Introduction to Malingering
Few mental disorder cases reach the courts without an expressed or implied allega- tion of malingering, having as primary motivation, financial gain, and then sympa- thy and social support.
Malingering is listed in the DSM-5 as the subject of Differential Diagnosis con- erning Factitious Disorder; as a condition not attributable to a mental disorder that may become the focus of clinical attention. It is the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives (a recognizable goal), such as... financial compensation” (APA 2000, p. 739).
The clinical presentation is diverse and heterogeneous. It defines a responsive style, rather than an identifiable syndrome, and is characterized by peculiar descrip- tions of severity, duration, and degree of distress.
In deception, the individual tries his/her best to appear as if describing a current and debilitating clinical entity. The clinical interview is the only viable method of concentrating on motivation.
A malingerer is not a dishonest patient that lies or distorts the past, or a manipu- lative patient, or the disengaged aloof or defensive patient, or the one that wants badly to be seen as suffering, as a patient. Malingering only describes the deliberate fabrication or gross exaggeration of symptoms for a recognizable goal.
There are two main situations in which the diagnosis of malingering can be clearly confirmed: when these persons think they are unobserved and are caught in the act and when they actually confess that they are faking.
An essential third option, and the one that sheds the most light during the exami- nation, consists of the thorough collection of collateral data, including any prior medical and psychiatric records and complete progress notes of the therapist, rather than summary reports. If the clinician possesses more factual information about the case than the claimant knows, it helps the examiner to assess the claimant’s veracity.
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Case 12a: Malingered Kleptomania Versus Shoplifting
I was asked to examine a woman with an apparent compulsory behavior to steal.
Her defense attorney referred his client to me, hoping I would fine her suffering from Kleptomania.
This was a Ukrainian woman, Ms. Kozak, that presented to me in the company of her sister who asked to be present to assist with translating as needed. Ms. Kozak had serious limitations with the English language. I spent 1 h with her, reviewing some material Ms. Kozak brought along and examining her. She was 50 years old, divorced, and working 20 h weekly as a “home attendant” with the Ukrainian elderly. No occupational problems had ever been reported about her.
Ms. Kozak told me that she never had legal problems for stealing or shoplift- ing before. She lived with, and took care of, her 103-year-old grandfather, who was presently infirmed and bedridden. Twelve days prior, she had started taking Elavil (antidepressant) 25 mg, and lorazepam (mild sedative) 0.5 mg p.r.n., both twice daily, as per a psychiatrist that after that first visit referred her to the local mental health center. There was no history of mental health treatment in this country.
“Sometimes I don’t know what I’m doing… I was with my sister and her mother- in-law, shopping at Wal-Mart.” Ms. Kozak replaced the price tags of three to four items (women’s clothing) with tags indicating lesser price. She added that this was done “in the open… sort of.”
Ms. Kozak told me that she received special education, as her speech was delayed until she was 4–5 years old, due to cognitive and behavioral problems. She would suddenly feel overwhelmed and act bizarrely, thinking that people wanted to poison her. The examinee said that she completed the eighth grade. Also, I was told that when Ms. Kozak was 1 year of age, she became sick with meningitis.
I heard from her that her father had a mental illness, was deaf/mute from birth, and was disabled. Her mother, also a deaf/mute from birth, was diabetic and lived with her sister. Ms. Kozak was the eldest of the four children; only one of them remains in Ukraine. She added that the brother that lives in America does not speak to her since she is “not normal.” She came to the United States 4 years ago and had a son in college. Ms. Kozak mentioned that her grandparents helped her to raise her son.
Encouraged by her sister, Ms. Kozak took a 2-week course and trained to become a home attendant, same as her sister was. Ms. Kozak was working in this capacity for 1.5 years, 4 h per day, for a total of 20 h weekly.
“I don’t go shopping at all now… I have my sister doing it for me… I don’t understand what happened.”
She also mentioned that in her country, she had been the subject of physical abuse by her ex-husband and that on one occasion, she took a knife to attack him, but did not hurt him. She was then hospitalized in a mental institution for several months, some 16 years ago. During her time in the hospital, her husband divorced her, without her knowing about it. I was told that, in total, Ms. Kozak was psychiat- rically hospitalized three times.
