1. Malingering
Karen S. Brink
21 February 2008

2. Content Definitions and Terminology International trends
Guidelines for Claims Assessors
Guidelines for Occupational Therapists

3. Definitions
Intentional simulation or exaggeration of psychological or physical symptoms for secondary gain (American Psychiatric Association, 1994)
Malingering is intentional production of false or exaggerated symptoms motivated by external incentives, such as obtaining compensation or drugs, avoiding work or military duty, or evading criminal prosecution. (DSM:IV-TR V65.2 )
Malingering is not a psychiatric disorder

4. Terminology Accident neurosis Accident victim syndrome
Aftermath neurosis American disease
Attitudinal pathosis Compensationitis
Entitlement neurosis Functional overlay
Greenback neurosis Justice/ Litigation neurosis
Neurotic neurosis Profit neurosis
Railway brain/ spine Secondary gain neurosis
Syndrome of disproportionate disability
Traumatic hysteria

5. The Psychology of Lying
Type of Lies
White
Humourous
Altruistic
Defensive
Aggressive
Pathological
Secondary gain

6. Secondary gains
Gratification of preexisting dependency or revengeful strivings
Attempt to elicit care-giving or sympathy
Family anger
Entitlement after struggling, dutiful attention to responsibilities
Ability to withdraw from unpleasant life roles, activities and responsibilities
Adoption of sick role (socially sanctioned)
Blame of failures placed on illness beyond one’s own control
Maintenance of status in family
Holding spouse/partner in relationship
Financial rewards (income replacement, settlement, debt protection, subsidized childcare, housing)
Protection from legal obligations
Job manipulation (promotion/transfer)
Secondary losses
Economic losses
Loss of meaningfully relating to society through work
Loss of work social relationships
Loss of social support network
Loss of meaningful and enjoyable family roles and activities
Loss of recreational activities
Loss of respect from family and friends
Negative sanctions from family
Loss of community approval
Loss of respect from helping professions
New role not comfortable and defined
Social stigma
Guilt
Tertiary gains
Gratification of altruistic needs
Desired change in role
Dependency
Gain sympathy from social network
Admiration and respect from others
Financial gain
Tertiary losses
Increased responsibilities at home and work
Emotional suffering
Disturbance and discord within relationship
Guilt/obligation to stay in undesirable relationship
Stigmatization
Financial hardship

7. Kaplan & Sadock
Malingering is different from lying in that it is intended deception about a physical or psychological problem (as opposed to deception about anything else). Obviously, it is possible for an evaluee to both lie and malinger but the two are separate issues to be considered in a criminal forensic evaluation
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 )

8. Non-diagnostic terminology
Symptom magnification syndrome
Symptom exaggeration
Abnormal illness behaviour
Effort
Motivation
Effort (sub-maximal/insincere)
Illness behaviour/sick role/ psychological overlay

10. International trends Prevalence: 30% of disability cases
Standards (Travis)
Use of at least 3 multiple data sources (3)
Use multiple data collection methods (>=3)
Triangulation of data
Consistency
Performance across repeated trials, similar tests, expected function, diagnosis
Distraction
Effort behaviours
Self-reported vs observations
30% of disability cases (neuropsyche – Slick et al. 2003)
25-30% of fibromyalgia, chronic fatigue syndrome, depression
40% of chronic pain (Mittenberg, et al. 2002)

11. Specific FCE tests Test designs not primarily for detection of effort
Validity/ Reliability
Malingering
Blankenship FCE
Not published
Good, but take care of false positives
BTE Work Simulator
Moderate
Unknown
EPIC & SFS
Good
Isernhagen FCE
Good (with use of Borg)
Key FCA
Unknown*
PWPE (Ergoscience)
Smith PCE
Valpar CWS-Joule
Good (Varies between samples)
Modapts
Test designs not primarily for detection of effort
2004: Five tests were able to discriminate
Table not to be misconstrued or used as research

12. Guidelines for OTs Guidelines needs to be reviewed
Malingering guidelines are specific to all diagnoses
High prevalence with referrals
Comply with international trends
Varied approach
Take care with terminology (effort, symptom exaggeration, motivation, psychological overlay)
Focus should remain on function
Varied approach is favoured by all professions in field of disability assessment, incl self-reports, observations, tests, ADL, activities

13. Guidelines for Claims Assessors
Be aware of your own prejudices and feelings
Contractual decision and not moral argument
Can’t win ‘em all
Long-term management of claim
Professionalism during interaction with suspected malingerer
Consistency assessment part of claims process
Use reputable opinions (specialists, OT, forensics)
Ask for certain tests, or if second opinion, alternative tests
Be specific with forensics
Unannounced, follow-up
Read between lines of reports
41.7% rarely use terms malingering; 12.5% never use term; More than 80% instead says that the test results are invalid, inconsistent with the severity of the injury or indicative of exaggeration: Detecting malingering – a survey of experts’ practices 2004 (Slick, Tan, Strauss, Hultsch)
Use of significant others in detection of malingering
The clarification process Some clinicians may wish to speak directly to the evaluee regarding evidence of feigning to further the assessment or to give the evaluee a chance to explain discrepancies. The statement, "Remember your ABCS" may be useful to clinicians who decide to seek clarification from evaluees:
Avoid accusations of lying.
Beware of countertransference.
Clarification, not "confrontation."
Security measures.
Be cautious in the use of leading questions when interviewing evaluees suspected of malingering; use open-ended questions at the outset of the interview and later ask detailed questions that help characterize symptoms as typical or atypical of the mental illness in question

14. The future of malingering
Impact on disability claims will not change:
Age old practice, psychodynamics remain the same
Always a consideration by definition of financial gain
Guidelines, training and tests developed as research and experience increases
Financial assistance to aid further research
HISTORICAL BACKGROUND Malingering was documented in biblical times. David "feigned insanity and acted like a madman" to avoid a king's wrath (1 Samuel 21:11-16). In 1843, malingering found its way into the English medical literature.10 Four years later, a French surgeon described the use of ether to distinguish feigned from real disease.11 In the late 19th century and early 20th century, the introduction of worker's compensation led to numerous pejorative terms such as compensation neurosis to describe suspected malingering.12 During World War II, the British dropped pamphlets over German troops instructing them how to feign injury in order to obtain military leave.13 Recently, a German CD-ROM named the "Sickness Simulator" was available for purchase on the Internet; the program instructed employees on how to malinger in order to obtain sick leave.
Price £10 / 13 Euros / $16 (US)