DSM-5 and Malingering: a Modest Proposal

[erg923]

http://www.springerlink.com/content/45t28j6164vx5ng5/fulltext.pdf

Well written article on a hugely relevant topic, at least in my area of practice. The current DSM definition has been especially problematic in neuropsychological practice. Thoughts on this from the psychiatric community?

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[whopper]

The DSM is not the only source to blame. The entire area has been left vague. Several notables in the field have stated that they do not believe malingering should be put in a patient's chart even if the evidence is overwhelming that the person is malingering. What if the person's malingering is causing harm to him/herself or others? What then?

Very little is taught to psychiatrists on how to confront this issue. Even when it taught, it's not taught well. I know several forensic psychiatrists, even at name brand institutions that do not know how to test for it and only go on clinical judgment that by studies show no better validity than a layman, but they have the balls (or lack of conscience) to go to Court and claim a person is or is not malingering without any real data.

Psychologists IMHO have more training in this area than we do as a whole. Not surprisingly, the article above was written by a psychologist. Rogers, considered an authority and an APsychiatricA award winner is a psychologist. I've seen very few psychiatrists with statistical experience with malingering. Of course there are exceptions. Resnick at Case Western and Mossman at U. of Cincinnati for example are two forensic psychiatrists who do rely on very good scientific standards and are top experts in the field. Every psychologist I've seen in this situation do a number of tests such as the MMPI, SIRS, M-FAST, PAI, etc that actually have validity in detecting malingering. They go to Court, then some smooth operator forensic psychiatrist with a $5000 suit, a hairdo, and some time in a tanning salon testifies without anything other than clinical opinion and just a few hours of seeing the person. Since judges and juries don't have any real knowledge of the math and science behind malingering evaluations, they don't know that the psychiatrist's opinion is no better in this case than a layman, while the psychologist's opinion is probably leaps and bounds more accurate because there were a battery of tests done.

There are several grey areas with malingering. A person may be gaining things other than external benefits.

At the last AAPL, Michael First attended. For those of you who don't know who he is, he is the editor of the DSM. People openly stated to him that they believed the DSM's handling of malingering was too simplistic. He did not give much of a response. Why I don't know.

 

[AcronymAllergy]

Good article. At the very least, the adoption of the possible/probably/definite categories, along with accompanying guidelines at each level (ala Slick et al.'s criteria for malingering on neuropsychological testing), would be a huge improvement on the current DSM's handling of malingering.

 

[erg923]

Yes, the first author is old professor of mine. And yes, I tend to cringe at the purely "clinical judgment" crowd too. That paradigm has been difficult to change in medicine. However, its been difficult to change in psychology too though. I suspect that you guys most often deal with purely psychiatric malingering, where as neuropsychologists often deal with both kinds, malingering (more often gross exaggeration) of neuropsychological deficits and/or psychiatric symptoms. Thus, I wouldn't expect many psychiatrists to know or care about the work of Paul Green, Grant Iverson, Kyle Boone, Rich Rogers, etc, the WMT/MSVT, and all the embedded validity measures within common neuropsych tests. I am, however, shocked at the lack of discussion and training on the topic in general psychiatry. I think objective psychometric measures such as M-FAST, or at least the SIRS, should be standard practice should a physician suspect something. The instruments are inexpensive, have sensitivity and specificity that exceeds the accepted standard for clinical practice. I cannot fathom a reason why you would actually prefer to use a less accurate method in isolation (eg., clinical judgment). Just in the last decade, 5 new symptom validity scales have been developed within the MMPI-2 and the new MMPI-RF. We have come so far that we can now, using regression models, actually predict failure of a cognitive effort test (eg., WMT) based on the 25 item RBS subscale in the MMPI-2-RF. In other words, we have come so far in this area within just the past 10-15 years that I am shocked that the psychiatric profession (e.g., the DSM committee) appears so apathetic about a subsequent revision of the construct. I just dont get it?

I especially celebrate the article's focus on how the current term description denotes only wrong and/or bad things (antisocial personality, legal settings, incoperative with assessments) and ignore the adaptational motivations that often underlie the behavior (military deployment, percieved need to receive immediate psychiatric or medical help, financial desperation). In my mind the worst thing a clinician can do is conclude malingering, write it down in the chart, and not think about or care WHY the patient feels the need to do this. Its a conscious effort after all, right? This is where are therapeutic skills are suppose to be utilized, when patients engage in behavior that we don't fully understand and/or will get them in trouble.

