Malingering

Malingering is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the intentional fabrication or gross exaggeration of psychological or physical symptoms, with the key criteria of being motivated by some external gains. In the context of an offender population, these motivations may include (a) delaying or reducing the length of incarceration, (b) being prescribed unnecessary medication, or (c) receiving unwarranted benefits (e.g., compensation for a feigned disability). As a response style, malingering is categorized as a condition that may be a focus of clinical attention rather than as a formal diagnosis with explicit inclusion and exclusion criteria. Within the psychological and medical fields, malingering and other forms of deception represent a highly relevant clinical issue for accurate assessment and effective treatment of offenders.

This article provides a broad overview and understanding of malingering in the context of criminal psychology. In particular, some common myths and misconceptions of malingering are addressed. The prevalence of malingering in forensic settings and broad subtypes of malingered presentations are then discussed. This is followed by an overview of response styles that have been developed to conceptualize malingering. Given the focus on criminal psychology, individuals being evaluated will be referred to as offenders rather than clients or patients. As a key emphasis of this article, the development of detection strategies for malingering and a focus on commonly used measures of malingering are highlighted.

Malingering Within the Forensic Setting

In the context of criminal psychology, a small subset of offenders may perceive a strong advantage for malingering to avoid potentially extreme consequences, such as lengthy incarcerations. For example, successful malingering during an insanity trial might result in extended hospitalization that avoids decades of prison time. This externally motivated feigning is distinguished from factitious disorders. For the latter diagnoses, individuals intentionally produce exaggerated symptoms in response to some internal motivation, such as treatment seeking. It should also not be confused with poor or suboptimal effort, which may occur as a result of genuine psychopathology in examinees who have no intention to fake impairment. From this perspective, malingering is highly relevant to criminal psychology because it is a potential mechanism through which offenders can attempt to achieve their external goals. At the same time, however, unsuccessful malingering can have extremely negative consequences that may include increased sentencing and the limiting of treatment options, even for genuine disorders.

Professionals in criminal contexts may experience an understandable inclination toward adopting a negative bias, in assuming the worst about their clientele. On the contrary, many offenders have genuine mental disorders. Thus, it would be unduly biased to assume that most criminals are just gaming the system. Even when confronted with the death penalty, as an extreme example, most convicted offenders do not malinger despite facing their imminent execution. Therefore, professionals have been urged to conscientiously evaluate malingering in each individual case and not simply assume a negative bias toward criminals.

Fundamental Misconceptions About Malingering

Common and potentially damaging misconceptions are often observed concerning malingerers and the nature of malingering itself. It is essential to identify and refute such serious misconceptions, which may lead to false conclusions with far-reaching consequences. Five key misconceptions are outlined:

• An offender who grossly exaggerates in one domain must be malingering in all domains. Therefore, all symptoms should be dismissed as bogus. This all-or-nothing misconception of malingering overlooks the clinical observation that many—if not the majority of—malingerers also have genuine disorders. Also, malingering cannot be considered a permanent response style but rather represents a situational response to a specific context.
• Inconsistent responding is tantamount to malingering because feigners often have trouble being consistent. Possibly stemming from the negative bias, this misconception myopically views malingering as the only cause of inconsistency. Marked inconsistencies can also arise from clinical issues and cognitive impairment. For self-administered measures, for example, limited ability to read or impaired concentration frequently contributes to pervasive inconsistencies.
• Malingerers are easy to identify because their presentations are obviously exaggerated. Some medical and mental health professionals may have overly positive appraisals of their abilities to accurately evaluate malingering. Such misappraisals can stem from encountering egregious cases of unskilled and preposterous efforts at malingering. However, many malingerers are more skilled and less obvious in their feigned presentations; they can only be detected by standardized measures that employ—as described below—well-validated detection strategies.
• Malingering and other forms of deception occur in most forensic cases. This misconception again reflects a negative bias more than a conceptual or empirical basis. Although certainly true that malingering occurs in a small subset of offenders, research suggests that malingering is neither rare nor pervasive. Furthermore, this concept ignores the full spectrum of possible deception from white lies to sophisticated frauds, within which malingering is distinguishable as a very specific and clinically relevant response style.
• Malingering and genuine mental disorders are mutually exclusive. A particularly detrimental assumption is that malingering precludes the presence of a genuine mental disorder for an individual. However, an offender may wish to feign some particular symptoms (e.g., psychotic symptoms in order to be found incompetent to stand trial) but genuinely has a severe mental illness (e.g., depression or anxiety). If all of an examinee’s symptoms are summarily dismissed once exaggeration is noted for some symptom domain, the offender may fail to receive much-needed mental health care.

