Adolescent Malingering (Help Please!)

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gizmo23

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Hello Everyone!

I'm new to this site. I have a question regarding suspected malingering of psychosis by an adolescent. My thought originally was to go with the PAI-A due to the clinical useful and the NIM and PIM scales. Which is what I did. Now I'm afraid I made a clinical error because the MMPI-A likely has better malingering scales. What do you all think? Can I get away with using the PAI-A since I've already administered it (it's not totally scored but is valid) I also plan on doing a more in-depth interview. Any suggestions or comments are welcome.

-A nervous clinician
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Justanothergrad said:
I would be hesitant to conclude malingering based only on self report scales as a general rule, particularly without some evidence of secondary gains/motivation for secondary gains.

Not in adolescents, but also a good read in comparing pai/mmpi validity scale rates (in adults)
http://www.ncbi.nlm.nih.gov/pubmed/20207423
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Thank you! I'm definitely going to dive in to get more information as this is my first day with the case and I still have to get more information. I guess I'm just nervous about choosing the PAI-A over the MMPI-A. I'm having a bit of hindsight bias already.
 
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This is not a text bound diagnosis, just like everything else.
 
There are no malingering scales on those instruments, and viewing them as such is a fast path to misinterpreting your results. Malingering is a term for a relatively defined set of circumstances and if your determination of that is coming down to a single instrument choice, you need to find some supervision with someone who is competent in assessment to help guide you through this (e.g., looking at external incentive, rule-outs like factitious disorder, etc.).
 
Agree with others, I'd tread with caution here. Although I suspect it very often, I rarely use the m word in my documentation. Generally that occurs when I have clear evidence of some secondary gain (not hard in my population) and indicators below statistical chance on some measures. I'd argue that it's much easier to tease out malingering on PVT's than it is on SVT's. I frequently get well within normal limits on cognitive testing while seeing validity indicators on the MMPI-RF over cutoffs in the literature.

Trying to find it in psychosis, even harder. My tact here would be to hopefully find multiple sources of collateral informant here.
 
The referral question, as is usually the case, is not sufficient IMO. The question is going to be what the recommendations are going to be on how to address the case. In many treatment settings, it typically doesn't matter that much whether the patient is feigning symptoms or not, but the staff tend to focus on it as though it changes the treatment. If someone is feigning symptoms, unless it is for clear financial or legal gain, then they are usually fairly ill and will benefit from treatment anyway. Nearly, if not every, case of "suspected malingering" that I have seen in treatment settings has been misdiagnosis and poor conceptualizing by other members of treatment team.
 
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Remember though, context matters. Base rates will vary wildly depending on that. In my setting, very diff than smalltown, I actually deal with the opposite, providers who refuse to believe that someone is faking/exaggerating cognitive concerns, rather than the other way around. Even in the context of a preponderance of evidence.
 
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Obviously context matters, but whether someone is lying should matter in every context. In fact, it should be a priority. That individual that decided on outpatient treatment for his "severe anxiety", that constantly complained to his family doc about severe anxiety, is the same person that will eventually apply for disability/or other situations where there is gain etc. If you don't look for lying in all contexts, and make it a priority, then if you're doing the disability assesment those first couple actions by this person will simply be used as proof that they have a legitimate problem. Furthermore, the idea that treatment would be the same is also silly. Huge difference between treating someone for severe anxiety and factitious disorder.
 
psych844 said:
Obviously context matters, but whether someone is lying should matter in every context. In fact, it should be a priority. That individual that decided on outpatient treatment for his "severe anxiety", that constantly complained to his family doc about severe anxiety, is the same person that will eventually apply for disability/or other situations where there is gain etc. If you don't look for lying in all contexts, and make it a priority, then if you're doing the disability assesment those first couple actions by this person will simply be used as proof that they have a legitimate problem. Furthermore, the idea that treatment would be the same is also silly. Huge difference between treating someone for severe anxiety and factitious disorder.
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Remember though, failing PVT/SVT's is not a binary thing, they are not simply "lying or not lying." Sometimes we also see exaggeration of a pre-existing condition. Some people may feel the need to "prove" their problems. Most of us doing assessments have seen this pattern, many times. Our tests merely tell us whether or not someone failed a PVT/SVT, they do not tell us why they did so. So yes, we should generally consider validity concerns a possibility in all assessments, we still need to examine a range of possibilities when validity concerns are present.
 