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Ms. Kozak’s sister told me that Ms. Kozak was depressed and added, “Sometimes she loses her memory.” She assured me that her sister had never done anything like what she is charged with doing. The sister also told me that Ms. Kozak does not drive because she is afraid of her getting behind the wheel, due to her nervousness and depression. I was told that, at home, she cried easily and often.
She was casually and comfortably dressed and well groomed. Ms. Kozak appeared her stated age and was courteous and appropriate. Her mood appeared somewhat labile, crying with ease (she was also facing serious, criminal charges).
She appeared ashamed of the actions she took and at times would childishly giggle.
Furthermore, she was able to provide me with identifying information, knew who the current president was, and was also able to carry out “serial 7s” with some errors, “100-97-94-91-87-84-81-77-74-71-67-64-61.”
Ms. Kozak presented me with photocopies of some “official-looking” docu- ments, written in a Slovak language, and reportedly translated into English by an
“official-looking” translation. The material indicated that as far back as 1967 and until 1994 (2 years before she came to this country), she had been found to be totally and permanently disabled with the diagnosis of “schizophrenic dementia.”
The English translation of the documents stated, at the bottom of the page, “This is an accurate translation from the Ukrainian original,” and an identifiable signature appeared below with no typed name next to it. Other pages would read, “The authenticity of the translation is certified,” followed by a different signature with again no typed name next to it.
One of the reportedly “officially translated documents” read on top, “USSR – Department of Health – Hospital for patients with Mental illness” (verbatim). The information included on this document read, “This document is given to Ms. Kovak and certifies that in consequence of hard brain infection illness ‘Meningitis’, that she had go through childhood, she has brain injury that includes partial loss of memory, recurrent headaches, inadequate behavior.”
Despite these “ominous clinical” assertions about her seriously compromised state of mind, Ms. Kovak had not been under psychiatric care until after she was arrested for criminal behavior at the department store. Ms. Kovak was not occupa- tionally disabled and was able to care for the elderly and infirmed, and her mental status did not reveal any of the clinical characteristics observed in individuals afflicted by kleptomania.
As a result of the IME, I was of the opinion, within a reasonable degree of psy- chiatric probability, that this woman prepared a scam designed to walk off the store with articles of clothing having paid less than the price originally marked for them.
Primer on Traumatic Brain Injury, a Common Complaint in the Malingerer
Psychiatric problems, particularly depression and anxiety, have been found to occur commonly in patients suffering from traumatic brain injury (TBI). It is the second most common neurological condition, after migraine headaches. In particular,
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closed-head injuries typically result in more diffuse impairments than do open head injuries. Although outside the scope of this book, we will delve into a brief overview of the pathological and physiological underpinnings that govern traumatic brain injury and its symptomatic manifestations. A number of highly credible and repu- table sources have helped in compiling the information to follow, and it may behoove the interested reader to learn further on the topic; in particular, we refer- ence a manuscript written by Dr. Slagle, D.O, from 1990 that still remains an impor- tant text for TBI, concussion, and their related psychiatric manifestations.1
A concussion refers to the temporary loss or diminution of consciousness or other function due to a blow to the head. Moreover, there need not be any macro- scopically observable damage to the gross structure of the brain, although micro- scopic nerve and blood vessel damage may occur. A contusion refers to the actual bruising of the brain, usually involving some combination of swelling, laceration, and hemorrhage that can be clearly observed. A concussion refers to the altered state of behavior and consciousness that the injury produces, while a contusion is its observable pathophysiological correlate. In closed-head injuries, contusions are most likely to occur in brain regions that lie near bony prominences within the base of the cranial cavity, particularly the frontal and temporal lobes.
In closed-head injury, a blow to the movable head produces a much more severe brain injury than one to a rigidly fixed head, which is one reason for head supports on automobile seats. Nearly all head injuries have some rotational component to the trauma due to the various motions and forces on the brain, via the head’s suspension on the flexible neck.
The rotational acceleration/deceleration injuries, or whiplash events, produce a sudden shifting of the brain within the skull, twisting and turning of the brain, where diffuse microscopic axonal injury occurs, creating stretching and tearing (known as shearing), which pulls apart axons and disrupts cell bodies. A short circuit of the neuronal system ensues. This correlates with loss of consciousness or with a period of feeling stunned, confused, and disoriented. (It also happens in the shaken baby syndrome, where the infant’s brain is damaged by shaking.)
