Legal Medicine 48 (2021) 101810

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Legal Medicine
journal homepage: www.elsevier.com/locate/legalmed

Cues for feigning screening in whiplash associated disorders

David Pina b, c, Esteban Puente-López b, *, José Antonio Ruiz-Hernández a, b, c,
Carmen Godoy-Fernández c, Bartolomé Llor-Esteban a, b
a
Murciás Institute of Biosanitary Research - Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
b
External Service of Forensic Sciencies and Techniques - Servicio Externo de Ciencias y Técnicas Forenses (SECyTEF), Murcia, Spain
c
University of Murcia, Dep. Psychiatry and Social Psychology, Murcia, Spain

A R T I C L E I N F O A B S T R A C T

Keywords: The objective of this work is to evaluate the ability of a series of possible feigning indicators, extracted from
Malingering and feigning detection relevant literature in the field, to discriminate between clinical patients with genuine symptomatology and
Whiplash associated disorders instructed malingerers. A sample of 273 participants divided into two groups was used for this study: 153
Non-verbal and behavioral cues
whiplash associated disorder patients who were evaluated at a multidisciplinary medical center in the region of
Lie detection
Murcia (Spain), between December 2017 and March 2019 and 120 healthy controls with malingering in­
Feign
structions, students of the Faculty of Medicine of the University of Murcia. In order for researchers to evaluate the
indicators included in the study, a 22-step checklist (CDS) was developed, consisting of 22 criteria divided into 5
dimensions. Our results show that 18 of 22 indicators could discriminate between groups. Dimension 2 “Attitude
toward the situation of illness” presented the greatest capacity for discrimination. In general terms, malingerers
express a much more negative experience of the condition than the clinical patients.

1. Introduction pain, which serves to exacerbate it [5,22,31]. Because of this, evidence

Malingering, defined the intentional production or imitation of false
or exaggerated physical and/or psychological symptomatology to obtain
an external benefit [4], is a worldwide problem, with an estimated 40%
of incidence in the forensic context and serious implications in the
doctor-legal evaluation of the patient [47]. Of all the conditions usually
malingered in this context, pain-related pathologies, in particular
Whiplash-Associated Disorders (WAD) are the ones that imply the
greatest risk, and it is estimated that between 20 and 40% of the patients
feign the symptoms presented [26].
Whiplash injury is considered “easy to fake and difficult to disprove”
because the vast majority of the physical symptoms that conform it are
difficult to objectify, and its assessment focuses on finding structural or
anatomical divergences through not very effective diagnostic practices
[37,40,50,53]. In addition, it is a complex condition to evaluate because
it is influenced by multiple psychosocial factors that can affect the
presentation of symptoms. For example, the evidence indicates that the
presence of high-severity pain may produce a traumatic condition that
generates anxious-depressive symptomatology, and the presence of such
symptomatology leads patients to adopt maladaptive coping styles that
generate a negative emotional state in which more attention is paid to
suggests that the assessment of malingering should follow a multidi­
mensional, or multi-method, approach and not be limited to a single
source of information [42].
Malingering in WAD, and pain in general, has been investigated
through a psychometric perspective based mainly on the application of
the Symptom Validity Test (SVT), the effectiveness of which is very
limited [49]and so far, it has not been possible to develop a specific
method that can effectively discriminate malingered from genuine
symptoms. Given the importance of adequately controlling for the risk of
symptom exaggeration and malingering in the forensic context, it is
necessary to develop new techniques or approaches that achieve this
goal [6,8]. To solve this problem, a recent line of research has attempted
to apply its tools in the field of lie detection in the medical-legal context.
Akehurst et al. [1] designed a checklist using behavioral and verbal
indicators extracted from the relevant literature of lying and malin­
gering/feigning and, although the results of this tool were positive
(approximately 80% accuracy), many of the indicators included in the
study were not useful for detecting malingering in the medical-legal
field. On the other hand, Boskovic et al. [8] evaluated the effective­
ness of the Verifiability Approach [36] to assess the symptom exagera­
tion, obtaining significant results but finding the same problem as the

* Corresponding author at: Departamento de Psiquiatría y Psicología Social, Universidad de Murcia, Campus de Espinardo, Murcia 30100, Spain.
E-mail address: esteban.puente@um.es (E. Puente-López).

