Every clinician is familiar with patients who describe their complaints in a way that raises concerns as to the plausibility of their symptom reports. In these patients, the frequency (‘I have panic attacks every hour’), intensity (‘my pain is always 10 on the 0-10 numerical pain rating scale’), and/or co-occurrence (‘I have panic attacks, experience pain, hear voices, and suffer from dyslexia’) of symptoms seem to be out of the clinically plausible range. When this is the case, some might argue that the patient is a malingerer, i.e., a healthy person who fabricates symptoms in order to obtain an incentive (e.g., compensation money). That, however, would be a highly premature conclusion, and this for two reasons.
First, clinical impressions of symptom plausibility often turn out to be wrong. When you as a clinician want to find out whether a patient engages in symptom over-reporting, it is best to use a Symptom Validity Test (SVTs). Typically, these tests list a range of atypical, rare or non-existent symptoms (e.g., ‘my headaches are so severe that my feet hurt’), the idea being that patients who over-report their symptoms tend to endorse such items on a wide scale. When this happens, the patient fails the SVT. Although they do not possess laser accuracy, many SVTs have an excellent psychometric track record in identifying symptom over-reporting. Also, SVTs are rather insensitive to genuine cognitive impairments (Dandachi-FitzGerald, et al., 2019).
In one of our studies (Dandachi-FitzGerald et al., 2017), we compared clinical impressions of neuropsychologists and their patients’ performance on SVTs. Of the 152 patients for whom neuropsychologists had predicted plausible symptom presentations, 14 patients (9.2%) failed on SVTs. Of the 51 patients for whom neuropsychologists had predicted questionable symptom validity, 35 patients (68.6%) passed the SVTs. Thus, clinical impressions of questionable symptom presentation are far from perfect. Our findings show that SVTs have incremental value in that they may correct initial clinical judgment.
Symptom Over-Reporting Does Not Indicate Malingering
Second, people who malinger often go over the top in endorsing implausible symptoms on an SVT. However, as we explained in our recent review paper (Merckelbach et al., 2019), the reverse is certainly not true. Not every patient who over-reports symptoms is a malingerer. Certain personality characteristics might influence symptom reporting. For example, some people experience alexithymia: these individuals are poor at figuring out what they feel and whether it is abnormal. They might misinterpret mild and everyday symptoms – fatigue, headaches, muscle pain, sleep problems – as the alarming signs of a disease and in doing so, they might over-report symptoms. Thus, this type over-reporting does reflect poor interoception and/or limited mentalization ability rather than deliberate fabrication of symptoms. In one study (Merckelbach et al., 2018) that involved a group of 40 psychiatric outpatients with no obvious motive to exaggerate, we observed that symptom over-reporting was moderately associated with alexithymia (r = .56). Relatedly, poor mentalization skills – i.e., the ability to think about one’s own inner state (e.g., needs, desires, feelings, beliefs, intentions) and that of others – might predispose to symptom over-reporting (Hong et al., 2019).
People often have a keen interest in whether they suffer from symptoms. That is why they find the information provided by medical apps or clinicians highly relevant. However, when this information overstates the seriousness of symptoms, it might fuel escalation of symptom reports. In one lab study (Van Helvoort et al., 2019), we asked healthy research participants to complete a symptom list and then provided them with false feedback about some of the symptoms that appeared on the list. Many research participants accepted the feedback and some (33%) confabulated reasons for symptoms that they originally had not endorsed. Thus, misinformation is yet another pathway to symptom over-reporting, a pathway that has little to do with malingering.
Why is it Important?
Symptom over-reporting should not be equated with malingering. Therefore, failure of SVTs signals over-reporting, but not necessarily malingering. Patients might over-report symptoms because they have certain trait characteristics (e.g., alexithymia, poor mentalization ability) or have been exposed in the past to misinformation about the chronicity and seriousness of their symptoms. Still, clinicians might find it useful to administer SVTs to their patients. It is highly informative for clinicians to know when and why their patients over-report their symptoms. For example, when symptom over-reporting goes unnoticed, patients might receive an incorrect diagnosis and a less effective treatment based on their symptom reports. That is, problems that are truly present might be overlooked during treatment. In addition, some patients might not benefit from treatment interventions that generally yield positive effects. In such circumstances, symptom over-reporting, which is a phenomenon at the subjective level of self-reports, might overshadow improvements in the behavioral realm. Consideration of multiple pathways that lead to over-reporting, may help clinicians to gain a better understanding of why a patient over-reports his/her symptoms. This in turn may help clinicians to better manage symptom over-reporting and optimize treatment outcome (Hong et al., 2019).
- How often do you encounter patients who engage in over-reporting of their symptoms?
- Do you trust your clinical impression in this regard?
- Do you think that Symptom Validity Tests (SVTs) might predict treatment progress?
Merckelbach, H., Dandachi-FitzGerald, B., van Helvoort, D., Jelicic, M., & Otgaar, H. (2019). When patients overreport symptoms: More than just malingering. Current Directions in Psychological Science, 28321-326. https://doi.org/10.1177/0963721419837681
Harald MerckelbachPh.D. is a full professor of legal psychology at Maastricht University, Maastricht, the Netherlands. His research focusses on dissociative symptoms, crime-related amnesia, malingering, and symptom misinformation. See www.haraldmerckelbach.nl
Dandachi-FitzGerald BrecciaPh.D. is a clinical psychologist and assistant professor of psychology at Maastricht University, Maastricht, the Netherlands, where she studies symptom over-reporting and how it affects treatment outcome. A related research topic in which is interested concerns adverse side-effects of psychological treatment.
Dandachi-FitzGerald, B., Duits, A.A., Leentjens, A.F.G., Verhey, F.R.J., & Ponds, R.W.H.M. (2019). Performance and symptom validity assessment in patients with apathy and cognitive impairment. Journal of the International Neuropsychological Societies.https://doi.org/10.1017/S1355617719001139
Dandachi-FitzGerald, B., Merckelbach, H., & Ponds, R. W. (2017). Neuropsychologists’ ability to predict distorted symptom presentation. Journal of Clinical and Experimental Neuropsychology, 39257-264.https://doi.org/10.1080/13803395.2016.1223278
Hong, V., Pirnie, L., & Shobassy, A. (2019). Antisocial and borderline personality disorders in the Emergency Department: Conceptualizing and managing “malingered” or “exaggerated” symptoms. Current Behavioral Neuroscience Reports, 6127–132. https://doi.org/10.1007/s40473-019-00183-4
Merckelbach, H., Prins, C., Boskovic, I., Niesten, I., & À Campo, J. (2018). Alexithymia as a potential source of symptom over‐reporting: An exploratory study in forensic patients and non‐forensic participants. Scandinavian Journal of Psychology, 59192-197. https://doi.org/10.1111/sjop.12427.
van Helvoort, D., Otgaar, H., & Merckelbach, H. (2019). Worsening of Self-Reported Symptoms Through Suggestive Feedback. Clinical Psychological Science2167702619869184. https://doi.org/10.1177/2167702619869184