Yale Psychiatry Grand Rounds: October 29, 2021

October 29, 2021

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"Clinical Advances in the Assessment of Malingering"

Richard Rogers, MD, Visiting Professor, University of North Texas

ID7097

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00:00For those of you who don't know me, I'm Mike.
00:02Norco in the law and psychiatry division,
00:05and it is my great pleasure today
00:07to be able to introduce our speaker.
00:10Doctor Richard Rogers is a
00:12Regents professor of psychology
00:13at the University of North Texas.
00:16He is with us this semester as a
00:18visiting professor at the Yale
00:20School of Medicine in the law
00:22and Psychiatry division at CMHC.
00:24His past academic appointments
00:26include the section on psychiatry
00:28and law at Rush University and the
00:31Division of Forensic Psychiatry
00:33at the University of Toronto.
00:35Doctor Rogers earned a Bachelor of
00:37Science in Education and English
00:38Literature from Worcester State College,
00:41a Masters in counseling psychology
00:43from Assumption College, and his pH.
00:45D from Utah State University.
00:47He is a diplomat of the American
00:50Board of Forensic Psychology and
00:52is an internationally renowned
00:54expert in forensic psychology.
00:56He is one of the most influential
00:58scholars in forensic psychology and
01:00psychiatry with an H index of 81 and I-10.
01:03Index of 254.
01:05Doctor Rogers has 229 peer reviewed
01:09publications going back to 1975 and is
01:12the author of 65 books and book chapters.
01:16He has won numerous prestigious awards,
01:18including the Amicus Award from the American
01:21Academy of Psychiatry and the Law Apple,
01:23for distinguished contributions
01:25to forensic psychiatry.
01:27The Manfred Gumaca reward of the
01:29Apea and Apple for outstanding
01:31contribution to the forensic literature
01:34for his book clinical assessment
01:36of malingering and deception.
01:38And the Applied Research Award
01:40and the Public Policy award of the
01:43American Psychology Association
01:45for his distinguished professional
01:47contributions to the field.
01:48Only the third psychologist ever
01:51to win both awards,
01:53Doctor Rogers is a pioneer in the
01:55rigorous validation of forensic
01:56assessment instruments.
01:58He is best known for his validation
02:00of the structured interview of
02:02reported symptoms, the service,
02:04and the Service 2.
02:06He has recently completed a decade
02:09of NSF funded research on Miranda
02:11warnings and reasoning.
02:13Dr.
02:13Rogers has presented all over the
02:15world on a variety of topics related
02:17to forensic psychology and the law,
02:19especially malingering and fainting,
02:21and his recent work on jury deception
02:25and understanding of Miranda warnings.
02:27**** has been with us in Lawrence
02:30Psychiatry since early September and
02:31we have all profited from his talks,
02:33insights and suggestions,
02:35especially to our research groups
02:38and trainees.
02:39We are looking forward to his
02:41presentation today on clinical advances
02:42in the assessment of malingering.
02:50Thank you so much for such a
02:53wonderful introduction. It's been
02:56really a great pleasure to be here
02:57for the last several months.
03:01I have no trying
03:02to move my slide forward.
03:08I'll do it this way.
03:11This is actually the Today is the day we
03:14are completing review all my in person
03:16residents as we might describe it in.
03:19These are days of the pandemic.
03:22I will still be with the division through
03:25January and possibly a bit beyond.
03:32Three decades of work has gone into clinical
03:36assessment of malingering and deception.
03:38I think if you would kindly look at the
03:41first edition there on the left hand
03:44panel and I hope that all of you can
03:46affirm that was not a facsimile of me,
03:48although in the earlier years
03:50that was the TV pointed statement.
03:56When Anshel disclosures,
03:58I think is very important.
03:59He saw what she did have the calling card,
04:01Testament book and the primary
04:05off author of the service.
04:08Two in the service.
04:10I will provide a few examples from those.
04:13There is a one or two mentions
04:15of the extra in the summer, but
04:17without any details provided at all.
04:22The objectives for today.
04:23I think whenever we start to
04:25think let's look forward,
04:27let's see where things are advancing.
04:29It's oftentimes helpful to take
04:31a very brief look historically
04:33of where we've come from.
04:35So nice to do that.
04:36I also want to talk about some of
04:39the fundamental weaknesses, the DSM
04:415 and the second assessment model,
04:44which I think have real implications
04:46in terms of our day-to-day
04:48practice, both in clinical
04:50and forensic evaluations.
04:52Moving on to what I think
04:53are perhaps more positive topics,
04:55we'll talk a bit about some effective
04:57scales and detection strategies.
05:00These are continuing to be refined. As
05:04uh as time continues to go by,
05:07we'll also talk about some
05:09frontiers and current advances
05:11in terms of the assessment.
05:15Critical lens from the past.
05:19I don't think they chose or Mason.
05:20Cox was a person who was quiet
05:24and expressing his viewpoints.
05:26He suggested in 1811 that we
05:28could invest his get to the
05:30bottom of the issue sometimes for
05:33posing plaint painful operations.
05:35Nauseating remedies, active medicines,
05:38blisters, clashes have induced
05:41the pseudo manic to throw off his
05:44imposture and windows don't work.
05:46He suggested things that could
05:48become more decisive.
05:50Such as a capacity of existing heat,
05:52cold, hunger, and thirst.
05:54Certainly a different moral
05:55and ethical values then.
05:57Hope we would see expressed today.
06:02But not to allow the extreme too.
06:05In fact, is a cloud, our judgment,
06:08or our view of what was
06:11considered to be signs of fainting lunacy.
06:15You'll notice that there is a
06:16number of things here which I think
06:18are actually quite good. The idea of acting
06:22winden factors on stage,
06:24both increasing the symptoms
06:27the sun onset, of course makes some sense.
06:29The idea of never concealing. The symptoms
06:32is also there. The expression
06:34of course of absurd thoughts is
06:37something we might bear in mind.
06:39One area which I think we've lost
06:41track of a bit over the last 150
06:46to 200 years, has been what
06:49will it was many malinger.
06:50It's what are some of the things
06:52that are intact which are very
06:55hard for the person to fake
06:57an eye contact, I think is really in central
07:00one where. And perhaps the person
07:02who's a schizophrenic disorder has
07:05difficulty making eye contact.
07:07A malingerer who is pretending,
07:11or faking a psychotic disorder
07:14must have no difficulty.
07:15Is that all? Likewise,
07:17in terms of somehow illuminating
07:20their failing students, friends and
07:23family is oftentimes intact with malingerers
07:30They also suggested some assessment methods,
07:33so also some active interventions.
07:35The idea of suggesting
07:38and filler ethnic boomed.
07:40Many of you know, is really one of
07:43the Giants in the area of assessment,
07:45malingering, because proposes that in
07:48fact is I suggesting a symptom, and then
07:51seeing that symptom appears. Obviously
07:54you'd have to be careful
07:55about individuals who
07:56have a high level suggest ability, but
07:59a. Idea which I have not seen in the
08:03twenty 20th century and 21st century is
08:06one of writing samples and this strikes
08:09me as being a really bright idea.
08:12A person who in fact who speaks, see
08:14she's very, very disorganized.
