Suspected Malingering: Guidelines for Clinicians

by Michael R. Harris, M.D., and Phillip J. Resnick, M.D.

Psychiatric Times December 2003 Vol. XX Issue 13

Dr. Harris is assistant professor of psychiatry and behavioral sciences at the

University of Louisville School of Medicine. He has indicated that he has
nothing to disclose relating to the subject matter of this article.

Dr. Resnick is professor of psychiatry and director of the division of forensic

psychiatry at the Case Western Reserve University School of Medicine. He has
indicated that he has nothing to disclose relating to the subject matter of this
article.

(Portions of this article were modified with permission from "Retrospective

Assessment of Malingering in Insanity Defense Cases" in Predicting the Past: The
Retrospective Assessment of Mental States in Civil and Criminal Litigation,
available from American Psychiatric Press Inc.-Ed.)

Malingering is defined in DSM-IV-TR as the intentional production of false or

grossly exaggerated physical or psychological symptoms, motivated by external
incentives such as avoiding military duty, avoiding work, obtaining financial
compensation, evading criminal prosecution or obtaining drugs (American
Psychiatric Association, 2000).

Malingerers faking psychiatric illness may be seeking prescription drugs with

abuse potential, desire hospital admission for social reasons ("three hots and a
cot") or may want a psychiatric diagnosis to obtain disability benefits.

Psychiatrists are at a disadvantage compared to other medical specialists when

confronted with the possibility of a malingering patient, since we depend more
heavily on the accurate self-report of internal mental states by our patients.
Occasionally, a psychiatrist interviews a patient whose symptoms "just don't
feel right" or whose reported symptoms do not seem to fit with the clinician's
observations. In a time when treatment resources are scarce and information
about psychiatric illness is widely available to the public, identifying a
malingerer may not only save time and money but can make limited services more
available to those with legitimate needs.

No foolproof method exists for identifying malingerers. Forensic psychiatrists

and psychologists frequently deal with situations where the risk of malingering
is high, such as in criminal populations. There has been a good deal of research
in the development of specialized psychological instruments designed to detect
certain types of malingering. However, the ever-creative malingerer may also
keep up with the literature and access to the Internet or a medical library may
provide enough information to successfully malinger in a cursory examination.
In this article, we will present advice for clinicians when dealing with
suspected malingerers in treatment settings. This includes: when to suspect
malingering, clinical interview techniques that may help detect malingering and
specialized techniques to aid in the determination of malingering. We will also
explore what can be done when malingering is strongly suspected.

When To Suspect Malingering

Several authors have noted that psychiatrists are reluctant to consider the
possibility of malingering, even in situations where a nonprofessional would
consider such behavior understandable (Rosenhan, 1973; Yates et al., 1996). One
reason is that the diagnosis of malingering is a direct accusation that the
examinee is a liar, and psychiatrists rightly understand that they are not
"human polygraphs." An accusation of lying may damage, if not destroy, any
therapeutic relationship that exists between patient and doctor.

All interactions with psychiatric patients do not require that malingering be

ruled out. Approaching each patient with too skeptical an attitude can have
disastrous results if important symptoms like sui-cidal intent or psychotic
thought processes are ignored. The clinician should suspect malingering most
strongly when atypical, bizarre or absurd presentations are found in the context
of external motives, such as seeking prescription drugs, shelter or disability
payments (Cunnien, 1997).

Clinicians should also realize that patients may have a legitimate psychiatric
diagnosis but still malinger. For example, a patient with genuine schizophrenia
may malinger suicidal ideation to seek hospital admission due to homelessness.
These are more difficult cases; sorting out which symptoms are real and which
are fake may require considerable time and effort.

Characteristics of Malingering

All malingerers are actors who portray their illnesses as they understand them
(Ossipov, 1944) and often overact their part (Wachspress et al., 1953).
Malingerers sometimes mistakenly believe that the more bizarrely they behave,
the more psychotic they will appear.

