Assessment of Malingering in a Jail Setting

1. Assessment of Malingering in a Jail Setting Gregory Sokolov MD Medical Director, Sacramento County Jail Psychiatric Services & Assistant Clinical Professor, University of California at Davis, Department of Psychiatry

2. Lecture Objectives • Malingering: definition & prevalence in forensic/correctional settings • Assessment of malingering (SIRS; M-FAST) • Research (in progress)-malingering in jail • Case studies

3. “Trans-Institutionalization”(Criminalization of the Mentally Ill) Source: US Dept. of Health Human Services & Dept of Justice statistics

4. Treatment Issues & Challenges in Correctional Psychiatry • High rates of co-morbid substance dependence and personality disorders (Antisocial) • Malingered symptoms of mental illness (“hearing voices”) for secondary gains of housing change, mental health defense, SSI benefits, etc • Misuse of psychotropic medications for sleep • “Cheeking” of medications for sale or bartering

5. Malingering (DSM-IV-TR) • “The intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as…evading criminal prosecution or obtaining drugs.” • Contrast with Factitious Disorders; Ganser’s Syndrome (Dissociative Disorder NOS)

6. Malingering (DSM-IV-TR) “Malingering should be strongly suspected”: • Medico-legal evaluations • Marked discrepancy between person’s claimed stress or disability and objective findings (reported vs. observed symptoms) • Lack of cooperation with diagnostic interview • Antisocial Personality Disorder

7. Malingering & Criminal Justice System • Competency to stand trial (CST) assessments: 60,000 referrals in US / year • Base rates of malingering estimated from 8% to 17.4% • Surveys of psychiatrists / psychologists working in forensic settings: report malingering in 16-18% patient population Cornell DG, Hawk GL: Law & Human Behavior (1989) Rogers R, et al: Law & Human Behavior (1998) Rogers R: Clinical Assessment of Malingering & Deception (2nd Ed. 1997)

8. Malingering & Criminal Justice System United States v. Greer (1998): • Greer arraigned on federal charges of kidnapping and firearms violations • Sent to federal medical center for evaluation of competency to stand trial • Psychologist testified Greer was competent and malingering; judge ruled competent • Over next year, while awaiting trial, Greer disruptive in jail, re-evaluated, ruled incompetent, and committed to another federal medical center for restoration

9. Malingering & Criminal Justice System • After period of hospitalization, psychologist again concluded Greer was malingering and competent; court agreed • Greer engages in self-injurious behaviors in jail, disruptive in court during trial • At sentencing, court enhances Greer’s sentence (by 25 months) for obstruction of justice due to feigning of mental illness • US 5th Circuit Court of Appeals: “A defendant who playacts psychosis essentially tries to create a records that includes inaccurate testimony and factual conclusions”

10. Malingering & Jail Inmates • Potential motives for malingering in jail population may include: • Avoid or delay legal proceedings with a “mental defense” (insanity, incompetent to stand trial) • Obtain a preferred housing change (i.e. psych ward, hospital unit) • Evidence to obtain SSI benefits after release • Obtain psychotropic medications (sedation)

11. Handbook of Correctional Mental Health (American Psychiatric Publishing-2005)

12. “Malingering Models” in Correctional Settings • “Criminological Model”: Malingering is a specific manifestation of antisocial behavior and attitudes: • “Chronic conning” (meds to get “high” or sell, transfer to another unit with more privileges, transfer to hospital where escape is more probable, etc) Handbook of Correctional Mental Health-(APPI) 2005 Jaffe ME, Sharma KK. J Forensic Sci (1998)

13. “Malingering Models” in Correctional Settings • “Adaptational Model”: Malingering is an attempt to succeed when faced with adverse circumstances: • (CA: ”third-strike psychosis”) • ? Misreporting of anxiety/mood symptoms as “voices” (consider administering anxiety scales along with malingering scales) Handbook of Correctional Mental Health-(APPI) 2005 Jaffe ME, Sharma KK. J Forensic Sci (1998)

