How often do you diagnose Malingring!

[ronin12]

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how often you label someone a malingerer ?
What is your comfort level or reservations with this diagnoses ?

 

[PsyDGrrrl]

Fairly often.

(I work in a forensic hospital with Incompetent to Stand Trial patients.)

 

[erg923]

see below

 

[erg923]

Slick, D.J., Sherman, E.M.S., & Iverson G.L. (1999). Diagnostic criteria for malingering neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist 13, 545-561.

I realize this is a little bit of a different population than those who are attempting to feign pure psych phenomena, however, many of the criteria still apply. With those claiming cognitive or neurologic problems, (and I guess in psych too) you quickly realize the complexity of the issue because there are so many shades of gray and alternate scenarios that can account for unusual presentations (i.e. exaggeration of symptoms that really are present in combination with faking a few all togerther, extreme somatization, conversion DO, factitious, DO, etc). To rule all these diagnoses out, you have to establish that the act is "intentional" and that it is within the person's awareness. The word "intentional" is the tricky part here, in my opinion. Not genuine, but out of the person's awareness? I certainly think that's possible in certain cases. I'll never really know for sure which ones, so that's why I don't use the term itself in most circumstances, unless its blantanly, and I mean blantanly, obvious. I have concluded it personally many times, but have described in a report as "malingering" rarely. There are better phases that convey the notion that the presentation is unlikely to be genuine, but without conveying the impression that everything they report is neccesarily 100 percent feigned. I think neurologists often use the term "functional" to describe an abnormal neurologic exam that is deemed unlikely to have any true neurological/organic basis. The term "malingering" has such finality to it, and carries such a negative connotation, that it can lead to other providers in the future (psych or otherwise) to have a negative bias before even hearing the patient's complaints. I generally like to avoid that potential if I can. Even in a pure psychiatric case, I would not recommend relying on abnormal/unusual symptom presentation and clinical judgment alone. I would hate to be on the stand with just that. I would highly recommend using at least some psychometric data such as the SIMS, SIRS, M-FAST, the MMPI's F(p) scale, or something similar so you can have statistical/normative base rate comparisons to justify your clinical impression.

For a good overview of the ethics involved here I would also recommend:
Iverson,G (2006). Ethical issues associated with the assessment of exaggeration, poor effort, and malingering. Applied Neuropsychology, 13(2) 77-90.

.

 

[Tradewind]

It's an honor. Only a couple times a year or so.

 

[whopper]

This is a paritcular area that actually inspired me to go into forensic psychiatry...because IMHO there were too many chicken s____ doctors who were not willing to diagnose this disorder.

During residency, I had at least 1 patient a week who met the criteria for malingering to the point where it should've been diagnosed. Then when admitted to the inpatient unit would do something such as grab a nurse's butt or on that order while showing no symptoms of an Axis I disorder, or fake symptoms in such an easily detectable manner, but were diagnosed with Psychosis, Mood DO NOS, Impulse Control DO NOS which even the diagnosing doctor didn't even agree with.

I do believe that people need to be given the benefit of the doubt, but some of these patients were known to the system to do this for years. No one was willing to put their foot down. They were given the diagnosis label, and then it created the usual revolving door system. The malingerer would end up back in the Psyche emergency center, and the crisis staff & doctor, who only have a few hours tops to evaluate a patient are dealing with a situation where the inpatient doctor had labeled them with a bona-fide Axis I, making it more difficult for that team to discharge the patient. Then in inpatient, the patient needs an Axis I to get medicaire billing, which often times an attending would do for biling, and not even agree with the diagnosis.

The cost to the system probably ran over 6 figures a year on some of these chronic "professional" patients.

Not addressing malingering can also be counter-therapeutic to the patient's real problem. E.g. if a patient is a homeless alcoholic, and gets a false Depressive DO NOS diagnosis, it could reinforce that patient's desire to continue to drink knowing that he can just go to the hospital, claim he's suicidal, and now he gets a free 5 day stay with 3 hots & a cot.

Putting down a Malingering Diagnosis however does have its fair share of problems. If you are willing to put that diagnosis, you do run the risk of a patient upping the ante, and then actually doing something harmful just to give them ammo to sue or upset you. There's not a good amount of data supporting what to do with these types because people are too scared to do controlled studies on this diagnosis, and very few want to address this issue because any printed recommendations may turn out to be wrong, and this area is highly controversial and inviting a lawsuit. Our lack of understanding, & the litigious system are preventing us from making attempts to better understand it.

 

[Tradewind]

I am chicken s____!

One thing to consider when giving the diagnosis of malingering is, do the medications you recommend for the patient fit the psychiatric diagnoses?

If a patient is only malingering and nothing else, having the patient on psychotropics is a bad idea. Clinically and legally.

But I suppose patients can malinger and have say, depression NOS, in which case an SSRI would be appropriate. But once malingerers start getting a slew of medications for unclear reasons, that's going down a slippery slope.

 

[Therapist4Chnge]

From what I've seen/read, it obviously will vary on your population. The forensic population seems to have a much higher incidence, though also be careful because it is also an under-diagnosed population (outside of the ASP / Borderline / Substance Abuse Dxs).

I don't feel comfortable officially dx'ing malingering without at least a few assessment measures (some mentioned above and some others depending on the case), as it can greatly influence future treatment.

 

[whopper]

If a patient is only malingering and nothing else, having the patient on psychotropics is a bad idea. Clinically and legally.

Agree-which added to my own frustration.

And as bad as it was, this is a situation I've seen happen in several places. My own comment of what happened where I did residency wasn't specific to that place. I've seen or heard this happen in almost every psyche emergency center & short term unit I've heard of where I talked to the attendings & staff on what happens there or worked at myself. A former teacher of mine had a list of all the places he worked at and mentioned it happened at all places he's been which included some prominent Ivy Leagues among several other hospitals.