Prevalence Within Forensic Settings

Importantly, the majority of offenders being assessed do not attempt to malinger during evaluation; however, it occurs with sufficient regularity that its assessment is essential. In recognition of these concerns, the American Psychiatric Association began to encourage the use of screening criteria for malingering with the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980. Although its prevalence is by nature difficult to assess, extensive surveys have suggested base rate estimates of malingering ranging from approximately 10% to 20% in forensic settings. Malingering and related response styles have been consistently recognized as an important clinical concern for criminal psychology, particularly because forensic assessments differ substantially from typical assessments.

In the context of mandated evaluations, both system (e.g., the pressure of required participation) and personal factors (e.g., unfavorable consequences from accurate self-disclosures) lead professionals to consider whether offenders are malingering. Contrastingly, most individuals in typical inpatient or outpatient settings seek treatment of their own volition and are motivated to receive accurate results from their psychological testing. In most instances, they are also protected from negative consequences by the guarantee of confidentiality. In forensic contexts, however, clinician–client relationships are fundamentally altered. Within correctional settings, for instance, professionals work for the institution or legal system rather than the offender being evaluated. Typically, these clinicians are professionally obligated to report negative findings that may include malingering and uncooperativeness as well as any institutional misconduct.

Offenders may have substantial motivation to malinger, especially when faced with high-stakes legal outcomes. For competency to stand trial, a finding of incompetence may lead to a delay of the criminal trial along with the modest benefits of a forensic hospital rather than a county jail. For insanity at the time of a crime, an acquittal may lead to better living conditions and possibly fewer years of confinement, although the length of sentences depends largely on the jurisdiction. However, many offenders may view malingering as an unacceptable risk because of the serious negative consequences associated with unsuccessful feigning. For instance, offenders pleading insanity are essentially admitting to the criminal acts while also raising questions about their mental state. If found to be sane and malingering, a conviction is almost a certainty, while the malingering could contribute to an even longer sentence.

Subtypes of Malingering

Although malingering shares some key similarities across contexts (e.g., fabrication of symptoms for an external goal), research has clearly demonstrated its complexity, which includes several domains and varied motivations. Three subtypes of malingering are identified within a criminal context:

• Feigned mental disorders: Offenders in this domain simulate severe psychopathology and marked psychological impairment. For example, inmates may fabricate severe psychiatric symptoms in order to receive unwarranted medications so that they can do easy time.
• Feigned cognitive impairment: Offenders simulating cognitive impairment (e.g., learning or intellectual disability) intentionally fail cognitive tasks rather than fabricating symptoms per se. Relevant examples include a fraudulent person malingering cognitive problems resulting from an automobile accident in order to maximize personal injury compensation or a defendant feigning an intellectual disability so as to be found incompetent to stand trial.
• Feigned medical complaints. This subtype includes offenders who exaggerate or fabricate symptoms of physical illness, pain, or disability. As an example, a claimant may malinger chronic pain in order to be awarded workers’ compensation. In addition, inmates may simulate a chronic medical condition to avoid institutionally required work responsibilities. Again, as an important distinction, feigned medical impairments are motivated by external gain, whereas factitious disorders use simulated physical symptoms for internal needs.

Overview of Response Styles

Response styles refer broadly to the intentional misrepresentation of psychological information in order to manipulate how examinees are perceived. These response styles may range from total denial to complete fabrication of symptoms, in service of identified goals. More specifically, the intent may be to create either a more positive (e.g., faking good by denying substance abuse) or negative (e.g., faking bad by exaggerating psychotic symptoms) impression. Other, less intentional response styles (e.g., irrelevant or random responding) are also possible but typically reflect an examinee’s lack of engagement in the assessment process rather than a deliberate attempt to portray a specific presentation. Having recognized that various levels of deception may occur across different settings, patients, and disorders, it is important to emphasize that response styles discussed here apply only to intentional and goal-motivated deception.

The importance of evaluating response styles on psychological measures has been long recognized in the field of psychological assessment because extensive research has demonstrated that most response styles can markedly distort or even nullify the validity of test results. To address their vulnerability to response distortion, some psychological tests, especially multiscale inventories, began in the 1940s to develop and implement scales to detect response styles. These scales, often referred to as validity indices, utilize specific detection strategies as a systematic approach to detect response distortion. Several common strategies— specific to malingering—are discussed in greater detail in the following section.

Detection Strategies for Malingering

Accurate evaluation for potential malingering is often challenging because the assessment of mental disorders relies predominantly on self-reported symptoms and subjective distress. Persons with severe mental disorders often sincerely lack insight into their psychopathology. Therefore, the challenge of validity indicators is to differentiate genuine efforts (e.g., poor insight) from intentional distortion (e.g., malingering) to improve the methodological precision of psychological measures. Focusing on malingering, research has clearly established that detection strategies tend to be most successful when they focus on separating feigned versus genuine presentations for a particular domain. Commonly used detection strategies fall into two broad categories that can be applied to feigned mental disorders: unlikely presentations and amplified presentations.

