James Knoll, MD

A patient, a colleague, or perhaps you have been stalked. The chances of a woman being stalked are an estimated 1 in 14; for men, it is 1 in 50.¹ Fearful stalking victims may restrict their lives, change jobs, and curtail social activities to protect themselves from unwanted attention, physical assault, or even murder. They may develop anxiety, depression, or posttraumatic stress disorder (PTSD).^2,3

Historical, clinical, and behavioral factors increase a stalker’s risk for committing violence (Table 1).^2-7 As a psychiatrist, you may be asked to consult with local law enforcement and stalking victims to assess and manage victims’ risk. To best protect them, be aware of:

• 5 types of stalkers and their typical response to management strategies
  
• legal and safety issues to consider before taking actions that might endanger stalking victims
  
• strategies to help victims protect themselves
  
• interventions for victims and stalkers.
  

Table 1

Factors that increase the risk of violence

Stalker types

Mullen et al⁸ developed a clinically oriented, validated stalker classification system to identify an individual stalker’s type, risks, and probable responses to management interventions (Table 2).

Rejected stalkers—the most common and dangerous type—pursue the victim, often a former intimate partner, after a relationship ends. They often acknowledge a complex and volatile mix of desire for reconciliation and revenge. These stalkers likely have a history of criminal assault.

Rejected stalkers appear to respond best to a combination of coordinated legal sanctions and mental health intervention. Because they are most likely to be violent, rejected stalkers need intensive probation or parole supervision.⁵

Intimacy-seeking stalkers want an intimate relationship with a victim they believe is their “true love” and tend to imbue their victims with special desirability, excellence, and other qualities consistent with their belief of romanticized love. Most have erotomanic delusions, and the rest have morbid infatuations with the victim. Intimacy-seeking stalkers typically are unperturbed by legal sanctions, viewing them as the price to pay for “true love.” They often require court-mandated psychiatric treatment.

Incompetent stalkers know the victim is disinterested but forge ahead in hopes that their behavior will lead to a relationship. Their stalking can be viewed as crude or “incompetent” attempts to court the victim. Incompetent stalkers often are intellectually limited; they feel entitled to a partner but because of underdeveloped social skills are unable to build upon lesser forms of social interaction. Unlike intimacy-seekers, incompetent stalkers do not endow the victim with unique qualities.

In addition to needing legal sanctions and possible mental health treatment, incompetent stalkers often require social skills training. Otherwise, they are likely to continue their pattern of stalking with other victims.

Resentful stalkers who suffer from mental illness generally require court-ordered psychiatric treatment but are difficult to engage in therapy. Legal sanctions may inflame this type of stalker.

Predatory stalkers prepare for a sexual assault. They stalk to discover the victim’s vulnerabilities and seldom give warnings, so the victim is often unaware of the danger.

Predatory stalkers frequently suffer from paraphilias and have prior convictions for sexual offenses. They must be secured in a correctional or forensic setting to address their paraphilias and propensity for violence.

Table 2

Identifying types of stalkers

Managing victims’ risk

Effectively managing a victim’s stalking risk is a dynamic process. It is critical to use professional judgment in a flexible manner and to work as a team with professionals from other agencies (Box).^9-12

Protective orders. Obtaining a protective order may or may not be helpful. Most domestic violence research indicates that such orders protect abused women.¹³ This is important because stalking by a former intimate partner often occurs in relationships characterized by domestic violence.¹⁴ In addition to potentially preventing stalking behavior, a protective order may provide legal evidence of the course of stalking, as well as document a “fearful victim,” which is required by law to obtain a criminal conviction.

No conclusive studies have investigated the effectiveness of protective orders specifically related to stalkers, so consider the stalker’s reaction to previous orders.¹⁵ Counsel a victim who obtains a protective order against a former intimate partner to avoid developing a false sense of security. Rejected stalkers who have considerable emotional investment in the relationship may not be deterred by the threat of criminal sanctions. Furthermore, stalkers who are psychotic may misperceive and disregard criminal injunctions. In rare cases, a protective order may escalate stalking and violence.¹⁵

Dramatic moments. Advise a victim to remain vigilant during “dramatic moments” when violence risk may be especially heightened.¹⁵ These include:

• arrests
  
• issuance of protective orders
  
• court hearings
  
• custody hearings
  
• anniversary dates
  
• family-oriented holidays.
  

• arranging to be out of town on that date
  
• notifying law enforcement and victim advocates.
  

Treating victims’ symptoms

As a result of the risks they face, stalking victims often suffer significant “social damage.” To cope with being stalked, many victims must make substantial life changes, such as relocating or finding new employment. They may need to restrict outings, adapt security measures, and take time off from work.¹⁶ This social damage and anxiety may predispose them to substance abuse.¹⁷

Stalking victims also experience emotional distress.^3,18 They commonly report symptoms of anxiety disorders, in particular PTSD, and one-quarter experience depression and suicidal ruminations.¹⁹ Victims who perceive their stalking as severe report elevated levels of helplessness, anxiety, PTSD, and depression.²⁰

Few studies focus on the duration of victims’ symptoms or their successful treatment.²¹ Mullen⁸ has recommended a comprehensive approach that includes education, supportive counseling, psychotherapy, and pharmacotherapy. In particular, cognitive-oriented therapy can target common issues such as anxiety leading to feelings of loss of control and associated avoidance. Pharmacotherapy for anxiety or depressive symptoms follows recommended treatment guidelines.

Because the stalking and associated stress may have an adverse impact on the victim’s personal relationships, partner and family therapy may be necessary. Support organizations for stalking victims, such as Survivors of Stalking, can provide education, safety information, and emotional support.

Improving victims’ safety

Coach a victim to take responsibility for his or her safety by becoming familiar with local stalking laws, resources, and law enforcement policies.^13,22 Emphasize that a victim must be assertive to ensure that safety measures are in place (Table 3).^3,8,10,15,18

As soon as unwanted pursuit is apparent, the victim should unequivocally tell the stalker that no relationship is wanted.⁸ This message must be firm, reasonable, and as clear as possible. The victim should not attempt to deliver the message gently or let the stalker “down easy.” Otherwise, the stalker may believe the victim is ambivalent about the decision and will continue or redouble his or her efforts.

After delivering this message, the victim should not engage in any further discussion or initiate contact with the stalker. The victim must avoid all contact to minimize the effects of “intermittent positive reinforcement.”¹⁵

The victim should document and preserve evidence by recording the dates and times of each unwanted contact, including vandalism, in an “incident log” or journal. Encourage him or her to photograph and note the date of any property damage. This documentation will help establish a clear course of illegal conduct and can prove invaluable to police and prosecution efforts.

