Assessment of Malingering Assessment of Malingering in a Jail Settingin a Jail Setting

Gregory Sokolov MDGregory Sokolov MD

Medical Director, Sacramento County Medical Director, Sacramento County Jail Psychiatric ServicesJail Psychiatric Services

&&Assistant Clinical Professor, University Assistant Clinical Professor, University of California at Davis, Department of of California at Davis, Department of

PsychiatryPsychiatry

Lecture ObjectivesLecture Objectives

MalingeringMalingering: definition & prevalence in : definition & prevalence in forensic/correctional settingsforensic/correctional settings

Assessment of malingering (SIRS; M-Assessment of malingering (SIRS; M-FAST)FAST)

Research (in progress)-malingering in jailResearch (in progress)-malingering in jail

Case studiesCase studies

““Trans-Institutionalization”Trans-Institutionalization”(Criminalization of the Mentally Ill)(Criminalization of the Mentally Ill)

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

State hospitalptsMentally illprisoners

Source: US Dept. of Health Human Services & Dept of Justice statistics

Treatment Issues & Challenges in Treatment Issues & Challenges in Correctional PsychiatryCorrectional Psychiatry

High rates of co-morbid substance dependence and High rates of co-morbid substance dependence and personality disorders (Antisocial)personality disorders (Antisocial)

Malingered symptoms of mental illness (“hearing Malingered symptoms of mental illness (“hearing voices”) for secondary gains of housing change, voices”) for secondary gains of housing change, mental health defense, SSI benefits, etcmental health defense, SSI benefits, etc

Misuse of psychotropic medications for sleepMisuse of psychotropic medications for sleep

““Cheeking” of medications for sale or barteringCheeking” of medications for sale or bartering

Malingering (DSM-IV-TR)Malingering (DSM-IV-TR)

““The intentional production of false or The intentional production of false or grossly exaggerated physical or grossly exaggerated physical or psychological symptoms, motivated by psychological symptoms, motivated by external incentivesexternal incentives such as…evading such as…evading criminal prosecution or obtaining criminal prosecution or obtaining drugs.”drugs.”

Contrast with Factitious Disorders; Contrast with Factitious Disorders; Ganser’s Syndrome (Dissociative Ganser’s Syndrome (Dissociative Disorder NOS)Disorder NOS)

Malingering (DSM-IV-TR)Malingering (DSM-IV-TR)

““Malingering should be strongly suspected”:Malingering should be strongly suspected”:

Medico-legal evaluationsMedico-legal evaluations

Marked discrepancy between person’s Marked discrepancy between person’s claimed stress or disability and objective claimed stress or disability and objective findings (reported vs. observed symptoms)findings (reported vs. observed symptoms)

Lack of cooperation with diagnostic Lack of cooperation with diagnostic interviewinterview

Antisocial Personality DisorderAntisocial Personality Disorder

Malingering & Criminal Justice Malingering & Criminal Justice SystemSystem

Competency to stand trial (CST) Competency to stand trial (CST) assessments: 60,000 referrals in US / yearassessments: 60,000 referrals in US / year

Base rates of malingering estimated from Base rates of malingering estimated from 8% to 17.4%8% to 17.4%

Surveys of psychiatrists / psychologists Surveys of psychiatrists / psychologists working in forensic settings: report working in forensic settings: report malingering in 16-18% patient populationmalingering in 16-18% patient population

Cornell DG, Hawk GL: Law & Human Behavior (1989)Rogers R, et al: Law & Human Behavior (1998)Rogers R: Clinical Assessment of Malingering & Deception (2nd Ed. 1997)

Malingering & Criminal Justice Malingering & Criminal Justice SystemSystem

United States v. Greer (1998)United States v. Greer (1998)::Greer arraigned on federal charges of Greer arraigned on federal charges of kidnapping and firearms violationskidnapping and firearms violationsSent to federal medical center for evaluation of Sent to federal medical center for evaluation of competency to stand trialcompetency to stand trialPsychologist testified Greer was competent and Psychologist testified Greer was competent and malingering; judge ruled competentmalingering; judge ruled competentOver next year, while awaiting trial, Greer Over next year, while awaiting trial, Greer disruptive in jail, re-evaluated, ruled disruptive in jail, re-evaluated, ruled incompetent, and committed to another federal incompetent, and committed to another federal medical center for restorationmedical center for restoration

Malingering & Criminal Justice Malingering & Criminal Justice SystemSystem

After period of hospitalization, psychologist After period of hospitalization, psychologist again concluded Greer was malingering and again concluded Greer was malingering and competent; court agreedcompetent; court agreedGreer engages in self-injurious behaviors in jail, Greer engages in self-injurious behaviors in jail, disruptive in court during trialdisruptive in court during trialAt sentencing, court enhances Greer’s sentence At sentencing, court enhances Greer’s sentence (by 25 months) for obstruction of justice due to (by 25 months) for obstruction of justice due to feigning of mental illnessfeigning of mental illnessUS 5US 5thth Circuit Court of Appeals: “A defendant Circuit Court of Appeals: “A defendant who playacts psychosis essentially tries to who playacts psychosis essentially tries to create a records that includes inaccurate create a records that includes inaccurate testimony and factual conclusions”testimony and factual conclusions”

