In Session With Philip J. Resnick, MD
Malingering of Psychiatric Symptoms
Dr. Resnick is director of the Division of Forensic Psychiatry at Case Western University School of Medicine
and adjunct professor at Case Western University School of Law. He is also director of the Fellowship in Forensic
Psychiatry at Case Western Reserve University and director of the Court Psychiatric Clinic in Cleveland. Dr. Resnick
has served as a consultant in the cases of Andrea Yates, Scott Peterson, and Theodore Kaczynski. He is a past president
of the American Academy of Psychiatry and the Law. Dr. Resnick is an editor of Medicine
and Law journal,
and associate editor of International Journal of Offender Therapy and Comparative Criminology. He was honored
as a Distinguished Life Fellow of the American Psychiatric Association in 2003.
What is malingering?
Malingering is defined in
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),1
as the intentional production of false or grossly exaggerated physical or psychologic
symptoms. It is motivated by external incentives, such as avoiding work or
obtaining financial compensation. It is not a medical disorder, but rather a
V-code. A person with malingered symptoms is presenting fraudulent symptoms and
is not a genuine patient seeking help.
Everyone engages in what
might be called “impression management,” where people put their best foot
forward. For example, a person may present himself in a better light at a job
interview than on a regular day at a job he has had for 10 years. Behavior on a
first date is different than on a 20th date. A person under evaluation for
worker’s compensation, where the results of the examination will affect how
much money that person gets, will be tempted to have some mild exaggeration of
what is self-serving. However, genuine malingering is a gross exaggeration with
a conscious effort to deceive. Clinically significant malingering is carried
out by people who obviously have some material gain. Malingering primarily
occurs in medical and legal contexts, such as avoiding criminal prosecution,
disability evaluation, avoiding the military, or seeking drugs.
The DSM-IV states that one should strongly suspect
malingering if ≥2 of the following four items are present: medical/legal
context, lack of cooperation, marked discrepancy between claims and objective
findings, and antisocial personality. Although antisocial personality is
listed, a majority of studies suggest that people with antisocial personalities
are not more likely to malinger, or to be successful at doing so, than the general
The external inducements
associated with malingering differentiate it from factitious disorder, in which
the primary motivation is the pleasure of being in the patient role.
Are any particular psychiatric symptoms malingered
more than others?
disorder (PTSD) is the easiest to malinger because people can be easily coached
to report the “right” symptoms. The list of symptoms are readily available on
the Internet and they are virtually all subjective, so it is very difficult to
ascertain when someone is malingering. Depression is also frequently
malingered, especially after a worker’s compensation injury. A person who has
genuinely injured his back but who has not received as much financial
compensation as expected might claim to be experiencing depression due to the
What are some methods of evaluating whether or not a
person is malingering?
The Structured Interview
of Reported Symptoms is the best objective test that measures whether someone
is faking psychotic symptoms.5 For someone faking memory deficits,
there are four or five psychologic tests.
One such widely used test
is the Test of Malingered Memory (TOMM). The TOMM involves what is called the
forced choice principle. For example, a person could be shown 10 words and told
to remember them. The person is then shown 20 words and is told to pick out the
original 10 words. If the person has no memory for the original 10, the person
would get approximately 50% correct. If the person manages to get 90% wrong, it
proves that the person remembers the words and is avoiding picking them by
design. This forced choice principle underlies many of the tests used to detect
malingering, including the TOMM. There are other psychologic tests that are
based on the same principle but are more sophisticated.
There are also clinical
ways to ascertain if someone is malingering.6 The more an evaluator
knows about the genuine symptom, the harder it is for the malingerer to get
away with it. For example, an evaluator might ask a patient claiming to have
auditory hallucinations a series of questions, starting with, “How often do
these auditory hallucinations arise?” A patient who alleges that the
hallucinations are continuous might be malingering, since studies have shown
that auditory hallucinations are intermittent.7 The evaluator can
also ask the patient, “Do the voices ever ask you questions?” If the patient
answers yes, the evaluator might ask for an example of a question the patient
was asked. The nature of the question is a clue to whether ot not the patient
is malingering. Genuine auditory hallucinations that ask questions tend to be
chastising, such as, “Why are you not doing your homework?” or “Why are you
smoking?” Such voices are not information seeking. They do not say, “What is
the weather like?” or “What time is it?”8 In other words, people
view their voices as omniscient, but the voices never view the individual as
knowing more than they do.
