Current issues in the diagnosis and management of malingering

The association between clinicians' initial judgments of feigning and outcomes on symptom validity measures among pretrial forensic psychiatric inpatients

Research suggests the use of validated symptom validity tests to detect feigning is imperative to increase accuracy over unaided clinical judgment, especially in forensic settings. This study examined performance on the Miller Forensic Assessment of Symptoms (M-FAST) and Structured Interview of Reported Symptoms (SIRS) during 297 assessments of forensic inpatients. The risk of being identified as feigning on the M-FAST or SIRS was similar for those who were referred for evaluation of feigning compared to those who were not, but individuals with malingering designations prior to the evaluation scored significantly higher than those without on the M-FAST and several SIRS subscales. Findings support the importance of utilizing objective methods of data collection.

The Relationship Between Psychiatric and Cognitive Symptom Feigning Among Forensic Inpatients Adjudicated Incompetent to Stand Trial

The accurate assessment of feigning is an important component of forensic assessment. Two potential strategies of feigning include the fabrication/exaggeration of psychiatric impairments and the fabrication/exaggeration of cognitive deficits. The current study examined the relationship between psychiatric and cognitive feigning strategies using the Structured Interview of Reported Symptoms and Test of Memory Malingering among 150 forensic psychiatric inpatients adjudicated incompetent to stand trial. A greater number of participants scored within the feigning range on the Structured Interview of Reported Symptoms than on the Test of Memory Malingering. Relative risk ratios indicated that individuals shown to be feigning cognitive deficits were 1.68 times more likely to feign psychiatric symptoms than those not shown to be feigning cognitive deficits. Likewise, individuals shown to be feigning psychiatric deficits were 1.86 times more likely to feign cognitive deficits than those not shown to be feigning psychiatric symptoms. Overall, findings suggest that psychiatric feigning and cognitive feigning are related, but can be employed separately as feigning strategies. Therefore, clinicians should consider evaluating for both feigning strategies in forensic assessments where cognitive and psychiatric symptoms are being assessed.

Improving the Detection of Feigned Knowledge Deficits in Defendants Adjudicated Incompetent to Stand Trial

Malingering is relatively common in criminal forensic evaluations as base rates of malingering have ranged from 20% to 30%. Given that the most prevalent criminal forensic evaluation is the assessment of competency to stand trial, the assessment of feigning during competency evaluations is necessary for accurate findings. Most of the response style literature focuses on feigning mental health symptoms, but in competency evaluations, individuals may attempt to feign legal knowledge deficits in order to be found incompetent to stand trial. The current investigation includes two studies: 195 students instructed to simulate feigned mental illness or incompetence to stand trial and one using a sample of 130 state psychiatric hospital residents who had been adjudicated incompetent to stand trial. The purpose of the study was to evaluate the Inventory of Legal Knowledge’s (ILK; Musick & Otto, 2010) ability to detect individuals who are feigning legal knowledge deficits. Classification utility statistics, including sensitivity, specificity, positive predictive power, and negative predictive power are provided for each cut-score on the ILK beginning with a cut-score of 24 (which is the lower end of the range of chance) are provided. The current cut-score of 47 provided in the professional manual of the ILK was shown to create a large number of false positives and suggests that modifications to this cut-score are required.

[Factitious diseases in oncology]

Factitious diseases and pathomimias and particularly Munchausen's syndrome, due to their rarity, are poorly diagnosed by medical teams working in oncology. Consequences can be serious and result in unadapted surgery or non justified implementation of chemotherapy and radiotherapy regimens. These patients simulate diseases in order to attract medical attention. They might become belligerent and are likely to promptly discharge themselves from hospital if they do not get the desired attention or are unmasked. With two following case reports and literature review, we would like to alert clinicians about difficulties encountered in diagnosis and management of factitious disorders. When faced with this diagnosis, the patient will tend to deny reality and break contact with the medical team who exposed him. Medical peregrinating behavior surrounded by conflicts with medical team, past psychiatric illness, history of working in the medical and paramedical field and social isolation can guide the diagnosis. Somaticians and especially surgeons working in the oncologic field must remain vigilant about this diagnosis and collaborate with either the psycho-oncologic team or the consultation-liaison psychiatric team. Some recommendations for medical professionals how to cope with these patients will be suggested.