The victim should preserve any evidence—including gifts, mementos, and other materials—by placing it in a plastic bag labeled with the date, time, and place it was received. Encourage the victim to:

• resist the urge to discard evidence that may evoke feelings of fear, shame, or disgust
  
• avoid handling evidence, and store it in a secure location.
  

• establish a post office box to prevent someone from stealing mail containing personal information
  
• shred personal mail instead of placing it in the trash.
  

Security experts often advise victims not to adhere to their usual, predictable routines by, for example, taking different daily travel routes or being prepared to go out of town at short notice.² Victims should also make contingency plans in case their social supports are unavailable in an emergency. Victim advocacy agents can give information about services and locations of local “safe houses” or domestic violence shelters.

Table 3

Victim safety strategies

Treating stalkers

Failing to treat a mentally ill stalker may result in continued risk to the victim. For example, an intimacy-seeking stalker with erotomanic delusions who is confined without treatment likely will be released with no significant reduction in risk. No reliable outcome data exist on treatment for stalkers, however, so you must rely on empirically derived clinical data.

If you work with stalkers, you must be familiar with your state’s duty-to-protect statutes and relevant case law related to stalking so you can discuss legal obligations with the stalker before beginning treatment.

Most stalkers will be difficult to engage in treatment because they have been compelled by a court order to seek therapy. Initially you are likely to encounter the stalker’s striking lack of insight into the nature and consequences of this behavior. The stalker may seek validation for his or her actions while demonstrating little interest in ending the obsessional behavior. Expect well-entrenched defenses of denial, rationalization, and minimization.

A comprehensive description of treatment for stalkers is beyond the scope of this article. However, clinicians with experience treating stalkers recommend the following interventions:⁴

• thorough psychiatric assessment and diagnosis
  
• treatment of Axis I or II pathology
  
• cognitive-behavioral therapy to focus on the stalker’s misperceptions
  
• motivational interviewing techniques to help the stalker appreciate the need for intervention
  
• victim empathy development
  
• social skills enhancement
  
• periodic risk assessments.
  

• Stalking Resource Center, National Center for Victims of Crime. www.ncvc.org/src.
  
• Pinals DA, ed. Stalking: a psychiatric perspective. New York: Oxford University Press; 2007.
  
• The Antistalking Web Site resources. www.antistalking.com/resource.htm.
  
• U.S. Department of Justice anti-stalking resources. www.usdoj.gov/ovw/stalking.htm.
  

The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

A patient, a colleague, or perhaps you have been stalked. The chances of a woman being stalked are an estimated 1 in 14; for men, it is 1 in 50.¹ Fearful stalking victims may restrict their lives, change jobs, and curtail social activities to protect themselves from unwanted attention, physical assault, or even murder. They may develop anxiety, depression, or posttraumatic stress disorder (PTSD).^2,3

Historical, clinical, and behavioral factors increase a stalker’s risk for committing violence (Table 1).^2-7 As a psychiatrist, you may be asked to consult with local law enforcement and stalking victims to assess and manage victims’ risk. To best protect them, be aware of:

• 5 types of stalkers and their typical response to management strategies
  
• legal and safety issues to consider before taking actions that might endanger stalking victims
  
• strategies to help victims protect themselves
  
• interventions for victims and stalkers.
  

Table 1

Factors that increase the risk of violence

Stalker types

Mullen et al⁸ developed a clinically oriented, validated stalker classification system to identify an individual stalker’s type, risks, and probable responses to management interventions (Table 2).

Rejected stalkers—the most common and dangerous type—pursue the victim, often a former intimate partner, after a relationship ends. They often acknowledge a complex and volatile mix of desire for reconciliation and revenge. These stalkers likely have a history of criminal assault.

Rejected stalkers appear to respond best to a combination of coordinated legal sanctions and mental health intervention. Because they are most likely to be violent, rejected stalkers need intensive probation or parole supervision.⁵

Intimacy-seeking stalkers want an intimate relationship with a victim they believe is their “true love” and tend to imbue their victims with special desirability, excellence, and other qualities consistent with their belief of romanticized love. Most have erotomanic delusions, and the rest have morbid infatuations with the victim. Intimacy-seeking stalkers typically are unperturbed by legal sanctions, viewing them as the price to pay for “true love.” They often require court-mandated psychiatric treatment.

Incompetent stalkers know the victim is disinterested but forge ahead in hopes that their behavior will lead to a relationship. Their stalking can be viewed as crude or “incompetent” attempts to court the victim. Incompetent stalkers often are intellectually limited; they feel entitled to a partner but because of underdeveloped social skills are unable to build upon lesser forms of social interaction. Unlike intimacy-seekers, incompetent stalkers do not endow the victim with unique qualities.

In addition to needing legal sanctions and possible mental health treatment, incompetent stalkers often require social skills training. Otherwise, they are likely to continue their pattern of stalking with other victims.

Resentful stalkers who suffer from mental illness generally require court-ordered psychiatric treatment but are difficult to engage in therapy. Legal sanctions may inflame this type of stalker.

Predatory stalkers prepare for a sexual assault. They stalk to discover the victim’s vulnerabilities and seldom give warnings, so the victim is often unaware of the danger.

Predatory stalkers frequently suffer from paraphilias and have prior convictions for sexual offenses. They must be secured in a correctional or forensic setting to address their paraphilias and propensity for violence.

Table 2

Identifying types of stalkers

Managing victims’ risk

Effectively managing a victim’s stalking risk is a dynamic process. It is critical to use professional judgment in a flexible manner and to work as a team with professionals from other agencies (Box).^9-12

Protective orders. Obtaining a protective order may or may not be helpful. Most domestic violence research indicates that such orders protect abused women.¹³ This is important because stalking by a former intimate partner often occurs in relationships characterized by domestic violence.¹⁴ In addition to potentially preventing stalking behavior, a protective order may provide legal evidence of the course of stalking, as well as document a “fearful victim,” which is required by law to obtain a criminal conviction.