08:16We've asked to write about a
08:19particular topic and it becomes
08:21a very much more rational.
08:23This will be a good indication
08:25that the VERBALIZATIONS may
08:28not be entirely accurate.
08:30They also had the idea of
08:32active interventions, unpleasant
08:34drugs, emetics, purgatives,
08:37believing of course that the insane
08:40walked complaint and then there were
08:42the threats of physical intervention.
08:45And then I guess the final step was the
08:48idea of physical interventions themselves,
08:51such as whipping, intoxication and
08:54the horrorland chair. I suspect
08:56there's a few of you who
08:58are wondering what is the.
09:00A whirling shell look like.
09:04So here is a a a illustration
09:06of the whipping chair.
09:08I am kind of surprised that
09:09the if you all the gear ratio
09:11appears to be really quite low,
09:13which probably means this is not
09:14going to be keep having the person
09:17spin in any dramatic fashion.
09:23Really excellent book for those of
09:25you by John Coley for those of you
09:28who love history, I've II must say
09:31I've only read chapters of this,
09:34but it really expressed, I think,
09:36high level OM. This was at the end
09:41into the early 20th century,
09:44the end of 19th century, in terms
09:46of lingering in feigned illness.
09:59And I found this really, very interesting.
10:01The argument is making is that there is a.
10:07Almost anyone who wants a disability will get
10:10a disability. So in the year this is
10:13the year 1911 forty or 23,000 cases
10:18life in charity of those were settled
10:22out of court of those decided in court.
10:25I hope you can see the the
10:27one with that slide of those.
10:29The designing court.
10:3080% of them went for the applicant in
10:33only 20% went for the respondents.
10:42Building on this, this was after
10:44World War One. Seltzer took, I think,
10:46kind of a very interesting approach
10:48and what he did is, he said, let's look at VA
10:53records compared to military records.
10:56And of course all of us in the
10:58audience can can see immediately
11:00that there would be some cases that
11:03would come up post military service.
11:05And if I have someone found the
11:07numbers but roughly what he's saying
11:10is is three times more disabilities.
11:13Then in fact, it's what there was injuries
11:16during during the actual combat itself,
11:20ending up with the conclusion it is
11:23ridiculously easy to prove a disability.
11:29No, I'm going to turn to
11:31kind of a time of transition.
11:34I think both in terms of both in
11:36terms of hospitals and facilities
11:39as well as in in terms of the
11:42practice of forensic practice and
11:44the assessment of malingering.
11:45So this is just a brief historical.
11:48This file was in the public domain is
11:52a picture of Illinois State hospital.
11:54I actually joined. This facility,
11:58six months after they moved to the
12:02new facility that you might think,
12:05would be a time of excitement.
12:07It truly was.
12:08It's also a time of very difficult
12:11change because they took people
12:13who were called guards back in.
12:15If you will,
12:16the prison days they trained
12:18them for several weeks hold them
12:20security therapy aids in thought.
12:22Of course they can make that transition.
12:30So one of the things are probably
12:32speaking a little bit to my longevity.
12:34I'll talk about a couple reviews
12:37which happened pretty pretty
12:39much at the time of this,
12:41and so this was the first which appeared
12:44in behavioral sciences and the law.
12:49And what struck me,
12:50I don't know if anyone looked the
12:52literature mill in the recent decades.
12:54But there are thousands of
12:56studies back in 1984, however,
12:59the officials didn't highly different.
13:01At that time there were 53 studies
13:04I could find and to be quite frank,
13:07we cast with the ten other
13:09studies a very broad net.
13:11So we were trying to be as inclusive
13:14as possible in this the case studies,
13:16I'll talk about those in just a moment,
13:19but you'll see the MPI.
13:21Is probably the only measure
13:23which stands out with any real
13:25body of literature behind.
13:30One of the tables from this,
13:34now ancient review.
13:36You'll know CSS CSS for case studies the PT.
13:42As far as psychological
13:44testing you'll see here,
13:46that number of these are actually
13:49feeling similar to that slide.
13:52I showed you a faint
13:54lunacy back in the 1800s.
13:59I think the one just get
14:02to that in just a sack.
14:04So the case study is a very difficult
14:08because to really gain much knowledge
14:12from their wonderfully descriptive.
14:14But there are frankly and
14:16exercise and circularity.
14:18'cause this is a situation
14:21where we're taking individuals.
14:24And and label them as a malingerer.
14:27Then in fact,
14:28it's describing some of the
14:29characteristics and then flipping
14:31around and saying in these
14:33are the characteristics of a
14:34president who is malingering.
14:36So it's really difficult to get
14:38away from that.
14:39I think when you look at the case studies,
14:41the only thing which is different
14:43from what we found back in the
14:4619th century was a sequence of
14:49symptoms and that not distilling
14:51on Thunder has been something which
14:54researches on believing in response.
14:56Styles have not worked out a
14:59way to systematically evaluate
15:01the sequence of symptoms.
15:14I have a overactive mouse.
15:16So that's the but really which we saw
15:21in 84 was if you will, beyond the MPI.
15:25What I've described as a
15:28hopeless mishmash of methods.
15:30Not a very good site.
15:33Did another review.
15:34This is close to 10 years later and
15:37this was one of individuals in terms
15:40of feigned cognitive impairment, and.
15:45The findings there were the most recently,
15:48the most prominently
15:50studied was raised 15 item.
15:52Andre Ray developed this idea in the 1940s.
15:56The idea was to present people with
15:5915 different types of information,
16:00which of course would be a very difficult,
16:03so perhaps to remember. However,
16:07the to make the test similar,
16:10there are sequences such as 321,
16:13so it's only actually five concepts
16:15that need to be remembered.
16:16It represented the state of the art in 1993,
16:20and we've come really a
16:22long ways from that point.
16:24A total of five studies in
16:27two simulation studies.
16:29I guess if we want to say go good news first,
16:31you know about 80% of those
16:34individuals who are not.
16:35Faking, in fact is were
16:38successful at the task.
16:40However, from lingers for
16:42those people simulating,
16:44they didn't think I don't have
16:45to look at that hat off,
16:48and so you'll see the numbers there were,
16:50say 15 to 23%,
16:52so it was largely unsuccessful.
16:58Did that article did basically summarize
17:01all this in the literature and we found
17:04that there were a number of areas where
17:07a number of strategies that were used.
17:10The floor effect is where you ask
17:13people totally simple questions that
17:15almost anyone who could get correct.
17:17So for example who is older,
17:20you or your mother?
17:23Probably most people can get that.
17:26Makes you have error.
17:28Sometimes these were very strange answers,
17:31so it wasn't how right did they get.
17:32It was how wrong did they get it?
17:34And then although this has not
17:37been found much more recently.
17:39Losing some work on games like symptoms,
17:41which is approximately answers
17:42asked you know what is 11 * 11?
17:45Perhaps response would be 120.
17:48You look up the next two.
17:51I will show a bit more sophistication,
17:53so in terms of violation
17:55for learning for them,
17:56so will you give up a list of words,
17:59see how many they can recall?
18:01See how making recognize in person,
18:04spring forth with good effort
18:06most of the time the recognitions
18:08can be way higher than the recall
18:10and then another approach which
18:12I think is kind of interesting
18:14is substantially below chance.
