Hey, I wanted to put this post up because times are getting stranger, and assessing those inner voices is important. I remember in school, my teacher kept telling us if someone hear voices ask, how many? I just didn’t understand the purpose of feeding into the delusions or validating something that wasn’t “real”.
Anyway, this article is a nice breakdown of the importance of assessing real hallucinations voices versus malingering ones. It completely changed my view about hallucinations since I assumed most people wouldn’t “lie” about something so debilitating. Basically the more you know or assess, the more you can rule out:
About Audible Hallucinations vs. Malingering
The benefit of the doubt?
“Mr Arnold,” a 50-year-old Army veteran with a history of chronic depression and alcohol use disorder (in remission) was admitted to the hospital after complaining of “voices telling me to bayonet my wife… or someone else.” His outpatient psychiatrist, who had been treating with mirtazapine 45 mg/day and quetiapine 300 mg/day over the previous year, documented new onset command hallucinations and admitted the patient involuntarily based on homicidal ideation.
On subsequent exam with the inpatient team, Mr Arnold did not appear acutely depressed. His chief complaint was that he was hearing the voices of 3 military personnel—“a lieutenant, sergeant, and corporal”— who were all telling him to “kill people.” He then stated that he had “struck a deal with the corporal” such that he would not have to kill anyone if he killed himself. Mr Arnold, therefore, planned to do so by refusing all food other than milk and yogurt.
If the infamous social experiment by the late psychologist David Rosenhan, PhD, published in 1973 with the title “On Being Sane in Insane Places”1 taught us anything, it was that psychiatrists working in clinical settings may not always be the best at detecting malingered voice-hearing. Although a recent book has claimed that Rosenhan misrepresented what actually happened when he and 7 others were hospitalized based on false reports of hearing a voice saying words like “empty,” “hollow,” and “thud,”2 the take-home message of his experiment remains the same. When help-seeking individuals present with fabricated claims about hearing voices, psychiatrists will often respond in kind, offering antipsychotic therapy based on a provisional diagnosis of psychosis.
Without the ability to look inside the minds of patients who endorse hearing voices, and in the absence of any established biological marker or reliable neuroimaging blueprint for auditory verbal hallucinations, clinicians often resort to a benefit-of-the-doubt approach that assumes a help-seeking patient is ill. However, colluding with false claims of psychosis and disability and unnecessary exposure to antipsychotic side effects is not beneficial to patients.
In order to distinguish between real and feigned psychotic symptoms, a generation of psychiatrists has followed the guidelines of forensic psychiatrist Phillip Resnick, MD, who first published specific criteria more than 20 years ago to alert clinicians of suspicion of malingered auditory verbal hallucinations.3,4
However, more recent survey data has revealed that genuine auditory verbal hallucinations are more heterogeneous across the psychosis spectrum than originally thought5, such that Resnick has since de-emphasized typical and atypical features of voice-hearing in favor of “topics of inquiry” when assessing for malingered auditory verbal hallucinations (Table 1).6 Beyond the details of answers to such inquiries, suspicion of malingering should begin with purported symptoms that are endorsed in a cartoonish fashion with vagueness, evasiveness, inconsistency, and contradiction when further details are probed. The more a clinician asks, the less is learned, and often the encounter ends with hostile defensiveness by the patient. Clinicians must therefore take care to inquire about details as they would any other reported symptom, with open-ended questions that avoids premature confrontation about suspected misrepresentation during initial diagnostic interviews.
Since malingering is defined by feigned symptoms in the service of secondary gain, suspicions of malingering should be plausibly connected to identifiable rewards. When such incentives are not apparent, a broader differential diagnosis that includes factitious disorder should also be considered.