No conclusive studies have investigated the effectiveness of protective orders specifically related to stalkers, so consider the stalker’s reaction to previous orders.¹⁵ Counsel a victim who obtains a protective order against a former intimate partner to avoid developing a false sense of security. Rejected stalkers who have considerable emotional investment in the relationship may not be deterred by the threat of criminal sanctions. Furthermore, stalkers who are psychotic may misperceive and disregard criminal injunctions. In rare cases, a protective order may escalate stalking and violence.¹⁵

Dramatic moments. Advise a victim to remain vigilant during “dramatic moments” when violence risk may be especially heightened.¹⁵ These include:

• arrests
  
• issuance of protective orders
  
• court hearings
  
• custody hearings
  
• anniversary dates
  
• family-oriented holidays.
  

• arranging to be out of town on that date
  
• notifying law enforcement and victim advocates.
  

Treating victims’ symptoms

As a result of the risks they face, stalking victims often suffer significant “social damage.” To cope with being stalked, many victims must make substantial life changes, such as relocating or finding new employment. They may need to restrict outings, adapt security measures, and take time off from work.¹⁶ This social damage and anxiety may predispose them to substance abuse.¹⁷

Stalking victims also experience emotional distress.^3,18 They commonly report symptoms of anxiety disorders, in particular PTSD, and one-quarter experience depression and suicidal ruminations.¹⁹ Victims who perceive their stalking as severe report elevated levels of helplessness, anxiety, PTSD, and depression.²⁰

Few studies focus on the duration of victims’ symptoms or their successful treatment.²¹ Mullen⁸ has recommended a comprehensive approach that includes education, supportive counseling, psychotherapy, and pharmacotherapy. In particular, cognitive-oriented therapy can target common issues such as anxiety leading to feelings of loss of control and associated avoidance. Pharmacotherapy for anxiety or depressive symptoms follows recommended treatment guidelines.

Because the stalking and associated stress may have an adverse impact on the victim’s personal relationships, partner and family therapy may be necessary. Support organizations for stalking victims, such as Survivors of Stalking, can provide education, safety information, and emotional support.

Improving victims’ safety

Coach a victim to take responsibility for his or her safety by becoming familiar with local stalking laws, resources, and law enforcement policies.^13,22 Emphasize that a victim must be assertive to ensure that safety measures are in place (Table 3).^3,8,10,15,18

As soon as unwanted pursuit is apparent, the victim should unequivocally tell the stalker that no relationship is wanted.⁸ This message must be firm, reasonable, and as clear as possible. The victim should not attempt to deliver the message gently or let the stalker “down easy.” Otherwise, the stalker may believe the victim is ambivalent about the decision and will continue or redouble his or her efforts.

After delivering this message, the victim should not engage in any further discussion or initiate contact with the stalker. The victim must avoid all contact to minimize the effects of “intermittent positive reinforcement.”¹⁵

The victim should document and preserve evidence by recording the dates and times of each unwanted contact, including vandalism, in an “incident log” or journal. Encourage him or her to photograph and note the date of any property damage. This documentation will help establish a clear course of illegal conduct and can prove invaluable to police and prosecution efforts.

The victim should preserve any evidence—including gifts, mementos, and other materials—by placing it in a plastic bag labeled with the date, time, and place it was received. Encourage the victim to:

• resist the urge to discard evidence that may evoke feelings of fear, shame, or disgust
  
• avoid handling evidence, and store it in a secure location.
  

• establish a post office box to prevent someone from stealing mail containing personal information
  
• shred personal mail instead of placing it in the trash.
  

Security experts often advise victims not to adhere to their usual, predictable routines by, for example, taking different daily travel routes or being prepared to go out of town at short notice.² Victims should also make contingency plans in case their social supports are unavailable in an emergency. Victim advocacy agents can give information about services and locations of local “safe houses” or domestic violence shelters.

Table 3

Victim safety strategies

Treating stalkers

Failing to treat a mentally ill stalker may result in continued risk to the victim. For example, an intimacy-seeking stalker with erotomanic delusions who is confined without treatment likely will be released with no significant reduction in risk. No reliable outcome data exist on treatment for stalkers, however, so you must rely on empirically derived clinical data.

If you work with stalkers, you must be familiar with your state’s duty-to-protect statutes and relevant case law related to stalking so you can discuss legal obligations with the stalker before beginning treatment.

Most stalkers will be difficult to engage in treatment because they have been compelled by a court order to seek therapy. Initially you are likely to encounter the stalker’s striking lack of insight into the nature and consequences of this behavior. The stalker may seek validation for his or her actions while demonstrating little interest in ending the obsessional behavior. Expect well-entrenched defenses of denial, rationalization, and minimization.

A comprehensive description of treatment for stalkers is beyond the scope of this article. However, clinicians with experience treating stalkers recommend the following interventions:⁴

• thorough psychiatric assessment and diagnosis
  
• treatment of Axis I or II pathology
  
• cognitive-behavioral therapy to focus on the stalker’s misperceptions
  
• motivational interviewing techniques to help the stalker appreciate the need for intervention
  
• victim empathy development
  
• social skills enhancement
  
• periodic risk assessments.
  

• Stalking Resource Center, National Center for Victims of Crime. www.ncvc.org/src.
  
• Pinals DA, ed. Stalking: a psychiatric perspective. New York: Oxford University Press; 2007.
  
• The Antistalking Web Site resources. www.antistalking.com/resource.htm.
  
• U.S. Department of Justice anti-stalking resources. www.usdoj.gov/ovw/stalking.htm.
  

The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

A patient, a colleague, or perhaps you have been stalked. The chances of a woman being stalked are an estimated 1 in 14; for men, it is 1 in 50.¹ Fearful stalking victims may restrict their lives, change jobs, and curtail social activities to protect themselves from unwanted attention, physical assault, or even murder. They may develop anxiety, depression, or posttraumatic stress disorder (PTSD).^2,3

Historical, clinical, and behavioral factors increase a stalker’s risk for committing violence (Table 1).^2-7 As a psychiatrist, you may be asked to consult with local law enforcement and stalking victims to assess and manage victims’ risk. To best protect them, be aware of:

• 5 types of stalkers and their typical response to management strategies
  
• legal and safety issues to consider before taking actions that might endanger stalking victims
  
• strategies to help victims protect themselves
  
• interventions for victims and stalkers.
  

Table 1

Factors that increase the risk of violence

Stalker types

Mullen et al⁸ developed a clinically oriented, validated stalker classification system to identify an individual stalker’s type, risks, and probable responses to management interventions (Table 2).

Rejected stalkers—the most common and dangerous type—pursue the victim, often a former intimate partner, after a relationship ends. They often acknowledge a complex and volatile mix of desire for reconciliation and revenge. These stalkers likely have a history of criminal assault.

