Diagnosis Of Malingering Research Articles

The diagnosis of malingering in general hospitals in the United States: A retrospective analysis of the National Inpatient Sample

ObjectiveTo characterize the socio-demographics and comorbid medical and psychiatric diagnoses of patients in the general hospital diagnosed with malingering. MethodWe conducted a retrospective observational cohort study using data from the 2019 National Inpatient Sample, an all-payors database of acute care general hospital discharges in the United States, querying for patients aged 18 and older discharged with a diagnosis of “malingerer [conscious simulation],” ICD-10 code Z76.5. Results45,645 hospitalizations (95% CI: 43,503 to 47,787) during the study year included a discharge diagnosis of malingering. 56.1% were for male patients, and the median age was 43 years (IQR 33 to 54). Black patients represented 26.8% of the patients with a discharge diagnosis of malingering, compared to 14.9% of all patients sampled. Zip codes in the lowest household income quartile comprised 39.9% of malingering diagnoses. The top categories of primary discharge diagnoses of hospitalizations included medical (“Diabetes mellitus without complications”), psychiatric (“Depressive disorders”), and substance use (“Alcohol-related disorders”) disorders. “Sepsis, unspecified organism,” was the most common primary diagnosis. ConclusionThe striking overrepresentation of Black patients in hospitalizations with diagnosis of malingering raises concern about the roles of implicit and systemic biases in assigning this label. The disproportionate number of patients of low socioeconomic status is further suggestive of bias and disparity. Lower health literacy in these populations may result in a limited knowledge of traditional ways to meet one's needs and thus greater reliance on malingered behavior as an alternative means. Accurate description of these patients' socio-demographics and comorbid medical and psychiatric diagnoses with reliable data from large samples can lead to improved understanding of how the malingering label is applied and ultimately better patient care.

Concepts and controversies of malingering: A re-look.

Since time immemorial, humans have tried to feign physical and mental illnesses for various reasons. This led to the development of the concept of illness deception or malingering when one tries to assume a sick role and feigns signs and symptoms to gain external incentives. The conceptual framework of malingering has undergone several changes and there is sufficient evidence to demonstrate that malingering exists. However, the diagnosis of malingering has not yet been established in the mainstream psychiatric nosological systems and still it is present in the appendices as an additional area requiring attention. This is due to the poor construct validity of the diagnosis, problems in defining malingering, problems in assessment by psychological tests and clinical assessment methodology, no well-established guidelines to detect malingering and issues related to labelling/reporting malingering. Because of several controversies in multiple domains of assessment and ethical-social issues, malingering as a distinct entity is grossly neglected. In the upcoming arena of law suits and consumer benefits suits, it is extremely important to have a better understanding of the conceptual issues related to malingering and the controversies related to it. In this review, a brief overview of evolution of concepts and controversies related to malingering is described.

The Incidence of Diagnosis of Munchausen Syndrome, Other Factitious Disorders, and Malingering.

Background Systematic studies on factitious disorders and malingering in large populations are rare. To address this issue, we performed a nationwide epidemiological study in Norway on the incidence of these diagnoses in an unselected patient population. In particular, we tried to confirm the diagnoses and to estimate the contribution of Munchausen syndrome to the spectrum of factitious disorders. Methods We analyzed data obtained from the Norwegian Patient Registry (NPR), which provided a deidentified list of all patients from 2008 to 2016 who had received the ICD-10 diagnosis of F68.1 or the diagnosis code Z76.5. Results Altogether, 237 patients (99 females; 138 males) received a diagnosis of F68.1. Code Z76.5 was applied to 52 patients (12 females; 40 males), all diagnosed within health institutions. Three of 1700 specialists (somatic specialist, psychologist, or psychiatrist) in private practice had diagnosed a factitious disorder in altogether 87 patients. After contacting these specialists, we could identify no true case of F68.1. For 24 of 146 patients who were equally distributed by gender within health institutions, we managed to identify the diagnosing healthcare providers. Of these 24 patients, only 11 correctly qualified for code F68.1. Only two female patients qualified for a Munchausen syndrome diagnosis. Conclusions There is a male predominance for the diagnosis of malingering. An earlier suspicion of a female predominance for Munchausen syndrome is upheld. There is significant underdiagnosing and misdiagnosing for both conditions and for factitious disorders in general. To separate the most serious form of factitious disorders from milder forms and to facilitate more systematic research, we recommend a specific ICD diagnosis for Munchausen syndrome.