psych844 said:
Obviously context matters, but whether someone is lying should matter in every context. In fact, it should be a priority. That individual that decided on outpatient treatment for his "severe anxiety", that constantly complained to his family doc about severe anxiety, is the same person that will eventually apply for disability/or other situations where there is gain etc. If you don't look for lying in all contexts, and make it a priority, then if you're doing the disability assesment those first couple actions by this person will simply be used as proof that they have a legitimate problem. Furthermore, the idea that treatment would be the same is also silly. Huge difference between treating someone for severe anxiety and factitious disorder.
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You are misunderstanding my point likely because you have not seen how "that patient is faking" is used as a justification for poor treatment in treatment contexts. Of course, treatment will vary, that is why I made the point about accurate conceptualizing. Also, factitious is much different from malingering and many of the patients in treatment settings that are accused of malingering tend to be the former more than the latter. I also do conduct disability assessments and the base rate for feigning and exaggerating symptoms is obviously higher than it is in a treatment setting where there is less secondary gain. As far as someone building a case for disability by lying to everyone. That's not really how that works in my experience. Put it this way, in my experience, most people, including even my patients who are disabled, want to be productive and make more than the paltry sum that social security disability pays. The VA system skews that a bit because I have heard reports of as much as 3k per month which isn't too bad especially since it's not taxed the same as regular income.
 
smalltownpsych said:
Put it this way, in my experience, most people, including even my patients who are disabled, want to be productive and make more than the paltry sum that social security disability pays.
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Pretty sure the entire Institute of Medicine hearing did not agree with that.
 
WisNeuro said:
Remember though, context matters. Base rates will vary wildly depending on that. In my setting, very diff than smalltown, I actually deal with the opposite, providers who refuse to believe that someone is faking/exaggerating cognitive concerns, rather than the other way around. Even in the context of a preponderance of evidence.
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Yup. I was talking to a colleague the other day and explained to him that to help him more accurately differentiate Borderline PD as opposed to Bipolar. On a related note, I recall that the base rate for Borderline PD is about 20% inpatient and 10% inpatient and that Bipolar I is about 1% to 2% in population, does anyone know off the top of their head, the base rates for Bipolar I based on treatment setting? It appears to be over diagnosed, as I am sure you are all aware, but it always helps to know the numbers better.
 
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PSYDR said:
Pretty sure the entire Institute of Medicine hearing did not agree with that.
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What they want and what they do are two different things and how society incentifies that equation makes a difference. I am curious about that hearing though, do you have a link?

Also, I wasn't thinking about active substance users in my comment, and that also skews the equation.
 
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psych844 said:
Obviously context matters, but whether someone is lying should matter in every context. In fact, it should be a priority. That individual that decided on outpatient treatment for his "severe anxiety", that constantly complained to his family doc about severe anxiety, is the same person that will eventually apply for disability/or other situations where there is gain etc. If you don't look for lying in all contexts, and make it a priority, then if you're doing the disability assesment those first couple actions by this person will simply be used as proof that they have a legitimate problem. Furthermore, the idea that treatment would be the same is also silly. Huge difference between treating someone for severe anxiety and factitious disorder.
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On top of what others have said (and with the risk of self promotion for a soon to be available article), the mean differences between malingering groups and similar comparison groups is only one standard deviation within the MMPI-2-RF. Keeping in mind that scales show poor sensitivity with 3SD differences for identifying malingering, thats somewhat problematic. It makes the ability to discriminate between those groups much more difficult. This problem continues even after removing intermediary groups that failed only some SVTs in an attempt to identify malingerers/non-malingers as a binary process (which it are not). There simply are not as large of differences as you might imagine across contexts (disability evaluations, veteran affairs evals, etc.) to make the easy judgement. In terms of the ethics of service provision, which is preferred- over diagnosing or under diagnosing? Which causes greater harm?

I would also be very wary of getting in the business of predicting future behavior.
 
smalltownpsych said:
What they want and what they do are two different things and how society incentifies that equation makes a difference. I am curious about that hearing though, do you have a link?
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I have personal experience with a bunch of people who have mental health concerns (mostly anxiety, GAD, panic). I think I know about 4-5 in total. (family and friends) These people have issues, no doubt about that, but the constant with all of them is over-exaggeration of symptoms, and a scary degree of self-pity, and lack of responsibility. It is not so much lying, or malingering, as distorting the truth to fit a certain narrative. A narrative that is in line with their self-pity.

I have a friend who's on disability because of Social anxiety and GAD. But I've known him 10 yrs..his main issues are def motivation and self-esteem. For example, he isn't lying when he says that his anxiety causes him sleep issues...or in the least, he has always had sleep issues. He also claims this is his #1 problem. But this is also the same guy that had no issues staying up 48-72 hrs with minimal sleep, and then would ask me to hang out and be very social. (on a consistent basis..for years). So fatigue/sleep can't be on one hand the number one reason you can't get a job, but you can be social with me, and be around many other people, when you've slept 6 hrs in 3 days. (and be happy at that).