Rejected stalkers appear to respond best to a combination of coordinated legal sanctions and mental health intervention. Because they are most likely to be violent, rejected stalkers need intensive probation or parole supervision.⁵

Intimacy-seeking stalkers want an intimate relationship with a victim they believe is their “true love” and tend to imbue their victims with special desirability, excellence, and other qualities consistent with their belief of romanticized love. Most have erotomanic delusions, and the rest have morbid infatuations with the victim. Intimacy-seeking stalkers typically are unperturbed by legal sanctions, viewing them as the price to pay for “true love.” They often require court-mandated psychiatric treatment.

Incompetent stalkers know the victim is disinterested but forge ahead in hopes that their behavior will lead to a relationship. Their stalking can be viewed as crude or “incompetent” attempts to court the victim. Incompetent stalkers often are intellectually limited; they feel entitled to a partner but because of underdeveloped social skills are unable to build upon lesser forms of social interaction. Unlike intimacy-seekers, incompetent stalkers do not endow the victim with unique qualities.

In addition to needing legal sanctions and possible mental health treatment, incompetent stalkers often require social skills training. Otherwise, they are likely to continue their pattern of stalking with other victims.

Resentful stalkers who suffer from mental illness generally require court-ordered psychiatric treatment but are difficult to engage in therapy. Legal sanctions may inflame this type of stalker.

Predatory stalkers prepare for a sexual assault. They stalk to discover the victim’s vulnerabilities and seldom give warnings, so the victim is often unaware of the danger.

Predatory stalkers frequently suffer from paraphilias and have prior convictions for sexual offenses. They must be secured in a correctional or forensic setting to address their paraphilias and propensity for violence.

Table 2

Identifying types of stalkers

Managing victims’ risk

Effectively managing a victim’s stalking risk is a dynamic process. It is critical to use professional judgment in a flexible manner and to work as a team with professionals from other agencies (Box).^9-12

Protective orders. Obtaining a protective order may or may not be helpful. Most domestic violence research indicates that such orders protect abused women.¹³ This is important because stalking by a former intimate partner often occurs in relationships characterized by domestic violence.¹⁴ In addition to potentially preventing stalking behavior, a protective order may provide legal evidence of the course of stalking, as well as document a “fearful victim,” which is required by law to obtain a criminal conviction.

No conclusive studies have investigated the effectiveness of protective orders specifically related to stalkers, so consider the stalker’s reaction to previous orders.¹⁵ Counsel a victim who obtains a protective order against a former intimate partner to avoid developing a false sense of security. Rejected stalkers who have considerable emotional investment in the relationship may not be deterred by the threat of criminal sanctions. Furthermore, stalkers who are psychotic may misperceive and disregard criminal injunctions. In rare cases, a protective order may escalate stalking and violence.¹⁵

Dramatic moments. Advise a victim to remain vigilant during “dramatic moments” when violence risk may be especially heightened.¹⁵ These include:

• arrests
  
• issuance of protective orders
  
• court hearings
  
• custody hearings
  
• anniversary dates
  
• family-oriented holidays.
  

• arranging to be out of town on that date
  
• notifying law enforcement and victim advocates.
  

Treating victims’ symptoms

As a result of the risks they face, stalking victims often suffer significant “social damage.” To cope with being stalked, many victims must make substantial life changes, such as relocating or finding new employment. They may need to restrict outings, adapt security measures, and take time off from work.¹⁶ This social damage and anxiety may predispose them to substance abuse.¹⁷

Stalking victims also experience emotional distress.^3,18 They commonly report symptoms of anxiety disorders, in particular PTSD, and one-quarter experience depression and suicidal ruminations.¹⁹ Victims who perceive their stalking as severe report elevated levels of helplessness, anxiety, PTSD, and depression.²⁰

Few studies focus on the duration of victims’ symptoms or their successful treatment.²¹ Mullen⁸ has recommended a comprehensive approach that includes education, supportive counseling, psychotherapy, and pharmacotherapy. In particular, cognitive-oriented therapy can target common issues such as anxiety leading to feelings of loss of control and associated avoidance. Pharmacotherapy for anxiety or depressive symptoms follows recommended treatment guidelines.

Because the stalking and associated stress may have an adverse impact on the victim’s personal relationships, partner and family therapy may be necessary. Support organizations for stalking victims, such as Survivors of Stalking, can provide education, safety information, and emotional support.

Improving victims’ safety

Coach a victim to take responsibility for his or her safety by becoming familiar with local stalking laws, resources, and law enforcement policies.^13,22 Emphasize that a victim must be assertive to ensure that safety measures are in place (Table 3).^3,8,10,15,18

As soon as unwanted pursuit is apparent, the victim should unequivocally tell the stalker that no relationship is wanted.⁸ This message must be firm, reasonable, and as clear as possible. The victim should not attempt to deliver the message gently or let the stalker “down easy.” Otherwise, the stalker may believe the victim is ambivalent about the decision and will continue or redouble his or her efforts.

After delivering this message, the victim should not engage in any further discussion or initiate contact with the stalker. The victim must avoid all contact to minimize the effects of “intermittent positive reinforcement.”¹⁵

The victim should document and preserve evidence by recording the dates and times of each unwanted contact, including vandalism, in an “incident log” or journal. Encourage him or her to photograph and note the date of any property damage. This documentation will help establish a clear course of illegal conduct and can prove invaluable to police and prosecution efforts.

The victim should preserve any evidence—including gifts, mementos, and other materials—by placing it in a plastic bag labeled with the date, time, and place it was received. Encourage the victim to:

• resist the urge to discard evidence that may evoke feelings of fear, shame, or disgust
  
• avoid handling evidence, and store it in a secure location.
  

• establish a post office box to prevent someone from stealing mail containing personal information
  
• shred personal mail instead of placing it in the trash.
  

Security experts often advise victims not to adhere to their usual, predictable routines by, for example, taking different daily travel routes or being prepared to go out of town at short notice.² Victims should also make contingency plans in case their social supports are unavailable in an emergency. Victim advocacy agents can give information about services and locations of local “safe houses” or domestic violence shelters.

Table 3

Victim safety strategies

Treating stalkers

Failing to treat a mentally ill stalker may result in continued risk to the victim. For example, an intimacy-seeking stalker with erotomanic delusions who is confined without treatment likely will be released with no significant reduction in risk. No reliable outcome data exist on treatment for stalkers, however, so you must rely on empirically derived clinical data.

If you work with stalkers, you must be familiar with your state’s duty-to-protect statutes and relevant case law related to stalking so you can discuss legal obligations with the stalker before beginning treatment.

