Understanding Malingering: Assessment and Implications

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Holly A. Miller, Ph.D.
College of Criminal Justice
Sam Houston State University
 
 
Malingering
Theory and assessment
Miller Forensic Assessment of Symptoms Test
Development of the M-FAST
Utility of the M-FAST
Brief overview of studies
Administration and scoring of the M-FAST
Practice administration
Interpretation
Questions
 
 
The DSM-IV-TR defines malingering as:
Intentional production of false or grossly
exaggerated physical or psychological symptoms,
motivated by external incentives (APA, 2000)
Why might someone malinger?
Prevalence of malingering
Around 8% of general evaluations
Around 20% of forensic evaluations
Miller, 2000; Rogers & Cruise, 2000; Rogers, Salekin,
Sewell, & Goldstein, 1996
 
 
When to assess for malingering
Rogers suggests under these circumstances
Atypical presentation of symptoms
Unusually high number of unusual or obvious
symptoms
Nonselective endorsement of symptoms
Discrepancies between reported and documented
history of mental illness
 
 
 
Why not just use clinical judgment?
DSM criteria
Marked discrepancy between reported impairment and
objective findings
Lack of cooperation during evaluation or treatment
Medico-legal context presentation
Presence of APD
What research reports on accuracy of clinical
judgment
Utilizing DSM criteria results in high false-positive rates
Studies strongly support that objective assessment
instruments are significantly more accurate than clinical
judgment (Miller, 2005; Rogers 1984; Ziskin, 1984)
 
 
Miller, H. A. (2005). The Miller-Forensic
Assessment of Symptoms Test (M-FAST):  Test
generalizability and utility across race,
literacy, and clinical opinion. 
Criminal Justice
& Behavior
, 
32 
(6), 591-611.
Study 1 – initial M-FAST items (79 items)
280 forensic patients; 5 psychiatrists; 8 psychologists
M-FAST; SIRS; Mtest; MMPI-2
Study 2 – final M-FAST (25 items)
50 forensic patients; 5 psychiatrists; 8 psychologists
M-FAST; SIRS; Mtest; MMPI-2
 
 
Study 1 Clinical opinion v. M-FAST results
Psychiatrist Opinion
AUC = .72 (SE = .05)
CI = .62 - .81
19 FP; 17 FN
Psychologist Opinion
AUC = .80 (SE = .04)
CI = .72 - .88
15 FP; 11 FN
M-FAST (79 items)
AUC = .89 (SE = .02)
CI = .85 - .93
 
 
Study 2 Clinical opinion v. M-FAST results
Psychiatrists
AUC = .65 (SE = .09)
CI = .47 - .83
7 FP; 7 FN
Psychologists
AUC = .73 (SE = .08)
CI = .57 - .89
9 FP; 4 FN
M-FAST (final version)
AUC = .95 (SE = .03)
CI = .88 – 1.00
6 FP; 1 FN
 
 
 
 
 
How to catch a malingerer
Previous research has indicated important areas
of assessment:
Certain response styles
Certain interview strategies
Several instruments include assessment of
response styles or were specifically designed to
assess malingering
MMPI-2
PAI
SIRS
However, there remains a need for a brief screen
for malingered mental illness
 
 
M-FAST items were developed to
operationalize the response styles and
interview strategies that have been validated
for identifying individuals who are malingering
Reported vs Observed symptoms (RO)
Extreme Symptomatology (ES)
Rare Combinations (RC)
Unusual Hallucinations (UH)
Unusual Symptom Course (USC)
Negative Image (NI)
Suggestibility (S)
 
 
M-FAST is a structured interview of 25 items
representing the “proven” detection strategies
Administration is approximately 5-10 minutes
Scoring is approximately 10 minutes
Does not require the ability to read (examinee)
Has been translated into Korean and Spanish
M-FAST was developed using both known-
group and simulation studies
 