Malingerers are eager to call attention to their illnesses, in contrast to

patients with schizophrenia, who are often reluctant to discuss their symptoms
(Ritson and Forrest, 1970). Malingerers may try to take control of the interview
and behave in an intimidating, bizarre manner. Malingerers sometimes accuse
clinicians of regarding them as faking; this behavior is rare in genuinely
psychotic persons.

It is more difficult for malingerers to successfully imitate the form than the
content of schizophrenic thinking (Sherman et al., 1975). Derailment, neologisms
and incoherent word salads are rarely simulated. Positive symptoms of
schizophrenia are faked more often than negative symptoms.
Patients malingering psychosis often choose to fake intellectual deficits also
(Bash and Alpert, 1980). For example, a man who had completed one year of
college alleged he did not know the colors of the U.S. flag. Malingerers are
more likely to answer, "I don't know" to detailed questions about psychotic
symptoms, such as hallucinations and delusions, or to act as if they are unsure
of the "correct" answer.

Detecting Malingering

To date, no studies have demonstrated that clinicians can consistently detect

malingering solely on the basis of an unstructured clinical interview.
Psychiatrists' ability to detect lies in strangers is little better than chance
(Ekman, 1985). Numerous authors have demonstrated that the nature and quality of
data obtained during interviews are affected by interviewer bias, use of leading
questions and situational factors (Lovinger, 1992; Masling, 1966; Robins, 1985).
In one study, the use of leading questions or symptom checklists allowed
malingerers unfamiliar with psychiatric disorders to qualify for diagnoses of
major depression and posttraumatic stress disorder (Lees-Haley and Dunn, 1994).
Examiners' confidence in their ability to detect malingering has no relationship
to their actual ability (Ekman, 1985).

When evaluating the potential for malingering, clinicians should utilize

multiple sources of data, including interviews, collateral sources of
information and psychometric tests (Resnick, 1997). Reliance on clinical
interviews alone will not allow the clinician to diagnose malingering in any but
the most obvious cases. Inconsistency between the reported symptoms and clinical
observations, the patient's reports and collateral history, symptom patterns
with known psychiatric illnesses, or the patient's reported symptoms and their
actual known functioning are all frequently seen in malingerers.

Clinicians should be particularly careful to ask open-ended questions in

suspected malingerers and let patients tell their complete story with few
interruptions. Details can be clarified later with specific questions. Inquiries
about hallucinations should be carefully phrased to avoid giving clues about the
nature of true hallucinations.

Clinicians may want to modify their interview style when patients are suspected
of malingering psychosis. The interview may be prolonged since fatigue
diminishes the malingerer's ability to maintain a counterfeit account (Anderson
et al., 1959). The clinician may get additional clues by asking leading
questions that emphasize a different illness than the malingerer is trying to
portray (Ossipov, 1944). Questions about improbable symptoms may be asked to see
if the malingerer will endorse them. For example: "Have you ever believed that
automobiles are members of organized religion?" (Rogers, 1986).

Malingered Psychosis
Detailed knowledge about actual psychotic symptoms is the clinician's greatest
asset in recognizing simulated psychosis. Consequently, we will provide detailed
information about the phenomenology of genuine hallucinations and delusions.
Patients reporting hallucinations with any atypical features should be
questioned in great detail about the nature of their symptoms. Patients with
either psychosis (Goodwin et al., 1971) or acute schizophrenia (Mott et al.,
1965; Small et al., 1966) will show a 76% rate of hallucinations in at least one
sensory modality. The incidence of auditory hallucinations in people with
schizophrenia is 66% (Mott et al., 1965; Small et al., 1966). Sixty-four percent
of hallucinating patients described hallucinations in more than one modality
(Small et al., 1966). The incidence of visual hallucinations in patients who are
psychotic is estimated at 24% (Mott et al., 1965) to 30% (Small et al., 1966).
Hallucinations are usually (88% of the time) associated with delusions
(Lewinsohn, 1970). Hallucinations are also generally intermittent, rather than
continuous (Goodwin et al., 1971).