Malingering & Jail InmatesMalingering & Jail Inmates

Potential motives for malingering in jail Potential motives for malingering in jail population may include:population may include:

1.1. Avoid or delay legal proceedings with a Avoid or delay legal proceedings with a “mental defense” (insanity, incompetent to “mental defense” (insanity, incompetent to stand trial)stand trial)

2.2. Obtain a preferred housing change (i.e. psych Obtain a preferred housing change (i.e. psych ward, hospital unit)ward, hospital unit)

3.3. Evidence to obtain SSI benefits after releaseEvidence to obtain SSI benefits after release

4.4. Obtain psychotropic medications (sedation)Obtain psychotropic medications (sedation)

Handbook of Correctional Mental Health Handbook of Correctional Mental Health (American Psychiatric Publishing-2005)(American Psychiatric Publishing-2005)

““Malingering Models” in Malingering Models” in Correctional SettingsCorrectional Settings

““Criminological Model”:Criminological Model”: Malingering is a Malingering is a specific manifestation of antisocial specific manifestation of antisocial behavior and attitudesbehavior and attitudes::

““Chronic conning” (meds to get “high” or sell, Chronic conning” (meds to get “high” or sell, transfer to another unit with more privileges, transfer to another unit with more privileges, transfer to hospital where escape is more transfer to hospital where escape is more probable, etc)probable, etc)

Handbook of Correctional Mental Health-(APPI) 2005Jaffe ME, Sharma KK. J Forensic Sci (1998)

““Malingering Models” in Malingering Models” in Correctional SettingsCorrectional Settings

““Adaptational Model”:Adaptational Model”: Malingering is an Malingering is an attempt to succeed when faced with attempt to succeed when faced with adverse circumstances: adverse circumstances: (CA: ”third-strike psychosis”) (CA: ”third-strike psychosis”)

? Misreporting of anxiety/mood symptoms as ? Misreporting of anxiety/mood symptoms as “voices” (consider administering anxiety scales “voices” (consider administering anxiety scales along with malingering scales)along with malingering scales)

Handbook of Correctional Mental Health-(APPI) 2005Jaffe ME, Sharma KK. J Forensic Sci (1998)

Jail Malingering & AntipsychoticsJail Malingering & Antipsychotics““Iatrogenic” malingering reported in VA substance Iatrogenic” malingering reported in VA substance treatment programtreatment program““Intranasal quetiapine abuse” reported at LA Intranasal quetiapine abuse” reported at LA County Jail, driven by drug’s sedative and anxiolytic County Jail, driven by drug’s sedative and anxiolytic effects rather than antipsychotic propertieseffects rather than antipsychotic propertiesCase report of “intravenous quetiapine abuse” in Case report of “intravenous quetiapine abuse” in Canadian jailCanadian jailAbuse of quetiapine has led to some correctional Abuse of quetiapine has led to some correctional formularies restricting or limiting itsformularies restricting or limiting its use use

Pierre JM, Wirshing DA, Wirshing WC. Psychiatr Serv (2003)Pierre JM, et al. Am J Psychiatry (2004)Hussain MZ, et al Am J Psychiatry (2005)

Jail Malingering & AntipsychoticsJail Malingering & Antipsychotics

Is removing medication from jail formulary the Is removing medication from jail formulary the answer?answer?

Mobile (AL) Register Mobile (AL) Register (March 5, 2005):(March 5, 2005):““Federal prisoner who was being held at Mobile Federal prisoner who was being held at Mobile County Metro Jail tried to commit suicide after County Metro Jail tried to commit suicide after officials took away his [Seroquel].”officials took away his [Seroquel].”““Jail staff indicated that they had banned the Jail staff indicated that they had banned the medicine because some inmates had been medicine because some inmates had been using it to get high.”using it to get high.”After legal motion filed, US District Court After legal motion filed, US District Court approved inmate transfer pt to federal medical approved inmate transfer pt to federal medical facilityfacility

Malingering: AssessmentMalingering: Assessment

Collateral behavioral observations Collateral behavioral observations (nursing, custody)(nursing, custody)

Clinical interview, malingered “voices”:Clinical interview, malingered “voices”:1.1. Continuous rather than intermittentContinuous rather than intermittent

2.2. Vague, inaudibleVague, inaudible

3.3. Not associated with delusions or thought disorderNot associated with delusions or thought disorder

4.4. No strategies to cope with “voices”No strategies to cope with “voices”

5.5. Claim that all instructions are obeyedClaim that all instructions are obeyed

Resnick PJ. Psychiatr Clin North Am (1999)

Malingering AssessmentMalingering Assessment::Structured Interview of Reported Symptoms Structured Interview of Reported Symptoms