If a patient is discharged without medications, it adds more problems in terms of managed care billing and possibly even future investigations into the case. E.g. if a patient came to a psyche ER and was labelled as "suicidal", and no medication was given, there needs to be some good documentation. The path of least resistance is to start an SSRI, which the attendings often times knew full well would not be continued. The doctor could always argue that the person had one of the "NOS" disorders, which prompted a nurse manager to nickname them "FOS" (Full of S___, e.g. Depressive Disorder Full of Shi_).

Add to the problem, ER doctors often times at least where I worked wrote down "suicidal" when the patient full well wasn't because it allowed them to dump to psychiatry. If the patient denied they were suicidal, the ER doctor kept planting it in their head with questions like "are you sure? Are you absolutely sure? How can one truly ever know? Common, we just want to make certain so we make sure you get the best treatment."

Getting a patient for the first time, and hearing them claim they are suicidal--that IMHO gives the patient enough benefit of the doubt. However when the patient's been seen several times (several admissions), has been doing this for quite a long time, never showed any objective DSM criteria for a mood, anxiety or psychotic disorder, and a definite pattern & motive of malingering has been identified--I think action needed to be taken. Unfortunately I rarely saw action taken.

And in the defense of doctors who do this, there really is no established standard on this because of the lack of data & research to confront this difficult issue. Several books have actually reccommended to not use confrontation. So what is a doctor supposed to do in that situation? Some would even interpret the Hippocratic Oath to give these people unlimited patience & continued benefits of the doubts no matter how long they continue to malinger--since confrontation can lead to harm. There are also several standards where doctors are not supposed to call the authorities for people are trying to fraud the system, nor does law enforcement actually do anything in several cases. I've had several people use terroristic threats to get into inpatient, and the police wouldn't touch them. They'd respond "they're crazy, that's your department". They even at times dropped off people to the emergency center who were arrested for a crime (but in my opinion had no mental illness) and reported to a judge the person was mentally ill and the judge ordered the person brought to the hospital--even though I--the doctor did not agree with the police officer's assessment, and my own assessment was not given to the judge who made the decision.

Then the person who was arrested--who claimed to be suicidal would see the police leave, and they'd have a big smile on their face knowing they didn't have to go to jail, and possibly might be acquitted of their crime or given a big reduction in sentence.

The one place where I've been given a very stable & structured setting to diagnose malingering is in a forensic setting because the court in this specific case brought people to the forensic unit specifically to find out what's going on. I also got the time & resources to do a battery of tests to detect malingering such as 24 hr observation, psychometric testing etc. If the person is found to be malingering--they're going to a safe environment--prison or jail, where if the person doesn't drop their suicidal threat, they're put in a Ferguson smock & given disciplinary burgers.

However these methods aren't available in nonforensic settings. Nonforensic psychiatrists are trapped in the situation I mentioned above, and hospitals and manged care usually will not allow a psychiatrist to do the psychometric testing to determine if someone is malingering.

 

[ronin12]

In VA system Malingering is probably one of the common presentations for potential gains i.e SC disability claims. But i noticed during my training even attendings were hesitant of labeling someone a malinger because of potential negative consequences for patient and for provider(pt backlash). this hesitancy results in abuse of system especially in VA hospitals.
I guess Neuropsych testings can be valuable , as some of them have lie or inconsistancy scales.

 

[Therapist4Chnge]

In VA system Malingering is probably one of the common presentations for potential gains i.e SC disability claims. But i noticed during my training even attendings were hesitant of labeling someone a malinger because of potential negative consequences for patient and for provider(pt backlash). this hesitancy results in abuse of system especially in VA hospitals.

I guess Neuropsych testings can be valuable , as some of them have lie or inconsistancy scales.

This is exactly what I was talking about above. I'll be finishing my training at a VA (doing mostly neuropsych/rehab evals), so I think I'm going to run into this a lot.

 

[erg923]

I also am finishing up a prac year at the Palo Alto VA and I can say that we do not hesitate to assess effort through use of multiple SVTs during our polytrauma clinic evals.

 

[erg923]

I guess Neuropsych testings can be valuable , as some of them have lie or inconsistancy scales.

You guess correctly. 🙂 However, its personality measures that usually utilize true consistency and lie scales (VRIN and TRIN and the F family scales on the MMPI), npsych utilizes a slightly different approach. There are some psychometric instruments (not neuropsych) that utilize norms sets from both normals and forensic populations that can readilly be used by psychiatrists or other mental heallth professsionals who are not formally trained in psychometric theory or assessment. I think the best normed one to my knowledge is the Structured Inventory for Malingered Symptoms (SIMS) which was developed by Rogers and his group at North Texas. This is helpful and should be used as convergent evidence of malingering. It should never be the sole basis of evidence. In the SIMS cross-validation sample, sensitivity was .96 and specificity was .88. And just to clarify, I have no financial investiment in this instrument, it is just a really good screnner in my opionion. Also, the Miller-Forensic Assessment of Symptoms Test (M-FAST) is used frequently in legal/forensic settings. The two aforementioned instruments can be readily be administered by psychiatrists because they use cut-scores and little interpretation goes into the actual score itself (i.e., it's in the normal range or its not). This is in contrast to formal Npsych testing where interpretation is actually quite complex and requires formal training in psychometric theory and integrated assessment of both cognition and personality, because there are simply so many potential explanations for a test score being in the "impaired" range (i.e., anxiety, distractions in the environment, psycyh related interferences such as depression, existing premorbid problems that are below expectation but not necessarily abnormal, poor norming of the test itself, whether the norms are even appropriate for the given client, and only lastly, true organic brain dysfunction).