 

[erg923]

AcronymAllergy,

Some have argued, and I have always agreed, that the Slick criteria do more harm than good by implying that malingering is a test based/bound decision, when in fact, it is, or should be, a clinical decision superimposed on objective statistically-normed data. Several authors have had to recently modify Slick's criteria for use with chronic pain patients and included the indicator "compelling inconsitencey"

My personal problem with the construct of "Malingering" as used in the current DSM-IV is that it doesn't allow for any subtle variation in the way people malinger, nor does it allow for degrees of diagnostic certainty in relation to it. This is particularly problematic in the nature of the work I do, as I think psychologists tend to be more willing to "call it as they see it" compared to psychiatrists, but would prefer to do it in degrees of certainty and severity, rather than using an all or nothing term with such pejoritive overtones. Bottom line is that the categorical nature of thing needs to change. Seeing as how no investigator has ever found the contruct to be anything other than continious/demensional, I can not understand how this would be allowed to remain as is in a book that is suppose to be so empirically based.

 

[whopper]

I think objective psychometric measures such as M-FAST, or at least the SIRS, should be standard practice should a physician suspect something. The instruments are inexpensive, have sensitivity and specificity that exceeds the accepted standard for clinical practice. I cannot fathom a reason why you would actually prefer to use a less accurate method in isolation (eg., clinical judgment).

I have theories but all of them point to cutting corners and billing. If, for example, I write malingering on a person's diagnosis, by the time they leave the hospital, the insurance company may not want to pay the bill.

If I got 5 malingers and I bill depression on all of them, that's 5 billing statements. If I write malingering on them, that's no money for the work I put in.

Another problem is existing psychiatrists in teaching curriculum don't know how to do the tests above. Many will not choose to learn something new and show "weakness" to their residents by admitting they don't know how to do something important.

What makes it much more pathetic is forensic psychiatrists, even faculty at name worthy institutions don't know how to administer them. During my interviews, and a few rotations, I asked. Sometimes when I asked, when the people told me they didn't know what I was talking about. I wrote about this awhile ago in another thread, but I asked a forensic psychiatrist testifying in Court and he became irate with me. A psychologist testifying for the other side had a battery of tests. I asked the psychiatrist what objective data he had and he could only say his clinical opinion (which as I mentioned above is no better than a layman in studies). That psychiatrist seemed offended that I even asked the question. This did not surprise me. Medical doctors tend to be a bit narcissistic.

I asked the psychologist about the tests and he was more than happy to give me information on them. The psychiatrist by the way was my official instructor, the psychologist was not. This was not at my fellowship, it occurred during residency. I specifically chose my fellowship because my program director is an expert, despite being a psychiatrist, at psychological testing and in fact even advanced the state of the art in it.

 

[erg923]

And who did the jury believe?

That attitude is not unique to psychiatrists. Athough there is no doubt that psychologists (especially academic neuropsychologists) have been the pioneers in the development of ever more sophisicated symptom validity measures, (eg., MSVT/WMT, Dot Counting, various MMPI response bias scales) up until the mid 90's, most psychologists did not employ any of this in their assessments and simply assumed testing effort to be "valid" based on behavioral observation (ie., clinician judgment). We now know (and have since Meehl's 1954 book) that relying on judgment and/or clinical experience/instuition alone produces an unaccpetablly high rate of false-negatives. It has taken 15 years or so for the majority of my profession to finally come around and see the enormous impact malingering (by "malingering" I am reffering to exaggeration of symptomatology via suboptimal effort on cogntive tests AND deliberate endorsement and fabrication of cognitive and psychological symptoms) has on both our tests' norms and our clinical diagnoses, treatments, and disability system.

Unfortunately, many in our profession (for reasons I do not understand) continue to ignore the data on this topic. A comment on a list-serve I belong to summed it up best when the person described how he often talks to physicians about the base-rate of symptom distortion in the general psych populaton. He noted the response he often recieves is "I do not want to go to work each day thinking X number of my patients are malingering in some way. I'd just prefer not to know that." Sigh...

 

[AcronymAllergy]

AcronymAllergy,

Some have argued, and I have always agreed, that the Slick criteria do more harm than good by implying that malingering is a test based/bound decision, when in fact, it is, or should be, a clinical decision superimposed on objective statistically-normed data. Several authors have had to recently modify Slick's criteria for use with chronic pain patients and included the indicator "compelling inconsitencey"

My personal problem with the construct of "Malingering" as used in the current DSM-IV is that it doesn't allow for any subtle variation in the way people malinger, nor does it allow for degrees of diagnostic certainty in relation to it. This is particularly problematic in the nature of the work I do, as I think psychologists tend to be more willing to "call it as they see it" compared to psychiatrists, but would prefer to do it in degrees of certainty and severity, rather than using an all or nothing term with such pejoritive overtones. Bottom line is that the categorical nature of thing needs to change. Seeing as how no investigator has ever found the contruct to be anything other than continious/demensional, I can not understand how this would be allowed to remain as is in a book that is suppose to be so empirically based.

