International Journal of Forensic Mental Health | 2022, Vol. 21, No. 4, 334-347 | The Role Played by Theory of Mind and Empathy in the Feigning of Psychopathology
Marzia Di Girolamo; Department of Psychology, University of Turin, Turin, Italy
Luciano Giromini; Department of Psychology, University of Turin, Turin, Italy
Jessica Bosi; Department of Psychology, University of Surrey, Guildford, UK
Lara Warmelink; Department of Psychology, Lancaster University, Lancaster, UK
Ilaria La Scala; Department of Psychology, University of Turin, Turin, Italy
Caterina Loiacono; Department of Psychology, University of Turin, Turin, Italy
Federica Miraglia; Department of Psychology, University of Turin, Turin, Italy
Alessandro Zennaro; Department of Psychology, University of Turin, Turin, Italy
In this article, we hypothesized that in order to feign mental illness, one would need to have empathy and be able to understand other’s mental states. To test this hypothesis, we asked 432 healthy volunteers to feign depression, PTSD or schizophrenia while completing a self-report test that measures the severity of the feigned condition’s symptoms and the Inventory of Problems - 29 (IOP-29). Additionally, all participants were administered a theory of mind (ToM) task and an empathy measure with the request to respond truthfully. Results from a series of linear regression models revealed that higher cognitive empathy is associated with increased symptom endorsement on self-report symptom questionnaires and higher ToM abilities are associated with less credible feigned profiles, especially in the case of feigned depression.
Theory of mind; empathy; malingering; assessment; IOP-29
Summary of the Research
“Malingering is the intentional feigning, production, or significant exaggeration of physical or psychological symptoms, or the intentional misattribution of genuine symptoms to an unrelated event or series of events when this is specifically motivated by external incentives or rewards (American Psychiatric Association, 2013; World Health Organisation, 2018)…malingering is strictly related to some specific contexts, for example, to avoid work, to evade criminal prosecution or to obtain economic indemnities thanks to a physical or psychopathological diagnosis…Malingering detection remains challenging yet is crucial for making correct diagnoses when it is likely to occur, and to ensure that resources will be allocated appropriately to those that actually require them…knowledge of exactly which processes underlie successful malingering is elusive. Most research is focused on antisocial personality traits…Several different cognitive and psychiatric disorders are commonly malingered. Amongst psychiatric disorders, the malingering of depression is particularly widespread in the forensic-psychiatric field…” (p. 334-335).
“During the first years of life, children develop Theory of Mind (ToM; Frith & Frith, 1999). ToM is a combination of processes, separated but interconnected, that contribute to improving someone’s capabilities to understand others’ behaviors and to make inferences about them…The person who feigns a psychiatric disorder has to think about how someone with depression, PTSD, or psychosis thinks and acts; moreover, they have to convince the examiner that these thoughts and actions are their own! Thus, they have to be able to understand what the examiner is thinking about their behaviors and responses. To succeed in this challenge, the people who feign must manipulate the examiner’s representation of their health condition. In this process, ToM and empathy capabilities could be a ‘plus’ or ‘must-have’ if one has high levels of empathy and thus the ability to vicariously experience another’s feelings, could this help them to fake diseases in a more convincing and effective way? There is little research on this question in the literature…” (p. 336).
“This research aimed to analyze whether an individual with higher levels of Theory of Mind (ToM) and/or empathy would be more capable of feigning psychological symptoms of several mental health disorders. We tested this with the feigning of three psychological disorders: depression, PTSD or schizophrenia. Successful feigning was measured in two ways. Firstly, by a self-report measure of symptoms of the condition the participants were meant to feign. Secondly, a symptom validity test (SVT) was included. This would assess whether the participants were able to feign in a credible way. Two hypotheses were proposed. The first was that participants with high levels of ToM and empathy would provide more dramatic portrayals of symptoms on the clinical tests, because good skills in ToM or empathy are likely to provide a greater identification with the psychopathological condition…The second hypothesis was that participants with high levels of ToM and empathy would however not necessarily provide more credible results on the SVT…” (p.336).
