Forensic Assessments of Racial-Ethnic Differences in Genuine and Malingered Psychotic Presentations.

Competent forensic practice has required continued training and professional practice in differentiating between genuine and malingered presentations, especially within the spectrum of psychotic disorders. Historically, practitioners valued racial, ethnic, and cultural differences but often considered them as peripheral matters. In contemporary forensic practice, however, language and culture play preponderant roles. This commentary is focused on core features of malingering via a cultural lens. Three core, race-informed principles, such as biases against the African American Language, are highlighted and discussed. Related subjects for forensic practice include relevant clinical constructs such as malingering bias and "imposed etics," specifically, the imposition of mainstream values and discounting of cultural differences.

Examination of the Modified Somatic Perception Questionnaire (MSPQ) in a large sample of credible and noncredible patients referred for neuropsychological testing.

OBJECTIVE: The current study evaluated MSPQ sensitivity to noncredible PVT performance in the context of external incentive, and examined MSPQ false positive rates in noncompensation-seeking neuropsychology patients; and investigated effects of ethnicity/culture, gender, and somatoform diagnosis on MSPQ scores, and relationships with PVT and MMPI-2-RF data. METHOD: MSPQ scores were compared in credible (n = 110) and noncredible (n = 153) neuropsychology referrals. RESULTS: Noncredible patients scored higher than credible patients. When the credible group was divided into those with somatoform orientation (n = 39) versus those without (n = 71), the credible nonsomatoform group scored lower than the other two groups, who did not differ from each other. MSPQ elevations were found in ethnic minorities, and in individuals who learned English as a second language or concurrently with another language. MSPQ elevations were also associated with chronic systemic diseases, neurologic illness, and substance abuse. Women scored higher than men, but men and women were equally represented among those patients scoring beyond cut-offs. MSPQ scores were minimally related to PVT data but were more strongly correlated with MMPI-2-RF scales, particularly over-report validity scales, RC1, and Somatic/Cognitive scales, with more widespread relationships observed in noncredible patients. CONCLUSIONS: A cut-off of 18 resulted in few false positives in credible nonsomatoform patients, and appears appropriate for identifying physical symptom over-report (due to malingering or somatoform orientations), with associated sensitivity of 29%. However, clinicians are cautioned regarding using the MSPQ in patients with systemic, neurologic, and substance abuse conditions, and in ethnic minorities and non-monolingual English-speakers.

Cross-cultural feigning assessment: A systematic review of feigning instruments used with linguistically, ethnically, and culturally diverse samples.

The cross-cultural validity of feigning instruments and cut-scores is a critical concern for forensic mental health clinicians. This systematic review evaluated feigning classification accuracy and effect sizes across instruments and languages by summarizing 45 published peer-reviewed articles and unpublished doctoral dissertations conducted in Europe, Asia, and North America using linguistically, ethnically, and culturally diverse samples. The most common psychiatric symptom measures used with linguistically, ethnically, and culturally diverse samples included the Structured Inventory of Malingered Symptomatology, the Miller Forensic Assessment of Symptoms Test, and the Minnesota Multiphasic Personality Inventory (MMPI). The most frequently studied cognitive effort measures included the Word Recognition Test, the Test of Memory Malingering, and the Rey 15-item Memory test. The classification accuracy of these measures is compared and the implications of this research literature are discussed. (PsycINFO Database Record

Identifying feigning in trauma-exposed African immigrants.

As the populations of Western countries become more diverse, the risk of inaccurately generalizing knowledge from majority ethnic groups to minority groups is increasing. However, few of the measures used in forensic assessment are based on normative samples that represent the considerable diversity present in forensic settings. This study examined 4 commonly used measures of feigning: the Dot Counting Test (DCT; Boone, Lu, & Herzberg, 2002); the Miller Forensic Assessment of Symptoms (M-FAST; Miller, 2001); the Test of Memory Malingering (TOMM; Tombaugh, 1996); and a validity scale (atypical responding; ATR) on the Trauma Symptom Inventory-2 (Briere, 2011). The study compared performance on these measures of feigning among 3 groups of African immigrants: honest participants with and without posttraumatic stress disorder, and participants asked to feign distress-related symptoms. The data were used to assess the classification accuracy of each measure and the effect of demographic and cultural variables. Three of the 4 measures (M-FAST, TOMM, and ATR) significantly differentiated between participants asked to respond honestly and those asked to feign, although no measure produced higher than moderate classification accuracy. The M-FAST and DCT produced high false positive rates in the honest groups, ranging from 33% to 63%. Surprisingly, demographic and cultural variables were not significantly associated with test scores. The results emphasize the need for future related research. (PsycINFO Database Record

Specificity data for the b Test, Dot Counting Test, Rey-15 Item Plus Recognition, and Rey Word Recognition Test in monolingual Spanish-speakers.

