Conversion, Factitious Disorder and Malingering: A Distinct Pattern or a Continuum?

This chapter is aimed at highlighting the recent findings concerning physiopathology, diagnosis, and management of conversion, factitious disorder, and malingering. Conversion disorder is the unintentional production of neurological symptom, whereas malingering and factitious disorder represent the voluntary production of symptoms with internal or external incentives. They have a close history and this has been frequently confounded. Practitioners are often confronted to medically unexplained symptoms; they represent almost 30% of neurologist's consultation. The first challenge is to detect them, and recent studies have confirmed the importance of "positive" clinical bedside signs based on incoherence and discordance, such as the Hoover's sign for the diagnosis of conversion disorder. Functional neuroimaging has allowed a better understanding of the pathophysiology, and highlighted abnormal cerebral activation patterns in conversion disorder in relation to motor, emotional, and limbic networks, different from feigners. This supports the theory evoked by Charcot of a "psychodynamic lesion," which is also reflected by the new term introduced in the DSM-5: functional neurological disorder. Multidisciplinary therapy is recommended with behavioral cognitive therapy, antidepressant to treat frequent comorbid anxiety or depression, and physiotherapy. Factitious disorder and malingering should be clearly delineated from conversion disorder. Factitious disorder should be considered as a mental illness and more research on its physiopathology and treatment is needed, when malingering is a non-medical condition encountered in medico-legal cases.

An International Perspective on Feigned Mental Disabilities: Conceptual Issues and Continuing Controversies.

In forensic contexts, an increased prevalence of feigned symptom presentations should be expected, although it will probably vary by the context and specific forensic issue. Forensic experts should examine this possibility proactively while maintaining a balanced perspective that actively considers clinical data for both feigning and genuine responding. Psychological measures and standardized methods developed for feigning and other response styles can facilitate these often complex determinations. The current article provides an international perspective on the issue of feigned mental disabilities. In particular, important conceptual issues are discussed, such as the categorical versus dimensional approaches to feigning, and the advisability of well-defined rather than single-point cut scores for accuracy in clinical decision-making. Salient problems of differential diagnosis include a spectrum from malingering and factitious disorders to somatoform and conversion disorders. In rendering these important diagnostic distinctions, the questions of motivations and intentions remain key. However, the establishment of motivation cannot be facilely assumed from the context. Instead, forensic psychologists and psychiatrists bear the professional burden of carefully evaluating motivation and recognizing the clinical reality that sometimes the motivation in especially challenging cases may not be fully determined. Copyright © 2017 John Wiley & Sons, Ltd.

Improving the Detection of Feigned Knowledge Deficits in Defendants Adjudicated Incompetent to Stand Trial.

Malingering is relatively common in criminal forensic evaluations as base rates of malingering have ranged from 20% to 30%. Given that the most prevalent criminal forensic evaluation is the assessment of competency to stand trial, the assessment of feigning during competency evaluations is necessary for accurate findings. Most of the response style literature focuses on feigning mental health symptoms, but in competency evaluations, individuals may attempt to feign legal knowledge deficits in order to be found incompetent to stand trial. The current investigation includes two studies: 195 students instructed to simulate feigned mental illness or incompetence to stand trial and one using a sample of 130 state psychiatric hospital residents who had been adjudicated incompetent to stand trial. The purpose of the study was to evaluate the Inventory of Legal Knowledge's (ILK; Musick & Otto, 2010) ability to detect individuals who are feigning legal knowledge deficits. Classification utility statistics, including sensitivity, specificity, positive predictive power, and negative predictive power are provided for each cut-score on the ILK beginning with a cut-score of 24 (which is the lower end of the range of chance) are provided. The current cut-score of 47 provided in the professional manual of the ILK was shown to create a large number of false positives and suggests that modifications to this cut-score are required.

Identifying Reverse Malingering in the Civilian Occupational Setting.

