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.

2. Brodie JD. Personal communication, 2005.

3. Yates BD, Nordquist CR, Schultz-Ross RA. Feigned psychiatric symptoms in the emergency room. Psychiatr Serv 1996;47:998-1000.

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.

9. Sadock BJ, Sadock VA. Kaplan & Sadock’s synopsis of psychiatry, 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2003;898.-

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.

13. Lewinsohn PM. An empirical test of several popular notions about hallucinations in schizophrenic patients. In: Keup W (ed.). Origin and mechanisms of hallucinations. New York: Plenum Press; 1970;401-3.

14. Goodwin DW, Anderson P, Rosenthal R. Clinical significance of hallucinations in psychiatric disorders: a study of 116 hallucinatory patients. Arch Gen Psychiatry 1971;24:76-80.

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16. Kasper ME, Rogers R, Adams PA. Dangerousness and command hallucinations: an investigation of psychotic inpatients. Bull Am Acad Psychiatry Law 1996;24:219-24.

17. Thompson JS, Stuart GL, Holden CE. Command hallucinations and legal insanity. Forensic Rep 1992;5:29-43.

18. Cornell DG, Hawk GL. Clinical presentation of malingerers diagnosed by experienced forensic psychologists. Law Hum Behav 1989;13:375-83.

19. Cummings JL, Miller BL. Visual hallucinations: clinical occurrence and use in differential diagnosis. West J Med 1987;146:46-51.

20. Wessely S, Buchanan A, Reed A, et al. Acting on delusions: I. Prevalence. Br J Psychiatry 1993;163:69-76.

21. Edens JF, Guy LS, Otto RK, et al. Factors differentiating successful versus unsuccessful malingerers. J Pers Assess 2001;77(2):333-8.

22. Ritson B, Forest A. The simulation of psychosis: a contemporary presentation. Br J Psychol 1970;43:31-7.

23. Edens JF, Buffington JK, Tomicic TL. An investigation of the relationship between psychopathic traits and malingering on the Psychopathic Personality Inventory. Assessment 2000;7:281-96.

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

25. Pelfrey WV. The relationship between malingerers’ intelligence and MMPI-2 knowledge and their ability to avoid detection. Int J Offender Ther Comp Criminol. 2004;48(6):649-63.

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27. Miller HA. Examining the use of the M-FAST with criminal defendants incompetent to stand trial. Int J Offender Ther Comp Criminol 2004;48(3):268-80.

Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.²²

Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.²³

Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.

Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.

Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.

Table 4

Clinical factors that suggest malingering

Absence of active or subtle signs of psychosis
Marked inconsistencies, contradictions
Patient endorses improbable psychiatric symptoms Mixed symptom profile (eg, endorses depressive symptoms plus euphoric mood) Overly dramatic Extremely unusual (‘Do you believe that cars are a part of an organized religion?’)
Patient is evasive or uncooperative Excessively guarded or hesitant Frequently repeats questions Frequently replies, ‘I don’t know’ to simple questions Hostile, intimidating; seeks to control interview or refuses to participate
Psychological testing indicates malingering (SIRS, M-FAST, MMPI-2)
SIRS: Structured Interview of Reported Symptoms
M-FAST: Miller Forensic Assessment of Symptoms Test
MMPI-2: Minnesota Multiphasic Personality Inventory, Revised

Psychological Testing

Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:

Structured Interview of Reported Symptoms (SIRS)
Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
Miller Forensic Assessment of Symptoms Test (M-FAST).¹¹

SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.²⁴

Two MMPI-2 scales—F-scale and F-K Index—are the most frequently used test for evaluating suspected malingering. When using the MMPI-2 in this manner, consult the literature for appropriate cutoff scores (see Related resources). Although the MMPI-2 is the most validated psychometric method to detect malingering, a malingerer with high intelligence and previous knowledge of the test could evade detection.²⁵

M-FAST was developed to provide a brief, reliable screen for malingered mental illness. This test takes 10 to 15 minutes to administer and measures rare symptom combinations, excessive reporting, and atypical symptoms.¹¹ It has shown good validity and high correlation with the SIRS and MMPI-2.^26,27

Confronting the Malingerer

If a thorough investigation indicates that a patient is malingering psychosis, you may decide to confront the evaluee. Avoid direct accusations of lying,¹⁰ and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, “You haven’t told me the whole truth.”

A thoughtful approach that asks the evaluee to clarify inconsistencies is more likely to be productive and safer for the examiner. When confronting individuals with a history of violence and aggression, have adequate security personnel with you.

Related resources

Structured Interview of Reported Symptoms (SIRS). Available for purchase from Psychological Assessment Resources at www3.parinc.com (enter “SIRS” in search field).
Graham JR. MMPI-2: Assessing personality and psychopathology. New York: Oxford Press; 2000. (Source of cutoff scores to use MMPI-2 scales [F-scale and F-K Index] to evaluate suspected malingering).
Psychological Assessment Resources, Inc. Miller Forensic Assessment of Symptoms Test (M-FAST). Available at: www3.parinc.com (enter “M-FAST” in search field).