I've seen this time and time again. (motivation issues, lack of interest, self-esteem issues masquerading as mental illness)
 
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Honestly it's times like these that I think having the background that I've hand (having mental health concerns myself, and having people around me that have them also), is pretty handy. If you had a pretty normal life, I think it's hard to get any of this.
 
psych844 said:
Honestly it's times like these that I think having the background that I've hand (having mental health concerns myself, and having people around me that have them also), is pretty handy. If you had a pretty normal life, I think it's hard to get any of this.
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I would be wary of assuming motivation for all people because of personal experience. Thats not a good bias to bring into an assessment. It includes some value-added impact on your own interpretation of the data and the fact remains that determining malingering is not easy and should be done with extreme caution because it has long lasting impacts when subsequent folks view those files.
 
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psych844 said:
Honestly it's times like these that I think having the background that I've hand (having mental health concerns myself, and having people around me that have them also), is pretty handy. If you had a pretty normal life, I think it's hard to get any of this.
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I'd caution against making assumptions of people in here. Plenty of psychologists have the "benefit" of experience with mental illness at various levels. Some have even suffered from, researched, and treated mental illness. Additionally, many would argue that we can treat and research mental disorders just fine without having personally suffered from them.
 
Justanothergrad said:
I would be wary of assuming motivation for all people because of personal experience. Thats not a good bias to bring into an assessment. It includes some value-added impact on your own interpretation of the data and the fact remains that determining malingering is not easy and should be done with extreme caution because it has long lasting impacts when subsequent folks view those files.
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I didn't say that I would use that personal experience to make decisions, just that it is helpful on some level within the context of doing a neutral/clinical assessment.
 
psych844 said:
I didn't say that I would use that personal experience to make decisions, just that it is helpful on some level within the context of doing a neutral/clinical assessment.
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I think we had more of a problem with the logic that someone who has not experienced a particular mental illness cannot be neutral, while one that has experienced that mental illness can be. The opportunity for bias exists in both, albeit most likely in different ways.
 
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WisNeuro said:
I'd caution against making assumptions of people in here. Plenty of psychologists have the "benefit" of experience with mental illness at various levels. Some have even suffered from, researched, and treated mental illness. Additionally, many would argue that we can treat and research mental disorders just fine without having personally suffered from them.
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I'm just arguing that having suffered with mental illness myself, and having day-to-day experience with friends and family who also suffer from mental illness, does imo give you a bit of an advantage. You have known these people for many years, and they have been open about their struggles because you are close to them..so you see these trends, and I think you get at the heart of what these people's issues are. You see their good days and their bad. Now this experience means little without me getting clinical training as well. But I think if you get clinical training, these kind of experiences can help a lot.
 
WisNeuro said:
I think we had more of a problem with the logic that someone who has not experienced a particular mental illness cannot be neutral, while one that has experienced that mental illness can be. The opportunity for bias exists in both, albeit most likely in different ways.
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Neutral? I never said that. I said you might not understand it as much (ie more likely to make a mistake).
 
Perhaps I'm obtuse, but if you aren't using that to inform your decision then how is it useful. Its a bias you bring to interpretation, particularly when you say others who haven't experienced it personally may not have a 'handy' skill set, as neuro mentions.
 
WisNeuro said:
Well, you mentioned a "neutral" assessment. and, what kind of mistake are you speaking of in the context of malingering during an assessment?
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Specifically, I'd say that you'd be less likely to pick up on malingering.
 
psych844 said:
Specifically, I'd say that you'd be less likely to pick up on malingering.
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Research would suggest that if you are relying on your intuition, instead of actuarial methods, you are going to mis-classify effort in an evaluation. I would have to say that teh evidence is against your opinion on this one. If you want some good material, I'd start with Meehl and work your way forward.
 
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psych844 said:
It's an opinion. I don't need to cite it. Pretty sure there is no research that shows the reverse, either.
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1. In science we assert opinions based on the accumulation of fact. You can have an opinion, but without evidence, you don't have room to argue the point. Either way, its a bias that is likely to influence your assessments and interpretations of reports.