 
Materials include manual and 8-page
interview booklet
Validated on people 18 yrs and older
Validated with different ethnic/race groups
Validated across gender
Validated with varied populations
In prison
On probation
In forensic hospital
In civil hospital
Outpatient disability assessment
 
 
Appropriate populations and limitations
Malingered psychopathology (not neuro)
Examinee must be able to understand items
Adults 18 yrs or older
Screening instrument and was not developed to
be the sole determinate of malingered mental
illness
Professional requirements
Mental health clinician with formal training in
diagnostic interviewing and assessment
 
 
M-FAST should be preceded by a clinical
interview
To gather both symptom information and
observable behavior (RO assessment help)
Read aloud instructions for administration to
client
Suggestibility item
1
st
 response dictates how you ask last part of item
Read items and possible responses of each item
May repeat once – but offer no explanation
 
 
With partner, practice administration
Partner role play a malingerer
Want to appear mentally ill, without elevating
M-FAST score
Then reverse roles
 
 
Scoring instructions provided on last page of
interview booklet
Score individual items
Score scales
If more than 2 items missing, not considered
valid administration
 
 
Malingering is distinct from most forms of
psychopathology; however the presence of
malingering does not rule out a psychiatric
disorder
Significant consequences for malingering
diagnosis
Choosing of a cut score for M-FAST
More acceptable to have false positives than
false negatives
Cut score of 6 utilized
 
 
Three levels
Total scale
Provides an estimate of the likelihood that the examinee is
malingering
Interpretive statement: The examinee’s total score on the M-
FAST was significantly elevated, indicating that this
individual may be malingering mental illness.
Scales
Provides information on how the individual is malingering
Can make interpretive statements about scale elevations,
but utilize total score for overall assessment
Each scale has own “cut score”
Suggestibility item (scale)
Manual provides interpretative statement examples
Items
 
 
Next step
Further malingering assessment is warranted if
client elevated M-FAST
 
 
Competency to stand trial – forensic inpatients
Jackson, R., Rogers, R., Sewell, K. W. (2005). Forensic
applications of the M-FAST: Screening for feigned disorders
in competency to stand trial evaluations. 
Law and Human
Behavior, 29
(2), 199-210.
Vitacco, M. J., Rogers, R., Gabel, J., Munizza, J. (2007).
An evaluation of malingering screens with competency to
stand trial patients: A known-groups comparison
. Law and
Human Behavior, 31
(3), 249-260.
Miller, H. A. (2004). Examining the use of the M-FAST with
criminal defendants incompetent to stand trial.
International Journal of Offender Therapy and
Comparative Criminology, 48
(3), 268-280.
 
 
Validity Studies
Vitacco, M. J., Jackson, R. L., Rogers, R., Neumann, C. S., Miller,
H. A. Gabel, J. (2008). Detection strategies for malingering with
the M-FAST: A confirmatory factor analysis of its underlying
dimensions. 
Assessment, 15
(1), 97-103.
Miller, H. A. (2005). The Miller Forensic Assessment of Symptoms
Test (M-FAST): Test generalizability and utility across race,
literacy, and clinical opinion. 
Criminal Justice and Behavior, 32
(6),
591-611.
Veazey, C. H., Hays, J. R., Wagner, A. L., & Miller, H. A. (2005).
Validity of the Miller Forensic Assessment of Symptoms Test in
psychiatric inpatients. 
Psychological Reports, 96
(3), 771-774.
Guy, L. S., & Miller, H. A. (2004). Screening for malingered
psychopathology in a correctional setting: Utility of the Miller
Forensic Assessment of Symptoms Test (M-FAST). 
Criminal Justice
and Behavior, 31
(6), 695-716.
 
 
Civil forensic settings
Alwes, Y. R., Clark, J. A., Berry, T. R., Granacher,
R. P. (2008). Screening for feigning in a civil
forensic setting. 
Journal of Clinical and
Experimental Neuropsychology, 30
(2), 1-8.
 
