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 those who were unable to return to the front.

Private Harry Farr: Fought at Mons and at the Somme, July 1916. Four times hospitalized 1915-1916 with “shellshock.” Finally refused to return to the trenches; court-martialed October 1916: The charge: “Misbehaving before the enemy in such a manner as to show cowardice.” Shot the next morning at age 25. Refused a blindfold. Not a coward.

Private Herbert Burden enlisted at age 16 by falsifying his age -- to join the Northcumberland Fusiliers. After the battle of Bellwarde Ridge, he went missing. Charged with desertion. Executed July, 1915 at age 17—not yet old enough to join the regiment.

20 Malingering in World War I

Private Thomas Highgate: Could not stand the carnage of the Battle of Mons; fled and hid in a barn after the battle. Was undefended at trial because all of his regimental comrades had been killed or captured. Executed September 8, 1914 -- the first British execution of the war.

Highgate’s legacy: His village of Shoreham, Kent struggled for 80 years whether to include his name on the war memorial in the town. A divided nation.

“Soldier’s Heart” had been described during the American Civil War (Dr. DaCosta): noted elevated blood pressure, pulse, hyper-alert; sometimes called “irritable heart” -- “disrupted neural connections…”

Why call it “Shell-shock”?

SHELL SHOCK AND THE “SHOT AT DAWN CAMPAIGN”: Relatives and supporters of the executed men campaigned to win posthumous pardon. The campaign asserted that the men were mostly psychologically traumatized by shell-shock and not cowards. The campaign went on for decades.

-- In August, 2006 all 306 executed British soldiers were pardoned. 21 Society’s Response

U.S. v. Binion, 132 Fed. Appx. 89 (8th Circuit 2005):

Dammeon Binion was arrested for possession of a firearm by a convicted felon. Representing himself, the defendant filed a pro se motion for a competence to proceed to trial evaluation, in which psychological tests were administered by a psychologist, and the evaluating psychiatrist reported the results to the court. Based on the test results and the discrepancy between these results and the defendant's observed behavior, the experts concluded that the defendant was most likely feigning mental illness and had no actual mental disorder. The psychiatrist stated that the defendant's malingering was a “form of recreation rather than a design to accomplish secondary material gain.”

Binion pled guilty to the offense, but because of his reported malingering, he was also charged with obstruction of justice, which enhanced his sentence recommendations. The court stated that because of the feigned illness, Binion was not accepting responsibility for his behavior as is normally required in a plea of guilty, and the normal reduction in sentence for a guilty plea was therefore waived.

22 Society’s Response

U.S. v. Batista, 483 F.3d 193 (2007)

Braulio Antonio Batista was charged with conspiracy to distribute 150 grams or more of crack cocaine. He pled guilty and was sentenced to a 188-month term of imprisonment. Batista claimed in his appeal that the District Court erred by granting a two-level enhancement for obstruction of justice, failing to grant a reduction for acceptance of responsibility, failing to grant a downward departure based on significantly reduced mental capacity, and failing to apply the “safety valve” provision of the Sentencing Guidelines. Batista also argued that his sentence was unreasonable under the factors set out in 18 U.S.C. § 3553(a). The Court stated, “For the reasons set forth below, we will affirm the District Court’s judgment of sentence.”

The Court stated, “Batista’s actions went beyond the mere exploration or presentation of a defense of mental incompetence to the feigning of a mental illness in an attempt to avoid facing trial or punishment for his crime. Batista’s false representation of mental illness was sufficient for the District Court to find that he had not accepted responsibility for his action. Batista’s initial admission of guilt is not sufficiently extraordinary to overcome the later behavior that led to the obstruction of justice enhancement.”

23

Malingering: Why is it sometimes so difficult to ascertain?

Jerry’s case—Possession of Stolen Vehicle

24 25

26

Malingering: What’s wrong with this picture?

From DSM-5:

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

27

Various Models of Malingering

Rogers (Clinical Assessment of Malingering and Deception, 1997) suggests three historical models for malingering:

• Pathogenic Model: “[T]he underlying force behind malingering is a mental disorder…[a person] attempts to gain control over emerging symptoms, the patient creates the symptoms and portrays them as genuine.”

• Criminological Model: Rogers states, “[The] DSM models presuppose that malingering is likely to occur with (1) persons diagnosed with antisocial personality disorder (APD), (2) evaluations conducted for forensic purposes, (3) persons uncooperative with evaluation and treatment, and (4) persons whose claims are discrepant with objective findings.” Rogers notes that this model “has faltered on conceptual and empirical grounds…the association between APD and malingering is likely illusory.”

