Malingering

1. Malingering Anthony Cozzolino, M.D. Chief Psychiatrist Santa Clara Valley Medical Center Adjunct Clinical Faculty- Stanford University

2. “Though this be madness, yet there is method in it”. Shakespeare, Hamlet “The pure and simple truth is rarely pure and never simple”.Oscar Wilde “If you tell the truth, you don't have to remember anything …”Mark Twain

3. Educational Objectives • To understand how malingering is defined • To differentiate various forms of malingering • To learn how to detect malingering of mental illnesses • To gain an understanding of the basic assessment tools for detection of malingering • Discuss an actual case of malingered mental illness

4. Definitions • Webster’s: To pretend incapacity (as illness) so as to avoid • work or duty • DSM III: Classified as Condition Not Attributable to a Mental • Disorder that is Focus of Attention or Treatment • DSM IV V65.2: • “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. Definitions (cont.) • Strongly suspect if: • Medical-legal context of presentation • Marked discrepancy between reported symptoms and objective findings • Lack of cooperation with evaluation or treatment regimen • Presence of Antisocial Personality Disorder Diagnostic and Statistical Manual of Mental Disorders IV-TR 2000

6. Classifications of Malingering 3 major categories: 1- Pathogenic - indicates underlying psychopathology (resembles somatoform disorders due to unconscious nature) 2 - Criminological - adopted by DSM - uncooperative and oppositional with antisocial personalities - criticized as “moralistic” theme of “badness” 3 - Adaptive - considers as constructive attempt to manage adversarial circumstance Rogers, Richard 1990

7. General Considerations (cont.) • Is malingering adaptive? • DSM suggests may be adaptive in some cases • Individuals use “cost-benefit analysis” in deciding to malinger: • - likelihood of successful outcome if honest vs. malinger • - more likely if perceives adversarial interaction and stakes are high • - estimate ease of successfully deceiving interviewer • - perceive minimal consequences if caught

8. A lie would have no sense unless the truth were felt dangerous.Alfred Adler

9. Definitions (cont.) • Distinguish from: • Factitious Disorders • - also characterized by intentional production of symptoms • - goal to assume the “sick role” rather than other secondary • gains • - absence of external incentives • Somatoform Disorders • - unconscious origin of symptoms

10. Prevalence of Malingering • Unclear statistics due to obvious underreporting • Average person lies ~ twice per day • 1% prevalence among in clinical practice • Criminal defendants- 10-20% • U.S. Accounting Office: follow up study reported 40% of individuals considered totally disabled - no disability at one year after declaration of injury • Most common motives: • - seeking hospitalization, obtaining food/shelter, medications, avoidance of prosecution….money

11. Common Associations • Lying - deception not specific to physical or psychological problem (e.g. for any reason) • Feigning - distortion regardless of intent • Deception • Misleading • Fabrication - deliberate misstatement • Confabulation - unintentional filling in of information

12. General Considerations • Underreported • - clinicians hesitate to label • - concerns over liability • - clinical practice relies on veracity of client’s statements made • - fear of generating anger in client • Ethical dilemmas • - establishing good client rapport, yet appearance of “seducing” individuals into revealing information which may have negative consequences • - injustice if over-estimate malingering

13. Rogers et al (1990): Malingering study • Examined college students and criminal defendants • Allowed time to study materials on mental disorders • Instructed to malinger, tested with SIRS • Results: • Rarely gave convincing presentation • 90% believed were convincing • Both college students and defendants pretended psychosis (paranoid and hallucinating), anxiety, depression • Predictable strategies commonly employed: • - answer all questions incorrectly • - ridiculous answers to simple questions • - talking as little as possible, ignoring specific questions • - frequent contradictory statements

14. Subtypes/Forms of Malingering • Simulation/ pure malingering: attempting to deceive in a pathological direction • - feigning symptoms that do not exist, or gross exaggeration - “faking bad” or “positive malingering” • - attempting to manipulate in a non-pathological direction - “faking good”. • Partial malingering: conscious exaggeration of existing physical or psychological symptoms

15. Subtypes/Forms of Malingering (cont.) • Staged events: carefully orchestrating or planning an event with a • desired result of actual injury • Data tampering: altering records to simulate a disorder (e.g. adding • or removing substances from lab specimens) • Ganser’s Syndrome: offering approximate answers to questions • - found in prison population (aka “prison psychosis”) • - classified in DSM as Dissociative Disorder NOS • Opportunistic malingering: exploiting a naturally occurring event • or pre-existing condition for gain • Symptom invention: consciously complaining of symptoms that • have no relation to an actual injury or pre-existing condition

16. Evaluation of Malingering • Important to clearly understand quality of genuine disease state • Ascertain motivations to malinger • Distinguish motivation for feigning symptoms vs. presence of actual illness • 3-question framework: • 1- Does individual exhibit “classic signs” of malingering? • 2- Does individual have foreseeable motive or believe would gain from illness? • - avoiding punishment by pretending to lack capacity • - avoiding military duty • - obtaining benefits (social security, compensation) • 3- Could an actual illness be present which would cause him to produce what appears consciously produced (i.e personality disorders, cognitive disorders)?