https://doi.org/10.1016/j.legalmed.2020.101810
Received 2 July 2020; Received in revised form 5 November 2020; Accepted 11 November 2020
Available online 18 November 2020
1344-6223/© 2020 Elsevier B.V. All rights reserved.
D. Pina et al.
previous authors: the tools used are not entirely effective due to the fact
that they are designed to evaluate testimonies, or subjects with very
specific characteristics, which is not usually common in the medical-
legal context. Other research has attempted to validate exclusively
behavioral indicators, known as non-organic signs, that can be used to
identify malingering of physical symptoms such as pain [54], but the
studies present various theoretical and empirical limitations that
compromise the usefulness of their results. Hence, to date, it has not
been possible to associate specific behavioral or verbal indicators with
feigning or malingering [23].
In view of the limited evidence and usefulness of a tool such as the
one proposed by Akehurst et al. [1], there is a need in the medical-legal
context to identify and validate feigning indicators that are specific to
that setting. In view of all the above, the objective of this work is to
evaluate the ability of a series of cues, extracted from relevant literature
in the field, to discriminate between clinical patients with genuine
symptomatology and instructed malingerers. We hypothesize that the
indicators included in the study will be able to discriminate significantly
between these groups (Hypothesis 1) and that the malingering group
will obtain higher scores on the indicators than the clinical patient group
(Hypothesis 2).
2. Methodology
2.1. Participants
A sample of 273 participants divided into two groups was used for
this study.
2.2. Clinical patients
The initial sample included 180 clinical patients randomly selected
who were evaluated at a multidisciplinary medical center in the region
of Murcia (Spain), between December 2017 and March 2019. All of them
came to the center, referred to by their insurance company, for an
assessment of bodily harm following a motor vehicle accident (MVA).
As inclusion criteria we used: (a) the person was being evaluated to
assess a WAD; (b) they were between 18 and 60 years of age; (c) agreeing
to sign an informed consent; and (d) not have been diagnosed with
another disease, anomaly, or medical alteration that could distort the
responses to the applied tools. Failure to comply with any of these
criteria meant exclusion from the study. No patient was ruled out when
applying the criteria described, but 24 patients attended refused to
participate after the initial explanation of the objectives of the study,
and no data could be collected beyond sex (10 women and 14 men) and
the reason for non-participation (16 of them claimed to be in a hurry and
8 did not want to undergo any type of assessment that was not imposed
by the insurance companies).
Thus, the final sample included 153 participants, 78 men (51%) and
75 women (49%), with an average age of 37.1 years (SD = 11.6) and an
age range of 18 to 62 years. Regarding educational level, 48.4% had
university studies, 13.1% had high school or vocational training (be­
tween 16 and 18 years of age) and 23.5% had secondary education
(between 12 and 15 years of age). Concerning marital status, 49.7% of
the participants were married, 42.5% were divorced, and the remaining
7.8% were single. As far as the economic level was concerned, the
average level (between 15,000 and 20,000 euros per year) predomi­
nated, at 46.4%, followed by 28.1% with a low economic level (15,000
euros per year). More than half of the sample lives in Murcia capital
(56.9%). Lastly, 83.5% of participants had paid employment at the time
of the evaluation, and the rest (16.5%) were unemployed.
2.3. Instructed malingerers
This group was composed of 120 healthy controls with malingering
instructions, students of the Faculty of Medicine of the University of
2
Legal Medicine 48 (2021) 101810
Murcia between February and April 2019. They were presented with the
experiment in a subject taught by a professor of the research team and
enrolled by email. The age range was 19 to 50 years, with a mean age of
23.77 (SD = 7.14). The majority of the participants were women
(66.9%), single (87.6%), and resided in Murcia capital (60.3%). None of
the selected participants had suffered or suffered from WAD. As inclu­
sion criteria we used: (a) agreeing to sign an informed consent and (b)
passing a manipulation check. No participant was ruled out due to the
application of these criteria.
2.4. Measurement instruments
2.4.1. Checklist of feigning detection (CDS)
The markers included were selected among those that showed the
greatest discriminatory capacity in the study of Akehurst et al. [1], from
the cognitive dimensions of Leventhal (Commonsense Self-Regulation
Model [CS-SRM]; [29,30]), and from the publications of Ferrari [21],
McDermott, and Feldman [34], Resnick [39], and Vrij [52], among
others. The complete list of indicators and their source are included in
Appendix 1.
In order for researchers to evaluate the indicators included in the
study, a 22-step checklist (CDS) was developed, consisting of 22 criteria
divided into 5 dimensions (Unusual details and thoughts about the
event, Attitude toward the situation of illness, Attitude toward the
evaluation, Cause and Inconsistencies). The dimensions had 4 response
levels ranging from 0 (not present) to 3 (strongly present), one for each
indicator. The items on Dimensions 2 to 5 are worded so that a high
score indicated an increased risk of feigning. On the other hand,
Dimension 1 contains two CBCA criteria (Criteria-Based Content Anal­
ysis; [48]) whose presence indicates honesty, so its items were assessed
in reverse to match the design of the other dimensions. The complete
checklist is shown in Appendix 2.
2.4.2. Brief pain inventory – Short form (BPI)
The BPI [10–13] is an 11-item self-report measure, where each item
is scored on a visual analogue scale (VAS) that was developed with
scores ranging from 0 to 10 to allow patients to measure the severity of
the clinical pain suffered, as well as the degree of social impairment
[12]. It provides two indexes, Pain severity and Pain interference. Its
Cronbach alpha ranges from α = 0.77 to 0.91. In our study we obtained
an alpha of 0.87.
2.4.3. Manipulation check
To ensure that malingerers had properly understood and remem­
bered their instructions, we used a manipulation check with five open-
ended questions on which they were evaluated: recall (What were
your instructions?), comprehension (Tell me in your own words what you
were asked to do), compliance with the instructions (Describe how moti­
vated you felt to do this research), reported effort (From 1 to 10, how hard
have you tried?), internal motivation (Were you motivated by the chal­
lenge of “beating” the test?), and external incentives (Did you take your
role more seriously for fear of losing the reward?). These instructions
were subsequently assessed by one of the researchers, giving them a
score of 1 to 5 (very bad, bad, regular, good and very good) based on the
adequacy of the response to a correction template provided to them
(available for use by emailing the corresponding author).
2.5. Procedure and design
A simulation design was used to compare the indicators between
clinical sample and healthy controls under malingering instructions
(instructed malingerers).
Participants assigned to the groups of clinical patients were recruited
randomly at a specialized multidisciplinary medical center in the Region
of Murcia (Spain). These patients went to the clinic after suffering an
MVA to assess the possible physical or psychological damage. To avoid
D. Pina et al. Legal Medicine 48 (2021) 101810