• Adaptation Model: “[W]ould-be malingerers engage in a cost-benefit analysis when confronted with an assessment they perceive as indifferent, if not inimical to their needs. Malingering is more likely to occur when (1) the context of the evaluation is perceived as adversarial, (2) the personal stakes are very high and (3) no other alternative appears to be viable.” 28

Response Styles

Rogers (2008) suggested that “the most common error appears to be overspecification of response styles. For instance, criminal offenders are frequently miscategorized as malingerers simply because of their manipulative behavior, which may include asking for special treatment (e.g., overuse of medical call for minor complaints) or displaying inappropriate behavior (e.g., a relatively unimpaired inmate exposing his genitals).”

Rogers suggests that practitioners try to determine which response style best fits the clinical data, by asking two questions: (1) Do the clinical data support a nonspecific (e.g., “unreliable informant”) description? (2) If yes, are there ample data to determine a specific response style?

Rogers presented some examples of nonspecific terms: • Unreliability is a very general term that raises questions about the accuracy of reported information…makes no assumption about the individual’s intent or the reasons for the inaccurate data. • Nondisclosure describes a withholding of information (i.e., omission). It makes no assumptions about intentionality. An individual may choose to not disclose or be compelled by internal demands to withhold information. 29

Rogers (2008) Nonspecific terms

• Self-disclosure refers to how much individuals reveal about themselves; high self-disclosure when the person evidences a high degree of openness. A lack of self-disclosure does not imply dishonesty, but simply unwillingness to share personal information. • Deception is an all-encompassing term used to describe any consequential attempts by individuals to distort or misrepresent their self-reporting. As operationalized, deception includes acts of deceit, often accompanied by nondisclosure. • Dissimulation is a general term used to describe an individual who is deliberately distorting or misrepresenting psychological symptoms. This may be a useful term, as it would include difficult clinical presentations that do not clearly represent malingering or any specific response style.

30 Overstated Pathology

Rogers (2008) stated that important distinctions must be made between malingering and other terms used to describe overstate pathology, and presented three recommend terms below:

• Malingering has been defined by the DSM as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external symptoms” (APA, 2000). Rogers notes that this presentation must be the fabrication or gross exaggeration of multiple symptoms. Minor exaggerations or isolated symptoms do not qualify as malingering. The requirement of external incentives does not rule out the co-occurrence of internal motivations.

• Factitious presentations are characterized by the “intentional production or feigning” of symptoms that is motivated by the desire to assume the “sick role” (APA, 2000). This diagnosis must be excluded if any external incentives are present, and this categoric exclusion can be problematic “because most patient roles also involve concomitant modifications of work and family responsibilities.”

31

• Feigning is the deliberate fabrication or gross exaggeration of psychological or physical symptoms without any assumptions about its goals. Rogers states that this term “was introduced because standardized measures of response styles (e.g., psychological tests) have not been validated for assessment of any individual’s specific motivations. Determinations can be made for feigning but not their underlying specific motivations.

Rogers suggests there are three terms that should be avoided in clinical and forensic practice, as they “lack well-defined and valid descriptions.” • Suboptimal effort (also referred to as “incomplete” or “submaximal” effort) is sometimes used as a proxy for malingering. Rogers notes that the “best” efforts by an individual may be affected by a variety of internal and external factors. • Overreporting simply refers to an unexpectedly high level of item endorsement, especially on multiscale inventories. These are often erroneously identified as feigning; however this descriptive term lacks clarity with respect to content. • Secondary gain, on the other hand, does have clear definition. It may be part of an unconscious defense process motivated by intrapsychic needs, a need perpetuated by social context, or the deliberate use an illness to gain special attention. 32 Simulated Adjustment

Rogers (2008) described other closely related terms used to present response styles associated with simulated adjustment: • Defensiveness refers to the deliberate denial or gross minimization of physical and/or psychological symptoms. • Social desirability is the pervasive tendency for an individual to “present themselves in the most favorable manner relative to social norms and mores.” Rogers suggests this should be carefully distinguished from defensiveness. • Impression management refers to deliberate efforts to control others’ perceptions of an individual, it may range from maximizing social outcomes to the portrayal of a desired identity.

