DETECTION OF MALINGERED PSYCHOSIS
From Forensic Psychiatry Review Course, presented by the American Academy of Psychiatry and the Law
Phillip J. Resnick, MD, Professor of Psychiatry, and Director, Fellowship in Forensic Psychiatry, Case Western Reserve
University School of Medicine, and Adjunct Professor of Law, Case Western Reserve University School of Law, Cleveland,
OH
Educational Objectives
| The goal of this program is to facilitate the detection of malingered mental illness. After hearing and assimilating this
program, the clinician will be better able to:
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 | 1. Enumerate 5 common reasons for faking psychosis.
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| 2. Discuss why different approaches are necessary when interviewing a patient for treatment and when interviewing
for forensic purposes.
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| 3. Recognize characteristics that help in the detection of lying.
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| 4. Review the phenomenology of hallucinations.
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| 5. Discuss clues to malingered psychosis and to malingering in the insanity defense.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgements
Dr. Resnick was recorded at Forensic Psychiatry Review Course, held October 15-17, 2007, in Miami Beach, FL, and
sponsored by the American Academy of Psychiatry and the Law. The Audio-Digest Foundation thanks Dr. Resnick
and the AAPL for their cooperation in the production of this program.
| Introduction: malingering—intentional production or gross exaggeration of symptoms in pursuit of easily
identified goal; factitious disorder—intentional production of symptoms for pleasure of being in sick
role (motivation not otherwise understandable in view of individual’s environmental circumstances);
reasons for faking psychosis—1) to avoid criminal punishment (not guilty by reason of insanity); 2) to
avoid hazardous military duty or conscription; 3) to obtain financial gain; 4) among prisoners, to obtain
drugs or to facilitate escape or transfer to “easier” confinement; 5) to be admitted to psychiatric
hospital as haven from police or to obtain free room and board
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| Forensics vs treatment: treating clinician tends to take patient’s story at face value because patient does
not serve own interest in lying; however, when clinician examines patient in medicolegal context, patient
may believe his or her self-interest will be served by deception
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| Diagnosis of malingering: mental health professionals reluctant to make diagnosis of malingering due to
1) fear of legal liability (inherent in diagnosis of malingering is implication that patient is lying, and
some courts have ruled this is defamation of character), and 2) fear of retaliation by malingerer
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| Research on detection of lying: facial expressions offer least reliable cues for detecting lies (in study, facial
pleasantness incorrectly rated by observers to be associated with honesty); feigned smile more
likely to be asymmetric; attention to voice rather than to visual clues improves detection of lies
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| Lying: study shows average adult tells 1 lie per day, average college student, 2 lies per day; when college
students talk to own mothers, 50% of what students say is not true; in spite of commonness of lying, people
tend to believe in truthfulness of others
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| Clues to deception: applicable only if person being questioned is anxious while lying and if that is
change from baseline; liars—give shorter answers; speak in higher pitched tone; give more hesitant answers;
make more grammatical errors; make more slips of tongue; make more negative statements;
give more irrelevant answers in response to questions (however, irrelevant statements included in narrative
account of event suggest truthfulness); make more over-generalized or vague statements; exhibit
more self-manipulating gestures, such as rubbing or scratching; distance themselves from listener by
using passive, rather than active, forms and by hedging statements; show more discrepancy between
verbal and nonverbal communication; blink eyes more often; have more dilated pupils; make statements
that seem rehearsed; liars who exaggerate their false statements less likely to be caught
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| Unpremeditated lies more easily detected than planned lies: planning lie ahead of time makes liar less
likely to have to pause for words and freer to control his or her tone of voice and other potential clues
to deception
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| Common errors in lie detection: liars do not demonstrate less eye contact with interviewers; liars do not
have “shifty” eyes; people mistakenly think someone is lying when he or she gazes less, smiles less,
shifts his or her posture, speaks more slowly, and takes longer to answer questions
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| Malingering: “things are not always as they first appear”; consider individual from several different
points of view and obtain collateral information whenever possible; malingerer can often be tripped up
if examiner knows more than malingerer about phenomenology of symptom
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| Phenomenology of hallucinations
