3 Medicolegal aspects of neuropsychiatry: malingering
Authors: Bass Christopher 
Published: December 2022

Dr Bass trained in Psychiatry at Kings College Hospital in London and worked as Consultant in Liaison Psychiatry at the John Radcliffe Hospital in Oxford from 1991–2011. From 1992–2007 he worked in a joint pain clinic with pain clinicians.

His clinical interests include chronic persistent pain and fabricated illnesses, including fabricated or induced illness in children. He co-edited Hysterical Conversion: Clinical and Theoretical Perspectives (with Halligan P and Marshall J), OUP 2001; and Malingering and Illness Deception (with Halligan P and Oakley D) OUP, 2003. In 2014 he published a review of factitious disorders and malingering in the Lancet and in 2017 [with Dr Yates] a systematic review of the perpetrators of medical child abuse.

The bulk of his medico legal work involves assessment in cases of persistent pain and ‘functional’ disorders after accidents, and summarised in a recent review in the Journal of Personal Injury Law, 2021.

Malingering is an emotive word which is not advisable to use in a medico-legal context or correspondence. It describes a behavioural strategy, not a mental illness, and glossary definitions are not only unhelpful but misleading. Alternative terms will be suggested for the spectrum of behaviour subsumed under the term Malingering. Prevalence rates are estimated to be as high as 30% in settings associated with litigation/disability evaluation, but its frequency in clinical practice is unknown.

In this talk I will describe those neurological disorders where difficulty in determining the degree of symptom exaggeration/amplification is most likely in medico-legal settings. These include mild traumatic brain injury, functional neurological disorder [FND], and a controversial syndrome called complex regional pain syndrome Type 1.

A thorough and detailed interview is essential. In medicolegal settings this is facilitated by the investigating clinician being provided with multiple sources of additional information such as witness statements and employment records. Because a person’s recollections of their past symptoms, illnesses and episodes of care are often inconsistent from one enquiry to the next, establishing a chronology or ‘time-line’ of

The legal concept of Fundamental dishonesty, introduced in 2015 under Section 57 of the Criminal Justice and Courts Act, will be briefly described, as will recent Court judgements of relevance to neuropsychiatrists. Case vignettes will be presented to demonstrate examples of symptom exaggeration leading to the termination of a medicolegal case.

Causal mechanisms will be briefly described, which include putative organic factors and psychological mechanisms that showcase the relevance of cognitive dissonance for research on malingering.

Finally, techniques to detect deception in medicolegal settings include use of covert surveillance and review of social medica accounts, and brief mention will be made of these. Specialised psychological tests based on negative response bias [Symptom validity testing] administered by neuropsychologists will be described in another presentation