By Susan Ballinger MAPS
Past Chair, APS College of Clinical Psychologists
Malingering is a term that is often used in a simplistic way by politicians, health bureaucrats and unfortunately sometimes by psychiatrists and psychologists. In our recent adventures concerning the NSW Workcover legislation, it was a common perception that a very high proportion of Workcover claimants were malingerers. It was difficult to avoid the conclusion that these assertions were based on wishful thinking at worst, or individual clinical impressions at best.
In the assessment of psychological impairment, there are undoubtedly some people who deliberately inflate their symptoms and a smaller number who consciously lie about their condition. The best available evidence indicates that such faking, while significant, is small in comparison to those who present themselves genuinely. There is little agreement about actual proportions - estimates vary from about 7% to 30%. The DSM-IV states that the essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding work, obtaining financial compensation, evading criminal prosecution or obtaining drugs. Thus the definition of the term is harshly black and white, failing to allow for any greys in the complexity of human motivation and emotion.
What do we know about the concept of malingering?
In a presentation at the APS Annual Conference this year, Associate Professor Richard Bryant outlined some characteristics in the reports of malingerers of Post Traumatic Stress Disorder (PTSD). They tend to over-report salient symptoms such as flashbacks and nightmares and to under-report negative symptoms such as emotional numbing. Their style of reporting is hesitant, vague and while exaggerated, it lacks detail in responses. The symptoms of PTSD are increasingly well known in the public arena and would be discussed, for example, between personal injury lawyers and their clients, making it easier to mimic the condition. Richard Bryant described a normative study of reactions of fakers and PTSD cases after watching a film of a motor-vehicle accident. There was no difference in many parameters between PTSD cases and fakers, but avoidant response clearly discriminated between the two.
There is a much larger group of people who exaggerate their symptoms, either consciously or unconsciously. Very often they feel their problems have been summarily dismissed by their employer and they have been judged harshly by their work mates. Psychological injury is not visible like a physical injury, so people with chronic intractable pain syndromes or neurological or stress-related impairments can easily be seen as 'bunging it on'. Further, insurance companies and litigation cause seemingly endless visits to various assessors for each 'side', which too often lead to the injured person feeling invalidated. Very often, the financial circumstances of the whole family are diminished with loss of income.
Depression, anger and anxiety, with their concomitants of fatigue, loss of concentration and motivation and social withdrawal, lead to a vicious cycle of all of these and deteriorating family relationships. These people feel growing pressure to 'prove' the reality of their symptoms and increasingly emphasise their sufferings to assessors, while ironically, their symptoms increase. This group does not fit the DSM-IV definition of malingering. There is a risk, however, that they may be placed in this category, if psychometric malingering test results are used too rigidly and without background interpretation.
The issue of exaggeration that is not malingering is very important. There is a substantial literature on attributional and self-serving biases, and related personality variables (e.g. high emotionality). Often in compensation/liability determination contexts a key question is not only the level of distress, but also the causal attributions and the focusing of all of an individual's distress on work issues. The human inclination to try to make sense of distress, minimise ambiguity and externalise the causes may result in distressed individuals presenting in clinical assessment contexts with misattributions about and externalisation of their distress, often unwittingly facilitated by well-meaning treating clinicians who rely on conventional wisdom regarding the common causes of 'stress' rather than the evidence base.
In the past 10 years, an increasing number of valid and reliable tests to determine whether an injured person is responding truthfully have been developed, and Australian courts are increasingly recognising their usefulness. Among them are the Structured Interview of Reported Symptoms, the Test of Memory Malingering, the Malingering Probability Scale and the Validity Indicator Profile. There are also validity scales embedded in commonly used assessment tools such as the Minnesota Multiphasic Person-ality Inventory, the Personality Assessment Inventory and the Multidimensional Anxiety Question-naire. These have greatly increased the accuracy of identifying faking in psychoses, memory, and symptoms of PTSD and neuropsychological damage.
However, as with all psychometric tests, they must not be taken just at face value. Many factors, often interacting, can influence the results of standard psychometric tests of malingering. Depression, fatigue, anger, loss of concentration, dissociation, chronic physiological arousal, pain, environmental factors such as sub-optimal testing conditions, are just some of them. Further, psychological illnesses such as depressive illness or major psychoses, which may be either pre-existing or co-morbid to the main diagnosis, can have profound effects on the presentation and performance of the injured. I recently assessed a Victims of Crime Tribunal (VCT) claimant - a young man who had been bashed on the head in a pub brawl. He presented very much as if he was faking his symptoms. His psychometric test results all pointed to deliberate exaggeration. It was not until I spoke to his former employer that a picture of a pre-existing, schizophrenic illness became apparent, immediately casting his behaviour and test results in a very different light.
Psychological assessment and reporting of impairment
A psychological assessment report should contain the following elements, all of which have a bearing on the assessment of the possibility of malingering:
What are our roles and responsibilities?
Psychologists have the tools and expertise to offer objective and evidence-based assessments of exaggerations and inconsistencies in symptom patterns. There is a great need for this expertise to be recognised much more widely by insurers, the courts and legislators. To this end, it is incumbent upon psychologists to ensure they have up-to-date skills to write fully adequate and competent reports. Assessment of psychological impairment places us in the public spotlight, and every report that is less than adequate reflects poorly on our profession.
The VCT of NSW has set a useful precedent for assessors of victims of crime. They instruct that whether or not the person has a compensable injury is not a psychological question, but a legal one, to be determined by the tribunal. Similarly, it is my opinion that the question of whether or not the subject is lying, is not a psychological issue but a legal one. Stating that a person is a malingerer has the potential to cause psychological distress. Too often, those we are assessing have been abused by the system and we must be careful in our work, as far as possible, to "do no harm". Further, psychologists can lay themselves open to being sued when they make open assertions of malingering. For these reasons, I believe that it is not advisable to use the term 'malingering' in a psychological report. Rather we should report on any exaggerations and inconsistencies in symptom patterns and explore the often complex reasons behind them. The court or tribunal can then make a judgement about the presence of malingering.
My thanks to Dr Peter Cotton for his helpful commentary on this issue.
References and further reading
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, 1994
Bernard, L.C. (1990), Prospects for faking believable memory deficits on neuropsychological tests and the use of incentives in simulation research. Journal of Clinical and Experimental Neuropsychology, 12, 715-728
Bryant, R., Identification of Malingering, Workshop held on 1st October at APS Annual Conference, Gold Coast, September 2002.
Daubert v. Merrill Dow Pharmaceuticals. U.S. Supreme Court, 509, U.S., 579, 1993.
Measurement of Psychological Impairment in Matters of Civil Litigation: a paper prepared by the Australian Psychological Society - Division of Professional Affairs Working Group on the Measurement of Psychological Impairment. December, 1999.
Rogers, R. (1997), Clinical Assessment of Malingering and Deception. New York, Guilford Press.
Rogers, R., Harrell, E.H. and Liff, C.D. (1993), Feigning neuropsychological impairment: A critical review of methodological and clinical considerations. Clinical Psychology Review, 13, 255-274.