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| Frequency: schizophrenia—66% of people with schizophrenia have auditory hallucinations, 33% have visual;
free-standing visual hallucinations (in absence of auditory) unusual; bipolar mania—47% have auditory
hallucinations, 23% have visual; only 7% have visual hallucinations in absence of auditory;
organic brain syndromes—highest incidence (33%) of visual hallucinations without auditory
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| Generalizations: hallucinations generally associated with delusions (88%), but only 33% of people with
delusions have hallucinations; hallucinations usually related to some psychic purpose; 80% of olfactory
hallucinations involve unpleasant odors; gustatory hallucinations usually unpleasant, and particularly
associated with paranoia about being poisoned; hallucinations generally clear (only 7% vague or
inaudible)
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| Faked hallucinations: in study, nonpsychotic and schizophrenic prisoners asked to pretend to be psychotic
and hallucinating; faked hallucinations reported as more frightening and abusive, more uncontrollable,
unbearably distressing, less predictable, and less context-dependent; genuine schizophrenics
much more comfortable with their hallucinations
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| Genuine hallucinations: often incorporate common sex-based insults; women’s hallucinations accuse
them of sexual promiscuity, men’s hallucinations accuse them of homosexuality (consistent across all
cultures)
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| Auditory hallucinations: when asking questions, voices in genuine auditory hallucinations do not ask for
information (eg, what time is it?), but rather chastise (eg, why are you smoking? why haven’t you done
your homework?); patients view their voices as omniscient; in study, patients divided their voices into
benevolent or malevolent; benevolent voices tend to say kind, protective things and to evoke positive
emotions; individual may seek these out and be unwilling to give them up (eg, by taking medications);
malevolent voices give evil commands that evoke negative emotions such as anger or fear; individual
may argue with these voices, not comply with commands, and try to avoid them; person with genuine
auditory hallucinations has strategies for making them go away, person faking hallucinations usually
does not; person with genuine hallucinations knows and avoids activities that make voices worse; genuine
auditory hallucinations usually intermittent rather than continuous
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| Visual hallucinations: usually of normal-sized people (smaller-than-life-size hallucinations sometimes
produced by toxic psychosis, alcohol, and atropine-like effect of some drugs); genuine visual hallucinations
occur in color, not black and white; genuine hallucinations do not change if eyes open or
closed; “dramatic hallucinations of monsters or cyclops or a Martian bought me a beer” atypical and
suspect
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| Summary of suspect hallucinations: auditory—continuous rather than intermittent; vague or inaudible;
not associated with delusions; stilted language; no strategies to diminish voices; voices’ instructions
obeyed (most schizophrenics ignore command hallucinations); voices ask questions seeking information;
visual—absence of concomitant auditory hallucinations in person claiming to have schizophrenia;
hallucinations in black and white; hallucinations dramatic or atypical; hallucinations change with
eyes closed; miniature or giant figures seen; visions unrelated to delusions or to auditory hallucinations
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| Clues to malingered psychosis: “malingerers are actors portraying their part as best they understand it”;
most common error of malingerer is overacting (“they got their idea of what a crazy person is from the
movies and television rather than from genuinely experiencing the symptoms”); malingerers eager to
call attention to their illness (genuine schizophrenics reluctant to discuss their symptoms); more difficult
for malingerer to fake form of schizophrenic thinking than content; malingerer’s symptoms may
fit no known diagnostic entity; malingerer may claim sudden onset of delusion (in reality, systematized
delusions usually take several weeks to develop); malingerer’s behavior unlikely to conform to alleged
delusions (acute schizophrenic behavior usually does conform; however, “burned out” schizophrenic
may no longer show agitation over his or her delusions); malingerers likely to have contradictions in
their accounts of their illness; malingerers more likely to try to seize control of interview and to act in
intimidating manner; malingerers more likely to repeat questions or to answer questions slowly (to
give themselves more time to make up answers); rare for malingerers to show perseveration; malingerers
tend to describe dramatic positive symptoms of psychosis and rarely describe negative symptoms
such as blunted affect, apathy, and difficulty initiating activity; malingerers may pretend to be ignorant
or uneducated, or to have cognitive deficits or low IQ; genuine hallucinations usually respond to antipsychotic
medications faster (median 27 days) than delusions (76 days); be skeptical of claims that hallucinations
or delusions cleared in a few days
