Thursday, 3 February 2011

Malingering and the Expert Witness Psychologist (Devon/South West)

An overriding issue in psychology within a medico-legal arena is the issue of malingering. Malingering involves the exaggeration (fake bad) or underplay (fake good) of symptoms, either consciousely or unconsciousely for secondary gain (an ulterior motive). It differs from a number of other presentations, including somatization, health anxiety/hypocondriasis, and medically unexplained symptoms to name but a few. Psychologists should always bare the possibility of malingering in mind, especially during litigation because of monetary gains. The symptoms most commonly feigned include those associated with mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system, and false attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population.
Diagnosis and detection

The DSM-IV-TR states that malingering is suspected if any combination of the following are observed:

1. Medicolegal context of presentation
2. Marked discrepancy between the person’s claimed stress of disability and the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying with prescribed treatment regimen
4. The presence of Antisocial Personality Disorder
However, these criteria have been found to be of little use in actually identifying individuals who are malingering.
Some features at presentation which are unusual in genuine cases include:
1. Dramatic or atypical presentation
2. Vague and inconsistent details, although possibly plausible on the surface
3. Long medical record with multiple admissions at various hospitals in different cities
4. Knowledge of textbook descriptions of illness
5. Admission circumstances that do not conform to an identifiable medical or mental disorder
6. An unusual grasp of medical terminology
7. Employment in a medically related field
8. Pseudologia fantastica (i.e., patients' uncontrollable lying characterized by the fantastic description of false events in their lives)
9. Presentation in the emergency department during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (e.g., holidays, late Friday afternoons)
10. A patient who has few visitors despite giving a history of holding an important or prestigious job or a history that casts the patient in a heroic role
11. Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
12. Acceptance, with equanimity, of the discomfort and risk of surgery
13. Substance abuse, especially of prescribed analgesics and sedatives
14. Symptoms or behaviors only present when the patient knows he is being observed
15. Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
16. Reporting of wild psychological symptoms, and silly wrong answers on questionaires, not likely in patients with similar but real conditions.
17. Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
18. Coinciding indigence or homelessness of the patient, with impending cold weather and a need for indoor lodgings.
19. Giving approximate answers to questions, usually occurring in factitious disorder with predominantly psychological signs and symptoms (see Ganser Syndrome)
20. Eagerly endorsing symptoms suggested by a clinician, but not mentioned by the patient, though they would have been prominent and obvious had they been real.
21. A test for factitious mental disorders presents symptoms which are extremely improbable. Endorsing these symptoms which almost never occur can raise doubt of the person's sincerity.

If a psychologist suspects malingering in a case of possible brain damage (i.e. caused by head trauma or stroke), they may look for a discrepancy between the patient's reported functions of daily living and their performance on neuropsychological tests. In theory, any neuropsychological test could be used in this way, depending on the context. No one test, administered by itself, can proffer a diagnosis of malingering, so a neuropsychological examination typically consists of a battery of tests. Two tests commonly used to determine malingering are:
• Minnesota Multiphasic Personality Inventory (MMPI) (see Validity scales)
• The Test of Memory Malingering (TOMM)
The psychiatrist or neuropsychologist may use these tests, and use the DSM-IV TR criteria while adding a "dimensional analysis" to assist in diagnosis and treatment. Dimensional analysis consists of learning the patient’s history, information about similar cases, and the context of the illness, which could help differentiate cases of malingering from factitious disorders. Tests are rarely conclusive but often need to be triangulated and weighed against other forms of information, including presentation and self reported symtpoms as mentioned before.

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