Acad Psychiatry DOI 10.1007/s40596-014-0253-1
FEATURE: LETTER TO THE EDITOR
Screening for Malingering in the Emergency Department Atika Zubera & Mahreen Raza & Eric Holaday & Rashi Aggarwal
Received: 2 July 2014 / Accepted: 5 November 2014 # Academic Psychiatry 2014
To the Editor: Malingering is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.” Although it appears to be a simple diagnosis, malingering presents numerous challenges to physicians, especially in the setting of emergent care, where physicians are under considerable time constraints and may not have any prior knowledge of a patient. A study by Yates et al. identified that urban emergency departments may have an especially high prevalence of malingering, with up to 13 % of patients proven or strongly suspected of malingering [1]. Of these patients, none received a primary diagnosis of malingering and most were not confronted about potentially malingering. Malingering was also found to be a major cause of public expenditure not only in health care but also among disability claimants. Chafetz et al. [2] estimated the cost of malingering based on mental disorder published by the Social Security Administration totaling $20.02 billion in 2011. Many urban hospitals, which may have high rates of malingering, are also academic centers, where residents play a large role in patient triage and treatment. Almost all residents may feel uncomfortable labeling a patient as a “malingerer” without concrete data to back up what is usually a purely clinical diagnosis of malingering. Lack of proper education and training of the residents in this area make the residents very ambivalent in making the diagnosis and often deferring the decision to the attending physician. A thorough understanding of potential signs of malingering is required. Clinical skills alone are not typically enough to diagnose or detect malingering and, on the other
A. Zubera (*) : M. Raza : E. Holaday : R. Aggarwal Rutgers New Jersey Medical School, Newark, NJ, USA e-mail: [email protected]
hand, a mistaken diagnosis of malingering may not only compromise the patient–physician relationship, but also render the physician liable for any harm from denying a deserving patient of necessary treatment. Humphreys and Ogilvie [3] found that 3 out of 10 patients diagnosed with malingering fully met the criteria for schizophrenia at 20-year follow-up. Therefore, it would be a useful exercise for both training and academic purposes for resident physicians to have a screening questionnaire to utilize in conjunction with their clinical interview. A screening tool for psychiatric malingering could increase confidence in making decisions on patient dispositions, decrease the liability for the clinicians, decrease the likelihood of error based exclusively on clinical judgment, and improve efficiency in utilization of hospital resources by avoiding unnecessary hospitalizations due to feigned psychiatric mental illness. The questionnaire should be viewed as a tool comparable to a medical intake form, to supplement, not supersede, a physician’s assessments. Additionally, a good tool should be relatively easy to administer. For example, residents could use such a questionnaire when performing a suicidal risk assessment and compare their subjective impressions with the objective data of the questionnaire. As a physician in training becomes more experienced, they may only wish to utilize the screening questionnaire with difficult cases. We reviewed about 27 questionnaires that can be used to detect malingering. Of these questionnaires, the Structured Interview of Reported Symptoms (SIRS) and Miller Forensic Assessment of Symptom Test (M-FAST) appear to be the most promising, because they are designed to assess malingering for a wide range of psychiatric illnesses. A PubMed literature search revealed seven articles discussing the use of the M-FAST in the context of differentiating psychiatric malingering from psychiatric disease. The SIRS tool is more widely studied, with 34 articles studying its use in malingering. No articles were found that specifically investigated
Acad Psychiatry
the M-FAST or SIRS used in the setting of a psychiatric emergency department. SIRS questionnaire is a wellvalidated structured interviewing tool to evaluate for malingering. It consists of 172 items and can be administered in about 30–40 min. It has a sensitivity of 80 % and specificity of 97.5 %. A subsequent review study has reaffirmed the validity of the SIRS across many research studies, although a significant variability in sensitivity and specificity was detected, primarily attributable to variations between study methodologies. The M-FAST questionnaire is a structured interview modeled after SIRS but with fewer questions. It consists of 25 items and can be administered in 5–10 min. The questions fall within the following seven non-overlapping scales: reported versus observed, extreme symptomatology, rare combination, unusual hallucinations, unusual symptom course, negative image, and suggestibility. Although no overall specificity or sensitivity has been reported, one study found M-FAST to have a sensitivity of 92 % and a specificity of 87 % for detecting malingering versus post-traumatic stress disorder (PTSD) in war veterans [4]. The M-FAST questionnaire possesses several qualities that may be useful in the emergency room triage setting in comparison with other validated tests for psychiatric malingering, such as the SIRS. Its shorter time requirement is useful in the clinical triage setting where a longer interview is not practical. Additionally, it is simple to interpret, because each item is scored as yes or no with a pre-determined cutoff value to indicate malingering. Because the M-FAST is administered in a structured interview format, it can be used with patients who would be unable to complete written assessments. Lastly, its high sensitivity makes it useful as a screening tool to rule out psychiatric malingering in a large population. Additionally, the longer administration time and higher specificity of the SIRS may make it well suited as a diagnostic test to support diagnoses of malingering in individuals for whom there is a high suspicion of malingering found by the M-FAST screen. Although the M-FAST scale appears to show a great potential to fill this role, there is insufficient data available at this
