Malingering...Question

[clement]

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Is there any definitive consensus on whether it's more common in either gender?

 

[Therapist4Chnge]

There are so many confounding variables I'm not sure it can be reduced down to merely gender. You may have more luck if you are looking at special populations, but it is too broad of a question otherwise.

 

[whopper]

If you want the end all be all book on malingering, get Richard Rogers' Clinical Assessment of Malingering and Deception.

Richard Rogers, Ph.D. is a Guttmacher award winner (the highest forensic honor bestowed by the American Psychiatric Assocation) and the author of the SIRS--the gold standard test in malingering.

Per that book, there isn't much data on the differences between gender in regards to malingering. The M-FAST, a screening test used to detect malingering of mental illness found no significant differences between the sexes.

IMHO more work needs to be done on this area.

On the side, it wasn't until I went through my forensic fellowship that I got adequate training in the detection of malingering and what to do once you've established someone is a malingerer. From my experience in residency, and from my colleagues in other programs, they were often given conflicting data on what to do in this situation and few attendings wished to tackle this area.

I found this frustrating because the staff and residents believed so many patients we saw were malingering, and then to see an attending write down "psychosis NOS" when they didn't even believe in that diagnosis was more frustrating.

This is an area that most do not want to deal with, and several attendings are willing to diagnose someone with a mood, psychotic, or anxiety disorder even if they believe the patient is malingering and not suffering from that disorder because it is easier to do that than confront the issue.

The DSM-IV-TR IMHO does no adequately address the issue either. It brings up a very oversimplistic definition of the disorder, and then it leaves you there.

 

[ClinPsycMasters]

I find malingering such an interesting topic of study. Some people are so good it boggles the mind. It's not easy to outsmart a bunch of PhDs and MDs but they can, which makes me think how wonderful it would be if they could use their "intelligence" in more people-friendly ways. 🙂

Whopper: I looked at book reviews on Amazon and some people don't find that book you recommended, very user-friendly. It's not a manual as much as a collection of chapters on different topics. Do you know of a good book that is more geared towards clinical use?

 

[Chrismander]

Is there an easy way to get a hold of the M-FAST? I can't seem to find it online. Is it in any books?

 

[Therapist4Chnge]

Do you know of a good book that is more geared towards clinical use?

Learning to assess for malingering (in multiple areas) is best done through mentorship, as there is quite a bit of variance between the assessments, interview structure, and the standards. The best books I've found on the topic tend to be in the forensic arena, though they are not exhaustive, particularly in regard to the more neuropsych-focused malingering issues/assessments.

Is there an easy way to get a hold of the M-FAST? I can't seem to find it online. Is it in any books?

It is still under copyright and needs to be purchased from the publisher, who in this case is PAR.

http://www4.parinc.com/Products/Product.aspx?ProductID=MFAST#

 

[whopper]

I looked at book reviews on Amazon and some people don't find that book you recommended, very user-friendly

I actually very much agree the book is not user-friendly, but it still is the best book out there on the topic.

There are specific chapters that may be more geared for clinicians vs. court expert witnesses.

If you actually want to read part of the book, it's on google-books.
http://books.google.com/books?id=uy...&resnum=1&ved=0CCgQ6AEwAA#v=onepage&q&f=false

But if you actually want a user-friendly book on malingering, you're going to have to get Phil Resnick's booklet on malingering. He gives at least one lecture at year on it at the annual AAPL conference. I have that booklet. It's about 40 pages (and that is only based on my memory).

I've been to Resnick's lecture. It's worth it to go to the AAPL conference just for that. The room was filled with several non-forensic psychiatrists, all of whom found the lecture very informative and useful. Resnick himself is an entertaining lecture with a passion for what he teaches. You will not be bored for one moment of his lectures.

The reason why I feel Roger's book is better is Rogers goes into very detailed descriptions. This may be more than what a clinical psychiatrist needs, but for a forensic psychiatrist, this is exactly what I want.

Rogers book is entertaining if you take it one chapter at a time concerning a specific malingering issue. E.g. if you have someone malingering a specific issue--e.g. memory problems, then reading that specific section is actually very entertaining because it contains detailed information that is very case specific.

The problem with the M-FAST is it's only used for screening. If someone tests positive on the M-FAST, that doesn't not mean they really are malingering. If someone tests negative, okay then, maybe they aren't malingering.

The real gold standard is the SIRS. One advantage I have in the locations I work at is these tests are available for anyone to use. We have a specific forensic testing room with dozens of types of psychological testing such as the TOMM (test of memory malingering), the SIRS, the M-FAST among several other tests. There's a one-way mirror, cameras for taping the interviews, etc. It's pretty cool and I haven't seen this type of support in most programs. In fact some programs, I asked the program director during the interview if they were going to train me in these tests, and the PD didn't even know what I was talking about.

