Original article| Volume 90, ISSUE 7, P1117-1126, July 2009

Prevalence of Malingering in Patients With Chronic Pain Referred for Psychologic Evaluation in a Medico-Legal Context


      Greve KW, Ord JS, Bianchini KJ, Curtis KL. Prevalence of malingering in patients with chronic pain referred for psychologic evaluation in a medico-legal context.


      To provide an empirical estimate of the prevalence of malingered disability in patients with chronic pain who have financial incentive to appear disabled.


      Retrospective review of cases.


      A private neuropsychologic clinic in a southeastern metropolitan area.


      Consecutive patients (N=508) referred for psychologic evaluation related to chronic pain over a 10-year period (1995–2005).


      Not applicable.

      Main Outcome Measures

      Prevalence of malingering was examined using 2 published clinical diagnostic systems (Malingered Pain-Related Disability and Malingered Neurocognitive Dysfunction) as well as statistical estimates based on well validated indicators of malingering.


      The prevalence of malingering in patients with chronic pain with financial incentive is between 20% and 50% depending on the diagnostic system used and the statistical model's underlying assumptions. Some factors associated with the medico-legal context such as the jurisdiction of a workers' compensation claim or attorney representation were associated with slightly higher malingering rates.


      Malingering is present in a sizable minority of patients with pain seen for potentially compensable injuries. However, not all excess pain-related disability is a result of malingering. It is important not to diagnose malingering reflexively on the basis of limited or unreliable findings. A diagnosis of malingering should be explicitly based on a formal diagnostic system.

      Key Words

      List of Abbreviations:

      CI (confidence interval), CVLT (California Verbal Learning Test), FCE (Functional Capacity Evaluation), MMPI-2 (Minnesota Multiphasic Personality Inventory-2), MND (Malingered Neurocognitive Dysfunction), MPRD (Malingered Pain-Related Disability), PDRT (Portland Digit Recognition Test), TBI (traumatic brain injury), TOMM (Test of Memory Malingering), WAIS-III (Wechsler Adult Intelligence Scale-III)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders.
        4th ed, text revision. American Psychiatric Association, Washington (DC)2000
        • Meehl P.E.
        • Rosen A.
        Antecedent probability and the efficiency of psychometric signs, patterns, or cutting scores.
        Psychol Bull. 1955; 52: 194-216
        • Fishbain D.A.
        • Cutler R.
        • Rosomoff H.L.
        • Rosomoff R.S.
        Chronic pain disability exaggeration/malingering and submaximal effort research.
        Clin J Pain. 1999; 15: 244-274
        • Kay N.R.
        • Morris-Jones H.
        Pain clinic management of medico-legal litigants.
        Injury. 1998; 29: 305-308
        • Leavitt F.
        • Sweet J.J.
        Characteristics and frequency of malingering among patients with low back pain.
        Pain. 1986; 25: 357-364
        • Mittenberg W.
        • Patton C.
        • Canyock E.M.
        • Condit D.C.
        Base rates of malingering and symptom exaggeration.
        J Clin Exp Neuropsychol. 2002; 24: 1094-1102
        • Miller H.
        Accident neurosis.
        Br Med J. 1961; 1: 919-925
        • Miller H.
        Accident neurosis.
        Br Med J. 1961; 1: 992-998
      1. Public attitude monitor (survey).
        Insurance Research Council, Oak Brook1992
      2. Public attitude monitor (survey).
        Insurance Research Council, Oak Brook1993
        • Greve K.W.
        • Bianchini K.J.
        • Black F.W.
        • et al.
        The prevalence of cognitive malingering in persons reporting exposure to occupational and environmental substances.
        Neurotoxicology. 2006; 27: 940-950
        • Larrabee G.J.
        Assessment of malingering.
        in: Larrabee G.J. Forensic neurospsychology: a scientific approach. Oxford Univ Pr, New York2005: 115-158
        • Binder L.M.
        Assessment of malingering after mild head trauma with the Portland Digit Recognition Test.
        J Clin Exp Neuropsychol. 1993; 15: 170-182
        • Binder L.M.
        Portland Digit Recognition Test manual.
        2nd ed. Private Publication, Portland1993
        • Tombaugh T.
        Test of Memory Malingering manual.
        MultiHealth Systems, New York1996
        • Green P.
        Green's Word Memory Test for Window's: user's manual.
        Green's Publishing Inc, Edmonton2005
        • Greiffenstein M.F.
        • Baker W.J.
        • Gola T.
        Validation of malingered amnesic measures with a large clinical sample.
        Psychol Assess. 1994; 6: 218-224
        • Wechsler D.
        Wechsler adult intelligence scale.
        3rd ed. Psychological Corp, San Antonio1997
        • Millis S.R.
        • Putnam S.H.
        • Adams K.M.
        • Ricker J.H.
        The California Verbal Learning Test in the detection of incomplete effort in neuropsychological evaluation.
        Psychol Assess. 1995; 7: 463-471
        • Millis S.R.
        • Volinsky C.T.
        Assessment of response bias in mild head injury: beyond malingering tests.
        J Clin Exp Neuropsychol. 2001; 23: 809-828
        • Delis D.C.
        • Kramer J.H.
        • Kaplan E.
        California verbal learning test.
        Research ed. Psychological Corp, New York1987
        • Delis D.C.
        • Kramer J.H.
        • Kaplan E.
        California verbal learning test.
        2nd ed. Psychological Corp, New York2000
        • Butcher J.N.
        • Dahlstrom W.G.
        • Graham J.R.
        • Tellegen A.
        • Kaemmer B.
        MMPI-2: manual for administration and scoring.
        Univ of Minnesota Pr, Minneapolis1989
        • Bianchini K.J.
        • Greve K.W.
        • Glynn G.
        On the diagnosis of malingered pain related disability: lessons from cognitive malingering research.
        Spine J. 2005; 5: 404-417
        • Slick D.J.
        • Sherman E.M.
        • Iverson G.L.
        Diagnostic criteria for malingered neurocognitive dysfunction: proposed standards for clinical practice and research.
        Clin Neuropsychol. 1999; 13: 545-561
        • Larrabee G.J.
        Assessment of malingered neuropsychological deficits.
        Oxford Univ Pr, New York2007
        • Millis S.R.
        Evaluation of malingered neurocognitive disorders.
        in: Rizzo M. Esslinger P.J. Principles and practice of behavioral neurology and neuropsychology. W. B. Saunders Co, Philadelphia2004: 1077-1089
      3. Greve KW, Bianchini KJ. Classification accuracy of the Portland Digit Recognition Test in traumatic brain injury: results of a known-groups analysis. Clin Neuropsychol; In press.

