What is… Malingering

MH@H insights into psychology: malingering

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.

Detection strategies

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.

Fascinating stuff.

 

You can find the rest of my What Is series here.

Sources:

  • 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

 

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28 thoughts on “What is… Malingering

  1. kachaiweb says:

    I can only speak for what I know in my country. The psychiatric patients here would never choose the hospital above general population in the long term. When you’re forced into that kind of psychiatric care, you’ll never get out. They call it a life sentence of monitoring, while in prison you can do your time and be done with it. The ones who do ‘malinger’ are the ones who don’t know better and therefore don’t know what they are trying to obtain. I would ask such a person 1 question: do you want to be in the forensic institution? When the answer is ‘yes’, it is suspicious in my book.

  2. BeckiesMentalMess.wordpress.com says:

    This is really interesting. As you may know, I watch a great deal of true life criminal TV series/Netflix stories. One in particular is “Mindhunter”. I found it so compelling to learn how in the earlier years of the FBI developing their behavioral science unit (I hope I got that correct), but the studies of criminals that had already been locked away, and how they studied their behavior in order to assess criminals that were still out there and how to actually learn the mindset of a criminal whether mentally ill or not.
    Not to make this a long winded comment, but when I was living in that transitional housing program… I was forced to share an apartment with a male schizophrenia patient of the same mental health facility I belonged to. There were several occasions he would neglect taking his medications, and there were several occasions he would scream out at night as if responding to persons speaking to him.
    I could go on about how many times he woould stalk outside of my bedroom as well as threaten me with a knife when exiting the bathroom.
    He was finally removed after I had video clipped an instance one evening. I contacted one of the other housemates in the building, (We had become very good friends even to this day), and he stayed with me and kept guard to prevent this person from getting to me.
    It was one of the scariest things that happened to me in that house.
    I thank you for sharing this with us. It brought some light to a very bad situation that I lived through.

  3. Jenni says:

    Thanks for being informative. I love learning about this! I actually know people who have done this for a state check, and it’s heart wrenching that they do it. There are people with real illnesses. Great post!!

  4. crushedcaramel says:

    I have used that word for years without having any idea what it meant!!!

    Oh dear me…when people have asked us what we were doing (parents, teachers, supervisors) one of my favourite answers was “we are malingering”. I had no idea at all what it meant, it just sounded like such a great word!!!

  5. Meg says:

    Great post! Yeah, people definitely do this to get government SSI or disability. Here in America, the government looks extra close at applications due to mental illness for that reason; although some physical issues, like fibromyalgia, are equally difficult to prove. I thank my lucky stars, because I think I lucked out and had all the info they needed to believe that I’m mentally ill–it sort of came together like a miracle, and I was approved three months later. But for people who apply and say, “I’m depressed and can’t work,” or something, there has to be evidence, documentation, medical input, etc., etc., etc. And it is sad that many people just make it up and hope for the best. I’ve been told there are areas in my state of Kentucky where everyone attempts this as par for the course. I hope that’s not true.

    I can definitely see faking mental illness if you’ve been arrested. Knowing you committed a crime would be scary enough! How terrifying!

    • ashleyleia says:

      I’m guessing people who committed crimes in the first place aren’t scared knowing they committed a crime, they’re not happy about getting caught. 😉

  6. Michelle says:

    I never knew this was a thing. I have heard of people lying about mental illness for social security reasons but not in the criminal justice system

  7. skinnyhobbit says:

    I would be interested in factitious disorders as well. One of my family members sorta malingers. I say “sorta” because he probably does experience some genuine symptoms, which he then exaggerates when there’s incentives.

    He openly told me he WISHES he has schizophrenia (he has never had psychotic symptoms, Ever), so he could get out of his military duties. Outright told me that people with schizophrenia are LUCKY because they have less “difficult” military duties.

    I asked him if he knew just how awful the stigma around schizophrenia is, and if he REALLY wanted to trash all chances of a full time job or render himself ineligible for health insurance…

    Turns out, he does, again sort of…. He wants care which he THINKS he’ll get from such a diagnosis (He is wrong about that, because the system is hell). I can understand the desire for care, even as I don’t approve of how he expresses it.

    He feels entitled to financial support and to not have to work (He said so several times and regularly goes around telling people he’s depressed)… Because he feels robbed of his childhood. I can understand even as I really don’t agree with how he feels entitled.

    He tried exaggerating symptoms, and making up certain symptoms (so a mix of factitious and malingering?) but was not believed by an army psychologist familiar with the numerous incentives for malingering or factitious symptoms.

    It sometimes pisses me off because I’ve several diagnosed mental conditions, face stigma and discrimination, and worked myself into two burnouts just trying to self support myself… And there he is moaning about how he “wants” to be seen and pitied as mentally ill because he thinks it’ll get him charity.

      • skinnyhobbit says:

        Yeppp… It’s HARD to fake mental illness lol! But I think he’s got some genuine depression and anxiety symptoms. Which, most interestingly, he refuses professional help for, while telling everyone and anyone how depressed he is. I might blog about my irritation since he’s been “acting up” lately.

        He does exaggerate physical symptoms too, in a weirdly proud manner. I take it as him wanting attention and sympathy. Attention and wanting validation of distress is a need after all. I however greatly dislike his choice of expressing those needs.

        Most commonly “gastric issues” caused by “eating too much chilli” so “I must have damaged my stomach lining.” Jitters and insomnia from “too much coffee. Oh look I drank until I almost vomited. I’ve a headache now!.” Knee pains from “my injured knee” especially when it is raining. Being “hard if hearing” and having “tinnitus” but of course, he doesn’t want medical treatment…

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