Malingering and Personality Disorder
DEFINITION OF CLINICAL TERMS
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
Antisocial Personality Disorder
According to the DSM-5, the essential feature of Antisocial Personality Disorder is a pervasive
pattern of disregard for and violation of the rights of others, that begins in childhood or early
adolescence and continues into adulthood (APA, 2013, p. 659). This pervasive pattern is
indicated by three (or more) of the following:
1) Failure to conform to social norms with respect to lawful behaviors, as indicated by
repeatedly performing acts that are grounds for arrest.
2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure.
3) Impulsivity or failure to plan ahead.
4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5) Reckless disregard for safety of self or others.
6) Consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations.
7) Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another (APA, 2013, p. 659).
This pattern has also been referred to as psychopathy, sociopathy, or dissocial personality disorder.
Because deceit and manipulation are central features of antisocial personality disorder, it may
be especially helpful to integrate information acquired from systematic clinical assessment with
information collected form collateral sources (APA, 2013, p. 659).
Additionally, for this diagnosis to be given, the individual must be at least age 18 years
(Criterion B) and must have had a history of symptoms of conduct disorder before age 15 years
(Criterion C). Finally, the occurrence of antisocial behavior is not exclusively during the course
of schizophrenia or bipolar disorder (APA, 2013, p. 659).
Malingering
According to the DSM-5, Malingering is 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 (APA, 2013, p.726).
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Malingering and Personality Disorder
The DSM-5 further states that malingering should be strongly suspected if any combination of
the following is noted:
1) Medicolegal context of presentation (e.g., the individual is referred by an attorney to
the clinician for examination, or the individual self-refers while litigation or criminal
charges are pending).
2) Marked discrepancy between the individual’s claimed stress or disability and the
objective findings and observations.
3) Lack of cooperation during the diagnostic evaluation and in complying with the
prescribed treatment regime.
4) The presence of antisocial personality disorder (APA, 2013, p. 726-727).
MALINGERING and PERSONALITY DISORDER
Kucharski, L. T., Falkenbach, D. M., Egan, S. S., & Duncan, S. (2006). Antisocial Personality
Disorder and the Malingering of Psychiatric Disorder: A Study of Criminal Defendants.
International Journal Of Forensic Mental Health, 5(2), 195-204.
Researchers designed this study to determine whether criminal defendants undergoing courtordered evaluations for competency to stand trial, insanity, or to aid in sentencing who
presented with antisocial personality disorder were more likely to malinger psychopathology
on measures validated for the assessment of malingering.
Criminal defendants with antisocial personality disorder (APD), those with a personality
disorder other than APD (OPD) and those without a personality disorder (NoPD) were
compared on validated measures of malingering.
The APD group scored significantly higher on the Minnesota Multiphasic Personality
Inventory- 2(MMPI-2) ]F, Fp, and F-K scales and the Personality Assessment Inventory (PAI)
Negative Impression Scale.
A greater proportion of those in the APD group exceeded accepted cutoff scores on the
Structured Interview of Reported Symptoms (SIRS) scale.
While this finding supports the DSM-IV association between APD and malingering, the
predictive utility of APD in discriminating malingerers from honest responders was poor, with
many with APD not attempting to malinger and those without APD presenting potentially
malingered profiles.
Selective citations are as follows:
1) The Minnesota Multiphasic Personality Inventory (MMPI-2) is a 567-item objective measure
of personality characteristics, psychiatric symptoms, and response bias that uses a True or False
response format (p. 198).
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Malingering and Personality Disorder
2) The Structured Interview of Reported Symptoms (SIRS) is a 172-item structured interview
that is composed of detailed, repeated, and general inquires…created for the detection of
malingering in order to measure specific strategies identified in the literature (p. 198).
3) The Personality Assessment Inventory is a 344-item objective self-report measure designed to
reliably assess personality and psychopathology (p. 199).
4) The results of this study demonstrate that criminal defendants diagnosed with antisocial
personality disorder score significantly higher than those with other personality disorders and
those with no personality disorder on psychometric measures of malingering (p. 202).
5) These results provide some support for the DSM-IV caution that malingering should be
suspected in those who present with APD (p. 202).
6) However, the results of this study demonstrated that protocols suggestive of malingering by
those without APD were relatively common and that, while more likely to produce protocols
suggestive of malingering, many participants in the APD group did not exceed cutoffs that
would raise concern that they were attempting to feign a psychiatric disorder (p. 202).
7) That is, the modal approach to evaluation was one of not attempting to deceive. These
findings suggest that while deception may be an inherent characteristic of APD, many did not
choose a strategy to malinger a psychiatric disorder (p. 202).
8) These results lend support to the adaptational model of malingering, in that malingering
psychiatric symptoms was not automatically employed by those with APD. That is, for those
with APD, malingering was not necessarily viewed as an advantageous approach (p. 202-203).
9) The finding that potential malingering was evident in those without APD suggests that
malingering as a started was attempted in those without a presumed inherent tendency to
deceive. Again, this is more consistent with an adaptational model than the one proposed by
the DSM-IV (p. 203).