Npsych assessment tends to use a multimethod approach in its assessment for exaggeration of cognitive performance. One method simply utilizes base rates and uses statistics (TOMM), others involves looking for implausible patterns of performance when compared to the known or reported injury or disease (reliable digit span performance, extreme number of set-loss errors on the Wisconsin Card sort). And of course, there is good old fashion discrepancies between behavior and test performance. If you bomb the CVLT but can tell me the results of last week's events in great detail something is fishy. Or when a person tells me they are still having severe memory problems 1 year post being hit in the head with their son's nerf football…..hmmm......🙄

PS: T4change: You are in a great program for these issues, as I used to have a supervior who was a studernt of Wily Mittenberg. I know he is probably not yoiur clinical supervior there, but he is a great resource for assessing for malingering, poor effort, etc.

 

[Therapist4Chnge]

PS: T4change: You are in a great program for these issues, as I used to have a supervior who was a studernt of Wily Mittenberg. I know he is probably not yoiur clinical supervior there, but he is a great resource for assessing for malingering, poor effort, etc.

I only know Dr. Mittenberg in passing, but I've heard great things from other students. Most of my assessment training came under Dr. Charles Golden and Dr. David Shapiro, who are both experts in their respective areas. It will be interesting to see what kind of assessments I have access to at my VA....as I think malingering r/o will be a pretty common refferal.

I like the TOMMS, SIRS, a personality assessment, and hopefully at least one more specific assessment (depending on the refferal).

 

[erg923]

I have always tended to work with people who are big fans of Paul Green's tests, the Word Memory Test (WMT) and Medical Symptom Validity Test (MSVT). They have the added benefit of having large samples of criterion groups (dementia, depression, fibromyalgia, etc) so you can do profile comparisons and reduce the potential for false postive you can get with things like TOMM that simply use cut-scores.

For purely psych issues, I also like the SIMS, although we generally will do a SIRS first. The literature using analogue malingerers is quite clear that MMPI F(p) is not significanlty more lowewr in coached malingerers vs malingerers who were not coached . Hence, F(p) it still a powerful discriminator even among those who may actively study how to feign a condition.

 

[nancysinatra]

Is there any treatment for malingering? Is it really a diagnosis, or just a description? Do patients ever admit to it on their own or ask for help? If that ever happened, would they be able to find a sympathetic psychotherapist?

Do people on the higher socioeconomic end ever get diagnosed with this, or is it mainly inpatient VA or forensic patients? What about outpatients? Does anyone know how often it is diagnosed outside of psychiatry?

 

[ronin12]

You guess correctly. 🙂 However, its personality measures that usually utilize true consistency and lie scales (VRIN and TRIN and the F family scales on the MMPI), npsych utilizes a slightly different approach. There are some psychometric instruments (not neuropsych) that utilize norms sets from both normals and forensic populations that can readilly be used by psychiatrists or other mental heallth professsionals who are not formally trained in psychometric theory or assessment. I think the best normed one to my knowledge is the Structured Inventory for Malingered Symptoms (SIMS) which was developed by Rogers and his group at North Texas. This is helpful and should be used as convergent evidence of malingering. It should never be the sole basis of evidence. In the SIMS cross-validation sample, sensitivity was .96 and specificity was .88. And just to clarify, I have no financial investiment in this instrument, it is just a really good screnner in my opionion. Also, the Miller-Forensic Assessment of Symptoms Test (M-FAST) is used frequently in legal/forensic settings. The two aforementioned instruments can be readily be administered by psychiatrists because they use cut-scores and little interpretation goes into the actual score itself (i.e., it’s in the normal range or its not). This is in contrast to formal Npsych testing where interpretation is actually quite complex and requires formal training in psychometric theory and integrated assessment of both cognition and personality, because there are simply so many potential explanations for a test score being in the "impaired" range (i.e., anxiety, distractions in the environment, psycyh related interferences such as depression, existing premorbid problems that are below expectation but not necessarily abnormal, poor norming of the test itself, whether the norms are even appropriate for the given client, and only lastly, true organic brain dysfunction).

Npsych assessment tends to use a multimethod approach in its assessment for exaggeration of cognitive performance. One method simply utilizes base rates and uses statistics (TOMM), others involves looking for implausible patterns of performance when compared to the known or reported injury or disease (reliable digit span performance, extreme number of set-loss errors on the Wisconsin Card sort). And of course, there is good old fashion discrepancies between behavior and test performance. If you bomb the CVLT but can tell me the results of last week’s events in great detail something is fishy. Or when a person tells me they are still having severe memory problems 1 year post being hit in the head with their son’s nerf football…..hmmm......🙄

PS: T4change: You are in a great program for these issues, as I used to have a supervior who was a studernt of Wily Mittenberg. I know he is probably not yoiur clinical supervior there, but he is a great resource for assessing for malingering, poor effort, etc.

thanks for detailed information.
are any of these tests are available for free or are they copyright material ?. if free how can we access them
I never witnessed of any va providers using these instruments to determine SC disability.which is greatly abused system.

 

[erg923]

Because most tests were developed with their own specific norm sets, it cost signficant money to develop them. Therefore, they do have to be purchased. So, yes they are copyrighted and not in public domain.

As, Im sure you know, the VA has been faulted for many things since the troops started coming back from OEF/OIR, including underdiagnosis (and overdiagnosis in some cases) of PTSD, massive wait times and red tape for geting proper compensation, and for being woefully underprepared for the triage of mental health services to the vast number of veterans. I am surprised, however, that both you and Whooper mentioned a seeming lack of axcess to formalized evaluations of malingering at your facility. This is a something many psychologists specialize in. However, there is no reason why psychiatrists can't utilize some of these instruments I mentioned for more careful assessments.

I think the inpatient "frequent flyers" are a little bit a different issue here, as there may be ligitamate mental health/substance abuse issues, but they have developed a type of learned helpless toward the system (ie., they abuse it, use it for shelter, or till they get there SSD check). I worked as a psych tech in undergrad and saw this countless times. im sure you have too.

 

[erg923]

Is there any treatment for malingering? Is it really a diagnosis, or just a description? Do patients ever admit to it on their own or ask for help? If that ever happened, would they be able to find a sympathetic psychotherapist?