Malingering is a common phenomenon in the workplace. However, reverse malingering can be just as common, but may have greater negative consequences for employees and employers. The only research on reverse malingering has been conducted in the military; however, little is known about this phenomenon in the civilian setting.

Causalidad y simulación. Comunicación de un caso y breve revisión de la literatura / Causality and simulation. A case report and brief review of the literature

Presentamos una revisión sobre la simulación laboral, seguido de un caso práctico en el cual no fue posible el establecimiento de la causalidad médico-legal para los déficits permanentes (AU)

We establish the medical-legal causality between injury and damage inflicted by a doctor, an important step in medico legal expertise, for which guiding criteria exist. The no establishment of the causality may lead to a reflection on this subject and it is in this case that simulation might become important (AU)

Types or modes of malingering? A confirmatory factor analysis of performance and symptom validity tests.

Recently, the dichotomy between performance validity tests (PVT) and symptom validity tests (SVT) has been suggested to differentiate between invalid performance and invalid self-report, respectively. PVTs are typically used to identify malingered cognitive impairment, while SVTs identify malingered psychological or somatic symptoms. It is assumed that people can malinger different types of problems, but the impact of modes of reporting invalidly has been largely unexplored. A mixed neurological sample (n = 130) was tested with the Test of Memory Malingering, the Forced Recognition part of the California Verbal Learning Test, and the self-report Structured Inventory of Malingered Symptoms (SIMS). Confirmatory factor analyses testing both method- and content-based factor models found best fit for the method-based division. Regression analyses of other self-rating and performance-based tests provided further support for the importance of type of methods used to collect information. While acknowledging the types of symptoms malingered, the clinician is advised also to consider how information is gathered by using both PVTs and SVTs. SIMS is a good candidate for a stand-alone SVT, although the utility of the Low Intelligence subscale is questionable as a validity measure.

[DSM-5: from 'somatoform disorders' to 'somatic symptom and related disorders']. / DSM-5: van somatoforme stoornissen naar 'somatic symptom and related disorders'

BACKGROUND: The DSM-IV somatoform disorder category was controversial and has undergone major changes in DSM-5. AIM: To provide a critical description of DSM-5 somatic symptoms and related disorders (SSD). METHOD: To review the new classification system for somatic symptom and related disorders (SSD) as set out in DSM-5 RESULTS: Whereas the symptoms of somatoform disorder were always considered to be medically unexplained, in DSM-5 the symptoms of somatic symptom disorder can now sometimes be explained by a medical condition. The criterion is that the individual has a maladaptive reaction to a somatic symptom. In DSM-5 the terms somatisation disorder, pain disorder and undifferentiated somatoform disorder have been discarded, whereas factitious disorder as well as psychological factors affecting other medical conditions have been added to somatic symptom disorder and other disorders. Conversion disorder remains as it was in DSM-IV. Hypochondriasis has been renamed 'illness anxiety disorder'. CONCLUSION: The new description of somatic symptom disorder in DSM-5 represents a big step forwards, because the decision has been made to use, for classification, a positive criterion, namely maladaptive reaction to a somatic symptom, instead of the earlier negative criterion, namely that the symptoms should be medically unexplained. Before attaching the ssd label to an illness, the clinician will have to weigh up the clinical consequences of this psychiatric diagnosis.

Rates of computational errors for scoring the SIRS primary scales.

We entered item scores for the Structured Interview of Reported Symptoms (SIRS; Rogers, Bagby, & Dickens, 1991) into a spreadsheet and compared computed scores with those hand-tallied by examiners. We found that about 35% of the tests had at least 1 scoring error. Of SIRS scale scores tallied by examiners, about 8% were incorrectly summed. When the errors were corrected, only 1 SIRS classification was reclassified in the fourfold scheme used by the SIRS. We note that mistallied scores on psychological tests are common, and we review some strategies for reducing scale score errors on the SIRS.

A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V.