Auditory Hallucinations

Goodwin and colleagues (1971) described the following characteristics of

auditory hallucinations. Both male and female voices were heard by 75% of
patients. Two-thirds of patients could identify the person speaking (Goodwin et
al., 1971; Kent and Wahass, 1996; Leudar et al., 1997). The message was usually
clear; it was vague in only 7% of the cases. The content of hallucinations was
accusatory in about one-third of the cases. Small et al. (1966) reported that
the major themes in auditory hallucinations of patients with schizophrenia were
persecution or instructions.

Auditory hallucinations usually consist of single words or phrases, especially

early in the disease process (Leudar et al., 1997; Nayani and David, 1996).
Hallucinated voices tend to become more complex over time, from single words to
entire sentences. The number of voices heard also increases (Leudar et al.,
1997). The syntax of long-standing auditory hallucinations is usually in
complete sentences and mirrors the syntax typically used by the patient (Nayani
and David, 1996). In affective disorders, the content of the hallucination is
usually mood-congruent and related to delusional beliefs (Asaad, 1990).

Schizophrenic hallucinations tend to consist of ego-dystonic, derogatory

comments about the patient or the activities of others (Goodwin et al., 1971;
Leudar et al., 1997; Oulis et al., 1995). Nayani and David (1996) found that
female subjects described terms of abuse conventionally directed at women (e.g.,
"slut"), while men described insults such as those imputing homosexuality (e.g.,
"queer"). About one-third of people with auditory hallucinations reported that
voices asked them questions such as, "Why are you smoking?" or "Why didn't you
do your essay?" (Leudar et al., 1997). Genuine hallucinated questions tend to be
chastising rather than information-seeking.

Command hallucinations are auditory hallucinations that instruct a person to act

in a certain manner. Studies of schizophrenic auditory hallucinations have found
that 30% to 64% included commands or instructions (Goodwin et al., 1971;
Hellerstein et al., 1987; Mott et al., 1965; Small et al., 1966). Command
hallucinations also occurred in 30% (Goodwin et al., 1971) to 40% (Mott et al.,
1965) of alcoholic-withdrawal hallucinations. Patients with affective disorders
reported that 46% of their hallucinations were commands (Goodwin et al., 1971).

Junginger (1990) reported that 39% of patients with command hallucinations

obeyed them. Those patients with hallucination-related delusions and
hallucinatory voices that they could identify were more likely to comply with
the commands. Kasper and colleagues (1996) reported that 84% of psychiatric
inpatients with command hallucinations had obeyed them within the last 30 days.
Junginger (1995) later found that 43% of the subjects reported full compliance
with their most recent command hallucination. Compliance with commands is much
less likely if the commands are dangerous (Junginger, 1995; Kasper et al.,
1996). Non-command auditory hallucinations and delusions are usually present
with command hallucinations (85% and 75%, respectively) (Thompson et al., 1992).

Leudar and colleagues (1997) found that most patients in their study engaged in
an internal dialogue with their hallucinations. Many were able to cope with
chronic hallucinations by incorporating them into their daily life as a kind of
internal advisor. They considered their advice in the context of the moment.
Interestingly, sometimes patients reported that hallucinated voices would insist
on certain actions after the patient refused to carry them out. They would
rephrase their requests, speak louder or curse the patient for being
noncompliant. In contrast, malingerers are more likely to claim that they were
compelled to obey commands without further consideration.

Patients suspected of feigning auditory hallucinations should be asked what they

do to make the voices go away or diminish in intensity. Genuine patients are
often able to stop auditory hallucinations when their schizophrenia is in
remission (Larkin, 1979). Frequent coping strategies are: specific activities,
changes in posture, seeking out interpersonal contact and taking medication
(Falloon and Talbot, 1981; Kanas, 1984). Schizophrenic hallucinations tend to
diminish when patients are involved in activities (Goodwin et al., 1971).

The suspected malingerer may also be asked what makes the voices worse. Eighty
percent of people with genuine hallucinations reported that being alone worsened
their hallucinations (Nayani and David, 1996). Voices were also made worse by
listening to the radio and watching television (Leudar et al., 1997). Television
news programs were particularly hallucinogenic.