Most stalkers will be difficult to engage in treatment because they have been compelled by a court order to seek therapy. Initially you are likely to encounter the stalker’s striking lack of insight into the nature and consequences of this behavior. The stalker may seek validation for his or her actions while demonstrating little interest in ending the obsessional behavior. Expect well-entrenched defenses of denial, rationalization, and minimization.

A comprehensive description of treatment for stalkers is beyond the scope of this article. However, clinicians with experience treating stalkers recommend the following interventions:⁴

• thorough psychiatric assessment and diagnosis
  
• treatment of Axis I or II pathology
  
• cognitive-behavioral therapy to focus on the stalker’s misperceptions
  
• motivational interviewing techniques to help the stalker appreciate the need for intervention
  
• victim empathy development
  
• social skills enhancement
  
• periodic risk assessments.
  

• Stalking Resource Center, National Center for Victims of Crime. www.ncvc.org/src.
  
• Pinals DA, ed. Stalking: a psychiatric perspective. New York: Oxford University Press; 2007.
  
• The Antistalking Web Site resources. www.antistalking.com/resource.htm.
  
• U.S. Department of Justice anti-stalking resources. www.usdoj.gov/ovw/stalking.htm.
  

The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

Reputed Cosa Nostra boss Vincent “The Chin” Gigante deceived “the most respected minds in forensic psychiatry” for years by malingering schizophrenia.¹ Ultimately, he admitted to maintaining his charade from 1990 to 1997 during evaluations of his competency to stand trial for racketeering.

A lesson from this case—said a psychiatrist who concluded Gigante was malingering—is, “When feigning is a consideration, we must be more critical and less accepting of our impressions when we conduct and interpret a psychiatric examination…than might be the case in a typical clinical situation.”²

Even in typical clinical situations, however, psychiatrists may be reluctant to diagnose malingering³ for fear of being sued, assaulted—or wrong. An inaccurate diagnosis of malingering may unjustly stigmatize a patient and deny him needed care.⁴

Because psychiatrists need a systematized approach to detect malingering,⁵ we offer specific clinical factors and approaches to help you recognize malingered psychosis.

What is Malingering?

No other syndrome is as easy to define yet so difficult to diagnose as malingering. Reliably diagnosing malingered mental illness is complex, requiring the psychiatrist to consider collateral data beyond the patient interview.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.⁶ In practice, malingering commonly must be differentiated from factitious disorder, which also involves intentional production of symptoms. In factitious disorders, the patient’s motivation is to assume the sick role, which can be thought of as an internal or psychological incentive.

Three categories of malingering include:

• pure malingering (feigning a nonexistent disorder)
• partial malingering (consciously exaggerating real symptoms)
• false imputation (ascribing real symptoms to a cause the individual knows is unrelated to the symptoms).⁷

Motivations. Individuals usually malinger to avoid pain (such as difficult situations or punishment) or to seek pleasure (such as to obtain compensation or medications) (Table 1). In correctional settings, for example, inmates may malinger mental illness to do “easier time” or to obtain drugs. On the other hand, malingering in prison also may be an adaptive response by a mentally ill inmate to relatively sparse and difficult-to-obtain mental health resources.⁸

Table 1

Common motives of malingerers

Interview Style

When you suspect a patient is malingering, keep your suspicions to yourself and conduct an objective evaluation. Patients are likely to become defensive if you show annoyance or incredulity, and putting them on guard decreases your ability to uncover evidence of malingering.⁹

Begin by asking open-ended questions, which allow patients to report symptoms in their own words. To avoid hinting at correct responses, carefully phrase initial inquiries about symptoms. Later in the interview, you can proceed to more-detailed questions of specific symptoms, as discussed below.

If possible, review collateral data before the interview, when it is most helpful. Consider information that would support or refute the alleged symptoms, such as treatment and insurance records, police reports, and interviews of close friends or family.

The patient interview may be prolonged because fatigue may diminish a malingerer’s ability to maintain fake symptoms. In very difficult cases, consider monitoring during inpatient assessment because feigned psychosis is extremely difficult to maintain 24 hours a day.

Watch for individuals who endorse rare or improbable symptoms. Rare symptoms—by definition—occur very infrequently, and even severely disturbed patients almost never report improbable symptoms.¹⁰ Consider asking malingerers about improbable symptoms to see if they will endorse them. For example:

• “When people talk to you, do you see the words they speak spelled out?”¹¹
• “Have you ever believed that automobiles are members of an organized religion?”¹²

Watch closely for internal or external inconsistency in the suspected malingerer’s presentation (Table 2).

Table 2

Clues to identify malingering during patient evaluation

Malingered Psychotic Symptoms

Detecting malingered mental illness is considered an advanced psychiatric skill, partly because you must understand thoroughly how genuine psychotic symptoms manifest.

Hallucinations. If a patient alleges atypical hallucinations, ask about them in detail. Hallucinations are usually (88%) associated with delusions.¹³ Genuine hallucinations are typically intermittent rather than continuous.

Continue to: Auditory hallucinations

Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).¹⁴ In schizophrenia, the major themes are persecutory or instructive.¹⁵

Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:

• do not always obey the voices, especially if doing so would be dangerous¹⁶
• usually present with noncommand hallucinations (85%) and delusions (75%) as well¹⁷

Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:

• engaging in activities (working, listening to a radio, watching TV)
• changing posture (lying down, walking)
• seeking interpersonal contact
• taking medications.

If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.

Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:

• an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
• a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”

Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.

Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).¹⁸

Genuine visual hallucinations are usually of normalsized people and are seen in color.¹⁴ On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.

Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.¹⁹

Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.

Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.²⁰

Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).

With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.

Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.

Table 3

Uncommon psychosis presentations that suggest malingering

Where Malingerers Trip Up

Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.²¹

Continue to: Numerous clinical factors suggest malingering...

Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.²²

Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.²³

Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.

Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.

Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.

Table 4

Clinical factors that suggest malingering

Psychological Testing

Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:

• Structured Interview of Reported Symptoms (SIRS)
• Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
• Miller Forensic Assessment of Symptoms Test (M-FAST).¹¹

SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.²⁴

Two MMPI-2 scales—F-scale and F-K Index—are the most frequently used test for evaluating suspected malingering. When using the MMPI-2 in this manner, consult the literature for appropriate cutoff scores (see Related resources). Although the MMPI-2 is the most validated psychometric method to detect malingering, a malingerer with high intelligence and previous knowledge of the test could evade detection.²⁵

M-FAST was developed to provide a brief, reliable screen for malingered mental illness. This test takes 10 to 15 minutes to administer and measures rare symptom combinations, excessive reporting, and atypical symptoms.¹¹ It has shown good validity and high correlation with the SIRS and MMPI-2.^26,27

Confronting the Malingerer

If a thorough investigation indicates that a patient is malingering psychosis, you may decide to confront the evaluee. Avoid direct accusations of lying,¹⁰ and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, “You haven’t told me the whole truth.”

