The Difficulties of Assessing Malingering in Anxiety Disorders - Essay Example

Detecting Malingering Malingering is the phenomenon where a patient exaggerates a physical or mental impairment, in an attempt to gain attention or some other kind of benefit. Some of the common forms of malingering exist in terms of display of mental disorders, such as memory loss or panic attacks or anxiety disorders arising out of undue stress. While physical symptoms of a particular disorder are not so easy to fake, because they can be easily subjected to a battery of tests that will uncover the true therapeutic condition, this is not the case with mental disorders, where the diagnosis made by a physician is often based upon observed behavior and the self reported symptoms of the patient. In view of the basic assumptions that are made about the honesty of self reporting by the patient, the detection of mild forms of malingering becomes difficult. Forensic and other tests have been developed to detect malingering, especially in the case of those individuals whose competency to stand trial for criminal convictions is being tested. Malingering: Malingering has been defined by the American Psychiatric Association as the “intentional production of false or grossly exaggerated physical or psychological symptoms” in the pursuit for “external incentives” (APA, 1994, p 63). Some of these incentives may be escaping criminal conviction, receiving financial compensation or in order to gain access to drugs or medication. In some cases, individuals may exhibit symptoms of malingering solely for the purpose of receiving sympathy and care through being cast in a patient’s role, and in particular may be a component of psychiatric conditions such as anxiety or personality disorders. (APA, 1994:648). Malingering is generally encountered in the case of those individuals for conditions that may be easily faked such as pain or anxiety and is most prevalent in male dominated environments such as the military or in correctional facilities and veteran hospitals. Malingering poses a challenge in health care because it affects the delivery of health care to patients who may genuinely need it by diverting treatment and medical resources to those who are not really ill and by wasting the time and energy of staff members thereby resulting in burnout among nurses and medical personnel.(Resnick, 1998). Malingering on the pretext of anxiety disorder is particularly prevalent among school children. It shows up in the form of refusal to attend school. Evans (2000) conducted a study on malingering in school refusals due to purported anxiety disorders and found that the anxiety, avoidance and malingering are functional and has identified three basic subtypes, which can be used by practitioners in identifying and dealing with malingering. The difficulties in detecting malingering: Individual malingerers tend to deliberately perform worse than their actual ability, however malingering is not often reported as such because the clinicians would then have to infer that a patient demonstrating such symptoms was dishonest. Carroll (2003) discusses malingering in the military, where individuals often exhibit a variety of symptoms or may even inflict injury on themselves in order to avoid military duties that may place them in a critical or dangerous situation. The most common motive for these malingerers is to avoid difficult or arduous duty. Caroll (2003) points out that with the sophisticated medical technology that is available in present times, such as CT and MRI scans, laboratory testing and forensic scans, it is now easier to detect those individuals who are malingering physical conditions of illness. However, there are some physical symptoms that can still be feigned, such as chronic low back pain and migraine headaches. False claims of depression caused by anxiety disorders and suicidal behavior are successfully employed by malingerers and it is more difficult to detect. Caroll (2003) also points out that it is even more difficult to detect malingering in the case of Post Traumatic stress Disorder which is anxiety and stress related, since this ailment is primarily diagnosed on the basis of self reported symptoms. According to Rogers (1997), there is an underlying assumption of honesty in self disclosure when a patient reports his or her symptoms; however with the high demand for managed care, the desire to maintain confidentiality of a patient’s medical history and respect for autonomy of the patient, the accuracy of the self report made by the patient may be suspect but this is difficult to prove. Both Rogers (1997) and Resnick (1984) have therefore recommended a multi-method approach in order to detect malingering, which includes interviews, psychological testing, behavior observation and the integration of the results obtained from all these tests with collateral information. In examining the effectiveness of the Personality Assessment Inventory, Rogers et al (1993) have pointed out that the test was ineffective in detecting feigned generalized anxiety disorder. They also discovered that the level of sophistication did not appear to be relevant in detecting malingering, although such sophisticated malingerers were able to achieve higher clinical levels in simulating depression. In carrying out any kind of personality or other evaluative test, the credibility of a patient’s self report is vital for purposes of the assessment. Berry et al (1995) have undertaken a comparison