Evidence-Based Reviews

Faking it: How to detect malingered psychosis

Current Psychiatry. 2005 November;4(11):12-14,16,19-21,25

References

1. Newman A. Analyze this: Vincent Gigante, not crazy after all those years. New York Times, April 13, 2003.

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4. Kropp PR, Rogers R. Understanding malingering: motivation, method, and detection. In: Lewis M, Saarini C (eds). Lying and deception. New York: Guilford Press; 1993.

5. Kucharski LT, et al. Clinical symptom presentation in suspected malingerers: an empirical investigation. Bull Am Acad Psychiatry Law. 1998;26:579-85.

6. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: American Psychiatric Association; 2000.

7. Resnick PJ. Malingering of posttraumatic stress disorders. In: Rogers R (ed). Clinical assessment of malingering and deception (2nd ed.). New York: Guilford Press; 1997;130-52.

8. Kupers TA. Malingering in correctional settings. Correctional Ment Health Rep. 2004;5(6):81-95.

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10. Thompson JW, LeBourgeois HW, Black FW. Malingering. In: Simon R, Gold L (eds). Textbook of forensic psychiatry. Washington, DC: American Psychiatric Publishing; 2004.

11. Miller HA. M.-FAST interview booklet. Lutz, FL: Psychological Assessment Resources; 2001.

12. Rogers R. Assessment of malingering within a forensic context. In Weisstub DW (ed.). Law and psychiatry: international perspectives. New York: Plenum Press; 1987;3:209-37.

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24. Rogers R. Structured interviews and dissimulation. In: Rogers R (ed). Clinical assessment of malingering and deception. New York: Guilford Press; 1997.

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Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).¹⁴ In schizophrenia, the major themes are persecutory or instructive.¹⁵

Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:

do not always obey the voices, especially if doing so would be dangerous¹⁶
usually present with noncommand hallucinations (85%) and delusions (75%) as well¹⁷

Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:

engaging in activities (working, listening to a radio, watching TV)
changing posture (lying down, walking)
seeking interpersonal contact
taking medications.

If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.

Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:

an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”

Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.

Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).¹⁸

Genuine visual hallucinations are usually of normalsized people and are seen in color.¹⁴ On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.

Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.¹⁹

Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.

Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.²⁰

Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).

With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.

Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.

Table 3

Uncommon psychosis presentations that suggest malingering

Hallucinations
Continuous Voices are vague, inaudible Hallucinations are not associated with delusions Voices use stilted language Patient uses no strategies to diminish hallucinations Patient states that he obeys all commands Visual hallucinations in black and white Visual hallucinations alone in schizophrenia
Delusions
Abrupt onset or termination Patient’s conduct is inconsistent with delusions Bizarre content without disorganization Patient is eager to discuss delusions

Where Malingerers Trip Up

Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.²¹

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