Let’s be honest with ourselves for a moment. Few of us have made it into adulthood without engaging in, or entertaining the notion of malingering or feigning illness. My first conscious recollection of malingering began at age 8. You see, I was obsessed with my babysitter, Kitty who fit the perfect part of a flower girl in the late 1960’s. She began babysitting us at age 16. After a couple years she had taken a job as an office assistant with my family’s medical doctor. She still watched us when my parents went out, but my parents were getting boring and staying home for longer periods. I hadn’t seen her in months and was pressing my parents to leave, somewhere, anywhere for an evening, so I could be in her presence again.
My devious plan of deception began the moment I heard that my brother would be taken to the doctor’s office for strep throat. I skillfully convinced my mother early on the morning of the appointment that I too had fallen ill. I played it up well, and my nurturing Italian Catholic mother easily fell prey. The funny thing is, I willingly endured a full course of penicillin, all for the few moments I was able to work my eight-year-old magic with Kitty as she sat behind the desk at the doctor’s office. She entertained me with a smile, and laughed at my attempts at humor. I actually thought I had a chance…..
While this case is silly, it certainly illustrates our capacity, even from an early age, to manipulate others for the needs of our internal desires. What we gain from our deceptions can range from attention, emotional support, removal from responsibilities, financial gain, and to a variety of other selfish goals. As Neuropsychologists, I and many of my colleagues, are pushed directly into the crossfire during the course of independent medical evaluations where we are asked to discern real cognitive and psychological issues from those that may be caused by deception. Neuropsychologists have, over the last two decades, developed a wide variety of empirically validated methods to identify low effort, and outright deception. These methods include separate standardized measures of effort, pattern analysis of regular neuropsychological measures, and analysis of embedded measures within our regular neuropsychological measures. I initially began using these measures in the early 1990’s on forensic cases. However, for well over a decade, in my own practice, we have been administering and analyzing several measures of effort on every patient, no matter who the referral source may be. We do this because even in cases where there is no workers compensation claim, disability claim, or a lawsuit in the works, we find that a significant number of patients exaggerate or otherwise put forth poor effort for assorted array of secondary gain issues that may not be obvious at first glance.
When we look at the research, we find fairly consistent findings with regard to the number of individuals who deliver invalid assessment profiles based on the reason for referral. Research suggests that anywhere between 33 and 40% of patients who are referred for neuropsychological assessment as part of an independent medical evaluation in which a disability claim, workers compensation claim, or a personal injury claim is present, will exhibit exaggerated performance, such that the entire data set must be invalidated. Approximately 22% of college students seeking medications or accommodations for ADHD are faking. These figures are consistent with my own findings in my work with such claims, and is also true in my work with capital murder defendants (although, interestingly, some research suggests that the rate of exaggeration with capital murder defendants is actually somewhat lower than that seen with litigating civil claims. But others indicate that it is higher.
More interesting, is the fact that a sizable number of patients with no obvious financial incentive exaggerate impairment on neuropsychological measures. In my own practice between 10 and 15% of adults referred to me for neuropsychological assessment, exhibit poor effort or exaggerated performance (this is consistent with research within the medical literature of individuals with exaggerated medical complaints). Most of the offenders are referred for complex and atypical neurological issues. Child patients are hit and miss (perhaps 5 to 10% of my child referrals exhibit verified poor effort), and their poor effort is usually due to a lack of appreciation of how we can really mess up their lives with our findings when we wrongly assume that they gave a rat’s fanny about the assessment.
If you think about it, the above statistics are staggering and force us to reevaluate the validity of our interpretations in assessments, and clinical conclusions regarding our psychotherapy cases. These findings also absolutely obligate those in the medical profession to evaluate patients for effort and veracity, particularly in cases where claims are made or where benefits may be at stake. To evaluate, render an opinion, or draw a conclusion, without thoroughly validating performance in these high-risk patients will absolutely cause us to be wrong at least 33 to 40% of the time. With our lower risk patients, we will be wrong between 10 and 15% of the time.
For the vast majority of psychologists who do few assessments, or limit their assessments to brief psychological evaluations, the task of detecting deception becomes complicated. Other than the validity scales on the MMPI, there are few methods to detect deception that meet the sensitivity and specificity requirements that are obtainable within neuropsychological measures. Evaluations that target feigning of psychiatric issues such as the SIMS are occasionally useful for individuals feigning psychosis, but also possess an unacceptable rate of false positives with certain patient populations that confound the interpretation. Even more complex, is the detection of malingering or exaggeration within clients who are referred for psychotherapy. Most of us who have been in practice for a while have had at least one client who remained in psychotherapy for a period of time and within six months of leaving, inform us that they are involved in some type of legal matter. We are then asked by their attorney to render an opinion, or we are asked by the client themselves to draft a letter in support for one type of benefit or another, whether it be worker’s compensation, or disability. This type of request places us in a quandary. We have to ask ourselves whether we are ethically able to support such a request without explicitly, and prominently, stating the limitations of our opinions due to the unknown quantity of factor “d” (deception) that might be present.
This is particularly true given the rather high likelihood that the patient consciously sought psychotherapy as a means to an end, rather than as a true desire for psychological stability. All of us have been played like a cheap Kentucky fiddle at one time or another. I have seen patients for neuropsychological evaluation who outwardly denied the presence of litigation, yet found myself served with a subpoena for records within weeks after seeing the patient. These are the realities of our practice. We owe it to ourselves to keep our eyes wide open and to employ tools at our disposal to help us know the creature that we are interacting with.
The literature pertaining to symptom validity testing is large and complicated. Presently, neuropsychologists are required to become proficient with symptom validity measures as it has become a standard of care issue in our specialty. Clearly, symptom validity techniques are in need of development in other areas, particularly general clinical psychology. Some measures of symptom validity have been developed recently for use with claimants of chronic pain, PTSD, ADHD and dyslexia. While we will never detect all aspects of deception in our patients, it behooves all health professionals to develop and use measures that can help us move toward the underlying truth of our patients’ alleged situation. By doing so, health care providers will move closer to the potential that we have in our work with our patients and in our ability to assist those who must make crucial decisions regarding matters pertaining to our patients; whether these matters be related to better psychological care, monetary benefits, or civil/criminal proceedings.