Motivation and emotion/Book/2021/Malingering motivation

Overview
Malingering is when an individual fakes, or significantly exaggerates physical or psychological symptoms in order to gain external benefits. While malingering is not classified as a mental disorder, it is included in the DSM-V under a V-code, also known as other conditions that may be a focus of clinical attention, as malingering can affect the diagnosis and treatment of a patient, whether it is because the malingering is an indicator of other underlying psychological conditions; or because it is motivated by purely external benefits. (Alozai & McPherson, 2021) Common motivations for malingering include: financial compensation, revenge, obtaining drugs and prescription medicine for use, avoiding or reducing criminal charges, avoiding military draft, and avoiding distressing situations and environments. The diversity of motivations and recent research indicate that malingering is a tool that is used in certain circumstances, rather than a trait. (Sahoo et al., 2020) Because of this, malingering cannot be treated with medicine or psychological interventions. Rather, malingering is stopped when the individual either achieves their goal, or gives up because pursuing it is futile. (Alozai & McPherson, 2021) This can be achieved through indirectly confronting the malingerer. (Schnellbacher & O’Mara, 2016)

While malingering is not an everyday occurrence, it can have dire consequences. Malingering within the United States military is a criminal offence, with charges including dishonourable discharge and jailtime, ("What to Know About Malingering in the Military - Court Martial Law", 2019) and, in the United States, malingered disability claims cost the Social Security Administration $20.02 billion dollars in 2011. (Chafetz & Underhill, 2013)

Focus questions:
 * What is malingering?
 * What motivates malingering?
 * How can malingering be managed?

Aetiology of Malingering
Unlike other conditions, such as factitious disorder where the patient fakes or significantly exaggerates their symptoms in order to be seen as sick by other people, malingerers fake their symptoms in order to gain external benefits. Because of this, malingering is not classified as a mental disorder, however, it is included in the DSM-V under a V-code, also known as other conditions that may be a focus of clinical attention. (Alozai & McPherson, 2021) This is because malingering affects the diagnosis and treatment of a patient, because while malingering can be motivated by purely external benefits, malingering can also be an indicator of other underlying psychological conditions or other issues.

Common Motives for Malingering
While the motivation for malingering will vary from individual to individual, common malingering motivations include: financial compensation, which can occur through civil lawsuits or disability benefits; revenge, which could look like an individual pretending to be injured, and blaming the injury on someone they dislike so that they are held liable for the injury; obtaining drugs and prescription medication for use, e.g., opioids; avoiding or reducing criminal charges, and avoiding distressing environments and situations, whether it is a child avoiding school because they are being bullied, or an adult attempting to avoid their military draft. (Alozai & McPherson, 2021) The above motivations indicate that malingering is a situation specific tool that individuals use, rather than a trait or a condition. (Sahoo et al., 2020) Interestingly, these motivations fall under two categories, personal gain, and avoidance. Because malingering requires a decent level of effort, and deception skills, it can be understood that individuals whose malingering is motivated by personal gain, malinger because they consider deception to be acceptable behaviour, and to these individuals, malingering is merely a tool for them to achieve their needs. This can be seen in a study conducted by Wright et al. (2015) that found that good lying skills (a factor necessary in malingering), was not necessarily associated with individuals whose had traits within the dark triad- narcissism, Machiavellianism, and psychopathy; rather, good liars were individuals who considered deception to be acceptable. Conversely, individuals who malinger to avoid situations or environments do so because they are desperate and see no other options, which can be seen with individuals malingering to avoid a military draft. (Sahoo et al., 2020) However, there can be overlap between the two categories, whether it is because the individual's malingering is motivated by multiple motivations, or because the individual has one motivation that falls under both categories.

Case Study: The Mysterious Rash

A 14 year old girl was referred to a hospital for a possible case of chronic fatigue. At the time, she was experiencing fatigue, reduced appetite, nausea, and she had a pink rash under her cheeks. These symptoms had begun a fortnight before the visit, and was also accompanied by conjunctivitis. At this point, she had missed school for a month. The doctor conducted a physical examination. With the exception of the presence of conjunctivitis and her rash, her results were unremarkable. However, the doctor noticed that her rash could be removed with alcohol wipes, which suggested that it was makeup.