When a duck is not a duck: non-organic bases for aphasia and dementia

ABSTRACTBackground: There are numerous reports in the literature describing cases of non-organic speech and language disorders. Most reports do not contain specific diagnoses (other than a “psychogenic” disorder); however, establishing which of the many psychogenic disorders are at play may be important for management and prognosis. This paper is inspired by 10 patients who presented to speech–language pathology (SLP) services with speech, language and/or cognitive impairments incongruent with organically based disorders. Non-organic symptoms are neurological complaints thought to be incompatible with recognised neurological or medical conditions. The patients, discussed here, presented with abnormal speech (stuttering, backward speech), language (aphasia) and/or cognition (dementia) that were ultimately reconciled in the psychiatric context.Aims: The aim is to provide empirical and clinical evidence that supports multidisciplinary assessment of patients who present with speech, language and cognitive impairments that do not seem to have a clear organic basis. The clinical data are discussed in the context of “non-organic” disorders and include exploration of relevant assessment and management issues.Methods and Procedures: Clinical files of 10 patients diagnosed with psychogenic disorders were retrospectively reviewed and evaluated on several factors contributing to their profiles. They included analysis of speech, language, neuroimaging, social and medical histories and psychological stressors reported by each patient.Outcomes and Results: Based on assessment results, a number of psychiatric conditions were identified, including conversion, factitious disorder, malingering and Ganser syndrome. Performance on language and cognitive tests was inconsistent with neurological disorders. Each patient appeared to be dealing with some sort of emotional conflict (e.g., unexpected obligation to take care of disabled parents or returning to an extremely stressful workplace). While those with the diagnosis of malingering, factitious or conversion disorders did not show imaging abnormalities, patients with abnormal imaging were initially diagnosed with Ganser syndrome and were found on a follow-up assessment to exhibit signs suggestive of behavioural variant fronto-temporal dementia.Conclusions: The literature suggests that as many as 30–60% of patients with seemingly non-organic symptoms end up with a neurological diagnosis that explains their initial somatic complaints, a proportion large enough to treat all non-organic disorders seriously. In addition to SLP, successful management of somatic communication disorders requires a multidisciplinary approach and an understanding that they may represent an alternative mode of communicating socially unacceptable feelings or thoughts. Additionally, regardless of questionable veracity of presenting symptoms, presence of abnormal neuroimaging findings should raise concerns of a neurodegenerative disorder.

The Validity and Reliability of the Turkish Version of Miller Forensic Assessment of Symptoms Test (M-FAST).

The aim of this study was to show the validity and reliability of the M-FAST Turkish Version. Translation and back-translation of the M-FAST was done, then the M-FAST Turkish Version was created with linguistic equivalence. The study was performed with 97 detainees and convicts sent from penal institutions who were internalized at our hospital forensic psychiatry service. M-FAST Turkish Version was applied to evaluees and as a result of clinical interview according to DSM-IV-TR diagnostic criteria and various data explorations the evaluee was examined for malingering. To investigate the internal consistency of the scale, Cronbach's alpha and test-retest methods were used. In order to check the validity of the scale, in addition to the clinician's diagnosis, participants were requested to fill the Minnesota Multiphasic Personality Inventory (MMPI) F and K validity scales. The mean age of participants was 31.8±9.3 (SD) years. 47 evaluees (48.5%) were diagnosed as malingering. In the internal consistency analysis, Cronbach's alpha Coefficient was found to be .93. Test-retest relationship that was applied to 22 evaluees was found to be highly significant and strong (r=.89, p<.001). M-FAST scores were significantly high at the malingering group (n=47) (z=-8.02, p<.001). ROC curve analysis suggested a score of ≥7 points as the optimal cut-off for a malingering level for the M-FAST. Kappa coefficients of malingering ± groups were found to be, M-FAST≥7 Kappa: .83; F>16 Kappa: .29; F-K>16 Kappa: .30. For diagnosis of malingering, M-FAST Scale and the MMPI inventory scales were evaluated with the Binary Logistic Regression analysis and only M-FAST scores were found to be significant in prediction of malingering. The findings of this study support that, M-FAST Turkish Form represents the structure of the original scale and can be used as a reliable and valid instrument.

