NPsych - Malingering

[WisNeuro]

For the neuro people out there (and maybe for a few who aren't), how do you handle malingering in your reports/notes? Just curious. I tend to be a hardliner and pretty blunt about it, but wondering how it's handled by others.

---

Members don't see this ad.

 

[Therapist4Chnge]

It depends if it is a Clinical v. Forensic evaluation. In a clinical eval I talk about possible contributory factors to poor effort and provide recommendations to address any areas of concern from a treatment perspective. In a forensic eval I'm much more explicit bc it is a different relationship/purpose/etc.

 

[BuckeyeLove]

If I've got multiple data points suggesting feigning (i.e., qualitatively outlandish symptom reporting, TOMM score in which binomially there's a 99.9 % chance they'd score better just guessing, M-FAST score with PPP of 100%) I'm not going to equivocate. Even if they have a history of SMI but are also overtly feigning I tend to be pretty blunt. With less pronounced elevations on measures I might be a little less likely to throw the label out there. I do get concerned about how the label seems to follow folks around though. Some of my colleagues seem to treat it as a scarlet letter of sorts if a patient/defendant has been labeled with it before, even when the potential for legitimate psychopathology could also be present.

 

[WisNeuro]

It depends if it is a Clinical v. Forensic evaluation. In a clinical eval I talk about possible contributory factors to poor effort and provide recommendations to address any areas of concern from a treatment perspective. In a forensic eval I'm much more explicit bc it is a different relationship/purpose/etc.

I can see that distinction, but what if your clinical context exists with a forensic underlying current (i.e., VA)?

 

[AcronymAllergy]

It's tough, and I probably don't take as hard line a stance on it as might be common, at least in terms of overtly mentioning the term in my reports. When my evals are in a clinical context, I'll of course state if the data indicates that the patient was providing (willfully) suboptimal effort, and like T4C, will also mention factors that could be contributing as well as associated recommendations. Relatedly, when possible, I'll try to indicate what "typical" course/prognosis would be like given the person's history, injury/illness characteristics, etc.

I would likely be a bit more frank in a phone call to the referring provider, particularly if they were interested in that aspect of the evaluation specifically. Like BuckeyeLove mentioned, there's a tendency for that term in particular (along with "somatization") to follow folks around for a long time, and potentially negatively color future clinicians' views/interactions, when mentioned in a chart.

 

[cara susanna]

I'm especially curious about how people handle this in the VA system, given that patients may have access to their records through MyHealthEVet.

 

[Therapist4Chnge]

I can see that distinction, but what if your clinical context exists with a forensic underlying current (i.e., VA)?

That's the trickiest combo. I actually have a case like this now. Clinical eval, though I suspect there will be a new/added Dx pursued.

 

[smalltownpsych]

For myself, I tend to just report the results and what they are indicative of relative to the normative sample and the references available for that measure. If there are potential secondary gains for malingering, I also point that out. Ultimately, I don't see myself as the ultimate arbiter of fact, that is for others to determine, especially in a forensic setting. Even in a a clinical setting, I comment on the results and the potential causes for those results. The referring provider, along with the patient can determine which is the "real" reason.

 

[Pragma]

As others have mentioned, depends on the context and the nature of the data. I generally discuss various explanations for suboptimal effort, including secondary gain.

 

[WisNeuro]

I'm especially curious about how people handle this in the VA system, given that patients may have access to their records through MyHealthEVet.

If it's really bad (i.e., below statistical chance) I am blunt about it. It is in the report as such, and this isn't a surprise to the patient, because I have told them as much in the feedback. I still have a job, so it's gone well so far. Other times, failure, but still above chance levels, I have to comment that there is questionable effort and that the results are likely an underestimate of true function. Then you have to go on chart data and known data. Such as a mild concussion without LOC will not cause catatsrophic memory loss. Or that their severe impairment on testing is not consistent with their presentation (e.g., working full-time, having driven to the appointment from 1+hour away).

 

[PsyDr]

I just outline my justifications.