possible biases, the application of the CDS was carried by three physi­ and clinical patients could be correctly identified on the basis of the
cians of the medical center, experts in the assessment of bodily harm and indicators that yielded significant results (p < .05), we ran a binary lo­
forensic medicine, with more than 25 years of experience. These pro­ gistic regression, using Group as dependent variable and the indicators
fessionals applied the checklist during their clinical evaluation routine, as covariates. This analysis was run using the Forward Selection (Wald)
after a detailed explanation of the purpose and procedure of the study. method with 0.44 as a cut-off point for classification. This cut-off point
All participants were asked to sign the informed consent. was chosen taking into account the proportion of each group. Finally,
The clinical evaluation routine of the physicians consisted of a Cohen’s [14] d was calculated, using the means and standard deviations
clinical-forensic-interview including an exploration of the characteris­ of the indicators in the two groups, to assess the effect size [46]. Because
tics of the accident, a medical assessment of bodily harm, and a study of the original values proposed by Cohen [15] are indicative and must be
possible psychological damage. This last study was conducted via the adapted to the studied context [7], we used the categorization that
interview, without the application of psychometric instruments and, in Rogers et al. [45] proposed specifically for the assessment of malin­
case of severe psychological symptomatology, the patient was referred gering (moderate ≥ 0.75; large ≥ 1.25; very large ≥ 1.50).
to another center for a complete psychological assessment. To offer an estimated cut-off point from which the possibility of
Instructed malingerers were evaluated at university facilities using a feigning can be considered, two ROC (Receiver Operating Character­
procedure equivalent to that of the clinical patients. They were first istic) analyzes were performed. The first used the sum of all the in­
subjected to a bodily damage assessment protocol and were subse­ dicators (raw score) and the second was done by recoding each
quently asked to complete the scales included in the study. They were indicator, so that scores of 1, 2 and 3 were coded as 1 (positive result of
told that they should simulate having suffered an accident that had feigning). Scores of 0 were not changed and were considered a negative
produced neck pain or WAD and they had to convince the study eval­ result (no feigning). In both cases, the sensitivity, specificity, area under
uator (presented as a Resident Internal Physician [MIR] of Traumatol­ the curve, standard error of the area under the curve, accuracy and
ogy) that they actually suffered from the condition. As a reward for positive / negative predictive power (PPP and PPN) of the optimal cut-
participating in the experiment, they were offered a bonus of 0.5 points off points were calculated. Because the exact prevalence of feigning in
in the subject in which the study had been presented. Following Rogers the context and location studied is unknown, the last three statistics
and Bender [42] advice and to get the students to recreate the real were calculated for a prevalence of 10%, 30%, and 50%.
context as faithfully as possible, they were warned that only those who
managed to correctly fake the WAD and deceive the evaluator would 3. Results
receive the reward bonus. If they failed to convince the evaluator they
did not get any reward. When the experiment was completed, the par­ Tables 1 and 2 present the collisions-related factors and injury-
ticipants were subjected to the previously presented manipulation related characteristics of the clinical patients. All participants in this
check. Those who did not achieve a score of 4 in all of the variables of group underwent a full clinical assessment after suffering an MVA. The
that manipulation check were excluded from the experiment (Criterion assessment was carried out after an average of 35.76 days (SD = 10.17)
b). To avoid the problem of coaching [51], no information or training since the accident, with a range of 27 to 59 days. All of the participants
was offered on how to malinger, only the importance of being consistent claimed to have cervical pain, with an average severity of 5.82 (SD =
with what was expected from subjects who had suffered a WAD was 1.13) in the BPI. The majority of the accidents occurred during the
emphasized. daytime (70.6%), in the city (68.6%), and were produced by a rear-end
The instructions they received (Appendix 3) were designed accord­ crash (69.3%) while the driver was looking forward (80.4%). Most pa­
ing to the requirements proposed by Rogers and Cruise [43] of clarity, tients claimed that they were wearing a seat belt (94.1%). The patients
specificity, contextualization, and motivation. After developing the in­
structions, they were evaluated using the key aspects of the simulation Table 1
design proposed by Rogers and Bender [42] and operationalized by Collision-related factors in clinical patients.
Gonzalez-Ordi, Santamaría-Fernández, and Capilla-Ramirez [24].
n %
A second investigator was in charge of evaluating the group of
Moment of the day the collision occurred
instructed malingerers. This investigator was a member of the research
Daytime 108 70.6
group, blinded to the conditions and objectives of the study, and with Nighttime 40 26.1
previous experience in the clinical and forensic context. This researcher At dawn 3 2.0
was instructed by the same doctor who assessed the clinical patients to At dusk 2 1.3
apply exactly the same bodily damage assessment procedure. At the end Seat occupied
Driver’ seat 37 24.2
of the session, the malingerers were requested to fill out a questionnaire
Front seat occupant 50 32.7
in which they were asked about their motivation to simulate, their Back seat occupant 66 43.1
preparation, and the means through which they had obtained Impact location
information. Front 34 22.2
Rear 106 69.3
Side 13 8.5
2.6. Data analysis Type of road
Rural 16 10.5
The data were encoded and analyzed on a database with generic City 105 68.6
labels (Group 1 instead of clinical patients and Group 2 instead of ma­ Highway 32 20.9
Seat belt fastened
lingerers) by a member of the research team foreign to the study, thus No 9 5.9
avoiding any bias derived from the analyst recognizing the groups. All Yes 144 94.1
statistical analyses were performed with the SPSS statistical package Position of the head
version 25. Forward 123 80.4
Turned to the left 16 10.5
To decide which statistical test should be used to analyze the dif­
Turned to the right 14 9.2
ference of means between the two groups, the normality of the distri­ Car status
bution was confirmed with the Shapiro-Wilk test and the variance Irreparable damage 4 2.6
homogeneity of the variables was determined with Levenés test. As the Serious damage 18 11.8
distribution of the sample was normal, these differences were analyzed Average damage 109 71.2
Minor damage 22 14.4
with an independent Studentś t-test. To examine whether malingerers