Visual Hallucinations

Visual hallucinations are volunteered much more often by malingerers than by

individuals who are genuinely psychotic (46% versus 4%, respectively) (Cornell
and Hawk, 1989). Dramatic, atypical visual hallucinations should definitely
arouse suspicions of malingering.
Visual hallucinations are usually of normal-sized people and are seen in color.
Alcohol-induced hallucinations are more likely to contain animals (Goodwin et
al., 1971). Visual hallucinations in psychotic disorders appear suddenly and
typically without prodromata. Psychotic hallucinations do not usually change if
the eyes are closed or open. In contrast, drug-induced hallucinations are more
readily seen with the eyes closed or in darkened surroundings (Asaad and
Shapiro, 1986).

Occasionally, small (Lilliputian) people are seen in alcoholic, organic (Cohen

et al., 1994) or toxic psychosis (Lewis, 1961), especially anticholinergic drug
toxicity (Asaad, 1990). They are seen in only about 5% of patients with
schizophrenia (Goodwin et al., 1971; Leroy, 1922).

Malingered Delusions

Delusions are not merely false beliefs that cannot be changed by logic. A
delusion is a false statement made in an inappropriate context and, most
importantly, with inappropriate justification. Normal people can give reasons,
can engage in a dialogue and can consider the possibilities of doubt. People
with true delusions usually cannot provide adequate reasons for their
statements.

Delusions vary in content, theme, degree of certainty, degree of systemization

and degree of relevance to the person's life in general. According to Spitzer
(1992), most delusions involve the following general themes: disease (somatic
delusions), grandiosity, jealousy, love (erotomania), persecution, religion,
being poisoned and being possessed. Delusions of nihilism, poverty, sin and
guilt are commonly seen in depression. Technical delusions refer to the
influence of such items as telephone, telepathy and hypnosis and occur seven
times more often in men than in women (Kraus, 1994).

A malingering patient may claim the sudden onset of a delusion. In reality,

systematized delusions usually take several weeks to develop. As true delusions
are given up, they first become somewhat less relevant to the everyday life of
the patient, but the patient still adheres to the delusional belief. A decrease
in preoccupation with delusions may be the first change seen with adequate
treatment. In a later stage, the patient might admit to the possibility of
error, but only as a possibility. Only much later will the patient concede that
the ideas were, in fact, delusions (Sacks et al., 1974). Thus, malingering
should be suspected if a patient claims that a delusion suddenly appeared or
disappeared.

In assessing the genuineness of delusions, consider their content and associated

behavior. The content of feigned delusions is generally persecutory,
occasionally grandiose, but seldom self-deprecatory (East, 1927). Malingerers'
behavior usually does not conform to their alleged delusions, whereas acute
schizophrenic behavior usually does. However, "burned out" patients with
schizophrenia may no longer behave in a manner consistent with their delusions
after a year. The Table summarizes suspect hallucinations and suspect delusions.

Malingered PTSD

Posttraumatic stress disorder is easy to fake because it is defined almost

completely by subjective criteria. Lists of symptoms associated with PTSD can be
easily found in books, magazine articles, on the Internet and even as part of
popular rap songs. To evaluate the genuineness of alleged PTSD, the clinician
must examine the reasonableness of the relationship between the reported
symptoms and the stressor; the time elapsed between the stressor and development
of symptoms; and the relationship between current symptoms and psychiatric
problems before the stressor.

The clinician should insist on detailed descriptions of symptoms. Malingering

patients may know which symptoms to report but may be unable to give convincing
descriptions or examples from their personal life. Behavioral observations
during the examination may assist in evaluating symptoms of irritability,
exaggerated startle response and difficulty concentrating. Malingerers may also
exaggerate the severity of the stressor. Malingerers may give a neat recitation
of symptoms seemingly taken straight from the diagnostic manual. In addition,
malingerers are likely to concentrate on reliving the trauma, whereas patients
with genuine PTSD focus more on the phenomenon of psychic numbing.