of several personality scales in order to assess the extent to which those instruments were able to address invalidating response sets. For example, they point out that the validity of the MCMI scales may be suspect because they are developed on the basis of a small and highly selected derivation sample and it may be necessary to cross validate the results with other clinically relevant samples. Similarly, they also advise against the use of the NEO-PI-R test because it does not assess the validity of the responses and therefore may be inadequate where malingering is to be assessed. The test does not conduct normal validity scales and merely contains one validity aspect, in that it asks whether the respondents have answered the questions honestly. The Rosharch test for intelligence has also been found to be subject to defensive responding and may therefore not be completely suitable to detect malingering, especially when individuals claim to be suffering from anxiety disorders. Since this is a case of self reported symptoms, therefore it becomes more difficult for malingering to be detected when the participants claim to be suffering from anxiety disorder. Tests to detect malingering: The clinical assessment of malingering requires a systematic application of empirically validated detection strategies. In their review of two tests – the Structured Interview of Reported Symptoms (SIRS) and the Minnesota Multi-phasic Personality Inventory-2 (MMPI2), Rogers et al (2005) are of the view that these tests have not fully addressed the question of whether individual scales represent well defined dimensions. Their study consisted of two separate phases. During the first phase, the original SIS normative sample was examined utilizing maximum likelihood factor analysis, while the second phase of the test was a cross validation of the two factor model based on combined data from both the forensic and correctional mental health settings. Their findings confirmed the two factor model, thereby providing support for the basis that both Spurious Presentation and Plausible Presentation are both relevant in assessing malingering. The MMPI and MMPI-2 tests are most frequently used for forensic analysis purposes, in order to detects fake or bad responses bias and the utility of both these versions has been established (www.forensicpsychology.org). The MMPI-2 scale contains several validity indices, which are geared towards discriminating between those who are answering honestly and those who are malingering, and the F (infrequency) scale is held to be the most useful one in identifying malingerers. The development of the F scale has taken place by selecting those items that are endorsed by less than 10% of the standardization sample. A scale of F 120 has been suggested as the cut off point where individuals who are really psychotic may be distinguished from those who are exaggerating or feigning psychiatric or anxiety disorders. (www.forensicpsychology.com). Rothke et al (2000) have examined data from several clinical samples and presented results showing the application of the MMPI-2 and different response patterns obtained from different groups on the basis of a new validity scale, which specifically enables the identification of any exaggeration of so called psychiatric symptoms, such as anxiety related disorders. They also suggest judicious use of the F(p) scales in conjunction with other validity scales, with a special cautionary note about setting up single cut off scores. Forensic evaluation is often used to detect malingering in response styles, especially in individuals who are being tested for their competency to stand trial. The attitude of defendants in forensic evaluations is likely to be more adversarial as compared to therapeutic situations. Jackson, Roberts and Sewell (2005) have assessed forensic applications of the Miller Forensic Assessment of Symptoms Test (MFAST) in which individuals are screened for feigned disorders in their competency to stand trial. This is one area where individuals are most likely to exhibit false symptoms of mental illness and anxiety disorders in order to escape the implications that may arise out of their current legal circumstances. The MFAST is a brief structured interview which also utilizes screens in order to enable assessors to identify those who may be malingering. The screens are useful because they enable assessors to identify within a relatively short time, individuals who may potentially be malingering. The MFAST test is composed of 25 items which are grouped into seven subscales, and the administration time for the test is about 10 minutes. The validity and reliability of this test in forensic evaluations has been established in both clinical and non clinical samples.