Faking it: How to detect malingered psychosis
Feigned schizophrenia symptoms usually won’t deceive the clinician who watches for clues and is skilled in recognizing the real thing.
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
Common motives of malingerers
To avoid pain
Conscription into the military
To seek pleasure
Free room and board
Workers’ compensation or disability benefits for alleged psychological injury
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).
Clues to identify malingering during patient evaluation
In subject’s report of symptoms
Gives a clear and articulate explanation of being confused
In subject’s own reported history
Gives conflicting versions
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.
Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).14 In schizophrenia, the major themes are persecutory or instructive.15
Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:
- do not always obey the voices, especially if doing so would be dangerous16
- usually present with noncommand hallucinations (85%) and delusions (75%) as well17
Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.
Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:
- engaging in activities (working, listening to a radio, watching TV)
- changing posture (lying down, walking)
- seeking interpersonal contact
- taking medications.
If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.
Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:
- an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
- a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”
Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.
Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).18
Genuine visual hallucinations are usually of normalsized people and are seen in color.14 On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.
Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.19
Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.
Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.20
Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).
With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.
Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.
Uncommon psychosis presentations that suggest malingering
Where Malingerers Trip Up
Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.21
Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.22
Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.23
Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.
Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.
Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.
Clinical factors that suggest malingering
Absence of active or subtle signs of psychosis
Marked inconsistencies, contradictions
Patient endorses improbable psychiatric symptoms
Patient is evasive or uncooperative
Psychological testing indicates malingering (SIRS, M-FAST, MMPI-2)
SIRS: Structured Interview of Reported Symptoms
M-FAST: Miller Forensic Assessment of Symptoms Test
MMPI-2: Minnesota Multiphasic Personality Inventory, Revised
Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:
- Structured Interview of Reported Symptoms (SIRS)
- Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
- Miller Forensic Assessment of Symptoms Test (M-FAST).11
SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.24