17. Clinical Indicators of Malingering

19. “All malingerers are actors who portray their illnesses as they understand them, often overacting the part” - Philip J. Resnick, M.D.

20. Abnormality presented as context-specific • May laugh or display defensiveness when confronted • Often speak in higher-pitched voice, make frequent errors of grammar, “slips of the tongue” • - voice/speech changes more accurate than facial expressions • - basis of voice stress analysis • Overact the part - abrupt onset and offset of symptoms, dramatic gestures noted • - may also be seen in personality disorders • Quick to call attention to illness, not guarded • Most attempt to feign psychosis, memory deficits, depression • with suicidality, PTSD

21. Indicators (cont.) • Express symptoms do not fit any particular diagnostic entity • - display symptoms across multiple diagnostic categories • Commonly believe that nothing must be remembered correctly, i.e the more inconsistent and absurd, the better the deception • Often repeat questions and answer slowly • Inconsistencies in observed symptoms or reports • Note: facial expressions/eye blinking not reliable and may distract interviewer

22. Interview Techniques • May at times need to be cunning- since malingerers act part, interviewer must make them forget or abandon role temporarily • In forensic settings, important to interview defendant as soon as possible after incident (days) • - reduces likelihood of coaching by others • Interview should involve frequent changes, e.g. giving indications that interview part is over and “just chat” • Collateral information critical • Important to observe individual when does not know is observed

23. Interview Techniques (cont.) • Attempt to learn relevant information about defendant that defendant does not know clinician has. • Take careful history of past psychiatric symptoms before current - less likely to be guarded or understand relevance • Longer interviews more conducive to detection • Obtain labs (substances, blood levels of medications) and objective tests

24. Specific Disorders

25. Psychosis • Psychosis (hallucinations, delusions): • Clinically essential to ascertain details of reported symptoms • Inquire about mechanisms to to diminish symptoms • - walking, listening to music, watching TV, seeking interpersonal contact common in genuine illness

26. Psychosis (cont.) • Genuine hallucinations intermittent rather than continuous • Male and female voices heard by >75% • Typically contain both familiar and unfamiliar voices • Mostly reported as “outside of head” • Usually heard with clarity rather than vague • Visual hallucinations normal-sized people, objects • Visual hallucinations don’t change with eyes open or closed, worse in isolation

27. Psychosis (cont.) • Unlikely to display subtle signs of psychosis- blunted affect, • impaired relatedness, concreteness • More difficult for malingerers to imitate the form than the content - derailment, neologisms, word distortions rarely simulated • Feigned psychosis often of sudden onset or abrupt cessation • Content of feigned hallucinations often grandiose or persecutory, • not self-deprecatory • Claim that all commands followed

28. Malingered Cognitive Deficits • Cognitive/memory impairment common following actual accidents/head injuries • - common malingered disability • Malingered mutism • - difficult to sustain- used when facing severe penalties • - actual catatonia: posturing, waxy flexibility • Amnesia • - most common claim- 30-50% of homicide perpetrators • - apparent self-serving timing, recovery of symptoms • - episode- specific rather than global memory impairment • - demonstrate ability to recall events prior to and following event • - presence of antisocial traits > histrionic characteristics

29. Post-traumatic Stress Disorder (PTSD) • Dramatic increase in claims since VA offered government compensation • Common in personal injury cases • Malingerers emphasize more dramatic symptoms - “text book presentation” : flashbacks, nightmares, not avoidance/ social withdrawal • May report inability to work, but has normal social functioning • Show questionable employment history • Call attention to high functioning prior to incident • Has poor compliance with treatment recommendations • P. Resnick, Guidelines for Evaluation of Malingering in PTSD, in R. I Simon (Ed.), Posttraumatic Stress Disorder in Litigation, 194, American Psychiatric Publishing, Washington, DC (2003).

30. Testing/Assessment- Indicators of Malingering • Intentional wrong responders • Individual knows correct response but offers incorrect response • Individual knows cannot give all wrong responses to be convincing: chooses strategy • - inattention • - slow responses- effective on timed responses • - random wrong responses • - perform worse than by chance • Give test that is simple but appears difficult

31. Assessment Tools (cont.) Rey 15- item test: A B C 1 2 3 a b c o oo ooo I II III • Display for 10 seconds, wait for 15 seconds, ask to recall • Failure to reproduce 3/5 suggests malingering (barring severe cognitive deficits)