(Miller 2001). However, as pointed out by Jackson, Roberts and Sewall (2005), the MFAST test has a number of constraints, out of which there are a lack of studies that have independently cross validated the results and lack of adequate research on its applications to specific forensic issues. The test is an important one where it is vital that malingering must be identified, because individuals most often resort to malingering in an effort to demonstrate a lack of competency to stand trail through anxiety attacks or mental illness, all of which is geared towards avoiding a stay in jail and achieving a substitution stay in a mental hospital instead. Moreover, as these authors point out, MFAST screens only serve to provide an indication that a respondent may be malingering but this is not equivalent to conclusive evidence and therefore, it must be used in competency trials with caution. A research report by Griffin et al (1997) redesigned the Rey Visual Memory test comprised of 15 items, through the introduction of more complex figures, increasing internal logic and pattern redundancies, into a 16-item test. This test was an improvement on the previous one, because it was not significantly related to age, intelligence, mental status or memory of the participant, thereby demonstrating improved face validity. The old Rey scale however, was contaminated by illness and ability components of the participants. The Rey II qualitative scoring system was found to accurately detect 31% more college malingerers than the original Rey system, while the Rey II quantitative scoring system was able to detect 21% more clinical malingerers. Therefore, this gave the Rey II test a 79% higher sensitivity to college malingerers and 20% higher sensitivity in the clinical population.(Griffin et al, 1997). Fisher and Rose (2005) tested the efficacy of both the Rey scales and concluded that the addition of a standard memory test in the Rey II scale improves the detection of individuals who are feigning memory impairment. Conclusions: With the development of sophisticated technology such as CT and MRI scans, it has now become more difficult to fake the symptoms of genuine physical disorders. However, it is still difficult for medical personnel to successfully identify malingerers who are faking the symptoms of mental disorders such as memory loss, or mental illness which includes panic attacks or anxiety disorders. The reason for this is the basic assumption that patients are inherently honest in their self reporting of symptoms, since this is the basis upon which the doctor is able to arrive at his or her diagnosis. In arriving at a diagnosis of malingering, the medical practitioner would be forced to arrive at the conclusion that the so called patient is lying. However, malingering is a significant drain on medical resources because it is a waste of staff time and energy and results in the diversion of medical resources towards the treatment of non existent illness, while those who are really ill cannot be allotted the necessary time and resources that they may need. Several tests exist to detect malingering. The forensic tests appear to offer the greatest degree of reliability, although screen tests only provide an inference of malingering and are not necessarily a foregone conclusion. Standard personality and memory tests may be inadequate in some aspects to detect malingering, since they may not posses necessary validity to ensure that a respondent is not lying on the test. The Rey test as expanded to 16 items offer a better degree of deductive ability, while the MMPI-2 and ISRI are also well established tests in terms of reliability of the test instruments. However, as indicated above, experts have pointed out the need to establish reliable and accurate cut off points on memory scale scores, since those who are malingering tend to deliberately try and score a lower than average score that is significantly lower than what they are capable of in order to establish purported memory deficiency and mental impairment. The difficulty in establishing malingering in the case of anxiety disorders is the fact that since the symptoms are self reported, it is often difficult to detect with a degree of accuracy. Anxiety disorders, unlike malingering of physical symptoms cannot be clearly established, since the medical practitioner has to reply upon the report of the patient. As demonstrated above, the tests that exist to detect malingering offer limited reliability and validity in detecting malingering, mainly because it is a mental condition and effective measures do not exist to measure whether a patient’s self reported symptoms of anxiety are in fact, actually true. Therefore in conclusion it may be stated that the detection of malingering is a difficult exercise, because the reliability and validity of many of the tests have not been cross validated in independent studies. However, with careful implementation and administration of the tests taking into account the cautionary factors that have been pointed out by experts, it may be possible to establish malingering with a higher degree of accuracy than what was possible before. 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(1997), “Rey II: Redesigning the Rey Screening Test of malingering”, Journal of Clinical Psychology, 53: 757-766. * Jackson, Rebecca L, Rogers, Richard and Sewell, Kenneth, W, 2005. “Forensic Applications of the Miller Forensic Assessment of Symptoms test (MFAST): Screening for feigned disorders in competency to stand trial evaluations” Law and Human Behavior, 29(2):199-210 * Miller, H.A. (2001), “MFAST: Miller Forensic Assessment of Symptoms test Professional Manual.” FL: Psychological Assessment Resources, Inc. * MMPI in Court. [online] Retrieved August 3, 2007 from: http://www.forensicpsychology.org/exports/MMPI.htm * Resnick, P. (1998). “Clinical assessment of malingering and deception”. San Diego: Specialized Training Services. * Rogers, Richard, Ornduff, Sidney R and Sewell, Kenneth W, 1993. “Feigning specific disorders: A study of the Personality Assessment Inventory.” Journal of Personality Assessment, 60(3): 554-560 * Rogers, Richard. 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