Psychopathy and Malingering

Educational Objectives

The goal of this program is to improve the assessment and management of persons with psychopathy and malingering. After hearing and assimilating this program, the clinicians will be better able to:

1. Identify behavioral and speech patterns of individuals with psychopathy.
2. Distinguish between psychopathy and antisocial personality disorder.
3. Assess for threat risk in persons with psychopathy.
4. Diagnose malingering.
5. Differentiate between malingering and somatization and factitious disorders.

Summary

Sociopathy

Antisocial personality disorder (ASPD): one of the oldest personality disorders and psychiatric diagnoses; colloquially called sociopathy; has a longitudinal history; issues begin in childhood (ie, conduct disorder); as children proceed into adulthood, ASPD manifests with antisocial behaviors, eg, ignoring right vs wrong, telling lies to take advantage of others, not being sensitive to the needs of others, using charm or wit to manipulate others, having a sense of superiority, having problems with the law, being hostile, aggressive, violent, or threatening to others and having minimal or no guilt about the episode, and doing dangerous things with no regard for the safety of others; more common than it is thought to be; not all persons with ASPD are criminals, and many have regular jobs

Diagnosing ASPD: social history should be examined for cues of childhood conduct disorder presentations beginning prior to age 15 yr; cues include destruction of property, lying, serial dishonesty, theft, serious rule violations, and aggression towards people and animals; this does not necessarily mean killing or torturing, but significant cruelty and aggression toward peers; many persons with ASPD never come to the attention of law enforcement and can be high-functioning; they may have superior intelligence, which allows them to read, manipulate, and/or control scenarios; they may lack empathy, which is advantageous in business; high-functioning individuals are secretive but tend to have superficial charm; in one-to-one interviews, they report not being fond of people; they have good social skills, which are not deep but are effective in superficial conversation, relationship bonding, and business partnerships; lower-functioning persons with ASPD are prone to incarceration

Research on ASPD: research may be confounded as it is mostly conducted in forensic and correctional populations; this occurs because subjects tend to be found there, are a captive audience, and are provided incentives; research conducted in this subpopulation may not be representative of the population as a whole; in Foucha v Louisiana, the Supreme Court clarified that ASPD could not be used as a monodiagnosis for long-term commitment

Psychopathy

Overview: not clearly defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition (DSM-5), and not always researched in medical environments; persons with psychopathy are often abnormally calm, but a person with ASPD may be offended if the clinician does not fall for their superficial wit or become upset if dishonesty is pointed out; psychopaths do not explode under pressure but do underreact when heart rate or breathing is expected to rise; they avoid developing relationships and lack a conscience or moral compass; some believe that genetics and biology play a stronger role in psychopathy than ASPD; psychopaths may appear superficially normal but will not typically form attachments, will hurt others without guilt, and build relationships only to benefit themselves; in contrast, persons with ASPD may be able to empathize in limited situations (eg, with close friends or family) and may have some remorse if their sociopathy hurts people close to them

Elements: include superficial charm, an inflated self-esteem and a crossover to narcissism, deceitfulness, intense yet shallow emotions, a high degree of boredom, and a need for stimulation; many persons are risk or novelty seeking and feel uncomfortable if they are not doing things to challenge themselves, which can bring them to attention; in this context, thrill-seeking meets a lack of accountability and/or morality; psychopathic traits exist to some degree in everyone, and it should not be glorified or stigmatized; as with all diagnoses in the DSM-5, the traits should be possessed and affect the person in a dysfunctional mechanism; as with ASPD, most research was conducted in prisons and/or forensic units, leading to selection bias

Traits in psychopathy: include disinhibition (ie, calmness, novelty-seeking behavior, underresponse to threatening situations), meanness (ie, aggressively seeking resources one needs with no regard for others), and boldness (ie, being socially dominant, emotionally resilient, assertive, not intimidated); used moderately, these qualities lead to successful relationships, but in psychopathy, they occur in the extreme; intimidation in psychopathy may border on the need to be the intimidator, differentiating it from confidence; Hare Psychopathy Checklist-Revised looks at interpersonal and affective facets (ie, grandiosity, callousness, manipulation, lack of remorse) and lifestyle and behaviors (ie, aggression, impulsivity, lack of responsibility, seeking sensation); boredom and need for stimulation can lead to psychopathy being exposed and makes them vulnerable; the checklist scores from 0 to 40, with 30 usually being the cutoff