32. Assessment Tools Bender-Gestalt and Rorschach - gross distortions, detailed abnormalities, highly dramatic on Bender suggest malingering - may reject plates on Rorschach when feel incapable of distorting, or may overly distort - Exner scoring system- emphasizes texture, color, form, movements WAIS- comprehension scale - silly or evasive responses - questions are in increasing order of difficulty; may test by even numbers in normal order, odd number for reverse telling first group “easier” and next group “harder” (not validated) MMPI-2 - highly reliable - F-K scale: higher number = increased likelihood of malingering (+10 score indicates 97.5% certainty of malingering) - F score: valid if score >100 (may also indicate uncooperativeness, gross misunderstanding, severe psychosis)

33. Assessment Tools (cont.) • Structured Interview of Reported Symptoms (SIRS) • Developed by Richard Rogers, PhD, 1992 • Designed to systematically assess deliberate distortion of symptoms • High sensitivity and specificity • 156 questions answered as: No Answer, No, Sometimes, Definite Yes • Profiles: honest, indeterminate, probably feigning, definite feigning • Scores < 71 = honest, >76 definite feigning

34. Assessment Tools (cont.) • Amytal interview (“Truth Serum”) • Introduced in 1930’s for treatment of psychosis • Most commonly used in catatonia, hysteria with mutism, stupor, recover memories in Dissociative Identity Disorder, fugue states • Often used in conjunction with hypnotherapy • Allows individual to talk about repressed memories • Considered unreliable in detecting malingering • - individuals can maintain lies while receiving amytal

35. Polygraphy • Used by law enforcement agencies including FBI on staff • - 40,000 people per year by federal government • Based on emotional and physiological effects of lying • - measures hyperarousal (increased respiration, bp, pulse, galvanic skin response) • Requires extensive preparation of test questions • - relevant questions (related to offense) • - control questions- not related to offense but similar behavior • - irrelevant questions (“are you sitting in a chair?”) • Reliability continues to be debated- psychopaths can “beat the test”, anxiety may mimic dishonest responses • - inadmissible in most jurisdictions- juries cannnot know was taken • - does not meet standards of evidence

36. Search Warrant for….Your Brain? • fMRI can potentially detect deception • Considered more accurate than polygraphy • Multiple studies indicated activity in 5 distinct brain regions: • - subjects asked to lie • - twice as many brain areas activated when lying to not • - right inferior frontal, right orbitofrontal, right middle frontal, left middle temporal and right anterior cingulated areas (areas of cognitive control, calculation) • 2 U.S. companies competing for marketing (No Lie, Cephos) • Many ethical dilemmas • Not currently admissible, does not meet standards of evidence newsoffice@mit.edu

37. Vincent “The Chin” Gigante: “ The Oddfather”

38. “Oddfather” (cont.) • Mafia boss of Genovese crime family- charged with murder, conspiracy, racketeering • Over decades, observed to be slobbering, talking to himself, wandering in his pajamas through Greenwich Village • In court quivered, played with his ear, rubbed his chest, talked to himself, eyes wandering Defense: - cannot communicate with defendant in meaningful way - suffering from schizophrenia, dementia - not competent to stand trial Prosecution: - feigning insanity for years - competent to stand trial

39. Odd Father (cont.) • 7-year debate over mental status/competency • Received extensive psychiatric evaluations including 5 past presidents of AAPL, Richard Rogers • Evaluating psychiatrist and psychologist at Butner Federal Prison diagnosed possible cognitive disorder (moderate to severe memory impairment) • - could have been caused by his sleep and anti-anxiety medications • - may also be malingering

40. Initial statement by evaluating defense psychiatrist: “I have worked with dementia patients for many years; he is exactly the kind of patient we see in a dementia clinic” - Dr. Wilfred van Gorp, PhD

41. Odd Father (cont.) • Pled Guilty 2003 • Admitted to deceiving psychiatrists from 1990-1997 • Prosecution played audiotapes of phone calls he made to his family and friends since imprisonment in 1997

42. Following conviction: "It should make all of us humble that we can indeed be had...We don't get inside somebody's brain." - Dr. van Gorp: New York Times interview April 2003

43. Conclusions • Malingering must be considered in all forensic evaluations • Injustice if falsely diagnosed, serious consequence if not diagnosed • Malingered disorders differ in presentation from actual illnesses - know actual phenomenology of disorders - note inconsistencies in reported symptoms and observed symptoms • Use multi-pronged approach to increase accuracy • Apply 3-question approach to support malingering versus legitimate presentation of mental illness

44. Conclusions (cont.) • 1- Does individual exhibit “classic signs” of malingering? • 2- Does individual have foreseeable motive or belief that he would gain from having illness? • avoiding punishment by pretending to lack capacity • avoid military duty • obtain benefits (housing, social security, financial compensation) • 3- Could an actual illness be present which would cause him to produce what appears consciously produced?

45. There are only two things. Truth and lies. Truth is indivisible, hence it cannot recognize itself; anyone who wants to recognize it has to be a lie. Franz Kafka