Useful tips to recognize malingering duing a clinical interview

[PsyKardinal]

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Ok folks I have complained before that there is not enough research/clinical practice related threads, so here goes my first topic to discuss.

Malingering during a clinical interview. For the student or unfamiliar, malingering is Malingering is a medical and psychological term that refers to an individual fabricating or exaggerating the symptoms of mental or physical disorders for a variety of motives, including getting financial compensation (often tied to fraud), avoiding work, obtaining drugs, getting lighter criminal sentences, or simply to attract attention or sympathy. Because malingerers are usually seeking some sort of primary or secondary gain, this disorder remains separate from Somatization disorders and factitious disorders in which the gain is not obvious.

A clinical interview would be the 1st time assessment of the patient utilizing subjective criteria Q and A process (not using a test such as MMPI or Beck Depression Inventory). So I have some clinical pearls of wisdom I will contribute further along in the discusion, but I wanted to ask.

How do you determine malingering? How do you handle it? What particular population does this behavior the most and what do they gain from it?

Discuss

Jeff

 

[Therapist4Chnge]

Great topic!

Might as well jump into a fun (if not sometimes frustrating) topic.

How do you determine malingering? How do you handle it? What particular population does this behavior the most and what do they gain from it?

Discuss

Jeff

Malingering happens across the board, though I've heard it happens quite frequently in the forensic population, though ironically psychological problems are also UNDER reported in the forensic population. The secondary gains in prison are pretty straight forward, as are the avoidance of a Dx.

I've found people wanting a Dx as an EXCUSE to their behaviors, whether it is substance related, personality, etc. I had a patient who picked out an axis-II dx and sweared by it, and frequently cited it as the reason why she did what she did, even though the actual Dx really didn't fit her case. A previous professional mentioned the Dx though improperly Dx'ed it, and since then it seemed to be the crutch with which she leaned the most. I've also seen it frequently in ADD / ADHD....again as an excuse, and secondarily as a means to get the medication (whether for recreation or for studying)

As for screening......I think a solid clinical interview is essential. Consistency can be hard for some, and changing up how you go about your clinical interview, and what you ask can help shed some light on possible malingering. Many times it is omission and truth bending that are problematic, though as you work with the patient, those areas should come back up again. I don't mind a structured clinical interview, but I prefer a more unstructured interview because it allows for a bit more leeway by the clinician to get the answers to their questions. I often prefer to meet with the person first and talk with them, and then later collect the typical information. I don't like having a pre-conceived notion of what I'm looking for, because often times going in blank allows me more of a clean read.

There are of course assessments used to detect malingering, but I probably would only do one of those if it is a formal assessment for court, school, etc. If it was for individual work, I'd probably want to explore their need to malinger, as the malingering is merely a Sx of another problem.

-t

 

[Therapist4Chnge]

seems like a bad idea to discuss on the forum

How so? I don't think anyone would be able to really use the info given here to help 'beat' the system. We could also open up the topic to discuss effectiveness of certain assessments compared to others.

-t

 

[PsyKardinal]

Not really sure how this could be a bad topic to discuss. Folks that malinger are not going to really read this website and go Ahhaaa...that is how to do it.

One of my favorite techniques if the potential is available, interview the family or complete your interview and then on the points of concern send a coworker in to follow up.

Jeff

 

[Logic Prevails]

Long time no post - I like the idea of doing more clinical posts... I have some interesting ones to put up shortly.

If I had a hunch that someone was malingering, I would innocently ask questions about symptoms that clinicians know are likely unrelated to an illness, but the general public may not. If they endorse them, then they may be malingering. I would also ask about symptoms that either have an extremely high base rate, or an extremely low one, and see how they respond.

If all signs point to 'faker', then I would try to use some assessment measures (if appropriate) to figure it out. The Victoria Symptom Validity Test (VSVT) appears to be a memory test, but even individuals with temporal lobe damage can do it. If they bomb this 5 minute test - they are faking.

 

[socialcog]

I'll contribute later today but first I have to run. Great topic!

 

[PsyKardinal]

Settings may have an impact upon malingering, ie. emergency room or late friday evening admissions. I find that malingering patients quickly figure out when the least experienced staff work or have the least ablity to access medical records. The times are weekends, evenings, or overnight; while some of the settings are in the ER or Hospital Admissions.

No names used so as to not violate HIPAA. I was working admissions at my hospital overnight, when I came on at 2300 was briefed that a female possible patient (now named Jane for ease of reading) had attempted to be admitted because her husband kicked her out of the house and she had no other place to go. At the time of assessment earlier in the day she was not suicidal, psychotic, or homicidal. She was turned away at that time with the suggestion of seeking a motel room and some family counseling with a list of referrals.

At 0330ish, she returns screaming and dishelved that she was detoxing from marijuana and needed a bed before she keeled over and had a siezure. So the obvious point of malingering is that it is not medically dangerous to stop using marijuana its just a good idea. I reassessed her, she provided no new clinical information that indicated needing to admit her. So end result I calmed her down helped her call the husband and called a cab to send her home.

Hope that was an interesting read.

Jeff

 

[TherapistDave]

Are we worried more about asking for help with certain situations than explaining how we dealt with certain situations? I have a question that my entire team has been struggling with.

This client (God bless him) is like a fly that will not go away. He loves to check himself into the hospital claiming that His brain is not working correctly; each time he tells me this, I point out that he was somehow able to call the paramedics, to which he replies "oh, yeah...uh..."

Anyway, he is totally attention seeking, and his diagnosis is paranoid schizophrenia, but lately his psychologist and I have been thinking that maybe he is just malingering so as not to have to deal with life in general; we have also been struggling with what to do with this guys as far as practical assistance goes; I have tried numerous things - talking with him about anything, checking on him weekly, now we are on this kick to go places together (the mall, the supermarket, anywhere).

Part of the problem (I think) is that we don't ahev the resources to help him adequately, as evidenced by constant hospital visits (once a week on average). Similarly, we are starting to think that he says the things he does and does these things so that he doesn't have to face up to reality. There have been times where we will be talking with him, and he says something really off the wall and then laughs - like he knows what he just said was really random and crazy, but also he knows that he's getting away with it.

I hate to "blame the victim," and I'm not posing this question to get rid of this client, I genuinely want to help him. The problem is that it's so hard to get past his malingering and attention-seeking behavior, even our licensed Psych. struggles with ideas. Any thoughts?

 

[Therapist4Chnge]

I think it is important to be able to talk about the clinical piece, though how we talk about it may be tricky. I think case examples are a great way to conceptualize issues, though de-identifying is of primary concern.

I definitely can relate to your concerns Jon....I know this is something we've been going back and forth with as a staff (as case discussion happens in all of the areas of SDN).

Let me check with Lee and see how he wants to handle stuff like this.

-t

 

[psy86]

Yeah, I agree with Jon that discussing cases in this way is inappropriate. (I also agree that the examples offered are not necessarily indicative of malingering.)

 

[PsyKardinal]

Ok then we need more folks to contribute some more clinical research ideas. Malingering was maybe not the best subject but at least it got people to talk, outside of the can I get into XYZ school with these grades and research.

 

[Therapist4Chnge]

Ok then we need more folks to contribute some more clinical research ideas. Malingering was maybe not the best subject but at least it got people to talk, outside of the can I get into XYZ school with these grades and research.

Agreed.

Feel free to post a new topic, I'm always up for a good discussion.

-t