For forensic: I just call it. I tend to use the term "bull****" to attorneys on the phone. If I am defense, I might go harder. If I am plaintiff or criminal defense, I tell them that there might be something wrong with their client, but there is no way for me to tell because they are lying.

For clinical: I say that based upon the current information at hand, they have factitious disorder. This diagnosis will be considered until new variables including secondary gain become apparent, which would indicate that the individual is malingering and purposely using health insurance for forensic purposes (i.e., insurance fraud).

For VA stuff: I just point out that inconsistencies and say I cannot opine about the claimed condition without resorting to speculation. Based upon the dose response literature, the reported injury is unlikely to cause any persisting cognitive difficulties. They say X, but their reported social behavior says otherwise. Validity tests were failed, which is consistent with the difference between the vet's stated daily functioning and cognitive scores that are literally lower than someone who had a hemispherectomy who requires full time nursing care.

 

[Justanothergrad]

Am I the only one who thinks that so many of the validity tests included in multi-axil systems (PAI,MMPI,etc) are completely worthless? Without additional tests examining effortful responding, I'm always nervous and never confident about my ability to conclude intentional response bias.

Just take a look at the pearson correlations between validity tests and some of the clinical scales on common measures of pathology. Within the VA, I don't see a lot of collaborative data to support that label, and its a dangerous one. I think we have come to rely on integrated assessment systems with these validity indicators built in because of their ability to differentiate groups, but I just can't help but get nervous when I see .8 correlations between a validity index and a clinical scale (e.g., Caldwell, 2006) on a major instrument.

 

[WisNeuro]

Really depends on the extent of the performance on those validity measures and where you set your cutoffs. Like an RBS that is 5+ SD's from the mean? that's meaningful. I tend to rely more on PVT's rather than SVT's though.

 

[Justanothergrad]

Really depends on the extent of the performance on those validity measures and where you set your cutoffs. Like an RBS that is 5+ SD's from the mean? that's meaningful. I tend to rely more on PVT's rather than SVT's though.

Agreed, those 5+ SD cases can be pretty hard to argue as within any type of normative level of effort. Those folks tend to have a number of behavioral tickers that make me squint at them funny anyway though.

It has just seemed to me that we try very hard to make hardline decisions possible and simple to deduce (e.g., the cut-off of 120 for Fp/Fp-r suggests invalidity) whereas I'm not entirely convinced its that easy to decide. Aside from issues of standard error of measurement, it the culture of validity scale responses can be largely problematic. I believe it was Arbisi et al (1994) who noted the need for Fp because of the ~60% invalidity rate of MMPI-2's within the VA system. That said, I think that is a culture we have in psych of trying to prove ourselves as a science (for lack of a better way to say it) far faster using greater interpretive stretches from research findings than we should be ready to do given the often only fledgling evidence based support. But thats not here or there.

I would make some argument, particularly in cases where the individual presents with issues of higher anxiety/perseverative thinking, that there should be an expected increase in validity markers- perhaps to the point of profile invalidity dependent upon symptom severity. This brings me again to my (recently formulated) belief that group discrimination is good as a marker, but that it falls victim to the same problem inherent to drug trials. Namely, comorbidity causes a great deal of complication that we are not yet able to deal with as effectively as we would like. I don't have anything firm to support this other than a few good rambling sessions with buddies after work, but as a thought experiment it seems a potential problem that makes theoretical sense.

 

[WisNeuro]

Well, I would also caution against looking at these things as a dichotomous variable, as many do.

 

[psych844]

These kind of threads are so discouraging lol

 

[Justanothergrad]

Well, I would also caution against looking at these things as a dichotomous variable, as many do.

Agreed. But that's the nature of forensic evaluations and that is the answer a lawyer wants- "Are they or are they not malingering".

These kind of threads are so discouraging lol

Think of them as encouraging for establishing needed areas of research Assessment is the history of psychology. I'm a firm believer that it would do well if we returned to a greater focus on it. There is lots to be done.

 

[WisNeuro]

^^Meh, it's part of the deal no matter what branch of healthcare you work in.