10) The identification of malingering is a complex process that requires substantial forensic and
clinical sophistication. Employing validated psychometric measures to detect malingering,
together with clinical history variables and clinical presentation indicators characteristic of
malingering in combination, in our view, represents the best forensic practice. Using APD, as
suggested by the DSM-IV, as a diagnosis suggestive of malingering, is we believe of limited
utility, as the rate of false positive and false negative misdiagnosis would be so high as to
preclude opinions based on APD diagnosis from admissibility in court (p. 203).
Pierson, A. M., Rosenfeld, B., Green, D., & Belfi, B. (2011). Investigating the Relationship
Between Antisocial Personality Disorder and Malingering. Criminal Justice & Behavior,
38(2), 146-156.
This study investigated whether the diagnosis of antisocial personality disorder (APD) reliably
assists in the forensic clinical evaluation of malingering.
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Forensic patients with antisocial personality disorder (APD) were compared to forensic patients
without APD on a validated measure of malingering (Structured Interview of Reported
Symptoms [SIRS]).
Results indicated that patients with APD were not significantly more likely to exceed accepted
cutoff scores on the SIRS (i.e., 17.9% vs. 11.6%, respectively), nor were they more likely to be
suspected of malingering by clinicians (17.9% vs. 18.6%).
Although there was a high level of disagreement between clinicians’ determination of
malingering and classification by the SIRS, this relationship was not significant. Furthermore,
patients with APD who were suspected by clinicians to be malingering were not more likely to
be classified as responding genuinely using the SIRS.
These findings challenge the recommendation issued by the Diagnostic and Statistical Manual
of Mental Disorders (4th ed., text revision) that advises clinicians to be highly suspicious of
malingering in the presence of APD.
Selective citations are as follows:
1) Contrary to what is suggested in the guidelines put forward in the DSM-IV, the results of this
study demonstrate that forensic psychiatric defendants with APD do not evidence a greater
likelihood of malingering than those without APD (p. 153-154).
2) Although participants with APD exceeded the cutoffs on the SIRS with slightly greater
frequency than participants who did not meet criteria for APD (18% vs. 12%) this weak
association was not statistically significant (p. 154).
3) The vast majority of patients with APD were classified as genuine on the SIRS (82%),
indicating that the diagnosis of APD offers little benefit for clinicians in the identification of
malingering (p. 154).
4) These findings contradict those of Kucharski and colleagues (Kucharski, Falkenbach, et al.,
2006), who found that defendants with APD demonstrated significantly greater propensity to
malinger than those with other personality disorders and those with no personality disorder (p.
154).
5) However, because they found that more than 50% of participants with APD were classified as
genuine by the SIRS, Kucharski and colleagues reached the same conclusion that this study
suggests: that a diagnosis of APD offers little, if any, benefit for the assessment of malingering
(p. 154).
6) This study represents the first attempt to use a reliable, structured approach to assessing
antisocial personality disorder. Prior research has typically relied on clinical diagnosis for
establishing the presence of a personality disorder rather than systematic diagnostic interviews.
Without a systematic approach, clinicians may be more inclined to diagnose an individual with
APD when they suspect malingering and, conversely, to suspect malingering in patients who
exhibit evidence of an antisocial personality style (p. 154).
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Malingering and Personality Disorder
Kucharski, L. M. (2006). Psychopathy and malingering of psychiatric disorder in criminal
defendants. Behavioral Sciences & The Law, 24(5), 633-644.
Because the use of deception is an important clinical characteristic of psychopathy, there is
intuitive appeal to the idea that psychopathy and malingering are associated. There is, however,
very little research showing that psychopaths are more likely to malinger.
This study aimed to determine whether psychopathic criminal defendants were more likely to
attempt to feign psychiatric disorder by comparing severe, moderate, and mild psychopaths as
determined by their scores on validated measures of malingering.
Data analysis results suggest that psychopathy is not a clinically useful indictor of malingering.
Selective citations are as follows:
1) Confirmatory bias is more likely to be manifested if evaluators believe that psychopathy and
malingering are strongly associated. The theoretical association between APD and malingering
described in the DSM-IV may serve to strengthen the belief in a psychopathy-malingering
association, as most forensic mental health professionals now view psychopathy as a more valid
and predictive condition than antisocial personality disorder (p. 641-642).
2) Research on the association of psychopathy and malingering is limited, particularly the study
of actual pretrial criminal defendants evaluated for the courts (p. 642).
3) The results of this study demonstrate that criminal defendants who present with severe
psychopathy score significantly higher than those with low psychopathy on most validated
measures for the assessment of malingering, lending some support for the DSM-IV
recommendation of considering malingering when APD is present (p. 642).
4) The current findings that those with severe psychopathy score higher than those with low
psychopathy on most validated measures of malingering are, however, significantly diminished
by the observation that while psychopaths score higher on validated measures of malingering, a
high proportion of those with severe psychopathy do not show evidence of exaggeration (p.
642).
