the assessment of malingering with the m-fast

THE ASSESSMENT OF

MALINGERING WITH THE M-

FASTHolly A. Miller, Ph.D.

College of Criminal JusticeSam Houston State University

OVERVIEW Malingering

Theory and assessment Miller Forensic Assessment of Symptoms

TestDevelopment of the M-FASTUtility of the M-FAST

Brief overview of studiesAdministration and scoring of the M-FASTPractice administration InterpretationQuestions

MALINGERING The DSM-IV-TR defines malingering as:

Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives (APA, 2000)

Why might someone malinger? Prevalence of malingering

Around 8% of general evaluations Around 20% of forensic evaluations

Miller, 2000; Rogers & Cruise, 2000; Rogers, Salekin, Sewell, & Goldstein, 1996

MALINGERING When to assess for malingering Rogers suggests under these

circumstancesAtypical presentation of symptomsUnusually high number of unusual or

obvious symptomsNonselective endorsement of symptomsDiscrepancies between reported and

documented history of mental illness

MALINGERING Why not just use clinical judgment?

DSM criteria Marked discrepancy between reported impairment and

objective findings Lack of cooperation during evaluation or treatment Medico-legal context presentation Presence of APD

What research reports on accuracy of clinical judgment Utilizing DSM criteria results in high false-positive rates Studies strongly support that objective assessment

instruments are significantly more accurate than clinical judgment (Miller, 2005; Rogers 1984; Ziskin, 1984)

MALINGERING Miller, H. A. (2005). The Miller-Forensic

Assessment of Symptoms Test (M-FAST): Test generalizability and utility across race, literacy, and clinical opinion. Criminal Justice & Behavior, 32 (6), 591-611.Study 1 – initial M-FAST items (79 items)

280 forensic patients; 5 psychiatrists; 8 psychologists

M-FAST; SIRS; Mtest; MMPI-2Study 2 – final M-FAST (25 items)

50 forensic patients; 5 psychiatrists; 8 psychologists

M-FAST; SIRS; Mtest; MMPI-2

MALINGERING Study 1 Clinical opinion v. M-FAST

results Psychiatrist Opinion

AUC = .72 (SE = .05)CI = .62 - .8119 FP; 17 FN

Psychologist Opinion AUC = .80 (SE = .04)CI = .72 - .8815 FP; 11 FN

M-FAST (79 items)AUC = .89 (SE = .02)CI = .85 - .93

ROC Curve

Diagonal segments are produced by ties.

1 - Specificity

1.00.75.50.250.00

Sen

sitiv

ity

1.00

.75

.50

.25

0.00

ROC Curve

Diagonal segments are produced by ties.

1 - Specificity

1.00.75.50.250.00

Sen

sitiv

ity

1.00

.75

.50

.25

0.00

ROC Curve

Diagonal segments are produced by ties.

1 - Specificity

1.00.75.50.250.00

Sen

sitiv

ity

1.00

.75

.50

.25

0.00

MALINGERING Study 2 Clinical opinion v. M-FAST results Psychiatrists

AUC = .65 (SE = .09) CI = .47 - .83 7 FP; 7 FN

Psychologists AUC = .73 (SE = .08) CI = .57 - .89 9 FP; 4 FN

M-FAST (final version) AUC = .95 (SE = .03) CI = .88 – 1.00 6 FP; 1 FN

ROC - Psychiatrists

1.00 .75 .50 .25 0.00

1.00

.75

.50

.25

0.00

ROC - Psychologists

1.00 .75 .50 .25 0.00

1.00

.75

.50

.25

0.00

ROC – M-FAST

1.00

.75 .50 .25 0.00

1.00

.75

.50

.25

0.00

MALINGERING How to catch a malingerer

Previous research has indicated important areas of assessment: Certain response styles Certain interview strategies

Several instruments include assessment of response styles or were specifically designed to assess malingering MMPI-2 PAI SIRS

However, there remains a need for a brief screen for malingered mental illness

DEVELOPMENT OF THE M-FAST M-FAST items were developed to

operationalize the response styles and interview strategies that have been validated for identifying individuals who are malingeringReported vs Observed symptoms (RO)Extreme Symptomatology (ES)Rare Combinations (RC)Unusual Hallucinations (UH)Unusual Symptom Course (USC)Negative Image (NI)Suggestibility (S)

DEVELOPMENT OF THE M-FAST M-FAST is a structured interview of 25

items representing the “proven” detection strategies

Administration is approximately 5-10 minutes

Scoring is approximately 10 minutes Does not require the ability to read

(examinee) Has been translated into Korean and

Spanish M-FAST was developed using both known-

group and simulation studies

ADMINISTRATION AND SCORING Materials include manual and 8-page

interview booklet Validated on people 18 yrs and older Validated with different ethnic/race groups Validated across gender Validated with varied populations

In prison On probation In forensic hospital In civil hospital Outpatient disability assessment