If you want to get good at detecting malingerers, aside from some very good clinical experience ,you should IMHO, do these tests several several times. After you've done some of these tests dozens of times, they become like the back of your hand.

Unfortunately, it seems most psychiatry residency programs don't teach this type of stuff. I find this odd since in almost every program I've seen with emergency psychiatry, and inpatient in an urban area, there's plenty of patients where the staff suspects malingering, yet little is done about it on several levels.

Of the few doctors I knew who tried to confront malingerers that did not have forensic training, they were willing to kick out a patient based merely on clinical observation. While that could be enough in some cases, this is a very risky situation unless the documentation is very good and thorough. Malingering is in essence calling the patient a liar, and an upset patient is much more likely to seek a lawsuit. Having the proper testing is a great way to add a layer of defense should you have to confront malingering.

 

[Chrismander]

Whopper--does that book you're recommending have the M-FAST and SIRS in it? How long does the SIRS take to administer? How long does the M-FAST take?

 

[Therapist4Chnge]

I'll typically do a Rey 15 as a quick screen, if it is funky I'll throw in a TOMM and a SIRS. I'd want an MMPI or MCMI (depending on the patient population). After that a solid clinical interview usually seals the deal. If there are TBI issues, I'd add a few more neuro assessments for rule-outs. I don't do forensic work, so I'm not sure how different that would be, but I can feel pretty confident in my opinion if I can have the above data (in an ideal world).

As for the book recommendations....you aren't going to find "an easy read" that is also comprehensive enough to get a good handle on malingering assessment. You'd need a primer, and then a book like the Rogers one mentioned above once you understand the basics in the field. There are also some decent review articles out there on malingering assessments. Those articles include the statistics behind the assessments, which will inform the clinician's choices in assessment.

 

[ClinPsycMasters]

I actually very much agree the book is not user-friendly, but it still is the best book out there on the topic....

Rogers book is entertaining if you take it one chapter at a time concerning a specific malingering issue. E.g. if you have someone malingering a specific issue--e.g. memory problems, then reading that specific section is actually very entertaining because it contains detailed information that is very case specific....

Thanks Whopper. At work, I am interested in detecting malingering of memory problems. However, I would love to learn about other topics as well. I enjoy reading about malingering research. It's as close as I can get to a criminal's high. 🙂

 

[whopper]

Whopper--does that book you're recommending have the M-FAST and SIRS in it? How long does the SIRS take to administer? How long does the M-FAST take?

the M-FAST does not take long. Less than half an hour. Remember, this is only a screening test.

The SIRS takes about half an hour to administer, but scoring it is a pain in the butt. Another pain in the butt is if you actually want to look at yourself in the mirror and believe you are doing the test well, you need to read the manual. the manual isn't easy or fast reading. Expect to take an entire day reading the manual, and expect that reading to not be enough to master this test.

It really isn't a tough test. Once you do it a few times, it gets easier and easier.

Reason why reading is important is you have to understand the math behind it. For example, the way the test is scored, if the test suggests the person is malingering, they most likely are. If the test does not suggest the person is malingering, that does not mean they are not malingering. The reason why this is, is that the author of the test (Rogers) made it so that there will be very few false positives. It seems he did not want people to be falsely accused of malingering. In pushing the scoring method in that direction, it sacrifices results in the false negative area.

So, if you simply do the test without understanding much about it, and the SIRS suggests the person is not malingering, you might start believing the person is not malingering. If you know how to interpret the results for real, and you clinically believe the person is malingering, IMHO, the way the test is designed, clinically, and legally, you still have enough ground to pursue the possibility of malingering. If the test is positive, that's very good proof the person is malingering, and you can have confidence the test is accurate.

Does that book you're recommending have the M-FAST and SIRS in it?

Unfortunately no. It does, though, give a lot of data on these tests.

The M-FAST and SIRS is available where I work, but copying for you would be a pain in the butt and a copyright violation.

If any of you are interested in forensic fellowship and find any of this interesting, I suggest you ask if the programs where you interview have these tests. available and will train you in them. Most forensic psychiatry programs don't. In fact some of the PDs won't even know how to administer them. One PD I know at a name-brand institution didn't know how to administer these tests. When I brought it up with him (in what I at least believed I thought was in a polite manner), he literally became red-faced and started yelling at me, and tried to pimp me as what I interpreted as a type of ego-defense.

I saw this guy testify during a court case and the forensic psychologist administered the SIRS among several other tests. The PD only had clinical opinion, and it was a pretty bullspit one IMHO that he was willing to give. I was very impressed with the psychologist's use of these tests, so I asked the PD if he could help me get training in those tests....that's when he got mad. After the guy calmed down, he mentioned that he could still beat the psychologist's testimony because he was more suave, charismatic, and a better salesman at his testimony--which he appeared quite proud of. He then tried to point out that the psychologist a few times stuttered. In short, he was relying completely on his ability to charm the judge and hardly anything on scientific merit. I found that odd since I only asked because I wanted to learn, not because I was trying to point out any flaws, but the guy's responses just, if anything, pointed to me that his approach was full of them.