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D. Pina et al. Legal Medicine 48 (2021) 101810

Table 2 Table 3
Injury-related characteristics of the clinical patients. Studentś T-Test results between clinical patients and instructed malingerers.
n % Item and indicator M M (SD) t df d p
(SD) Malingerers
On sick leave
C.P.
Yes 23 15.0
I1 Unusual 1.07 0.45(0.90) − 4.49 271 0.51 0.000
No 130 85.0
symptoms (1.33)
In judicial process
I2 Own mental 1.12 0.69 (1.03) − 3.39 271 0.34 0.013
Yes 3 2.0
state (1.38)
No 150 98.0
I3 False attribution 0.12 0.20(0.60) − 1.16 271 0.15 0.244
to real symptoms (0.52)
With attorney 138 90.2
I4 Lack of 0.07 0.58(0.88) − 6.20 271 0.99 0.000
Yes 15 9.8
cooperation (0.24)
No
I5 Hostile or 0.09 0.26(0.60) − 3.41 271 0.41 0.001
Informed in urgency service 143 93.4
defensive (0.29)
attitude
Not informed by an expert 10 6.6
I6 Blaming a third 0.81 1.27(1.40) − 2.56 271 0.36 0.011
Perception of situation
person for the (1.21)
Somewhat troublesome 19 12.4
symptoms
Troublesome or frustrating 116 75.8
I7 Blaming a third 1.87 1.98(1.32) − 1.56 271 0.09 0.084
Very troublesome or very frustrating 18 11.8
person for the (1.09)
Symptomatology reported
accident
Pain 153 100
I8 Negative 0.59 1.53(1.21) − 11.29 271 1.18 0.000
Dizziness 30 19.6
improvement (0.52)
Paresthesias 46 30.1
prognosis
Excessive sensitivity 6 3.9
I9 Confirmation of 0.19 1.04(0.95) − 8.68 271 1.20 0.000
Other (low back pain) 5 3.3
many symptoms (0.57)
Affected areas
I10 Unlikely 0.14 0.75(0.99) − 6.16 271 0.89 0.000
Cervical 153 100
symptoms (0.49)
Lumbar 5 3.3
I11 Contradictory 0.05 0.52(0.82) − 6.07 271 0.84 0.000
M SD
pattern of (0.26)
Pain Severity 5.82 1.13
symptoms
Time Since the accident 35.76 10.17
I12 Extreme 0.18 1.60(1.09) − 12.85 271 1.81 0.000
Abbreviations: M, Mean; SD, standard deviation. symptoms (0.60)
I13 Extreme 1.01 1.89(1.03) − 9.35 271 1.00 0.000
sensitivity to (0.81)
who occupied the back seat (43.1%) predominated, followed by the pain
front seat occupant (32.7%). Finally, most of the cars suffered from I14 High sensibility 1.12 1.53(0.85) − 4.74 271 0.67 0.000
medium-serious damage, fully reparable (71.2%), whereas 2.6% suf­ in unaffected (0.47)
area
fered irreparable damage. In terms of diagnosis, all of the clinical pa­
I15 Loss of 1.10 1.83(1.01) − 7.51 271 1.13 0.000
tients were diagnosed only with WAD, with the cervical area as the most unaffected (0.39)
affected. Five patients (3.3%) also reported suffering from lower back dermatome
pain. All patients were diagnosed by the three experts of the multidis­ sensitivity
ciplinary medical center. I16 Significant 0.38 1.66(1.01) − 11.57 271 1.52 0.000
increase in pain (0.76)
None of the patients suffered neurological signs, except for 6 over­ intensity
reporting patients who claimed to have mild dizziness, 3 of them when I17 Inability to 0.53 1.70(0.98) − 11.05 271 1.48 0.000
moving their heads abruptly. Similarly, no fractures or serious muscu­ control (0.69)
loskeletal injuries were observed. symptoms
I18 Resistance to 1.02 1.05(0.25) − 1.17 271 0.17 0.244
evaluation (0.13)
3.1. Differences between groups and regression analysis I19 Emphasis on 1.13 1.34(1.26) − 1.42 271 0.18 0.156
the negative (1.12)
The results presented in Table 3 show significant differences between aspects of the
symptoms
groups in 18 of the 22 cues included in the study. It can be observed that I20 No 0.76 1.77(0.99) − 9.32 271 1.23 0.000
the group of instructed malingerers obtained higher scores on the in­ improvement (0.73)
dicators than the group of clinical patients. Only the cues I3 False IA1 Perception of 0.99 1.55(0.67) − 7,69 271 1.01 0.000
attribution to real symptoms, t(271) = − 1.16, p = .24; I7 Blaming a third illness status (0.49)
IA2 Symptom 1.60 1.17(1.02) 4.17 271 0.52 0.000
person for the accident, t(271) = − 1.56, p = .08; I18 Resistance to
identity (0.57)
evaluation, t(271) = − 1.17, p = .24; and I19 Emphasis on the negative
aspects of the symptoms, t(271) = − 1.42, p = .15, could not discriminate Abbreviations: C.P., Clinical Patients; SD, standard deviation; df, degree of
between the two groups. freedom.
The indicators with a large and moderate effect size were: I12
Extreme symptoms, t(271) = − 15.85, p = .00, d = 1.81; I16 Exponential 4.17, p = .00, d = 0.52.
increase in pain that does not correspond to the usual course of the We also used a logistic regression analysis to assess whether group
pathology, t(271) = − 11.57, p = .00, d = 1.52; I17 Inability to control membership can be predicted based on the CDS indicators, including
symptoms, t(271) = − 11.05, p = .00, d = 1.48; I20 No improvement, t only those that had yielded significant results. The analysis concluded in
(271) = − 9.32, p = .00, d = 1.23; I9 Confirmation of many symptoms, t eight steps, with a Nagelkerke R2 of 0.858 as fit value, and correctly
(271) = − 8.68, p = .00, d = 1.20; and I8 Negative improvement prog­ classifying 91.4% of the sample, c2(1, N = 153) = 4.59, p < .05. Table 4
nosis, t(271) = − 11.29, p = .00, d = 1.18. The cues with the least effect shows the cues obtained in the analysis, the OR, and the probability
size, excluding those not significant, were I2 Own mental state, t(271) = associated with belonging to each group.
− 3.39, p = .01, d = 0.34; I5 Hostile or defensive attitude, t(271) =
− 3.41, p = .00, d = 0.41; I6 Blaming a third person for the symptoms, t
(271) = − 2.56, p = .01, d = 0.36; and IA2 Symptom identity, t(271) =

