In Session With Philip J. Resnick, MD

Malingering of Psychiatric Symptoms

Philip J. Resnick, MD

What is malingering?

Malingering is defined in the Diagnostic 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 population.^2-4

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?

Posttraumatic stress 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 back injury.

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.

Does the 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 the bill.

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 liars?

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 psychiatric illness?

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.

References

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. 1993;54(4-B):2191.

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 Press; 1997.

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; 2003:543-554.

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. 1997;27(4):885-898.

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.

If you have any questions and/or comments regarding the interview with Phillip J. Resnick, MD, please submit a “Letter to the Editor” to Norman Sussman, MD, at [email protected].

Disclosure: Dr. Resnick is on the speakers bureau of AstraZeneca and Pfizer.