Psychiatric care providers should be trained to use current changes in the somatoform disorders criteria. New diagnostic criteria for Somatic Symptom disorders in the proposed DSM-V is discussed and compared with its older counterpart in DSM-IV. A new category called Somatic Syndrome Disorders is suggested. It includes new subcategories such as "Complex Somatic Symptom Disorder" (CSSD) and "Simple Somatic Symptom Disorder" (SSSD). Some of the subcategories of DSM-IV derived disorders are included in CSSD. While there are some changes in diagnostic criteria, there are concerns and limitations about the new classification needed to be more discussed before implementation. Functional somatic disturbance, the counterpart of converion disorder in DSM-IV, can be highly dependet on the developmental level of children. However, the role of developmental level needs to be considered.

The development and classification accuracy of the life assessment questionnaire in the detection of pain-related malingering.

This paper describes three phases of the development and validation of the Life Assessment Questionnaire (LAQ), a multi-scale inventory for assessing potential malingering in adults reporting chronic pain. Study 1 involved scale construction and item analysis. Discriminant validity was investigated in Study 2 by comparing scores for the clinical reference group with participants instructed to simulate chronic pain. Study 3 examined the convergent validity of the LAQ with the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Behavioral Assessment of Pain (BAP). Results revealed that the simulation groups scored significantly higher than the clinical reference group across all scales. Receiver operating characteristic analysis revealed sensitivity and specificity scores ranging from 0.44 to 0.57 and 0.88 to 0.93, respectively. Positive predictive power values ranged between 0.79 and 0.88. Strong convergent validity was found for the LAQ. These studies demonstrated the effectiveness of the LAQ in classifying individuals who feign pain complaints, supporting the utility of the LAQ for reaching conclusions about the presence of malingering.

[Crime-related amnesia: real or feigned?]. / Tatbezogene Amnesien - authentisch oder vorgetäuscht?

In the context of criminal forensic evaluations, experts are often confronted with the problem of offenders' claims of crime-related amnesia. Because of the far-reaching legal consequences of the expert opinion, the nature of the suspected memory disorder has to be investigated with special care and due consideration of differential diagnoses. While the diagnosis of organic amnesia is comparatively easy to make, the same is not true for dissociative amnesia. Despite existing theoretical explanations such as stress, peritraumatic dissociation or repression, to date there is no sound, scientifically based and empirically supported explanation for the occurrence of genuine, non-organic crime-related amnesia. In the criminal context of claimed amnesia, secondary gain is usually obvious; thus, possible malingering of memory loss has to be carefully investigated by the forensic expert. To test this hypothesis, the expert has to resort to methods based on a high methodological level. The diagnosis of dissociative amnesia cannot be made by mere exclusion of evidence for organic amnesia; instead, malingering has to be ruled out on an explicit basis.

Reducing the probability of false positives in malingering detection of Social Security disability claimants.

The Symptom Validity Scale (SVS) for low-functioning individuals (Chafetz, Abrahams, & Kohlmaier, 2007) employs embedded indicators within the Social Security Psychological Consultative Examination (PCE) to derive a score validated for malingering against two criterion tests: Test of Memory Malingering (TOMM) and Medical Symptom Validity Test (MSVT). When any symptom validity test is used with Social Security claimants there is a known rate of mislabeling (1-specificity), essentially calling a performance biased (invalid) when it is not, also known as a false-positive error. The great costs of mislabeling an honest claimant necessitated the present study, designed to show how multiple positive findings reduce the potential for mislabeling. This study utilized a known-groups design to address the impact of using multiple embedded indicators within the SVS on the diagnostic probability of malingering. Using four SVS components, Sequence, Ganser, and Coding errors, along with Reliable Digit Span (RDS), the positive predictive power was computed directly or by the chaining of likelihood ratios. The posterior probability of malingering increased from one to two to three failed indicators. With three failed indicators, there were essentially no false positive errors, and the total SVS score was in the range consistent with Definite Malingering, as shown in Chafetz et al. (2007). Thus, in a typical PCE when an examiner might have only a few embedded indicators, more confidence in a diagnosis of malingering might be obtained with a finding of multiple failures.

