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January 1, 1999
A team approach to assessing malingering produces confidence in diagnosis, said a group of psychiatrists and mental health professionals from the William S. Hall Psychiatric Institute in Columbia, S.C. The group includes a psychiatrist, two psychologists, and a social worker who work together to conduct outpatient criminal forensic evaluations.
Richard Frierson, M.D., said the model the teams at Hall Institute use to detect malingering is also applicable to civil psychiatry and could be used with outside contract psychological services. The essential feature of malingering, according to DSM-IV, said Frierson, is the intentional production of falsely or grossly exaggerated symptoms motivated by external factors such as wanting to avoid work or military duty, trying to obtain financial compensation in personal injury cases, or evading criminal responsibility. The symptoms are intentional rather than unconscious, he explained at a presentation at the October meeting of the American Academy of Psychiatry and the Law.
At times "we see patients who present with atypical symptoms, and I wonder where are the textbook cases," said Frierson. "You have to consider that sometimes with factitious diseases patients are not avoiding work or criminal prosecution but want to be in the patient role."
The team suspects malingering in several circumstances, said Frierson. These include when patients come from a legal setting; when they are referred from an attorney for disability or work compensation evaluations; or there is a criminal issue related to competency, criminal responsibility, or a personal injury case. A marked discrepancy between what the patient is claiming and the objective findings in an interview, lack of cooperation during diagnostic evaluation, or the presence of an antisocial personality disorder may also indicate that the patient is producing false symptoms.
Hall Institute does evaluations for the entire state of South Carolina, said Frierson. Ninety-five percent of the court orders call for evaluating competency and criminal responsibility together, he noted. The state uses the Dusky model for competency and a modified M'Naughten standard for criminal responsibility. South Carolina also has a third category of guilt called "guilty but mentally ill," a verdict based on the capacity to conform to the requirements of the law.
Over the past five years, the number of requests for outpatient evaluations has doubled while the crime rate has not increased, noted Frierson. Part of the reason for this phenomenon, he said, is that pathology of illness has become more severe, and more children and adolescents are being referred. Lawyers have become more sophisticated in deciding when to request evaluations, he added.
At Hall, evaluations are conducted by a psychiatrist and a social worker, who consult psychologists as necessary for testing. Before an appointment for a clinical interview is scheduled, the psychiatrist and social worker gather information from the court order and the arrest warrant or indictment from the police department as well as from victim and witness statements. They determine the type of crime and whether substance abuse is involved.
Social workers obtain a social history from the family and review medical and mental health records. They gather information from extended family and from public defenders. They talk to employees of the local jail where the person is incarcerated to find out how he or she is functioning there. If a child is being evaluated, social workers obtain information from school records.
The rate of malingering revealed by evaluations at Hall is about five percent, said Frierson. About 25 percent of this 5 percent have a major mental illness, primarily schizophrenia or major depressive disorders.
Malingerers may fake incompetence by trying to appear retarded, while their social history reveals a higher level of functioning, said Frierson. They may stutter or report atypical hallucinations. Though presenting with evidence of psychosis with delusions, they may be able to do harder tasks or interact well with people.
They are referred for testing if they have atypical psychotic symptoms or inconsistencies within the psychiatric interview such as missing easy questions but correctly answering ones that are more difficult. If there is inconsistency between their social history and clinical presentation, or the action for which defendants are charged occurs during their first psychotic break, the psychiatrist refers them to the psychologist for testing.
"Whenever I see someone whose crime occurred during what I believe is a general first psychotic break or see someone who does not have a documented history of mental illness but after their arrest I find that they've become psychotic in the jail, I always give a psychological evaluation to rule out malingering," said Frierson. "I find that when I have to go to court and provide testimony, having done that helps give me some degree of increase in my credibility."
Psychologist Steven Shea discussed several tests used to assess malingering. Shea said one set of tests is used to assess cognitive aspects of malingering and another to detect exaggeration or faking. To test for cognitive deficit, he uses the Rey 15-Item Memory Test. Since even people who are retarded are able to reproduce strings of items used in the test, those who cannot do so may be malingering, he said.
Shea said he favors the Personality Assessment Inventory (PAI) for testing patients at Hall because it is short and easy to understand by those taking it. The PAI has an inconsistency scale that can suggest malingering and is also helpful in diagnosing patients, he said.
The Structured Interview of Reported Symptoms (SIRS) is also a good test to use to detect malingering, said Shea. It assesses the extent of malingering or the psychopathology of mental disorders. "Its strength is that we have a lot of patients who have mental illness and who also are malingerers. The SIRS helps us tease out questions of what parts of the mental illness are real, what parts are feigned, what areas are exaggerated, what aren't. It helps us tease out legal issues and discern what are the cries for help."
Testing, said psychologist Geoffrey McKee, Ph.D., also helps separate out those who are simply distressed from the pressures of their current situation (including incarceration) from those who are malingering.
"The most important value of a multi-disciplinary determination of malingering is improvement in diagnosis," said McKee. With comprehensive data and input from several disciplines, there is greater likelihood of identifying those who are truly mentally ill, he said, and professionals can feel more confident in their opinions. They can better corroborate and contradict patients' self-reports, and expert testimony can have more basis in actuarial data than impressionistic data.