Do people on the higher socioeconomic end ever get diagnosed with this, or is it mainly inpatient VA or forensic patients? What about outpatients? Does anyone know how often it is diagnosed outside of psychiatry?

Its a behavioral description. A label.

Yes, people have admitted to me (and my supervisors) that they were told to "play up" their memory problems by lawyers for bogus lawsuites. Only after being confonted with the fact that the eval was invalid because due to apparent poor effort on cognitive meaures, and/or their MMPI profile suggeted exagerattion. We have a pretty good idea how long the cognitive sequela from mTBI lasts, so when someone comes in complaining of memory problems after they got hit in the head with a marshmellow 6 months ago, red flags start going up. . Willy Mittenberg and Glen Larabbe have done some work on prevalance rates in forensic evals and well as outpatient clinical neuropsychology practice. I do not know the numbers off hand, but they were startling high.

I think the inpatient "frequent flyer" who says he's suicidal so he can get a meal and some shelter is a different animal. After some time it becomes quite obvious that they are using and abusing eveything the healthcare system can offer. In these cases,Ii think malingering is quite obvious. What I have been talking about is the really difficult cases, primarily outpatients, who are seeking large compensations or to get out of legal trouble (ie., workers comp, malpractice tort), or competecy evals.

 

[nancysinatra]

Its a behavioral description. A label.

Yes, people have admitted to me (and my supervisors) that they were told to "play up" their memory problems by lawyers for bogus lawsuites. Only after being confonted with the fact that the eval was invalid because due to apparent poor effort on cognitive meaures, and/or their MMPI profile suggeted exagerattion. We have a pretty good idea how long the cognitive sequela from mTBI lasts, so when someone comes in complaining of memory problems after they got hit in the head with a marshmellow 6 months ago, red flags start going up. . Willy Mittenberg and Glen Larabbe have done some work on prevalance rates in forensic evals and well as outpatient clinical neuropsychology practice. I do not know the numbers off hand, but they were startling high.

I think the inpatient "frequent flyer" who says he's suicidal so he can get a meal and some shelter is a different animal. After some time it becomes quite obvious that they are using and abusing eveything the healthcare system can offer. In these cases,Ii think malingering is quite obvious. What I have been talking about is the really difficult cases, primarily outpatients, who are seeking large compensations or to get out of legal trouble (ie., workers comp, malpractice tort), or competecy evals.

Malingering is the intentional fabricating of illness for the purpose of achieving secondary gain, is it not? Does it matter how much contact the ''patient" has with the health care system? Not that long ago "Time Out New York" had a blurb on the art of calling in sick to work. I would think malingering is probably rampant in the world, but only "diagnosed" in its most extreme form, such as when disability benefits are at issue.

So outside of a court of law, how much weight does a doctor's "diagnosis" of this "label" carry? Won't the parties who need to know already have figured it out? For example, bosses and coworkers have been on to this forever.

I used to have a coworker in a lab who faked the death of his roommate's mother's best friend. He then disappeared from work for a week, saying that this "death" was so traumatizing to him that he just could not be there for that whole week. We never learned if anyone had died or not.

(I know this has nothing to do with the tests you guys are talking about, although maybe someone could invent a mini psychological test that can be used by bosses at work to see who's telling the truth, similar to those defibrillators that are found in shopping malls and can be used by lay people...)

 

[whopper]

Won't the parties who need to know already have figured it out? For example, bosses and coworkers have been on to this forever.

Here's the problem.

If someone is malingering, and a doctor wrote in a note that they are suffering from a medical disorder, this pretty much give the patient a free pass. Bosses can't override a liscenced medical doctor, and doing so brings upon a lot of problems for that boss.

However while a note from a doctor sounds reasonable, the reality of the situation is the doctors that are willing to write a note that does not meet standard of care assessments are out there more than most students think.

I don't have any studies backing this up, but let me tell you of a situation--that was in NYC of all places. My wife used to work in the occupational health office at a prominent research institution, which was the place where employees went to get time off, workmen's comp, file for disability. Most of the cases there were bogus. E.g. a lab rat bit someone, and they wanted 2 months off from work. I've been bitten by lab rats several times and went back to work in 10 minutes. I just washed the bite, put a band-aid on & viola. These people wanting 2 months off almost all the time got a doctor to write a note to justify it. They were actually witnessed by others working at others places while on that 2 month off period.

What goes on is there's a handful of doctors willing to sign pretty much anything because it gets the patient out of their office sooner. Then when employees find out they've found their dream doctor-they tell all their friends about him, and the network starts. Pretty much all the employees that filled out bogus requests for time off & workman's comp at my wife's place of employment all had the same few doctors doing it. It in some ways actually financially benefits that doctor since that doctor is getting more patients who are quick easy in & outs---kinda like the doctors that give out as much xanax & percocet a patient wants.

The countermeasures to keep these doctors in check aren't very open. Given the nature of medicine, and that there is limited access to the individual patient's notes if at all--you can't prove beyond a reasonable doubt that the doctor is acting in bad faith in the individual case--though the numbers at occupational health clearly indicate there is some wrong doing on group level (hard to prove on an individual level). Reporting doctors to the state board rarely creates a response, and when it does, its often only on the most extreme of levels (e.g. a doctor jumping on a patient's belly to cause an abortion).

While it sounds terrible that a doctor would do this--yes they are out there. It is sometimes hard for a student to fathom because students have worked so hard to get into medical school, work hard while in it, work hard in residency--that they sometimes create a mindset that no one in the profession would stoop to such unethical behavior. Unfortunately there are plenty of doctors out there that are like this.

So even in cases where the bosses have figured it out, are they willing to go through an all out war where they may have to hire doctors, lawyers, investigators to prove someone's lying for workman's comp? Nope. They usually grin & bear it so long as its not too bad. If it is bad, they'll try to get rid of the person through other means.

 

[erg923]

(I know this has nothing to do with the tests you guys are talking about, although maybe someone could invent a mini psychological test that can be used by bosses at work to see who's telling the truth, similar to those defibrillators that are found in shopping malls and can be used by lay people...)