In true posttraumatic dreams, the typical pattern is a few dreams that re-enact
the traumatic event, followed by nightmares that are variations on the traumatic
theme, in which other elements of the patient's daily life are incorporated.
Malingerers may claim repetitive dreams that exactly re-create the trauma night
after night without variation. Posttraumatic dreams are frequently accompanied
by body movements and thrashing in bed, in contrast to non-traumatic dreams (van
der Kolk et al., 1984). The person may awake suddenly in a state of panic.
Middle insomnia is specifically associated with PTSD, as opposed to initial
insomnia or early awakening.

The themes of intrusive recollections and dreams are different in true and
malingered PTSD. Military veterans with combat PTSD often report themes of
helplessness, guilt or rage. Dreams in true PTSD generally convey a theme of
helplessness with regard to the particular traumatic events that occurred during
combat. In malingered PTSD, the themes of intrusive recollections are more often
anger toward generalized authority; dreams emphasize themes of grandiosity and
power. The re-experienced "trauma" in malingerers is often not consistent with
their self reports of the original trauma (Smith, personal communication).

Differences have been observed between veterans with true and malingered PTSD in
their expression and acknowledgment of feelings. In true PTSD, the veteran often
denies or has numbed the emotional impact of combat. In malingered PTSD, the
veteran will often make efforts to convince the clinician how emotionally
traumatizing combat was for him by acting out the alleged feelings. The true
PTSD veteran generally downplays symptoms, while the malingerer overplays them.
For instance, the veteran with true PTSD tries not to bring attention to his
hyperalertness and suspicious eye movements. In contrast, the PTSD malingerer
presents his suspiciousness with a dramatic quality, as if he were trying to
draw attention to it. As a further example, a PTSD malingerer may volunteer that
he thinks of nothing but Vietnam and relishes telling his combat memories.

An important characteristic of PTSD is the avoidance of environmental conditions

associated with the trauma. For example, the veteran with PTSD may stay home on
hot rainy days because of the resemblance to the weather in Vietnam. Camping may
be avoided because the veteran finds himself looking for trip wires in the bush.
In addition, crowds may be avoided because combat usually occurred in a crowd.
In malingered PTSD, the veteran is unlikely to report having such postcombat
reactions to environmental stimuli.

Confronting a Suspected Malingerer

The only gold standard for diagnosis of malingering is a confession by the

suspected malingerer. When a clinician has done a thorough assessment and
suspects malingering, the problem of what to do next arises. Suspicions of
malingering should be communicated to the patient in a nonconfrontational style,
giving the patient the opportunity to save face. It is better to say, "The
evidence we have does not support a diagnosis of schizophrenia" than, "You're
lying to me. Get out!"

Reactions will vary from patient to patient, but some patients will "come clean"
to a clinician who appears willing to help, despite being lied to. Other
malingerers will react angrily, which is understandable, since their drive for
external rewards has been thwarted. This situation should be dealt with as you
would any angry patient, protecting your own physical safety and setting firm
limits on verbal threats or other provocations.

It is important to remember that just because a patient malingers one

psychiatric condition does not mean they cannot have a different one. If your
evaluation has demonstrated conditions such as substance abuse disorders,
personality disorders, psychosocial dysfunction or other conditions, the patient
should be offered or referred for appropriate treatment. Legitimate psychiatric
diagnoses should be treated appropriately. Future psychotherapy sessions may
offer the opportunity to process the patient's attempts to malinger, which may
enhance the therapeutic relationship and promote increased honesty between
patient and clinician.

Conclusion

The detection of malingered mental illness is often a challenging task. The

decision that an individual is malingering is ascertained by assembling all of
the clues from a thorough evaluation of a patient's past and current functioning
with corroboration from clinical records and other persons. Clinicians must be
thoroughly grounded in the phenomenology of psychiatric symptoms and aware of
the common differences between genuine and malingered psychiatric symptoms.
Although the identification of a person with malingered mental illness may be
viewed by some clinicians as a distasteful chore, accurate assessment is
essential in treating patients and critical in conducting forensic assessments.

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