14. Jail Malingering & Antipsychotics • “Iatrogenic” malingering reported in VA substance treatment program • “Intranasal quetiapine abuse” reported at LA County Jail, driven by drug’s sedative and anxiolytic effects rather than antipsychotic properties • Case report of “intravenous quetiapine abuse” in Canadian jail • Abuse of quetiapine has led to some correctional formularies restricting or limiting its use Pierre JM, Wirshing DA, Wirshing WC. Psychiatr Serv (2003) Pierre JM, et al. Am J Psychiatry (2004) Hussain MZ, et al Am J Psychiatry (2005)

15. Jail Malingering & Antipsychotics Is removing medication from jail formulary the answer? Mobile (AL) Register (March 5, 2005): • “Federal prisoner who was being held at Mobile County Metro Jail tried to commit suicide after officials took away his [Seroquel].” • “Jail staff indicated that they had banned the medicine because some inmates had been using it to get high.” • After legal motion filed, US District Court approved inmate transfer pt to federal medical facility

16. Malingering: Assessment • Collateral behavioral observations (nursing, custody) • Clinical interview, malingered “voices”: • Continuous rather than intermittent • Vague, inaudible • Not associated with delusions or thought disorder • No strategies to cope with “voices” • Claim that all instructions are obeyed Resnick PJ. Psychiatr Clin North Am (1999)

17. Malingering Assessment:Structured Interview of Reported Symptoms (SIRS): • Developed by Rogers, et al 1992; eight primary scales: • Rare symptoms (RS); • Symptom Combinations (SC); • Improbable/Absurd Symptoms (IA); • Blatant Symptoms (BL); • Subtle Symptoms (SU); • Severity of Symptoms (SEV); • Selectivity of Symptoms (SEL); • Reported vs. Observed Symptoms (RO) • Responses on these scales are classified as honest, indeterminate, probable, or definite Rogers R, Bagby RM, Gillis JR. SIRS-Psychological Assessment Resources (1992)

18. Malingering Assessment:Structured Interview of Reported Symptoms (SIRS): • An individual is considered to be malingering if he/she scores in the probable or definite range > 3 scales • Highly reliable measure extensively validated in correctional and forensic samples • Very low false-positive rates (accurately identifying malingering) Rogers R. Handbook of Diagnostic and Structured Interviewing (2001) Norris Mp, May MC. Law & Human Behavior (1998)

19. Malingering Assessment:Structured Interview of Reported Symptoms (SIRS): Limitations of the SIRS: • No indices to detect cognitive feigning • No information on genuine psychopathology is obtained (in contrast to MMPI-2) • Lengthy to administer (>1 hr); limits utility as rapid screening tool or for large numbers of subjects • Does not identify person’s motivation for feigning symptoms (nor does any psychological test)

20. Malingering: Assessment (SIRS) Sample questions: • “Do you believe [automobiles] have their own religion?” • “Do you become fearful of soft household objects for no real reasons?” • “Can common insects be used for electronic surveillance?”

21. Malingering Assessment:Miller Forensic Assessment of Symptoms (M-FAST) • Developed by Miller (2001) • 25 items designed as initial screen for malingered psychopathology; (“positive” screen may require further evaluation with SIRS) • Brief to administer (~5 min) • Research indicates cut off score of > 6 effective screen for malingered incompetence to stand trial Miller HA: Psychological Assessment Resources, Inc. (2001) Jackson R, Rogers R, Sewell K. Law & Human Behavior (2005)

22. Malingering Assessment:(M-FAST) Sample questions (“Rare combinations” & “Extreme symptoms”: • “The times when you can’t go to sleep, do you often smell strange odors that are not really there?” • “When I hear voices, my hands begin to sweat” • “Often, I get the strange feeling that I am from another planet” • “On many days I feel so bad that I can’t even remember my full name”

23. Summary Points: • There should be strong suspicion for malingering in forensic settings • Malingering for psychotropic medications is a growing problem for jails • Assessment of malingering should involve collateral observations and records • Consider the adjunctuse of validated screens (M-FAST) and tests (SIRS) • Need better exchange of clinical information between forensic settings (i.e., jails and state hospitals)