OVERVIEW

Definition

Malingering is 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.

General Principles of Assessing Malingered Mental Illness

The best way to ascertain whether a person is malingering is to know the detailed characteristics of genuine psychiatric symptoms. Obtaining collateral information and prior psychiatric records is critical in assessing the presence of malingering. Clues to faked auditory hallucinations include

Claiming that all command hallucinations had to be obeyed
Stating that voices sound mechanical or robotic
Hearing only female or only children’s voices and
Reporting no repetitive voices.¹ Persons with genuine mental illness or intellectual disability may malinger additional symptoms to accomplish a specific purpose. Psychological testing is often useful to confirm malingering.²

CLINICAL SCENARIOS

Scenario #1: A 58-year-old homeless alcoholic man comes to a psychiatric emergency room seeking hospital admission for “depression.” When the psychiatrist expresses reluctance to admit the patient, he threatens to kill himself if he is not admitted. Review of the patient’s chart reveals that he has had two admissions for similar “depression” within the last year when his preferred homeless shelter was full.

There is considerable pressure to hospitalize patients who allege they are suicidal even when you strongly suspect they are malingering. Conditional threats of suicide are more often seen in malingerers than in persons with genuine suicidality.
In this example, the psychiatrist could decline to admit the patient after carefully assessing and documenting the prior pattern of misuse of hospital admissions with the conditional threat of suicide. Before discharging such a patient a second clinician should concur with the decision (3).

Scenario #2: A 34-year-old man came to a teaching hospital psychiatric clinic for an initial visit seeking treatment. He reported that he had an auto accident one month ago and he endorsed every symptom of Posttraumatic Stress Disorder. In his second visit he requested that the psychiatric resident prepare a report for his attorney because he was suing the driver who caused his recent accident. The patient denied having had any other traumatic events in his life.

The psychiatric resident should decline to prepare a report and refer the patient to a forensic psychiatrist.
A forensic psychiatrist would gather past medical and police records and not accept the evaluee’s complaints at face value.
This patient actually began experiencing PTSD symptoms after he caused a life threatening accident four months earlier, whereas the “fender bender” one month ago was not his fault. This is an example of false imputation; that is, a person with genuine symptoms knowingly attributing them to a different cause.

Scenario #3: You are asked to evaluate the legal sanity of a 26 year old man charged with the stabbing death of his mother. You learn that he has a history of schizophrenia with four prior psychiatric hospitalizations and a history of cocaine addiction. The evaluee states that he heard God’s voice instructing him to kill his mother. God was “screaming” at him and he felt he had to obey. He described God’s voice as “robotic.”

Psychiatrists should not be doing examinations of legal insanity unless they have had forensic training or supervision.
In this case, a careful chart review showed that the defendant had a pattern of prior hallucinations which were accusatory; they told him “you are no good” and “you should kill yourself.” His records revealed that he had never reported a command hallucination or hearing the voice of God before the homicide.
The defendant later confessed that he killed his mother over an argument about money for drugs rather than because of his command hallucinations. This is an example of a person with genuine schizophrenia faking an exculpatory command hallucination.

ADDITIONAL TIPS

To label a person a malingerer is to call them a liar. This means that if malingering is listed as a formal conclusion, the clinician can be sued for both malpractice and the intentional tort of defamation of character. It is fine to discuss malingering as a possibility in your differential diagnosis, but it should not be listed as a final conclusion unless the evidence is overwhelming, it has been confirmed by psychological testing and/or the patient confirms that they made false or exaggerated statements.

REFERENCES

McCarthy-Jones S, Resnick PJ. Listening to voices: the use of phenomenology to differentiate malingered from genuine auditory verbal hallucinations. Int J Law Psychiatry. 2014 Mar-Apr;37(2):183-9.
McDermott BE. The evaluation of malingering, in The American Psychiatric Association Publishing Textbook of Forensic Psychiatry, 3rd edition, Gold L and Frierson R (eds.). Arlington, VA: American Psychiatric Publishing Inc.; 2017.
Kontos N, Taylor JB, Beach SR. The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation. Gen Hosp Psychiatry. 2018 Mar-Apr;51:30-35. Available from: https://www.sciencedirect.com/journal/general-hospital-psychiatry/vol/51/suppl/C

Additional Reading

Rogers R. (ed.), Clinical Assessment of Malingering and Deception, 4th ed., New York: The Guilford Press, 2018.
Weiss KJ, Van Dell L. Liability for Diagnosing Malingering. J Am Acad Psychiatry Law. 2017 Sep;45(3):339-347. Available from: http://jaapl.org/content/45/3/339.long

Overview | Clinical Scenarios | Additional Tips | References

By Phillip Resnick, MD