 
Diagnostic-specific malingering assessment
Messer, J. M., & Fremouw, W. J. (2007). Detecting malingered
posttraumatic stress disorder using Morel Emotional Numbing Test-
Revised and the Miller Forensic Assessment of Symptoms Test (M-
FAST). 
Journal of Forensic Psychology Practice, 7
(3), 33-57.
Guriel-Tennant, J., & Fremouw, W. J. (2006). Impact of trauma
history and coaching on malingering of posttraumatic stress
disorder using the PAI, TSI, and M-FAST. 
Journal of Forensic
Psychiatry & Psychology, 17
(4), 577-592.
Guy, L. S., Kwartner, P. P., & Miller, H. A. (2006). Investigating the
M-FAST: Psychometric properties and utility to detect diagnostic
specific malingering. 
Behavioral Sciences & the Law, 24
(5), 687-
702.
Guriel, J., Yanez, T., Fremouw, W. J., Shreve-Neiger, A., Ware, L.,
Filcheck, H., & Farr, C. (2004). Impact on coaching on malingered
posttraumatic stress symptoms on the M-FAST and TSI. 
Journal of
Forensic Psychology Practice, 4
(2), 37-56.
 
 
 
 
Holly A. Miller, Ph.D.
Assistant Dean of Undergraduate Programs
Associate Professor
College of Criminal Justice
Sam Houston State University
Huntsville, Texas 77341-2296
936-294-1686; hmiller@shsu.edu
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Malingering, intentional fabrication of symptoms for external gain, presents challenges in assessment. The M-FAST (Miller Forensic Assessment of Symptoms Test) offers a detailed approach for identifying malingering behaviors. Research suggests relying solely on clinical judgment may lead to inaccuracies, emphasizing the need for objective assessment tools. The prevalence of malingering in evaluations varies, highlighting the importance of proper assessment protocols for more accurate results.


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  1. THE ASSESSMENT OF MALINGERING WITH THE M-FAST Holly A. Miller, Ph.D. College of Criminal Justice Sam Houston State University

  2. OVERVIEW Malingering Theory and assessment Miller Forensic Assessment of Symptoms Test Development of the M-FAST Utility of the M-FAST Brief overview of studies Administration and scoring of the M-FAST Practice administration Interpretation Questions

  3. MALINGERING The DSM-IV-TR defines malingering as: Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives (APA, 2000) Why might someone malinger? Prevalence of malingering Around 8% of general evaluations Around 20% of forensic evaluations Miller, 2000; Rogers & Cruise, 2000; Rogers, Salekin, Sewell, & Goldstein, 1996

  4. MALINGERING When to assess for malingering Rogers suggests under these circumstances Atypical presentation of symptoms Unusually high number of unusual or obvious symptoms Nonselective endorsement of symptoms Discrepancies between reported and documented history of mental illness

  5. MALINGERING Why not just use clinical judgment? DSM criteria Marked discrepancy between reported impairment and objective findings Lack of cooperation during evaluation or treatment Medico-legal context presentation Presence of APD What research reports on accuracy of clinical judgment Utilizing DSM criteria results in high false-positive rates Studies strongly support that objective assessment instruments are significantly more accurate than clinical judgment (Miller, 2005; Rogers 1984; Ziskin, 1984)

  6. MALINGERING Miller, H. A. (2005). The Miller-Forensic Assessment of Symptoms Test (M-FAST): Test generalizability and utility across race, literacy, and clinical opinion. Criminal Justice & Behavior, 32 (6), 591-611. Study 1 initial M-FAST items (79 items) 280 forensic patients; 5 psychiatrists; 8 psychologists M-FAST; SIRS; Mtest; MMPI-2 Study 2 final M-FAST (25 items) 50 forensic patients; 5 psychiatrists; 8 psychologists M-FAST; SIRS; Mtest; MMPI-2