I personally don't know that I'd say the Slick criteria did more harm than good, as, in my opinion, it was an excellent first (diagnostic) step in paving the way for the idea that effort is something deserving of objective assessment, and that there are gradations in our certainty as to the malingering status of an individual. While the concept of effort testing had of course existed prior to the criteria, it was one of the first attempts to encourage clinicians to formally include data from such testing into their diagnostic decisions.

I will, however, definitely agree that more attention should be paid to the circumstances surrounding the evaluation, as well as to possible explanations for suspected suboptimal effort.

 

[whopper]

And who did the jury believe?

That's the problem. Judges and juries don't know how forensic science works. Get an awkward psychologist with numbers backing that he is more than 95% likely to be accurate who stutters on the stand vs. someone who appears confident and smooth but only has clinical opinion, judges and juries will not know to go with.

And unfortunately the slick forensic psychiatrist can state several comments that although true are misleading. E.g. "Everything I have done meets or exceeds the standard" (yeah well the standard is pretty low), "I am a board certified psychiatrist. If I had such little opinion of my clinical abilities why would I be board-certified" (board certification IMHO is bullspit. Some of the best psychiatrists I've seen aren't, some of the worst are...). You get the point.

 

[AcronymAllergy]

That's the problem. Judges and juries don't know how forensic science works. Get an awkward psychologist with numbers backing that he is more than 95% likely to be accurate who stutters on the stand vs. someone who appears confident and smooth but only has clinical opinion, judges and juries will not know to go with.

And unfortunately the slick forensic psychiatrist can state several comments that although true are misleading. E.g. "Everything I have done meets or exceeds the standard" (yeah well the standard is pretty low), "I am a board certified psychiatrist. If I had such little opinion of my clinical abilities why would I be board-certified" (board certification IMHO is bullspit. Some of the best psychiatrists I've seen aren't, some of the worst are...). You get the point.

This is, unfortunately, seemingly true in more cases than not. Being an expert witness is definitely an acquired skill requiring much practice and "trial by fire." It's just as much about your presentation, eloquence, and ability to appropriately explain your findings to the jury as it is the science backing your testimony.

 

[nitemagi]

Interesting thread. I've been trying to keep up on this literature, and I've picked up on some interesting talks at the AAPL conferences the last couple of years.

A key point I haven't seen here yet is that all presumption (and all rating scales) are based on the presumption of ignorance of real impairment. The more educated someone is on what real illness looks like, the less valid the measures for detecting it.

 

[whopper]

The more educated someone is on what real illness looks like, the less valid the measures for detecting it.

True. In fact my PD told me that some lawyers have had their clients had so many SIRS done on them that they bought one on their own and learned how to beat the test. While he is not certain a specific lawyer that he could point out taught their client how to beat it, he is confident at least some of them have given his experience.

I had someone up for three counts of murder that I believe was malingering. I performed an M-FAST and he scored only a 6. In case you didn't know, that's the lowest possible score someone could score that suggests malingering. The higher the number, the more likely they are malingering. I was surprised because his clinical presentation was "flaming" for malingering based on Resnick's criteria of clinical identification. (BTW that criteria is not an end all be all. It should be supported with psychological testing). I did some investigation and found that he tried to use an NGRI defense in another state, was evaluated by a Court psychologist, and that doctor determined he was not eligible for that defense. That psychologist, I figure, did do an M-FAST but I could not get access to his report.

So I theorized that this guy might be savvy to psychological testing. A SIRS was done and that test very strongly pointed to malingering.

Someone who's taken the SIRS and got a hold of his test results could figure out how the test works.

Those tests also aren't full proof though they do add real objective data. While I mentioned that clinical observation is no better than a laymen, on occasion, it can pick up something that is just so blatantly and obviously malingering (such as the person even telling staff he's malingering) that it will hold in Court.

A doctor, however, saying a person is malingering or not only based on seeing them for a handful of hours and the person is not showing any strong signs either way is for all intents and purposes, a not very useful evaluation.

Ways to get useful information from clinical observation include the following: observing the patient around the clock (24 hours a day for several days. I call it "extended clinical observation") and recording if he doing tasks inconsistent with his diagnosis. E.g. the person claims to be psychotic only around staff. When he is with patients his behavior is stable. The person is doing tasks that require complex cognitive skill such as acquiring cigarettes that are contraband. The person is playing card or board games coherently.

