Determinations of malingering: evolution from case-based methods to detection strategies.

Methods for the classification of malingering have advanced from idiosyncratic case studies to systematic research. As an outgrowth of individual feigning scales, detection strategies have been developed and validated that are conceptually based and tested across measures. This article briefly reviews detection strategies for two distinct domains: feigned cognitive impairment and feigned mental disorders. It examines general categories of detection strategies (i.e., unlikely and amplified) and clinical methods (e.g., multiscale inventories and structured interviews). Recommendations are presented for malingering screens and malingering determinations.

Key words: detection strategies; feigning; malingering.

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Professional and public interest in malingering has waxed and waned during the last 150 years, often influenced by social and political change. Wessely (2003, p. 33) provided valuable insights into how the introduction of financial compensation for injured workers raised widespread fears about "the opening of the floodgates to new armies of malingerers". He noted the Collie (1917) extrapolations about exponential increases in malingering based on questionable inferences from non-fatal accidents. Similar concerns were voiced about veterans' compensation following World War I. Seltzer (1936) estimated the presence of 300,000 genuine service-connected disabilities but Veterans Administration records documented more than 1 million disability claims; Seltzer (p. 229) concluded that it is "ridiculously easy to prove a 'disability'". In recent years, concerns over litigation explosion in damage awards (Robbennolt & Studebaker, 2003) may be fueling another cycle of malingering overestimates. Recently, neuropsychologists estimated the prevalence of "malingering" at 30.1% of disability/worker compensation and 28.7% of personal injury cases (Mittenberg, Patton, Canyock, & Condit, 2002). But these estimates are inflated by using a much broader categorization that encompasses suspected malingering and even simple symptom exaggeration.

Methods for the detection of malingering have evolved gradually from the 1800s and can be categorized in three general phases: case studies, group differences, and detection strategies. The next sections examine the evolution of assessment methods through these phases.

Case Studies and Early Observations

For case studies, Geller, Erlen, Kaye, and Fisher (1990) provide a comprehensive review of detection methods used in the 19th century. As summarized in their review, various authors have suggested a range of indicators of feigned "lunacy", including (a) interview behaviour (e.g., the ability to maintain eye contact and hesitations in responding), (b) feigned presentation (e.g., increased symptoms when observed, overacts the role, and never conceals symptoms), (c) areas of intact functioning (e.g., no observed sleep disturbance, normal appetite, normal facial expressions, and close feelings towards some family and friends), and (d) atypical symptoms (e.g., rapid onset, absurd thoughts, and no fluctuation of symptoms). Unlike most modern assessment methods, 19th century clinicians also advocated interventions, such as asking the individual to repeat his or her ideas (feigners are often able to complete this without difficulty), and obtaining a writing sample (feigners are often more coherent in their writings than verbalizations). Other suggested interventions are problematic (e.g., threatening violence and drug challenges, such as emetics). As discussed subsequently, modern assessment methods for malingering often overlook both areas of intact functioning and simple interventions.