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D. Pina et al. Legal Medicine 48 (2021) 101810

Table 4
Results of the binary logistic regression analysis with Group (Clinical patient or malingerer) as dependant variable.
Item and indicator B SE X2 Wald p OR 95% CI

I4 2.31 0.70 10.73 0.001 10.10 2.52–40.32

Lack of cooperation
I5 1.07 0.57 3.51 0.061 2.93 0.95–9.04
Hostile or defensive attitude
I8 1.56 0.31 25.21 0.000 4.75 2.58–8.74
Negative improvement prognosis
I9 0.61 0.35 3.33 0.082 1.84 0.92–3.66
Confirmation of many symptoms
I11 1.50 0.685 7.21 0.007 4.50 1.50–13.53
Contradictory pattern of symptoms
I12 0.93 0.26 12.12 0.000 2.55 1.50–4.32
Extreme symptoms
I13 1.63 0.61 7.17 0.000 5.15 1.55–17.09
Extreme sensitivity to pain
I15 0.93 0.44 4.32 0.037 2.54 1.05–6.11
Loss of unaffected dermatome sensitivity
Constant − 16.66 2.33 50.99 0.00 0.00

Abbreviations: SE, standard error; OR, odds ratio; CI, confidence interval.

3.2. Classification accuracy 4. Discussion

In order to offer an estimated cut-off score, a ROC analysis was
performed with the raw score of the CDS cues (Fig. 1). As can be seen in
Table 5, an Area Under the curve of 0.94 (SEAUC = 0.01) was obtained,
with 13, 14 and 15 as optimal cut-off scores. 15 was the score that
reached the most specificity (0.93), with a 7% false positive rate and a
sensitivity of 0.81. It was also the value that achieved the highest ac­
curacy considering a prevalence of 10% and 30% (89.81% and 90.77%
respectively).
An additional evaluation strategy was considered, transforming the
original CDS cues scores in a positive feigning result (scores 1, 2 or 3) or
negative feigning result (score 0). As can be seen in Fig. 2 and Table 5,
with 5 or 6 positive indicators, a sensitivity between 0.65 and 0.78, and
a specificity between 0.82 and 0.94 was reached, which represents 18%
and 6% of false positives. The accuracy varied between 80.70% and
90.39% depending on the prevalence.
Fig. 1. ROC Curve for the raw scores.
We consider that the two research hypotheses proposed in this study
have been confirmed, as most of these indicators could differentiate
between groups, with instructed malingerers being those who obtained a
higher score on the selected indicators. The current work is one of the
few researches that evaluate feigning indicators in WAD, and we believe
that the findings obtained may be useful in view of a number of con­
siderations. Below we describe how the cues have been expressed in
each group:
Dimension 2 “Attitude toward the situation of illness” presented the
greatest capacity for discrimination. The results in this dimension indi­
cate that malingerers express a much more negative attitude toward the
illness situation than the clinical patients. Most of the malingerers report
a “very disturbing” experience, usually describing their experience of
the illness as a severe and highly disruptive process, whereas the clinical
patients admit that, although their quality of life has been significantly
altered, this situation is not excessively traumatic (IA19). The results
obtained in this dimension also indicate that the malingerers manifest
low symptom control capacity (I17), in most cases stating that they
cannot reduce the pain caused by the injury, even through the use of
medicines. They also claim to have experienced an exponential increase
in pain since the accident, which does not correspond to what is ex­
pected in WAD (I16). Clinical patients, on the other hand, have a much
more positive perception of control. They consider that they can relieve
the symptomatology and, unless they perform some sudden movement,
they can reduce the pain to tolerable levels or make it disappear almost
entirely.
In the same vein, the malingerer group reports a much more negative
view of the improvement prognosis, stating that the symptoms will last a
long time (I8). They tend to express a catastrophic and pessimistic view
of the process undergone, in which they have not experienced any
improvement (I20). Clinical patients, in contrast, have a much more
optimistic view of the recovery process. Most of them have experienced
a noticeable improvement over the first two weeks and consider that the
symptoms suffered will disappear relatively quickly. Faced with the
question “how do you think you will feel in two months?” most of them
answer “cured” or “completely cured.”
It was further evident that the malingerers have a much more
generalist and non-specific discourse, both about the symptoms and
about the consequences. In general, malingerers offer a vague and
imprecise description of the symptomatology suffered (AI2), they can
list the symptoms they presumably experience, but do not refer to spe­
cific places or areas. Similarly, they complain about to a very negative
experience, but do not provide a detailed description of it.
In view of these results, we think that the malingerers believe that if

