Transcript Assessment of Malingering in a Jail Setting

Assessment of Malingering
in a Jail Setting
Gregory Sokolov MD
Medical Director, Sacramento County
Jail Psychiatric Services
&
Assistant Clinical Professor, University
of California at Davis, Department of
Psychiatry
Lecture Objectives
Malingering: definition & prevalence in
forensic/correctional settings
Assessment of malingering (SIRS; MFAST)
Research (in progress)-malingering in jail
Case studies
“Trans-Institutionalization”
(Criminalization of the Mentally Ill)
400,000
350,000
300,000
State hospital
pts
Mentally ill
prisoners
250,000
200,000
150,000
100,000
01
20
94
19
90
19
79
19
19
69
50,000
0
Source: US Dept. of Health Human Services & Dept of Justice statistics
Treatment Issues & Challenges in
Correctional Psychiatry
High rates of co-morbid substance dependence
and personality disorders (Antisocial)
Malingered symptoms of mental illness (“hearing
voices”) for secondary gains of housing change,
mental health defense, SSI benefits, etc
Misuse of psychotropic medications for sleep
“Cheeking” of medications for sale or bartering
Malingering (DSM-IV-TR)
“The intentional production of false or
grossly exaggerated physical or
psychological symptoms, motivated
by external incentives such
as…evading criminal prosecution or
obtaining drugs.”
Contrast with Factitious Disorders;
Ganser’s Syndrome (Dissociative
Disorder NOS)
Malingering (DSM-IV-TR)
“Malingering should be strongly suspected”:
Medico-legal evaluations
Marked discrepancy between person’s
claimed stress or disability and objective
findings (reported vs. observed symptoms)
Lack of cooperation with diagnostic
interview
Antisocial Personality Disorder
Malingering & Criminal Justice
System
Competency to stand trial (CST)
assessments: 60,000 referrals in US / year
Base rates of malingering estimated from
8% to 17.4%
Surveys of psychiatrists / psychologists
working in forensic settings: report
malingering in 16-18% patient population
Cornell DG, Hawk GL: Law & Human Behavior (1989)
Rogers R, et al: Law & Human Behavior (1998)
Rogers R: Clinical Assessment of Malingering & Deception (2nd Ed. 1997)
Malingering & Criminal Justice
System
United States v. Greer (1998):
Greer arraigned on federal charges of
kidnapping and firearms violations
Sent to federal medical center for evaluation of
competency to stand trial
Psychologist testified Greer was competent and
malingering; judge ruled competent
Over next year, while awaiting trial, Greer
disruptive in jail, re-evaluated, ruled
incompetent, and committed to another federal
medical center for restoration
Malingering & Criminal Justice
System
After period of hospitalization, psychologist
again concluded Greer was malingering and
competent; court agreed
Greer engages in self-injurious behaviors in jail,
disruptive in court during trial
At sentencing, court enhances Greer’s sentence
(by 25 months) for obstruction of justice due to
feigning of mental illness
US 5th Circuit Court of Appeals: “A defendant
who playacts psychosis essentially tries to
create a records that includes inaccurate
testimony and factual conclusions”
Malingering & Jail Inmates
1.
2.
3.
4.
Potential motives for malingering in jail
population may include:
Avoid or delay legal proceedings with a
“mental defense” (insanity, incompetent to
stand trial)
Obtain a preferred housing change (i.e. psych
ward, hospital unit)
Evidence to obtain SSI benefits after release
Obtain psychotropic medications (sedation)
Handbook of Correctional Mental Health
(American Psychiatric Publishing-2005)
“Malingering Models” in
Correctional Settings
“Criminological Model”: Malingering is a
specific manifestation of antisocial
behavior and attitudes:
“Chronic conning” (meds to get “high” or sell,
transfer to another unit with more privileges,
transfer to hospital where escape is more
probable, etc)
Handbook of Correctional Mental Health-(APPI) 2005
Jaffe ME, Sharma KK. J Forensic Sci (1998)
“Malingering Models” in
Correctional Settings
“Adaptational Model”: Malingering is an
attempt to succeed when faced with
adverse circumstances:
(CA: ”third-strike psychosis”)
? Misreporting of anxiety/mood symptoms as
“voices” (consider administering anxiety scales
along with malingering scales)
Handbook of Correctional Mental Health-(APPI) 2005
Jaffe ME, Sharma KK. J Forensic Sci (1998)
Jail Malingering & Antipsychotics
“Iatrogenic”
malingering reported in VA substance
treatment program
“Intranasal quetiapine abuse” reported at LA
County Jail, driven by drug’s sedative and anxiolytic
effects rather than antipsychotic properties
Case report of “intravenous quetiapine abuse” in
Canadian jail
Abuse of quetiapine has led to some correctional
formularies restricting or limiting its use
Pierre JM, Wirshing DA, Wirshing WC. Psychiatr Serv (2003)
Pierre JM, et al. Am J Psychiatry (2004)
Hussain MZ, et al Am J Psychiatry (2005)
Jail Malingering & Antipsychotics
Is removing medication from jail formulary the
answer?