Malingered voice-hearing in clinical settings
Mr Arnold ate well on the unit and was continued on mirtazapine and quetiapine, which was reduced to 50 mg/day for insomnia. On further questioning, he reported hearing voices dating back to military service 20 years prior, and possibly as far back as childhood; chart review revealed no such complaints in previous notes. In addition to hearing voices, he endorsed significant difficulties with memory, including improbable claims that he was unaware of current world events, like the United States was at war with Iraq (which was true at the time). Due to atypical and inconsistently reported symptoms that spanned both psychotic and cognitive domains, malingering was suspected, and psychological testing was ordered for diagnostic clarification.
Most of the published literature on characteristics of malingered psychosis has been derived from studies of those instructed to feign symptoms within forensic samples in which the prevalence of malingering can be as high as 65%.7 Due to several key potential differences, however, the reports of voluntary simulators in such settings may not be a good representation of malingered psychosis encountered by psychiatrists in routine clinical practice (Table 2).8 Just so, the prevalence of malingering in clinical settings is largely unknown and likely varies widely across different patient populations and health care systems.
Unlike malingering in forensic settings, in which it is usually related to an avoidance of punishment for criminal behavior, malingering in clinical settings is usually motivated by an attempt to obtain care or social services (eg, hospital admission, medication, disability income) and often co-occurs with real mental illness, including substance use disorders. Malingered psychotic claims in clinical settings are often based on real experience with historical psychotic symptoms, and they may not be as cartoonish as the claims of some forensic simulators.
Clinicians should also bear in mind that feigned symptoms in clinical settings often represent iatrogenic malingering that is incentivized by structural barriers to receiving comprehensive care.8,9 Since hospital admission criteria have become more stringent with decreasing inpatient beds through the years, claims of suicidality or psychosis are often necessary to justify hospitalization. Consequently, a common complaint from a patient seeking admission is that they are “hearing voices telling me to kill myself.” Beyond auditory verbal hallucinations reflecting a psychotic disorder, such simple claims might variably represent an idiom of distress, a mislabeled experience (eg, a depressive rumination rather than a hallucination), a non-psychotic hallucination10-12, or iatrogenic malingering. Detailed clinical interviewing is required to tease apart these crucial distinctions.
With increasing recognition of the heterogeneity of voice-hearing experiences across the psychotic spectrum, relying on “correct” answers to questions about features of endorsed auditory verbal hallucinations to guide assessments of malingering has significant limitations.13 However, survey results indicate that typical features of auditory verbal hallucinations include voices that are clear, repetitive, at least partially controllable, and sound like real speech where the speaker is identifiable.5 In contrast, atypical and improbable experiences feigned by those wanting to appear psychotic might include seeing and hearing animals talking, describing an angel and devil on either shoulder alternately encouraging and discouraging bad behavior, claiming no control over voices, or endorsing command hallucinations that are always obeyed.6,8,13 Still, the detection of malingered auditory verbal hallucinations is often less about right and wrong answers about such details and more about whether those details can be consistently described at all.
Neuropsychological testing (Table 3) can be a useful supplement to clinical interviewing to help validate suspicions of malingered psychosis. The Structured Interview for Reported Symptoms (SIRS) 14, the Structured Inventory of Malingered Symptomatology (SIMS)15, and the Miller Forensic Assessment of Symptoms Test (M-FAST)16 represent gold standard assessments for the detection of malingered psychosis, based largely on questions that query endorsement of atypical, absurd, or outlandish psychotic symptoms. Similar tests have been validated to assess malingered cognitive symptoms including the Test of Memory Malingering (TOMM)17 and the Victoria Symptom Validity Test (VSVT).18 Having access to staff trained to administer such tests can be a great aid to reliable diagnostic assessment. However, tests of malingering have established norms that are based on voluntary simulators, may be less useful in clinical settings in the absence of outlandish claims, and should not be relied upon as a substitute for careful and thorough clinical interviewing.
“Finding the pony”
Attempts to complete neuropsychological testing were initially met with resistance, including threats to kill members of the treatment team. (“The deal with the corporal is off . . . I’m going to take everyone out!”) However, after Mr Arnold was told that he would be discharged in response to these threats, he retracted them, became apologetic, and agreed to complete testing. He scored well above the cut-off scores for malingering on the SIMS, M-FAST, TOMM, and VSVT based on gross over-endorsement of unusual symptoms.