When this was brought up, she denied that she was applying makeup at first, however, she ended up tearfully confessing that she applied makeup to her cheeks and eyes so that she could avoid school. This was because a classmate was spreading a rumour that he had sex with her, and because of this, she was feeling harassed, and embarrassed. The family was then referred to counselling to resolve this issue, and she was able to return to school. Since then, she has continued to do well with no further episodes. (Peebles et al., 2005)

Personality Traits and Conditions Associated with Malingering
Moderate links between malingering, and fantasy proneness, and antisocial personality disorder have been made. Peace & Masliuk (2011) found that in the context of malingered trauma, higher levels of fantasy proneness and dissociation in individuals was associated with exaggerated symptom reporting. However, the levels varied depending on what the motivation of the malingering was. As in their study, they found that participants whose malingering motivations were compensation or revenge had higher symptom scores in comparison to their counterparts who had other motivations. Antisocial personality disorder has also been associated with malingering, with the DSM-V even including it as an indicator of malingering. This is because individuals with antisocial personality disorder typically have little regard for rules and social norms, (Fisher & Hany, 2021) and as such, are more inclined to use malingering as a tool to achieve their goal. However, this is a flawed perspective, as it assumes that the majority of individuals with antisocial personality disorder who seek medical help are malingerers, even though there is an equal number of patients with antisocial personality disorder who are seeking medical help for genuine reasons, which leads to misdiagnosis, and the patient not being treated. This assumption also disregards the fact that individuals without antisocial personality disorder are just as likely to malinger. (Sahoo et al., 2020)



However, it is hard to make generalisations about malingerers as the demographics and motivations of malingerers are incredibly diverse. Recent research also indicates that malingering is not a trait, rather, it is a situation-specific tool whose use is influenced by adaptational factors rather than criminological factors. (Sahoo et al., 2020) This can be seen with the historical prevalence of malingering; one example of this is the Tom of Bedlam, a popular trope present in English folklore, and even in Shakespeare's play, King Lear; that was based on a scam that was prevalent in the 15th century England- a malingering beggar with odd mannerisms, dressed in ragged and peculiar clothes, claims to have been released from St. Mary of Bethlehem Asylum (Bedlam) in London. At the time, Bedlam only housed a small number of patients, so very few of these beggars would have been genuinely from Bedlam. However, this did not stop individuals, and at one point, the scam became so popular that hospital officials had to put a notice in the London Gazette, disclaiming the scam. (Mason, 2014)

Psychological Theories
Multiple psychological models have been proposed to explain why malingering occurs. However, due to the diverse demographics of malingerers, the majority of these models have failed to fully explain the factors that motivate malingering. Several theories that have been proposed include; the pathogenic model, which suggests that the malingered symptoms will erode and eventually be replaced with genuine symptoms, as malingering is caused by an individual's pre-existing illness, and, the malingered symptoms are the individual's attempt to control their experience of it, and also gain external benefits. (Rogers et al., 1994) However, this theory has been disregarded due to lack of replication. (Sahoo et al., 2020) Another theory is the criminological model. This theory suggests that motivation to malinger is rooted in a disregard for social norms and laws in socially deviant individuals who use malingering as a tool to achieve their goals. (Rogers et al., 1994) While this theory bears some weight, it however is not applicable to all cases of malingering. (Sahoo et al., 2020) The last theory, the adaptational model, stems from the humanistic school of psychology, and it proposes that malingering is an individual's method of coping with extreme stress. There are several assumptions that accompany this model; one, the patient sees the diagnostic process as involuntary, or antagonistic; two, the patient cannot see any alternative ways of achieving their goal; three, the patient believes that there are no other ways of achieving their goal. (Sahoo et al., 2020)

Detecting Malingering
There are multiple ways of detecting malingering. These include tests, reviewing the patient's medical history, and looking for indicators of malingering in the patients behaviour. While the biggest indicator of malingering will be the patient's behaviour, the best approach is to use a combination of methods as this will ensure a richer understanding of the patient.