An evaluator might ask a
patient claiming to have visual hallucinations whether the visions are in color
or black-and-white. The malingerer has a 50% chance of guessing wrong. The
correct answer is that visual hallucinations are in color.
One of the better clues to
detect malingering of PTSD is the nature of reported nightmares. Genuine PTSD
nightmares are associated with body movement, such as the patient thrashing
around and having the sheets thrown off the bed. A sleeping partner can confirm
this. PTSD nightmares usually also start out repeating the trauma, and then
they will replicate the affective component with different manifest content.9 For example, a woman who was raped
may have dreams for 1–2 weeks of being
raped. Then, she may have dreams of being tied down, helpless, and tortured,
which is the same affect she experienced in the rape, but a different manifest
content. Traumatic nightmares dissipate over time. Hence, a report of having
had the same unchanged dream every night for 3 years about having been raped
would be highly suspicious of malingering because that is not how genuine
traumatic nightmares work.
When I teach workshops, I
make the point that the clinician should never ask himself if the patient is
ill or faking. That is the wrong question. Instead, the clinician should ask if
the patient is malingering, whether he has genuine symptoms or not. For
example, a person with genuine schizophrenia who kills his mother over a
dispute about being given money from a social security check to buy drugs may
then allege falsely that he heard God’s voice instructing him to kill his
mother. The person is genuinely schizophrenic, but he is malingering a specific
symptom in order to be excused from the crime by reason of insanity. Thus, the
question is not, “Is the patient ill or faking?” but rather, “Whether ill or
not, is the patient faking a particular symptom?”
Are there medical/legal ramifications if a doctor
gives a false diagnosis of malingering?
Yes. A doctor can be sued
for malpractice and even defamation of character. I was actually called as an
expert in two cases where mental health professionals were sued for defamation
of character, which may not even be covered by their malpractice policy,
because it is an intentional tort. I would advise doctors to list the evidence
suggesting malingering but not to reach a definitive conclusion unless the
evidence is overwhelming. To make a formal diagnosis in the absence of clear
cut proof is to put oneself at risk.
What should a clinician do once he or she suspects a
patient of malingering?
The clinician should first
gather all of the information without behaving in a challenging or
non-believing manner. Then, I recommend a gentle confrontation so that the
patient does not lose face. For example, instead of a direct accusation, a
clinician might say, “I have examined hundreds of people with this type of
symptom, and what you are telling me does not ring completely true. Is there
anything you can add to help explain this?” This gives the patient a chance to
back off without being called a liar.
I think the critical issue
in treating a malingerer is setting limits. For example, a patient with a minor
leg injury might malinger more pain than exists in order to seek heavy duty
analgesics to feed an addiction or to sell on the street. In that case, it is
appropriate for the clinician to say that the pain is out of proportion to his
physical findings and that he cannot prescribe the medication.
A physician might decide
to fire a patient who is found trying to steal a prescription pad or do
something frankly illegal.
When a clinician is convinced someone is exaggerating
symptoms, the clinician should document that in his records in case the records
are subpoenaed or the clinician is asked for a letter summarizing those
records. For example, a patient with a minor back injury who goes repeatedly to
physicians complaining of severe pain might be trying to build a paper trail to
get heavier worker’s compensation. The patient is misrepresenting himself in
order to create a record, but the patient will be unsuccessful if the clinician
has documented the possibility of malingering.
doctor/patient relationship or privilege still hold if a patient lies?
I would not say that there is any automatic voiding of the
doctor/patient relationship simply because someone lied. There are many minor
lies. People repeatedly lie about the quantity of alcohol they consume. They
might lie about having a sexually transmitted disease because of stigma and
embarrassment. They might minimize a criminal record if asked if they have had
any trouble with the law. Such lies are so commonly made that I would not say
that they void the doctor/patient duty. However, if someone is consciously
lying and trying to use the clinician as a dupe to accomplish some illegal
purpose, such as getting money which is undeserved or to get a letter to avoid
reporting to their draft board, then the clinician’s duty is to the truth. The
clinician should document it in his records. The clinician can also choose to
fire a patient who is noncompliant, who is disrespectful, or who does not pay
If a clinician
treats a patient and then finds out the patient is malingering, is the
clinician liable if the patient responds negatively to treatment?
