EFFORT, EXAGGERATION, AND THE LIMITS OF THE MALINGERING LABEL

One of the most common questions I get from attorneys on both sides is some version of, “Is this person malingering?” It’s a fair question. In a medicolegal evaluation, the credibility of the data matters just as much as the data itself. If the results are not valid, everything built on top of them, from the diagnosis to the impairment rating, becomes invalid. But the answer to that question is rarely as simple as yes or no, and the word “malingering” carries more weight than most people realize.

Every neuropsychiatric evaluation I conduct includes measures designed to assess the validity of the results. These fall into two broad categories, and it is helpful to understand the difference between them.

Performance validity tests (PVTs), also known as effort measures, look at whether a person put forth adequate effort on cognitive testing. Some are standalone tests, created specifically for this purpose. Others are embedded within standard cognitive measures, such as Reliable Digit Span, so that effort can be monitored throughout the evaluation rather than at a single point in time. These tasks are designed to be easy enough that even individuals with significant brain injuries, i.e. dementia, perform well on. When someone performs below expected levels, it tells us their effort is suspect. Some PVTs use a forced choice format, where a person could get roughly half the items correct simply by guessing. When someone scores significantly below chance on these tasks, it is a stronger indicator, because it suggests the person knew the correct answer and intentionally selected the wrong one.

Symptom validity tests (SVTs) look at how a person reports their symptoms. On instruments like the MMPI-2-RF and MBMD, validity scales help identify whether someone is reporting symptoms in an unusual, inconsistent, or exaggerated way. Some scales flag reporting of rare psychiatric symptoms, others flag overreporting of somatic complaints, and others identify inconsistent or random responding. These scales also work in the other direction. Some individuals minimize their problems or present themselves in an overly favorable light, which can be just as important to identify.

It is important to note that these measures tell us about the credibility of the data. They do not tell us about a person’s character, and they do not tell us why the person responded the way they did. That distinction is often lost, and it is where many reports run into trouble.

As a golden rule of thumb, I never interpret any piece of data in isolation. One below expected score on a single validity measure is not, by itself, a basis for a conclusion. Even individuals who are trying their best can fail an isolated measure, particularly when they are in significant pain, are heavily medicated, or are severely depressed. This is why the research supports using multiple validity measures throughout an evaluation, and why the pattern across those measures matters far more than any single score.

Beyond the validity measures themselves, I look at the full picture. I consider consistency between test scores and the person’s reported daily functioning. I review medical, employment, and treatment records, including how symptoms have been described over time and to different providers. I look at whether complaints have stayed stable, improved, or escalated, and whether that course makes sense given the nature of the injury. I consider behavioral observations during the interview and testing, such as how the person navigates the office, follows conversation, recalls their own history, and manages the length of the evaluation. I also look at whether the pattern of results makes sense neurologically. Certain injuries produce certain patterns base on what we know about neuroanatomy and neurochemistry and results that do not fit any known pattern deserve a closer look.

For example, if someone with a mild concussion performs worse than individuals with severe dementia, yet drove themselves to the appointment, gave a detailed and organized history, and recalled specific dates without difficulty, that inconsistency is meaningful. On the other hand, if validity concerns are limited to one measure and everything else lines up with the records and my observations, that tells a very different story. Convergence across multiple sources of information is what makes an opinion defensible, and it is what allows that opinion to hold up under scrutiny.

The DSM defines malingering as the intentional production of false symptoms, motivated by external incentives such as financial compensation, avoiding work, or obtaining medication. Notice the two key elements: intent and motive. Neither one can be directly measured by a test. Malingering is also not a mental disorder. It is a description of behavior, and labeling someone as malingering is essentially a statement about why they did what they did.

When an injured worker shows signs of overreporting or inadequate effort, there can be many reasons behind it. Some individuals are genuinely distressed and are, in effect, crying for help. They may have felt dismissed by providers, their employer, or the system as a whole, and they worry they won’t be believed unless they emphasize how bad things are. Others are dealing with emotional dysregulation, depression, anxiety, or chronic pain that colors how they experience and describe their symptoms. Some have developed a genuine belief that they are more impaired than they are, which is a clinical issue in its own right.

And yes, some are in fact motivated by external gain and feigning altogether. However, in a medical population, these factors often overlap, and the same person may be influenced by more than one at the same time. Therefore, it is speculative for any evaluator to claim certainty about which one is driving the presentation.

For this reason, I am careful with the term. Language such as “noncredible performance,” “invalid profile,” or “symptom overreporting” describes what the data show without assigning an intent that cannot be proven. This is not about softening the findings. It is about staying within what the evidence can actually support, which is what a forensic opinion should always do.

In my view, the more useful question is not why someone is exaggerating, but what we do about it. When validity concerns are present, I state them clearly in the report and explain what they mean for the rest of the findings. I adjust my interpretation accordingly. Scores obtained under questionable effort likely underestimate true ability, so I do not treat them as an accurate measure of impairment. I rely more heavily on the data that are valid, on the records, and on my observations. When the cognitive data are too unreliable to interpret, I say so, rather than assigning a rating that the data cannot support. In most cases, when someone fails an effort measure, I will actually not proceed with cognitive testing.

Invalid results do not mean there is no injury, and a valid injury does not mean exaggeration should be overlooked. A person can have a real condition and still overstate it. A person can also fail an effort measure for reasons that have nothing to do with external gain. Our job is to separate what is credible from what is not, as objectively as possible, and to explain how we got there.

Validity testing is one of the most important tools in forensic neuropsychology, but it is only one tool. A sound opinion comes from integrating test data, records, and observations, and from being transparent about the limits of what any evaluator can know. It is also what gives the trier of fact something reliable to work with, and that is what serves everyone involved.