  7. MALINGERING Study 1 Clinical opinion v. M-FAST results Psychiatrist Opinion AUC = .72 (SE = .05) CI = .62 - .81 19 FP; 17 FN Psychologist Opinion AUC = .80 (SE = .04) CI = .72 - .88 15 FP; 11 FN M-FAST (79 items) AUC = .89 (SE = .02) CI = .85 - .93 ROC Curve 1.00 .75 .50 .25 Sensitivity 0.00 0.00 .25 .50 .75 1.00 1 - Specificity Diagonal segments are produced by ties. ROC Curve 1.00 .75 .50 .25 Sensitivity 0.00 0.00 .25 .50 .75 1.00 1 - Specificity Diagonal segments are pr oduc ed by ties. ROC Curve 1.00 .75 .50 .25 Sensitivity 0.00 0.00 .25 .50 .75 1.00 1 - Specificity Diagonal segments are pr oduc ed by ties.

  8. MALINGERING Study 2 Clinical opinion v. M-FAST results Psychiatrists AUC = .65 (SE = .09) CI = .47 - .83 7 FP; 7 FN Psychologists AUC = .73 (SE = .08) CI = .57 - .89 9 FP; 4 FN M-FAST (final version) AUC = .95 (SE = .03) CI = .88 1.00 6 FP; 1 FN ROC - Psychiatrists 1.00 .75 .50 .25 0.00 0.00 .25 .50 .75 1.00 ROC - Psychologists 1.00 .75 .50 .25 0.00 0.00 .25 .50 .75 1.00 ROC M-FAST 1.0 .75 .50 .25 0.0 .25 .50 .75 0.0 1.0

  9. MALINGERING How to catch a malingerer Previous research has indicated important areas of assessment: Certain response styles Certain interview strategies Several instruments include assessment of response styles or were specifically designed to assess malingering MMPI-2 PAI SIRS However, there remains a need for a brief screen for malingered mental illness

  10. DEVELOPMENT OF THE M-FAST M-FAST items were developed to operationalize the response styles and interview strategies that have been validated for identifying individuals who are malingering Reported vs Observed symptoms (RO) Extreme Symptomatology (ES) Rare Combinations (RC) Unusual Hallucinations (UH) Unusual Symptom Course (USC) Negative Image (NI) Suggestibility (S)

  11. DEVELOPMENT OF THE M-FAST M-FAST is a structured interview of 25 items representing the proven detection strategies Administration is approximately 5-10 minutes Scoring is approximately 10 minutes Does not require the ability to read (examinee) Has been translated into Korean and Spanish M-FAST was developed using both known- group and simulation studies

  12. ADMINISTRATION AND SCORING Materials include manual and 8-page interview booklet Validated on people 18 yrs and older Validated with different ethnic/race groups Validated across gender Validated with varied populations In prison On probation In forensic hospital In civil hospital Outpatient disability assessment

  13. ADMINISTRATION AND SCORING Appropriate populations and limitations Malingered psychopathology (not neuro) Examinee must be able to understand items Adults 18 yrs or older Screening instrument and was not developed to be the sole determinate of malingered mental illness Professional requirements Mental health clinician with formal training in diagnostic interviewing and assessment

  14. ADMINISTRATION AND SCORING M-FAST should be preceded by a clinical interview To gather both symptom information and observable behavior (RO assessment help) Read aloud instructions for administration to client Suggestibility item 1stresponse dictates how you ask last part of item Read items and possible responses of each item May repeat once but offer no explanation

  15. ADMINISTER M-FAST With partner, practice administration Partner role play a malingerer Want to appear mentally ill, without elevating M-FAST score Then reverse roles

  16. ADMINISTRATION AND SCORING Scoring instructions provided on last page of interview booklet Score individual items Score scales If more than 2 items missing, not considered valid administration

  17. INTERPRETATION Malingering is distinct from most forms of psychopathology; however the presence of malingering does not rule out a psychiatric disorder Significant consequences for malingering diagnosis Choosing of a cut score for M-FAST More acceptable to have false positives than false negatives Cut score of 6 utilized