A thoughtful approach that asks the evaluee to clarify inconsistencies is more likely to be productive and safer for the examiner. When confronting individuals with a history of violence and aggression, have adequate security personnel with you.

Related resources

• Structured Interview of Reported Symptoms (SIRS). Available for purchase from Psychological Assessment Resources at www3.parinc.com (enter “SIRS” in search field).
• Graham JR. MMPI-2: Assessing personality and psychopathology. New York: Oxford Press; 2000. (Source of cutoff scores to use MMPI-2 scales [F-scale and F-K Index] to evaluate suspected malingering).
• Psychological Assessment Resources, Inc. Miller Forensic Assessment of Symptoms Test (M-FAST). Available at: www3.parinc.com (enter “M-FAST” in search field).

Reputed Cosa Nostra boss Vincent “The Chin” Gigante deceived “the most respected minds in forensic psychiatry” for years by malingering schizophrenia.¹ Ultimately, he admitted to maintaining his charade from 1990 to 1997 during evaluations of his competency to stand trial for racketeering.

A lesson from this case—said a psychiatrist who concluded Gigante was malingering—is, “When feigning is a consideration, we must be more critical and less accepting of our impressions when we conduct and interpret a psychiatric examination…than might be the case in a typical clinical situation.”²

Even in typical clinical situations, however, psychiatrists may be reluctant to diagnose malingering³ for fear of being sued, assaulted—or wrong. An inaccurate diagnosis of malingering may unjustly stigmatize a patient and deny him needed care.⁴

Because psychiatrists need a systematized approach to detect malingering,⁵ we offer specific clinical factors and approaches to help you recognize malingered psychosis.

What is Malingering?

No other syndrome is as easy to define yet so difficult to diagnose as malingering. Reliably diagnosing malingered mental illness is complex, requiring the psychiatrist to consider collateral data beyond the patient interview.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.⁶ In practice, malingering commonly must be differentiated from factitious disorder, which also involves intentional production of symptoms. In factitious disorders, the patient’s motivation is to assume the sick role, which can be thought of as an internal or psychological incentive.

Three categories of malingering include:

• pure malingering (feigning a nonexistent disorder)
• partial malingering (consciously exaggerating real symptoms)
• false imputation (ascribing real symptoms to a cause the individual knows is unrelated to the symptoms).⁷

Motivations. Individuals usually malinger to avoid pain (such as difficult situations or punishment) or to seek pleasure (such as to obtain compensation or medications) (Table 1). In correctional settings, for example, inmates may malinger mental illness to do “easier time” or to obtain drugs. On the other hand, malingering in prison also may be an adaptive response by a mentally ill inmate to relatively sparse and difficult-to-obtain mental health resources.⁸

Table 1

Common motives of malingerers

Interview Style

When you suspect a patient is malingering, keep your suspicions to yourself and conduct an objective evaluation. Patients are likely to become defensive if you show annoyance or incredulity, and putting them on guard decreases your ability to uncover evidence of malingering.⁹

Begin by asking open-ended questions, which allow patients to report symptoms in their own words. To avoid hinting at correct responses, carefully phrase initial inquiries about symptoms. Later in the interview, you can proceed to more-detailed questions of specific symptoms, as discussed below.

If possible, review collateral data before the interview, when it is most helpful. Consider information that would support or refute the alleged symptoms, such as treatment and insurance records, police reports, and interviews of close friends or family.

The patient interview may be prolonged because fatigue may diminish a malingerer’s ability to maintain fake symptoms. In very difficult cases, consider monitoring during inpatient assessment because feigned psychosis is extremely difficult to maintain 24 hours a day.

Watch for individuals who endorse rare or improbable symptoms. Rare symptoms—by definition—occur very infrequently, and even severely disturbed patients almost never report improbable symptoms.¹⁰ Consider asking malingerers about improbable symptoms to see if they will endorse them. For example:

• “When people talk to you, do you see the words they speak spelled out?”¹¹
• “Have you ever believed that automobiles are members of an organized religion?”¹²

Watch closely for internal or external inconsistency in the suspected malingerer’s presentation (Table 2).

Table 2

Clues to identify malingering during patient evaluation

Malingered Psychotic Symptoms

Detecting malingered mental illness is considered an advanced psychiatric skill, partly because you must understand thoroughly how genuine psychotic symptoms manifest.

Hallucinations. If a patient alleges atypical hallucinations, ask about them in detail. Hallucinations are usually (88%) associated with delusions.¹³ Genuine hallucinations are typically intermittent rather than continuous.

Continue to: Auditory hallucinations

Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).¹⁴ In schizophrenia, the major themes are persecutory or instructive.¹⁵

Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:

• do not always obey the voices, especially if doing so would be dangerous¹⁶
• usually present with noncommand hallucinations (85%) and delusions (75%) as well¹⁷

Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:

• engaging in activities (working, listening to a radio, watching TV)
• changing posture (lying down, walking)
• seeking interpersonal contact
• taking medications.

If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.

Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:

• an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
• a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”

Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.

Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).¹⁸

Genuine visual hallucinations are usually of normalsized people and are seen in color.¹⁴ On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.

Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.¹⁹

Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.

Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.²⁰

Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).

With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.

Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.

Table 3

Uncommon psychosis presentations that suggest malingering

Where Malingerers Trip Up

Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.²¹

Continue to: Numerous clinical factors suggest malingering...

Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.²²

Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.²³

Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.

Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.

Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.

Table 4

Clinical factors that suggest malingering

Psychological Testing

Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:

• Structured Interview of Reported Symptoms (SIRS)
• Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
• Miller Forensic Assessment of Symptoms Test (M-FAST).¹¹

SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.²⁴

Two MMPI-2 scales—F-scale and F-K Index—are the most frequently used test for evaluating suspected malingering. When using the MMPI-2 in this manner, consult the literature for appropriate cutoff scores (see Related resources). Although the MMPI-2 is the most validated psychometric method to detect malingering, a malingerer with high intelligence and previous knowledge of the test could evade detection.²⁵

M-FAST was developed to provide a brief, reliable screen for malingered mental illness. This test takes 10 to 15 minutes to administer and measures rare symptom combinations, excessive reporting, and atypical symptoms.¹¹ It has shown good validity and high correlation with the SIRS and MMPI-2.^26,27

Confronting the Malingerer

If a thorough investigation indicates that a patient is malingering psychosis, you may decide to confront the evaluee. Avoid direct accusations of lying,¹⁰ and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, “You haven’t told me the whole truth.”

