Holly A. Miller, Ph.D.

College of Criminal Justice

Sam Houston State University
 Malingering
 Theory and assessment
 Miller Forensic Assessment of Symptoms Test
 Development of the M-FAST
 Utility of the M-FAST
 Brief overview of studies
 Administration and scoring of the M-FAST
 Practice administration
 Interpretation
 Questions
 The DSM-IV-TR defines malingering as:
 Intentional production of false or grossly
exaggerated physical or psychological symptoms,
motivated by external incentives (APA, 2000)
 Why might someone malinger?
 Prevalence of malingering
 Around 8% of general evaluations
 Around 20% of forensic evaluations
 Miller, 2000; Rogers & Cruise, 2000; Rogers, Salekin,
Sewell, & Goldstein, 1996
 When to assess for malingering
 Rogers suggests under these circumstances
 Atypical presentation of symptoms
 Unusually high number of unusual or obvious
symptoms
 Nonselective endorsement of symptoms
 Discrepancies between reported and documented
history of mental illness
 Why not just use clinical judgment?
 DSM criteria
 Marked discrepancy between reported impairment and
objective findings
 Lack of cooperation during evaluation or treatment
 Medico-legal context presentation
 Presence of APD
 What research reports on accuracy of clinical
judgment
 Utilizing DSM criteria results in high false-positive rates
 Studies strongly support that objective assessment
instruments are significantly more accurate than clinical
judgment (Miller, 2005; Rogers 1984; Ziskin, 1984)
 Miller,H. A. (2005). The Miller-Forensic
Assessment of Symptoms Test (M-FAST): Test
generalizability and utility across race,
literacy, and clinical opinion. Criminal Justice
& Behavior, 32 (6), 591-611.
 Study 1 – initial M-FAST items (79 items)
 280 forensic patients; 5 psychiatrists; 8 psychologists
 M-FAST; SIRS; Mtest; MMPI-2
 Study 2 – final M-FAST (25 items)
 50 forensic patients; 5 psychiatrists; 8 psychologists
 M-FAST; SIRS; Mtest; MMPI-2
 Study 1 Clinical opinion v. M-FAST results
 Psychiatrist Opinion 1.0 0
ROC Curve

 AUC = .72 (SE = .05) .75

.50

 CI = .62 - .81 .25

Sensitivity
 19 FP; 17 FN
0.0 0
0.0 0 .25 .50 .75 1.0 0

1 - Sp ecif icity

 Psychologist Opinion
Di ag on al seg men ts are prod uce d by tie s.

ROC Curve
1 .0 0

 AUC = .80 (SE = .04) .75

 CI = .72 - .88
.50

.25
Sensitivity

 15 FP; 11 FN 0 .0 0
0 .0 0 .25 .50 .75 1 .0 0

 M-FAST (79 items)

1 - S pe cificity
Di ag on al se gm en ts a re pro du ced b y ti e s.

ROC Curve

AUC = .89 (SE = .02)

1 .0 0

 .75

 CI = .85 - .93 .50

.25
Sensitivity

0 .0 0
0 .0 0 .25 .50 .75 1 .0 0

1 - S pe cificity
Di ag on al se gme nts a re pro du ced b y ti e s.
 Study 2 Clinical opinion v. M-FAST results
 Psychiatrists ROC - Psychiatrists

AUC = .65 (SE = .09)

1.00

 .75

 CI = .47 - .83 .50

 7 FP; 7 FN .25

 Psychologists
0.00
0.00 .25 .50 .75 1.00

ROC - Psychologists

 AUC = .73 (SE = .08)

1.00

 CI = .57 - .89
.75

.50

 9 FP; 4 FN .25

 M-FAST (final version) 0.00

0.00 .25 .50 .75 1.00

AUC = .95 (SE = .03)