18:16For farmers.
18:16There was one case study that was imported.
18:19Of an adolescent female she was given.
18:24She was given 400 trials and
18:27she finally got one correct.
18:29My guess is and there's no way
18:30that I'm engaging in mind reading,
18:32but she might have said to herself
18:34I'll be here forever if I don't
18:36get at least one of these, correct?
18:42So this this, I think is kind of fun.
18:44This is again warning his thermal side.
18:46But this is what we see in terms
18:48of periods of exploration.
18:50Some of the efforts put forth I
18:52mention applicable my own in here
18:55so that we would have a like a
18:57good notion of where these are.
19:03So willing exclusive frania.
19:06I have to admit that some
19:07some of these items seem a bit much to me,
19:11particularly only give people two
19:14choices about hearing voices.
19:15This is something that has never
19:18happened to me, or every day at noon
19:20the devil tells me to kill someone.
19:23Uh, I think there must be a third choice.
19:27And then regarding the torture of animals,
19:29I realize that many people
19:31are sensitive to cats etc.
19:33But a I have the uncontrollable
19:35urges to kill my neighbors pet
19:38knows we have no apostrophe there.
19:41Oh, I do not enjoy this or
19:43proof of it in others.
19:50Some others in terms of screen.
19:53Whenever I see people that are not real,
19:56they always appear in black and white.
20:02Most of the time when
20:03people are talking to me,
20:05I say their words spelled out nowadays,
20:08of course, so that would not maybe not
20:11be a psychotic or or fake symptom,
20:13since they have banners.
20:15Whenever you watch any kind of news
20:17show and so that becomes interesting,
20:20this other one, I think send #11
20:23seems rather troubling to me.
20:25Whenever I'm sitting in a chair,
20:27I have to take,
20:28I have to breathe a deep breath
20:30in order to not get sick.
20:40It is. This is my handwriting,
20:43so take it for what it's worth.
20:45So these are a few items that
20:47have not made it into our
20:49particular tester or anything else.
20:51Who's out there might be just a
20:53little over the top lamp shades
20:55were invented for punishment,
20:57not even sure what that means.
20:58Automobiles have their own religion and
21:01vacuum cleaners will purify your mind.
21:12And. Here are some physical symptoms,
21:15so these sound very distressing to me.
21:18The buzzing in my ears keep switching,
21:20switching from left to right.
21:23You'd think it would have come back
21:25right to left my stomach at times,
21:27or also loudly.
21:28That can be heard from by people
21:30outside of the room at times.
21:32My fingernails, which I've been told,
21:34sometimes I sleep with my eyes open.
21:39OK, well I think hopefully
21:40that was a I bet entertaining.
21:43Let's move on to me dearest topic.
21:46Which some issues?
21:48Some really profound issues
21:50with the DSM as well as the MD,
21:54which I'll explain in a few
21:56minutes classifications.
22:02Sell DSM five. This is defined,
22:08so I think that there's,
22:09I think the definition is good.
22:11Intentional production of faults or grossly
22:15exaggerated physical or psychological
22:17symptoms motivated by external incentives.
22:21Two things should really pay attention to.
22:23The fact is that it's not completely made up,
22:27is a gross exaggeration.
22:28I would humbly submit the difference
22:31between a suicide gesture.
22:33In an attempt would not
22:35be a gross exaggeration.
22:37But in fact,
22:39having occasional thoughts about death.
22:41To saying I was,
22:42I had a serious attempt on my own life,
22:46would represent a gross exaggeration,
22:51and I think a critical point here is
22:54motivation cannot just be assumed,
22:57it has to be something that is closely
22:59evaluating and I'll give you a bit
23:01more evidence of that in a minute.
23:06The difference between
23:09motivation in our inference,
23:10I said extrapolation of our inference
23:13of what might be the incentive.
23:16I think it's absolutely critical that we
23:18see the difference between those two.
23:21So many help meant many health
23:24care providers, including myself,
23:26completely have multiple opportunities
23:29to pad our compensation in terms of on a
23:32time we put into a forensic consultation,
23:34for example, but I suspect I will
23:37ask for a raise of hands.
23:39I suspect that very few of us
23:42actually engage in that behavior.
23:44So if I were to say most of
23:48my colleagues are fraud.
23:51People who engage in fraud.
23:53You can see how I'm taking a potential
23:58incentive and making in calling it a that.
24:02In fact, it's your all motivation.
24:06Let's go for extreme example here.
24:09You would think in terms of competency
24:12to be executed that this would be set.
24:15The motivation would be
24:17staying alive at all costs.
24:21I don't have good data on this,
24:23uh, but the anecdotal data
24:26that I have is on on average,
24:30maybe about 10% of cases in
24:34terms of post conviction.
24:37This clear evidence of malingering.
24:40I've dealt with about a dozen
24:42or so cases myself.
24:44Meantime, some called in because his
24:46concerns that this might possibly
24:48something to at least consider A to rule out,
24:51so using that as the top end,
24:54that would be roughly 30%.
24:58I I still don't see even in these
25:01extreme circumstances that there
25:03is that people are trying to
25:07linger in order to stay alive.
25:10Who are also suggests about 10%,
25:13probably more in fact is on
25:16denying any mental desires.
25:18Apparently the stigma of being
25:20mentally disordered outweighs
25:21any other consideration.
25:27Sorry, I mean.
25:42So from DSM three to DSM five,
25:46I think important distinction must be
25:49made that a diagnosis have explicit
25:53inclusion and exclusion criteria V codes,
25:57and as many of you are very well aware,
25:59there are dozens and dozens of V
26:02codes are simply problems that require
26:05or potentially require clinical
26:07attention and DSM. Five lists.
26:13SEV code in. Under that code they
26:16have a couple in there for indices of
26:19when it should be strongly suspected.
26:22I have seen very seasoned practitioners.
26:25I'm thinking now of a board certified
26:28forensic psychologist who said look this
26:30guy meets three of the four of these.
26:33Therefore he is malingering.
26:39Imagine if that happened by way.
26:41Any case of serial killer.
26:43Sometimes to be honest,
26:44I get involved in these cases and I'm
26:47really not quite sure why we need
26:49to go through this whole exercise.
26:51This person had already been given had
26:54already been sentenced to death twice,
26:56so this was a third time around
26:59and he he did kill folks.
27:02I think suggesting he is
27:04probably not all intact.
27:06He tended to kill persons at that
27:08time was called a halfway house.
27:10For their money.
27:12I do think, however.
27:14Looking at the DSM 5,
27:16is this as a malingering bias
27:19and it's fatally flawed?
27:24There's a very little threshold,
27:26so in terms of winning by it's it's
27:28a very little threshold for saying
27:31when should we strongly suspect it.
27:33So it says medical legal context,
27:35which means in every single
27:37case that comes before us.
27:40In fact, it should be considered.
27:43Is really the lack of cooperation
27:45in assessment and treatment.
27:47This is a really, you know, traps.
27:48I don't need the emphasis
27:50with explanation point,
27:51but this is really indiscriminant assertion.
27:53Look, we have many people who
27:56lack cooperation, drug denials,
27:58positive pressure management,
28:00and perhaps the most obvious
28:03is in terms of involuntary
28:05hospitalizations we we have to
28:08force this person into treatment.