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| However: persons who have true schizophrenia may also malinger psychosis to escape criminal responsibility,
and since they have experienced real hallucinations, their faking is much harder to detect; do
not ask whether patient genuinely ill or faking; instead, ask whether symptoms faked to obtain some
benefit
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| Clues to malingering in insanity defense: malingerers have alternative nonpsychotic motive for their
crime; Michigan study showed 96% of persons found not guilty by reason of insanity acted alone (partners
not likely to go along with psychotic plan); malingerers have 2 layers of denial of responsibility
(“they stretch their story so that if you believe even part of what they say, they are less likely to be held
accountable”); psychotic explanation for crime suspect if crime fits same pattern of previous crimes for
which offender was convicted
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| Case example 1: man living in Australia bought knife and traveled to United States to murder parents;
claimed that his parents were trying to kill him; evidence in favor of genuine hallucinations—inappropriate affect
(laughter when describing murdering his father); defendant recognized voice he heard, and was
therefore more likely to obey its commands; disparate ideas; hearing >1 voice (mean 2.5 voices in studies
of hallucinations); delay in claiming voices told him to commit crime (faker would be expected to
make this point early on to establish nonresponsibility); evidence in favor of faked hallucinations—
inappropriate affect (could be due to medications or other psychiatric disorder); defendant thrust forward
his illness and his nonresponsibility; defendant identified voice as that of Vincent van Gogh (how would
he recognize this voice?); inappropriate laughter could be interpreted as being that of someone caught in
lie; defendant claimed voice of Taj Mahal told him to commit crime on day of crime (however, he purchased
weapon in Australia and traveled to United States to commit crime); conclusion—defendant genuine
schizophrenic who made up fake command hallucinations because he knew that crime he had
committed was wrong
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| Case example 2: 47-yr-old man presented to Veterans Affairs hospital desiring admission, claiming to have
seen little green men; history of alcoholism and 3 previous psychiatric hospitalizations for alcoholism; evidence
in favor of genuine hallucinations—hallucinations in color; description of little green men as smaller
than normal people characteristic of alcoholic hallucinations; details of appearance of little green men
very specific, and patient did not hesitate in proffering them; hallucinations intermittent; evidence in favor
of faked hallucinations—little green men stereotypical; contradictions in size and clothing of little green
men (although this could be due to alcoholic dementia with confabulation); conclusion—hallucinations
genuine
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| Psychologic tests for malingering: gold standard is Structured Interview of Reported Symptoms (SIRS);
for malingered memory impairment, various symptom validity tests available
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Suggested Reading
Hirsch AR, Wolf CJ: Practical methods for detecting mendacity: a case study. J Am Acad Psychiatry Law 29:438, 2001;
Jackson RL et al: Forensic applications of the Miller Forensic Assessment of Symptoms Test (MFAST): screening for feigned
disorders in competency to stand trial evaluations. Law Hum Behav 29:199, 2005; Leudar I et al: What voices can do with
words: pragmatics of verbal hallucinations. Psychol Med 27:885, 1997; Pankratz L: Patients Who Deceive: Assessment and
Management of Risk in Providing Health Care and Financial Benefits. Springfield, Il: Charles C. Thomas, 1998; Poythress
NG et al: The relationship between psychopathic personality features and malingering symptoms of major mental illness. Law
and Human Behavior 25:567, 2001; Resnick PJ, Knoll J: Faking it: How to detect malingered psychosis. Current Psychiatry
4:13, 2005; Resnick PJ: Malingering of psychiatric symptoms. Primary Psychiatry 13:35, 2006; Resnick PJ: Malingering.
In: Kulick FB, McDonald JJ, eds. Mental and Emotional Injuries in Employment Litigation. Washington, DC: Bureau of
National Affairs, Inc., 1994; Rogers R, ed: Clinical Assessment of Malingering and Deception, 2nd ed. New York: Guilford
Press, 1997; Simon RI, ed: Posttraumatic Stress Disorder in Litigation: Guidelines to Forensic Assessment. Washington,
DC: American Psychiatric Press, 2003; Steffan JS, Morgan RD: Diagnostic accuracy of the MMPI-2 Malingering Discriminant
Function Index in the detection of malingering among inmates. J Pers Assess 90:392, 2008; Vitacco MJ et al: Detection
strategies for malingering with the Miller Forensic Assessment of Symptoms Test: a confirmatory factor analysis of its underlying
dimensions. Assessment 15:97, 2008; Vitacco MJ, Rogers R: Assessment of malingering in correctional settings. In: Scott
CL, Gerbasi JB, eds. Handbook of Correctional Mental Health. Washington, DC: American Psychiatric Press, 2005; Zatzick
DF et al: Predicting posttraumatic distress in hospitalized trauma survivors with acute injuries. Am J Psychiatry 159:941 2002;
Ziskin J, Faust D: Coping with Psychiatric and Psychologic Testimony, 5th ed, Vol I, II, III. Los Angeles, CA: Law and
Psychology Press, 1995.
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