TBI is a traumatically induced physiological disruption of brain function and can be caused by (1) the head being struck, (2) the head striking an object, or (3) the brain undergoing movement in the skull without any direct external trauma to the head. TBI is manifested at least by one of the following:
1. Any period of loss of consciousness
2. Any loss of memory for events immediately before (retrograde amnesia) or after the accident (anterograde amnesia)
3. Any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused)
4. Focal neurological deficit(s) that may or may not be transient but where the severity of the injury does not exceed the following: post-traumatic amnesia
1 Slagle, D.A. Psychiatric disorders following closed head injury: An overview of biopsychosocial factors in their etiology and management (1990) Int’l J. Psychiatry in Medicine. 20, (1), 1–35.
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(PTA) not greater than 24 h; after 30 min, an initial Glasgow Coma Scale (GCS) of 13–15 (measuring degree of responsiveness; a score of 13–15, mild TBI with clinically significant findings; 10 or less, severe TBI); and loss of consciousness for 30 min or less
It is important to remember that a person may physically look fine and yet has sustained a TBI that affects his/her memory, day-to-day functioning, and personal- ity. MRI, CT scans, or x-rays of the skull and brain can also be normal. In fact, they cannot tell a physician if the person is awake or asleep and alive or dead. They are not tests of functional impairments. Concussions are characterized by a lack of demonstrable focal neurological deficit and a clinical course of apparent recovery.
TBI patients present with symptoms characteristic of pathology from frontal and temporal areas, grouped into five clusters. These include:
1. Affective: apathetic, with little motivation, moodiness, depression, anxiety, and general mood instability.
2. Behavioral: restlessness, irritability, and agitation (from out of the blue, with minimal or no provocation, very quickly they become explosive). It is typical that they become remorseful, although not necessarily blaming others but them- selves for this behavior and may also feel withdrawn. They have an overall inability to deal with stress.
3. Somatic: headaches, dizziness, fatigue, and sleep disturbance.
4. Cognitive: disturbed memory, concentration, distractibility and inattentiveness, and lack of spontaneity.
5. Perceptual: tinnitus, sensitivity to noise and light also occur.
Case 12b: Claim of Post-concussion Disorder Secondary to Traumatic Brain Injury Seeking Neurological/Psychiatric Disability to Function at Work
Mr. Fitz was 46 years old and out of work due to a work-related accident that reportedly incapacitated him, some 8 months ago. His work consists of transport- ing goods in a truck, including boxes of home appliances, and unloading them at designated sites.
Hospital records where he was taken from the scene describe that while unload- ing boxes, a box of 20 lb. fell on him, hitting his head and causing loss of conscious- ness of up to 30 min. In the ER, Mr. Fitz appeared confused and disoriented, his speech was not clear, and he did not recall the event. He was hospitalized. He was prescribed phenytoin (anticonvulsant). Two days later, Mr. Fitz was much improved.
Neuropsychological tests were administered 1.5 and 3 months after the occur- rence. The claimant was vague in his responses; he remembered that on the day of the incident, he had driven his truck and that he tried to move away from the falling boxes. He added that he saw bright lights and that his head hurt. Mr. Fitz mentioned that he felt dizzy and with vertigo. Some months later, the claimant was prescribed
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sertraline (antidepressant), which he was not consistently taking. He reported being
“nervous” at night and with disturbed sleep.
During the neuropsychological tests, some “unusual” fine hand tremor was noted, more pronounced when asked to copy some simple images. He could write his name, but when writing a short sentence, his body would shake. He was able to draw a triangle, which he identified as “pyramid” and had trouble drawing a circle.
Mr. Fitz could not complete the alphabet. At some point he turned emotional, looked at his daughter, who was in the room with him, acting as translator, and asked her who she was.
All these aspects were catalogued by the psychologist as histrionic and dis- proportional and made her think of malingering. Despite this concern, the exam- iner reached the opinion that Mr. Fitz was unable to return to work, which included driving his truck on the road and unloading boxes. The psychologist suggested a psychiatric IME be done. Mr. Fitz had two such evaluations performed.
Mr. Fitz’s orthopedist found that he was fit to work in his occupation 10 weeks after the event. A neurologist diagnosed post-concussion syndrome; a CT scan of the head was normal, and an EMG (test to assess the speed of nerve conduction) did not show radiculopathy, a neurologic condition related to an impinged nerve caus- ing pain and impairment in the respective muscle groups involved.