The above examples go way beyond a simple 3-5 hour interview. The person has to be observed for several days by staff. Unfortunately that is not often what happens in many Court evaluations. In many of them the person is only interviewed for a few hours, then the report is produced.

If you understand the math behind the SIRS, if it points to someone as malingering, they are most likely malingering. The author of that test made it so that false positives would be very rare. If it's negative, that does not mean the person is not malingering. At the cost of a very low false positive rate, it has a higher likelihood of a false negative. The author made it this way because he did not want innocent people being fingered as malingering.

All of this information is important because you will occasionally get mixed results based from the tests. When this happens, then the next best thing to use is extended clinical observation.

 

[sunlioness]

I don't remember learning much more about malingering than a definition of it. Though maybe I am not remembering completely. Just read this discussion now since I have some people now I am clinically suspicious of [suspect exaggerated reports of suicidality in order to stay inpatient and avoid certain things on the outside] and did just order some testing. We shall see. Though I still don't know that I know what to do about it even if the testing does support my clinical suspicion. I was reading up a bit on involuntary discharges (what little I could find on the topic) and it seems that doing so is always legally risky. Anyone have any experience with this?

 

[whopper]

I kicked out many a malingerer. I've discharged malingerers who told me they were going to commit a crime the second they were going to be discharged.

Depending on the clinical scenario, you may see malingerers all the time or very rarely. In private practice, I cannot think of any one of my patients who are malingering. All of them either have insurance or pay out of pocket. I can't think of anyone at the moment who would want to pay out of pocket if they were malingering when the only thing I can offer him is an antidepressant for faking depression. I tell my patients upfront they will not get benzos from me unless they're already on them, in which case I will eventually stop it once their anxiety is under control with SSRIs or another non-narcotic method to treat it. I only give out stimulants for ADHD where solid testing was done, and I will try Wellbutrin before a stimulant is used.

Compare that to the ER in a poor urban setting, I've noticed malingering occurred quite often. It was usually someone crashing on cocaine claiming to be suicidal. YEs they were depressed but they just wanted someone to take care of them and they were willing to say "suicide" as a terroristic threat to make sure they got into the hospital.

Other situations are different. Rogers (THE Rogers, the guy who's the #1 authority on malingering) wrote that in a forensic setting, malingering occurs in a significant minority. The percentage is below 50% but not much more. He also mentioned, (and this is from memory so I might be wrong, I'll try to double check) that in non-forensic settings, malingering occurs about 10% of the time.

Detecting malingering and dealing with it is an area that most psychiatrists know nothing about. General psychiatrists as an overwhelming majority I've seen don't know how to deal with it and even if they do, they are likely just cutting their reimbursements (mentioned above).

As a result, most psychiatrists I've seen are ill equiped and without much support from their institutions on dealing with it.

Where I practice, the city is willing to reimburse the hospital for detecting malingerers because they are of the notion that it saves money to society. If someone is caught malingering, the city will still reimburse the hospital when Medicaire or insurance companies will not.

 

[nitemagi]

Where I practice, the city is willing to reimburse the hospital for detecting malingerers because they are of the notion that it saves money to society. If someone is caught malingering, the city will still reimburse the hospital when Medicaire or insurance companies will not.

v65.2

 

[sunlioness]

As a result, most psychiatrists I've seen are ill equiped and without much support from their institutions on dealing with it.
.

I would say that's pretty apt. This is something else that happened to me on Tues when I was the admitting attending. We got a bed search from the Mother Ship Hospital in our network on a patient in their ED. He came to the ED after getting in a fight with his girlfriend who kicked him out of the house. He got drunk and snorted some cocaine and then came to the hospital claiming that he wanted to "take a bridge." When the case was run by me (his UDS was positive for cocaine, his EKG and labs were fine), I tried to either divert him to a crisis center or barring that, a dual dx facility. I was then told by an administrator that I had to accept the patient because there were only two other hospitals who were in network for his insurance and that the other one had turned him down because they were full and we had an obligation to Mother Ship Hospital.

My hands were tied, so I accepted the patient. As soon as he was accepted, the Mother Ship Hospital said, "Oh and by the way, this guy has a long h/o using psych hospitalization when he's homeless." Gee, thanks. Also come to find out that the other sister hospital who refused him because they were "full" was actually sending nurses home that day because their census was so low. (Someone who works on my unit knows someone who works on theirs.)

So yesterday, I get the guy on my service and he states that once he sobered up, he actually didn't feel suicidal or even depressed anymore, but felt he "needed to see the process through." He did not want any meds. He apparently made up with his girlfriend and is welcome to return there now, which is fortunate and we discharged him.

