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How to distinguish between malingering, genuine psychosis

SAN DIEGO — At a session on detection of malingering mental illness here at the U.S. Psychiatric and Mental Health Congress, Phillip Resnick, MD, professor of psychiatry, Case Western Reserve University, Cleveland, offered tips on how mental health providers can differentiate between patients feigning mental illness and patients with genuine mental illness.

It should be noted, Resnick said, that there is a difference between malingering and feigning. Unlike malingering, which is motivated by external incentives, feigning is an individual’s deliberate fabrication or exaggeration of symptoms without any assumption of goals.

Phillip Resnick

There are a number of purposes for malingering, Resnick said, including avoidance of criminal punishment or military duty, financial gain, transfers out of prison or hospital admission among the homeless. Among prisoners specifically, relocation, medication, compensation, attention or amusement may all be reasons why inmates may fake a mental illness, he said.

Common beliefs regarding lying, including eye contact avoidance, less smiling and fidgeting, should not be used to determine if a patient is lying, said Resnick, as they are nothing more than myths.

It may be difficult to distinguish between genuine, suspect and malingering hallucinations in patients with schizophrenia, he said, since about 66% of patients have auditory hallucinations and 33% have visual hallucinations.

Patients who have genuine psychotic hallucinations may hear voices of angered neighbors or messages of very negative context (eg, you’re not good enough).

In contrast, those who are malingering auditory hallucinations may:

• hear voices that have little negative content or are attributed to angels or spirits;
• claim to have obeyed all commands heard from voices;
• seem less capable of handling their hallucinations; and/or
• Be extremely distressed, uncontrollable and less predictable.

Genuine hallucinations tend to be simpler or be gender-based insults, such as referring to the patient as promiscuous for women or homosexual for men, he said.

While not necessarily a sure sign of malingering, he said that patients who hear only female, child or animals voices, voices that are always yelling or robotic sounding and voices that refer to the patient as Mr. or Mrs. are all atypical in auditory hallucinations.

According to Resnick, about one-third of patients with auditory hallucinations report being asked questions; however for patients with genuine hallucinations, the questions tend to be more demanding, such as ‘why are you’ or ‘why didn’t you’, rather than information-seeking questions.

Resnick warned that when treating patients with auditory hallucinations, it is important to ask what type of voices they are hearing. If the patient is hearing benevolent or encouraging voices, they may be very reluctant to give that up, in which case they may be resistant to getting treatment.

Patients who have genuine malevolent auditory hallucinations, however, will most likely have tried various attempts to rid themselves of the voices. Most commonly, patients who claim to hear voices commanding them to do things, such as to commit suicide, are most likely to attempt to ‘pray the voices away’, according to Resnick.

Cultural differences can also play a factor. Resnick cited data stating that patients from the United States tend to hear hallucinations that are harsher, less likely to be from a divine voice and more likely to lead to a psychotic diagnosis.

Patients with suspect visual hallucinations may:

• report visions of monsters or other supernatural objects;
• changes in hallucinations when eyes are closed;
• visions of miniature or giant figures;
• visions that are unrelated to delusions or auditory hallucinations; and/or
• visions in only black and white.

In contrast to suspect visions, patients with genuine visual hallucinations may report being upset or distraught, resulting in distress or fear. They may also report never having seen the visual before.

Good indicators of malingered psychosis include overacting of psychosis, calling attention to the illness, contradictions in their stories and sudden onset of delusions, Resnick said. Individuals may also attempt to intimidate mental health providers. They may also say ‘I don’t know’ a lot, because as a provider you have exceeded their knowledge of how to fake the answers.

The median response times to antipsychotics for complete elimination of delusions is 76 days and for hallucinations, 27 days, according to Resnick, who pointed out that if a patient reports elimination of delusions or hallucinations, it could be a good indication of malingering.

Patients with schizophrenia may be most able to fake symptoms of hallucinations or delusions, Resnick noted, which is why it is important to not try and analyze whether patients are truly mentally ill, but rather if they are faking certain symptoms, regardless of illness. – by Casey Hower

For more information:

Resnick PJ. The Detection of Malingered Mental Illness. Presented at: U.S. Psychiatric and Mental Health Congress; Sept. 10-13, 2015; San Diego.

Disclosures: Resnick reports no relevant financial disclosures.