Indicators of Malingering in the DSM-V
The DSM-V lists four indicators of malingering. These are:


 * The medicolegal context of the presentation, as a lawyer could send a client for an evaluation ahead of their trial so that they can use a diagnosis as a reason to have their client's sentence reduced. (Alozai & McPherson, 2021) However, this alone is not an adequate indicator of malingering, as there are also individuals who receive psychological evaluations ahead of their trial due to genuine symptoms.
 * The inconsistencies between the client's claimed symptoms, and observed behaviour and symptoms is a big indicator, especially in suspected malingerers who are not well educated about the symptoms of the illness they are attempting to fake.
 * Another indicator of malingering is lack of compliance with diagnosis, treatment, and follow-up.
 * The DSM-V also lists having antisocial personality disorder as an indicator of malingering, as individuals with antisocial personality disorder are more inclined to use tools such as malingering to achieve their goals. However, this is a dangerous generalisation to make as individuals with antisocial personality disorder could be presenting to a psychologist for legitimate reasons. (Alozai & McPherson, 2021)

Other Indicators of Malingering
Outside of the DSM-V, there are also other indicators of malingering. These include:


 * Abnormal presentation, and atypical symptoms for the condition the patient claims to have, as this can be an indicator of a patient not being well educated on the symptoms of a particular disorder, and including symptoms from other conditions in their performance. However, abnormal presentation in genuine patients, as well as atypical symptoms, can also be indicative of other factors such as dual diagnoses, or the patient simply having atypical symptoms, which is uncommon, but possible. (Schnellbacher & O’Mara, 2016)
 * A patient's use of specific terminology is also another indicator as it can be a sign of a malingering patient doing their research beforehand. However, there are also many genuine patients who are well educated on their condition. (Schnellbacher & O’Mara, 2016) This is especially true for patients from marginalised backgrounds (e.g., disabled people) who are inclined towards educating themselves on symptomology and other aspects of their conditions so that they can self advocate, due to the historic, and ongoing discrimination they have faced. (Dossey, 2015)
 * The patient's willingness to discuss embarrassing or distressing symptoms with the psychologist in the absence of a close relationship with the psychologist can also be indicative of a malingering patient attempting to make their 'symptoms' seem as authentic as possible by including compromising details. (Schnellbacher & O’Mara, 2016)
 * Other indicators include when a patient describes their symptoms vaguely, and when a patient is unable to describe what they do to lessen the effects of their symptoms. (Schnellbacher & O’Mara, 2016) While each of the indicators alone is not a good sign of whether a patient is malingering, when put together, they provide a reliable indicator of malingering.

Finding Evidence of Malingering
When faced with the possibility of malingering, it is important for the psychologist to gather evidence before proceeding. That way, should the psychologist's actions be questioned, they have evidence to support their actions. There are multiple ways gathering evidence of malingering can be achieved.

Firstly, ask the patient about improbable symptoms in order to catch them out. Unless the patient is well educated on the condition, or their symptoms are genuine, the patient will answer yes, under the assumption that the symptom is legitimate. These improbable questions can be asked in between several genuine questions in order to make the improbable questions seem more realistic.

A review of the patient's medical history and records also provides a good indicator of whether a patient is malingering. (Sahoo et al., 2020) If necessary, this review can also be accompanied by lab tests to rule out physical symptoms. (Alozai & McPherson, 2021) There are also a variety of tests that can be used to detect malingering, whether it be for detecting general malingering, or detecting malingering cases with specific disorders. (Alozai & McPherson, 2021) Many of these tests employ The Floor Effect in their design. This is when a cognitive test designed so that individuals with cognitive impairments can easily complete it, however, it is designed to look harder than it actually is, so that when a participant fails the test, this is an indicator of malingering. (Walczyk et al., 2018)



Tests for Detecting Malingering
There are a variety of tests that can be used to detect malingering. Commonly used tests include:


