Malingering, Feigning, and Response Bias in Psychiatric/Psychological Injury: Implications for Practice and Court

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Ideals of collaboration and mutuality in the doctor-patient relationship loom large in medical education and, for most physicians, in our motives for entering the field. It can be hard to accept, and even harder to identify and responsibly deal with, patients who do not negotiate that relationship in good faith. Nonetheless, doctors are socially positioned to meet people who disingenuously seek the benefits and compensations associated with sickness. With its lack of pathological biomarkers, psychiatry is a particularly fraught specialty in which to encounter this problem. Unless one chooses to take all patient accounts at face value, then the possibilities of malingering and other types of deception must be attended to. Yet, there is little clinical attention to this topic. The psychiatrist who wishes to thoughtfully consider conscious deception in his or her assessments must turn to forensic experts for help.

Enter Gerald Young’s cinder block-sized, single-author text Malingering, Feigning, and Response Bias in Psychiatric/Psychological Injury: Implications for Practice and Court. More a treatise than a reference, this book is the author’s attempt to bring some order and, in the process, some change to a topic that he presents as sorely in need of both. Malingering opens with an extended, multifaceted treatment of the definitional and descriptive issues inherent in the assessment of potentially feigned psychiatric presentations. Subsequent sections deal with issues in the detection of malingered and exaggerated complaints and of misrepresented effort on examination, then with a range of issues having to do with differential diagnosis (eg, conversion disorder), treatment, and ethics. Focusing throughout on posttraumatic stress disorder (PTSD), traumatic brain injury/neurocognitive impairment, and pain and disability, Young also attempts to construct rigorous systems for diagnosing misrepresented presentations of these pathologies.

The greatest clinical strength of this text is in its earliest sections, which cover the prevalence and definitions of malingering. Prevalence rates cited in Young’s comprehensive literature reviews are staggering—up to over 50% in the setting of civil suits and disability claims, although usually hovering around 40%. Still, once the author gets down to deconstructing these data, problems of definition emerge. These numbers include exaggeration, poor effort, and all manner of intentional suboptimal performance in their definitions. Young makes the case that if the label malingering were attached solely to feigning of illness for material gain, these numbers would drop considerably (perhaps to 10%-15%). This point is not made in the service of minimizing the problem of feigning, but rather in order to bring greater rigor and nuance to it. Other sections of the book expand on that nuance in clinically meaningful ways, particularly in collecting and summarizing work on response biases, such as that of Richard Rogers, as well as reviewing a vast literature on deception detection.

Of course, there are no magical means of achieving the latter, and, even if there were, most of what is covered here is oriented toward psychological testing in the forensic context. Those involved in psychological testing will find much to think about and debate in the author’s comprehensive coverage and critique of the literature in this area. Young’s attempts to develop comprehensive diagnostic systems for malingered PTSD, neurocognitive disability/dysfunction, and pain disability/dysfunction will likewise be thought-provoking for forensic psychiatrists and psychologists. Clinicians may find it slow-going to sift through these sections in order to find gems relevant to their work, but the effort is worth it. Malingering may not be psychopathology, but this book makes it clear that identifying and handling it responsibly is a challenging task for any medical professional.

Young’s book is far from perfect. First and foremost, it seems to have gone largely unedited; there are many grammatical errors, much redundancy (the book likely did not need to be as long as it is), and chapters that are not clearly connected to the topic (eg, “Transdiagnostic Therapeutic Module on Free Will and Change”). Some chapters are almost entirely composed of tables (albeit useful ones), with minimal discussion of their content. Chapters in the Supplements section include this very book in their reference lists. While it is certainly the author’s prerogative to include his own text, the book contains a distracting number of personal pronouns and declarations of its “major contributions.”

All of that said, Malingering, Feigning, and Response Bias in Psychiatric/Psychological Injury provides much food for thought and contains a great deal of content that forensic psychiatrists and psychologists, as well as clinicians, would find helpful. It would be a worthy holding for libraries at academic medical centers, as well as for specialists who frequently encounter feigned presentations of psychopathology.

Nicholas Kontos, MD

[email protected]

Author affiliation: Harvard Medical School, Boston, Massachusetts.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2015;76(4):e539 (doi:10.4088/JCP.14bk09652).

© Copyright 2015 Physicians Postgraduate Press