Malingering mental disorders: Clinical assessment

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Summary

Malingering is the dishonest and intentional production of symptoms. It can cause considerable difficulty as assessment runs counter to normal practice, and it may expose clinicians to testing medicolegal situations. In this first part of a two-article review, we explore types of psychiatric malingering and their occurrence across a range of common and challenging scenarios, discussing presentations that may help delineate true from feigned illness. A framework is provided for undertaking an assessment where malingering is suspected, including recommendations on clinician approach, the use of collateral information, and self-evaluation of biases. The uses, and limitations, of psychometric tests are discussed, including ‘general’, malingering-specific and ‘symptom validity’ scales.

Learning Objectives

• Understand the challenges of determining ‘real’ from ‘malingered’ symptomatology across a range of psychiatric conditions

• Have a rational strategy for approaching a clinical assessment where malingering is suspected

• Appreciate the role and limitations of various psychometric tests that can be used in such assessments

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Most cited references 11

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The ICD-10 Classification of Mental and Behavioural Disorders : Clinical Descriptions and Diagnostic Guidelines

Organisation mondiale de la santé, World Health Organization, WHO … (1992)

Provides clinical descriptions diagnostic guidelines and codes for all mental and behavioural disorders commonly encountered in clinical psychiatry. The book was developed from chapter V of the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The clinical descriptions and diagnostic guidelines were finalized after field testing by over 700 clinicians and researchers in 110 institutes in 40 countries making this book the product of the largest ever research effort designed to improve psychiatric diagnosis. Every effort has been made to define categories whose existence is scientifically justifiable as well as clinically useful. The classification divides disorders into ten groups according to major common themes or descriptive likeness a new feature which makes for increased convenience of use. For each disorder the book provides a full description of the main clinical features and all other important but less specific associated features. Diagnostic guidelines indicate the number balance and duration of symptoms usually required before a confident diagnosis can be made. Inclusion and exclusion criteria are also provided together with conditions to be considered in differential diagnosis. The guidelines are worded so that a degree of flexibility is retained for diagnostic decisions in clinical work particularly in the situation where provisional diagnosis may have to be made before the clinical picture is entirely clear or information is complete. ... As befitting a publication of considerable influence the amount of work that went into preparing ICD-10 has been formidable... - The International Journal of Social Psychiatry

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Base rates of malingering and symptom exaggeration.

William C Patton, D Condit, E M Canyock … (2002)

Base rates of probable malingering and symptom exaggeration are reported from a survey of the American Board of Clinical Neuropsychology membership. Estimates were based on 33,531 annual cases involved in personal injury, (n = 6,371). disability (n = 3,688), criminal (n = 1,341), or medical (n = 22,131) matters. Base rates did not differ among geographic regions or practice settings, but were related to the proportion of plaintiff versus defense referrals. Reported rates would be 2-4% higher if variance due to referral source was controlled. Twenty-nine percent of personal injury, 30% of disability, 19% of criminal, and 8% of medical cases involved probable malingering and symptom exaggeration. Thirty-nine percent of mild head injury, 35% of fibromyalgia/chronic fatigue, 31% of chronic pain, 27% of neurotoxic, and 22% of electrical injury claims resulted in diagnostic impressions of probable malingering. Diagnosis was supported by multiple sources of evidence, including severity (65% of cases) or pattern (64% of cases) of cognitive impairment that was inconsistent with the condition, scores below empirical cutoffs on forced choice tests (57% of cases), discrepancies among records, self-report, and observed behavior (56%), implausible self-reported symptoms in interview (46%), implausible changes in test scores across repeated examinations (45%), and validity scales on objective personality tests (38% of cases).

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Evaluation of the appropriateness of multiple symptom validity indices in psychotic and non-psychotic psychiatric populations.

Ryan Schroeder, Paul Marshall (2011)

Although it is recognized that significant cognitive deficits are inherent in many psychiatric disorders, there is minimal research on whether the deficits can cause a failing score on symptom validity tests (SVTs). The performances of 104 and 178 patients with psychotic disorders and non-psychotic psychiatric disorders, respectively, on seven SVTs were examined. Analyses indicate that most of these SVTs have specificity rates of 90% or better for both clinical groups. Further, only 7% of patients in the psychotic group and 5% of patients in the non-psychotic psychiatric group produced false-positive classifications based on malingering criteria similar to those suggested by Slick et al. (i.e., failure of two or more SVTs or failure of one SVT at statistically significantly worse than chance rates). Consequently this research indicates that psychiatric disorders typically do not adversely affect SVT performance.

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Author and article information

Journal

Title: BJPsych Advances

Abbreviated Title: BJPsych advances

Publisher: Royal College of Psychiatrists

ISSN (Print): 2056-4678

ISSN (Electronic): 2056-4686

Publication date Created: January 2017

Publication date (Electronic): January 02 2018

Publication date (Print): January 2017

Volume: 23

Issue: 1

Pages: 27-35

Article

DOI: 10.1192/apt.bp.116.015958

SO-VID: e865ad00-acca-4527-b3bb-77cf76ba58db

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https://www.cambridge.org/core/terms

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