Rogers includes other response styles that are not as well understood as malingering, defensiveness, and described response styles: • Irrelevant Responding: Individual does not become psychologically engaged in the assessment process…the responses are not necessarily related to the content of the inquiry. • Random Responding: A subset of irrelevant responding…most frequently observed when subjected to forced choice format. • Role assumption—the individual may occasionally assume the role of another person responding to psychological measures. • Hybrid responding—an individual’s use of more than one response style in a particular situation, and for example may include honest responding and 33 defensiveness.

Definitions: Conceptual Clarity, Occasional Muddlement

Rogers suggests that there are gradations of malingering and defensiveness, including response styles such as unreliability, malingering, and defensiveness.

Dissimulation: Any deliberate distortion or misrepresentation of psychological symptoms (in some places used to denote defensive distortion). Dissimulation can include malingering, defensiveness, irrelevant responding, or random responding (DeClue, 2002).

Feigning: The deliberate fabrication or gross exaggeration of psychological or physical symptoms without any presumption about goals, purpose, or intent (DeClue, 2002). Often cannot discern goal or conscious purpose.

34 Common Misconception of Malingering

Rogers (2008) presents some common misconceptions about malingering: • Malingering is very rare. Studies suggest it is not rare in either forensic or clinical settings. • Malingering is a static response style, i.e., “Once a malingerer, always a malingerer.” Research indicates efforts at malingering are related to specific objectives. • Deception is evidence of malingering, i.e., “malingerers lie; therefore, liars malinger.” Deceptions by manipulative patients may be mistaken for malingering. • Malingering precludes genuine disorders. The analysis of a diagnosis begins with a genuine disorder, and then upon discovering malingering, the genuine disorder disappears. • Malingering is an antisocial act by an antisocial person. A perpetuated myth by the DSM, and confuses common characteristics (e.g., criminality in criminal settings). • Malingering is analogous to the iceberg phenomenon, i.e., any evidence of malingering is sufficient for its classification. • Malingering has stable base rates. Rogers (1998) noted that there are marked base rate variations (i.e., SD=14.4%) for malingering across forensic settings. Overall base rates are low (e.g., 10-30%), but with standardized assessments,

base rates may exceed 50%. 35 Feigning versus Malingering

The problem of inferring the patient’s conscious aims: Which kind of mistake would we prefer to make?

Not every instance of feigning is easily classified: patient’s aims can be both (not always so clear re motive: “sick role” also includes practical factors in patient’s life – e.g., a dependent patient wants to be in sick role, but now is relieved of responsibility for housework, shopping, child care, elder care, etc.).

Malingering is not either/or, black and white.

Malingering can be by patients with actual psychiatric disorder.

Malingering can be partial, some exaggeration of actual symptoms; report of symptoms that no longer exist.

“False imputation” is when the patient ascribes symptoms to an unrelated cause (e.g., ADHD vs drug use…).

36 Detection Strategies

Common characteristics versus discriminating characteristics, e.g., DSM-5.

Experience with real patients; detailed inquiry, e.g., mental status examination

Test Protocols:

Structured Interview of Reported Symptoms (SIRS) (2nd edition, SIRS-2) • Rare Symptoms • Unusual Symptom Combinations • Improbable Symptoms • Blatant Symptoms • Subtle Symptoms • Severity of Symptoms • Selectivity of Symptoms • Observed Symptoms

37 Detection Strategies

Miller-Forensic Assessment of Symptoms Test (M-FAST) • Reported versus Observed Behavior • Extreme Symptomatology • Rare Combinations • Unusual Hallucinations • Unusual Symptom Course • Negative Image (self-perception) • Suggestibility

Structured Inventory of Malingered Symptomatology (SIMS) • Unusual Psychotic Symptoms • Atypical Neurological Symptoms • Memory Impairment • Cognitive Incapacity • Affective Disorders

38 Detection Strategies

Validity Indicator Profile (VIP): Both verbal and non-verbal sections • Inconsistent Response Style versus Compliant Style • Irrelevant Response Style versus Suppressed Style

• Compliant: high effort to perform well • Inconsistent: willingness to respond correctly to some items, but is incomplete, intermittent, or minimal • Irrelevant: responses are not related to item content • Suppressed: efforts to answer items incorrectly

39 Detection Strategies

Minnesota Multiphasic Personality Inventory, 2nd Edition (MMPI-2)

• Markedly elevated L scores could suggest pervasive test- taking orientation (portraying oneself as overly positive)— would depress clinical scales • Markedly low L scores –may suggest efforts to exaggerate emotional symptoms • Elevated F scores may be due to random answering, poor reading skills, deliberately exaggerating difficulties • Elevated K scores may indicate efforts to slant their responses to minimize poor emotional control and poor personal ineffectiveness •VRIN and TRIN are imbedded validity indicators (e.g., inconsistency or contradictions) 40 Detection Strategies