A thoughtful approach that asks the evaluee to clarify inconsistencies is more likely to be productive and safer for the examiner. When confronting individuals with a history of violence and aggression, have adequate security personnel with you.

Related resources

• Structured Interview of Reported Symptoms (SIRS). Available for purchase from Psychological Assessment Resources at www3.parinc.com (enter “SIRS” in search field).
• Graham JR. MMPI-2: Assessing personality and psychopathology. New York: Oxford Press; 2000. (Source of cutoff scores to use MMPI-2 scales [F-scale and F-K Index] to evaluate suspected malingering).
• Psychological Assessment Resources, Inc. Miller Forensic Assessment of Symptoms Test (M-FAST). Available at: www3.parinc.com (enter “M-FAST” in search field).

Reputed Cosa Nostra boss Vincent “The Chin” Gigante deceived “the most respected minds in forensic psychiatry” for years by malingering schizophrenia.¹ Ultimately, he admitted to maintaining his charade from 1990 to 1997 during evaluations of his competency to stand trial for racketeering.

A lesson from this case—said a psychiatrist who concluded Gigante was malingering—is, “When feigning is a consideration, we must be more critical and less accepting of our impressions when we conduct and interpret a psychiatric examination…than might be the case in a typical clinical situation.”²

Even in typical clinical situations, however, psychiatrists may be reluctant to diagnose malingering³ for fear of being sued, assaulted—or wrong. An inaccurate diagnosis of malingering may unjustly stigmatize a patient and deny him needed care.⁴

Because psychiatrists need a systematized approach to detect malingering,⁵ we offer specific clinical factors and approaches to help you recognize malingered psychosis.

What is Malingering?

No other syndrome is as easy to define yet so difficult to diagnose as malingering. Reliably diagnosing malingered mental illness is complex, requiring the psychiatrist to consider collateral data beyond the patient interview.

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.⁶ In practice, malingering commonly must be differentiated from factitious disorder, which also involves intentional production of symptoms. In factitious disorders, the patient’s motivation is to assume the sick role, which can be thought of as an internal or psychological incentive.

Three categories of malingering include:

• pure malingering (feigning a nonexistent disorder)
• partial malingering (consciously exaggerating real symptoms)
• false imputation (ascribing real symptoms to a cause the individual knows is unrelated to the symptoms).⁷

Motivations. Individuals usually malinger to avoid pain (such as difficult situations or punishment) or to seek pleasure (such as to obtain compensation or medications) (Table 1). In correctional settings, for example, inmates may malinger mental illness to do “easier time” or to obtain drugs. On the other hand, malingering in prison also may be an adaptive response by a mentally ill inmate to relatively sparse and difficult-to-obtain mental health resources.⁸

Table 1

Common motives of malingerers

Interview Style

When you suspect a patient is malingering, keep your suspicions to yourself and conduct an objective evaluation. Patients are likely to become defensive if you show annoyance or incredulity, and putting them on guard decreases your ability to uncover evidence of malingering.⁹

Begin by asking open-ended questions, which allow patients to report symptoms in their own words. To avoid hinting at correct responses, carefully phrase initial inquiries about symptoms. Later in the interview, you can proceed to more-detailed questions of specific symptoms, as discussed below.

If possible, review collateral data before the interview, when it is most helpful. Consider information that would support or refute the alleged symptoms, such as treatment and insurance records, police reports, and interviews of close friends or family.

The patient interview may be prolonged because fatigue may diminish a malingerer’s ability to maintain fake symptoms. In very difficult cases, consider monitoring during inpatient assessment because feigned psychosis is extremely difficult to maintain 24 hours a day.

Watch for individuals who endorse rare or improbable symptoms. Rare symptoms—by definition—occur very infrequently, and even severely disturbed patients almost never report improbable symptoms.¹⁰ Consider asking malingerers about improbable symptoms to see if they will endorse them. For example:

• “When people talk to you, do you see the words they speak spelled out?”¹¹
• “Have you ever believed that automobiles are members of an organized religion?”¹²

Watch closely for internal or external inconsistency in the suspected malingerer’s presentation (Table 2).

Table 2

Clues to identify malingering during patient evaluation

Malingered Psychotic Symptoms

Detecting malingered mental illness is considered an advanced psychiatric skill, partly because you must understand thoroughly how genuine psychotic symptoms manifest.

Hallucinations. If a patient alleges atypical hallucinations, ask about them in detail. Hallucinations are usually (88%) associated with delusions.¹³ Genuine hallucinations are typically intermittent rather than continuous.

Continue to: Auditory hallucinations

Auditory hallucinations are usually clear, not vague (7%) or inaudible. Both male and female voices are commonly heard (75%), and voices are usually perceived as originating outside the head (88%).¹⁴ In schizophrenia, the major themes are persecutory or instructive.¹⁵

Command auditory hallucinations are easy to fabricate. Persons experiencing genuine command hallucinations:

• do not always obey the voices, especially if doing so would be dangerous¹⁶
• usually present with noncommand hallucinations (85%) and delusions (75%) as well¹⁷

Thus, view with suspicion someone who alleges an isolated command hallucination without other psychotic symptoms.

Genuine schizophrenic hallucinations tend to diminish when patients are involved in activities. Thus, to deal with their hallucinations, persons with schizophrenia typically cope by:

• engaging in activities (working, listening to a radio, watching TV)
• changing posture (lying down, walking)
• seeking interpersonal contact
• taking medications.

If you suspect a person of malingered auditory hallucinations, ask what he or she does to make the voices go away or diminish in intensity. Patients with genuine schizophrenia often can stop their auditory hallucinations while in remission but not during acute illness.

Malingerers may report auditory hallucinations of stilted or implausible language. For example, we have evaluated:

• an individual charged with attempted rape who alleged that voices said, “Go commit a sex offense.”
• a bank robber who alleged that voices kept screaming, “Stick up, stick up, stick up!”

Both examples contain language that is very questionable for genuine hallucinations, while providing the patient with “psychotic justification” for an illegal act that has a rational alternative motive.

