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Mentally ill or malingering? 3 clues cast doubt

Encountering any of the ‘3Ds’ is a signal to delve further into the authenticity of the individual’s presentation

Vol. 8, No. 12 / December 2009

Up to 15% of the U.S. inmate population has a bona fide serious mental illness,1 but psychiatrists working in jails or prisons also encounter manipulative inmates feigning psychiatric illness. Likewise, clinicians in the civilian sector who conduct worker’s compensation or disability evaluations need to be alert for malingering. My advice is to begin these evaluations with a thorough interview and mental status examination. Ask open-ended questions that allow patients to elaborate on their alleged complaints and their often atypical symptoms, and carefully observe the individual’s behavior and affect.

In my 20 years working in a state prison system, I have identified common clinical scenarios—represented by “3Ds”—that should raise a clinician’s suspicion about the presence of a legitimate, significant Axis I disorder.

Demanding medications. Patients with severe mental illness rarely engage in this behavior and often have to be encouraged or coaxed to adhere to medications. However, manipulative patients I have evaluated demand only certain medications. They do not request agents such as fluoxetine or risperidone but insist that only sedating psychotropics with abuse potential, such as alprazolam or quetiapine, can effectively treat their symptoms.

Divulging symptoms too eagerly or dramatically.2 Typically, patients suffering from schizophrenia, bipolar disorder, or major depressive disorder are embarrassed by their symptoms and may attempt to minimize or conceal them until they have established a rapport with the clinician. To the contrary, I have seen numerous inmates feigning mental illness who immediately and openly declare, “I hear voices” or “I’m paranoid.”

Dependent or conditional threats of self-harm, violence, or litigation. Statements such as, “If you don’t do this for me, I will hurt myself or somebody else” or “I will sue you if you don’t do this” are more consistent with Axis II than Axis I pathology. Patients in the throes of severe depression or psychotic thinking usually do not possess the motivation or inclination to make conditional threats.

Although there is no substitute for a comprehensive diagnostic assessment that includes history, treatments, and mental status exam, my “3Ds” may put you on alert. These scenarios are not diagnostic, but encountering any of them is a signal to delve further into the authenticity of the individual’s presentation.


1. American Psychiatric Association Psychiatric services in jail and prisons. 2nd ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2000.

2. Resnick PJ. My favorite tips for detecting malingering and violence risk. Psychiatr Clin North Am. 2007;30(2):227-232.

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