Classification accuracy of the Millon Clinical Multiaxial Inventory-III modifier indices in the detection of malingering in traumatic brain injury.

The present study used criterion groups validation to determine the ability of the Millon Clinical Multiaxial Inventory-III (MCMI-III) modifier indices to detect malingering in traumatic brain injury (TBI). Patients with TBI who met criteria for malingered neurocognitive dysfunction (MND) were compared to those who showed no indications of malingering. Data were collected from 108 TBI patients referred for neuropsychological evaluation. Base rate (BR) scores were used for MCMI-III modifier indices: Disclosure, Desirability, and Debasement. Malingering classification was based on the Slick, Sherman, and Iverson (1999) criteria for MND. TBI patients were placed in one of three groups: MND (n = 55), not-MND (n = 26), or Indeterminate (n = 26).The not-MND group had lower modifier index scores than the MND group. At scores associated with a 4% false-positive (FP) error rate, sensitivity was 47% for Disclosure, 51% for Desirability, and 55% for Debasement. Examination of joint classification analysis demonstrated 54% sensitivity at cutoffs associated with 0% FP error rate. Results suggested that scores from all MCMI-III modifier indices are useful for identifying intentional symptom exaggeration in TBI. Debasement was the most sensitive of the three indices. Clinical implications are discussed.

Simulated dyslexia in postsecondary students: description and detection using embedded validity indicators.

The current investigation identified characteristics that discriminated authentic dyslexia from its simulation using measures common to postsecondary learning disability evaluations. Analyses revealed accurate simulation on most achievement measures but inaccurate feigning on neurolinguistic processing measures, speed on timed tasks, and error quantity. The largest group separations were on rapid naming, speeded orthographic, and reading fluency tasks. Simulators accurately feigned dyslexia profiles on cut-score and discrepancy diagnostic models but not on the more complex aspects of the clinical judgment model. Regarding simulation detection, a multivariate rule exhibited the greatest classification accuracy, followed by univariate indices developed from rapid naming tasks. The findings of the current study suggest that aspects of a comprehensive evaluation may aid in the detection of simulated dyslexia.

Criterion groups validation of the Seashore Rhythm Test and Speech Sounds Perception Test for the detection of malingering in traumatic brain injury.

A criterion-groups validation was used to determine the classification accuracy of the Seashore Rhythm Test (SRT) and Speech Sounds Perception Test (SSPT) in detecting malingered neurocognitive dysfunction (MND) in traumatic brain injury (TBI). TBI patients were classified into the following groups: (1) Mild TBI Not-MND (n = 24); (2) Mild TBI MND (n = 27); and (3) Moderate/Severe TBI Not-MND (n = 23). A sample of 90 general clinical patients was utilized for comparison. Results showed that both SRT correct and SSPT errors differentiated malingerers from non-malingerers in the Mild TBI sample. At 96% specificity, sensitivities were 37% for SRT correct and 59% for SSPT errors. Joint classification accuracy showed that the best accuracy was achieved when using a cut-off associated with a 4% false positive error rate in the Mild TBI sample. Specificity was considerably lower in the Moderate/Severe TBI and General Clinical groups. The clinical application of these findings is discussed.

Detection of malingering in mild traumatic brain injury with the Conners' Continuous Performance Test-II.

Classification accuracy for the detection of malingered neurocognitive dysfunction (MND) in mild traumatic brain injury (TBI) is examined for two selected measures from the Conners' Continuous Performance Test-II (CPT-II) using criterion-groups validation. Individual and joint classification accuracies are presented for Omissions and Hit Reaction Time Standard Error across a range of scores comparing mild TBI malingering (n = 27), mild TBI not-malingering (n = 31), and moderate-to-severe (M/S) TBI not-malingering (n = 24) groups. At cutoffs associated with at least 95% specificity in both mild and M/S TBI, sensitivity to MND in mild TBI was 30% for Omissions, 41% for Hit Reaction Time Standard Error, and 44% using both indicators. These results support the use of the CPT-II as a reliable indicator for the detection of malingering in TBI when used as part of a comprehensive diagnostic system.