Modeling community integration in workers with delayed recovery from mild traumatic brain injury

Background

Delayed recovery in persons after mild traumatic brain injury (mTBI) is poorly understood. Community integration (CI) is endorsed by persons with neurological disorders as an important outcome. We aimed to describe CI and its associated factors in insured Ontario workers with delayed recovery following mTBI.

Methods

A cross-sectional study of insured workers in the chronic phase following mTBI was performed at a rehabilitation hospital in Ontario, Canada. Sociodemographic, occupational, injury-related, clinical, and claim-related data were collected from self-reports, medical assessments, and insurers’ referral files. Community Integration Questionnaire (CIQ) scores were compared using analysis of variance or Spearman’s correlation tests. Stepwise multivariable linear regression models were used to evaluate the associations with CI.

Results

Ninety-four workers with mTBI (45.2 ± 9.9 years old, 61.2 % male) at 197 days post-injury (interquartile range, 139–416 days) were included. The CIQ total and subscale scores were similar to those reported in more severe TBI samples. The CIQ scores were moderately to strongly correlated with various sociodemographic, claim-related, and clinical variables. In the multivariable regression analysis, several covariates accounted for 36.4 % of the CIQ variance in the final fully adjusted model.

Discussion

This study evaluated CI in workers with mTBI, and analyzed its associated variables. Analysis revealed insomnia, head or neck pain, being married or in a relationship, time since injury, and a diagnosis of possible/probable malingering were independently associated with limited CI.

Conclusions

Workers with delayed recovery from mTBI experience difficulty with CI. Insomnia is a particularly relevant covariate, explaining the greater part of its variance. To enhance participation, care should focus on clinical and non-clinical covariates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0432-z) contains supplementary material, which is available to authorized users.

The Validity and Reliability of the Turkish Version of Miller Forensic Assessment of Symptoms Test (M-FAST)

INTRODUCTION

The aim of this study was to show the validity and reliability of the M-FAST Turkish Version.

METHODS

Translation and back-translation of the M-FAST was done, then the M-FAST Turkish Version was created with linguistic equivalence. The study was performed with 97 detainees and convicts sent from penal institutions who were internalized at our hospital forensic psychiatry service. M-FAST Turkish Version was applied to evaluees and as a result of clinical interview according to DSM-IV-TR diagnostic criteria and various data explorations the evaluee was examined for malingering. To investigate the internal consistency of the scale, Cronbach's alpha and test-retest methods were used. In order to check the validity of the scale, in addition to the clinician's diagnosis, participants were requested to fill the Minnesota Multiphasic Personality Inventory (MMPI) F and K validity scales.

RESULTS

The mean age of participants was 31.8±9.3 (SD) years. 47 evaluees (48.5%) were diagnosed as malingering. In the internal consistency analysis, Cronbach's alpha Coefficient was found to be .93. Test-retest relationship that was applied to 22 evaluees was found to be highly significant and strong (r=.89, p<.001). M-FAST scores were significantly high at the malingering group (n=47) (z=-8.02, p<.001). ROC curve analysis suggested a score of ≥7 points as the optimal cut-off for a malingering level for the M-FAST. Kappa coefficients of malingering ± groups were found to be, M-FAST≥7 Kappa: .83; F>16 Kappa: .29; F-K>16 Kappa: .30. For diagnosis of malingering, M-FAST Scale and the MMPI inventory scales were evaluated with the Binary Logistic Regression analysis and only M-FAST scores were found to be significant in prediction of malingering.

CONCLUSION

The findings of this study support that, M-FAST Turkish Form represents the structure of the original scale and can be used as a reliable and valid instrument.

Malingering psychosis: guidelines for assessment and management

PURPOSE

The purposes of this paper are to (a) identify theoretical underpinnings of malingering, (b) to discuss interview and intervention techniques based on pertinent literature, and (c) to offer an organized mnemonic to help clinicians easily identify possible malingered psychosis presentations.

CONCLUSION

Detecting the malingering of psychotic symptoms is a challenging task for Advanced Practice Psychiatric Nurses. Diagnosing a patient of malingering requires caution on the clinician's part.

PRACTICE IMPLICATIONS

A thorough understanding of potential signs of malingering vs. genuine psychosis is needed as well as knowledge of legal ramifications.

