Malingering: Detecting it or Proving Otherwise
So first of all, what is malingering? Malingering is an act, not a psychological condition. It involves pretending to have a physical or psychological condition to gain a reward or avoid something. For example, exaggerating or making up symptoms to obtain special accommodations or to be exempt from a process (e.g., VAWA, jury duty, USA Citizenship Exam Exemption, etc.).
Importantly, malingering is not a psychiatric disorder and different than a factitious disorder, in which, someone fakes symptoms but without a specific motive of reward. Also, malingering is different from a somatic disorder (someone experiencing psychological distress resulting from imagined or exaggerated symptoms).
Malingering has different levels of manifestation. Someone may fake all symptoms or just some partial symptoms. However, the goal is the same: to obtain a reward or to avoid a negative situation or requirement.
The benefits of malingering are obvious. For example, someone seeking compensation claiming untrue or exaggerated symptoms (e.g., seeking injury compensation after a fall, avoiding having to take the USA Citizenship exam, seeking attention from others, etc.).
How common is malingering? According to Mittenbery, W. et al (Journal of Clinical and Experimental Neuropsychology; January 2003; 24(8): 1094-102), malingering is present in 29% of personal injury, 30% of disability, 19% of criminal, and 8% of medical cases. Also, present in 39% of mild head injury, and 31% of chronic pain claims. Malingering is suspected among one-third of psychiatric emergency patients (Rumschik, S. M. & Appel, J. M.; Psychiatric Services; December 2010 https://doi.org/10.1176/appi.ps.201800140). The suspicion of malingering was found to 58% for suicidal ideation, 39% for depression, and 44% for multiple symptoms. In 2011, the estimated cost of medicolegal cases totaled $20 billions!
When it comes to immigration or personal injury cases, malingering can be an issue. The obvious benefits for an individual could be many. For example, in a VAWA case, exaggerating or making up symptoms related to alleged abuse by an ex-spouse. Or in attempting to forego the USA Citizenship exam, or in seeking higher compensation in an injury case by exaggerating or falsely reporting symptoms.
Of course, not just for ethical reasons, but also to have conviction in the cases that could be represented by psychologists or attorneys, proving otherwise: absence of malingering, would be important.
Fortunately, there are tools that can support absence of malingering. These instruments have been proven by multiple research studies to have strong validity and reliability. Because of this, it is important to include some of the following tests to screen for malingering and to present a stronger case.
MMPI-3: The validity scales of the MMPI-3 can help identify potential tendency to over report, having inconsistent responses, etc. Scores on MMPI-3 overreporting indicators and most substantive scales were higher among the Overreporting Group relative to the standard instructions group (SI) with very large effect sizes, and scores on MMPI-3 underreporting indicators were higher and most substantive scales scores were lower among the Underreporting Group relative to the SI group, with moderate to large effects. Classification accuracy estimates documented the effectiveness of MMPI-3 Validity Scales in detecting overreporting and underreporting. Bivariate correlations between MMPI-3 substantive scale scores and criterion measures (which were completed under SIs for all three groups) were substantially attenuated for both simulation groups relative to the SI Group. Bivariate correlations were also attenuated for groups identified as overreporting or underreporting using MMPI-3 Validity Scale scores relative to individuals with valid MMPI-3 protocols, highlighting the need for and importance of appraising threats to protocol validity when assessing personality and psychopathology by self-report.
Miller Forensic Assessment of Symptoms (M-FAST): In studies, the M-FAST has been found to be an effective screen when an individual is attempting to malinger the specific disorders of posttraumatic stress disorder, schizophrenia, major depressive disorder, and bipolar disorder. Several independent studies since the development of the M-FAST have indicated that the M-FAST is highly reliability; M-FAST internal consistency ranging from .90 to .92, scale (or strategy) internal consistency ranging from .53 to .82, and interrater reliability found to be 1.0.
The M-FAST is a brief screening measure designed to detect malingered mental illness in forensic settings by assessing individual response styles. can be administered in approximately 5 to 10 minutes. The measure may be more viable than other instruments in several situations because of its interview format (e.g., reading level of the test taker is irrelevant) and its brief administration time. The M-FAST items were developed to represent the following response styles/ strategies that have been validated for identifying malingered psychiatric symptoms: Reported versus Observed Symptoms, Extreme Symptoms, Rare Combinations, Unusual Hallucinations, Unusual Symptom Course, Negative Image, and Suggestibility. The M-FAST includes items that represent these detection strategies along with items that reflect actual symptoms of mental illness. The M-FAST contains 25 items, including 15 true or false questions, 5 Likert items, 2 yes/no questions, and 3 items designed to detect discrepancies between responses and observations.
Tests of Memory Malingering (TOMM): The TOMM is a recognition memory test that utilizes symptom validity testing (SVT), forced-choice, and floor-effect detection strategies. The TOMM presents the respondent with two alternatives per test item, allowing for a 50% chance of choosing correctly. Scores falling significantly below this probability level suggest malingering. The TOMM contains 50 items and consists of two memory learning trials, with each trial followed by an assessment of recognition memory. The respondent is initially shown a series of 50 line drawings, followed by a recognition assessment in which each drawing is presented alongside a foil. The subject is asked to identify the previously presented drawing and is given feedback regarding the correctness of the response. If the respondent does not achieve a correct score during the second trial on at least 45 items, a Retention Trial is administered. Malingering should be suspected if the respondent earns a score of 45 or less on the second trial or the Retention Trial.
Administering these tests do not guarantee absence of malingering but add a significant level of weight in screening for malingering. Incorporating one of these tests (or others) individually or combining them, as applicable, can add significant credibility to the results obtained as part of a psychological evaluation or for any the medicolegal case.
Finally, being able to assess for malingering will provide the professional assessing or representing the individual a greater peace of mind when presenting results or the merits of a case. Because of many of these multiple reasons, it is strongly recommended to include malingering assessment.
In my practice, the utilization of one or a combination of these tests is basically part of any psychological evaluation. Please contact us if you have any questions.