Personality Assessment Inventory (PAI)

• Inconsistency (ICN)—records inconsistent responses • Infrequency (INF)—indications of careless or random responses • Negative Impression (NIM)—indications of exaggerated unfavorable impression or malingering • Positive Impression (PIM)—suggest presentation of favorable impression or a reluctance to admit to minor flaws

41 Detection Strategies

Evaluation of Competency to Stand Trial-Revised (ECST- R) (Rogers)

• Protocol has Atypical Presentation Scale as one of the sections • 28 questions to elicit atypical responses • Rogers suggests three common motivations for feigning responses • To present as incompetent to proceed to trial • Concern for one’s safety—to escape real or imagined threats • Exaggerating or feigning symptoms to receive treatment 42 Detection Strategies

Competence Assessment for Standing Trial for Defendants with Intellectual Impairment (CAST-MR)

• This test has been used “off label” as a screening tool for persons without evidence of developmental disability • Three parts: • Basic Skills • Skills to Assist Defense • Understanding Case Events • Extremely low scores suggest feigning

43 Memory Impairment

Test of Memory Malingering (TOMM)

• 50 item recognition test • Administered twice • Optional third administration after delay

Rey Fifteen Item Test (FIT)

• Screening test • Low discrimination • Can screen out faking

44

Malingering: Taxon or Dimensional?

Rogers’ levels of exaggeration/fabrication model

Strong et al (2006): F and Fp scales  taxonomic (e.g., dichotomy) model of malingering

Walters, et al (2008): Factor analysis of SIRS, MMPI F , Fp and Ds scales:

Conclusion: That “Malingering is more accurately conceptualized as levels of exaggeration or fabrication rather than as a response style that is categorically distinct from honest responding”

“feigned psychopathology forms a dimension… rather than a taxon (malingering-honest dichotomy), and that malingering is a quantitative distinction rather than a qualitative one” ______

Malingering of psychiatric symptoms is not inconsistent with the presence of actual psychopathology. Psychotic patients are fully capable of exaggerating and fabricating.

The problem of how to report findings; caveats. 45 So—without these somewhat sophisticated protocols, what can we do to measure feigned symptoms?

Let’s look at some strategies that may help (Rogers, 2008):

Strategy Explanation

Rare symptoms Symptoms rarely reported by genuine patients Quasi-rare symptoms Symptoms rarely reported by normals Improbable symptoms Symptoms that are fantastic or absurd Symptom combinations Symptoms that are common but rarely occur together Indiscriminant Endorsement of excessive proportion of symptoms endorsement of symptoms Severity of symptoms Excessive number of symptoms endorsed as unbearable or extreme Obvious symptoms Excessive number of clear symptoms of mental disorder endorsed Reported versus Discrepancies between self-reported symptoms and observed symptoms observed symptoms Erroneous stereotype Endorsement of symptoms erroneously thought to symptoms be reported by patients with mental disorders 46 Berry and Nelson (2010) suggest the following after a review of available literature:

1. Focus on objective identification of feigned symptom reports, without attempting to infer volition or motivation.

2. Systematically review literature on techniques for detecting feigned symptoms or recommendations for clinical identification.

3. Employ multiple strategies for identifying false symptom reports.

4. Focus on minimizing false-positive rates for any single detection strategy to allow adequate sensitivity to feigning. 47 Motivation for symptom feigning

What are some possible motivating factors?

•Trying to look mentally ill to avoid criminal responsibility •Feigning incompetency to proceed to trial •Feigning psychotic condition at time of crime to support a mental state defense

•Trying to present emotional symptoms to support a personal injury claim

•Trying to present emotional symptoms in conjunction with physical injuries in L&I claims

•Trying to get the attention of mental health or medical providers 48

What about feigning no mental illness or minimizing symptoms?

What would motivate someone to minimize symptoms?

•Attempting to appear “normal”

•Avoid involuntary hospitalization

•Problems recalling symptom presentation

•Others?

49 How can we minimize our false positive rates?

•Do not ask “leading questions,” i.e., Do you have [this symptom]?

•Ask open-ended questions, i.e., •Tell me how you are feeling. •What makes you feel that way? •Tell me how your day has gone. •Tell me how you are sleeping. •Tell me how your work is going. •Tell me where you plan to stay tonight, get food. •Tell me about your family, your friends.

50