        • Greve K.W.
        • Bianchini K.J.
        • Doane B.M.
        Classification accuracy of the test of memory malingering in traumatic brain injury: results of a known-groups analysis.
        J Clin Exp Neuropsychol. 2006; 28: 1176-1190
        • Heinly M.T.
        • Greve K.W.
        • Bianchini K.J.
        • Love J.L.
        • Brennan A.
        WAIS digit span-based indicators of malingered neurocognitive dysfunction: classification accuracy in traumatic brain injury.
        Assessment. 2005; 12: 429-444
        • Etherton J.L.
        • Bianchini K.J.
        • Heinly M.T.
        • et al.
        Pain, malingering, and performance on the WAIS-III Processing Speed Index.
        J Clin Exp Neuropsychol. 2006; 28: 1218-1237
        • Etherton J.L.
        • Bianchini K.J.
        • Ciota M.A.
        • Heinly M.T.
        • Greve K.W.
        Pain, malingering, and the WAIS-III Working Memory Index.
        Spine J. 2006; 6: 61-71
        • Greve K.W.
        • Bianchini K.J.
        • Love J.M.
        • et al.
        Sensitivity and specificity of MMPI-2 validity scales and indicators to malingered neurocognitive dysfunction in traumatic brain injury.
        Clin Neuropsychol. 2006; 20: 491-512
        • Curtis K.L.
        • Greve K.W.
        • Bianchini K.J.
        • Brennan A.
        California verbal learning test indicators of Malingered Neurocognitive Dysfunction: sensitivity and specificity in traumatic brain injury.
        Assessment. 2006; 13: 46-61
        • Hennekens C.H.
        • Buring J.E.
        Epidemiology in medicine.
        Little, Brown and Co, Boston1987
        • Millis S.R.
        • Volinsky C.T.
        Assessment of response bias in mild head injury: beyond malingering tests.
        J Clin Exp Neuropsychol. 2001; 23: 809-828
        • Chafetz M.D.
        Malingering on the social security disability consultative exam: predictors and base rates.
        Clin Neuropsychol. 2008; 22: 529-546
        • Ardolf B.R.
        • Denney R.L.
        • Houston C.M.
        Base rates of negative response bias and malingered neurocognitive dysfunction among criminal defendants referred for neuropsychological evaluation.
        Clin Neuropsychol. 2007; 21: 899-916
        • Stevens A.
        • Friedel E.
        • Mehren G.
        • et al.
        Malingering and uncooperativeness in psychiatric and psychological assessment: prevalence and effects in a German sample of claimants.
        Psychiatry Res. 2008; 157: 191-200
        • Straus S.
        • Richardson W.
        • Glasziou P.
        • Haynes R.
        Evidence-based medicine: how to practice and teach EBM.
        3rd ed. Elsevier Churchill Livingstone, New York2005
        • Boone K.B.
        Assessment of feigned cognitive impairment: a neuropsychological perspective.
        Guilford Pr, New York2007
        • Greiffenstein M.F.
        • Fox D.
        • Lees-Haley P.R.
        The MMPI-2 fake bad scale in detection of noncredible brain injury claims.
        in: Boone K.B. Assessment of feigned cognitive impairment: a neuropsychological perspective. Guilford Pr, New York2007
        • Allum J.H.
        • Shepard N.T.
        An overview of the clinical use of dynamic posturography in the differential diagnosis of balance disorders.
        J Vestib Res. 1999; 9: 223-252
        • Artuso A.
        • Garozzo A.
