Transcript No Slide Title

Malingering
Anthony Cozzolino, M.D.
Chief Psychiatrist Santa Clara Valley Medical Center
Adjunct Clinical Faculty- Stanford University
“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
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
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”.
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
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
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
A lie would have no sense unless the truth were felt
dangerous.
Alfred Adler
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
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
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
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
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
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
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
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)?
Clinical Indicators of Malingering
“All malingerers are actors who portray their illnesses as they
understand them, often overacting the part”
- Philip J. Resnick, M.D.
• 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
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
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
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
Specific Disorders
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
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
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
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
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).
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
Assessment Tools (cont.)
Rey 15- item test:
A
1
a
o
I
B
2
b
oo
II
C
3
c
ooo
III
• Display for 10 seconds, wait for 15 seconds, ask to recall
• Failure to reproduce 3/5 suggests malingering (barring severe
cognitive deficits)
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)
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
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
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
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
[email protected]
Vincent “The Chin” Gigante: “ The Oddfather”
“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
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
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
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
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
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
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?
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