 * MMPI-2, also known as the Minnesota Multiphasic Personality Inventory 2, is a self report inventory that measures various aspects of personality and psychopathology. The MMPI-2 also has validity scales that are designed to detect non-reporting and inconsistent reporting, exaggeration of symptoms, and under-reporting of symptoms. This makes the MMPI-2 a popular choice for psychologists in a variety of settings and contexts, including detecting malingering. A study conducted by De Marchi and Balboni (2018) found that the MMPI-2 was effective in detecting malingerers.
 * SIMS, also known as The Structured Inventory of Malingered Symptomatology is a 75-item true-false inventory designed to measure malingering. It is commonly used by psychologists who are assessing victims of motor vehicle accidents on the behalf of insurance companies. While the SIMS was found to be more sensitive than other tests designed to identify malingerers, it had serious issues with specificity, (De Marchi & Balboni, 2018) as Cernovsky et al., (2019) found that many of the items on the SIMS listed legitimate medical symptoms, which would lead to the test misclassifying legitimate victims as malingerers.
 * NIM, also known as the Negative Impression scale, measures the extent to which respondents describe themselves in a negative manner, and is part of the PAI (Personality Assessment Inventory). The PAI is a 344-item self report inventory that assesses various aspects of the respondent's personality and psychopathology. The PAI contains four scales: validity scales, clinical scales, treatment consideration scales, and interpersonal scales. The NIM is a validity scale within the PAI and it can be used to measure malingering. Studies conducted by De Marchi & Balboni (2018) found the NIM to be an effective tool for detecting malingering. It's parent test, the PAI, is a popular choice as it also has good convergent validity with other tests such as the MMPI-2.
 * SIRS-2, also known as the Structured Interview of Reported Symptoms, is a structured interview with 172 items that is designed to detect malingering in respondents through assessing the distortion of self reported symptoms.(Heilbronner, 2011) The SIRS-2 also has a shortened version which contains only 25 items. This version is known as the Miller Forensic Assessment of Symptom Test (M-FAST). Research conducted by Rogers et al. (2009) has found the SIRS-2 to be a highly reliable measure. A study conducted by Guriel-Tennant and Fremouw (2006), also found that both the SIRS-2 and the M-FAST are effective at detecting malingering, and research done by Zubera et al. (2014) has found the M-FAST to be an effective tool for detecting malingering in the emergency department.

Criticisms of Malingering Tests
While tests are an accessible, effective, and easy to administer way of detecting malingering, especially when the psychologist has doubts about their ability to detect malingering, the results are unfortunately vulnerable to being manipulated. This can occur through a client being coached by their attorney, or a person who has done extensive research on symptomatology. (Brennan et al., 2009) A second criticism of malingering tests is that the questions are not culturally valid. An example of this can be seen with how people from Hispanic or Mediterranean cultures are more inclined to answer in extremes (e.g., strongly agree, or strongly disagree), which leads to their results indicating malingering, even when they're genuine patients. (Merten & Rogers, 2017)

Case Study: The Collegno Amnesiac

In March 1926, a man was admitted to the Collegno Asylum, Turin, Italy, after being arrested for stealing from a Jewish Cemetery. During his arrest, he was uncooperative and violent, refusing to give his name, and even attempting to throw himself down the stairs and beat his head against a wall. He was approximately 45 years old and he had no autobiographical memories.

He spent about a year in the asylum where his mental health improved considerably, save for his memories. During this time, he established good relationships with the nurses, doctors, and other patients. Later on, Renzo Canella later identified him as Guilio Canella, his brother, and a philosophy professor who disappeared during World War 1. The amnesiac was welcomed back into the family and he began to recover his memories.

Later, an anonymous letter was sent to the police, identifying 'Guilio Canella' as Mario Bruneri, a typesetter who was wanted for fraud. This led to multiple controversial court cases with split verdicts until the Turin High Court ruled that The amnesiac was Bruneri. This verdict was determined by the results of many cognitive tests conducted on the amnesiac by medical experts, as well as inconsistencies in character. A major contributor to these assessments was Professor Alfredo Coppola.

Coppola diagnosed the amnesiac with malingered retrograde amnesia (and was the only expert to do so). His approach to assessment was rather modern, as he used a combination of cognitive tests, close observation of behaviour, and a review of Canella and Bruneri's personal histories to arrive at the diagnosis.

