IT  DOESN'T  ADD  UP!

MALINGERING  IN  PSYCHIATRYDr  Wasim  Shaikh  

!Fellow,  Royal  Australian  and  NZ  College  of  Psychiatrists  

Member,  Royal  College  of  Psychiatrists,  UK  Cer@fied  Independent  Medical  Examiner  (ABIME)  

Comcare  Trained  Assessor  of  Permanent  Impairment  Trained  Assessor  of  Impairment  via  GEPI  

Approved  IME  -­‐  Workcover  and  TAC,  Victoria  Trained  Expert  Witness

IT  DOESN'T  ADD  UP!

THE  ‘QUATTRO’

PURPOSE

§ TALK  ABOUT  THE  ELEPHANT  IN  ROOM  

§ UNDERSTAND  TERMINOLOGY  

§ LEARN  OF  CLINICAL/  FORMAL  TOOLS  

§ DISCUSS  IMPLICATIONS

IMPORTANT!

§ INTEREST  NOT  EXPERTISE  

§ BIGGER  PICTURE  

§ CASES  

§ REFERENCES  AVAILABLE  

§ PRIVACY  OF  CONTENT

CASE

§ 36  YR  OLD  OFFICE  ASSISTANT  

§ BULLYING  RELATED  DEPRESSION  

§ CLAIMED  IMPAIRMENT  BUT  INCONSISTENCY  

§ HESITANT  TO  DISCUSS  PREVIOUS  HISTORY  

§ LIMITED  TREATMENT

TERMINOLOGY

§ ILLNESS  BEHAVIOUR  (+-­‐)  ABNORMAL    

§ MALINGERING  

§ FACTITIOUS  DISORDER  

§ FEIGNING

ILLNESS BEHAVIOUR

ADAPTIVE  BEHAVIOURAL  CHANGES  IN  SICK  !

NORMAL  PHENOMENON

ABNORMAL  ILLNESS  BEHAVIOUR

MALADAPTIVE  MANNER  OF  EXPERIENCING,  EVALUATING,  OR  ACTING,  IN  RESPONSE  TO  HEALTH  AND  ILLNESS  !ILLNESS  AFFIRMING  OR  DENYING  !DISPROPORTIONATE  TO    EVIDENT  PATHOLOGY  !

MALINGERING

INTENTIONAL  PRODUCTION  OR  GROSS  EXAGGERATION  OF  SYMPTOMS,  MOTIVATED    BY  EXTERNAL  INCENTIVES  !NOT  A    MENTAL  ILLNESS

FACTITIOUS  DISORDER

INTENTIONAL  PRODUCTION  OR  GROSS  EXAGGERATION  OF  SYMPTOMS,  TO  ASSUME  A  SICK-­‐ROLE  !CLASSED  AS  A    MENTAL  ILLNESS

FEIGNING

INTENTIONAL  PRODUCTION  OR  GROSS  EXAGGERATION  OF  PSYCHOLOGICAL  OR  PHYSICAL  SYMPTOMS  !NO  ASSUMPTIONS    REGARDING  GOALS  !NOT  A  MENTAL  ILLNESS

MALINGERING

MALINGERING  STATISTICS

§ 50%  CLAIMANTS  NOT  GENUINE  IN  HISTORY  REPORTS  

§ REVIEW  OF  11  STUDIES  -­‐  30%  MALINGERING  

§ INCONSISTENT  RELATIONSHIP  -­‐  SEVERITY/  DISABILITY  

§ NON-­‐RESPONSE/  INCAPACITY  UNTIL  SETTLEMENT  

§ 1:4  INCORRECT  DIAGNOSIS  OF  MALINGERING

CLINICIAN  RELUCTANCE

§ PEJORATIVE  NATURE  OF  TERM  

§ LITIGATION  FEAR  

§ CONCERNS  ABOUT  ERROR  

§ RISK  ISSUES  

§ CULTURE

FORMS OF MALINGERING

§ PRODUCTION OF SYMPTOMS WHERE THERE AREN’T

§ INTENTIONAL EXAGGERATION OF SYMPTOMS

§ MISATTRIBUTION OF SYMPTOMS

DSM - 5

§ REMOVAL OF MULTIAXIAL SYSTEM

§ NEW CATEGORY OF STRESS RELATED DISORDERS

§ CHANGES TO DEPRESSION CRITERIA

§ CHANGES TO PTSD CRITERIA

CLINICAL DETECTION

§ SIMILAR TO A CLINICAL SYNDROME

§ NO LITMUS TEST

§ CAN CO-EXIST WITH ILLNESS

§ REVIEW OF RECORDS VERY IMPORTANT

§ EXTENDED/ PROLONGED INTERVIEWS

FACTORS SUGG MALINGERING!

§ CIRCUMSTANCES

§ SYMPTOMS

§ EXAMINATION

§ OTHERS

FACTORS SUGG MALINGERING

CIRCUMSTANCES/ HISTORY

§ JOB DISSATISFACTION/ END OF EMPLOYMENT

§ ANTISOCIAL HISTORY/ HISTORY OF DISHONESTY

§ SUBSTANCE MISUSE

§ CHANGE IN DIAGNOSIS

FACTORS SUGG MALINGERING

SYMPTOMS  

§ INCONGRUENCE WITH KNOWN HISTORY AND FACTS

§ INCONGRUENCE WITH JUXTAPOSITION

§ INCONGRUENCE WITH COURSE OF ILLNESS

§ CLAIM OF FUTURE DECOMPENSATION

FACTORS SUGG MALINGERING

INTERVIEW PRESENTATION  

§ LACK OF COOPERATION, DISMISSIVE

§ MEDICAL JARGON/ KNOWLEDGE OF PI RATINGS

§ SPECIFIC MEMORY ISSUES

§ INCONSISTENCY IN EXAMINATION/ RISKS

FACTORS SUGG MALINGERING

OTHERS  

§ SUDDEN CHANGES IN WORK CAPACITY

§ CAPACITY FOR SPECIFIC/NON-WORK ACTIVITY

§ NON-COMPLIANCE WITH TREATMENT

§ SURVEILLANCE

FACTORS AGAINST MALINGERING

§ PARTICIPATION IN AGGRESSIVE TREATMENT

§ PARTICIPATION IN AGGRESSIVE REHABILITATION

§ PRO/RETROSPECTIVE OBJECTIVE EVIDENCE

§ OBVIOUS LOSSES

§ SELF DEFEATING BEHAVIOUR/ SYMPTOMS

CASE 2

§ 48 YO MIDDLE-EASTERN LADY, RTA, DEPRESSION

§ SUPPORTIVE GP, DENIES PREVIOUS HISTORY

§ DOCUMENTATION - PSYCHOTIC, SUICIDAL

§ FAKED FOR HOUSING BENEFITS

TAKE HOME MESSAGES

§ SUFFERING EXISTS, AS DOES MALINGERING

§ THERE IS MORE TO PSYCHIATRIC EXAMINATIONS…

§ RIGHT QUESTIONS = RIGHT ANSWERS

§ BENEFIT OF DOUBT TO CLAIMANT

THANK YOU