Daño psicológico en casos de víctimas de violencia de género: estudio comparativo de las evaluaciones forenses

With the aim of comparing in the forensic assessment of the psychosocial injury in intimate partner violence cases, the efficacy of the psychometric measure with the content analysis of the clinical interview, a study was designed. For this, forensic assessment not only must provide a diagnostic of the psychological injury, but also a differential diagnosis of malingering. 101 mentally healthy and with no-history of intimate partner violence (IPV) females answered, under malingering instructions of psychological injury consequence of IPV, to the MMPI-2, and were submitted to a free narrative interview, the forensic-clinical interview (Arce & Fariña, 2001). The results showed that participants had a very high capacity, 79.6%, to malinger in the psychometric measure, the MMPI-2. As for the differential diagnosis of malingering, the validity scales and configurations classified correctly as malingerers to the 80.2% of the protocols, failing in the remaining 19.8%. As in forensic assessment, the TypeII Error (classification of malingered injury as real) is not admissible; the psychometric measure is not sufficient evidence of psychological injury. The content analysis of the forensic-clinical interview revealed that 3% of the participants were capable to malinger the psychological injure, while in 97% were detected non-normative narratives, that is, were classified as false. Although the content analysis of the interview makes malingering significantly more difficult and detects more malingering than the psychometric measure, fails to comply with full control of the TypeII Error. Thus, the content analysis of the clinical-forensic interview is not in itself sufficient forensic evidence. The implications of the results for forensic practice are discussed.

Comparison between infrequency (F), fake bad scale (FBS) and infrequency psychopathology (F(p)) scales in diagnosis of malingering among post head trauma disability claims

BackgroundRecently, there is a growing research and clinical interest in the field of forensic neuropsychology. Within this discipline, identification of feigned symptoms presented during forensic assessment has become a particularly important topic. Studies have demonstrated how difficult it can be to detect feigned presentations. Clinicians and researchers have failed to rule out malingering especially in cases of mild or moderate brain damage. ObjectivesThe study aims to compare between infrequency (F), fake bad scale (FBS) and infrequency psychopathology (F(p)) scales in diagnosis of malingering to determine the best neuropsychological scale that can be used for diagnosis of malingering; aiming to help forensic psychiatrists in their practice. Patients and methodsA cross-sectional descriptive study included 150 participants with recent head trauma was subjected using a questionnaire (includes demographic data, cause and degree of traumatic brain injury) completed by the participants. Three valid scales (infrequency (F), fake bad scale (FBS) and infrequency psychopathology F(p)) were administered to patients diagnosed as mild and moderate traumatic brain injury and attending the neurosurgery department at Suez Canal University Hospital seeking for a medical report about their recent trauma. The diagnostic outcomes of these scales were compared with the expert diagnosis based on the convenient clinical diagnostic tool (diagnostic and statistical manual of mental disorders IV (DSM-IV)). ResultsThe study reveals a significant association (p<0.05) between expert diagnosis of malingering and FBS scale outcome, and statistically non-significant relationship (p>0.05) between expert diagnosis of malingering and the outcome of both (F) and (F(p)) scales. It also demonstrates that the FBS has the higher accuracy among the three studied scales. ConclusionFBS is the most specific scale among the three studied scales, as its specificity is 87% compared to 60.9% for F scale and 70% for F(p) scale, and it is also the most sensitive scale as its sensitivity is 93.5% compared to 48.3% for F scale and 38.7% for F(p) scale.