Of course, it didn't help that I asked the PD why he diagnosed the defendant with schizophrenia when it was readily apparent he wasn't psychotic, and the psychological tests also backed that he wasn't mentally ill.

The psychologist during his testimony factually brought up data that clinical opinion is only so accurate and that misdiagnosis is actually quite common. Then he brought up very good numbers showing the mathematical accuracy of his assessments based on the SIRS among other tests that were way above clinical accuracy.

But I'm digressing, and no this was not my own program (my own PD is highly respectable and very intellectually honest.) I brought up that the former guy was at a highly respected institution because in forensic psychiatry the best programs aren't at the name-brand institutions: U-San Diego, Case Western, U. Mass, U. of Rochester, Albert Einstein, U. of Cincinnati, although from what I understand, Harvard actually is a very good program (no that PD was not from Harvard).

 

[Therapist4Chnge]

Of course, it didn't help that I asked the PD why he diagnosed the defendant with schizophrenia when it was readily apparent he wasn't psychotic, and the psychological tests also backed that he wasn't mentally ill.

The psychologist during his testimony factually brought up data that clinical opinion is only so accurate and that misdiagnosis is actually quite common. Then he brought up very good numbers showing the mathematical accuracy of his assessments based on the SIRS among other tests that were way above clinical accuracy.

This is why mentorship is important and reading the manual will only give the basics. Doing a fellowship in the area is obviously the preferred route, but I'd STRONGLY advise against picking up a few assessments, reading the manual, and then giving the assessment. Doing a MMSE/checklist/screener is a very different animal than the more involved instruments you'd find in a malingering case.

Reporting on the data and making sense of the data is quite different. The actual explanation can be pretty complex when you need to factor in things like divergent data between assessments, particularly when multiple encounters are needed because of the variability of symptom presentation. Rogers et al. recently published a short article in this area, and even when using a statistically strong measure (SIRS), there were still issues.

I've read some horrific assessment reports where it was clear the clinican barely grasped the basics of the assessments, and even a mediocre clinican could tell that the report was useless. It is one thing to look like an idiot in front of a peer, but it is another to do it in a formal proceeding like a court case or review committee.

I watched someone get cross-examined about his rationale for his assessment selection, the statistically relevant data for each assessment he gave, and then his responses to cherry-picked quotes from the report...and it was rough. It was obvious the opposing counsel had an expert pick apart the report and absolutely skewer the clinician. I'm pretty confident that guy never got a referall from that lawyer again.

ClinPsycMasters...if you have an interest in the area, definitely read up on it, but unless you are doctorally trained and have been mentored in the area, I wouldn't attempt to give anyone these kind of assessments. Many experts would argue that malingering is one of the hardest things to diagnose well, and it can be a world of hurt for anyone who isn't well versed in the field. I learned from one of the premeir forensic experts, and he put the fear of God into me about doing forensic assessment reports (which inlcudes malingering measures). He also warned against anything involving custody evaluations, as both areas have a much higher probability of being dragged into court to defend your work.

 

[whopper]

I've read some horrific assessment reports where it was clear the clinican barely grasped the basics of the assessments, and even a mediocre clinican could tell that the report was useless. It is one thing to look like an idiot in front of a peer, but it is another to do it in a formal proceeding like a court case or review committee.

Agree. When giving these tests, it's important to know the mechanics behind them. For us medical doctors, it's like the PPD test. We know if the PPD is positive that doesn't prove the person has tuberculosis, it just means the person may have it and more testing is warranted.

Malingering tests are like that. The M-FAST is similar to the PPD test in this regard. You have to know the mechanics of what you're doing.

 

[kugel]

You have to know the mechanics of what you're doing.

That quote is so much more important, in almost everything we do as physicians and as psychiatrists, than most of us realize.
It can be so disastrous to accept the basic interpretation of a test without thinking about what the test actually measures and how applicable it is in the precise conditions it was used.

I like to use the example of BP readings because we use them all the time and rarely think about how they were obtained. I've witnessed staff taking BP with a machine while a pt was seizing and begin to act on outrageous readings that made no sense in the context - because they didn't understand how the machine works. And I've watched hundreds of nurses and doctors take manual BP readings by letting the pressure drop at ~10mgHg/sec, that's way too fast to get a proper reading. I saw a med/surg pt. prescribed Hydralzine TID for a single BP reading of 154/92, despite the fact that dozens of other readings over days were all normal. That single reading was taken by machine on the forearm because a PICC line in one arm and massive DVT in the other (from the last PICC line) precluded normal cuff placement.