ROC – M-FAST

 1.0
0

 CI = .88 – 1.00
.75

.50

 6 FP; 1 FN .25

0.0
0 0.0 .25 .50 .75 1.0
0 0
 How to catch a malingerer
 Previous research has indicated important areas
of assessment:
 Certain response styles
 Certain interview strategies
 Several instruments include assessment of
response styles or were specifically designed to
assess malingering
 MMPI-2
 PAI
 SIRS
 However, there remains a need for a brief screen
for malingered mental illness
 M-FAST items were developed to
operationalize the response styles and
interview strategies that have been validated
for identifying individuals who are malingering
 Reported vs Observed symptoms (RO)
 Extreme Symptomatology (ES)
 Rare Combinations (RC)
 Unusual Hallucinations (UH)
 Unusual Symptom Course (USC)
 Negative Image (NI)
 Suggestibility (S)
 M-FAST is a structured interview of 25 items
representing the “proven” detection strategies
 Administration is approximately 5-10 minutes
 Scoring is approximately 10 minutes
 Does not require the ability to read (examinee)
 Has been translated into Korean and Spanish
 M-FAST was developed using both known-
group and simulation studies
 Materials include manual and 8-page
interview booklet
 Validated on people 18 yrs and older
 Validated with different ethnic/race groups
 Validated across gender
 Validated with varied populations
 In prison
 On probation
 In forensic hospital
 In civil hospital
 Outpatient disability assessment
 Appropriate populations and limitations
 Malingered psychopathology (not neuro)
 Examinee must be able to understand items
 Adults 18 yrs or older
 Screening instrument and was not developed to
be the sole determinate of malingered mental
illness
 Professional requirements
 Mental health clinician with formal training in
diagnostic interviewing and assessment
 M-FAST should be preceded by a clinical
interview
 To gather both symptom information and
observable behavior (RO assessment help)
 Read aloud instructions for administration to
client
 Suggestibility item
 1st response dictates how you ask last part of item
 Read items and possible responses of each item
 May repeat once – but offer no explanation
 With partner, practice administration
 Partner role play a malingerer
 Want to appear mentally ill, without elevating
M-FAST score
 Then reverse roles
 Scoring instructions provided on last page of
interview booklet
 Score individual items
 Score scales
 If more than 2 items missing, not considered
valid administration
 Malingering is distinct from most forms of
psychopathology; however the presence of
malingering does not rule out a psychiatric
disorder
 Significant consequences for malingering
diagnosis
 Choosing of a cut score for M-FAST
 More acceptable to have false positives than
false negatives
 Cut score of 6 utilized
 Three levels
 Total scale
 Provides an estimate of the likelihood that the examinee is
malingering
 Interpretive statement: The examinee’s total score on the M-
FAST was significantly elevated, indicating that this
individual may be malingering mental illness.
 Scales
 Provides information on how the individual is malingering
 Can make interpretive statements about scale elevations,
but utilize total score for overall assessment
 Each scale has own “cut score”
 Suggestibility item (scale)
 Manual provides interpretative statement examples
 Items
 Next step
 Further malingering assessment is warranted if
client elevated M-FAST
 Competency to stand trial – forensic inpatients
 Jackson, R., Rogers, R., Sewell, K. W. (2005). Forensic
applications of the M-FAST: Screening for feigned disorders
in competency to stand trial evaluations. Law and Human
Behavior, 29(2), 199-210.
 Vitacco, M. J., Rogers, R., Gabel, J., Munizza, J. (2007).
An evaluation of malingering screens with competency to
stand trial patients: A known-groups comparison. Law and
Human Behavior, 31(3), 249-260.
 Miller, H. A. (2004). Examining the use of the M-FAST with
criminal defendants incompetent to stand trial.
International Journal of Offender Therapy and
Comparative Criminology, 48(3), 268-280.
 Validity Studies
 Vitacco, M. J., Jackson, R. L., Rogers, R., Neumann, C. S., Miller,
H. A. Gabel, J. (2008). Detection strategies for malingering with
the M-FAST: A confirmatory factor analysis of its underlying
dimensions. Assessment, 15(1), 97-103.
 Miller, H. A. (2005). The Miller Forensic Assessment of Symptoms
Test (M-FAST): Test generalizability and utility across race,
literacy, and clinical opinion. Criminal Justice and Behavior, 32(6),
591-611.
 Veazey, C. H., Hays, J. R., Wagner, A. L., & Miller, H. A. (2005).
Validity of the Miller Forensic Assessment of Symptoms Test in
psychiatric inpatients. Psychological Reports, 96(3), 771-774.
 Guy, L. S., & Miller, H. A. (2004). Screening for malingered
psychopathology in a correctional setting: Utility of the Miller
Forensic Assessment of Symptoms Test (M-FAST). Criminal Justice
and Behavior, 31(6), 695-716.
 Civil forensic settings
 Alwes, Y. R., Clark, J. A., Berry, T. R., Granacher,
R. P. (2008). Screening for feigning in a civil
forensic setting. Journal of Clinical and
Experimental Neuropsychology, 30(2), 1-8.
 Diagnostic-specific malingering assessment
 Messer, J. M., & Fremouw, W. J. (2007). Detecting malingered
posttraumatic stress disorder using Morel Emotional Numbing Test-
Revised and the Miller Forensic Assessment of Symptoms Test (M-
FAST). Journal of Forensic Psychology Practice, 7(3), 33-57.
 Guriel-Tennant, J., & Fremouw, W. J. (2006). Impact of trauma
history and coaching on malingering of posttraumatic stress
disorder using the PAI, TSI, and M-FAST. Journal of Forensic
Psychiatry & Psychology, 17(4), 577-592.
 Guy, L. S., Kwartner, P. P., & Miller, H. A. (2006). Investigating the
M-FAST: Psychometric properties and utility to detect diagnostic
specific malingering. Behavioral Sciences & the Law, 24(5), 687-
702.
 Guriel, J., Yanez, T., Fremouw, W. J., Shreve-Neiger, A., Ware, L.,
Filcheck, H., & Farr, C. (2004). Impact on coaching on malingered
posttraumatic stress symptoms on the M-FAST and TSI. Journal of
Forensic Psychology Practice, 4(2), 37-56.
 Holly A. Miller, Ph.D.
Assistant Dean of Undergraduate Programs
Associate Professor
College of Criminal Justice
Sam Houston State University
Huntsville, Texas 77341-2296
936-294-1686; hmiller@shsu.edu