MPA First Friday Forum: Formulating Diagnostic Impressions and Pitfalls of Self-Report

Catherine A. Carlson, Psy.D., LP

There is undetected psychosis and feigning in mental health settings. Some people lie about symptoms and impairments. Those who feign or malinger (feigning for secondary gain), typically emphasize and endorse psychotic symptoms or cognitive impairments for manipulative reasons. The most common motivation for malingering in non-forensic settings is money. Social Security Disability (SSDI) provides a monthly income. When feigning or malingering, dramatic acting and portrayals of purported symptoms are often part of the ruse. These are far from academy award winning performances given the frequent inconsistencies with bona fide mental illnesses. Some mimic portrayals of mental illness in movies, which are rarely accurate. I find much less drama when examining those with genuine disorders. Other people self-report (malinger) extreme anxiety to get benzodiazepines, a controlled substance that has high potential for abuse. I have rarely seen people feign a non-psychotic Major Depression. For some, the feigning itself is intrinsically reinforcing. Psychological needs related to attention and control are met by deceiving and manipulating others. If this behavior is habitual, and there is no evidence of feigning for secondary gain, a diagnosis of Factitious Disorder needs to be carefully considered. Then there are those with undetected and untreated psychosis, a particularly guarded subgroup, who generally deny psychotic symptoms they have experienced. When they voluntarily seek treatment, chief complaints usually consist of extreme anxiety (including panic attacks), ‘overwhelming stress,’ and/or self-diagnosed Posttraumatic Stress Disorder. They are willing to report anxiety but usually too guarded to disclose the underlying paranoid psychosis (including hallucinations) that is generating the intense anxiety.  They do not seek out treatment for ‘psychosis’ because they have limited to no insight into this condition. They know they are anxious (terrified is probably more accurate) but do not recognize the fears stem from irrational or delusional thought processes. People with non-psychotic depression seek out treatment for depression. Those with guarded psychotic illnesses seek treatment for anxiety not psychosis.

Most examples in my presentation are based on cases from outpatient settings. I cannot emphasize this enough; Assuming psychosis is ‘obvious,’ overtly agitated and disorganized, is a false assumption. Many people with an underlying paranoid psychosis are guarded, deny psychotic symptoms, and maintain behavioral control in public, especially in the presence of a mental health professional. (They do not want the latter meddling in their lives, calling them psychotic, or forcing them to take medication.) If they demonstrate reasonably organized thought processes, the psychosis may not be identified. A psychiatric crisis that results in a hospitalization is just that, a (behavioral) crisis. The majority of the time these individuals are not experiencing a full-blown crisis that results in or warrants involuntary hospitalization.

Assuming those with untreated psychotic conditions are incapacitated by symptoms is another false assumption. I have evaluated people with psychotic mood disorders in jail who are in general population, comply with rules, interact appropriately, and show no ‘obvious’ signs of psychosis. The manifestations of psychotic mood disorders are infinite and can go undetected for years. There have been many instances when I was the first to diagnose a longstanding psychotic condition. Be mindful you are seeing just a sampling of behavior and examinees are capable of impression management. Just because a husband and wife do not argue in a grocery store, the cashier should not conclude they never argue or there is no conflict in the relationship. Behavioral data from other sources is invaluable and warrants careful consideration.

Subjective data consists of personal judgments, accounts, and opinions and may or may not be reliable. Self-report and endorsements regarding specific symptoms or symptom expression (SE) falls under this category. Subjective data also includes diagnostic opinions from mental health professionals and collateral information from family or friends. Objective data is behavioral and generally far more reliable than subjective data. It is the clinicians’ purview and responsibility to determine reliability of available data. Pay close attention to what an examinee does in daily life (or has a history of doing) and see if it is consistent with SE. An examinee who endorses severe psychiatric symptoms and/or cognitive deficits should show impaired overall functioning because severe psychopathology produces impaired functioning.

