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.
Malingering should be strongly suspected if any combination of the following is noted:
1. Medicolegal context of presentation (e.g., the person is referred by an attorney to the clinician for examination)
2. Marked discrepancy between the person's claimed stress or disability and the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regime
4. The presence of Antisocial Personality Disorder
Malingering differs from Factitious Disorder in that the motivation for the symptom production in Malingering is an external incentive, whereas in Factitious Disorder external incentives are absent. Evidence of an intrapsychic need to maintain the sick role suggests Factitious Disorder. Malingering is differentiated from Conversion Disorder and other Somatoform Disorders by the intentional production of symptoms and by the obvious, external incentives associated with it. In Malingering (in contrast to Conversion Disorder), symptom relief is not often obtained by suggestion or hypnosis. (pp. 739-740)
There is no consistent prototype of what malingerers look like. The research in this area has not fully examined what types of individuals will malinger. There has been some suggestion that especially histrionic individuals and/or hypochondriacal individuals may be suspect but more research needs to be conducted to confirm/disconfirm these hypotheses.
Rogers et al. (1990) and Kropp & Rogers (1991) examined college students and criminal defendants in an attempt to determine how people go about malingering. The participants were considered knowledgeable (were either college students studying psychology or were criminal defendants incarcerate in a treatment facility for mental health problems) and were given time to prepare (were given case materials to read about various mental disorders). Participants were given instructions to malinger and then were administered the SIRS (precursor).
Despite the presumed psychological sophistication of the participants, they rarely came close to giving a convincing presentation. The majority (90%) believed that they had done a good job at fooling the examiner.
When asked about how they tried to fool the interviewer, both college students and inmates commonly pretended to be psychotic in some way. They would try to present that they were paranoid and experiencing hallucinations. Other commonly feigned problems were anxiety and depression. Generally, they described very unsophisticated strategies for malingering, including:
1. answering all questions in the opposite direction to the truth
2. offering ridiculous answers to straightforward questions
3. constantly playing with a pen, pencil, or paper
4. trying to talk as little as possible
5. ignoring certain questions
6. contradicting themselves often
These strategies are considered unsophisticated as they typically result in presentations very different from those of truly mentally ill individuals. Such behaviors are relatively infrequent in bona fide mentally ill individuals.
Applies to persons who are motivated by underlying psychopathology. This model includes the explicit prediction that the voluntary production of bogus symptoms will eventually erode and be replaced by a genuine disorder.
Early writers (i.e., Eissler, Menninger) posited a pathogenic process in which dissimulation represented an ineffectual coping with an underlying disorder. Discontent with this dynamic formulation appeared to reflect a growing realization that many malingerers did not subsequently become mentally ill. Indeed, some showed remarkable improvement in psychiatric and neurological problems once an external goal was achieved.
Recent research indicates that this model may have a modest role with non-forensic malingerers but a limited role with forensic malingerers.
Postulates an antisocial and oppositional motivation for malingering. This model proposes that psychopaths will be undeterred by either social convention or criminal law and may feign mental disorders to obtain unearned and undeserved rewards.
This is the model characterized by the DSM. Previously in the literature, it has been referred to by Rogers and others as puritanical and criticized as being unduly moralistic. The DSM-III, DSM-III-R, and DSM-IV formulations of malingering signaled a radical departure from the earlier pathogenic model and a decided shift toward a moralistic perspective of malingering. There appear to be implicit judgments of "badness" in three of the four indices (Rogers, 1990).
The puritanical model provides an unwieldy concoction of characterological variables (APD), contextual variables (medicolegal evaluations), and interpersonal variables (uncooperativeness). The only unifying theme of this model is one of "badness". That is, a bad person (sociopath) in a bad situation (forensic assessment), who is a bad participant (lack of cooperation).
Rogers views the usefulness of this model as either an explanatory model or a descriptive model as extraordinarily limited.
This model assumes that malingering is a constructive attempt to succeed in highly adversarial circumstances. It is consistent with a risk-benefit analysis in the choice of malingering over other alternatives.
Rogers proposed this model as an alternative to the criminological or puritanical model. He argues that the reconceptualization of malingering must disentangle explanatory models (why does malingering occur?) from detection models (who is malingering?). This adaptational model is presented as an explanatory model.
There are three underlying assumptions to this model:
(1) a person perceives the evaluation/treatment as involuntary or adversarial
(2) the person perceives that he or she has either something to lose from self-disclosure or something to gain from malingering
(3) the person does not perceive a more effective means to achieve his or her desired goal
see Rogers, 1990 , p. 185 for examples of research supporting the adaptational model of malingering
The adaptational model is consistent with decision theory in which choices made under conditions of uncertainty are based on expected utility and likelihood.
Recent research has indicated that this model can be subdivided into two broad dimensions: cost-benefit analysis and adversarial setting.
Recent research has examined the role of setting and gender in malingering. These researchers found that cost-benefit analysis appeared to be the most representative dimension of forensic cases followed by the criminological model and adversarial circumstances. In contrast, nonforensic cases were most prototypical for the adversarial circumstances followed by the cost-benefit analysis and the criminological model. The cost-benefit analysis showed the greatest difference with the weighing of alternatives and likely outcomes being very prototypical of forensic malingerers but only moderately so for nonforensic malingerers.
In a forensic setting, cases of feigned medical syndromes were more prototypical than feigned cognitive impairment. In nonforensic settings, the adversarial context was more salient to feigned mental disorders than either the simulation of cognitive impairment or medical syndromes.
One half of female nonforensic malingerers focused on feigned medical syndromes. In addition, the pathogenic model seems somewhat more germane to female than male malingerers in nonforensic settings.
The most difficult malingering to detect is that done by people who are actually psychotic or have a history of psychosis, as these individuals have experience with hallucinations and delusions and psychotic thinking. In these situations, the examiner must do his/her best to assess the individual's current mental status.
Rogers has used the above techniques as a basis for constructing an interview to detect malingering. In addition to the above techniques, the SIRS is designed to detect unusually large endorsement of symptoms of extreme or "unbearable" severity.
Advantages of the structured interview approach are that (1) it does not rely on the high degree of subjectivity the idiosyncratic styles of individual clinicians, and (2) the approach is more thorough as it applies all of the clinically relevant strategies universally to all evaluees.