Mr. Fitz had some sketchy psychiatric history. Roughly 15 years ago, he took an overdose of clorazepate (antianxiety) when his romantic partner left him, and he was in some mental health treatment for 6 months. He then moved in with his mother.
A psychiatrist examined him 5 months postaccident. Mr. Fitz explained that the reasons for him not to take sertraline were that it caused stomachache and turned him overactive and it was too costly, as the insurance company was not covering it.
He was found to be oriented, but not knowing who the actual president was. He added that he could not live alone since he was forgetful since the accident. He lived with his mother. Mr. Fitz was diagnosed with cognitive disorder, depressive disor- der, and possibly PTSD. “Secondary gain” (simulation or exaggeration) issues were mentioned but not considered beyond this point.
During my examination of Mr. Fitz, and as an example of how badly his state of health was, he said that one morning he woke up in the bathtub, with water up to his chest. He also mentioned that many times he did not recall what happened the day before, after he woke up in the morning. He would wake up depressed and nervous.
Claimant said that he studied until junior high school. Moments later, he stated that he did not recall his past. He added that those aspects he did remember were retaught to him by his mother, by showing him documents and pictures to help recover his memory; otherwise he had learned about his history anew.
Claimant said that he recently took his mother’s car, without permission, and later on he called her up, being lost somewhere. He mentioned that he was unable to have an intimate life with his girlfriend. Mr. Fitz said that he worked for the same company for 7 years. He then added that his mother had recently read to him all this information. He said that this had been his first accident at work. “I look at the
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calendar, daily to remind myself the date,” and repeated that he leaned on his mother to be informed about his past.
The insured said that he spent the day with his computer and music. His recent memory appeared intact. Mr. Fitz mentioned that his girlfriend told him that he had been saving money to move in with her. His hobby was to play the electronic key- board, compose songs, and transfer them to special electronic files in his computer.
He then added that he was relearning to play the piano. Claimant said that he felt depressed and overall slow, including a low appetite and energy level, and that he was disinterested and with little ability to concentrate. His language was coherent and goal-directed. His capacity to understand the questions, appreciate their mean- ing, and answer them showed an intact cognitive functioning. Mr. Fitz would add to most of his answers comments such as “I had to be reminded of this.”
He met with me at the request of the insurance company that paid his disability benefits. My examination of Mr. Fitz took place 8 months after the accident.
Claimant spent 3 uninterrupted hours with me. The examination consisted of struc- tured and unstructured techniques, like questionnaires and open-ended history-gath- ering questions, respectively.
I had the chance of seeing him, in the waiting room, chatting with a woman whom he came in with while preparing a cup of coffee for himself. I did not notice signs of his being slowed or disheartened. His exchange with the woman was fluid and friendly, and she did not have the need to clarify anything for him.
Once in the examination room, Mr. Fitz gently placed the cup of coffee next to his chair. Later on, he finished drinking his coffee and placed the empty cup in the garbage container. Claimant spelled his name and the street where he lived. He pro- vided his birth date, age, phone, and social security numbers. He told me that he was separated from his wife and that his mother had taught him all this anew. “According to my mother, I am separated since 1980… I don’t remember things… she sits next to me… first my name, next my birth date, my social security number, and so on…
my mom works with doctors… she used to be the receptionist at a doctor’s office…
now she works at the airport.”
Claimant told me that on two occasions, he lied down in his bed at night, with his pajamas on, and woke up in the bathtub with the water up to his neck. The water did not wake him up, nor his mother, whose bedroom was next to the bathroom. He added that he did not tell his mother about this, in order not to worry her.
I mentioned that his birthday, the year of the work-related accident, fell on the day after the 9/11 tragedy in NYC. Without delay, he talked about the amount of dead people as a result of it, “people like me,” he added. “People that did such acts were cowards that did not appreciate life. I heard in the news that the ones behind it were Arabs.”
“Since the accident, I always see a light with lots of shadows… it’s a white light that doesn’t hurt my eyes… it comes from the front of me… I walk through the light and see a lot of things… and I have, like, premonitions… in a dream I saw the disas- ter at the ‘Twin Towers’ before it happened… people told me it was going to hap- pen… I can see that an accident is about to happen, but not to whom, so I can’t prevent it.”
Case 12b: Claim of Post-concussion Disorder Secondary to Traumatic Brain Injury