In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is malingering.
Many of us living with mental illness spend quite a bit of time trying to pass as 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. 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, while 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 reluctant to talk about their trauma, someone feigning PTSD is more likely to freely bring it up.
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 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 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.
Over the years in my work as a mental health nurse, I’ve come across patients who’ve spent time in the criminal justice or forensic psychiatric systems. However, 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; however, it’s one where there’s a significant potential benefit from playing the crazy card 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/psychologist who chooses to specialize in forensics quickly develops a finely tuned bullshit radar.