Clinical Assessment of Malingering and Deception

Clinical Assessment of Malingering and Deception, 2nd edition

Rogers R, editor

New York: The Guilford Press; 1997. 525 pp with index

ISBN 1-57230-173-2 (cloth)

Malingering is somewhat of a taboo subject in clinical psychiatry and medicine. Physicians are so steeped, by history and training, in the trust and good faith that accompany the physician-patient relationship that the very idea that a patient could deliberately and maliciously mislead a doctor in a clinical setting is anathema to many physicians. The physician’s mindset is that the patient comes for help “in good faith”; an attitude of suspicion regarding motives is not likely to engender trust and promote rapport.

Human nature being what it is, however, it is clear, on a priori grounds alone, that not all who come into the office of a physician have pure and honest motives. Physicians are poorly prepared, by training and temperament, to spot such dissimulation. According to the authors of this book, this problem is becoming more prevalent, and we do our patients, our profession and our society little good by prolonging our ignorance. Our naivete was used by the antipsychiatry movement some years ago, by individuals who achieved notoriety by simulating psychiatric disorder to gain admission in a psychiatric hospital in order to condemn publicly the conditions therein.

This is the second and much expanded edition of a book first published in 1988. In his introduction, the editor estimates that the prevalence of dissimulation is approximately 15% in forensic psychiatry settings and 7% in nonforensic clinical settings. It is particularly likely to occur when the clinical setting is under outside, third-party control, rather than patient control. The author puts forward an “adaptational model” to explain why malingering occurs. This model posits that malingering is more likely in an adversarial (e.g., forensic) setting, when the stakes are high, when no other alternatives appear viable and when the aim is to cope with and if possible avoid a potentially destructive and conflictual situation. The author regards malingering and defensiveness as polar opposites: the malingerer creates or exaggerates symptoms, whereas the defensive individual denies or minimizes symptoms.

The rest of the book is divided into 4 parts. Section I contains the meat of the book and deals with diagnostic issues, including factitious disorder, malingered psychosis, the relationship of malingering to personality disorders and sociopathy, simulated amnesia and pseudomemory phenomena, misreporting of substance abuse, and post-traumatic disorder and deception in children.

Malingered psychoses (including delusions and hallucinations) are difficult to identify. Although they are not common, they should be considered in any patient with an atypical psychotic presentation, particularly when the phenomena seem bizarre and inappropriate. Concerning management, “the suspected malingerer should be given every opportunity to save face. Once feigning is denied, a malingerer may have difficulty admitting it later.” The identification of feigned psychosis is clearly an important clinical problem with many legal and other implications.

The chapter on simulated amnesia and pseudomemory includes a fascinating review of recovered memories and false-memory phenomena. Numerous studies have supported the conclusion that “confidence in a memory correlates only weakly with its fidelity.” Children who have witnessed nonsexual traumatic events, such as the assault or murder of their parents, all develop psychiatric symptoms, and none fail to recall the event, although they often engage in avoidance behaviour. Furthermore, durable, permanent memories of childhood events are not formed before the age of 3 or 4 years, when the development of the hippocampus is complete. The author concludes by emphasizing the importance of following well-established principles that govern the establishment, elaboration and reconstruction of all memories and that help to disengage the recovered memory/false memory debate from the tabloids and place it on a firm scientific foundation.

The chapter on malingering in post-traumatic disorders also provides a fine review of a controversial subject. The incidence of malingered psychological symptoms after injury is unknown, but estimates vary from 1% to 50%. The reluctance of psychiatrists to suspect malingering is exemplified by the case of a man who was presumably mute for 2 years after a head injury. Eleven psychiatric reports failed to mention the possibility of malingering; however, a skeptical neurologist observed the man speaking normally after an office visit. Recovery after settlement of litigation is often given as a justification for malingering, but recovery is likely not as common as was once thought. A minority of patients with post-traumatic somatoform pain disorder also have a post-traumatic stress disorder, and this may help to explain the pathogenesis of the pain. In complex cases, it is helpful to obtain corroborative information regarding patient behaviour in nonclinical settings, or even to admit the patient to hospital for observation and assessment. Previous history of sporadic employment, extensive absences from work and previous incapacitating injuries may also be helpful in supporting a hypothesis of malingering.

Section II reviews the use of psychometric assessment, including the MMPI-2, the Rorschach test and neuropsychological tests. Of these, the MMPI-2 appears to have the most value in identifying malingering and defensiveness. Section III deals with specialized methods of investigating patients suspected of malingering. These include chapters on interviews assisted by drugs (particularly amy-lobarbitone sodium), polygraphy, hypnosis, structured interviews (including particularly the SADS and the SIRS), detection of dissimulation in sex offenders and the use of self-report instruments. Section IV includes a useful summary of the field and techniques that may be used to confront a patient suspected of dissimulation. The author emphasizes the importance of being judicious in such a confrontation, the goal of which is to “clarify areas of ambiguity and offer insight into possible motivation/’ The author also gives examples of the wording of questions that may be used when confronting a patient suspected of defensiveness or malingering.

The editor is a forensic psychologist who has published extensively in this field; he is also the author of 6 of the 19 chapters in this book. The remaining chapters have been authored by North American psychologists and psychiatrists. Each chapter follows a consistent format, and there is little repetition and overlap. Post-traumatic stress disorder, amnesia and recovered memories are of intense topical interest in Western society and are very well reviewed in this book, which will stimulate interest in a field largely neglected by psychiatrists. The bibliography is extensive and up-to-date. This book can be highly recommended to clinicians, particularly those with an interest in psychiatry and the law and those involved in the management of patients with disability and post-traumatic disorders.