It's all very frustrating. I wish we did have better training, better understanding, and an administration that supported these things too.

 

[whopper]

Problems with diagnosing malingering.

1) According to Resnick during the AAPL review course, accusing someone of malingering could be considered maligning their good name. Malpractice insurance will not cover doctors who harm their patients' reputations. Put the two statements together and you arguably have a situation where a malpractice insurance company will not defend you for putting down the diagnosis should a patient sue because of it.

2) Doctors are supposed to do no harm. A diagnosis of malingering could cause harm. It could hurt the patient's reputation, and bar further services that are needed.

3) The reimbursement problem as I mentioned above.

4) Hardly any psychiatrists are trained in administering the tests known to detect malingering.

Another problem is this is an issue that as a whole, the profession has not been willing to confront this problem. Several doctors complain of malingerers yet there has not been a profession-wide stance on how to deal with the problem and for that reason several of the unanswered questions we have on what we should do are left in this status.

For example, I'm sure we're all in agreement that we shouldn't just let a chronic malingerer continue in his ways but the APA among other organizations will not put down a stance that on what should be the standard in dealing with malingering in clinical situations.

 

[erg923]

2) Doctors are supposed to do no harm. A diagnosis of malingering could cause harm. It could hurt the patient's reputation, and bar further services that are needed.

I would probably argue that telling a person that they have (or confirming and/or legitimizing) a diagnosis or disability that they do not have does quite a bit of harm....especially in the long run. I personally view having a wealth of data (both clinical observation and more objective testing) that supports one conclusion and then erring on the side of the other as quite a strange mindset.

 

[DrGachet]

I would probably argue that telling a person that they have (or confirming and/or legitimizing) a diagnosis or disability that they do not have does quite a bit of harm....especially in the long run. I personally view having a wealth of data (both clinical observation and more objective testing) that supports one conclusion and then erring on the side of the other as quite a strange mindset.

It's a matter of sensitivity/specificity. What are the costs to being wrong? I think they're much greater. I'm not even talking numbers but from a humanistic point of view. But you can calculate costs if you like.

It also depends on how much confidence you have in your intution/data/tests. It makes sense to call it what it is when you're extremely sure. It's common sense.

 

[erg923]

It's a matter of sensitivity/specificity. What are the costs to being wrong? I think they're much greater. I'm not even talking numbers but from a humanistic point of view. But you can calculate costs if you like.

It also depends on how much confidence you have in your intution/data/tests. It makes sense to call it what it is when you're extremely sure. It's common sense.

Of course, and keep in mind I am coming at this from a mostly outpatient secondary gain perspective, not as an ER doc who deals with homeless or substance abusers who use acute psych as a shelter. But when one sees a person who had a mTBI with only brief LOC with a negative imaging who fails a test that mentally ******ed children pass, and raddles off a list of symptoms where you wonder how they can put one foot in front of the other, much less find your office, then i have little patience for docs who wax philosophically bout all the possible "unconscious motivations and drives" that could be occurring in order legitimize or explain away their poor cognitive performance/symptoms.

I think our training and expertise is put to waste when we refuse to make these decisions. Touch decision are part of the job.

 

[IT514]

Of course, and keep in mind I am coming at this from a mostly outpatient secondary gain perspective, not as an ER doc who deals with homeless or substance abusers who use acute psych as a shelter. But when one sees a person who had a mTBI with only brief LOC with a negative imaging who fails a test that mentally ******ed children pass, and raddles off a list of symptoms where you wonder how they can put one foot in front of the other, much less find your office, then i have little patience for docs who wax philosophically bout all the possible "unconscious motivations and drives" that could be occurring in order legitimize or explain away their poor cognitive performance/symptoms.

Amen.

Afterall, what incentive do these patients have to make positive changes to their behavior if we keep reinforcing their FOSness??

 

[whopper]

I would probably argue that telling a person that they have (or confirming and/or legitimizing) a diagnosis or disability that they do not have does quite a bit of harm....especially in the long run.

I agree, very much so.

The problem, however, is you and I could agree, but there is no consensus printed in a highly respected source telling us what to do.

 

[PsyDGrrrl]

Problems with diagnosing malingering.

1) According to Resnick during the AAPL review course

Were you at the review course this year? I was there.

 

[whopper]

Nope. I was at the 2009 AAPL. I did not accumulate enough vacation days to go and I need them to attend the American Academy of Forensic Sciences convention in Chicago on February 2011. I'll be presenting at a lunch lecture, the topic: psychological autopsies including recent cases that may affect it's acceptability within the Daubert standard.

I would've loved to attend. My PD invites all the alumnae and professors in my program to a dinner.