 

[WisNeuro]

Agreed. But that's the nature of forensic evaluations and that is the answer a lawyer wants- "Are they or are they not malingering".

Actually, in forensics, it's really more of the "is this data valid?" rather than are they malingering. I think it's an easier beast to tackle when it comes to the cognitive side rather than the psychopathology side, though.

 

[Justanothergrad]

Actually, in forensics, it's really more of the "is this data valid?" rather than are they malingering. I think it's an easier beast to tackle when it comes to the cognitive side rather than the psychopathology side, though.

Yeh, I tend to agree that the cognitive stuff is a bit easier as well. I see those two questions as being pretty equal if the evaluation goes to court because one will often lead to the other in terms of what the lawyer will tend to ask (based on the two times I've had to sit on a stand- not a fun experience). In terms of writing the reports, absolutely its an argument made towards validity of the data.

 

[BuckeyeLove]

"Are they or are they not malingering".

Was asked exactly this while testifying this yesterday, but by a judge instead, and with a few more exclamation points.

Coincidentally, I evaluated a defendant this morning that appeared to attempt to feign disorganized psychotic symptomatology [not usually a go-to for folks feigning psychopathology]. Given the substantial nature of the symptom presentation of psychotic disorganization, it is something that in my opinion is incredibly difficult to feign, or at least keep up over time consistently [and as hypothesized, he become increasingly more coherent and cogent as the eval proceeded]. However, due to his “presentation” he was unable, or chose not to, partake meaningfully in any formal assessment of symptom validity. In this case, I have enough corroboratives to show that in the past he’s presented as completely cogent and linear (including jail staff observations of him on the ride over), and I feel comfortable based on a preponderance of evidence burden stating that he was more likely than not, malingering. I’ve seen plenty of evaluators diagnose malingering without the use of formal measures (heck the forensic psychiatrists simply provide clinical judgment when opining on the same psycholegal issues) but I’m wondering what your all’s thoughts are on assigning a malingering diagnosis without something quantitative to back it up, when you still have qualitatively /observationally significant data. I’m also curious as to whether any of you have encountered people attempting to feign this type of psychotic presentation in the past. Needless to say it was a fun eval.

 

[WisNeuro]

. Given the substantial nature of the symptom presentation of psychotic disorganization, it is something that in my opinion is incredibly difficult to feign, or at least keep up over time consistently [and as hypothesized, he become increasingly more coherent and cogent as the eval proceeded]. However, due to his “presentation” he was unable, or chose not to, partake meaningfully in any formal assessment of symptom validity. .

Look up the case of Vincent Gigante, dude tricked multiple high profile psychiatrists into saying that he was not competent to stand trial. Apparently all you have to do is wander around in your bathrobe for an extended period of time. During which, you are still masterminding a mafia crime organization.

 

[smalltownpsych]

Was asked exactly this while testifying this yesterday, but by a judge instead, and with a few more exclamation points.

Coincidentally, I evaluated a defendant this morning that appeared to attempt to feign disorganized psychotic symptomatology [not usually a go-to for folks feigning psychopathology]. Given the substantial nature of the symptom presentation of psychotic disorganization, it is something that in my opinion is incredibly difficult to feign, or at least keep up over time consistently [and as hypothesized, he become increasingly more coherent and cogent as the eval proceeded]. However, due to his “presentation” he was unable, or chose not to, partake meaningfully in any formal assessment of symptom validity. In this case, I have enough corroboratives to show that in the past he’s presented as completely cogent and linear (including jail staff observations of him on the ride over), and I feel comfortable based on a preponderance of evidence burden stating that he was more likely than not, malingering. I’ve seen plenty of evaluators diagnose malingering without the use of formal measures (heck the forensic psychiatrists simply provide clinical judgment when opining on the same psycholegal issues) but I’m wondering what your all’s thoughts are on assigning a malingering diagnosis without something quantitative to back it up, when you still have qualitatively /observationally significant data. I’m also curious as to whether any of you have encountered people attempting to feign this type of psychotic presentation in the past. Needless to say it was a fun eval.

Rule number one, don't tick off the judge!