Um...like a polygraph for the lay person?....🙂

 

[OldPsychDoc]

...(I know this has nothing to do with the tests you guys are talking about, although maybe someone could invent a mini psychological test that can be used by bosses at work to see who's telling the truth, similar to those defibrillators that are found in shopping malls and can be used by lay people...)

Waterboarding?

 

[whopper]

A problem with psychometric testing to rule out malingering in a clinical setting is that several of these tests take time, and if you discover the person is malingering you can't bill for it. So should you accomplish what you're trying to do--you're going to have one unhappy hospital employer, or you're going to spend a lot of time, and getting nothing out of it in terms of financial compensation, and potentially opening yourself up to a lawsuit since a discovery of malingering will definitelly upset the patient.

Several hospitals will not allow for this option, not only because of the above, but because it is not considered directly therapeutic.

Also add to what I mentioned above. Some interpret the Hippocratic Oath to give patients unlimited chances, and trying to catch them as malingerers is interpreted by some to violate a doctor/patient relationship. E.g. doctors aren't supposed to have people with a (+) UDS arrested on the spot for illegal use of illicit substances.

That's not an argument from me to enable malingerers to get away with everything. AS I mentioned above, I think too many doctors are chicken s___ over this issue. However that is a warning that if you proceed to diagnose someone as such, do it carefully, and think about the consequences. IMHO allowing every single potential malingerer continue their course enables the problem, and can also be interpreted by managed care as fraud. It also raises the price of hospital bills for everyone. Problem is that the lack of data & controversy over this issue has prevented anyone from making any real guidelines on how to deal with this in a clinical setting.

 

[ronin12]

personally i think in order to determine disability claims it is foolish not to use psychological testing i.e lie and inconsistency scales. this is most true in ptsd claims in VA system.which unfortunately is very frequently abused. if you are in war zone then exposure to trauma criteria is satisfied and you just learn the core symptoms and repeat them in office.it is so politically charged issue that you just have accept what they are telling you and treat them accordingly. the moment their ptsd claims are approved , then they magically dont need meds and vanish from the scene.it is sadly a fairly common occurance in VA system.

 

[erg923]

A problem with psychometric testing to rule out malingering in a clinical setting is that several of these tests take time, and if you discover the person is malingering you can't bill for it. So should you accomplish what you're trying to do--you're going to have one unhappy hospital employer, or you're going to spend a lot of time, and getting nothing out of it in terms of financial compensation, and potentially opening yourself up to a lawsuit since a discovery of malingering will definitelly upset the patient.

Several hospitals will not allow for this option, not only because of the above, but because it is not considered directly therapeutic.

Also add to what I mentioned above. Some interpret the Hippocratic Oath to give patients unlimited chances, and trying to catch them as malingerers is interpreted by some to violate a doctor/patient relationship. E.g. doctors aren't supposed to have people with a (+) UDS arrested on the spot for illegal use of illicit substances.

That's not an argument from me to enable malingerers to get away with everything. AS I mentioned above, I think too many doctors are chicken s___ over this issue. However that is a warning that if you proceed to diagnose someone as such, do it carefully, and think about the consequences. IMHO allowing every single potential malingerer continue their course enables the problem, and can also be interpreted by managed care as fraud. It also raises the price of hospital bills for everyone. Problem is that the lack of data & controversy over this issue has prevented anyone from making any real guidelines on how to deal with this in a clinical setting.

I do not really know how you deal with denying services to the chronically suicidal "frequent flyer" in an inpatient environment. Its a complex issue whren dealing with such immediate saftey risks.

However, the "Slick criteria" (from the article I mentioned in my first post) have been widely adopted in the field of clinical neuropsychology and forensic neuropsychology. This is mostly outpatient evals though. However, when an assessment is invalidated by poor effort and/or is suggestive of symptom exaggeration, this is written in the npsych report as such. Hence, if its an IME, workers comp, competency eval, etc, the person gets stuck with a report that does nothing to help their claims of disability. Further, if evidence strong enough, the report will explictly suggests the more likely conslusion/diagnosis; namely, that they are malingering most of the claimed symptomatology. I do not think their is a notion in my field (neuropsychology) that we are suppose to give people all the chances they need. generally speasking, neuropsychologists think of themselves as evaluators and diagnsosticians, rather than healers. Most psychologists also tend to view themselves as clinical scientists first and foremost. We follow the data to their conclusions, whatever they may be. If your test data and clinical interview are suspicious and symptom exaggeration is suggested by cognitive and/or personality measures, this is exactly what gets written in my report. Therefore, I can not advocate for services or compensation for you if you do not provide me with an accurate (honest) representation of your symptoms. End of story. However, keep in mind that if I am in private practice, and the patient is paying me for the eval (ie., they are the patient), they reserve the right to forbid me from releasing it to anyone. I would keep the malingerer's report in my records obviously, but could not release it to anyone without their permission. Hence, the malingerer (if he has another 3K to blow) has every right to "doctor shop" until he hits one that gets duped and gives him the diagnosis they need. This is how the cycle continues, in the outpatient world at least.

But do not ever doubt how difficult a call "malingering" can be in certain cases. The call between factitious, hypochondriases, and somatization all have to be carefully considered. Remember, the only difference between some of these and "malingering" is the clinician's judgement that the person knows what they are doing and is doing it for an external encentive.

The below article really spells out some good guidlelines for what the repsonsibility of the medical provide is after the label is offically concluded.
Iverson ,G (2006). Ethical issues associated with the assessment of exaggeration, poor effort, and malingering. Applied Neuropsychology, 13(2) 77-90.

 

[erg923]

A problem with psychometric testing to rule out malingering in a clinical setting is that several of these tests take time, and if you discover the person is malingering you can't bill for it.

Huh? Really? What is the logic of not billing a person for that if they are indeed malingering.