Suspected feigned knee extensor weakness: usefulness of 3D gait analysis. Case report

The purpose of the present case report is to show the potential for use of 3D gait analysis as an assessment method of feigned muscle weakness. We describe a patient complaining of right leg pain and weakness. Physical examination showed severe quadriceps muscle weakness in a highly abnormal gait pattern context. Conventional diagnostic workup did not show any relevant findings. Three-dimensional (3D) gait analysis was performed with a 3D motion capture system. Joint angles, internal moments and powers were computed from the motion data. Lower leg muscle surface-electromyography was also performed. During the late stance phase, flexor moment and negative power peaks (indicating eccentric knee extensor activity) were generated in the knee, together with relevant Rectus femoris activity. All findings were highly inconsistent with true quadriceps weakness and gave objective ground to suspect insincerity of patient complaints. 3D gait analysis might be a valuable clinical assessment tool in suspected feigned lower limb muscle weakness.

Patient privacy versus protecting the patient and the health system from harm: a case study

A 71-year-old man who presented to hospital with chest pain and a history of cardiovascular disease was repeatedly hospitalised over the course of a month for care that included multiple investigations, intensive care, transfer to and from a metropolitan hospital, discharge, and readmissions for collapse, hemiparesis, and vision change. The medical team excluded underlying disease related to his initial chest pain and subsequent neurological symptoms. A search for (undisclosed) prior hospitalisations revealed multiple previous admissions and invasive investigations at hospitals across Australia, resulting in a diagnosis of Munchausen syndrome. Assuming that, despite interventions, patients with Munchausen syndrome or somatoform disorders often continue to seek care at other hospitals, we discuss the implications of this patient's behaviour for the health care system, society, and the risk to his own health. In our view, this case highlights conflicts between privacy legislation and doctors' mandates to protect the patient from harm, as well as their duty to attend to the financial viability of health services by communicating with other potential health care providers. The health care system and similar patients may benefit from efforts to educate doctors about this spectrum of disorders and from considering the implementation of a highly confidential, structured notification system.

Traumatic brain injury and forensic neuropsychology

As part of a special issue of The Journal of Head Trauma Rehabilitation, forensic neuropsychology is reviewed as it applies to traumatic brain injury (TBI) and other types of acquired brain injury in which clinical neuropsychologists and rehabilitation psychologists may be asked to render professional opinions about the neurobehavioral effects and outcome of a brain injury. The article introduces and overviews the topic focusing on the process of forensic neuropsychological consultation and practice as it applies to patients with TBI or other types of acquired brain injury. The emphasis is on the application of scientist-practitioner standards as they apply to legal questions about the status of a TBI patient and how best that may be achieved. This article introduces each topic area covered in this special edition.

Morphological and functional evaluation of visual disturbances in a bilateral hand allograft recipient

Allograft recipients are exposed to risks owing to immunosuppression, and there is always the possibility that psychological issues interfere with the procedure's outcomes. An episode of blindness was suspected in a bilateral hand allograft recipient. The patient underwent a multidisciplinary evaluation, and clinical, electrophysiological, laboratory and a combination of functional and morphological magnetic resonance imaging (MRI) tests ruled out any visual process and revealed a secondary benefit, which turned out to be the use of privileges of the transplant support centre for several months. Composite tissue allograft recipients require a thorough psychological assessment before and after transplant procedures to prevent malingering.

Detection and management of malingering in people presenting for treatment of posttraumatic stress disorder: methods, obstacles, and recommendations

Malingering of symptoms of posttraumatic stress disorder (PTSD) has become a growing concern, particularly in healthcare and other settings in which the diagnosis is associated with financial incentives such as disability benefits. Although there is a steadily increasing body of research on methods for detecting PTSD malingering, little has been written on the assessment and practical management of malingering in treatment settings. The present article addresses this important issue, including a review of the methods, obstacles, and possible solutions for assessing PTSD malingering, along with suggestions for managing cases in which malingering is strongly suspected.

Wide-complex tachycardia as the presenting complaint in a case of malingering

Fabrications of lethal dysrhythmias are an extremely rare manifestation of malingering, with only one case described more than two decades ago. Recognition of this clinical entity is important because the diagnosis may be difficult to make, therapeutic implications for the patient are significant, and financial consequences of misdiagnosis are considerable. In this case report, we present an unusual example of malingering, in which a patient intentionally mimicked repeated episodes of unstable wide-complex ventricular tachycardia, by tapping on the chest wall cardiac leads, while feigning concurrent episodes of chest pain.