28:10An antisocial personality sets the bar
28:13very low for the majority of criminal cases,
28:16and the one here,
28:18which seems to have some effect is
28:20in terms of market discrepancies.
28:26It is really. I'm choosing these words.
28:31'cause I wanted to basically responsible,
28:33but I say it's doomed to failure and I think
28:36that is the case if you think about this.
28:38I've had the pleasure and challenges
28:41of of actually evaluating hundreds of
28:45persons of issues of malingering in every
28:48single case they had opposable thumbs.
28:52If we used opposable thumbs as inclusion
28:56criteria or sensitivity would be 100%.
29:00All home to our specificity
29:03would be virtually 0%,
29:04so it's very important that we do not
29:07use common characteristics and we try
29:10to make it accurate determination.
29:12Study that was done in 1990.
29:15Again, GSM three DSM 5 have been identical.
29:19The advantage shifts.
29:20This is this was done prior
29:22to the publication.
29:23The data was collected prior to
29:25the publication of DSM three.
29:27You'll see in fact is the rates that we had.
29:32We looked at two or more indices,
29:3420% sure positive and roughly
29:37an 80% false positive.
29:44As an analogy, if you would
29:46just think of army or dentist,
29:48I think that should be a frightening
29:49thought right there, and the procedure
29:52was one of a tooth extraction.
29:54I wouldn't of course get chewed
29:57out the damaged tooth eventually,
29:59but I don't think we want to experience
30:02that or have forensic examining
30:05goes through that level of error
30:07in part of the graciousness of these
30:11criteria is uncooperativeness was found.
30:14Roughly twice more likely to happen
30:17in genuinely psychotic patients
30:20who are uncooperative because of
30:22their illness than in Malingerers
30:24back to as many willing risk.
30:25Remember the 19th century in terms of
30:29concealing their symptoms, in fact,
30:32is never concealed their symptoms.
30:37So it's a full screen to use the
30:41DSM five has disastrous results.
30:43For example, in that case of
30:47the California serial murder,
30:49the person testified.
30:51Yep, medical, legal,
30:53avd and cooperative actually
30:55once put on the proper psychotic
30:58medication became very cooperative.
31:03Uh, this I'll go through very quickly
31:06because it is something probably of
31:08interest to only a small number of
31:11individuals who have the MD or the
31:15Malingered neurocognitive dysfunction,
31:17also called the slick criteria
31:19developed by three psychologists.
31:21I think in the Vancouver area.
31:25They suggest this as a comprehensive
31:28model eventually became approved by the
31:31National Academy of Neuropsychology.
31:36Again, we have that problem,
31:38which is a common theme.
31:40Is that to extrapolate incentive,
31:42they say if you're in this disability
31:45then you motivate a malingerer by
31:48the factor in a disability situation.
31:50They also try to be incredibly inclusive,
31:55so that if the performance is consistent
31:59with fainting across the whole
32:01range of areas or for the report is.
32:05Discrepant across history,
32:07brain functioning observations
32:10environments I know for those of
32:12us who do forensic in otherwise
32:14complex clinical evaluations,
32:16there are always inconsistencies
32:18in their record.
32:19In many times there's inconsistencies
32:22with the examinee because that
32:26person is clearly a poor historian.
32:30So this was testing the IMD.
32:33If you claim that you can read that,
32:35then that would be positive
32:37impression management,
32:38because I don't think that you can.
32:39The goal here is to look at how
32:41many white spaces there are,
32:43which are areas of this model
32:45that have not been tested.
32:52Malingering bias we see them looming,
32:55buyers come up yet again in these
32:58circumstances here because they're using
33:02minimal level of certainty for trouble.
33:05The criteria, if it just suggests
33:07something as opposed to that you're
33:09clear about this meeting their criteria.
33:12That's enough to call you a malingerer,
33:14if in fact it's all you need is two out
33:17of 10 criteria and there are hundreds
33:19of examples for each of those criteria.
33:21How it can be met?
33:23The possible incentive.
33:24We've already talked about.
33:25If you deny some past history,
33:28then that proves that you are
33:30faking and if you're faking,
33:32perhaps or the evidence you
33:35faking in say depression,
33:37then that would be can be used as a proxy.
33:40Vote for the fact you must be
33:43faking card in memory issues.
33:49However. To show how much we
33:52should think of this thing.
33:54As a seasoned, how high the standards
33:58are from malingering 2 ideas one is you
34:01have to feel fully account for other
34:05other explanations 100% of the time.
34:09And indeed, when we come
34:11to clinical realities,
34:13that is almost never an achievable standard,
34:16then the criteria for ruling out
34:19this mainly odd to some of you.
34:23This is actually pretty much
34:26taken almost verbatim.
34:27Will numeric and Lawrence
34:29shoot standard for insanity.
34:31So extremely high standard there.
34:37That kind of moves on, I think,
34:40to looking at probably more positive
34:44things in terms of kind of the new
34:47error and detection strategies.
34:54Here, and this could be
34:56done with a lot of detail,
34:58but I'll move it with it rather quickly.
35:02We have either unlikely strategies,
35:05unlikely testing strategies,
35:07you know it's the presence of this
35:10would give us some very much concerns
35:12in and onto amplified, which is.
35:15This could be a legitimate symptom.
35:17It's just got too much of it or
35:20too severe when it comes to that.
35:23So we are symptoms are those we should
35:26really occur in heterogeneous diagnostic
35:29sample and the most stringent would be 10%.
35:35There are a couple LAX ones which go
35:37to 20% and I think that's a mistake.
35:39Examples of this would be psychotic symptoms,
35:43say neologisms.
35:46Or very rare, even among individuals
35:50hospitalized for schizophrenic disorders.
35:53Very infrequent that they
35:55actually expressed geologist,
35:56seems, well,
35:57auditory hallucinations and other language.
36:00I know awkward moment with a
36:03patient who said he was visited
36:06by this lovely woman who spoke to
36:09him in Italian and then I asked
36:12him to say something in Italian.
36:14Yeah,
36:15it wasn't pretty.
36:21So for rare symptoms this is something
36:24from the service to when we look
36:26across a broad population of those
36:29in correctional clinical forensic,
36:31you'll see roughly between
36:3312 and 14% on these reported,
36:37and we have pretty much tripled
36:41those numbers when it comes to
36:44training simulators as those who.
36:48Gauged in a simulation study woolever
36:51as adults that we feel strongly
36:54that we've confirmed that they are
36:56willing are in clinical practice.
37:03Let's move on unlikely ones.
37:06In some of you might say, and I think
37:08would be able to generate question.
37:10Do we need to go that far
37:11because this is you might say,
37:13testing the limits.
37:14How far is this person willing
37:17to report symptoms?
37:18These examples I came up with
37:20may seem a bit too much on the
37:23physiological side or involved in health.
37:25Do you spell cremating bodies
37:27whenever you take a shower?
37:28Do hair dryers cause your brain to wrinkle?
37:31Probably not pleasant thoughts.
37:37As you can see, your genuine samples,
37:41the numbers go down even
37:43further for this info failures
37:45because it is really out there.
37:47Their percentage is about three to
37:50four times more, but still lower
37:53than under the rare symptoms.
