In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term: malingering
Most of us living with mental illness end up spending quite a bit of time trying to act as though we’re not mentally ill. However, sometimes when there’s sufficient incentive people will fake mental illness for secondary gain, and this is malingering.
One area where this may turn up is in criminal justice and forensic psychiatric settings, where offenders may feign illness in an attempt to avoid consequences for their criminal behaviour.
As a result, forensic mental health professionals must do some good detective work to differentiate genuine illness from malingering.
Malingerers may report the presence of multiple symptoms that are actually quite rare, or that are quite rare in combination. Symptoms may be presented as bizarre and exaggerated, and more subtle but common symptoms of illness (such as negative symptoms of schizophrenia) are not reported. There may be a sort of symptom whack-a-mole, with the person reporting a wide range of many different symptoms. They may also describe symptoms that are consistent with erroneous stereotypes, such as split personality with schizophrenia.
It’s also important to observe whether the person’s behaviour matches with described symptoms, and how consistent behaviour is across situations. A malingerer’s ability to act may be decreased when they are tired or under stress, or with a long interview.
While people who have PTSD are often somewhat reluctant to talk about their trauma, a malingerer feigning PTSD is more likely to freely bring up the trauma.
Characteristics of bona fide psychosis
There are certain common characteristics of genuine psychosis that a malingerer may get wrong.
Most commonly, auditory hallucinations are experienced intermittently rather than continuously. Most people with hallucinations also have delusions, but only around 35% of people with delusions have hallucinations.
Only around 5% of people with command hallucinations hear voices telling them to kill others. These are more likely to be obeyed if the voice(s) are familiar, or if the voice(s) are consistent with associated delusions.
Delusions usually do not have an abrupt onset or end, and they are usually not quickly volunteered. Bizarre delusions (e.g. aliens came into my room at night and stole my ovaries) are usually accompanied by thought disorder, which is hard to fake.
Tests for malingering
There are several psychometric tests that can be used in evaluating someone for malingering. Besides the examples listed here, there are tests that focus specifically on memory malingering.
The Miller Forensic Assessment of Symptoms test (M-FAST) looks at reported vs observed symptoms, extreme symptoms, rare combinations of symptoms, unusual suggestions, and suggestibility.
The Structured Interview of Reported Symptoms-2 (SIRS-2) considers how defensive the individual becomes in the face of attempts to alleviate their problem and whether there appears to be a random quality of endorsed symptoms.
The Malingering Probability Scale (MPS) is a true or false test based on items representing real and simulated psychopathology.
There are also some personality assessments that can detect malingering, including the Minnesota Multiphasic Personality Inventory (MMPI-2) and the Personality Assessment Inventory (PAI).
Over the years in my work as a mental health nurse I’ve come across patients who have spent time in either the criminal justice or forensic psychiatric systems, but I’ve never worked in a forensic setting so I’ve never had any involvement in these kinds of assessments.
The criminal justice/forensic is certainly not the only setting in which malingering occurs, but it’s one where there is a significant potential benefit that could result if the crazy card could be played effectively. A forensic psychiatric hospital would be more desirable than general population in a maximum-security prison any day of the week, so the incentive would certainly be there. At the same time, though, I think any psychiatrist or psychologist who chooses to specialize in forensics quickly develops a pretty finely tuned bullshit radar.
You can find the rest of my What Is series here.
- Much of the information in this post came from my own notes from readings I’ve done over the years, but I didn’t make note of the specific sources