Coppola tested the amnesiac's attention, short term memory (although then, it was simply called 'memory'), visual recognition, mental calculation, and language, as well as semantic memory. The test results for non-memory tests were normal. Several of the tests also employed the floor effect, which meant that test-takers with cognitive issues could pass them. The Amnesiac failed these tests. Interestingly, The Amnesiac's errors in the semantic memory tests were also extremely exaggerated. Coppola also noticed that during one of the memory tests, where the participant was meant to underline certain letters, The Amnesiac vertically struck out several of them, a common habit of typesetters. Coppola also noticed that as The Amnesiac's 'memories' came back, his 'memories' were all memories that he had been told about. As one last test, Coppola decided to evaluate The Amnesiac's piano skills. This is because Coppola understood that people with amnesia would retain their motor skills, and, Guilio Canella was a skilled piano player; so Coppola tested the amnesiac's procedural memory by evaluating his piano skills alongside two experts. Coppola's suspicions were confirmed. The amnesiac was unable to play the piano and his technique suggested that he had never played the piano until the evaluation, which suggested that he was, in fact Mario Bruneri. (Zago et al., 2004)

Treating Malingering
Malingering cannot be cured by medicine or psychological interventions. (Alozai & McPherson, 2021) This is because malingering is a tool, rather than an illness, and healthy and unhealthy individuals alike are capable of malingering.(Sahoo et al., 2020) Rather, malingering is stopped when the malingerer either achieves their goal, or gives up their goal because pursing it is futile. (Alozai & McPherson, 2021) When addressing the suspected malingering, broader terminology such as 'unreliable' and 'inaccurate' should be used before the term 'malingerer' is used, as it is a stigmatising term. (Shapiro & Teasell, 1998) Suspected malingerers should also never be confronted directly, as this can lead to negative consequences such as lawsuits. Rather, they should be confronted indirectly, so that they are encouraged to stop malingering, but also allowed an opportunity to save face. This strategy also allows the psychologist to address the motives behind the patient's malingering while also working with the patient to meet their needs, as malingering can also be an indicator of other underlying issues. (Schnellbacher & O’Mara, 2016) This can be seen with a study done on malingering that found that 3 in 10 suspected malingers who presented at the emergency department, showed symptoms of schizophrenia at follow-up appointments 20 years later. (Zubera et al., 2014) Another strategy for dealing with suspected malingerers is the Double Blind Technique, which is where the patient undergoes treatment, and is informed that their symptoms will improve due to the treatment. While this is an 'easy' way to get the patient to stop malingering by going along with their claims, this strategy leads the patient to undergoing unnecessary, and potentially harmful treatments and procedures. (Schnellbacher & O’Mara, 2016)

Delivering the News
When indirectly confronting a patient suspected of malingering, it is important to validate their concerns while also presenting the facts. Providing an empathetic delivery that is tailored to the patient's preferences is essential to minimising negative reactions from the patient. This can be achieved through adapting protocols designed for delivering bad news to patients. An example of one such protocol includes the SPIKES protocol, which is:


 * Settings: Ensure that the news is delivered in a private setting with limited interruptions, and, tailor other aspects to the patient's preferences, such as having family present, or delivering the news in a more informal location. In the context of malingering, the news would most likely be delivered in the psychologist's office.
 * Perception: Determine the patient's understanding of the situation. During this stage, the psychologist should ask the patient open-ended questions so that they can clarify any misunderstanding with the patient. This can be achieved through questions such as, "What's your understanding of the current situation?"
 * Invitation: This stage is when the psychologist obtains the patient's permission to deliver the bad news. If the patient declines, it is important for the psychologist to understand why they declined. This could look like, "I just got the results for [test patient underwent]. Is it alright if I share them with you now?"
 * Knowledge: When delivering the news, psychologists should be empathetic, delivering the information in small chunks and allowing the patient time to process it. They should also use accessible language and avoid using medical jargon. When indirectly confronting malingerers, this could look like, "So there is good news, and bad news. The good news is that we reviewed your symptoms and you don't have [condition patient was claiming to have], however, the symptoms you're describing are still worrying and we'd like to help you with that".
 * Emotions: Before proceeding with further information, or even immediate reassurance, the psychologist should acknowledge and accept the patient's response, which can be achieved through a combination of empathy, validation, and support. (Berkey et al., 2018)

Managing Negative Reactions
While indirectly confronting suspected malingerers can lead to a positive outcome, psychologists should always be prepared for negative reactions from patients. These reactions can range from, agitation, threats of escalation, and even violence. Negative reactions can be minimised through a calm and cooperative demeanour, which will prevent further escalation. These reactions can also be minimised by providing the patient with an advocate, or another psychologist who can provide a second opinion; or, when the patient threatens to escalate the complaint to relevant authority figures, help facilitate the patient's request by providing them with the contact details of the relevant authority. These steps help demonstrate that the psychologist is following procedure, and is willing to support further evaluation. (Schnellbacher & O’Mara, 2016)