37:57And my favorite,
37:59which probably says something about me.
38:01But it is in terms of Paris at
38:04symptoms and Paris has symptoms
38:06that assumes the relatively common
38:08but really occur together to have
38:10intense fears at the same time,
38:13your appetite for food increases.
38:15It was in the other direction.
38:16It would certainly make sense,
38:18but usually someone who is in
38:20fear of the life doesn't say.
38:23Let me sit down and shout out.
38:29So here's some examples from
38:30The Sims from The Sims.
38:32You look at the clinical forensic sample
38:34at 18% and over half of these are reported
38:39by individuals in the simulation study.
38:43Just this was kind of clever.
38:45Stay visit done with quantitative analysis.
38:47We looked at across the
38:49certified items we looked at,
38:51but correlations do not occur.
38:54So those are fee coefficients
38:57minus .5 - .05 excuse me.
38:59But in simulator you'll see it is .46,
39:03so it becomes a very interesting strategy
39:06for detecting people for malingering.
39:12Amplified these the ones
39:15which are too extreme.
39:17The cut need to cover a wide
39:19range of symptoms with this,
39:21but where the person is reporting
39:23things which are either
39:25extremely too painful to stand.
39:42I'm sorry I'm having a
39:44little difficulty here.
39:45You'll see with these they reported
39:49that in indeed these are avoided.
39:52In average populations.
39:53You can see that's very lively,
39:56different between average
39:59and fainting groups.
40:01Selectivity of symptoms and this side.
40:03I'm just trying here from the PA I.
40:06In terms of this is just like
40:09the Will Rogers of symptoms is
40:11not a symptom that is not liked.
40:14Usually something adaptable
40:16to multi scale inventories.
40:19Research came out in terms of
40:22how high are your elevations on
40:25these clinical scales and that
40:26can easily be used as a way of
40:29saying this is unlikely to be true.
40:31There's simply the magnitude of
40:34symptoms being reported is unrealistic.
40:40So let's look at some of the challenges.
40:44Select opinion, let's look at some
40:46of the challenges with malingering.
40:51I think a couple of enduring challenges
40:54have to do with how we assess the accuracy
40:58of our assessment and reporting in then
41:01in terms of refining things further,
41:03looking at detection strategies.
41:06They will tell us specifically
41:09what is being faked.
41:11Alright, so numbers we all believe in
41:14numbers II rather like this thing about
41:17Hines and 57 varieties of ketchup.
41:19He asserted this for decades.
41:22It was apparently a very effective
41:24marketing tool, but utterly false.
41:26Actually, numbers five and seven represented
41:29Hines and his wife's lucky numbers.
41:32We also have problems with numbers,
41:34which I think I've become fairly
41:37clear in terms of the replication
41:40crisis and social sciences.
41:42Described as a crisis of credibility in here,
41:46we've been very comfortable reporting
41:48things which are statistically
41:49significant but lack of clinical.
41:52For instance,
41:53clinical forensics relevance example
41:55would be correlations of .2 and
41:59call that empirical scientifically
42:02based correlates well.
42:03If you think of that in terms of music,
42:06help me turn on your favorite music station.
42:09You'll be listening to 96% static in 4%.
42:13Music.
42:17I think one of our efforts here
42:19has been particularly in clinical
42:22psychology is to over report things
42:26beyond the position which they are do.
42:33If people are in on psychological
42:36measures, for example,
42:37taking a one point difference and saying,
42:40and that's what we need to work on.
42:42During annoying they are
42:44ignoring the fact that there are
42:46significant measurement errors.
42:48The answers of that is well defined scores.
42:51We just eliminate just a narrow band
42:53where you're going to be making mistakes.
43:01Looking at this, uh,
43:03myself and Scott Bender,
43:05one of my former students,
43:07referred to this as the
43:09myth of lane accuracy.
43:11If you just remove for, say,
43:14the MPI to really narrow band of
43:17five key points on either side,
43:20you'd improved your life
43:22in your accuracy hugely.
43:26So here we go. If we look at if
43:29you remove that, it's a bit of
43:32research that we have conducted.
43:34Basically your coral classification
43:37errors are at 50% and we felt
43:41that many of you would want to
43:43go into court and say, you know,
43:44really, our accuracy here is
43:46pretty much the flip of the coin.
43:51If you think of why, if we,
43:54if we think about dunking a basketball,
43:56you know it's not equally probable
43:58of who's going to build a dunk.
43:59It persons who is not assuming
44:01both are in great shape.
44:03I would say that someone at 65
44:05is going to be a lot more likely
44:08than someone at 5.5 feet 5 inches
44:11not being able to do this.
44:13And I do think that perhaps
44:15that's something we should be
44:17expressing directly to the Court.
44:19In secretly quotes the USF Training
44:21Court has held in Hall V Florida
44:24that we cannot use a single point.
44:26Well, this was a death penalty case,
44:28and it was about IQ scores were they said,
44:31is you have to reflect the reality
44:34of the standard error of measurement.
44:36I'm sure those aren't their words,
44:38but we used from the amicus brief.
44:44They assume on my way they they they
44:46commented that this was a 95% confidence
44:48interval was what was legally required.
44:53Now you might say, well,
44:56this sounds like to me.
44:58Well, probably it does.
45:01This is as signatories of the
45:03American Psychological Association
45:05work inside Cashew Association,
45:07the American Academy of
45:08Psychiatry and the law,
45:10and saying national the National
45:12Association of Social Workers.
45:14So everyone was on board
45:15in a signatory of this.
45:19The amicus brief, in fact, is said,
45:23you know, it would be not without
45:27stands or practice if we did not
45:30report these SCMS and I know that they
45:34were perhaps united for a political
45:36reason or a social justice reason,
45:39namely the death penalty.
45:40But they did not make that distinction.
45:43So there's a question that many of
45:46us perhaps showing the discussion
45:48might see this from different.
45:50Perspectives
45:55alright, so the last bit here,
45:57which will be probably four or five minutes,
46:00is kind of emerging frontiers.
46:05So can we tell you we can tell,
46:07say the person is faking it,
46:09but can we tell what they're faking?
46:11So the first efforts in this
46:13direction was to develop a scale
46:16that had PTS type items on it,
46:18and then those who scored high.
46:20The researchers concluded,
46:22must be feigning PTSD.
46:25What they were missing is whether the
46:28scale was high would also be elevated
46:31in genuine patients with severe PTSD.
46:34Whether this scale would be elevating
46:36other people with other severe disorders.
46:38Schizoaffective disorder in
46:39whether this scale would be
46:41elevated for other failures.
46:43So is it really faint PDST or could
46:45be any other kind of painting?
46:51Second effort in this in these
46:53three examples where they come from
46:56different various versions of the MP Q.
46:59But Umm, PI2RF, is this a Mac scale for
47:03looking at people faking for people,
47:07faking medical complaints shaft.
47:10One of my former students looked at this in.
47:14It doesn't look good.
47:16The trouble with the the F scale use
47:19that genuine patients with somatoform
47:22disorders have high very high scores.
47:25In fact, it's on the scale.
47:27It also has four accuracy.
47:29It's a relatively ineffective
47:31for picking up those people,
47:33fainting medical problems,
47:35and finally it doesn't distinguish
47:37from other painters.