The current study provides specificity data on a large sample (n = 115) of young to middle-aged, male, monolingual Spanish speakers of lower educational level and low acculturation to mainstream US culture for four neurocognitive performance validity tests (PVTs): the Dot Counting, the b Test, Rey Word Recognition, and Rey 15-Item Plus Recognition. Individuals with 0 to 6 years of education performed more poorly than did participants with 7 to 10 years of education on several Rey 15-Item scores (combination equation, recall intrusion errors, and recognition false positives), Rey Word Recognition total correct, and E-score and omission errors on the b Test, but no effect of educational level was observed for Dot Counting Test scores. Cutoff scores are provided that maintain approximately 90% specificity for the education subgroups separately. Some of these cutoffs match, or are even more stringent than, those recommended for use in US test takers who are primarily Caucasian, are tested in English, and have a higher educational level (i.e., Rey Word Recognition correct false-positive errors; Rey 15-Item recall intrusions and recognition false-positive errors; b Test total time; and Dot Counting E-score and grouped dot counting time). Thus, performance on these PVT variables in particular appears relatively robust to cultural/language/educational factors.

Malingering? No evidence in a predominantly Hispanic workers' compensation population with chronic pain.

Providers suspect malingering when patients seek compensation for injury or when pain is unconfirmed via objective evidence, judged disproportionate to the cause, or recalcitrant to treatment. Suspicions or claims of malingering may prejudice treatment or reimbursement decisions. The purpose of this archival study was to identify malingering in a predominantly Hispanic workers' compensation population seeking treatment for pain. We used a correlational archival research design to collect data from the medical records of 91 patients treated over a 10-year period in a specialty clinic. Inclusion criteria included individuals with psychologic evaluation for persistent pain that affected function. Using a priori power analysis for a medium effect size, power of .80, and alpha of .05, data from 85 medical records were necessary to meet correlational significance. The study sample reflects the ethnicity, educational level, and socioeconomic status of the larger U.S.-Mexico border community. The majority (93%) had workers' compensation and about one-third had active litigation. No one was diagnosed with malingering or pain disorder with primarily psychologic origins. Depression coexisted with chronic pain, and patients reported serious impairment in physical, occupational, and social function an average of 5 years after the onset of chronic pain. However, the vast majority of patients returned to work. In our experience, there is no place for the labeling and resultant stigma of malingering in chronic pain sufferers.

Validation of the Spanish SIRS with monolingual Hispanic outpatients.

Psychologists are faced with formidable challenges in making their assessment methods relevant to growing numbers of Hispanic clients for whom English is not the primary or preferred language. Among other clinical issues, the determination of malingering has profound consequences for clients. In this investigation, we evaluated a Spanish translation of the Structured Interview of Reported Symptoms (SIRS; Rogers, Bagby, & Dickens, 1992) with 80 Spanish-speaking Hispanic American outpatients. Using a between-subjects simulation design, the Spanish SIRS was found to produce reliable results with small standard errors of measurement. Regarding validity, very large effect sizes (mean Cohen's d= 2.00) were observed between feigners and honest responders for the SIRS primary scales. We consider the potential role of the Spanish SIRS with reference to Spanish translations for other assessment instruments.

The origins of factitious disorder.

Factitious disorder is the deliberate simulation of illness for the purpose of seeking the sick role. It is a 20th-century diagnosis, though the grounds for its introduction are uncertain. While previous authors have considered the social changes contributing to growth in the disorder, this article looks at some of the pressures on doctors that may have created the diagnostic need for a disorder between hysteria and malingering. The recent history of those disorders suggests that malingering would no longer be acceptable when applied to the potentially larger numbers involved in workers' compensation or in mass conscription. Equally, the absolution given to hysteria on the basis of the Freudian subconscious would survive only as long as that model retained credibility. Growing egalitarianism and changing doctor-patient relationships in the 20th century would no longer tolerate a sharp division between culpable malingering and exculpated hysteria, which may previously have been made on grounds of class or gender. They would contribute to the need for a mediating diagnosis, such as factitious disorder.

