12/21/2009
Professionally and Politely Addressing
Malingering
Robert J. Barth, Ph.D.
Barth NeuroScience, P.C.
Chattanooga and Birmingham
Robert J. Barth, Ph.D.
Parkridge Hospital
Plaza
z Two,, Suite 202
Chattanooga, TN 37404
423/624--2000
423/624
Fax: 423/629423/629-0230
www.BarthNeuroScience.org
General Disclaimer
(learned from Dr. Melhorn)
All contents of this
presentation remain the
property
t off D
Dr. B
Barth,
th and
d
cannot be used for any
purpose in the absence of
Dr. Barth’s specific
authorization.
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12/21/2009
Malingering
“The essential feature of 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.”
“These
data show base
g
g
rates of malingering
that approach or
exceed 50%...”
Larrabee GJ. Assessment of Malingered
Neuropsychological Deficits. Oxford, 2007.
Professionally addressing
malingering
The purpose of
assessing for
malingering (from a
doctor’s perspective):
To protect the health of
the examinee
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12/21/2009
The purpose of assessing
for malingering
•
•
•
•
•
To protect the health of the examinee
Diagnosis is iatrogenic
Overtreatment creates a greater risk for a
patient’s
ti t’ health
h lth than
th undertreatment
d t
t
t creates
t
Impairment ratings are iatrogenic
Withdrawing from work leads to a worse
health outcome
Being involved in medical
medical--legal claims of
any kind leads to a worse health outcome
The purpose of assessing
for malingering
To protect the health of the examinee
For any examinee whose presentation is
consistent with malingering,
any diagnosis,
diagnosis treatment,
treatment impairment
ratings, removal from work, or
involvement in medical
medical--legal claims is
going to carry an
elevated risk of doing more harm
than good.
Professionally and politely
addressing malingering
Possibly perceived as
impolite:
“My opinion is that this
person is faking.”
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12/21/2009
Professionally and politely
addressing malingering
More polite:
1 Avoid opinions
1.
2. Stick with facts
3. Avoid accusations
Professionally and politely
addressing malingering
More polite:
“The examinee’s presentation is
consistent with the formal
guidelines for the assessment of
malingering.
Those guidelines consequently
mandate that a strong suspicion of
malingering should be adopted for
this examinee.”
Professionally and politely
addressing malingering
More polite:
“The examinee’s presentation is
objectively consistent (based on
test results) with a malingering
scenario, rather than being
consistent with a valid
presentation of impairment.”
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12/21/2009
Professionally and politely
addressing malingering
More polite:
“The examinee’s presentation involved
issues which indicate that almost
any diagnosis, treatment,
impairment rating, removal from
work, and involvement in medicalmedicallegal claims is going to be
associated with an elevated risk of
doing more harm than good…”
Professionally and politely
addressing malingering
More polite:
“Therefore, for the sake of the
examinee
examinee’s
s health,
health, an extremely
conservative approach should be
adopted for diagnosis, treatment,
impairment evaluation, disability
determination, and claims
administration.”
Professionally and politely
addressing malingering
More polite:
“In order to protect this person’s health,
health,
any diagnosis, treatment plan,
impairment rating,
rating removal from
work, or endorsement of a medicalmedicallegal claim, should be limited to
issues which are inarguable, because
they are supported by objective and
scientifically credible information.”
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12/21/2009
How to assess for
malingering:
1 G id li
1.Guidelines
2. Scientifically validated
objective testing
How to assess for
malingering:
1. Guidelines
Primary example:
The malingering guidelines
from the
American Psychiatric Association’s
Diagnostic System
Malingering guidelines from the
American Psychiatric Association
“Malingering should be strongly suspected if any
combination of the following is noted:
1. Medicolegal context of presentation (e.g., the
person is referred by an attorney to the
clinician for examination)
2 Marked
2.
M k d discrepancy
di
between
b t
the
th person's
'
claimed stress or disability and the objective
findings
3. Lack of cooperation during the diagnostic
evaluation and in complying with the
prescribed treatment regimen
4. The presence of Antisocial Personality
Disorder”
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12/21/2009
How to assess for
malingering:
2. Scientifically validated objective
testing
Prominent example:
The Symptom Validity Scale
of the
Minnesota Multiphasic Personality Inventory 2 (MMPI
(MMPI--2)
Psychology
y
gy has
extensively researched
the phenomenon of
malingering…
Psychology has extensively
researched the phenomenon of
malingering…
Many tests have been scientifically
validated for the objective
assessmentt off malingering
li
i
for…
f
-cognitive complaints
-mental illness
-pain complaints
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12/21/2009
•
•
•
•
Psychology has extensively
researched the phenomenon of
malingering…
Warning!!!
Researchers are scared of being sued,
therefore…
Almost all of the research is designed to miss
many to most examinees who are faking
This helps to insure that when a malingeringmalingeringlike result is obtained, we are indeed
probably dealing with someone who is faking
But when a honesthonest-like result is obtained, we
cannot claim with probability that the
examinee has been honest with us.
Standardized questionnaires in any honest doctor’s
office (you do not have to send the examinee to a
psychologist)
A Simple First Step
MMPI--2
MMPI
(Minnesota Multiphasic Personality Inventory, Second
Edition)
BHI--2
BHI
(Battery for Health Improvement – 2nd Edition)
If the examinee’s presentation
is consistent with malingering
in any way, then for the sake of
the examinee’s health…
health…
1. The consistency with malingering
should be listed in the diagnostic
f
formulation
l ti
2. Extremely conservative approach to
additional diagnosis (e.g, limited to
inarguable, objectively established, and
scientifically credible conclusions)
>>>>>
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12/21/2009
If the examinee’s presentation is
consistent with malingering in
any way, then for the sake of the
examinee’s health…
health…
3. Extremely conservative approach to treatment
((e.g,
g limited to treatment that is inarguably
g
y
justified by objective and scientifically credible
information)
4. Extremely conservative approach to impairment
evaluation (e.g., limit claims of permanent
impairment to inarguable, objectively verifiable,
and scientifically credible issues).
If the examinee’s presentation is
consistent with malingering in
any way, then for the sake of the
examinee’s health…
health…
5. Emphasize the reliable health benefits of work,
and the fact that any avoidance of work is
especially unjustifiable for this case.
6. Extremely conservative approach to claims
administration (e.g., do not accept presentation
as being injuryinjury-related unless there is
inarguable, objective, and scientifically credible
reasons for doing so).
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