47:39So those who feigning depression
47:41or TBI will also have elevations,
47:44so really not answering the
47:46question that is being asked of us.
47:50Saint Louis success.
47:51Emily Robinson worked with the lead on this
47:55of can we differentiate between people
47:58faking ADHD in other types of failures?
48:02For those of you who might not be
48:04aware of this particular problem,
48:06certainly in terms of college settings,
48:10you can either get illicit use of stimulants
48:13or all of your worst nightmare of a class.
48:16So there are reasons that looking at that.
48:19What we did is we find a different
48:22type of detection strategy stereotypes
48:25that people have about ADHD.
48:28Excuse me that do not appear to be true.
48:32So which of these are very strong results?
48:35Obviously need some replication,
48:37but it does clearly differentiate
48:41between faint and genuine ADHD.
48:43One standard used for CONSTA.
48:46If it's .8 or above,
48:48I think that's in it still.
48:50Also, 2.65 is huge,
48:53but it differentiate between people
48:55faking ADHD and taking other conditions.
48:58Again, it is a very large difference.
49:00Use it markedly.
49:01Elevated in individuals who
49:03are faking other conditions.
49:05Actually it goes in the opposite direction.
49:08So it works out very well.
49:14Three other issues that we might
49:16consider in it is in the research on
49:20if we make the content more ambiguous,
49:23it's harder to feign.
49:25We're not quite sure what the goal is.
49:27The question is so some work done on,
49:30not by myself, but on the extra suggests
49:34it should probably can reduce the
49:36ability of people to fake by about 50%,
49:39if in fact it's the questions are
49:41worded in a way that does not imply it.
49:44The answer. Second, we looked at can
49:48we look at the type of fainting?
49:50For example, in a legal case
49:53such as a competency cases,
49:55here the content was specific.
49:58So for example,
49:59asking bogus questions about the
50:02defense lawyer in the follow up
50:04questions were something about this
50:06affecting the person's ability to
50:08appear in court and put on a defense.
50:12In the third one,
50:14which I I find perhaps the
50:15most interesting of these is,
50:18can we actually tell people
50:19what the strategies are,
50:21and will this actually
50:22make it more difficult?
50:24I said paradoxically,
50:25but more difficult for them fake,
50:27so we might say we like you,
50:29sit down and take.
50:30This test will be looking at consistency,
50:33will be questions of similar difficulty.
50:35Look at how consistent you run.
50:36Those will look at how well you do
50:39as the item difficulty increases.
50:42We're going to measure the
50:44magnitude of your responses
50:46against with the correct responses,
50:49and by the way,
50:50we're keeping track of the response time.
50:52So with all those things in mind,
50:54please give us your very best effort.
50:56The initial research that we have
50:58suggests in some cases the person
51:00does the worst because they assigned
51:02to think like I get this done.
51:04I don't have any time.
51:06Is this one I should get right?
51:07Because it's on the easy side of things,
51:09and so I think that represents maybe.
51:12A great place that we could
51:14look at for further research.
51:18Thank you so much for your time.
51:20I'm really open to and will enjoy hearing
51:22the questions and ideas that you have.
51:36OK, well thank you very much.
51:38**** was very enjoyable presentation.
51:42Certainly anyone is free to either put
51:45something in the chat or raise a hand,
51:48or if we don't see your hand,
51:50just unmute and and.
51:54Let us know what your comment or question is.
51:57I was interested in in your
52:01improbable sort of questions.
52:03It reminded me of something that that
52:06we used to talk about sort of tongue in
52:09cheek during my training in the early 80s.
52:12You know, when when a patient would
52:15give you what we referred to as a
52:18positive review of symptoms and the
52:20the suggestion from other residents
52:21were to ask questions like that.
52:24Your teeth itch.
52:25And does your hair hurt?
52:27Is reminded me a lot of of the questions,
52:30including your handwritten ones
52:31that you showed us earlier.
52:35One in generating questions you have
52:37to be a bit careful about these.
52:40I was kidding around a couple of
52:44colleagues that in fact is as I was
52:47writing some of the original questions
52:49that didn't appear on the service,
52:51I found myself sitting alone during
52:55rush hour on the L in either psychotic
52:58or under the influence of drugs.
53:01You know, as you get your
53:02own seat during my shower.
53:16There could you talk a little
53:18bit about people's reactions to
53:23request that they be assessed
53:27for the malingering of symptoms
53:31and what that tells you?
53:34In and of itself, uhm,
53:38and do you have a script
53:41that you routinely use to
53:43explain to people the process?
53:46I'm thankful, actually.
53:49I think there are different
53:50ways of approaching it.
53:51One of the things for example,
53:53I take a disability case is that I will
53:57say in terms of the disability case,
54:00I will put things out there in
54:02terms of saying this is evaluation.
54:05We want to make sure we
54:07get accurate information.
54:07There are going to be measured starting
54:10to be given that will help us to
54:13understand whether you're being really
54:14forthright about this or whether perhaps.
54:17You're putting things on,
54:19you know you're making things
54:21separate worse than what they are,
54:22and I'm here really to kind of
54:25find out what is the most accurate
54:27account of what's going on with you.
54:30And I think there are problems.
54:34Of course,
54:34if you say to people, OK,
54:36I don't really believe you,
54:39and so now I'm going to give
54:40you a test for malingering.
54:42I think that's problematic.
54:44The thing is,
54:45is that most instances this is a routine.
54:48Part of my assessment is I will
54:51always consider those issues.
54:52Might just a library on that for
54:55just a moment in the recent why
54:57is announcing of criminal cases.
54:59I've had criminal cases.
55:01I'm thinking of the capital case
55:03in Atlanta where it's a very
55:05late in the assessment process.
55:07A person came in and in more
55:10or less the smell test,
55:12which is this person looks like
55:14smells like in in feels like a
55:16malingerer so many times I do it
55:19prophylactically to avoid those
55:21last minute experts coming in on it.
55:24But I do try to describe it more
55:27generally relative to interested.
55:29The response style in some cases I
55:31want you to be honest and forthcoming
55:34so it's on both positive vessels.
55:36Negative presentations.
55:42Stick in the chat.
55:43We have a couple of questions that
55:45are very similar about looking
55:47for your thoughts about a common
55:51clinical situation where people who
55:53are homeless come to the emergency
55:56department for Shelter and Food but
55:58make a chief complaint of suicidality.
56:01What are your thoughts about dealing
56:04with malingering in that situation?
56:08And this is a place where they will
56:11water on some values that people have.
56:16If I could just kind of put that aside
56:19for just a second one of the things I
56:22did a tiny bit of consultation with
56:25the Secret Service and the issue is,
56:28is how many people have found that.
56:30If they come in and say I feel
56:32like I'm going to kill someone,
56:33they may not receive services if they come
56:36in and say I'm going to kill the president,
56:39they immediately received services.
56:40So I think there's an article that
56:43described this going up into hundreds.
56:45So I I. I think you have people
56:48who have kind of learned how to
56:50game the system are the lingering.
56:52Yes, this is a much of a very
56:55much of a sustained effort.
56:57It seems helpful to me.
56:59The trouble with suicide?
57:01Yeah, I'm sure there's different
57:02points of view on this.