Poster Abstracts from the AAAP 20th Annual Meeting and Symposium

Poster Abstracts from the AAAP 20th Annual Meeting and Symposium

Aggregation Across Multiple Indicators Improves the Detection of Malingering: Relationship to Likelihood Ratios

Recent literature shows that aggregating across multiple symptom validity test (SVT) failures increases the probability of malingering over use of one indicator alone, supporting the criteria proposed by Slick, Sherman, and Iverson (1999) that require multiple sources of evidence for diagnosis of malingering. The present study reanalyzes with likelihood ratios data previously published by Larrabee (2003a) on litigants with definite malingering, contrasted with non-malingering patients with moderate and severe traumatic brain injury. Chaining of likelihood ratios demonstrated an increase in probability of malingering when multiple test scores were positive, with values ranging from. 713 to. 837 for one failed SVT,. 936 to. 973 for two failed SVTs, and. 989 to. 995 for three failed SVTs. Posterior probabilities of malingering derived from chaining of likelihood ratios closely approximated those obtained by direct computation of Positive Predictive Power, particularly when three SVTs were failed. Moreover, the five SVTs employed in these analyses did not intercorrelate significantly, satisfying the assumption that the tests be independent for chaining of likelihood ratios. Posterior probabilities derived from chaining of likelihood ratios, holding sensitivity and specificity constant at. 50 and. 90, respectively, and varying the malingering base rate from. 10 to. 90, showed a wide range of values,. 357 to. 978, for failure of one SVT. Failure of two SVTs yielded probabilities ranging from. 735 to. 996. Failure of three SVTs yielded values ranging from. 933 to. 999, demonstrating high probabilities of malingering irrespective of the base rate. These data support the Slick et al . recommendation that multiple positive findings are necessary for diagnosis of malingering. Suggestions are made for modification of the Slick et al . criteria based on the current results.

Negative Electroretinogram in the Differential Diagnosis of Malingering of Night Blindness in the Military

We evaluated the value of unusual electroretinogram (ERG) findings (negative ERG, which is selective reduction in the amplitude of the b-wave) in the differential diagnosis of night blindness in the military. We surveyed 3 years of data. Presumptive and final clinical diagnoses before and after negative ERG recordings were evaluated. A total of 495 ERGs were included. The mean age was 22 +/- 2.5 years (range, 20-33 years). Twenty-two patients (4.4%) had negative ERG. Final clinical diagnoses could be made for all except two patients (9%). The diagnoses were congenital stationary night blindness (CSNB) (14 patients), X-linked juvenile retinoschisis (five patients), and muscular dystrophy (one patient). Seven (50%) of 14 patients with CSNB had normal fundal appearance, symptoms of night blindness, and a presumptive clinical diagnosis of malingering before the ERG test. Negative ERG may prevent misdiagnosis of malingering for patients with CSNB with normal fundal appearance in the military.

The Booklet Category Test and Malingering in Traumatic Brain Injury: Classification Accuracy in Known Groups

A known-groups design was used to determine the classification accuracy of 12 Booklet Category Test variables in the detection of malingered neurocognitive dysfunction (MND) in traumatic brain injury (TBI). Participants were 206 TBI and 60 general clinical patients seen for neuropsychological evaluation. Slick, Sherman, and Iverson's (1999) criteria were used to classify the TBI patients into non-malingering, suspect, and MND groups. Classification accuracy of the BCT depended on the specific variable and injury severity examined, with some scores detecting more than 40% of malingerers with false positive error rates of 10% or less. However, the BCT variables are often influenced by cognitive ability as well as malingering, so caution is indicated in applying the BCT to the diagnosis of malingering. Application of these data in clinical practice is discussed.