Mobile (AL) Register (March 5, 2005):
“Federal prisoner who was being held at Mobile
County Metro Jail tried to commit suicide after
officials took away his [Seroquel].”
“Jail staff indicated that they had banned the
medicine because some inmates had been
using it to get high.”
After legal motion filed, US District Court
approved inmate transfer pt to federal medical
facility
Malingering: Assessment
Collateral behavioral observations
(nursing, custody)
Clinical interview, malingered “voices”:
1.
2.
3.
4.
5.
Continuous rather than intermittent
Vague, inaudible
Not associated with delusions or thought disorder
No strategies to cope with “voices”
Claim that all instructions are obeyed
Resnick PJ. Psychiatr Clin North Am (1999)
Malingering Assessment:
Structured Interview of Reported Symptoms
(SIRS):
1.
2.
3.
4.
5.
6.
7.
8.
Developed by Rogers, et al 1992; eight primary scales:
Rare symptoms (RS);
Symptom Combinations (SC);
Improbable/Absurd Symptoms (IA);
Blatant Symptoms (BL);
Subtle Symptoms (SU);
Severity of Symptoms (SEV);
Selectivity of Symptoms (SEL);
Reported vs. Observed Symptoms (RO)
Responses on these scales are classified as honest,
indeterminate, probable, or definite
Rogers R, Bagby RM, Gillis JR. SIRS-Psychological Assessment Resources (1992)
Malingering Assessment:
Structured Interview of Reported Symptoms
(SIRS):
An individual is considered to be
malingering if he/she scores in the
probable or definite range > 3 scales
Highly reliable measure extensively
validated in correctional and forensic
samples
Very low false-positive rates (accurately
identifying malingering)
Rogers R. Handbook of Diagnostic and Structured Interviewing (2001)
Norris Mp, May MC. Law & Human Behavior (1998)
Malingering Assessment:
Structured Interview of Reported Symptoms
(SIRS):
Limitations of the SIRS:
No indices to detect cognitive feigning
No information on genuine psychopathology is
obtained (in contrast to MMPI-2)
Lengthy to administer (>1 hr); limits utility as
rapid screening tool or for large numbers of
subjects
Does not identify person’s motivation for feigning
symptoms (nor does any psychological test)
Malingering: Assessment (SIRS)
Sample questions:
“Do you believe [automobiles] have their own
religion?”
“Do you become fearful of soft household objects
for no real reasons?”
“Can common insects be used for electronic
surveillance?”
Malingering Assessment:
Miller Forensic Assessment of Symptoms
(M-FAST)
Developed by Miller (2001)
25 items designed as initial screen for
malingered psychopathology; (“positive” screen
may require further evaluation with SIRS)
Brief to administer (~5 min)
Research indicates cut off score of > 6 effective
screen for malingered incompetence to stand
trial
Miller HA: Psychological Assessment Resources, Inc. (2001)
Jackson R, Rogers R, Sewell K. Law & Human Behavior (2005)
Malingering Assessment: (M-FAST)
Sample questions (“Rare combinations” &
“Extreme symptoms”:
“The times when you can’t go to sleep, do you
often smell strange odors that are not really
there?”
“When I hear voices, my hands begin to sweat”
“Often, I get the strange feeling that I am from
another planet”
“On many days I feel so bad that I can’t even
remember my full name”
Summary Points:
There should be strong suspicion for
malingering in forensic settings
Malingering for psychotropic medications is a
growing problem for jails
Assessment of malingering should involve
collateral observations and records
Consider the adjunct use of validated screens
(M-FAST) and tests (SIRS)
Need better exchange of clinical information
between forensic settings (i.e., jails and state
hospitals)