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teaching:malingering [on April 12, 2020]
teaching:malingering [on January 28, 2022] (current)
psychdb [Cognitive]
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 ====== Malingering ====== ====== Malingering ======
 +{{INLINETOC}}
 ===== Primer ===== ===== Primer =====
 **Malingering** is the intentional production false or grossly exaggerated physical or psychological complaints with the goal of receiving a reward. Malingering is //not// a mental disorder or diagnosis. **Malingering** is the intentional production false or grossly exaggerated physical or psychological complaints with the goal of receiving a reward. Malingering is //not// a mental disorder or diagnosis.
- 
-<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See also: **[[somatic:​home|]]**</​alert>​ 
  
 ==== Incidence ==== ==== Incidence ====
-  ​* [[https://​www.ncbi.nlm.nih.gov/​pubmed/​12650234|Mittenberg,​ W., PattonC., CanyockEM., & ConditD. C. (2002). Base rates of malingering and symptom exeggeration. Journal of clinical and experimental neuropsychology24(8), 1094-1102.]]+<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: **[[https://​www.ncbi.nlm.nih.gov/​pubmed/​12650234|Mittenberg,​ W. et al. (2002). Base rates of malingering and symptom exeggeration. Journal of clinical and experimental neuropsychology24(8)1094-1102.]]** 
 +</​alert>​ 
 +  * The true rates of malingering is difficult to determineas the nature of malingering involves deception. 
 +    * There is estimated to be a prevalence of 1% in psychiatric patients5% in military personnel, and between 10 to 20% in medicolegal cases.[(Benjamin JS, Virginia AS (editors): Kaplan & Sadock'​s Synopsis of Psychiatry, Ed 10PhiladelphiaLippincott Wiliams ​Wilkins2007.)] 
 +  * The incidence of malingering in forensic assessment settings is as high as 50%.[([[https://​pubmed.ncbi.nlm.nih.gov/​17886149/​|Ardolf,​ B. R., Denney, R. L., & Houston, ​C. M. (2007). Base rates of negative response bias and malingered neurocognitive dysfunction among criminal defendants referred for neuropsychological evaluation. The Clinical Neuropsychologist,​ 21(6), 899-916.]])] 
 + 
 +==== Not a Diagnosis ==== 
 +  * Malingering is not a diagnosis, even though it is encountered in the clinical setting. 
 +  * To establish ​malingering ​is difficult. Symptoms from malingering are intentional, ​and the motivation behind it is also intentional. 
 +  * The individual //​consciously//​ fakes, profoundly exaggerates,​ or claims to have a disorder or symptoms in order to attain a specific secondary (external) gain. 
 +    * This gain could be avoiding work, getting worker'​s compensation,​ or obtaining something of material value. Complaints from malingerers will end after they have achieved their gain (in comparison to [[somatic:​dsm-5:​factitious|factitious disorder]], which is not always the case). 
 + 
 +===== Assessment ===== 
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: **[[https://​www.psychiatrictimes.com/​view/​malingering-key-points-assessment|Lebourgeois III, H. W. (2007). Malingering:​ Key points in assessment. Psychiatric Times, 24(5), 21-21.]]** 
 +</​alert>​ 
 + 
 +===== Detecting Malingering ===== 
 +  * Even health professionals and professional "lie detectors"​ (e.g. - police officers, judges, border officers) are very poor at detecting malingering in most cases.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC6308182/​|Walczyk,​ J. J., Sewell, N., & DiBenedetto,​ M. B. (2018). A review of approaches to detecting malingering in forensic contexts and promising cognitive load-inducing lie detection techniques. Frontiers in psychiatry, 9, 700.]])] 
 +  * More structured and detailed psychometric testing may aid in improving detection, using detailed tests such as the: 
 +    * Structured Interview of Reported Symptoms (SIRS)  
 +    * Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)  
 +    * Miller Forensic Assessment of Symptoms Test (M-FAST) 
 + 
 +==== Cognitive ==== 
 +Individuals with malingering may feign cognitive impairment; several tests to detect for cognitive malingering include:  
 +  * Coin-in-hand test[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1072844/​|Kapur,​ N. (1994). The coin-in-the-hand test: a new" bed-side"​ test for the detection of malingering in patients with suspected memory disorder. Journal of neurology, neurosurgery,​ and psychiatry, 57(3), 385.]])] 
 +  * Tests of Memory Malingering (TOMM)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC6308182/​|Walczyk,​ J. J., Sewell, N., & DiBenedetto,​ M. B. (2018). A review of approaches to detecting malingering in forensic contexts and promising cognitive load-inducing lie detection techniques. Frontiers in psychiatry, 9, 700.]])] 
 +  * Rey Fifteen-Item Test (FIT) 
 +    * With this test, the clinicians detects whether there is a “floor effect”, which assumes the individual attempting to malinger will fail at a task which even a grossly impaired individuals are likely to perform adequately. 