• Unlikely presentations: This category encompasses detection strategies that represent highly unusual clinical presentations. Examples include (a) symptoms rarely observed among genuine patients and (b) fantastic or absurd symptoms. Going beyond individual symptoms, other detection strategies rely on unlikely pairs of symptoms or improbable patterns of symptoms. For example, it would be very unlikely for an individual claiming to be paranoid to be observed trusting most strangers.
• Amplified presentations: This category of detection strategies relies on identifying malingerers based on the intensity of their clinical presentations. Examples of intensity include the (a) breadth of symptoms (e.g., endorsing too many in an apparently indiscriminant manner), (b) severity of symptoms (e.g., reporting extreme and unbearable distress), and (c) frequency of symptoms (e.g., describing continuously present psychotic symptoms). For this category, malingerers severely exaggerate the intensity of symptoms beyond what is commonly reported by genuine patients. The crucial difference lies in the excessive magnitude of the purported impairment.

Clinical Assessment

Within the context of criminal psychology, offenders may have much to gain by malingering or much to lose by being honest, so careful and comprehensive clinical assessment is essential. Comprehensiveness is typically the best method for the detection of falsified responding, especially with skilled or coached malingerers, who can provide a sophisticated approach to feigning. To highlight an important distinction, psychological assessments can truly only evaluate for feigning (i.e., the exaggeration or fabrication of symptoms, with no assumptions about the nature of the individual’s motivations), not malingering, because psychological tests cannot definitively establish an offender’s particular, and sometimes complex, motivation. Several effective screening measures have been developed, including the Structured Inventory of Malingered Symptomatology and the Miller Forensic Assessment of Symptoms Test. However, screens are intended to be highly efficient at identifying possible cases (i.e., quick and dirty approach). Because of their brevity, they sacrifice accuracy for efficiency. Therefore, screens cannot be used to definitively determine that an examinee is feigning.

This section highlights three comprehensive measures of feigning, including multiscale inventories and interviews. The two most commonly used multiscale inventories for patterns of psychopathology that include multiple measures of feigning are the Minnesota Multiphasic Personality Inventory-2 and the Personality Assessment Inventory. Extreme elevations on these validity indicators can be interpreted as evidence of feigning. Importantly, moderate elevations can only be used as screens; they indicate the need for further assessment with specialized measures for malingering.

Structured interviews have assumed an increasingly prominent role in psychological assessment. They have standardized both the questioning and clinical ratings of psychological symptoms and associated features. For the assessment of feigning, the Structured Interview of Reported Symptoms, Second Edition utilizes eight distinct detection strategies to systematically distinguish between feigned and genuine clinical presentations. By applying a decision model, most examinees can be classified as displaying a feigned, questionable (i.e., not confidently interpreted as either feigning or genuine), or genuine presentation. An important goal of the Structured Interview of Reported Symptoms, Second Edition is to minimize false positives (i.e., misclassifying a genuine responder as a malingerer), which can have devastatingly negative effects in professional contexts such as forensic and correctional settings. The profoundly adverse consequences associated with misclassification may include potentially increased sentencing and limited treatment offerings.

Feigning measures must also address a further challenge; a presumably small percentage of malingerers prepare their simulated impairment by specifically researching and accessing information on how to outwit detection strategies. In some instances, this information is relayed to the examinee by others. Therefore, this use of information to foil detection strategies is referred to as coaching. For multiscale inventories, some feigning indicators have been shown to be more resistant to coaching than others. For the Structured Interview of Reported Symptoms, Second Edition, a countermeasure was introduced to detect sophisticated feigners who deny common psychological problems in their efforts to go undetected. Concerns about the impact of coaching again underscore the importance of comprehensive assessment utilizing well-validated detection strategies.

Future Directions

Future research will continue efforts for more precise classification of malingering and other response styles. It may be possible to identify what is feigned (e.g., post-traumatic stress disorder) from what is not (e.g., underlying depression). This sophisticated approach would avoid the all-or-none perspective to clinical interventions whereby any feigning precludes all treatment. In addition, further education and training are needed to refute the common myths of malingering. As an example, clinicians who disavow the fallacy of “once a malingerer, always a malingerer” can more objectively evaluate current treatment needs without being unnecessarily biased by evidence of past feigning. More complex detection strategies, such as symptom combinations (i.e., identifying symptoms that are unlikely to cooccur) can be further refined to remain effective even with coached feigners.

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