I have worked at private as well as academic medical centers in outpatient neuropsychology services. When we wrote a report that suggested that the person was probably grossly exaggeratting symptoms (we rarely say they are faking everything unless we have a videotape or something) the hospital did not give them a free pass on the bill! They requested a service (neuropsych eval) which we provided. They don't have to agree with the conclusions in order for us to bill them for the service! What kind of sense does that make?!

 

[whopper]

neuropsychologists think of themselves as evaluators and diagnsosticians, rather than healers. Most psychologists also tend to view themselves as clinical scientists first and foremost.

Which shows the limitations of the medical model in psychiatry vs psychologists. With the medical model, the patient is to have a disorder, and you are to treat it. It doesn't work well all the time outside this setting. Forensic psychiatrists for example are to declare to the people they evaluate as well that they have no doctor/patient relationship. This is very outside the norm for clinical psychiatrists.

The medical model IMHO has other flaws as well but that's another can of worms.

Huh? Really? What is the logic of not billing a person for that if they are indeed malingering

At the hospital where I did residency--malingering (or so I was told by the attendings) was not billable, and managed care did not want to compensate for it under the notion that they will only pay for treating illness, not for non therapeutic examinations. The problem was that by the time the treatment team figured out with some confidence that the person was malingering, they were in the hospital for a few days, ran up a bill, or had been there several times, and a factitious DO dx pretty much contradicted all the previous reports that the person had a mental illness. Not exactly consistent reporting, and an example of how "Monday Morning Quarterbacking" distorts perspectives when trying to judge what happened after the event is done with and the outcome is already known.

Medicare also handled the payment end of several of the malingerers--and they were pretty strict about not compensating if the person was not mentally ill in the conventional sense. Of course you could give the homeless malingerer a bill, but you pretty much 99.99999% of the time never expected one to pay for it. That forced the hospital to hope Medicare would do so, which from my understanding they didn't for such a dx.

However if this is different for other doctors here in their different systems, by all means let me know. I'm actually trying to come up with a way to study this issue more since it was one of the more frustrating issues with lack of research on it. (Problem is I'm trying to figure a way to do the research safely, and without the patient blowing up in my face & cutting their wrist in an acting out manner).

I do not really know how you deal with denying services to the chronically suicidal "frequent flyer" in an inpatient environment.

Not an easy thing. Aside from the argument that you could be wrong in telling someone they were malingering which would cause emotional harm, several would as I mentioned "up the ante"--harm themselves with the full intention of trying to prove you wrong (superficially of course--the harm and the proving wrong since they are really not mentall ill in the conventional sense), while knowing full well that since they are in the hospital, a superficial wound would be immediately treated.

But some docs get sick of seeing patients doing things such as claiming to be suicidal, then with a smile on their face say "now get me a sandwich bitch, you do what I say or I kill myself" on a chronic basis. No one ever had a standard of care solution to the above becuase no one ever established one.

 

[nancysinatra]

a factitious DO dx pretty much contradicted all the previous reports that the person had a mental illness.

...


Not an easy thing. Aside from the argument that you could be wrong in telling someone they were malingering which would cause emotional harm, several would as I mentioned "up the ante"--harm themselves with the full intention of trying to prove you wrong (superficially of course--the harm and the proving wrong since they are really not mentall ill in the conventional sense), while knowing full well that since they are in the hospital, a superficial wound would be immediately treated.

But some docs get sick of seeing patients doing things such as claiming to be suicidal, then with a smile on their face say "now get me a sandwich bitch, you do what I say or I kill myself" on a chronic basis.

Whopper, isn't some of the behavior you're describing Antisocial? If a person is so bent on getting a benefit that they will feign disease or manipulate people this much, then don't they start to have enough Axis II traits to qualify for a mental illness (and maybe even some treatment benefits, though not the ones they bargained for)?

Do people ever malinger by pretending to have an Axis II disorder? Or even another somatoform disorder? I guess those would be low yield--compared to TBI, PTSD or even suicidality...

Also when you say "factitious" above, are you still referring to malingering, as opposed to true factitious disorder?

 

[Therapist4Chnge]

Do people ever malinger by pretending to have an Axis II disorder?

I once worked with someone who would label her explosive outbursts as, "her borderline acting up again". She was not BPD.

 

[whopper]

Whopper, isn't some of the behavior you're describing Antisocial?

Yes some of it, actually a lot of it is. I've noticed several fake symptoms, and go to the hospital on the idea that "its all free", though in reality its paid for by the hospital &/or the taxpayers. In fact I've even convinced a few malingerers to drop their attempt after I mentioned to them how much it was costing the system, and that the real solution was for them to start picking up the pieces of their lives--which we were willing to help them with, but not willing to continue the charade that they were suicidal or what have you. Some do come in knowing full well it costs the system, and it certainly shows some antisocial component to want to run up services without concern for what it costs the system, but its on an order IMHO that does not cross the criteria for ASPD, and several people have a "buck the system" attitude, to the point where its arguably within the culturally accepted criterion of the DSM.

(In fact several pre-meds, medstudents even residents have argued "its all free" during the occasional debates for national socialized healthcare for everybody--no it isn't, unless you don't pay taxes have will never have to do so.)

Also when you say "factitious" above, are you still referring to malingering, as opposed to true factitious disorder?

Actually both, and thank you for pointing that out because I used the 2 terms somewhat interchangeably which could cause confusion. I apologize for that. I have only had perhaps about a handful of people that I genuinely believe had factitioius disorder (perhaps around 5) vs what is probably hundreds who I genuinely believed malingered.