Differential Diagnoses
The indicators of malingering also overlap with symptoms of other conditions. As, such before considering a patient to be a malingerer, it is important to consider the following diagnoses:


 * Factitious Disorder, which is where a patient fakes, or significantly exaggerates symptoms in order to gain the role of being a sick person. Factitious disorder is also an indicator of other underlying issues. This is especially true when children are presenting with it as it is indicative of deeper issues such as child abuse.
 * Conversion Disorder, which is when a patient experiences neurological symptoms (e.g., paralysis) which have psychological causes rather than physical causes.
 * Somatic Symptom Disorder, which is when a patient experiences physical symptoms whose origins cannot be explained by medical disorders, substance abuse, or other psychological conditions. (Alozai & McPherson, 2021)
 * Physical diagnoses such as chronic illnesses can be an explanation for the symptoms a patient is experiencing, as the symptoms of chronic illnesses can resemble malingering. An example of this is chronic fatigue syndrome, which is a disorder where the individual experiences extreme, and persistent chronic fatigue for at least six months, that also cannot be fully explained by underlying medical conditions. ("Chronic fatigue syndrome - Symptoms and causes", 2021) In circumstances such as these, lab tests can be conducted to determine whether the patient has any physical causes for their symptoms, which can help determine whether the patient's symptoms are genuine or malingered. (Shapiro & Teasell, 1998)
 * Thought disorders such as Psychosis and Schizophrenia can be an underlying cause of malingering behaviours, as a study conducted in an emergency department found that 3 out of 10 patients who were initially diagnosed with malingering met the criteria for schizophrenia at the 20-year follow up. (Zubera et al., 2014)

Avoiding Misdiagnosis
When psychologists are handling a potential case of malingering, as important as it is for them to find evidence, and ensure that the patient stops malingering, it is just as important for them to balance this out with the possibility that the diagnosis of malingering, is in fact, a misdiagnosis. This is because misdiagnosis can be immensely harmful for the patients, whether it be because misdiagnosis leads to the patient being unnecessarily harmed by untreated symptoms, or the resulting distress that occurs due to the stigma attached to the diagnosis of malingering. Misdiagnosis also damages the patient-psychologist relationship, and the psychologist is found liable for whatever occurs to the patient due to the misdiagnosis. (Shapiro & Teasell, 1998) This is especially prevalent with genuine patients from marginalised groups (e.g., women, ethnic minorities, disabled people), who have been misdiagnosed as malingerers due to the psychologist's own prejudices. (Dossey, 2015) Misdiagnosis can be avoided through a combination of, considering differential diagnoses, conducting lab tests in order to detect any physical causes of the symptoms, watching for any underlying causes of behaviour, (Shapiro & Teasell, 1998) and for psychologists to evaluate any unconscious biases that they may hold. (Dossey, 2015)

Conclusion
Malingering is when a patient fakes, or significantly exaggerates their symptoms in order to gain external benefits. It is a situation-specific tool whose use is mostly influenced by adaptational factors where the patient feels there is no other way to achieve their goal, which can be seen in circumstances such as a kid pretending to be sick in order to avoid school because they're being bullied, or a person who has been drafted into the military attempting to leave. The use of malingering can also be influenced by criminological factors, which can be seen in circumstances such as a person malingering to avoid criminal charges, or a person malingering to gain financial compensation.

Malingering can be detected through a combination of tests, observation of behaviour, and a review of their medical history. It cannot be treated with traditional therapy or medication as malingering is not a mental condition, and, malingerers will only stop malingering when they either achieve their goal or give up because pursing it is futile. However, it is important to still treat malingerers with empathy as malingering can be the result of other underlying issues. When confronting malingerers, it is important to do so in an indirect manner. This way, the malingerer is able to stop, while also saving face, and the psychologist is still able to offer help that is better suited to their needs. Though before diagnosing a patient as a malingerer, it is important to consider other possible diagnoses as there are diagnoses such as factitious disorder and physical diagnoses such as chronic illnesses whose symptoms can present in a manner that would be indicative of malingering, as misdiagnosis can lead to the patient's health being neglected, and the patient-psychologist relationship being damaged.