(SIRS):(SIRS):Developed by Rogers, et al 1992; eight primary scales:Developed by Rogers, et al 1992; eight primary scales:

1.1. Rare symptoms (Rare symptoms (RSRS); ); 2.2. Symptom Combinations (Symptom Combinations (SCSC););3.3. Improbable/Absurd Symptoms (Improbable/Absurd Symptoms (IAIA););4.4. Blatant Symptoms (Blatant Symptoms (BLBL); ); 5.5. Subtle Symptoms (Subtle Symptoms (SUSU); ); 6.6. Severity of Symptoms (Severity of Symptoms (SEVSEV); ); 7.7. Selectivity of Symptoms (Selectivity of Symptoms (SELSEL); ); 8.8. Reported vs. Observed Symptoms (Reported vs. Observed Symptoms (RORO))

Responses on these scales are classified as Responses on these scales are classified as honest, honest, indeterminate, probable, or definiteindeterminate, probable, or definite

Rogers R, Bagby RM, Gillis JR. SIRS-Psychological Assessment Resources (1992)

Malingering Assessment:Malingering Assessment:Structured Interview of Reported Symptoms Structured Interview of Reported Symptoms

(SIRS):(SIRS):

An individual is considered to be An individual is considered to be malingering if he/she scores in the malingering if he/she scores in the probable or definite range probable or definite range > > 3 scales3 scales

Highly reliable measure extensively Highly reliable measure extensively validated in correctional and forensic validated in correctional and forensic samplessamples

Very low false-positive rates (accurately Very low false-positive rates (accurately identifying malingering)identifying malingering)

Rogers R. Handbook of Diagnostic and Structured Interviewing (2001)Norris Mp, May MC. Law & Human Behavior (1998)

Malingering AssessmentMalingering Assessment::Structured Interview of Reported Symptoms Structured Interview of Reported Symptoms

(SIRS):(SIRS):

Limitations of the SIRS:Limitations of the SIRS:

No indices to detect cognitive feigningNo indices to detect cognitive feigning

No information on genuine psychopathology is No information on genuine psychopathology is obtained (in contrast to MMPI-2)obtained (in contrast to MMPI-2)

Lengthy to administer (>1 hr); limits utility as rapid Lengthy to administer (>1 hr); limits utility as rapid screening tool or for large numbers of subjectsscreening tool or for large numbers of subjects

Does not identify person’s motivation for feigning Does not identify person’s motivation for feigning symptoms (nor does any psychological test)symptoms (nor does any psychological test)

Malingering: Assessment (SIRS)Malingering: Assessment (SIRS)Sample questions:Sample questions:

““Do you believe [automobiles] have their own Do you believe [automobiles] have their own religion?”religion?”

““Do you become fearful of soft household objects Do you become fearful of soft household objects for no real reasons?”for no real reasons?”

““Can common insects be used for electronic Can common insects be used for electronic surveillance?”surveillance?”

Malingering Assessment:Malingering Assessment: Miller Forensic Assessment of Symptoms Miller Forensic Assessment of Symptoms

(M-FAST)(M-FAST)

Developed by Miller (2001)Developed by Miller (2001)25 items designed as initial screen for 25 items designed as initial screen for malingered psychopathology; (“positive” screen malingered psychopathology; (“positive” screen may require further evaluation with SIRS)may require further evaluation with SIRS)Brief to administer (~5 min)Brief to administer (~5 min)Research indicates cut off score of Research indicates cut off score of > > 6 effective 6 effective screen for malingered incompetence to stand screen for malingered incompetence to stand trial trial

Miller HA: Psychological Assessment Resources, Inc. (2001)Jackson R, Rogers R, Sewell K. Law & Human Behavior (2005)

Malingering Assessment:Malingering Assessment: (M-FAST)(M-FAST)Sample questions (“Rare combinations” & Sample questions (“Rare combinations” &

“Extreme symptoms”:“Extreme symptoms”:

““The times when you can’t go to sleep, do you The times when you can’t go to sleep, do you often smell strange odors that are not really often smell strange odors that are not really there?”there?”

““When I hear voices, my hands begin to sweat”When I hear voices, my hands begin to sweat”

““Often, I get the strange feeling that I am from Often, I get the strange feeling that I am from another planet”another planet”

““On many days I feel so bad that I can’t even On many days I feel so bad that I can’t even remember my full name”remember my full name”

Summary Points:Summary Points:

There should be strong suspicion for malingering There should be strong suspicion for malingering in forensic settingsin forensic settingsMalingering for psychotropic medications is a Malingering for psychotropic medications is a growing problem for jailsgrowing problem for jailsAssessment of malingering should involve Assessment of malingering should involve collateral observations and recordscollateral observations and recordsConsider the Consider the adjunctadjunct use of validated screens use of validated screens (M-FAST) and tests (SIRS)(M-FAST) and tests (SIRS)Need better exchange of clinical information Need better exchange of clinical information between forensic settings (i.e., jails and state between forensic settings (i.e., jails and state hospitals)hospitals)