 

[erg923]

I think it important to recognize that malingering is not a unitary construct. Resnick (1997) describes three types of malingering, labeled "pure malingering," "partial malingering," and "false imputation." Pure malingering is characterized by a complete fabrication of symptoms. Partial malingering is defined by exaggerating actual symptoms or by reporting past symptoms as if they are continuing. False imputation refers to the deliberate misattribution of actual symptoms to the compensable event. The latter two are by far the most common in prevalalence studies. Appreciating these types is important because mental health and legal professionals too often think conceptualize this as a black or white issue. There is alot of gray, and its hard to say what symtoms are complelety made up and what is symptoms may be exaggaerated for the purpose of "a cry for help." (ie., I really am having alot of problems, but maybe if I say I hear voices constantly and have memory problems too, maybe some one will finally listen to me). ​

 

[whopper]

I think all of us might (and should) have empathy and understanding for why a person may be tempted to greatly exaggerate symptoms.

Very much agree.

Several malingerers where I did residency were homeless, and had reasons which if we were in their shoes might sound reasonable to want a clean place to stay for the night. Others really do need help, though not on the scope of the typical, billable psychiatric inpatient help, but they do not know where else to go.

 

[erg923]

if you are in war zone then exposure to trauma criteria is satisfied and you just learn the core symptoms and repeat them in office.it is so politically charged issue that you just have accept what they are telling you and treat them accordingly.

I realize this highlights the differences between treating inpatients and assessing outpatient, but I still can't really buy this. I work in well known VA with 1 of the 3 National WRIISC Centers, as well as 1 of the 5 national Polytrauma Clinics. I work within an interdiciplinary team and can say that I don't know anyone who has this attitude. We are not encouraged to "roll-over" or be lenient because these are veterans. In fact, the VA has been charged with the exact opposite of that in the past. Remember this scandle a couple years ago.
http://www.npr.org/templates/story/story.php?storyId=90744878

 

[Thorazine]

im not sure if my question makes sense, but...

when you diagnose someone as malingering do you also have to comment on what they are trying to gain? it just seems like the diagnosis has to be put into context.

what do you do when you treat someone with a past malingering diagnosis? is this like treating someone with a scarlet letter on their forehead? i'd imagine you cant really shake that diagnosis, and all your future providers are going to be skeptical of anything you say. so wouldnt it be helpful to document the potential gains for faking symptoms?

i was right, that didnt make any sense...

 

[erg923]

I mentioned the "Scarlet Letter" potential in my first post on this thread. So, yes. That can happen. Especially if bold clinicians citing purely "clinical judgement" (im sure we are are familiar with Meehl's "Clinical vs. Actuarial Prediction") are hasty and frame it as an absolute, with no other possible explanation.

 

[Therapist4Chnge]

when you diagnose someone as malingering do you also have to comment on what they are trying to gain? it just seems like the diagnosis has to be put into context.

In an ideal situation it would be put into context, though sometimes the amount of time doesn't allow for a full fleshing out of that information and the report/recommendation focuses on only their performance.

what do you do when you treat someone with a past malingering diagnosis? is this like treating someone with a scarlet letter on their forehead?

That is one of my biggest concerns when looking at malingering, which is why I like to have a range of assessment data to evaluate before making a formal diagnosis. As for working with someone with a history of malingering.....it is important to keep it in mind, much like working with someone with a dx of BPD, HPD, etc.

 

[ronin12]

I realize this highlights the differences between treating inpatients and assessing outpatient, but I still can't really buy this. I work in well known VA with 1 of the 3 National WRIISC Centers, as well as 1 of the 5 national Polytrauma Clinics. I work within an interdiciplinary team and can say that I don't know anyone who has this attitude. We are not encouraged to "roll-over" or be lenient because these are veterans. In fact, the VA has been charged with the exact opposite of that in the past. Remember this scandle a couple years ago.
http://www.npr.org/templates/story/story.php?storyId=90744878

in multidisciplinary settings you are right it is quite difficult for malingerer to get his way via intimidation. in outpatient settings it is very unpleasant situation. most veterans don't know the difference between the treating psychiatrist and disability examiner . they think if you get dx from psychiatrist you will automatically get SC disability. I am sure there is great variation among va hospitals how they handle disability claims exams. what I have observed is different to what your experience is.

 

[erg923]

Although obviously some of this is antisocial-like behavior, I think all of us might (and should) have empathy and understanding for why a person may be tempted to greatly exaggerate symptoms. Especially in the case of returning veterans. These people are coming back to a poor economy, a public that disowned and dissassciated from the war long ago, and difficult readjustments to homelife to say the least. It is understandable that they feel the need to prove that they really are injured so they can get the proper medical benefits and/or monetary compenstation that they really do deserve. Remember, the VA population is not known for being a very psychologically insighful bunch. The culture of the military is unique. If its not a physical wound, its hard for your fellow soldiers and comrades to buy into the notion that you are injured because there is nothing that they can physically see. No wounds, no scars, no broken limbs, etc. It is not at all surprising to me that these individuals come back to the states feeling that they really do need to "prove" and "demonstrate" that they are suffering in order for someone to actually understand and take them seriously. If they have to "play up" their symptoms a little bit for people to actually notice and believe them....I dont think they give it a second thought. And frankly, I can't blame them. If playing up my hypervigiliance and depression to the point where it meets PTSD is the only way I can get the those extra lifelong VA benefits that I think I'm entitled to anyway, I would be tempted to do the same myself. People dont always just readily accept whatever "the man" hands them. That is just the human nature in all of us.

 

[ronin12]

Although obviously some of this is antisocial-like behavior, I think all of us might (and should) have empathy and understanding for why a person may be tempted to greatly exaggerate symptoms. Especially in the case of returning veterans. These people are coming back to a poor economy, a public that moved on from the war long ago, and difficult readjustments to homelife to say the least. It is understandable that they feel the need to prove that they really are injured so they can get the proper medical benefits and/or monetary compenstation that they really do deserve. Remember, the VA population is not known for being a very psychologically insighful bunch. The culture of the military is unique. If its not a physical wound, its hard for your fellow soldiers and comrades to buy into the notion that you are injured because there is nothing that they can physically see. No wounds, no scars, no broken limbs, etc. It is not at all surprising to me that these individuals come back to the states feeling that they really do need to "prove" and "demonstrate" that they are suffering, in order for someone to actually understand and take them seriously. If they have to "play up" their symptoms a little bit for people to actually notice and believe them....I dont think they give it a second thought. And frankly, I can't blame them. If playing up my hypervigiliance and depression to the point where it meets PTSD is the only way I can get the those extra lifelong VA benefits that I think I'm entitled to anyway, I would be tempted to do the same myself.

