Assessment of Psychosocial Contributions to Disability
4.4 An Introduction to Psychological Testing Concepts
4.4.3 Malingering, Exaggeration, and Denial
Sometimes, there are incentives for a patient to appear disabled. In disability settings, one of the principal uses of test validity measures is to detect malingering or exag- geration. Malingering is defined by the DSM-IV-TR as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining finan- cial compensation, evading criminal prosecution, or obtaining drugs” (p. 739).
According to the DSM-IV-TR, probable malingering exists when two or more of the following four conditions are present: (1) The patient presents in a medical/legal context; (2) There is a marked discrepancy between claimed disability and objective
findings; (3) The patient exhibits a lack of cooperation with testing or treatment (a malingerer may avoid diagnostic evaluations that would fail to support the symptomatic complaints; or treatment for which a genuine condition might respond); and (4) The patient has an antisocial personality disorder (American Psychiatric Association, 2000).
Studies have shown that psychological conditions can be easily faked (Hall, 2007) and that compensation for disability is associated with increased reports of symptoms (Binder & Rohling, 1996; Rohling et al., 1995). Despite this, the prevalence of malingering remains controversial. The most extensive review to date of pain-related malingering reviewed 68 studies and estimated that malin- gering was present in 1.25% to 10.4% of patients with chronic pain (Fishbain et al., 1999). In contrast, some more recent studies have suggested that there may be a 30–40% incidence of malingering of pain, emotional distress or cog- nitive symptoms in patients who were litigating or seeking benefits (Aronoff et al., 2007; Mittenberg et al., 2002). Variations in estimates of the prevalence of malingering may be explained in part by the fact that a recent study found that the prevalence of malingering was observed to increase along with the degree of potential for financial gain. Consequently, in situations where a high potential for financial gain was present, such as in federal litigation, the preva- lence of malingering could be significantly higher. This phenomenon could help to explain wide variations in estimates of the prevalence of malingering (Bianchini et al., 2006).
The DSM-IV-TR notes that prior to diagnosing malingering, other psychiatric explanations must be ruled out. These alternative explanations include factitious disorders, somatoform disorders (e.g., somatization, conversion disorder, pain disorder), or psychosis with somatic delusions (American Psychiatric Association, 2000). In contrast to malingering, where symptoms are feigned in the pursuit of some kind of external reward or secondary gain, in factitious disorders, symp- toms are produced for primary gain. As noted above, in factitious disorders, a patient reports symptoms without any intent of external reward such as a dis- ability settlement. Instead, in factitious disorders, the individual reports symp- toms because he or she wants to be a patient (Wise & Ford, 1999). Thus, while a healthy patient may aspire to have a career, a factitious patient wants nothing more than to be a patient, even to the point of turning down a monetary settle- ment if it would jeopardize patient status. In some cases, factitious symptoms are feigned. In other cases though, patients with factitious disorders may actu- ally self-induce a medical condition (such as by drinking a toxic substance or rubbing fecal material into a wound) in order to gain patient status (Mailis- Gagnon et al., 2008).
Malingering must also be distinguished from Somatoform Disorders.
Somatoform Disorders are psychiatric conditions, where psychological diffi- culties are expressed in a somatic form. In Somatoform Disorders, the indi- vidual is typically unaware of any relationship between physical symptoms and his or her psychological status, and is not in voluntary control of the physical symptoms (American Psychiatric Association, 2000). Significantly, Somatoform
Disorders may involve both the exaggeration of physical symptoms, and the simultaneous denial or minimization of psychological distress or dysfunction.
This, in fact, is the core of somatizing: denied psychological difficulties uncon- sciously manifest themselves as inflated complaints of physical symptoms (Ford, 1986). An example of this would be a patient who denies being anxious, but continues to interpret a pounding heart as a deadly sign of a heart attack, even after this has been medically ruled out. In other cases, the patient may actively conceal psychological difficulties, out of the fear that if they were reported, the physical symptoms would be taken less seriously. Malingering must also be distinguished from psychophysiological disorders, as stress and physiological arousal can sometimes lead to objective medical difficulties (Bruns & Disorbio, 2005; Bruns & Disorbio, 2009) such as stress-related hypertension (Pickering, 2001).
Finally, malingering must be distinguished from exaggerating. Patients with objective physical difficulties may exaggerate the report of associated symptoms for a variety of reasons. Exaggeration can be related to personality type, depressive negativism, a cry for help, or out of a patient’s perception that the physician is trivi- alizing the reported symptoms (Iverson, 2007). Cognitive styles such as catastroph- izing may also increase symptom reports (Sullivan et al., 2001). Further, one of the effects of litigation is that both sides may make biased or exaggerated statements as part of the adversarial process (Bornstein et al., 2002). While malingering involves the intentional report of information that is either a gross exaggeration or patently false, mild exaggeration is common and can occur for many reasons other than malingering.
Even when malingering is not judged to be present, environmental incentives can affect the treatment outcome. For example, research has shown that patients are less likely to recover from a back injury if they are in a lawsuit for that injury (Rohling et al., 1995). Similar studies have found that litigation is associated with poor outcome from treatment for head injury (Binder & Rohling, 1996), and for vocational rehabilitation (Lysgaard et al., 2005). Similarly, if a patient receives insurance compensation for disability (such as from the workers’ compensation system), this has also been found to be associated with a poor prognosis from care (Bernard, 1993; Deyo et al., 2005; Epker & Block, 2001; Greenough et al., 1994;
Groth-Marnat & Fletcher, 2000; Mannion & Elfering, 2006; Glassman et al., 1998;
Klekamp et al., 1998; Taylor et al., 2000). In general, research suggests that when patients are paid or hope to be paid for having symptoms, their symptoms are less likely to get better.
Overall, malingering is not a medical or psychiatric condition. In the case of disability determinations, malingering is an illegal, fraudulent act, which has con- sequences under both criminal and civil law. Thus, for a medical professional to label someone a “malingerer” is not an act of diagnosis, but is rather rendering a verdict. As stated by Mendelson and Mendelson (Mendelson & Mendelson, 2004),
“In our view, the ultimate issue of the veracity of the plaintiff is for the Court to decide, and epithets such as “malingerer” have no place in reports prepared for legal purposes by health care professionals” (p. 423).