 +  * Word Memory Test (WMT) 
 + 
 +<panel type="​info"​ title="​Conversion Disorder vs. Malingering*"​ subtitle=""​ no-body="​true"​ footer="​* = Note that these are only suggested features and is by no means definitive!">​ 
 +^ Malingering ​                                                                                                                                                                                                                                                                                                     ^ Conversion Disorder ​                                                                                                                                                                                                                                                   ^ 
 +| • Malingering​:​​ ​Aware​ ​of​ ​purpose​ ​of​ ​symptoms​\\ • Usually uncooperative,​ suspicious,​​ ​aloof​​\\ • Avoids​ ​examinations​​ and investigations ​(unless​ ​there is a financial​ ​benefit)\\ • Refuses​ ​employment​ ​with​ ​partial disability\\ • Describes​ ​accident​ ​in​ ​full​ ​"​perfect"​ detail ​ | • Not​ ​aware​ ​of​ ​purpose​ ​of​ ​their symptoms\\ • Cooperative,​​ ​appealing,​​ ​and more dependent\\ • Welcomes​ examinations and investigations\\ • ​Accepts​ ​employment​ ​with​ ​partial​ ​disability\\ • Describes accident​ ​with​ ​gaps​ ​and​ ​inaccuracies ​ | 
 +</​panel>​ 
 + 
 +==== Delusions and Hallucinations ==== 
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
 +See also: 
 +  * **[[http://​jaapl.org/​content/​early/​2019/​09/​13/​JAAPL.003867-19|Pierre,​ J. M. (2019). Assessing malingered auditory verbal hallucinations in forensic and clinical ​settings. The journal of the American Academy of Psychiatry ​and the Law47(4), 448-456.]]** 
 +  * **[[https://​pubmed.ncbi.nlm.nih.gov/​10083952/​|Resnick,​ P. J. (1999). The detection of malingered psychosis. Psychiatric Clinics of North America, 22(1), 159-172.]]** 
 +</​alert>​ 
 + 
 +  * Individuals may also feign psychotic symptoms such as [[teaching:​delusions-hallucinations|hallucinations or delusions]]. 
 +  * If a patient alleges unusual hallucinations,​ ask about them in detail. There are several key things to note:​[([[https://​pubmed.ncbi.nlm.nih.gov/​10083952/​|Resnick,​ P. J. (1999). The detection of malingered psychosis. Psychiatric Clinics of North America, 22(1), 159-172.]])] 
 +    * Hallucinations are almost always associated with delusions. 
 +    * Genuine hallucinations are typically intermittent rather than continuous. 
 +    * In [[psychosis:​schizophrenia-scz|schizophrenia]],​ the major themes are persecutory or instructive (command).[([[https://​pubmed.ncbi.nlm.nih.gov/​10083952/​|Resnick,​ P. J. (1999). The detection of malingered psychosis. Psychiatric Clinics of North America, 22(1), 159-172.]])] 
 +    * Auditory hallucinations are usually clear, not vague (7%) or inaudible 
 +    * Both male and female voices are commonly heard (75%) 
 +    * Voices are usually perceived as originating outside the head (88%) 
 +    * Real hallucinations tend to diminish when patients are involved in activities (patients typically cope by engaging in activities, changing posture, seeking interpersonal contact, taking medication) 
 +    * Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%) 
 +      * True visual hallucinations are usually of normal size and in colour 
 +  * Timeline of symptoms: 
 +    * Malingerers may claim that a delusion began or disappeared suddenly. 
 +    * In reality, systematized delusions usually take weeks to develop and much longer to disappear. 
 +  * Other features: 
 +    * Malingerers are more likely to give vague or "​hedge"​ their answers to straightforward questions.  
 +    * Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with schizophrenia are often reluctant to discuss their symptoms. 
 + 
 +<panel type="​info"​ title="​Uncommon Psychotic Presentations"​ subtitle="​Adapted from: Resnick, P. J., Knoll, J. (2005). Faking it: How to detect malingered psychosis. Current Psychiatry, 4(11), 12." no-body="​true"​ footer="">​ 
 +^ Hallucinations ​                                                                                                                                                                                                                                                                                                                                                                                                                     ^ Delusions ​                                                                                                                                                                                ^ 
 +| • Continuous\\ • Voices are vague, inaudible\\ • Hallucinations are not associated with delusions\\ • Voices use stilted language\\ • Patient uses no strategies to diminish or cope with hallucinations\\ • Patient states that they obey all commands\\ • Visual hallucinations in black and white\\ • Visual hallucinations alone in schizophrenia\\ • Visual hallucinations are exaggerated in size (very small or very large) ​ | • Sudden/​abrupt onset or termination\\ • Patient'​s behaviour is inconsistent with delusions\\ • Bizarre content without disorganization\\ • Patient is overly eager to discuss delusions ​ | 
 +</​panel>​ 
 + 
 + 
 +===== Other Diagnoses ===== 
 +  * [[teaching:​cognitive-bias-misdiagnosis-overdiagnosis|Misdiagnosis]] 
 +    * Malingering should not be considered until all other diagnoses have been considered! 
 +  * [[somatic:​home|]] 
 + 
 +==== Comparison of Somatic Disorders ==== 
 +<​imgcaption image1|>​{{ :​somatic:​dsm-5:​comparison_somatic_factitious_malingering.png?​direct&​800 |Comparison of Somatic Symptom Disorders, Factitious Disorder, and Malingering}} 
 +</​imgcaption>​
  
 {{tag>​ssx}} {{tag>​ssx}}