2. Not how science works. I don't have to disprove your lack of evidence to be skeptical.

3. Work on decision making in therapy is against you on this.
 
WisNeuro said:
Research would suggest that if you are relying on your intuition, instead of actuarial methods, you are going to mis-classify effort in an evaluation. I would have to say that teh evidence is against your opinion on this one. If you want some good material, I'd start with Meehl and work your way forward.
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Not sure where we are going wrong here. I'm 100% committed to the science, and relying on the assessment tools first and foremost, and understanding their benefits and limitations. BUT, as you guys have stated, assessments are complex, and ultimately you need to make a determination. If the actuarial methods fail you..you still have to make a decision, no?
 
psych844 said:
Not sure where we are going wrong here. I'm 100% committed to the science, and relying on the assessment tools first and foremost, and understanding their benefits and limitations. BUT, as you guys have stated, assessments are complex, and ultimately you need to make a determination. If the actuarial methods fail you..you still have to make a decision, no?
Click to expand...

Part of the difficulty is that even actuarial/objective methods aren't always black-and-white. We're all influenced by past experiences, and we all need to remain open to potential effects of biases based on these experiences. You've said that prior personal/interpersonal experience with mental illness might make you more apt to pick up on feigned symptoms; I wouldn't outright disagree, but then you could say that in an equal or greater number of cases, it might influence your decision-making toward inaccuracy...particularly if you view the bias as a positive one.
 
psych844 said:
Not sure where we are going wrong here. I'm 100% committed to the science, and relying on the assessment tools first and foremost, and understanding their benefits and limitations. BUT, as you guys have stated, assessments are complex, and ultimately you need to make a determination. If the actuarial methods fail you..you still have to make a decision, no?
Click to expand...
Meehl's work on actuarial assessment would suggest that the use of gut decision making is far from the way to turn and that, for best practice, you should rely on additional measures and expand your interpretive options through more testing/collateral contacts/etc. Assessment is complex and very often it doesn't produce a clean/neat/easy interpretation. Thats why its so important that we see assessment methods and ideas develop. But as I've said, bringing in a bias where you assume your gut is going to be accurate is a problem because, by in large, it isn't.
 
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smalltownpsych said:
What they want and what they do are two different things and how society incentifies that equation makes a difference. I am curious about that hearing though, do you have a link?
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I'm a behaviorist, so I'll partially disagree with that initial statement. I'd argue that verbal behavior and behavior are independently reinforced (e.g., weight loss literature, smoking cessation literature, etc).

As for the IOM report, it was a huge deal. One of the few times psychologists had congressional action. Any psychologist involved in disability stuff should have been informed about this.

http://www.nationalacademies.org/hmd/Reports/2015/PsychTesting.aspx
 
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AcronymAllergy said:
Part of the difficulty is that even actuarial/objective methods aren't always black-and-white. We're all influenced by past experiences, and we all need to remain open to potential effects of biases based on these experiences. You've said that prior personal/interpersonal experience with mental illness might make you more apt to pick up on feigned symptoms; I wouldn't outright disagree, but then you could say that in an equal or greater number of cases, it might influence your decision-making toward inaccuracy...particularly if you view the bias as a positive one.
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Absolutely. There are two problems, related but separate.
1. There are people who constantly use the words "science", or "objective", to suggest competence and neutrality, but have little competence and don't realize or think of their own biases. At least I realize what mine are.
2. There is also a group of people who have a great grasp of the methods, but have little real life experience to truly grasp how something that appears to be anxiety, or depression, could be something completely different, and not a mental illness at all.
 
The TOMM is terrible. You can put 10 PVT's in a battery and the person will fail almost everything, but pass the TOMM. And probably the Rey-15. The TOMM is what people give as a PVT when they want to turn a blind eye to possible data invalidity.
 
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WisNeuro said:
The TOMM is terrible. You can put 10 PVT's in a battery and the person will fail almost everything, but pass the TOMM. And probably the Rey-15. The TOMM is what people give as a PVT when they want to turn a blind eye to possible data invalidity.
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Aren't you saying that it has less sensitivity, but does that mean it has greater specificity? I seem to remember talking to the forensic people at my internship site about that. Regardless, the OP doesn't seem to have come back so wondering if they were not being forthright themselves. Spidey sense activates when someone has the one clinical question about malingering.
 
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smalltownpsych said:
Aren't you saying that it has less sensitivity, but does that mean it has greater specificity? I seem to remember talking to the forensic people at my internship site about that. Regardless, the OP doesn't seem to have come back so wondering if they were not being forthright themselves. Spidey sense activates when someone has the one clinical question about malingering.
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Depends on what your COI is defined as. Bottom line, if someone fails that, they are either pot committed, or you are probably testing an inpatient or SNF patient.
 
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