57:03The difficulty with that is we don't.
57:08We virtually do not want to challenge people
57:10in terms of saying if you don't cut yourself,
57:13I won't believe you.
57:15So this creates a problem and this is one
57:19of those problems that doesn't go away.
57:21As they would in other words,
57:23I think taking them more at face value
57:27than not seems to be an approach.
57:31It would be very difficult to
57:33turn someone away,
57:34or perhaps if they've done
57:36this dozens of times,
57:37you know we could look at that history
57:39and we could say, you know this.
57:41I'm so sorry that you're out in the
57:44cold and it's miserable etc etc.
57:46This releasing, going to work,
57:47fight and then maybe coming up with
57:50an idea that we don't have to push.
57:52The suicide button.
57:53Well, this happens, you know,
57:56in correctional facilities many, many times.
58:00And sometimes in one place where I did
58:04some research they were I was asking,
58:07you know about how who gets
58:09to see mental health services?
58:11They said OK,
58:12we have we have emergencies such as suicide.
58:16We have highly urging cases and
58:18then they were trying to think of
58:20the name of the other third one.
58:22But there was no name for it
58:25because everyone knew if not an
58:27emergency and possibly urgent.
58:29I'm just not getting services and you
58:33know that is really a part of the
58:35conundrum is that oftentimes these
58:38services or physical well being is at stake.
58:41Neutral,
58:42that was very helpful,
58:43but my notion would be I don't think
58:45you could turn the person away.
58:47I think you could evaluate them
58:49and no one has.
58:51No one has worked break yet on bogus
58:56suicide complaints and so that would
58:58be an area that could be looked at.
59:00It's just the professional
59:03responsibility as well as perhaps the
59:07legal responsibility said she would
59:09have that if you turn someone away.
59:13Even it was there half a dozen times,
59:16they come in with this.
59:17I would seem very hard to turn
59:19them away at that point.
59:23There's another question here asking
59:25if you could comment on racial
59:28and socioeconomic disparities among
59:30diagnosis of malingering and whether
59:32or not there's a difference in the
59:35likelihood that persons of color
59:37would be diagnosed as malingerers.
59:42Most of that there is there
59:44is very little data on.
59:46There are some methods out
59:48where individuals have been
59:50divided or even looked at in
59:53terms of their self identified.
59:57Race or ethnic background and so on.
59:59Some message, such as a service.
01:00:01We have similar data on those regarding
01:00:05regarding their their performances is an
01:00:10area that is oftentimes not looked at well.
01:00:14So this was a very bright question, so I'm
01:00:17going to kind of pass out one more piece.
01:00:19I think one of the places where they've
01:00:22been huge problems has been in the Spanish
01:00:25translation of malingering measures,
01:00:27which have been not been rigorously
01:00:30evaluated, and I think that
01:00:32creates just a dramatic problem.
01:00:34The private part of that question of
01:00:36the implications, I think, is due.
01:00:41Practitioners have in this was
01:00:44one has not been tackled directly.
01:00:47What do practitioners have a different
01:00:49mindset when they are seeing a person
01:00:52like a European American versus African
01:00:55American versus a person from a very
01:00:58different cultural background that may
01:01:00be very recently here in the states?
01:01:03And I'd really be interested if anyone
01:01:05else has seen any research on that,
01:01:07but I think that would be the area I
01:01:10can think of how states could be done,
01:01:14but they would probably.
01:01:15The ones I'm thinking of would
01:01:16not be very sophisticated.
01:01:18We provide some of this scenario
01:01:20and you embed that in it because
01:01:22I think it's probably the other
01:01:24person to person interaction,
01:01:26which is where you would see the types of
01:01:29questions being asked in the inferences
01:01:31of those questions relative to how.
01:01:34Individuals are seen as malingering.
01:01:38I also see a handup.
01:01:40Yes, Joseph, go ahead, done yourself.
01:01:46I think thanks for the presentation so and
01:01:49I apologize, I had to miss
01:01:51part of the beginning, so this was
01:01:52explained. Then just tell me so
01:01:54and I'm happy to be quiet again,
01:01:56but so in terms of disability
01:01:59evaluations and also evaluations in
01:02:01civil litigation, the problem is not
01:02:03typically the threshold of malingering,
01:02:05it's a substantiation of the deficits
01:02:07that you see in front of you in a
01:02:09lot of cases that I see are actually
01:02:11more mixed more along the lines
01:02:14of they have some difficulties.
01:02:16So they don't quite reach
01:02:18the threshold, and as
01:02:19such some of the more
01:02:21indeterminant thresholds that you
01:02:23talked about actually end up being
01:02:25pretty relevant to determine
01:02:27whether or not you can determine
01:02:30the degree of disability or the
01:02:31symptoms that they're presenting.
01:02:33Can you just comment on
01:02:34that in terms of popular,
01:02:35you use that in cases like that?
01:02:37Or do you always have
01:02:39a hard criteria to say,
01:02:40well, you got to reach
01:02:41this level, or will
01:02:43just take it face value
01:02:44of what you're saying?
01:02:46This whole piece of that question,
01:02:47and I think both of them are excellent
01:02:49to 19 touch up on either than Joseph so,
01:02:52so I think that's that's excellent.
01:02:55So let me point out, first of all,
01:02:58in terms of research where I think we
01:03:02have failed a bit and I think this touches
01:03:05upon your point slightly obliquely,
01:03:07but hits it mostly.
01:03:09We asked people relative to about
01:03:12the symptoms and and sometimes those
01:03:14symptoms are being faster, etc.
01:03:17The era that we've done very,
01:03:19very little research in is those.
01:03:24Is those where they're actually
01:03:28reporting symptoms accurately?
01:03:30What they're in claiming much more
01:03:33in capacity because of the symptoms?
01:03:36So here's a silly example,
01:03:38but inaccurate, but one.
01:03:39I had a person who came to see
01:03:42me as a part of a disability
01:03:45evaluation who was a dentist.
01:03:47And he basically said I've
01:03:49become anxious at times,
01:03:51sometimes during procedures in
01:03:54adult minor tremors in my hands.
01:03:57When I'm doing, say,
01:03:58is a dental procedure in a very
01:04:02concerned about that was a situation
01:04:05where I'm absolutely convinced
01:04:06that because of some of the other
01:04:09things that were reported in
01:04:10some of the records that this was
01:04:13probably a place where you may.
01:04:14I mean, I've had some a bit of anxiety,
01:04:17but not to the threshold
01:04:18that you needed treatment.
01:04:19ETC, but he was using it as a way of
01:04:23saying and thus I'm impaired and I
01:04:27think they continue to get benefits.
01:04:30So we've been sent very little time.
01:04:32I started a project I have not finished yet.
01:04:35I'll be quite honest about looking
01:04:37at how people report the symptoms,
01:04:40but not to exaggerate the symptoms,
01:04:42but to exaggerate its effect,
01:04:44to say on their work life or or
01:04:47other realms of their existence.
01:04:50I do think though,
01:04:52on from a dimensional perspective that
01:04:56we can say in this is my take on it.
01:04:59I would like us to.
01:05:00Be very clear this person is
01:05:02not malingering or meets the
01:05:04criteria for malingering.