5) The results of this study suggest that a confirmatory bias that hypothesizes the existence of a
significant association between psychopathy and malingering is likely to result in many
defendants with psychopathy being erroneously viewed as malingerers and a failure to detect
malingering in those without psychopathy (p. 642).
MALINGERING ASSESSMENT TOOLS
van Impelen, A., Merckelbach, H., Jelicic, M., & Merten, T. (2014). The Structured Inventory
of Malingered Symptomatology (SIMS): A systematic review and meta-analysis. The Clinical
Neuropsychologist, 28(8), 1336-1365.
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Malingering and Personality Disorder
The Structured Inventory of Malingered Symptomatology (SIMS) is an assessment aimed to
detect feigned psychopathology. Its construction was guided by the idea that naïve
respondents are likely to endorse bizarre, rare, atypical, or extreme symptoms on a
questionnaire when they attempt to feign or exaggerate symptoms. Thus, the SIMS presents
patients, claimants, defendants, or research participants with a list of 75 implausible symptoms
or statements that are to be endorsed or rejected (p. 1336).
Researchers in this study meta-analytically reviewed studies that used the SIMS to detect
feigned psychopathology.
Data analysis found that the SIMS (1) is able to differentiate well between instructed feigners
and honest responders; (2) generates heightened scores in groups that are known to have a
raised prevalence of feigning (e.g., offenders who claim crime-related amnesia); (3) may
overestimate feigning in patients who suffer from schizophrenia, intellectual disability, or
psychogenic non-epileptic seizures; and (4) is fairly robust against coaching.
Additionally, researchers found that the diagnostic power of the traditional cut scores of the
SIMS is not so much limited by their sensitivity—which is satisfactory—but rather by their
substandard specificity. This, however, can be worked around by combining the SIMS with
other symptom validity measures and by raising the cut score, although the latter solution
sacrifices sensitivity for specificity (p. 1336).
Overall, researchers conclude that though they found the SIMS to be a fairly sensitive test that is
reasonably robust again coaching, a serous weakness of the SIMS is its poor specificity when the
original cut scores are employed. These cut scores are more effective in ruling feigning out than
ruling it in (p. 1359).
Researchers advise clinicians to adopt a position of respectful skepticism toward respondents
with a heightened SIMS scores. The burden of proof for the conclusion that an individual feigns
symptoms rests on the shoulders of diagnostic experts. A deviant SIMS score alone does not
meet the burden of proof, but it should be an impetus for follow-up investigation (p. 1359).
Green, D., & Rosenfeld, B. (2011). Evaluating the gold standard: A review and meta-analysis
of the Structured Interview of Reported Symptoms. Psychological Assessment, 23(1), 95-107.
The Structured Interview of Reported Symptoms (SIRS) is a tool used to assess for feigned
mental disorders. It is composed of 172 items that are administered verbally to examinees. The
SIRS is often touted as the gold standard of measures of feigning. This label likely arises in part
out of the impressive accuracy rates reported in the extensive validation research that preceded
its publication. Since its publication, researchers not only have continued to investigate the
measure's utility but have expanded the study of the SIRS to include novel populations,
different study methodologies, and abbreviated versions.
This review examines 26 studies using the SIRS to identify feigning, evaluating both its
effectiveness at differentiating feigners from genuine responders and the potential impact of
moderating variables.
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Malingering and Personality Disorder
Meta-analyses revealed that research published since the initial validation studies demonstrate
higher sensitivity but lower specificity rates than those reported in the SIRS manual. Studies in
which feigners were composed of simulators yielded higher classification rates than studies
sampling actual suspected malingerers. Furthermore, genuine patient samples were
significantly more likely than nonclinical samples to be misclassified as feigning. Abbreviated
versions of the SIRS also demonstrated equivalent accuracy with the standard measure.
Overall, the results of this meta-analysis provide considerable support for the accuracy of SIRS
as a measure of feigned mental disorders.
Researchers conclude, however, that though the results of this meta-analysis suggest that the
SIRS appears highly effective in differentiating genuine respondents as a whole from feigners,
caution should be exercised before applying the accolade of gold standard as meta-analysis of
other measures have shown to be more robust.
Kucharski, L. S. (2007). Detection of Malingering of Psychiatric Disorder With the
Personality Assessment Inventory: An Investigation of Criminal Defendants. Journal Of
Personality Assessment, 88(1), 25-32.
Research on the use of self-report personality measure in the detection of malingering
psychiatric disorder has generally found acceptable diagnostic accuracy in differentiating
malingerers from those not attempting to feign psychiatric disorder. The research on the
diagnostic accuracy of the Personality Assessment Inventory (PAI) in the detection of
malingering has been less extensive despite the growing acceptance of the PAI by forensic
psychologists. Therefore, the purpose of this study was to assess the diagnostic accuracy of the
Personality Assessment Inventory on the detection of malingered psychiatric disorders.
Overall, the results of this study demonstrate that the PAI is a useful measure for the detection
of malingering for the evaluation of criminal defendants. However, researchers conclude that
caution should be exercised and multiple sources of information employed before evaluators
opine that a defendant is malingering.
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