Malingering is intentional faking of symptoms for all sorts of gains, it is medical term for fraud and in this case fraud is done for financial gains.will they be offered same courtesy and understanding if there potential gain is to avoid legal penalties due to criminal offenses..
Rationalization can not justify fraud.

combat veterans are covered for All VA health benefits for 5 years after their service.

 

[erg923]

I think "justify" and "condone" is much differnent than empathy and understanding. But, hey, thats the Carl Rogers in me. I do not justify any of this, I was simply hypothesisizing what might be going through their heads. I understand the thought process, and I feel empathy for the situation.

 

[ronin12]

I think "justify" and "condone" is much differnent than empathy and understanding. But, hey, thats the Carl Rogers in me. I do not justify any of this, I was simply hypothesisizing what might be going through their heads. I understand the thought process, and I feel empathy for the situation.

I think your hypothesis does make sense as it seems that malingering is more common in Vietnam veterans, who did not get same acceptance and appreciation as current war veterans get.

 

[whopper]

when you diagnose someone as malingering do you also have to comment on what they are trying to gain

IMHO yes--since the DSM gives a description of it, and we should try to live up to the DSM's expectation.

Its hard to claim someone is doing something for secondary gain when you cannot even ID what that 2ndary gain is.

 

[BabyPsychDoc]

http://www.amazon.com/Malingering-I...=sr_1_2?ie=UTF8&s=books&qid=1243684014&sr=1-2 is a pretty good discussion of the subject, edited by two European experts in the field. (I was incredibly fortunate to work with one of them).

 

[erg923]

I think your hypothesis does make sense as it seems that malingering is more common in Vietnam veterans, who did not get same acceptance and appreciation as current war veterans get.

While this may be your opinion based on your personal experiences, data from prevalence studies with VA populations do not bear this out, at least with PTSD. Please see this article for review of the available data:

McNally, R. (2007). Can we solve the mysteries of the National Vietnam Veterans Readjustment Study?. Journal of Anxiety Disorders, 21(2), 192-200

Empirical and conceptual analysis suggests that malingering is unlikely to account for the high prevalence of PTSD cases found in the original study sample (although I can identify numerous methodological flaws that do). Nevertheless, I think you make a good point, as in my mind, respondents in the original study sample may have invoked the Vietnam-PTSD narrative to make sense of postwar psychological difficulties that were indeed present (i.e., valid), but unrelated to their military service. This could have (and probably did) lead to a substantial minority of Vietnam vets attributing their psychological difficulties solely to experiences from the war. Hence, they feel they truly do deserve compensation from the military, since, in their mind, all their problems are tied to that experience. This is simple misattribution that experimental research (from social psychology) suggests we are all equally prone to falling victim to. So again, malingering and symptoms exaggeration in this population should come as a surprise to no one. And I do not necessarily think that all of it it so much true malingering (i.e., conscious lying), as it is misattribution of legitimate symptoms in this particular population.

As an aside, I again would be careful to not view the construct as if its all or nothing (complete fabrication of all symptoms), and keep in mind Resnick's (1997) model of malingering, that describes "pure malingering," "partial malingering," and "false imputation." All of these are malingering to a degree, but the latter 2 denote the msot frequent manifestation of the behavior, where symptoms are exgaggerated (not necearilty completely fabricated) and missatributed to events (ie., combat) that may have little casual responsibillity.

 

[ronin12]

While this may be your opinion based on your personal experiences, data from prevalence studies with VA populations do not bear this out, at least with PTSD. Please see this article for review of the available data:

McNally, R. (2007). Can we solve the mysteries of the National Vietnam Veterans Readjustment Study?. Journal of Anxiety Disorders, 21(2), 192-200

Empirical and conceptual analysis suggests that malingering is unlikely to account for the high prevalence of PTSD cases found in the original study sample (although I can identify numerous methodological flaws that do). Nevertheless, I think you make a good point, as in my mind, respondents in the original study sample may have invoked the Vietnam-PTSD narrative to make sense of postwar psychological difficulties that were indeed present (i.e., valid), but unrelated to their military service. This could have (and probably did) lead to a substantial minority of Vietnam vets attributing their psychological difficulties solely to experiences from the war. Hence, they feel they truly do deserve compensation from the military, since, in their mind, all their problems are tied to that experience. This is simple misattribution that experimental research (from social psychology) suggests we are all equally prone to falling victim to. So again, malingering and symptoms exaggeration in this population should come as a surprise to no one. And I do not necessarily think that all of it it so much true malingering (i.e., conscious lying), as it is misattribution of legitimate symptoms in this particular population.

As an aside, I again would be careful to not view the construct as if its all or nothing (complete fabrication of all symptoms), and keep in mind Resnick's (1997) model of malingering, that describes "pure malingering," "partial malingering," and "false imputation." All of these are malingering to a degree, but the latter 2 denote the msot frequent manifestation of the behavior, where symptoms are exgaggerated (not necearilty completely fabricated) and missatributed to events (ie., combat) that may have little casual responsibillity.

I wonder how were they able to quantify malingering in their studies.i am not suggesting that all of Vietnam vets are malingerer, but they constitute significant portion of VA population which you can not just simply ignore. symptoms variation is so blatantly tied to compensation approval/disapproval or how much will they get , it becomes fairly obvious . Again they do have legitimate psychiatric issues as well. but ptsd seems to be focus for many of them due to publicity.
current poor economy does not help at all and now there is almost flood of new claims. again i can understand underlying psychodynamics of their symptoms, but it is malingering which is a fraud , we can not just simply rationalize it to accept it as legitimate psychiatric illness.