Articles from prior issues of The Advocate

July/August, 1996

Is Your Patient Malingering?
by Richard C. Maddock, Ph.D. Baptist Memorial Hospital, Blytheville/Osceola, AR

BACKGROUND

ATTEMPTS TO MALINGER AND COACHING are problems that are often encountered by disability examiners. Functional Malingering has been encountered by this Examiner and is described by Rogers (1988) as either intellectual or physical malingering. It has been this Examiner’s finding that whereas some claimants will attempt to subvert or undermine a standardized test of intelligence, others will exaggerate physical symptoms. Two projects have been carried out with disability claimants, using data that was collected for clinical evaluation and then statistically analyzed for purposes of this project.

MEASURING ATTEMPTS TO “FAKE BAD” ON INTELLIGENCE TESTS

In the first project, the Peabody Picture Vocabulary Test - Form L (PPVT-L) was administered to claimants who were believed to be attempting to fake bad on a standardized test of intelligence so that they could receive benefits. The first twenty items were administered. The age range of these items is from pre-verbal, age 1 year 9 months to age 2 years 10 months. Therefore, they are extremely simple items, and require only that the claimant point to a drawing of the correct response and be able to identify some very simple items, such as a bus, a ball, a wheel, a snake, etc. (Dunn and Dunn, 1981). The null hypothesis would predict that on a test involving twenty multiple choice items with four options on each item, one of which is correct, there would be a statistical probability of getting five items correct on the basis of chance alone. However, it has been found that when individuals have been coached or are attempting to malinger they will usually get all or almost all of the items incorrect, which calls into question the validity of the null hypothesis. On the other hand, even it the claimant does not fail all of the items but is able to give at lease a 50% correct response pattern, these results may be analyzed in terms of test norms. For example, when a claimant gives 50% correct responses (10/20) he/she would be functioning at the 2 year 3 month old level, which is basically pre-verbal and generally inappropriate for any adult client and for most children that are seen as disability claimants; especially those who are capable of driving themselves to the office.

FAKING BAD ON PHYSICAL SYMPTOMS

Another area where functional malingering is often seen with adults is in the constellation of physical symptoms that are presented. The Wahler Physical Symptoms Inventory (Wahler, 1981) is an inventory of complaints in which the claimant indicates the frequency of occurrence from a list of 42 symptoms, covering all systems - cardiovascular, respiratory, musculoskeletal, etc. The underlying assumption is that a person who is physically disabled or sick will usually describe and limit their symptoms to one or two body systems, and that the more body systems that are involved, the more likely it is that functional malingering is involved. This is the rationale behind Scale 1 of the MMPI andMMPI-2, (Lachar, 1980, Hathaway & McKinley, 1940). The Wahler Physical Symptoms Inventory correlates .66 with Scale 1 of the MMPI.

DESCRIPTION OF METHODOLOGY

In this project, 71 disability claimants in Arkansas and Tennessee were given the Wahler Physical Symptoms Inventory for clinical purposes. These claimants were all appealing their disability claim before an Administrative Law Judge and were referred by the Office of Hearings and Appeals (OHA). The sample consisted of 40 females and 31 males. In addition to the OHA claimants, 26 claimants who were making application for disability benefits for the first time were also given the Wahler Physical Symptoms Inventory.. These two groups were then compared with the original sample reported upon by the author of the inventory (Wahler, 1983) which consisted of 78 males and 19 females (N=97). The total sample size in this analysis consisted of 97 claimants, who were then compared with the 97 who were reported upon by Wahler who took the inventory in the original sample. The overall project design consisted of a 2x2x3 factor factorial analysis of variance (male/female x Norms disability claimants / first time disability claimants/ OHA disability claimants). RESULTS OF THE STUDY

When compared to the norms established by Wahler (1981) it was noted that claimants who took the Inventory in the sample of OHA respondents were significantly higher than either the psychiatric patient norm group (p<.001) or the disability claimant norm group (p<.01) that were reported by the author in the test manual. No differences were noted between males and females in the study, and there were no interaction effects. In general, the major results were determined by whether the individual was a member of the OHA group, and the primary difference in those in this group was that their request for disability benefits had been under appeal and had been rejected at least one time before they took the Wahler Inventory.

DISCUSSION AND IMPLICATIONS OF THE RESULTS

The results of this study showed a highly significant difference between OHA patients and the other two groups: first time disability claimants and the disability claimants in the original (Wahler) sample. However no statistically significant differences were noted between the male and female clients, just as there were no significant differences between the first time disability claimants and the disability claimants in the original sample that are reported in the test manual. Often the judgement as to whether or not someone is malingering in order to obtain disability benefits is made on a subjective rather than an objective basis. This does not need to be the case when test scores are available which can assist disability examiners in reaching decisions that are more objective. This is true in at least two areas where malingering is often seen: intelligence testing and in the reporting of physical symptoms. In relation to intelligence testing, when an individual is taking a standardized test of intelligence such as the Wechsler Adult Intelligence Scale, they may try to “fake bad;” particularly if they have been led to believe that people with lower intelligence are more likely to be successful in their appeal for disability benefits. Whenever this attitude is encountered there are usually some initial indicators that alert the Examiner: *The claimant will frequently give a response on an arithmetic subtest that is +/-1 the correct answer.

