Reputed Cosa Nostra boss Vincent “The Chin” Gigante deceived “the most respected minds in forensic psychiatry” for years by malingering schizophrenia.1 Ultimately, he admitted to maintaining his charade from 1990 to 1997 during evaluations of his competency to stand trial for racketeering.

A lesson from this case—said a psychiatrist who concluded Gigante was malingering—is, “When feigning is a consideration, we must be more critical and less accepting of our impressions when we conduct and interpret a psychiatric examination…than might be the case in a typical clinical situation.”2

Even in typical clinical situations, however, psychiatrists may be reluctant to diagnose malingering3 for fear of being sued, assaulted—or wrong. An inaccurate diagnosis of malingering may unjustly stigmatize a patient and deny him needed care.4

Because psychiatrists need a systematized approach to detect malingering,5 we offer specific clinical factors and approaches to help you recognize malingered psychosis.

What is Malingering?

No other syndrome is as easy to define yet so difficult to diagnose as malingering. Reliably diagnosing malingered mental illness is complex, requiring the psychiatrist to consider collateral data beyond the patient interview.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.6 In practice, malingering commonly must be differentiated from factitious disorder, which also involves intentional production of symptoms. In factitious disorders, the patient’s motivation is to assume the sick role, which can be thought of as an internal or psychological incentive.

Three categories of malingering include:

pure malingering (feigning a nonexistent disorder)

partial malingering (consciously exaggerating real symptoms)

false imputation (ascribing real symptoms to a cause the individual knows is unrelated to the symptoms).7

Motivations. Individuals usually malinger to avoid pain (such as difficult situations or punishment) or to seek pleasure (such as to obtain compensation or medications) (Table 1). In correctional settings, for example, inmates may malinger mental illness to do “easier time” or to obtain drugs. On the other hand, malingering in prison also may be an adaptive response by a mentally ill inmate to relatively sparse and difficult-to-obtain mental health resources.8

Table 1

Common motives of malingerers

Motives Examples To avoid pain To avoid: Arrest Criminal prosecution Conscription into the military To seek pleasure To obtain: Controlled substances Free room and board Workers’ compensation or disability benefits for alleged psychological injury

Interview Style

When you suspect a patient is malingering, keep your suspicions to yourself and conduct an objective evaluation. Patients are likely to become defensive if you show annoyance or incredulity, and putting them on guard decreases your ability to uncover evidence of malingering.9

Begin by asking open-ended questions, which allow patients to report symptoms in their own words. To avoid hinting at correct responses, carefully phrase initial inquiries about symptoms. Later in the interview, you can proceed to more-detailed questions of specific symptoms, as discussed below.

If possible, review collateral data before the interview, when it is most helpful. Consider information that would support or refute the alleged symptoms, such as treatment and insurance records, police reports, and interviews of close friends or family.

The patient interview may be prolonged because fatigue may diminish a malingerer’s ability to maintain fake symptoms. In very difficult cases, consider monitoring during inpatient assessment because feigned psychosis is extremely difficult to maintain 24 hours a day.

Watch for individuals who endorse rare or improbable symptoms. Rare symptoms—by definition—occur very infrequently, and even severely disturbed patients almost never report improbable symptoms.10 Consider asking malingerers about improbable symptoms to see if they will endorse them. For example:

“When people talk to you, do you see the words they speak spelled out?” 11

“Have you ever believed that automobiles are members of an organized religion?”12

Watch closely for internal or external inconsistency in the suspected malingerer’s presentation (Table 2).

Table 2

Clues to identify malingering during patient evaluation

Internal inconsistencies Example In subject’s report of symptoms Gives a clear and articulate explanation of being confused In subject’s own reported history Gives conflicting versions External inconsistencies Example Between reported and observed symptoms Alleges having active auditory and visual hallucinations yet shows no evidence of being distracted Between reported and observed level of functioning Behaves in disorganized or confused manner around psychiatrist, yet plays excellent chess on ward with other patients Between reported symptoms and nature of genuine symptoms Reports seeing visual hallucinations in black and white, whereas genuine visual hallucinations are seen in color Between reported symptoms and psychological test results Alleges genuine psychotic symptoms, yet testing suggests faking or exaggeration

Malingered Psychotic Symptoms

Detecting malingered mental illness is considered an advanced psychiatric skill, partly because you must understand thoroughly how genuine psychotic symptoms manifest.

Hallucinations. If a patient alleges atypical hallucinations, ask about them in detail. Hallucinations are usually (88%) associated with delusions.13 Genuine hallucinations are typically intermittent rather than continuous.

Continue to: Auditory hallucinations