Trends and myths: Dr. Hare stated, “society is moving in the direction of permitting, reinforcing, and in some cases, valuing some of the traits listed in the psychopathy checklist”; psychopathy is not a synonym for violence or criminality; some common myths are that psychopaths are always male sex, and they develop psychopathy due to trauma or abuse; trauma is more commonly correlative, not causative; psychopathy has strong genetic influences; symptoms may appear as early as age 2 yr; another myth is that it is incurable; treatability and approaches vary; researchers have looked into psychopathy as a neurocognitive disorder

Psychopathy and narcissism: not all narcissists have psychopathic tendencies, but many psychopaths are immensely narcissistic; the way narcissism is handled is important; for many, it is a false superiority complex, and a blow to their ego can lead to concerning consequences; their self-esteem is artificial and can be easily offended or changed, leading to complications; a psychopath with a high degree of narcissism can be more dangerous, as they are more likely to find justification to exploit and mistreat; this is frequently seen in prison and forensic interviews, or on large scales (ie, mass atrocities, genocidal behavior); cruelty towards a group is enabled by demeaning and dehumanizing them; in cases of one-on-one violence, the psychopathic perpetrator often says the other person was inferior and deserved their contempt or fate

Other psychopathic tendencies: include gaslighting, psychological bullying, lack of contrition, self-serving victimhood, and situational usage; if caught in a mistruth, they “double down”, become forceful about their statement, and further externalize responsibility; this is common in ASPD and psychopathy; psychopaths may tell complex, layered, convincing lies; they can be talkative and may attempt to dominate the conversation; they may double down, stutter, or shift the topic if they feel they are not in control; these tendencies are also seen in the general population who are afraid of being interviewed; psychopaths tend to omit essential details, avoid words based on emotion, and refer to objectivity as much as possible; they may display cold-heartedness and are not bothered by fear and disgust; they have narrowing of attention and deficiency in response modulation; they do poorly with top-down attention, which may speak to the boredom; they have low frustration tolerance and may keep to themselves to keep the psychopathy unnoticed

Female psychopathy: though more rare, female psychopaths do exist; some degree of interest in social acceptance exists in this population; they have more neuroticism than psychosis in extreme manifestations; they are more prone to social and relational forms of manipulation and are more likely to use sexuality rather than force; this may be tied to cultural and gender norms, and bias in research is a factor; since women are viewed differently than men in these scenarios, they may adapt it to be more effective in their psychopathy; violent female psychopaths are less common than violent males psychopaths, though this may be affected by how they are located or diagnosed

Psychopathy in health care: psychopathy is overrepresented in acts of violence; psychiatrists have to manage a core group of persons who are violent toward themselves or others; the question is whether psychopathy is being assessed for enough, since it is not a formal DSM diagnosis; health care workers are more trusting and vulnerable to being taken advantage of by psychopathy, or to miss psychopathic diagnoses; treatability is key, especially when mitigating threat risk; threat assessment is challenging and done over months to years; psychopaths can appear well for long periods of time and still hold a grudge; this makes them more complicated to monitor than bipolar disorder or psychosis

The dark tetrad: psychopathic individuals have 4 main components that complicate things, namely narcissism, psychopathy, Machiavellianism, and sadism; the tetrad applies to a subcomponent of psychopaths; Machiavellianism is manipulative behavior and a talent for getting what one wants regardless of consequences; sadism is the component of enjoying cruelty; presence of all 4 is concerning in terms of threat assessment