The Reliable Digit Span test in chronic pain: classification accuracy in detecting malingered pain-related disability.

This study used criterion groups validation (known-groups design) to examine the classification accuracy of the Reliable Digit Span test (RDS) in a large group of chronic pain patients referred for psychological evaluation. The sample consisted of 612 patients classified into one of six groups based on evidence of malingered pain-related disability (MPRD): No-Incentive, Not MPRD; Incentive-Only, Not MPRD; Indeterminate; Possible MPRD; Probable MPRD; Definite MPRD. A total of 30 college student simulators were also included. Lower average RDS scores and higher rates of RDS failure were seen in patients classified as MPRD and in simulators. Consistent with previous literature in a variety of populations, RDS < = 6 provided the most accurate differentiation between MPRD and non-MPRD pain patients. Clinical implications are discussed.

The Wechsler Adult Intelligence Scale-III and malingering in traumatic brain injury: classification accuracy in known groups.

A known-groups design was used to determine the classification accuracy of Wechsler Adult Intelligence Scale-III (WAIS-III) variables in detecting malingered neurocognitive dysfunction (MND) in traumatic brain injury (TBI). TBI patients were classified into the following groups: (a) mild TBI not-MND (n = 26), (b) mild TBI MND (n = 31), and (c) moderate/severe (M/S) TBI not-MND (n = 26). A sample of 80 general clinical patients was used for comparison. Verbal IQ, Verbal Comprehension Index, and Working Memory Index detected approximately 25% of malingerers with a false positive (FP) error rate of approximately 5% in the mild TBI group. Comparable FP rates were obtained in M/S TBI. FP rates for Performance IQ, Perceptual Organization Index, and Processing Speed Index were acceptable in mild TBI but too high in M/S TBI. Previously studied specialized indicators (Vocabulary minus Digit Span and the Mittenberg formula) failed to differentiate malingerers from nonmalingerers. The clinical application of these findings is discussed.

Validation of diagnostic measures based on latent class analysis: a step forward in response bias research.

The use of criterion group validation is hindered by the difficulty of classifying individuals on latent constructs. Latent class analysis (LCA) is a method that can be used for determining the validity of scales meant to assess latent constructs without such a priori classifications. The authors used this method to examine the ability of the L scale of the MMPI-2 (J. N. Butcher et al., 2001), the Impression Management scale of the Balanced Inventory of Desirable Responding (D. L. Paulhus, 1991), and the Endorsement of Excessive Virtue scale of the Psychological Screening Inventory (R. I. Lanyon, 1970) to identify favorable response bias (misrepresentation) in a situation where no criterion for individual classifications existed. Results suggest that LCA can be used as a method for assessing the validity of scales that measure unobservable conditions.

Detecting malingered pain-related disability: classification accuracy of the Portland Digit Recognition Test.

This study used criterion groups validation to determine the classification accuracy of the Portland Digit Recognition Test (PDRT) at a range of cutting scores in chronic pain patients undergoing psychological evaluation (n = 318), college student simulators (n = 29), and patients with brain damage (n = 120). PDRT scores decreased and failure rates increased as a function of greater independent evidence of intentional underperformance. There were no differences between patients classified as malingering and college student simulators. The PDRT detected from 33% to nearly 60% of malingering chronic pain patients, depending on the cutoff used. False positive error rates ranged from 3% to 6%. Scores higher than the original cutoffs may be interpreted as indicating negative response bias in patients with pain, increasing the usefulness and facilitating the clinical application of the PDRT in the detection of malingering in pain.