ADMINISTRATION AND SCORING Appropriate populations and limitations

Malingered psychopathology (not neuro)Examinee must be able to understand items Adults 18 yrs or olderScreening instrument and was not

developed to be the sole determinate of malingered mental illness

Professional requirements Mental health clinician with formal training

in diagnostic interviewing and assessment

ADMINISTRATION AND SCORING M-FAST should be preceded by a clinical

interviewTo gather both symptom information and

observable behavior (RO assessment help) Read aloud instructions for administration

to client Suggestibility item

1st response dictates how you ask last part of item

Read items and possible responses of each item

May repeat once – but offer no explanation

ADMINISTER M-FAST With partner, practice administration Partner role play a malingerer

Want to appear mentally ill, without elevating M-FAST score

Then reverse roles

ADMINISTRATION AND SCORING Scoring instructions provided on last

page of interview booklet Score individual items Score scales If more than 2 items missing, not

considered valid administration

INTERPRETATION Malingering is distinct from most forms

of psychopathology; however the presence of malingering does not rule out a psychiatric disorder

Significant consequences for malingering diagnosis

Choosing of a cut score for M-FASTMore acceptable to have false positives

than false negativesCut score of 6 utilized

INTERPRETATION Three levels

Total scale Provides an estimate of the likelihood that the examinee

is malingering Interpretive statement: The examinee’s total score on

the M-FAST was significantly elevated, indicating that this individual may be malingering mental illness.

Scales Provides information on how the individual is malingering Can make interpretive statements about scale

elevations, but utilize total score for overall assessment Each scale has own “cut score” Suggestibility item (scale) Manual provides interpretative statement examples

Items

INTERPRETATION Next step

Further malingering assessment is warranted if client elevated M-FAST

M-FAST ARTICLES BY TOPIC Competency to stand trial – forensic

inpatients Jackson, R., Rogers, R., Sewell, K. W. (2005). Forensic

applications of the M-FAST: Screening for feigned disorders in competency to stand trial evaluations. Law and Human Behavior, 29(2), 199-210.

Vitacco, M. J., Rogers, R., Gabel, J., Munizza, J. (2007). An evaluation of malingering screens with competency to stand trial patients: A known-groups comparison. Law and Human Behavior, 31(3), 249-260.

Miller, H. A. (2004). Examining the use of the M-FAST with criminal defendants incompetent to stand trial. International Journal of Offender Therapy and Comparative Criminology, 48(3), 268-280.

M-FAST ARTICLES BY TOPIC Validity Studies

Vitacco, M. J., Jackson, R. L., Rogers, R., Neumann, C. S., Miller, H. A. Gabel, J. (2008). Detection strategies for malingering with the M-FAST: A confirmatory factor analysis of its underlying dimensions. Assessment, 15(1), 97-103.

Miller, H. A. (2005). The Miller Forensic Assessment of Symptoms Test (M-FAST): Test generalizability and utility across race, literacy, and clinical opinion. Criminal Justice and Behavior, 32(6), 591-611.

Veazey, C. H., Hays, J. R., Wagner, A. L., & Miller, H. A. (2005). Validity of the Miller Forensic Assessment of Symptoms Test in psychiatric inpatients. Psychological Reports, 96(3), 771-774.

Guy, L. S., & Miller, H. A. (2004). Screening for malingered psychopathology in a correctional setting: Utility of the Miller Forensic Assessment of Symptoms Test (M-FAST). Criminal Justice and Behavior, 31(6), 695-716.

M-FAST ARTICLES BY TOPIC Civil forensic settings

Alwes, Y. R., Clark, J. A., Berry, T. R., Granacher, R. P. (2008). Screening for feigning in a civil forensic setting. Journal of Clinical and Experimental Neuropsychology, 30(2), 1-8.

M-FAST ARTICLES BY TOPIC Diagnostic-specific malingering assessment

Messer, J. M., & Fremouw, W. J. (2007). Detecting malingered posttraumatic stress disorder using Morel Emotional Numbing Test-Revised and the Miller Forensic Assessment of Symptoms Test (M-FAST). Journal of Forensic Psychology Practice, 7(3), 33-57.

Guriel-Tennant, J., & Fremouw, W. J. (2006). Impact of trauma history and coaching on malingering of posttraumatic stress disorder using the PAI, TSI, and M-FAST. Journal of Forensic Psychiatry & Psychology, 17(4), 577-592.

Guy, L. S., Kwartner, P. P., & Miller, H. A. (2006). Investigating the M-FAST: Psychometric properties and utility to detect diagnostic specific malingering. Behavioral Sciences & the Law, 24(5), 687-702.

Guriel, J., Yanez, T., Fremouw, W. J., Shreve-Neiger, A., Ware, L., Filcheck, H., & Farr, C. (2004). Impact on coaching on malingered posttraumatic stress symptoms on the M-FAST and TSI. Journal of Forensic Psychology Practice, 4(2), 37-56.

THANK YOU!

Holly A. Miller, Ph.D.Assistant Dean of Undergraduate Programs

Associate ProfessorCollege of Criminal Justice

Sam Houston State UniversityHuntsville, Texas 77341-2296

936-294-1686; hmiller@shsu.edu