Diagnosis: Larsen et al (2022) argued that psychopathy assessments should be avoided because of ethical violations of nonmaleficence and beneficence, and they do not offer clear benefit to the patient; de facto and potential harms are associated with use of these checklists and are not outweighed by significant social benefits; clarify whether the diagnosis is done with the intention to treat or mitigate risk, or for placement in a correctional setting; weigh risks and benefits and identify other ways to assess risk that are not purely based in psychopathy; the stigma of a formal diagnosis may be harmful; the diagnosis is a significant one; treatment teams should be educated and understand what it means to avoid making the situation worse

Malingering

Overview: refers to persons who are not truthful with providers; lying is common and somewhat developmentally normal, starting around age 2 yr; by age 4 yr, 90% of children lie; most adults lie within the first 10 min of conversation, interviews, or online personal advertisements; lying is not tolerated in health care; even the best interviewers are not much better than chance at detecting lies; law enforcement is better at this as they interrogate rather than interview, but this can lead to more false-positives; a diagnosis of malingering can be harmful to patients; if present, it should be documented, but the clinician should be aware that those reading the chart will have different viewpoints; team members should be educated about when and why malingering happens, tolerate some empathy for malingerers, and utilize skills to mitigate risk

Definition: malingering is not a DSM-5 diagnosis but was an area of focus (V-code) in the DSM, Fourth Edition (DSM-4); defined as the intentional production of false or grossly exaggerated symptoms motivated by external incentives; 4 criteria must be met to validate malingering, ie, a medicolegal context of the presentation, marked discrepancy between the claimed disability and objective findings by the clinician, lack of cooperation during evaluation and prescribed treatment, and presence of ASPD; persons may have some of these symptoms but not be malingering; differential diagnoses include somatization disorders and factitious disorders (ie, Munchausen); factitious disorder involves intentional symptoms, but the goal is to be in the sick role, whereas in malingering, the goal is secondary gain; with somatization disorders, symptoms are not voluntarily created, and patients are much more likely to agree to procedures

Reasons for malingering: the secondary gain being sought by the patient must be identified as the person is suffering and relating a need, though in an inappropriate way; this offers a way to mitigate the risk and possibly improve the behavior; there may be true secondary gain or patients may have functional ignorance (ie, not knowing what a symptom means or how to describe it); patients may stretch the truth to please the clinician or the loved ones who brought them in, or to impress the degree of their suffering on the clinician; secondary gain may be anything from housing, avoiding legal charges, minimizing penalties, financial gain, substance use issues, avoiding work or social stressors (ie, respite), gaining sympathy or favors, or trying to produce reactions in a manipulative fashion; as stated by Dr. Berlin (2007), “it is useful to assume that the patient has just suffered some humiliation, disappointment, or loss, perhaps not great enough to correspond to the stated complaint, but not insignificant”

Considerations: health care professionals should be cautious as malingering can cause countertransference; the provider may end up not practicing standard of care if the malingering has upset them; apophenia is the perception of meaningful connections between unrelated things; whenever malingering appears on a chart, physicians and nurses start making connections where none exist; if the primary diagnosis is malingering, it is difficult to prove that standard of care and best practices were provided and sets the provider up for accusations of anchoring bias; hostile attributional bias is when the behavior of a person is interpreted as threatening or aggressive even if it is not; if someone is thought to be lying, their behavior is more likely to be interpreted as not only dishonest but also aggressive; appreciating that not all malingering is equal creates empathy and tolerance

Types of malingering: types include inventing symptoms, perseveration on past symptoms, or exaggeration of real symptoms (most common); it can be convincing if they have the symptom but exaggerate the intensity, frequency, and impact; another type is having symptoms but attributing them to a false cause to gain empathy or a secondary gain; signs of malingering include lacking distress when not directly observed, engaging in activities contrary to mood, symptoms not being consistent with true pathology, having collateral information that directly contradicts what the patient reports, and disappearance of symptoms when the secondary gain is received (trial-and-error method of detection)

Take-home points: malingering is often seen as something to rule people out from care, but malingering and mental illness can coexist; having the diagnosis does not mean a patient does not need care, but that a rapport should be established to solve the problem; clinicians should recognize their own countertransference; it is crucial to remember the “ABCS”, ie, avoid accusations of lying, beware of countertransference, clarify instead of confronting, and ensure security measures; the clinician should be self-aware when working with people who are malingering; extra interview time may help counter bias against them and prevent the provider from missing anything