time to determine if it is a valid clinical screening tool in the emergency department setting. In order to validate its usage, a study would need a larger sample size consisting of a general patient population with a broad spectrum of mental illnesses. Therefore, M-FAST questionnaire data acquired in the emergency department setting and retrospectively compared with other screening tool data or the patient’s clinical diagnosis could be invaluable in ascertaining the clinical accuracy of this tool. All physicians, especially those practicing in urban emergency departments, should consider malingering as a possibility, especially if there are secondary gains to be had. Potential secondary gains include food, shelter, medications, financial gains, and avoidance of familial, legal, or professional obligations. Other considerations in the clinical assessment may include atypical presentation, exaggeration of symptoms, poor effort, and non-adherence to the treatment. Systematic ruling out of alternative explanations is the cornerstone of detection. Nevertheless, it is important to find an objective tool to supplement our clinical judgment in fast-paced emergency settings. Hence, utilization of tools like M-Fast and SIRS could assist residents and clinicians in their decisionmaking process, help them attain confidence in patient triage, reduce health-care costs, and possibly decrease the likelihood of liability in their careers.
References 1. Yates BD, Nordquist CR, Schultz-Ross RA. Feigned psychiatric symptoms in the emergency room. Psychiatr Serv. 1996;47(9): 998–1000. 2. Chafetz M, Underhill J. Estimated costs of malingered disability. Arch Clin Neuropsychol. 2013;28(7):633–9. 3. Humphreys M, Ogilvie A. Feigned psychosis revisited-A 20 year follow up of 10 patients. Psychiatric Bulletin. 1996;20:666–9. 4. Ahmadi K, Lashani Z, Afzali MH, Tavalaie SA, Mirzaee J. Malingering and PTSD: detecting malingering and war related PTSD by Miller Forensic Assessment of Symptoms Test (M-FAST). BMC Psychiatry. 2013;13:154.
FEATURE: LETTER TO THE EDITOR
Screening for Malingering in the Emergency Department Atika Zubera & Mahreen Raza & Eric Holaday & Rashi Aggarwal
Received: 2 July 2014 / Accepted: 5 November 2014 # Academic Psychiatry 2014
To the Editor: Malingering is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.” Although it appears to be a simple diagnosis, malingering presents numerous challenges to physicians, especially in the setting of emergent care, where physicians are under considerable time constraints and may not have any prior knowledge of a patient. A study by Yates et al. identified that urban emergency departments may have an especially high prevalence of malingering, with up to 13 % of patients proven or strongly suspected of malingering [1]. Of these patients, none received a primary diagnosis of malingering and most were not confronted about potentially malingering. Malingering was also found to be a major cause of public expenditure not only in health care but also among disability claimants. Chafetz et al. [2] estimated the cost of malingering based on mental disorder published by the Social Security Administration totaling $20.02 billion in 2011. Many urban hospitals, which may have high rates of malingering, are also academic centers, where residents play a large role in patient triage and treatment. Almost all residents may feel uncomfortable labeling a patient as a “malingerer” without concrete data to back up what is usually a purely clinical diagnosis of malingering. Lack of proper education and training of the residents in this area make the residents very ambivalent in making the diagnosis and often deferring the decision to the attending physician. A thorough understanding of potential signs of malingering is required. Clinical skills alone are not typically enough to diagnose or detect malingering and, on the other
A. Zubera (*) : M. Raza : E. Holaday : R. Aggarwal Rutgers New Jersey Medical School, Newark, NJ, USA e-mail: [email protected]