  18. INTERPRETATION Three levels Total scale Provides an estimate of the likelihood that the examinee is malingering Interpretive statement: The examinee s total score on the M- FAST was significantly elevated, indicating that this individual may be malingering mental illness. Scales Provides information on how the individual is malingering Can make interpretive statements about scale elevations, but utilize total score for overall assessment Each scale has own cut score Suggestibility item (scale) Manual provides interpretative statement examples Items

  19. INTERPRETATION Next step Further malingering assessment is warranted if client elevated M-FAST

  20. M-FAST ARTICLES BY TOPIC Competency to stand trial forensic inpatients Jackson, R., Rogers, R., Sewell, K. W. (2005). Forensic applications of the M-FAST: Screening for feigned disorders in competency to stand trial evaluations. Law and Human Behavior, 29(2), 199-210. Vitacco, M. J., Rogers, R., Gabel, J., Munizza, J. (2007). An evaluation of malingering screens with competency to stand trial patients: A known-groups comparison. Law and Human Behavior, 31(3), 249-260. Miller, H. A. (2004). Examining the use of the M-FAST with criminal defendants incompetent to stand trial. International Journal of Offender Therapy and Comparative Criminology, 48(3), 268-280.

  21. M-FAST ARTICLES BY TOPIC Validity Studies Vitacco, M. J., Jackson, R. L., Rogers, R., Neumann, C. S., Miller, H. A. Gabel, J. (2008). Detection strategies for malingering with the M-FAST: A confirmatory factor analysis of its underlying dimensions. Assessment, 15(1), 97-103. Miller, H. A. (2005). The Miller Forensic Assessment of Symptoms Test (M-FAST): Test generalizability and utility across race, literacy, and clinical opinion. Criminal Justice and Behavior, 32(6), 591-611. Veazey, C. H., Hays, J. R., Wagner, A. L., & Miller, H. A. (2005). Validity of the Miller Forensic Assessment of Symptoms Test in psychiatric inpatients. Psychological Reports, 96(3), 771-774. Guy, L. S., & Miller, H. A. (2004). Screening for malingered psychopathology in a correctional setting: Utility of the Miller Forensic Assessment of Symptoms Test (M-FAST). Criminal Justice and Behavior, 31(6), 695-716.

  22. M-FAST ARTICLES BY TOPIC Civil forensic settings Alwes, Y. R., Clark, J. A., Berry, T. R., Granacher, R. P. (2008). Screening for feigning in a civil forensic setting. Journal of Clinical and Experimental Neuropsychology, 30(2), 1-8.

  23. M-FAST ARTICLES BY TOPIC Diagnostic-specific malingering assessment Messer, J. M., & Fremouw, W. J. (2007). Detecting malingered posttraumatic stress disorder using Morel Emotional Numbing Test- Revised and the Miller Forensic Assessment of Symptoms Test (M- FAST). Journal of Forensic Psychology Practice, 7(3), 33-57. Guriel-Tennant, J., & Fremouw, W. J. (2006). Impact of trauma history and coaching on malingering of posttraumatic stress disorder using the PAI, TSI, and M-FAST. Journal of Forensic Psychiatry & Psychology, 17(4), 577-592. Guy, L. S., Kwartner, P. P., & Miller, H. A. (2006). Investigating the M-FAST: Psychometric properties and utility to detect diagnostic specific malingering. Behavioral Sciences & the Law, 24(5), 687- 702. Guriel, J., Yanez, T., Fremouw, W. J., Shreve-Neiger, A., Ware, L., Filcheck, H., & Farr, C. (2004). Impact on coaching on malingered posttraumatic stress symptoms on the M-FAST and TSI. Journal of Forensic Psychology Practice, 4(2), 37-56.

  24. THANK YOU! Holly A. Miller, Ph.D. Assistant Dean of Undergraduate Programs Associate Professor College of Criminal Justice Sam Houston State University Huntsville, Texas 77341-2296 936-294-1686; hmiller@shsu.edu

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