*The claimant will often claim not to have basic information, such as name, birthdate, age, address, etc.

*The claimant will give no answer or will answer in vague, often non-verbal responses (shoulder-shrug, etc.)

*There will be considerable inter-test variability as well as intratest variability. The claimant will invariably do better on subtests which interest him/her. *If the evaluation involves a child who has been coached to fake bad, the parent will often object to leaving the room or will stand close by in order to monitor the child’s responses.

When these behaviors are observed the Examiner may want to administer the first twenty items of the Peabody Picture Vocabulary Test, Form L. The expectation would be that if only five (or fewer) items are answered correctly, that the null hypothesis can be rejected and it may be assumed that there are other factors governing the claimant’s test performance. These factors may include having been coached, previous rejection of eligibility for benefits or malingering. On the other hand, when claimants report a very wide range of physical symptoms that are problematic and disabling, the Examiner may suspect malingering in the area of physical health or well being. In order to verify this suspicion, the Wahler Physical Symptoms Inventory might be employed, since this Inventory tends to cover a large number of symptoms and is also correlated .66 with the Hypochondriasis Scale (Scale 1) on the MMPI-2. The assumption behind the Wahler Inventory and behind the MMPI is that the more systems that are involved in the complaint, the more likely the individual is to be malingering or faking. This assumption has not only empirical support in projects such as this one, but is also one that receives strong intuitive support from disability examiners who have encountered these problems for a long time.

PURPOSE

The purpose of this research is not to establish cutoffs which would replace clinical judgment and experience in identifying malingering. The purpose is simply to make the process more objective, to assist the clinician in arriving at a diagnosis and a determination, and to offer tools that may assist in the diagnosis of deception and malingering as it is seen in the disability application process.

For example, in Arkansas a Standard Score Regression Comparison (Evans, 1995) has been designed to assist Examiners to objectively identify children who qualify or do not qualify for the services of resource teaching (special education or Chapter1). Formerly this was a subjective process. Using regression, both the Full Scale IQ score and the Standard Scores yielded by an achievement battery are regressed together in order to determine areas where severe deficiencies may exist. The scores are then used to determine curriculum and placement. Similarly, when instruments such as the two described in this paper are available to disability examiners, they can be of special assistance in identifying deception and malingering. The present Examiner has used these tests to successfully screen claimants on a regular basis for the past three years. But more research is needed, and it is suggested that this current line of research be continued by including not only these two measures but also others that have already been collected. Such measures could include the validity and clinical scales of the MMPI and MMPI-2; the scores on the bender-Gestalt test, the scores on various inventories of depression and anxiety and possibly the scores on some tests of aptitude and ability. These scores could then be regressed upon the dependent variable which, in this case, would be the claimant’s success (or failure) to receive disability benefits. The underlying assumption in this research would then be that benefits were only awarded to deserving claimants.

CONCLUSION

Two types of deception have been investigated. These include deception on a standardized test of intelligence, such as the Wechsler Adult Intelligence Scale, the Wechsler Intelligence Scale for Children or the Stanford-Binet Intelligence Scales. Secondly, they include deception involving physical symptoms where the claimant overstates or exaggerates his or her physical problems in the interest of obtaining disability benefits. It was noted by this Examiner that overstatement of physical problems was common among claimants who were involved in the appeals process, as opposed to those applying for benefits for the first time. This statement has been verified in comparisons of these groups with the test norms and with other groups, and the finding of a highly significant statistical differences (p<.001). Although no similar study has been carried out on deception involving intelligence tests, the Peabody Picture Vocabulary Test - Form L (PPVT-L) has been found to be a useful tool in identifying tendencies to malinger and deceive. This is because the PPVT-L allows us to state the statistical probability of malingering, and therefore to make more objective decisions.

REFERENCES

Dunn, Leola M and Dunn, Leota M., (1981) Peabody Picture Vocabulary Test Manual Revised (Forms L & M). Circle Pines, MN: American Guidance Services.

Evans, L.D. (1995) Standard score regression analysis 3.1PC Version (software) Little Rock, AR: WtL Publishing.

Lachar, D. (1980) The MMPI: Clinical assessment and automated interpretation. Los Angeles, CA: Western Psychological Services.

McKinley, J.C. and Hathaway, S.R. (1940) A differential study of hypochondriasis. Journal of Psychology, 10, 255-268

Rogers, R. (1988) Clinical assessment of malingering and deception. New York: Guilford Press.

Wahler, H. J. (1983) Wahler physical symptoms inventory. Los Angeles, CA: Western Psychological Services, Inc.