Clinical and conceptual problems in the attribution of malingering in forensic evaluations.

The authors review clinical and conceptual errors that contribute to false attributions of malingering in forensic evaluations. Unlike the mental disorders, malingering is not defined by a set of (relatively) enduring symptoms or traits; rather, it is an intentional, externally motivated, and context-specific form of behavior. Despite this general knowledge, attributions of malingering are often made by using assessment tools that may detect feigning but cannot be relied upon to determine incentive and volition or consciousness (defining characteristics of malingering). In addition, forensic evaluators may overlook the possibility that feigning is a function of true pathology, as in Ganser syndrome or the factitious disorders, or that a seemingly malingered presentation is due to symptoms of an underlying disorder, such as dissociative identity disorder (DID). Other factors that set the stage for false positives, such as pressure on forensic specialists to identify malingering at all costs, failure to consider the base rate problem, and cultural variables, are also reviewed.

Languages of labor: negotiating the "real" and the relational in Indo-Fijian women's expressions of physical pain.

Medical personnel in public clinics in Fiji routinely contend that state-funded medical resources are misallocated on patients who complain of, but do not actually experience, physical pain. Frequently, these patients are identified as being Indo-Fijian women (i.e., women of South Asian origin in Fiji). In this article, I examine clinical interactions between medical staff and female Indo-Fijian patients to demonstrate how "real" and 'unreal' pain are distinguished in the clinical setting and to indicate some of the roles clinical encounters play in community processes that ascribe alternative meanings to physical pain. Focusing on how both physicians and women patients foster certain interpretations of physical pain over others, I argue that the category of 'unreal' pain, as employed by Fiji's physicians, consists of pain that medical professionals consider to be induced by psychological or physical, work-related stresses. I then show how Indo-Fijian women engage in a complementary but distinct discourse that emphasizes links between physical labor and pain and suggests that, in some cases, expressions of physical pain are as much an idiom of pride as an idiom of distress.

The medical detection of simulated occupational injuries: a historical and social analysis.

Occupational malingering is often thought to involve the deliberate feigning of disease by workers seeking undeserved financial gain. Concern about this form of malingering grew in the late 19th century as a result of the emergence of the new industrial economy and the institution of workers' compensation insurance. Medical judgments about the simulation of work injuries have placed physicians in a crossfire between the interests of employers and workers in numerous medicolegal debates. Because of uncertainty about the true cause of many occupational disorders and the highly charged social environment in which medical opinions are rendered, physicians' views about malingering are often swayed by cultural, political, and economic forces. The historical record shows that a medical diagnosis of occupational malingering can reflect deep-seated cultural and social biases toward women, Jews, immigrants, and other groups representing a potential threat to the privileged social class. Current efforts to eliminate fraudulent workers' compensation claims must be sensitive to the inherent ambiguities in the medical determination of work-relatedness and the potential for judgments about simulated work injuries to conceal deep-seated social biases and class prejudices.

The erroneous diagnosis of malingering in a military setting.

The paper describes difficulties in diagnosing individuals from different cultures, focusing specifically on cases of erroneous diagnosis of malingering among ultraorthodox Jewish inductees. During one year, 24 inductees diagnosed as malingerers by several army psychiatrists were re-examined by the authors and subsequently re-diagnosed as psychotic, suffering from a personality disorder, or mentally retarded. Factors underlying the misdiagnosis are discussed.

Disease, disorder, or deception? Latah as habit in a Malay extended family.

Thirty-seven cases of latah are examined within the author's Malay extended family (N = 115). Based on ethnographic data collected and a literature review, cases are readily divisible into two broad categories: habitual (N = 33) and performance (N = 4). The first form represents an infrequent, culturally conditioned habit that is occasionally used as a learned coping strategy in the form of a cathartic stress response to sudden startle with limited secondary benefits (i.e., exhibiting brief verbal obscenity with impunity). In this sense, it is identical to Western swearing. Performers are engaged in conscious, ritualized social gain through the purported exploitation of a neurophysiological potential. The latter process is essentially irrelevant, akin to sneezing or yawning. It is concluded that latah is a social construction of Western-trained universalist scientists. The concept of malingering and fraud in anthropology is critically discussed.