Malingering: A Growing and Costly Problem

The Diagnostic and Statistical Manual of Mental Disorders ("DSM-IV) defines "malingering" 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 financial compensation, evading criminal prosecution, or obtaining drugs."

In my practice as a clinical and forensic psychologist, I am often asked to consider whether examinees may have malingered psychological symptoms, such as PTSD or Major Depressive Disorder, in disability, worker's compensation and personal injury claims.

Malingering of psychological symptoms is a big and growing problem for those who pay for monetary benefits and treatment. The expansion of malingering and its associated unnecessary costs may be related to several factors such as decreased stigmatization resulting from acknowledging mental illness, increased availability of coverage for various forms of treatment for mental disorders and to an aversion by some mental health treating doctors to identify malingering by their patients.

Admitting to having a psychological problem does not appear to have the stigma attached to it that existed decades ago when treatment took place primarily in mental hospitals. As a graduate student in clinical psychology in the 1960s, I sometimes met patients who had been "locked up" in mental hospitals continuously for ten, twenty or thirty years or more. Receiving a diagnosis of a mental illness at that time could be, literally, a life sentence as a pariah. Psychiatric hospitals in those days were dark, noisy places with heavy locked doors. The keys to those locked doors were huge and often worn around staff members' necks. Forty years ago, psychiatric hospitals physically resembled prisons and there was little available in the way of what we now call "treatment".

Beginning in the 1960s, the Community Mental Health movement led the way to a major downsizing of mental hospital populations and the closing of many psychiatric hospitals altogether in the US. Instead of being treated in an inpatient setting, individuals needing mental health services would be treated in community mental health centers and often times in outpatient clinics.

In the 21st century, when psychiatric hospitalization is required because an individual is suicidal or dangerous to others as a result of a mental illness, the length of inpatient treatment is often measured in days or weeks rather than in months or years. The movement towards community mental health treatment centers "democratized" mental health treatment, placing treatment facilities within the communities they served rather than "up on a hill", far away from population centers. Most people today know of someone who is being treated for a mental disorder, or has had this treatment himself or herself. Acknowledging that one is being treated for a psychological disorder is, mostly, no longer a cause for shame. Today, in many circles it is considered acceptable or even fashionable to mention that one has a therapist or analyst. In my practice I occasionally see people who self-diagnose mental disorders for various reasons, one of which is to obtain benefits for which they might not otherwise be eligible. The personal costs, such as stigmatization, of making a claim for psychological damages in a disability, Worker's Compensation or personal injury case is not nearly as high as it would have been forty years ago.

The advent of modern psychiatric and psychological techniques may also be a factor in the increase of unnecessary costs paid for remediation or compensation for mental disorders. In my office in Boston I frequently conduct psychological evaluations of individuals receiving monetary or psychological treatment benefits who are suspected by the referral source of no longer having a disabling mental disorder or of having reached end result (maximum medical improvement) and are thought to be unlikely to obtain benefits, in the form of improved functioning, from additional psychological and psychiatric treatment. In Massachusetts, as in some other states, there is a mandated mental health benefit included in health insurance plans. If an individual has been in a motor vehicle accident, for example, and has become aware or has been advised that such a trauma can cause psychological symptoms, the accident victim may seek mental health treatment for those symptoms. Psychological symptoms alleged by the accident victim, such as nervousness or depression, may or may not be related to the accident. However, an individual may may attribute the emotional symptoms to the accident and seek treatment for those symptoms in order to substantiate or enhance a later claim for treatment and/or monetary benefits.

The ease with which an individual can access the mental health treatment system leads to consideration of a third factor that may contribute to the expansion of unnecessary costs for feigned mental disorders: the aversion apparently felt by some psychotherapists (psychologists, psychiatrists and social workers) to suggest that their patient may be malingering a mental disorder.

I have written several articles which discuss various aspects of the treating doctor's antipathy towards writing in their treatment notes the terms "faking", "exaggerating" or "malingering" in describing their patients. These documents can be found by clicking on the "Articles" button on my website. I spend a large proportion of my work day reviewing other doctor's psychological treatment records as a part of a psychological evaluation I am conducting. It is very rare to find a reference to exaggeration, faking or malingering in the psychotherapy treatment notes I review as a part of my evaluation. The reasons why references to "exaggeration", "faking" or "malingering" are nearly non-existent in treatment records seems to be rather straightforward. Psychotherapists tend to "bond" with their patients. Many psychotherapists proceed with treatment based on the idea that part of the psychotherapy treatment process is to empathize with the patient. Further, many psychotherapists attempt to enter into or acknowledge the patient's inner psychological world, no matter how distorted that world might be (think of a delusional patient) in order to treat that patient. Many psychotherapists believe that a suggestion that their patient may be malingering is a breach of the trust that is inherent in the psychotherapeutic relationship that would damage the relationship and impair the treatment process. As a result, a psychotherapist may unwittingly become a part of the process by which an patient, motivated to exaggerate or fake psychological symptoms, attempts to enhance the credibility of a claim of a mental disorder and the the likelihood of receiving compensation in the form of monetary benefits, avoidance of work or change in responsibilities.

With the advent of the internet and the resulting free flow of information about psychological tests, independent medical exams and information about how to fake believable mental disorders on psychological tests, the problem of malingering of mental disorders may grow worse. The appropriate response to suspected malingering of psychological symptoms by a litigant is a comprehensive forensic examination by a psychologist that contains the following elements: (1) a robust review of a litigant's psychological history; (2) a complete review of a litigant's functioning in such areas as interpersonal relationships, daily activities and ability to cope with stress, to concentrate and to make appropriate judgments; (3) a comprehensive mental status exam in which the psychologist maintains a degree of skepticism while attempting to document or rule out all alleged mental disorders according to the criteria available in the Diagnostic and Statistical Manual of Mental Disorders and (4) the use of psychological tests such as the Minnesota Multiphasic Personality Inventory (MMPI-2), Trauma Symptom Inventory (TSI) and Miller Forensic Assessment of Symptoms Test (M-FAST) which have built-in "Validity" scales which have been scientifically shown in published studies to be useful in identifying malingered psychological symptoms.