        • Contucci A.M.
        • Frenguelli A.
        • Di Girolamo S.
        Role of dynamic posturography (Equitest) in the identification of feigned balance disturbances.
        Acta Otorhinolaryngol Ital. 2004; 24: 8-12
        • Gianoli G.
        • McWilliams S.
        • Soileau J.
        • Belafsky P.
        Posturographic performance in patients with the potential for secondary gain.
        Otolaryngol Head Neck Surg. 2000; 122: 11-18
        • Greiffenstein M.F.
        • Baker W.J.
        • Gola T.
        Motor dysfunction profiles in traumatic brain injury and postconcussion syndrome.
        J Int Neuropsychol Soc. 1996; 2: 477-485
        • Mallinson A.I.
        • Longridge N.S.
        A new set of criteria for evaluating malingering in work-related vestibular injury.
        Otol Neurotol. 2005; 26: 686-690
        • Park S.S.
        Effect of effort versus volume on forced expiratory flow measurement.
        Am Rev Respir Dis. 1988; 138: 1002-1005
        • Schapmire D.
        • St James J.D.
        • Townsend R.
        • Stewart T.
        • Delheimer S.
        • Focht D.
        Simultaneous bilateral testing: validation of a new protocol to detect insincere effort during grip and pinch strength testing.
        J Hand Ther. 2002; 15: 242-250
        • Fink P.
        • Rosendal M.
        • Olesen F.
        Classification of somatization and functional somatic symptoms in primary care.
        Aust N Z J Psychiatry. 2005; 39: 772-781
        • Fink P.
        • Steen H.M.
        • Sondergaard L.
        Somatoform disorders among first-time referrals to a neurology service.
        Psychosomatics. 2005; 46: 540-548
        • Block A.R.
        • Gatchell R.J.
        • Deardoff W.W.
        • Guyer R.D.
        The psychology of spine surgery.
        American Psychiatric Association, Washington (DC)2003
        • Block A.R.
        • Ohnmeiss D.D.
        • Guyer R.D.
        • et al.
        The use of presurgical psychological screening to predict the outcome of spine surgery.
        Spine J. 2001; 1: 274-282
        • Gatchel R.J.
        • Gardea M.A.
        Psychosocial issues: their importance in predicting disability, response to treatment, and search for compensation.
        Neurol Clin. 1999; 17: 149-166
        • Linton S.J.
        A review of psychological risk factors in back and neck pain.
        Spine. 2000; 25: 1148-1156
        • Bond Jr, C.F.
        • DePaulo B.M.
        Accuracy of deception judgments.
        Pers Soc Psychol Rev. 2006; 10: 214-234
        • Faust D.
        • Hart K.
        • Guilmette T.J.
        Pediatric malingering: the capacity of children to fake believable deficits on neuropsychological testing.
        J Consult Clin Psychol. 1988; 56: 578-582
        • Faust D.
        The detection of deception.
        Neurol Clin. 1995; 13: 255-265
        • Grevitt M.
        • Pande K.
        • O'Dowd J.
        • et al.
        Do first impressions count?.
        Eur Spine J. 1998; 7: 218-223
        • Heaton R.K.
        • Smith Jr, H.H.
        • Lehman R.A.
        • et al.
        Prospects for faking believable deficits on neuropsychological testing.
        J Consult Clin Psychol. 1978; 46: 892-900
        • Meyers J.E.
        • Millis S.R.
        • Volkert K.
        A validity index for the MMPI-2.
        Arch Clin Neuropsychol. 2002; 17: 157-169