civil forensic settings • Alwes, Y. R., Clark, J. A., Berry, T. R., Granacher, R. P. (2008). Screening for feigning in a civil forensic setting. Journal of Clinical and Experimental Neuropsychology, 30(2), 1-8.

23. M-fast articles by topic • Diagnostic-specific malingering assessment • Messer, J. M., & Fremouw, W. J. (2007). Detecting malingered posttraumatic stress disorder using Morel Emotional Numbing Test-Revised and the Miller Forensic Assessment of Symptoms Test (M-FAST). Journal of Forensic Psychology Practice, 7(3), 33-57. • Guriel-Tennant, J., & Fremouw, W. J. (2006). Impact of trauma history and coaching on malingering of posttraumatic stress disorder using the PAI, TSI, and M-FAST. Journal of Forensic Psychiatry & Psychology, 17(4), 577-592. • Guy, L. S., Kwartner, P. P., & Miller, H. A. (2006). Investigating the M-FAST: Psychometric properties and utility to detect diagnostic specific malingering. Behavioral Sciences & the Law, 24(5), 687-702. • Guriel, J., Yanez, T., Fremouw, W. J., Shreve-Neiger, A., Ware, L., Filcheck, H., & Farr, C. (2004). Impact on coaching on malingered posttraumatic stress symptoms on the M-FAST and TSI. Journal of Forensic Psychology Practice, 4(2), 37-56.

24. Thank you! Holly A. Miller, Ph.D. Assistant Dean of Undergraduate Programs Associate Professor College of Criminal Justice Sam Houston State University Huntsville, Texas 77341-2296 936-294-1686; hmiller@shsu.edu