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D. Pina et al. Legal Medicine 48 (2021) 101810

Table 5
Classification accuracy.
Score AUC SEAUC SEN SPEC 10% 10% 30% 30% 50% 50%
PPP-NPP ACC PPP-NPP ACC PPP-NPP ACC

Raw score
13 0.94 0.01 0.87 0.81 0.47–0.98 89 0.77–0.92 87.93 0.88–0.84 86.85
14 0.94 0.01 0.85 0.89 0.46–0.98 89.81 0.77–0.94 88.47 0.88–0.87 88.19
15 0.94 0.01 0.81 0.93 0.52–0.98 90.77 0.80–0.93 89.30 0.90–85 87.83
Positive cues
5 0.85 0.02 0.78 0.82 0.38–0.97 85.33 0.70–0.89 83.45 0.84–0.78 81.57
6 0.85 0.02 0.65 0.94 0.51–0.96 90.39 0.80–0.87 85.55 0.90–0.74 80.70

Abbreviations: AUC, Area Under the Curve; SEAUC, Standard error of the Area Under the Curve; SEN, Sensitivity; SPEC, Specificity; PPP, Positive Predictive Power; NPP,
Negative Predictive Power; ACC, Accuracy; 10%, 30%, 50% prevalence rate.

evaluate it together with the indicated factors.

Fig. 2. ROC Curve for recoded scores (positive and negative results).
they admit a possible improvement or positive prognosis, this could
influence the doctor’s assessment, and he would grant them lower
severity and, therefore, less compensation. The findings obtained in this
dimension are consistent with those previously provided by Linell and
Easton [30] in a similar study, which found that malingerers reported
less control, more recovery time, and more severe consequences.
This result should be considered with caution. Previous studies have
shown that various emotional and psychological factors play an
important role in the condition development like, for example, the
perception of pain severity or functional disability [9,19,27]. The pos­
sibility that the negative vision of the illness process is the result of an
event prior to the accident, or personality traits [32] should be consid­
ered. Ferrari et al. [20] also pointed out two other elements to consider:
one is the benefit of assuming the sick person’s role. The accident might
be a solution to the patient’s vital problems and he or she unintention­
ally offers a more negative view of the illness process. Another element
is information about the illness provided to the patient and its influence
on his or her behavior. Patients who show a positive attitude may have
been adequately informed about WAD but the absence of information
about the improvement prognosis or the severity of symptoms can lead
to a more negative attitude.
In view of all this, we consider that the attitudes toward the situation
of illness can be useful for the assessment of feigning in the medical-legal
context and we believe that it would be interesting for future research to
Dimension 5, “Inconsistencies,” had the second most discriminative
capacity. The results obtained indicate that malingerers often confirm
the existence of many symptoms (I9), which is known as a trend towards
symptom over-endorsement [34]. On most occasions, they described the
symptoms inconsistently (I11) or they claimed suffering from symptoms
that did not belong to the pathology (I10). It has also been observed that
malingerers state that the symptoms suffered are extremely severe (I12).
They report suffering really severe pain (8–9 on the VAS) that does not
improve over time or with rehabilitation (I16), whereas clinical patients
report an intermediate pain severity (5–6 on the VAS) that fluctuates
depending on the effect of the medication.
It can also be observed that inconsistencies in the expression of
sensitivity caused by the injury are an effective indicator (I13, I14, I15).
Malingerers offer a polarized description, either extreme sensitivity or
total loss of it, sometimes both in the same dermatome. These results
coincide with previous findings in the feigning literature, which state
that the assessment of inconsistencies (internal and external) is a useful
and simple tool to detect deception in the legal-medical context [42].
However, not all inconsistency is synonymous with deception, and
evaluators should avoid the “inconsistency trap” and carefully assess
whether the inconsistencies observed are intentional or the result of
carelessness or confusion [44].
In the results obtained in Dimension 3, “Attitude toward the evalu­
ation,” it can be observed that malingerers have a somewhat more
distant and distrustful attitude than clinical patients, similar to the
profile of the dishonest subject presented in the literature of lie detection
[16,52]. The lack of cooperation observed in the group of instructed
malingerers is expressed exclusively at the verbal level by a more un­
enthusiastic and rigid narrative and a drier behavior towards the eval­
uator. In contrast, the clinical patient group makes an effort to establish
a cordial and close relationship with the assessor physician. We consider
that the possible explanation for these results is the evaluated person’s
view of the doctor. The genuine patient sees the assessor doctor as a
regular physician who can help them solve their problem, so they will
have a more positive attitude toward the evaluation. On the other hand,
the malingerer may consider the assessor as a “hostile evaluator” who
could uncover his or her “deception.” It seems unlikely that malingerers
will manifest a completely hostile attitude, as this would be detrimental
to the final report, so their attitude toward evaluation will be rather
distant and cautious.
As mentioned in Dimension 2 (Attitudes toward the situation of
illness), the results should be taken with caution and the evaluator
should consider that the hostile attitude shown by the patient may be
due to different variables, such as exposure to the legal-medical context
or anxiety caused by the disease process [17].
We consider that Dimension 1 “Unusual details and thoughts about
the event” and Dimension 4 “Cause” to be the least useful for evaluating
feigning in WAD. In Dimension 1, it was observed that patients provide
more superfluous and unusual details and make more allusions to their
own mental state, but we do not think it is of particular use, because

