Jude Bergkamp, Psy.D. Antioch University Seattle Ray Hendrickson, Ph.D., J.D. Western State Hospital . What have you heard about malingering? . How does it impact your work? . How many of you are at this conference to get out of work? 2 . Definitions & Diagnosis . Clinical Considerations . Alternative Perspectives . Recommendations 3 . Malingering – the intentional or conscious fabrication or gross exaggeration of mental health symptoms as a means towards gaining a desirable outcome. Feigning – Fabrication or exaggeration of symptoms without the assumption of motivation/secondary gain. Other terms include dissimulation, minimization, denial, and distortion . Positive impression management . Appear “normal” . Avoid stigma of mental illness . Avoid treatment . Avoid deprivation of liberty (hospitalization, loss of privilege/freedom 4 . Deceived “the most respected minds in forensic psychiatry” in CST evaluations from 1990 to 1997 . The Oddfather and The Enigma in the Bathrobe 5 . V65.2 Malingering . 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 military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Under some circumstances, malingering may represent adaptive behavior—for example, feigning illness while a captive of the enemy during wartime. 6 . Malingering should be considered if any combinations of the following is noted: . Medicolegal context of presentation [e.g., if referred by an attorney, or is self-referred while litigation or criminal charges are pending] . Marked discrepancy between the individual’s claimed stress or disability and the objective findings and observations. Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen. The presence of antisocial personality disorder. Problem: The external establishment of internal motivation or volition 7 Conscious Feigning Unconscious Feigning . Malingering . Conversion Disorder . Factitious Disorder . Somatization Disorder . Factitious Disorder by . Pain Disorder Proxy 8 . Medical/Legal Cases . Forensic Settings . Social Security Disability . Competency . Personal Injury . Criminal Responsibility . Worker’s compensation . Sentencing considerations . VA Benefits . Correctional . Treatment Settings . Preferable Housing . Chronic pain . Protective Custody . Seeking hospitalization or . Drug seeking housing . Social Contact . Release Considerations 9 Not so fast! DSM-IV-TR criteria result in a misclassification rate of over 80% (Rogers & Vitacco, 2002). How did you answer the ”get out of work” question? 10 . Pathogenic Model . Underlying force behind malingering is a mental disorder . This model has fallen out of favor with the changing perceptions of malingering . Criminological Model . Malingering as a form or result of antisocial and criminal behavior . The “dishonest criminal” theory . Engaging in dishonesty is a hallmark of ASPD . Adaptation Model . Malingering as an adaptive behavior to meet the needs of the individual at that time . Occurs when the stakes are high and the individual perceives that there is no other viable choice . Adversarial evaluation . Feigning illness while captive . Personal injury suits . Avoiding harm 11 . We can never truly determine motivation . No psychometric and normed measure to assess motivation/intention . Malingering is a state not a trait . Feigned and genuine symptoms are often present in the same person . Feigning can occur without malingering (secondary gain) . STIGMA! 12 . Beware of the pitfalls and limitations of malingering (clinical discourse and documentation) . Look for and refer for psychometric testing . Structured Interview of Reported Symptoms (SIRS) . Miller Forensic Assessment of Symptoms Test (M-FAST) . Minnesota Multiphasic Personality Inventory (MMPI-2) . Personality Assessment Inventory (PAI) . Quality consideration will incorporate testing and acknowledge limitations and implications 13 . Awareness of your emotions (hurt, mistrust, betrayal) . Avoid extracting a confession or playing “gotcha” . Consider the context and possible external/internal gains . Attempt to strategically meet basic human needs . Reinforce alternative coping mechanisms . Balance accountability with alliance/compassion/rapport . Provide face-saving . Firm boundaries . Consistent documentation and consultation 14 . Present observation in a straightforward and non- judgmental manner . I hear you telling me that everything is “fine,” although when I hear about ______(observation)___, I am having some difficulty understanding what is going on. I know how much you want people to believe that you have _____(symptoms)___ under control on your own. I see in the chart that ________ may still be going on. Can you help me understand? . I understand how hard it is for some of the people I meet to describe what is going on for them without feeling vulnerable or like it will be used against them. Whenever someone tells me only the good side, I become interested in what is being left out. According to you today, you are having no difficulties handling _____, but according to the treatment team you look like you are still struggling with ______. Why do you think they might think this? 15 . Because of the inconsistent or improbable nature of the clinical presentation of someone who is malingering, clinical probes may need to be broader . Some of the problems you describe are rarely seen in patients with mental illness. I am worried that you might be trying to make things seem worse than they are. Can you help me understand why this might be happening? . Earlier in the evaluation you said you experienced ________, but you described it differently now. I am having difficulties understanding which is more true for what you go through. Although you have discussed ______, when I read your chart, you don’t seem to have those difficulties when you are on the unit. What do you think helps you manage your struggles when you are not in session? 16 . Disengagement is the hallmark of suboptimal effort and irrelevant responses. Inquiries focus on re-engagement and rapport building: . I don’t think we got off on the right foot. Can we start again? Tell me in your words about _____ . I may not have asked that question in the most clear way. Getting a clear and honest answer from you is the quickest and best way to get information to move forward with treatment/this case. What can I do to make you feel more comfortable with this assessment? . I noticed that when you were taking the tests earlier, sometimes it looked like you didn’t pay close enough attention to the questions. Can we go through some of the information so I can have a better picture of what is going on for you? . Do you need a break? Is there a better time of the day for you to be able to concentrate on these questions? 17 The Social Nature and Costs of Malingering Malingering is always a social act. Not a psychiatric disorder. Malingering has no value or meaning in isolation. Malingering behavior correlates with social institutions that potentially reward “sickness behavior.” Rewards can be financial (a gain) or relief from social responsibility (e.g., military service, criminal responsibility). Social Legislation in 19th Century resulted in industrial compensation. An early notation: There is evidence that under the operation of the National Health Act the incidence of sickness, or rather the claims in respect of sickness, will prove to be considerably above the original estimates…. and it is only too probable that under the Insurance Act there will be a corresponding rise in the expenditure… of sickness claims. Edwin Smith, Editor The British Medical Journal, April, 1913 18 The Social Nature and Costs of Malingering Some U.S. Financial Costs: According to Chafetz & Underhill (2013), the Social Security Administration indicated that in 2011, 11 million workers received SS benefits because of disabilities, who were paid more than $119 billion out of the Social Security trust fund. In addition, SSDI payments were made to more than 8 million persons, 84% of whom were disabled, the remainder aged and blind. From SSDI data, according to Chafetz & Underhill, $32 billion were paid to mentally disabled individuals in 2011. Using Larabee, Millis, & Myers (2009) estimates of 40% malingering rate, the costs of SSDI in 2011 was more than $12 billion for malingering individuals. Using the same estimates of malingering, Chafetz & Underhill calculate a cost of more than $7 billion from SSI (adult) recipients due to mental disorder malingering. Thus, the total costs in 2011 for malingered mental illness was more than $20 billion according to Chafetz & Underhill. LoPiccolo et al. estimate total U.S. health insurance fraud at $59 billion per year. Annals of Med, 1999, 13, 166-174. Chafetz (2011) estimated the total annual costs of malingered disability to be about $180 billion for all programs. Thus, it is likely that the total costs due to malingered symptoms across all domains and programs currently to be in excess of $200 billion annually. 19 Malingering in World War I Between 1914 and 1918, the British Army executed 306 of their own soldiers. Executed by firing squads from their own units. The German army executed 25 of their own; the U.S. none. Courts martial included charges of desertion, cowardice, insubordination, etc. The Generals (e.g., Haig) wanted to make examples of