WAIS Digit Span-Based Indicators of Malingered Neurocognitive Dysfunction

The present study determined specificity and sensitivity to malingered neurocognitive dysfunction (MND) in traumatic brain injury (TBI) for several Wechsler Adult Intelligence Scale (WAIS) Digit Span scores. TBI patients (n = 344) were categorized into one of five groups: no incentive, incentive only, suspect, probable MND, and definite MND. Performance of 1,063 nonincentive patients (e.g., cerebrovascular accident, memory disorder) was also examined. Digit Span scores included reliable digit span, maximum span forward both trials correct, maximum span forward, combined maximum forward and backward span, Digit Span scaled score, maximum span backward both trials correct, and maximum span backward. In TBI, sensitivity to MND ranged from 15% to greater than 30% at specificities of 92% to 98%. Patient groups with documented brain pathology had higher false-positive error rates. These results replicate previous known-groups malingering studies and provide valuable data supporting the WAIS Digit Span scores in detection and diagnosis of malingering.

Traumatic stress and the differential diagnosis of malingering.

Although the detection of malingering is a legitimate concern of health professionals, it rarely features in training schedules and attracts little attention in journals of traumatic stress. But the item is raised here because of a specific request from the prosecution to examine the claim of traumatic amnesia raised by the defence against charges of murder and robbery. The request evoked examples from earlier professional practice in prisons and psychiatric units, and led to a search for reliable methods of assessment. The outcome, set within the usual time-constraints imposed by the Courts, resulted in the use of an ad hoc method for the analysis of Police-videotaped interviews. The justification for the method, and the proof of the conclusion lies in the fact that even the most adversarial of lawyers was obliged to accept the opinion and admit to the Court that his client had lied. The findings are presented here, buttressed with appropriate references to the work of leading expert witnesses and researchers, to suggest that malingering in clinical, criminal, and civil matters should receive more priority in textbooks of abnormal psychology and in the training of health professionals. Language: en

Pattern visual evoked potentials in malingering.

We previously developed a new method for estimating objective visual acuity by means of pattern visual evoked potentials (PVEP). In this study, this method was applied to the diagnosis of malingering. Six patients ranging in age from 40 to 54 years (mean 47 years) with suspected malingering were evaluated by means of the visual evoked potential test, optokinetic nystagmus (OKN) inhibition test, and the visual field test. In the PVEP study, the stimulus consisted of black and white checkerboards (39', 26', 15', and 9') with a visual angle of 8 degrees, contrast level of 15%, and a frequency of 0.7 Hz. One hundred PVEP responses were averaged per session. Routine ophthalmic examinations were normal in all patients. Five patients had a tubularly constricted visual field, and the remaining patient had a normal visual field. The objective visual acuities of the six patients estimated from PVEP were better than their subjective visual acuities estimated with Landolt rings. Among a variety of psychophysical and electrophysiologic ancillary tests, we consider our PVEP method a useful method for objectively determining visual acuity in a patient with signs of ocular malingering.

Current Issues in the Diagnosis and Management of Malingering

Malingering is a diagnosis that is frequently avoided by physicians. When there is a claim of symptoms or diseases that either are exaggerated or do not exist, the diagnosis of malingering should be entertained. Malingering is associated with a conscious intent to deceive in order to obtain a known gain. Psychoanalytical, criteria-based (DSM-IV) and ‘adaptational’ models have been advanced to explain malingering. The differential diagnosis of malingering includes factitious disorder, the somatoform disorders, the dissociative disorders, and specific medical conditions without somatoform disorder. Upon consideration of the differential diagnosis, confirmation of the suspicion of malingering is still required in order to make the diagnosis. Confirmation can be achieved by observation or by inferential methods. Observation can be employed with controlled environment observation or with covert, ‘real-world’ surveillance; inference may involve primary and/or secondary source information. It may be concluded that a greater attempt should be made to identify this diagnosis, as the cost of malingering to society is considerable.