6
D. Pina et al.
patients evaluated for whiplash, whether or not they are malingerers,
have usually suffered an accident and therefore will mention something
they have really experienced. These two indicators were obtained from
the CBCA and, although their effectiveness in other contexts is high
[2,3], we believe that a complete invention of the event is highly un­
likely in the legal-medical context. It is likely that the results obtained in
Dimension 1 are largely due to the use of instructed malingerers, who
have had to completely invent the accident. Likewise, the similar results
obtained in the study of Akehurst et al. [1] may be due to the fact that
the malingering students had not undergone the cold pressor procedure
and they completely invented the experience.
When synthesizing the above evidence, it can be observed that
instructed malingerers tend to overestimate the severity of WAD and
offer a much more negative and catastrophic view of the pathology than
the genuine patients. These results are compatible with the malingerer
profile that has been commonly presented in the bibliography (see
[18,34,42]). Despite this, the fact that the instructed malingerers
included in the present study were medical students should be consid­
ered. It is possible that their prior medical knowledge could have
affected their performance of the assigned role and, for future research,
it would be of interest to assess the indicators with a different
population.
We consider that these findings are promising and several of the
indicators studied may be useful for the medico-legal context, but we
believe that they cannot yet be recommended for use in clinical practice
and it would be convenient to try to replicate our findings in a known-
group design that includes probable or definitive malingerers. In the
same way, we have proposed two cut-off scores obtained using two
different scoring methods, but it would also be advisable to study which
scoring or interpretation method guarantees the best discrimination
capacity.
Likewise, we consider it necessary to point out that the CDS is an
aiding tool designed to be incorporated into a screening protocol made
up of more validated instruments. We believe that this tool can be useful
since, among other uses, it allows evaluators to have a way to study and
objectively quantify inconsistencies between observed symptoms and
reported symptoms, one of the strategies for feigning detection proposed
by Rogers and Bender [42], but this tool should not be used as the sole
decision element. Malingering detection must be made using a multi­
method approach with multiple sources of information, like
Appendix 1. Number of the item, indicator and source
Item and indicator
I1
Unusual symptoms
I2
Own mental state
I3
False attribution to real symptoms
I4
Lack of cooperation
I5
Hostile or defensive attitude
I6
Blaming a third person for the symptoms
I7
Blaming a third person for the accident
I8
Negative improvement prognosis
I9
Confirmation of many symptoms
I10
Unlikely symptoms
I11
Contradictory pattern of symptoms
7
Legal Medicine 48 (2021) 101810
psychometric or interview tools [38,47]. In this sense, malingering is a
possible explanation for the exaggeration of symptoms, but it is not the
only one [35]. The professional should consider all possible hypotheses
for such exaggeration and apply an evaluation protocol that is capable of
analyzing them. For example, first, the possibility of feigning should be
evaluated ruling out, among other things, defensiveness, social desir­
ability, factitious and somatoform disorders [42]. Once these alternative
hypotheses have been ruled out, the existence of a motivating external
incentive should be studied in order to consider malingering as the
possible explanation of the feigning.
Finally, it would be advisable to locate more indicators that can
correctly help to discriminate the two groups. In this sense, we believe
that variables that affect the expression of pain severity, such as pain
catastrophizing or the fear of movement, may be of interest. As pain is
conditioned by these variables, knowing the interaction among them
might be of interest to try to find inconsistencies in malingerers’
expression of WAD. Also, we think that an interview style prepared for a
non colaborative context, like The Scharff-technique [25,33], could be
of use in this subject.
The results we present have some limitations. First, a simulation
design was used with healthy subjects who followed malingering in­
structions. As Rogers and Bender [42] explains, these subjects do not
offer the same experience as real malingerers. While the internal validity
of the design is relatively high, the external validity, and the general­
ization of the results, may be limited. Secondly, the results obtained are
limited to the assessment of WAD patients in a litigant setting, so the
results could not be generalized to another context or condition. Third, it
was not possible to apply a neuropsychological evaluation to classify
clinical patients for a known-group design because the clinic where the
study was conducted imposed a strict temporal limitation for each case.
For this reason, possible malingerers cannot be guaranteed to have been
ruled out entirely from the clinical patients group. Four, although the
researcher evaluating the instructed malingerers was blinded, the
context and their age may be a source of bias.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Source
CBCA [48]
CBCA [48]
Resnick [39]
Resnick [39]; Vrij [52]
Resnick [39]; Vrij [52]
Ferrari et al. [20]
Ferrari et al. [20]
Linell and Easton [30], Leventhal, Leventhal and Contrada [28]
Rogers and Bender [42]
Rogers and Bender [42]
Rogers and Bender [42]
Ferrari, Russell, Carroll, and Cassidy [21]; McDermott and Feldman [34]
(continued on next page)
D. Pina et al. Legal Medicine 48 (2021) 101810