Visual hallucinations are experienced by an estimated 24% to 30% of psychotic individuals but are reported much more often by malingerers (46%) than by persons with genuine psychosis (4%).¹⁸

Genuine visual hallucinations are usually of normalsized people and are seen in color.¹⁴ On rare occasions, genuine visual hallucinations of small people (Lilliputian hallucinations) may be associated with alcohol use, organic disease, or toxic psychosis (such as anticholinergic toxicity) but are rarely seen by persons with schizophrenia.

Psychotic visual hallucinations do not typically change if the eyes are closed or open, whereas drug-induced hallucinations are more readily seen with eyes closed or in the dark. Unformed hallucinations—such as flashes of light, shadows, or moving objects—are typically associated with neurologic disease and substance use.¹⁹

Suspect malingering if the patient reports dramatic or atypical visual hallucinations. For example, one defendant charged with bank robbery calmly reported seeing “a 30-foot tall, red giant smashing down the walls” of the interview room. When he was asked detailed questions, he frequently replied, “I don’t know.” He eventually admitted to malingering.

Delusions. Genuine delusions vary in content, theme, degree of systemization, and relevance to the person’s life. The complexity and sophistication of delusional systems usually reflect the individual’s intelligence. Persecutory delusions are more likely to be acted upon than are other types of delusions.²⁰

Malingerers may claim that a delusion began or disappeared suddenly. In reality, systematized delusions usually take weeks to develop and much longer to disappear. Typically, the delusion will become somewhat less relevant, and the individual will gradually relinquish its importance over time after adequate treatment. In general, the more bizarre the delusion’s content, the more disorganized the individual’s thinking is likely to be (Table 3).

With genuine delusions, the individual’s behavior usually conforms to the delusions’ content. For example, Russell Weston—who suffered from schizophrenia—made a deadly assault on the U.S. Capitol in 1998 because he held a delusional belief that cannibalism was destroying Washington, DC. Before he shot and killed two U.S. Capitol security officers, he had gone to the Central Intelligence Agency several years before and voiced the same delusional concerns.

Suspect malingering if a patient alleges persecutory delusions without engaging in corresponding paranoid behaviors. One exception is the person with long-standing schizophrenia who has grown accustomed to the delusion and whose behavior is no longer consistent with it.

Table 3

Uncommon psychosis presentations that suggest malingering

Where Malingerers Trip Up

Malingerers may have inadequate or incomplete knowledge of the mental illness they are faking. Indeed, malingerers are like actors who can portray a role only as well as they understand it. They often overact their part or mistakenly believe the more bizarre their behavior, the more convincing they will be. Conversely, “successful” malingerers are more likely to endorse fewer symptoms and avoid endorsing overly bizarre or unusual symptoms.²¹

Continue to: Numerous clinical factors suggest malingering...

Numerous clinical factors suggest malingering (Table 4). Malingerers are more likely to eagerly “thrust forward” their illness, whereas patients with genuine schizophrenia are often reluctant to discuss their symptoms.²²

Malingerers may attempt to take control of the interview and behave in an intimidating or hostile manner. They may accuse the psychiatrist of inferring that they are faking. Such behavior is rare in genuinely psychotic individuals. Although DSM-IV-TR states that antisocial personality disorder should arouse suspicions of malingering, some studies have failed to show a relationship. One study has associated psychopathic traits with malingering.²³

Malingerers often believe that faking intellectual deficits, in addition to psychotic symptoms, will make them more believable. For example, a man who had completed several years of college alleged that he did not know the colors of the American flag.

Malingerers are more likely to give vague or hedging answers to straightforward questions. For example, when asked whether an alleged voice was male or female, one malingerer replied, “It was probably a man’s voice.” Malingerers may also answer, “I don’t know” to detailed questions about psychotic symptoms. Whereas a person with genuine psychotic symptoms could easily give an answer, the malingerer may have never experienced the symptoms and consequently “doesn’t know” the correct answer.

Psychotic symptoms such as derailment, neologisms, loose associations, and word salad are rarely simulated. This is because it is much more difficult for a malingerer to successfully imitate psychotic thought processes than psychotic thought content. Similarly, it is unusual for a malingerer to fake schizophrenia’s subtle signs, such as negative symptoms.

Table 4

Clinical factors that suggest malingering

Psychological Testing

Although many psychometric tests are available for detecting malingered psychosis, few have been validated. Among the more reliable are:

• Structured Interview of Reported Symptoms (SIRS)
• Minnesota Multiphasic Personality Inventory, Revised (MMPI-2)
• Miller Forensic Assessment of Symptoms Test (M-FAST).¹¹

SIRS includes questions about rare symptoms, uncommon symptom pairing, atypical symptoms, and other indices involving excessive symptom reporting. It takes 30 to 60 minutes to administer. Tested in inpatient, forensic, and correctional populations, the SIRS has shown consistently high accuracy in detecting malingered psychiatric illness.²⁴

Two MMPI-2 scales—F-scale and F-K Index—are the most frequently used test for evaluating suspected malingering. When using the MMPI-2 in this manner, consult the literature for appropriate cutoff scores (see Related resources). Although the MMPI-2 is the most validated psychometric method to detect malingering, a malingerer with high intelligence and previous knowledge of the test could evade detection.²⁵

M-FAST was developed to provide a brief, reliable screen for malingered mental illness. This test takes 10 to 15 minutes to administer and measures rare symptom combinations, excessive reporting, and atypical symptoms.¹¹ It has shown good validity and high correlation with the SIRS and MMPI-2.^26,27

Confronting the Malingerer

If a thorough investigation indicates that a patient is malingering psychosis, you may decide to confront the evaluee. Avoid direct accusations of lying,¹⁰ and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, “You haven’t told me the whole truth.”

A thoughtful approach that asks the evaluee to clarify inconsistencies is more likely to be productive and safer for the examiner. When confronting individuals with a history of violence and aggression, have adequate security personnel with you.

Related resources

• Structured Interview of Reported Symptoms (SIRS). Available for purchase from Psychological Assessment Resources at www3.parinc.com (enter “SIRS” in search field).
• Graham JR. MMPI-2: Assessing personality and psychopathology. New York: Oxford Press; 2000. (Source of cutoff scores to use MMPI-2 scales [F-scale and F-K Index] to evaluate suspected malingering).
• Psychological Assessment Resources, Inc. Miller Forensic Assessment of Symptoms Test (M-FAST). Available at: www3.parinc.com (enter “M-FAST” in search field).