hand, a mistaken diagnosis of malingering may not only compromise the patient–physician relationship, but also render the physician liable for any harm from denying a deserving patient of necessary treatment. Humphreys and Ogilvie [3] found that 3 out of 10 patients diagnosed with malingering fully met the criteria for schizophrenia at 20-year follow-up. Therefore, it would be a useful exercise for both training and academic purposes for resident physicians to have a screening questionnaire to utilize in conjunction with their clinical interview. A screening tool for psychiatric malingering could increase confidence in making decisions on patient dispositions, decrease the liability for the clinicians, decrease the likelihood of error based exclusively on clinical judgment, and improve efficiency in utilization of hospital resources by avoiding unnecessary hospitalizations due to feigned psychiatric mental illness. The questionnaire should be viewed as a tool comparable to a medical intake form, to supplement, not supersede, a physician’s assessments. Additionally, a good tool should be relatively easy to administer. For example, residents could use such a questionnaire when performing a suicidal risk assessment and compare their subjective impressions with the objective data of the questionnaire. As a physician in training becomes more experienced, they may only wish to utilize the screening questionnaire with difficult cases. We reviewed about 27 questionnaires that can be used to detect malingering. Of these questionnaires, the Structured Interview of Reported Symptoms (SIRS) and Miller Forensic Assessment of Symptom Test (M-FAST) appear to be the most promising, because they are designed to assess malingering for a wide range of psychiatric illnesses. A PubMed literature search revealed seven articles discussing the use of the M-FAST in the context of differentiating psychiatric malingering from psychiatric disease. The SIRS tool is more widely studied, with 34 articles studying its use in malingering. No articles were found that specifically investigated
Acad Psychiatry
the M-FAST or SIRS used in the setting of a psychiatric emergency department. SIRS questionnaire is a wellvalidated structured interviewing tool to evaluate for malingering. It consists of 172 items and can be administered in about 30–40 min. It has a sensitivity of 80 % and specificity of 97.5 %. A subsequent review study has reaffirmed the validity of the SIRS across many research studies, although a significant variability in sensitivity and specificity was detected, primarily attributable to variations between study methodologies. The M-FAST questionnaire is a structured interview modeled after SIRS but with fewer questions. It consists of 25 items and can be administered in 5–10 min. The questions fall within the following seven non-overlapping scales: reported versus observed, extreme symptomatology, rare combination, unusual hallucinations, unusual symptom course, negative image, and suggestibility. Although no overall specificity or sensitivity has been reported, one study found M-FAST to have a sensitivity of 92 % and a specificity of 87 % for detecting malingering versus post-traumatic stress disorder (PTSD) in war veterans [4]. The M-FAST questionnaire possesses several qualities that may be useful in the emergency room triage setting in comparison with other validated tests for psychiatric malingering, such as the SIRS. Its shorter time requirement is useful in the clinical triage setting where a longer interview is not practical. Additionally, it is simple to interpret, because each item is scored as yes or no with a pre-determined cutoff value to indicate malingering. Because the M-FAST is administered in a structured interview format, it can be used with patients who would be unable to complete written assessments. Lastly, its high sensitivity makes it useful as a screening tool to rule out psychiatric malingering in a large population. Additionally, the longer administration time and higher specificity of the SIRS may make it well suited as a diagnostic test to support diagnoses of malingering in individuals for whom there is a high suspicion of malingering found by the M-FAST screen. Although the M-FAST scale appears to show a great potential to fill this role, there is insufficient data available at this
time to determine if it is a valid clinical screening tool in the emergency department setting. In order to validate its usage, a study would need a larger sample size consisting of a general patient population with a broad spectrum of mental illnesses. Therefore, M-FAST questionnaire data acquired in the emergency department setting and retrospectively compared with other screening tool data or the patient’s clinical diagnosis could be invaluable in ascertaining the clinical accuracy of this tool. All physicians, especially those practicing in urban emergency departments, should consider malingering as a possibility, especially if there are secondary gains to be had. Potential secondary gains include food, shelter, medications, financial gains, and avoidance of familial, legal, or professional obligations. Other considerations in the clinical assessment may include atypical presentation, exaggeration of symptoms, poor effort, and non-adherence to the treatment. Systematic ruling out of alternative explanations is the cornerstone of detection. Nevertheless, it is important to find an objective tool to supplement our clinical judgment in fast-paced emergency settings. Hence, utilization of tools like M-Fast and SIRS could assist residents and clinicians in their decisionmaking process, help them attain confidence in patient triage, reduce health-care costs, and possibly decrease the likelihood of liability in their careers.
References 1. Yates BD, Nordquist CR, Schultz-Ross RA. Feigned psychiatric symptoms in the emergency room. Psychiatr Serv. 1996;47(9): 998–1000. 2. Chafetz M, Underhill J. Estimated costs of malingered disability. Arch Clin Neuropsychol. 2013;28(7):633–9. 3. Humphreys M, Ogilvie A. Feigned psychosis revisited-A 20 year follow up of 10 patients. Psychiatric Bulletin. 1996;20:666–9. 4. Ahmadi K, Lashani Z, Afzali MH, Tavalaie SA, Mirzaee J. Malingering and PTSD: detecting malingering and war related PTSD by Miller Forensic Assessment of Symptoms Test (M-FAST). BMC Psychiatry. 2013;13:154.