01:05:05If that is indeed the case,
01:05:07but in fact is that with regards to the
01:05:11reporting of the symptoms that there
01:05:14appears to be maybe some elaboration,
01:05:17some accentuation on some of these symptoms,
01:05:21and then in terms of what is
01:05:23needed in terms of typically are
01:05:25asked for which remediation plan
01:05:27or your ideas of what that might.
01:05:30Looks like then I think that
01:05:32could be incorporated into that.
01:05:36I find sometimes you know the use of words.
01:05:40I think it's very important
01:05:42to find what they're not.
01:05:43So because I have found in the
01:05:46world of disability evaluations
01:05:49that is very easy for people to ask
01:05:53you for proxies for malingering.
01:05:56You know in terms of and I think
01:05:58it's so to me it's important that
01:06:00we delineate that one measure,
01:06:02of which I rather like when it
01:06:06comes to disability cases.
01:06:08Is the ages 5,
01:06:09which is really much more of the
01:06:11things that you run into in terms
01:06:14of anxiety is on mood disorders,
01:06:16so comes a good Cam it,
01:06:18but only a screen for psychotic
01:06:21symptoms that infectious gets to
01:06:23a point where you can look at the
01:06:25levels of very they're reporting
01:06:27based upon what they're saying you
01:06:29know based upon collateral sources,
01:06:31hopefully inform at once.
01:06:34Recent case in Houston.
01:06:36This can be a pain in the *** to administer.
01:06:39Let's be honest about that.
01:06:40I had a case in Houston where
01:06:44I thought this could be.
01:06:45I had like a lot in an hour
01:06:47and a half or so far this.
01:06:48As it turns out we finished.
01:06:51I think in 20 to 30 minutes 'cause
01:06:54every symptom he he endorsed every
01:06:57single symptom and he endorsed
01:07:00it to the most extreme level.
01:07:03So it didn't take us long to
01:07:06go through and to find that,
01:07:08but when it's wants us to Mac like
01:07:10that and I can then compare what
01:07:13this person is reporting in terms of
01:07:15maybe trauma or PTSD type symptoms.
01:07:18I can compare systematically
01:07:20across different sources of data.
01:07:23Excellent question. Thank you very much.
01:07:34We've had some very difficult
01:07:35cases where, for example, surgeons
01:07:40who have had these great insurance
01:07:43policies that say if you can't function
01:07:46in the job that you were trained to do,
01:07:49then you will get a very high return on that.
01:07:53And when you have people who've
01:07:56gotten sued and then say I'm too
01:07:59anxious to do surgery anymore.
01:08:02Uh, I've found that very hard to
01:08:05evaluate in terms of, you know,
01:08:08you don't want to send somebody in
01:08:09who's really anxious to do that.
01:08:12At the same time I I've I've had
01:08:15a very hard time figuring out
01:08:16how much is exaggerated.
01:08:20I I would agree with you,
01:08:22Howard completely that some of the
01:08:25occupation specific ones are by
01:08:27far the most challenging because
01:08:29there is a lot of times they
01:08:32have very specific set of data.
01:08:34I assumed that these surgeries were
01:08:38not being recorded and if they were,
01:08:41I'm not quite sure how I would do
01:08:43with that data because I'm not in
01:08:45a position that I could comment
01:08:47on that whatsoever.
01:08:48Obviously that's something
01:08:49that we look for is.
01:08:51Are there recordings of this
01:08:53person that would allow you to see,
01:08:56but I can't imagine anything
01:08:58that we replicate surgery,
01:08:59but in some instances we see with
01:09:02the person has claimed those case.
01:09:05Canadian case we're was claiming all
01:09:09these issues and being able to move etc.
01:09:12That was not an occupational specific case,
01:09:15but there you know watching
01:09:17him gamble for hours on end.
01:09:18By the way,
01:09:19when the most warring things
01:09:21that you can possibly do,
01:09:22but you were able to at least
01:09:24get some clarity information.
01:09:25So to me the part of that task,
01:09:28if this is kind of a basic surgical
01:09:32team is would be to see if I would
01:09:35have the opportunity to have extended
01:09:38interviews and with members of the
01:09:41staff of the surgery staff and then
01:09:44the question would be, you know,
01:09:47the closing ranks and protecting.
01:09:49Person dies that would be inevitable
01:09:52that I would consider my abs.
01:09:55I agree with you,
01:09:56those can be extremely trying cases.
01:10:12So I don't see anything else in the chat
01:10:14I I was going to ask you that about the.
01:10:17One of the slides you started out
01:10:19with the the 1936 article from
01:10:21Seltzer about the difference in the
01:10:23rate of disability of people in the
01:10:25VA versus from the military records.
01:10:27Because I've seen some recent
01:10:30literature that describes that
01:10:32process and there are sort of legit.
01:10:34There are some legitimate reasons why
01:10:37people would minimize symptoms that they
01:10:39have while they're currently serving,
01:10:42but then bring them up more after
01:10:44they're discharged from the service,
01:10:46including things.
01:10:47Like the stigma of reporting,
01:10:50particularly mental health symptoms
01:10:52when one is actively in the service,
01:10:55particularly during wartime.
01:10:56Uh, ANOTHER is that it might reflect
01:10:59negatively on someone's chances of promotion.
01:11:02And once someone's left the service,
01:11:05those things are no longer a
01:11:08consideration and people may feel
01:11:10freer to to disclose the symptoms that
01:11:13they're that they're experiencing.
01:11:17Yeah, I, I think I think all that is true.
01:11:20I also think that and I I did
01:11:22not serve in the military.
01:11:24But I also think under the stress
01:11:26of combat where all of you are
01:11:29experiencing you from my stress is a
01:11:31very different world that when you
01:11:33come back to civilian life and the
01:11:35entire different set of stresses
01:11:37there that you're experiencing. But.
01:11:41Many times he seems I think then become
01:11:45much more of an issue at that time.
01:11:48And you wonder whether or not we could
01:11:51do might do a better job in terms of
01:11:54bringing people back and socializing, etc.
01:11:56A colleague of mine in the past, in fact,
01:12:01is was doing a lot of work with DoD
01:12:04and they were trying to use a virtual.
01:12:06They were using virtual realities
01:12:08as a way of training people how
01:12:11to be effective at killing.
01:12:13And one question he asked wouldn't do
01:12:15get a great response on what are you
01:12:17going to do to help deprogram them.
01:12:19Once they're done,
01:12:20and I think that that becomes a huge
01:12:24issue of we teach you how to become
01:12:27desensitized in that practically makes
01:12:29sense in terms of combat situations,
01:12:32but we doing enough at the other
01:12:34end and then of course,
01:12:36then there's obviously PTSD,
01:12:38which is many times we see a delayed onset,
01:12:42was there.
01:12:46OK, well take thank you very
01:12:48much for your presentation and
01:12:49for your discussion with us today.
01:12:51On behalf of everyone,
01:12:52I just want to express our
01:12:54gratitude for your being here in
01:12:56person even though in person meant
01:12:59so much of a virtual presence.
01:13:01But it was great having you
01:13:03with us and I'm so glad that
01:13:05we were able to conclude with
01:13:06this grand rounds presentation.
01:13:09Well, thank you so much again for having me.