Examination strategies in simulation and functional vision disorders

The diagnosis of malingering and functional visual loss should be proven by specific tests-after the exclusion of differential diagnoses such as optical disturbances, amblyopia, early stages of macula and optic nerve disease and cortical lesions. Malingering and functional visual loss are based on different causes and pathogenetic mechanisms. However, they produce the same symptoms and can therefore be examined by the same methods. The strategy consists of three parts: 1) check the reproducibility of the results, 2) specific procedures: provocation of reflectory responses, deception, measurement of the same function with different methods and objective methods and 3) proof. In alleged bilateral blindness the provocation of reflexes and deceptive strategies are especially useful, in alleged bilateral reduction of visual acuity deceptive methods (related to the size of the optotype), the examination of central vision by other methods (equivalents to visual acuity) and objective methods are applied. In alleged monolateral blindness or reduction of visual acuity the binocular tests are valuable. Additionally, methods to provoke reflexes, especially pupil reaction, are used as well as the measure of equivalents to visual acuity. In alleged concentric constriction of the visual fields three strategies are mainly used: 1) check if visual field size is in accordance with the visual angle, 2) different methods to examine the isopters and 3) different perimetric methods. In case of an alleged hemianopic field defect the following methods are of special value: 1) binocular examination, 2) reading ability, 3) different perimetric methods and 4) half-field stimulation. After finishing the specific tests the diagnosis of malingering or functional visual loss should be unambiguous and the existing function should be determined. Strategies for further management are shown--dependent on the pathogenesis: the aim is to avoid repetition and to set the right course for the future. In case of malingering the reliable expert's report is helpful. In case of functional visual loss it is important to avoid unnecessary examinations and to offer specific aids.

Shadows of the truth in patients with spinal pain: a review.

Spinal pain with or without referred pain is a major and costly health problem that can arise from many anatomical structures. Sophisticated diagnostic imaging devices cannot show some of these structures, and frequently imaging provides only a shadow of the truth. This review illustrates how symptoms may well have an organic cause that is not detectable by current methods of examination, including imaging. This study reviews some histopathological findings that can be associated with spinal pain with or without referred pain but cannot be seen on imaging. Some histopathological changes illustrate imaging device limitations. Awareness of the considerable limitations of even sophisticated imaging devices is necessary when managing patients with acute or chronic spinal pain with or without referred pain. Symptoms may well be genuine and not of psychogenic origin: a diagnosis of malingering, therefore, should not be made lightly.

Feigned psychiatric symptoms in the emergency room.

Psychiatrists providing emergency services at an urban general hospital completed questionnaires on 227 patients evaluated over a two-month period to assess whether they suspected the patient of malingering or of having secondary gains, and whether the patient was confronted about the suspicions. Thirteen percent of patients were strongly or definitely suspected of feigning symptoms; none received a primary diagnosis of malingering, and less than half were confronted. Suspected secondary gains included food and shelter, medications, financial gains, and avoidance of jail, work, or family responsibilities.

Differential diagnosis of malingering and factitious disorder with physical symptoms

AbstractThe present article attempts to clarify the difficult diagnostic discrimination between malingering and factitious disorder with physical symptoms. It is proposed that diagnostic evaluations focusing on the patient's observed symptomatology will be limited in their accuracy and utility. Instead, a longitudinal approach is needed to include the course of the disorder over time, its response to treatment, and the proposed etiology of the disorder. It is hoped that with a better understanding of these two disorders, prompt and accurate diagnosis can lay the foundation for effective management of both malingering and factitious disorders.

The use of placebo trials as part of a forensic assessment.

The detection of malingering in the context of forensic evaluations has received increasing attention in the literature, with more careful research and analyses of a variety of clinical methods being employed for that purpose. The author presents three clinical cases as examples of the use of placebo trials in the differential diagnosis of malingering, and discusses the validity of such trials as well as ethical issues raised by the use of placebos without informed consent. Suggested guidelines for the diagnostic use of placebos with forensic patients are presented.