There was one outrageous case where a woman with factitious
disorder was alleging to more than one physician that she had cancer. She moved
to another state and gave a new physician detailed information about which
anticancer drugs she had been taking from her previous physician. She said that
she had just got into town and she needed prescriptions for those drugs. The
physician prescribed the anticancer drugs, which were very potent and had
severe side effects. She took them, developed a bad untoward reaction, and
successfully sued the physician for prescribing the medication. The case was
settled out of court. The issue was that the physician should have sought the
records from the original treating physician instead of over-relying on the
factitious patient’s skilled presentation.
I have seen malpractice cases where there was improper
diagnosis, such as someone who in retrospect had clear bipolar disorder and was
treated for schizophrenia. These patients sued because they would not have
developed tardive dyskinesia had the diagnosis been correct. However, I have
not encountered any psychiatric case where someone was treated due to malingering.
I suppose it could happen in a jail; for example, where someone wants to get on
social security disability. The prisoner might malinger, be prescribed
antipsychotics, and develop a permanent side effect which could make the doctor
liable. The standard is whether a reasonable psychiatrist in similar circumstances
would also prescribe antipsychotics. There would be a basis for a malpractice
suit only if the prescription was made unreasonably.
Is there a psychiatric diagnosis for compulsive
There is no DSM
diagnosis for compulsive lying. However, articles usually phrase it as pathological
lying as opposed to compulsive lying. A pathological liar is usually defined as
someone who has a need to lie even when it is self-defeating. In other words,
an antisocial personality may lie to avoid responsibility or to make excuses.
We can all relate to that and do it a little bit in our lives. However, a true
pathological liar will make up a lie when there is not any obvious gain.
Can malingering actually be a form of another
Fifty years ago, when
psychoanalysis had much more influence, there were articles suggesting that
people who malingered were even sicker than those with frank illness.10
There were various dynamic explanations for how sick they were. However, in
light of today’s world, I do not agree. Anyone who is facing the death penalty
would prefer to pretend symptoms rather than be executed. A prisoner-of-war
might fake physical or psychiatric symptoms in an effort to then put himself in
a better position to escape. We would view that as adaptive and laudatory. I do
not think that we should view malingering as always bad or always good. It
depends on the circumstances.
1. Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. Cogburn RAK. A study of psychopathy and its relation
to success in interpersonal deception. Diss Abstr Int.
3. Kropp PR. The relationship between psychopathy and
malingering of mental illness. Diss Abstr Int. 1994;54(11-B):5945-5946.
4. Rogers R, ed. Clinical
Assessment of Malingering and Deception. 2nd ed. New York, NY: Guilford
5. Rogers R, Bagby RM, Dickens SE. Structured
Interview of Reported Symptoms (SIRS): Professional Manual. Odessa, FL:
Psychological Assessment Resources; 1992.
6. Resnick PJ. Malingering. In: Rosner R, ed. Principles
and Practice of Forensic Psychiatry. 2nd ed. Norwell, MA: Chapman and Hall;
7. Goodwin DW, Alderson P, Rosenthal R. Clinical
significance of hallucinations in psychiatric disorders. A study of 116
hallucinatory patients. Arch Gen Psychiatry. 1971;24(1):76-80.
8. Leudar I, Thomas P, McNally D, Glinski A. What voices
can do with words: pragmatics of verbal hallucinations. Psychol Med.
9. Garfield P. Nightmares in the sexually abused female
teenager. Psychiatr J Univ Ott. 1987;12(2):93-97.
10. Eissler KR. Malingering. In: Wilbur GB, Muensterberger
W, eds. Psychoanalysis and Culture. New York, NY: International
University Press. 1951:218-353.
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Disclosure: Dr. Resnick is on the speakers bureau of AstraZeneca and Pfizer.