When a head CT shows no abnormalities in a patient with s/s of stroke, it is still a stroke until proven otherwise b/c thrombotic events may not show up for a time on scan.

We all know about Positive and Negative Predictive Values, but those are calculated in particular contexts and it's up to us to decide how closely our patients' conditions mirror those contexts and what the data mean for our patient at this particular time.

 

[ClinPsycMasters]

That quote is so much more important, in almost everything we do as physicians and as psychiatrists, than most of us realize.
It can be so disastrous to accept the basic interpretation of a test without thinking about what the test actually measures and how applicable it is in the precise conditions it was used.

I agree with you. However, I think last few decades in particular we have seen a movement from the subjective towards the objective. There may come a point that we all rely on manuals exclusively; and subjective interpretations, experience, and other individual factors become irrelevant. That may be a "side effect" of standardization.

 

[Therapist4Chnge]

I agree with you. However, I think last few decades in particular we have seen a movement from the subjective towards the objective. There may come a point that we all rely on manuals exclusively; and subjective interpretations, experience, and other individual factors become irrelevant. That may be a "side effect" of standardization.

That won't happen. Assessments with the best designs and statistical report still requires integration of other information, which a manual cannot address at the level needed. Sadly people believe that just because they get data/results mean they have what they need, but it is that evaluation and integration of the data which makes the difference. The BP example is a great one because one can follow a manual, but nothing is practiced in a vacuum.

I'll pick on neuropsych again, since that is what I am most familiar. I have seen way too many reports where the clinician reports the data, but does not sufficiently address what it means. Just providing the scores and how they compare to the norms does little to advance the case. This is where many "dabblers" do the most damage, because they know enough to administer and (hopefully) score it correctly, but from then on it gets dicey. I have techs/graduate students to handle the administration and scoring....but the data are useless without being able to use it within the context of the patient's case.

 

[whopper]

Another often not addressed issue is that several doctors are under an impression that we're not supposed to even report malingering.

Doctors treating patients are supposed to be on their side. They have a fiduciary responsibility towards their patient. Fine. Some doctors interpret that as not pushing a malingering diagnosis because of the harm it can do to the patient. E.g. insurance companies may look at the patient's future expenses with suspicion. Confronting a malingering patient is also not easy.

IMHO, allowing a malingering patient to continue their malingering is also harmful. IMHO we should confront malingering, but we need strong evidence to back it up. There has been, however, as far as I'm aware, not profession-wide consensus on how to handle the problem. Several psychiatric texts don't give very good direction on what to do with these patients.

In other similar disorders, such as factitious disorder, the texts suggest to just calmly listen to the patient, but not to order any expensive tests, and not suggest any further in-depth investigations. None, as far as I'm aware, suggest confronting the patient.

 

[OldPsychDoc]

I think there's a ssemi-important distinction to be made between flat out malingering and "malingering without insight" (Yeah, I know it's not in any version of the DSM...). Just had a young man this week admitted because he was in pain from a jaw fx, couldn't get anything soft/pureed to eat at the shelter, and was in some psychological distress as a result... What family he had in the area was unwilling or unable to help, so all he knew to do was go to the hospital & get some help... Extremely weak admission, but he was hardly coming in blatantly saying "I need secondary gain". He just figured "Isn't that what a hospital is supposed to do?" 🙄

 

[PsychGraduate]

That won't happen. Assessments with the best designs and statistical report still requires integration of other information, which a manual cannot address at the level needed. Sadly people believe that just because they get data/results mean they have what they need, but it is that evaluation and integration of the data which makes the difference. The BP example is a great one because one can follow a manual, but nothing is practiced in a vacuum.

I'll pick on neuropsych again, since that is what I am most familiar. I have seen way too many reports where the clinician reports the data, but does not sufficiently address what it means. Just providing the scores and how they compare to the norms does little to advance the case. This is where many "dabblers" do the most damage, because they know enough to administer and (hopefully) score it correctly, but from then on it gets dicey. I have techs/graduate students to handle the administration and scoring....but the data are useless without being able to use it within the context of the patient's case.

Context, always context.

 

[PsychGraduate]

I think there's a ssemi-important distinction to be made between flat out malingering and "malingering without insight" (Yeah, I know it's not in any version of the DSM...). Just had a young man this week admitted because he was in pain from a jaw fx, couldn't get anything soft/pureed to eat at the shelter, and was in some psychological distress as a result... What family he had in the area was unwilling or unable to help, so all he knew to do was go to the hospital & get some help... Extremely weak admission, but he was hardly coming in blatantly saying "I need secondary gain". He just figured "Isn't that what a hospital is supposed to do?" 🙄

Well put👍