Tolerance for malingering: the dynamic of self-destruction is the idea that some lives are so complicated and full of pain that the only joy they find is by making others fail; their attempts to fool the clinician should be tempered with sympathy and empathy; the provider has an obligation to be direct when interviewing someone who is malingering; a “black-and-white” interviewing process is ideal as any ambiguity can lead to further aggression; understanding that the person is suffering and encouraging them to reveal the real cause of suffering so that they can be helped is useful; this approach generally does not make the patient feel like they are being caught in a lie, which may worsen their behavior

Readings

Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet. 2014;383(9926):1422-1432. doi:10.1016/S0140-6736(13)62186-8; Berlin J. The joker and the thief: Persistent malingering as a specific type of therapeutic impasse. Psychiatric Times: Psychiatric Issues in Emergency Care Settings. 2007;2(5). Available from: https://www.psychiatrictimes.com/view/joker-and-thief-persistent-malingering-specific-type-therapeutic-impasse; Buckholtz JW, Treadway MT, Cowan RL, et al. Mesolimbic dopamine reward system hypersensitivity in individuals with psychopathic traits. Nat Neurosci. 2010;13(4):419-421. doi:10.1038/nn.251; Cleckley HM. The mask of sanity. Postgraduate medicine; 1951; Edens JF, Kelley SE, Lilienfeld SO, et al. DSM-5 antisocial personality disorder: predictive validity in a prison sample. Law Hum Behav. 2015;39(2):123-129. doi:10.1037/lhb0000105; Hare, RD. A research scale for the assessment of psychopathy in criminal populations. Personality and individual differences. 1980;1(2):111-9; Hare RD. Without conscience : The disturbing world of the psychopaths among us. The Guildford Press; 1999; Larsen RR, Koch P, Jalava J, et al. Are psychopathy assessments ethical? A view from forensic mental health. Journal of Threat Assessment and Management. 2022;9(4):260–286. https://doi.org/10.1037/tam0000184; Lebourgeois III, HW. Malingering: Key points in assessment. Psychiatric times; 2007; Lowenstein J, Purvis C, Rose K. A systematic review on the relationship between antisocial, borderline and narcissistic personality disorder diagnostic traits and risk of violence to others in a clinical and forensic sample. Borderline Personal Disord Emot Dysregul. 2016;3:14. Published 2016 Oct 13. doi:10.1186/s40479-016-0046-0; Marsh AA. What can we learn about emotion by studying psychopathy?. Front Hum Neurosci. 2013;7:181. Published 2013 May 10. doi:10.3389/fnhum.2013.00181; Neumann CS, Jones DN, Paulhus DL. Examining the Short Dark Tetrad (SD4) Across Models, Correlates, and Gender. Assessment. 2022;29(4):651-667. doi:10.1177/1073191120986624; Park L, Costello S, Li J, et al. Race, health, and socioeconomic disparities associated with malingering in psychiatric patients at an urban emergency department. Gen Hosp Psychiatry. 2021;71:121-127. doi:10.1016/j.genhosppsych.2021.05.009; Schoenleber M, Sadeh N, Verona E. Parallel syndromes: two dimensions of narcissism and the facets of psychopathic personality in criminally involved individuals. Personal Disord. 2011;2(2):113-127. doi:10.1037/a0021870; Verschuere B, Te Kaat L. What Are the Core Features of Psychopathy? A Prototypicality Analysis Using the Psychopathy Checklist-Revised (PCL-R). J Pers Disord. 2020;34(3):410-419. doi:10.1521/pedi_2019_33_396; Weiss B, Feldman RS. Looking good and lying to do it: Deception as an IM strategy in job interviews. Journal of Applied Social Psychology. 2006;36(4):1070–1086.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Thrasher was recorded exclusively for Audio Digest. Audio Digest thanks Dr. Thrasher for his cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 2.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 2.00 CE contact hours.

Lecture ID:

PS530801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.