Factitious disorders encountered in patients with the diagnosis of reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) may be a misdiagnosis or at least not descriptive enough in patients with atypical hand posture and atypical edema. Seven patients with the previous diagnosis of RSD were investigated further because of inconsistent clinical picture with the underlying pathology and bizarre course of the disease. Four patients had clenched fist and three had factitious edema. These seven patients underwent psychological examination, and MMPI was applied to all. In two of these no psychological disorder was obtained according to DSM-IV. One patient could not adapt to MMPI. In two anxiety disorders, in one depression, and in one patient conversion disorder was diagnosed. We suggest that these patients are not motivated enough to improve their conditions and expectations of such patients may show some differences depending on the environment.

Somatization and conversion disorder

Somatization is the psychological mechanism whereby psychological distress is expressed in the form of physical symptoms. The psychological distress in somatization is most commonly caused by a mood disorder that threatens mental stability. Conversion disorder occurs when the somatic presentation involves any aspect of the central nervous system over which voluntary control is exercised. Conversion reactions represent fixed ideas about neurologic malfunction that are consciously enacted, resulting in psychogenic neurologic deficits. Treatment is complex and lengthy; it includes recovery of neurologic function aided by narcoanalysis and identification and treatment of the primary psychiatric disorder, usually a mood disorder.

Malingering by proxy: a form of pediatric condition falsification

The deliberate production or feigning of signs or symptoms in a child by a caretaker is well recognized as factitious disorder by proxy, a psychiatric condition commonly reported in the pediatric literature. However, it is not as well recognized that the false illness portrayal may also be the result of a parent instructing the child to malinger. A case report of a 13-year-old patient who feigned an immobile upper extremity for the purpose of obtaining a legal settlement is presented. Physicians are encouraged to make protecting the child from parental or iatrogenic harm a priority. Recommendations for careful confrontation and expedient resolution are made.

Factitious disorders and pathological self-harm in a hospital population: an interdisciplinary challenge

Factitious disorder, Munchausen's Syndrome, and deliberate self-harm have recently been conceptualized as different facets of self-destructive behavior. A descriptive typological classification has been presented by Willenberg et al., but has not yet been tested with a clinical sample. The instrument distinguishes between direct self-harm (e.g., self-inflicted wounds), self-induced disease (e.g., factitious fever), and indirect self-harm delegated to medical staff (e.g., repeated operations occasioned by feigned symptoms). All patients referred to the psychosomatic-psychotherapeutic liaison-consultation service or to the outpatients' department within 14 months (n = 995) and all patients discharged from in-patient psychosomatic-psychotherapeutic treatment within 2 months (n = 62) were assessed. Expert instruction and supervision were provided for the diagnosticians. The assessment was continued for a subsequent year, without special supervision (n = 1,058). Self-destructive behaviors were diagnosed in 7.5% of the cases in the first sample, with certainty (59.5%) or on suspicion (40.5%). In the subsequent sample without supervision, the rate reduced to 3.6%. Referrals had come from almost all clinical departments, including the emergency unit (26%), surgery, internal intensive care, endocrinology (9.5% each), neurology, infectiology, nephrology (7.1% each), dermatology, gastro-enterology, cardiology (4.8% each) and surgical intensive care (2.4%). The occurrence of pathological self-destructive phenomena is underrated when using only the ICD-criteria. The rate is influenced by diagnostic attention.

Reflex sympathetic dystrophy: misdiagnosis in patients with dysfunctional postures of the upper extremity

The purpose of this case-control study was to assess the frequency of the inappropriate diagnosis of reflex sympathetic dystrophy (RSD) in patients who presented with dysfunctional postures of the upper extremity (n = 43). This group of patients with a dysfunctional posture was compared with a randomly selected control group of patients who presented with pain but no dysfunctional posture (n = 88). The patients underwent radiographic evaluation after review of previous medical records and history and physical examination. Patients with dysfunctional postures had a significantly higher frequency (63%) of a previous inappropriate diagnosis of RSD compared with the control group (6%). None of the patients in either group had objective findings consistent with a diagnosis of RSD. Patients presenting with dysfunctional postures of the upper extremity may be misdiagnosed as having RSD and rarely meet the criteria for this diagnosis.