Without directly confronting Mr Arnold about his test results, a subsequent interview was held to ascertain potential motives for secondary gain. In doing so, the team learned that he made several unsuccessful attempts to obtain service-connected disability and had been recently told that his case was closed. The team responded empathically and guided him to resources about applying for Social Security Disability Insurance for legitimate medical complaints. He soon stopped endorsing psychotic symptoms and homicidal ideation and self-discharged the next day.
Clinicians should be mindful that confrontations about suspected or detected malingering may result in patients upping the ante with threats of violence or self-injury. It is therefore recommended that clinicians allow patients to save face when providing diagnostic feedback instead of accusing them of lying. Clinicians should also strive to “find the pony” by assessing patients in a thorough but non-confrontational manner with a goal of empathic and compassionate understanding of legitimate sources of personal distress.
Uncovering the secondary gain motives of malingering allow clinicians to identify the biopsychosocial origins of distress and offer interventions in kind, including psychotherapy, housing, disability income support, and treatment of substance use disorders. This holistic approach can be useful in both diagnosing and treating malingering through disincentivization. Non-antipsychotic pharmacotherapy targeting symptoms of insomnia, anxiety, and substance withdrawal can also help resolve co-occurring claims of hearing voices.19
Countertransference and treatment success
After discharge, Mr Arnold made no further mention of hearing voices to his outpatient psychiatrist, who had been given a “warm hand-off” by the inpatient team. However, after transferring care to a new psychiatrist the next year, Mr Arnold renewed complaints about hearing voices along with novel endorsement of posttraumatic stress disorder (PTSD) symptoms that he attributed to having a heavy object fall on him during military service. He was prescribed chlorpromazine, sertraline, and prazosin based on a diagnosis of atypical psychosis and PTSD.
After a few more years in treatment, Mr Arnold’s psychiatrist revised his diagnosis to reflect malingering and discontinued antipsychotic medication in favor of antidepressant monotherapy. However, Mr Arnold eventually decided that he no longer wanted to take any psychiatric medication and dropped out of psychiatric care. Over the next 5 years—12 years after his original hospitalization—he did well without psychiatric treatment and did not endorse psychiatric symptoms during primary care visits.
Successfully managing malingering requires clinicians to maintain awareness of countertransference issues. Physicians are not generally taught in medical school to consider malingering within a differential diagnosis or how to withhold requests for diagnoses and interventions that are requested but are harmful or not indicated.20 Psychiatrists may, therefore, find it difficult to diagnose malingering and are often more concerned about missing real mental illness (eg, false negatives) than the problem of inappropriate diagnosis (eg, false positives).8 Longitudinal assessment can often help resolve diagnostic ambivalence.
When a diagnosis of malingering is ultimately made, psychiatrists and other mental health workers must manage their reactions to the fact that the patient lied to them. This is best accomplished by understanding the ubiquity of lying as a normal and adaptive human behavior—the average person lies once or twice a day21—that is further incentivized by the limited resources for help available to people in distress due to difficult life circumstances. Like any clinical diagnosis, a diagnosis of malingering should ideally guide appropriate interventions, not steer patients away from mental health care altogether. Over time, however, resolution of malingering’s “symptoms” and the motivations that underlie them should be considered a treatment success.
Concluding thoughts
Auditory verbal hallucinations are a common claim when people malinger psychiatric symptoms since they suggest the presence of a severe mental illness and are largely unverifiable beyond clinical judgment. Careful clinical interviewing, identification of secondary gains, and supplemental psychological testing provide the best approach to assessment. Once a diagnosis of malingering is made, clinical management that recognizes iatrogenic causes and disincentivizes misrepresentation by addressing legitimate sources of distress can be therapeutic and can help to confirm the diagnosis.