The following contain altered case vignettes that illustrate the analytical breakdown of data. An examinee directed by his probation officer for an assessment denies all symptoms (subjective data), appears intense and wary (objective), and reports no job, no friends, or significant other (objective functioning). I infer the presence of a major mental illness from his impaired functioning and deem his self-report unreliable. An examinee endorses debilitating symptoms of depression and anxiety (subjective) but demonstrates impeccable hygiene (objective data: coiffed hair, high heels, cleavage showing, tight skirt, bright red lip gloss). Her alluring and meticulous presentation seems inconsistent with my experience of major depressive episodes which prompts me to look at all objective data carefully. (This examinee subsequently asks the medical provider to prescribe benzodiazepines, a controlled substance with high potential for abuse. When denied, her demeanor completely changes; she becomes demanding and argumentative.)  An examinee voluntarily shows up at an outpatient clinic with his girlfriend, and in a cooperative and calm manner, endorses multiple and longstanding symptoms of psychosis and mania, asks for medication for these symptoms, and shows ‘good insight’ into his psychosis. There are multiple red flags here that reveal his SE is unreliable. The severity of his SE is not consistent with his behavior during the interview; he endorsed confusion, racing thoughts, ongoing hallucinations, and acute paranoia in a calm, cooperative, and fully disclosing manner. Having a girlfriend, showing ‘good insight’ into his psychotic condition, and asking for medication for psychotic symptoms is inconsistent with a bona fide chronic psychotic condition. Another examinee presents with a history of several girlfriends, two children, a driver’s license, criminal charges (including drug and weapon possession), and is stylishly dressed for the examination. He says ‘I don’t know’ to most questions. He is administered an intellectual instrument and obtains a Full Scale IQ of 53. I know the test results, which are based on self-report (his responses to items), are not reliable. His objective functioning is not consistent with an IQ of 53 (mild to moderate mental retardation). Those with bona fide intellectual disabilities of this magnitude need a great deal of supervision, rarely have significant others or sexual relationships, and when interviewed, do not say ‘I don’t know’ all the time. SE that is consistent with objective functioning reflects convergent validity-- Elicit data about real world functioning not just diagnostic criteria.  I often obtain interesting and salient data when I shift focus from ‘symptoms’ to open-ended questions about basic activities and relationships. If an examinee reports debilitating cognitive impairments, at some point later in the examination, just ‘be curious’ and ask how he got to your office. If he came by himself and made bus changes, that is important objective data. Extemporaneous asides by examinees can reveal a level of functioning consistent or inconsistent withSE. I have found those who are feigning or malingering often report and endorse severe ‘symptoms’ and minutes later, in response to my casual inquiries, describe real world functioning that is inconsistent with the severity of their SE.  Do not accept SE at face value. Determine reliability of subjective data by recognizing and analyzing objective data.  

Psychological tests and instruments are a clinician’s tool. Results should not dictate diagnosis or supplant clinical judgment. I have several case examples that show test results can be misleading. Only the clinician can identify when the reflexive interpretation is inaccurate (based on the totality of reliable evidence). Instruments that do not have validity scales rely on self-report (subjective data) and therefore, produce results that may or may not be reliable. If erroneous (unreliable) data is entered, the results are erroneous. While checklists and scheduled interviews may assist in addressing diagnostic criteria, they do not inform as to the validity of results. This is also the case with standard intellectual instruments which rely exclusively on self-report and motivation to perform. I recommend administering at least one instrument with validity scales which provides objective data about an examinees’ response set. Validity scales inform on the presence of overreporting (suggestive of exaggerating, feigning), underreporting (suggests unwillingness to disclose, guarded), or normative responding (neither over nor underreporting). If an examinee’s approach shows overreporting on validity scales, his SE in interviews and on symptom checklists may not be reliable. Feigning or malingering needs to be ruled out. If validity scales show a response set of underreporting, then SE during interviews and other measures that rely on SE may not be reliable due to an unwillingness to disclose psychological problems. Guardedness is an identifiable quality that almost always hides an underlying paranoid psychosis. My presentation contains case examples that illustrate this telltale phenomena. While routinely using instruments with validity scales will be more expensive, it is far less costly than relying on unreliable SE which leads to erroneous diagnoses. That being said, it remains the clinician’s responsibility to determine the reliability of all test results. Over-reporting on validity scales does not equate with feigning. That is too simplistic. If all we needed were tests to diagnose, clinicians would be superfluous. Validity scales give the clinician additional objective data to consider but do not dictate diagnosis. Ultimately the diagnostic impression should be based on the totality of reliable evidence, which can only be determined by the clinician.  

The clinician must gather, recognize, reconcile, and synthesize data. A clinician will never have 100% of the data. Never. Not even close. Scientists from all fields grapple with this reality. To have patchwork pieces of data is workable, it has to be. Psychologists are not asked for the truth but an opinion, a diagnostic impression, to a ‘reasonable degree of psychological certainty.’ It is the clinician’s purview and responsibility to recognize inconsistencies and make diagnostic inferences; conclusions based on training, experience, available data, and reasoning. Critical analysis can unveil unreliable SE. Requiring a guarded paranoid psychosis to announce itself is tantamount to a jury requiring the accused to confess before finding him guilty. How many convictions would there be if the trier-of-fact was unwilling to render a verdict in the absence of a confession?  ‘Beyond reasonable doubt,’ or in the case of psychologists, ‘to a reasonable degree of psychological certainty,’ is the legal standard. It is perfectly acceptable, and often necessary, to make inferences and offer opinions based solely on reliable objective data.

If you are interested, I will be giving my presentation again at the Minnesota Psychological Association’s Annual Convention in April, 2017.

Catherine A. Carlson, Psy.D., LP

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