“A total of 432 healthy Italian volunteers…participated in this study…Taken together, the results revealed that higher cognitive empathy scores were associated with more extreme symptom endorsement on the clinical scales measuring the severity of the feigned condition’s symptoms and higher ToM scores were associated with less credible symptoms presentations on the IOP [Inventory of Problems]-29. This effect was strongest for those feigning depression and weak to non-existent for those feigning PTSD or schizophrenia. Additionally, there was no evidence that people with different levels of empathy and ToM were differentially endorsing symptoms from different subscales of the clinical tests. A hypothesized, but still intriguing finding is that cognitive empathy – but not affective empathy or ToM – was significantly positively associated with the severity of the feigned condition’s symptoms…What is most noteworthy, is that while cognitive empathy did perhaps aid our participants in endorsing the symptoms of the feigned conditions so to look more psychologically troubled, it likely did not help them to do so in a more credible way…” (p. 337-341).
“The fact that higher scores on the Faux-pas Recognition Test (FPRT) are associated with higher, less credible scores on the IOP-29 is surprising. Our second hypothesis was that skills in ToM and empathy would not contribute to a better stimulating performance, because emotional intelligence and intelligence in general, do not seem to provide better performance on the SVT…The results of our study suggest that ToM and empathy should only minimally influence one’s ability to pretend to be mentally ill. Higher levels of cognitive empathy could make the presentation of symptoms of any condition seem likely more severe; higher ToM levels might make the presentation of depression symptoms seem slightly less credible” (p. 342).
Translating Research into Practice
“…This has implications for the assessment of malingering in a clinical and forensic setting…the criminological model of malingering assumes that people with antisocial or psychopathic traits are more likely to malinger…Psychopathic traits are associated with reduced empathy…Future research should focus on weather our results replicate in this subpopulation as well. Doing so may help us understand the extent to which the presence of poor cognitive empathy could really make the presentation of someone with higher psychopathic traits appear somehow less severe or dramatic” (p. 341-342).
“From a practical standpoint, these findings once again underscore the importance of including symptom validity checks when performing a forensic mental health evaluation…Indeed, if an evaluee who is feigning or over-reporting has low levels of empathy, their clinical profile is unlikely to appear impaired, because less empathic individuals tend to have lower scores on clinical tests…If they have high levels of empathy, on the other hand, their overall presentation may perhaps look similar to that of an individual suffering from genuine mental health problems, but a psychometrically sound SVT like the IOP-29 would likely raise questions on the overall credibility of presented complaints also in this case. Accordingly, if the forensic assessor uses both clinical tests and effective SVTs, then the feigning of psychopathology is more unlikely to go undetected regardless of the empathy skills of the evaluee” (p. 342-343).
“On the other hand, our findings also suggest that individuals with poorer ToM abilities are for some reason more prone to generate credible results on a validity check when feigning depression…Although we could not find a definitive explanation for this unexpected and to some extent surprising result, and even though we cannot rule out that this could be just a random finding, for the time being we recommend forensic practitioners to be particularly cautious when assessing the credibility of symptoms of depression presented by individuals with very low ToM levels…Especially when assessing individuals with poor ToM skills, thus, administering more than one SVT would be beneficial” (p. 343-344).
Other Interesting Tidbits for Researchers and Clinicians
“To understand malingering in more depth, three theoretical models have been proposed…the first of which is the pathogenic model. According to this model, the patient exaggerates preexisting symptoms in an attempt to convince others of their veracity. Their motivation is to gain control over their real, emerging symptoms and in time, they become less able to control their malingering behaviors. The second is the criminological model, in which the patient aims to avoid legal consequences of their actions, i.e., malingering is conceived of as an anti-social act. The third one has been referred to as the adaptation model in which the patient undertakes a cost-benefit analysis and is more likely to malinger when faced with adversity and limited alternatives” (p. 336).