(continued )
Item and indicator Source

I12
Extreme symptoms
I13 Ferrari, Russell, Carroll, and Cassidy [21]; McDermott and Feldman [34]
Extreme sensitivity to pain
I14 Ferrari, Russell, Carroll, and Cassidy [21]
High sensibility in unaffected area
I15 Ferrari, Russell, Carroll, and Cassidy [21]
Loss of unaffected dermatome sensitivity
I16 Ferrari, Russell, Carroll, and Cassidy [21], Rogers [41]
Significant increase in pain intensity
I17 Linell and Easton [30], Leventhal, Leventhal and Contrada [28]
Inability to control symptoms
I18 Resnick [39]; Vrij [52]
Resistance to evaluation
I19 Rogers and Bender [42]
Emphasis on the negative aspects of the symptoms
I20 Linell and Easton [30], Leventhal, Leventhal and Contrada [28]
Lack of improvement
IA1 Linell and Easton [30], Leventhal, Leventhal and Contrada [28]
Perception of illness status
IA2 Linell and Easton [30], Leventhal, Leventhal and Contrada [28]
Symptom identity

Appendix 2. Checklist CDS (Checklist of feigning Detection)

Please, rate each of these items with the following score:

0. Not present; 1. Somewhat present; 2. Present; 3. Strongly present

Dimension 1 – Unusual details and thoughts about the event

• I1. When the patient talks about the accident and subsequent experiences, does he describe unusual details or unexpected
complications?
• I2. When the patient talks about the accident and subsequent experiences, does he describe his own mental state?
Dimension 2 – Attitude toward the situation of illness
• I8. Does the patient expect his symptoms to last a long period of time?
• I16. Does the patient complain of an exponential increase in pain since the accident that does not correspond to his condition?
• I17. Does the patient complain that he is unable to control his symptoms? (through medication)
• I19. Does the patient give very specific details of the injury and its sequelae, emphasizing the negative and disabling aspects of
them?
• I20. If the patient is asked about his status, does he say that he has not improved?
• *A1. Perception of illness status.
• *A2. Symptom identity.
Dimension 3 – Attitude toward the evaluation
• I4. Does the patient show lack of cooperation in the interview?
• I5. Does the patient show a defensive, distrustful or hostile attitude?
• I18. Does the patient try to avoid evaluation / exploration situations unless they are necessary to obtain an economic benefit?
Dimension 4 – Cause
• I6. Does the patient blame someone for his symptoms?
• I7. Does the patient believe that another person behaved carelessly and is that behavior what caused his accident?
Dimension 5 - Inconsistencies
• I3. Is the patient falsely attributing real symptoms to the WAD?
• I9. Does the patient tend to confirm the existence of many symptoms?
• I10. Are there symptoms that do not belong to whiplash?
• I11. Are there contradictions in the pattern of symptoms?
• I12. Has the patient reported extreme symptoms or an unlikely level of severity?
• I13. Does the patient complain of pain when brushing or pinching him slightly?
• I14. Does the patient complain of high sensitivity in any area other than the cervical or upper thoracic region?
• I15. Does the patient complain of loss of sensation in regions that do not correspond to the dermatome of the lesion?

Appendix 3. Instructions for malingerers.

“This study is about malingering in cases of road accidents. We ask you to take the role of a malingerer and we want you to imagine that you have
received an impact on your car while driving. Even if you’re feeling well and it doesn’t hurt too much (or at all), you’ve heard that compensation for
suffering a Whiplash Associated Disorder (WAD) is very generous and you want to do everything you can to receive it. You’re going to go to a medical
center so an evaluating physician will evaluate you and report your alleged injuries to the insurance company. This doctor will apply an evaluation
protocol and you will have to act exaggerating or inventing the symptoms of WAD.
It is essential that your WAD presentation is consistent with what is expected after a traffic accident. For example, severe psychopathology
such as schizophrenia or bipolar disorder are not consequences of this condition. You must prepare the condition before the seminar you have been
assigned to, we leave it up to you the method you follow, you can look online, in manuals, etc. We ask you to try to be completely believable, you have
to try to get into the role that we have assigned you as much as possible and complete the test as if you really suffered from the condition you have
prepared. If it the doctor “catches” you, you will not receive the bonus of the subject.
Will you be able to trick him/her? Go for it!”

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