Malingering of posttraumatic disorders van Resnick et al. (2012) - Article

It is very difficult to detect someone who’s malingering a posttraumatic stress disorder (PTSD). This is caused by the subjectivity of most of the symptoms required for the diagnosis. Also, the symptoms of PTSD are well known by the general public, which makes it more easy to feign them.

PTSD was first registered in the DSM-III of 1980. Before that, it symptoms were known as shell shock, battle fatigue, gross stress reaction and adjustment reaction to adult life. These were all categories that arose after a war. The Vietnam War intensified the societal awareness of the symptoms seen in returning veterans.

The subjectivity of the criteria has frequently been criticized. For example, criteria A of the DSM-IV-TR specifies that the victim should have experienced an event that he found intensely distressing, which is a quite subjective statement.

Researchers have established risk-factors which increase the likelihood of experiencing a traumatic event. These are:

1. A family history of mental disorders or substance problems

2. The male gender

3. Low education

4. Early conduct problems

5. Extraversion

There are also a few pre-traumatic characteristics which increase the likelihood of developing PTSD. These include prior psychiatric problems, childhood antecedents and background factors. The best predictor of developing PTSD is peritraumatic dissociation. Predictions about individuals suffering from PTSD are also based on the chronicity of the disorder. The DSM specifies between acute (symptoms endure less than 3 months) and chronic (symptoms endure for over 6 months). Recently researchers discovered pieces of the neurobiology of PTSD. They found that dysfunction of the hippocampus and an overactive amygdala are linked to PTSD.

It also depends on the sort of trauma that’s experienced whether victims are likely to develop PTSD. Victims of sexual trauma are very likely to develop PTSD, as are those who experience combat related trauma. The prevalence among these groups is higher than for people who for example get involved in a car- or work accident, or who experience civilian terrorism. The lifetime prevalence of PTSD is an estimate of 9%. Finally, PTSD very often co-occurs with another disorder (comorbidity). It is challenging for clinicians to determine whether the comorbid disorder was present prior to the event, and whether this disorder influences the current symptoms of the victim.

Malingering and conversion disorders

Malingering is motivated by an external gain. This may be financial profit, voiding military service, evading criminal responsibility or relief of responsibilities at home or at a job. False imputation is a form of malingering in which the individual attributes symptoms to an etiologically unrelated cause. This is much harder to recognize than pure malingering, because the individual can accurately describe the symptoms from personal experience. It is important to consider malingering in all referrals seeking compensation after a personal injury.

While malingering is conscious, conversion disorders unconsciously produce symptoms.

Judges should be aware of the fact that attorney’s might influence their clients and encourage them to feign certain symptoms in order to get compensation. They can tell them about the exact psychological symptoms they should suffer from and how to produce them. Caution is needed, because cases considering psychological symptoms are far more often seen as suspicious than cases with physical symptoms; even though psychological symptoms may even result in greater limitations.

The main motive for malingering PTSD is financial gain. Sometimes personal psychological reasons also contribute to the malingering, like ‘face-saving’ by looking for an official determinant of disability may be the solution to personal life crises (but are separate from the trauma).

Research has shown that people suffering from both PTSD and chronic pain experience more intense pain and affective distress, and thereby have a greater disability than people without PTSD. The difference between malingering PTSD and conversion disorder, is that people who malinger are aware of their motive, and people with conversion disorder aren’t. Also, people with conversion disorder truly have a disorder. This can be caused by a particular injury, in which case compensation is possible. Furthermore, malingerers are less cooperative, avoid examination, are able to describe the trauma in full detail and refuse employment with partial disability. On the other hand are people with conversion disorder, who are cooperative, welcome examination in order to determine what’s wrong, have gaps and inaccuracies in their story’s and accept employment if possible.

People with a low IQ from rural areas, with a low SES and little knowledge of physical and psychological symptoms are more likely to develop conversion disorders. Modeling occurs in patients with neurological disorders, in which case they mimic their own neurological symptoms or the symptoms of someone close to them in a version reaction.

Comorbidity

Postconcussive Syndrome (PCS) is a DSM diagnosis which describes cognitive, emotional and physical symptoms which occur longer than three months following a cerebral concussion. It is hard to diagnose PTSD after a trauma when pain, physical, psychological and neurological symptoms are also present. PCS and PTSD both require a trauma in order to be able to get the diagnosis, but it is also possible to have both due to the same injury.

Classification of malingering

Malingered PTSD can be recognized by a lack of detailed knowledge regarding the disorder. This will result in a poor presentation of the wrong symptoms during the clinical evaluation. Contributing members of society are less likely to malinger. Amnesia can be a very important part of diagnosing PTSD, but is also an easy way of malingering symptom to fake for malingerers. Faking amnesia symptoms can be recognized by overplaying the memory deficits, clear recollection of the trauma (while stating to suffer from memory loss) and an inability to remember overlearned data. Amnesia malingerers may also feign an impairment of the procedural memory, which is rarely impaired after a head trauma, and show poor performances on tests labeled as memory testing. Inconsistencies can be found internally and externally.

Collateral information

In order to optimize the usefulness of collateral information, it should be collected prior to the evaluation so the examiner can clarify inconsistencies that may occur during the examination. Witness accounts, police reports and other reports written at the time of the accident may be useful to gain an objective view of the trauma. It is also helpful to gain information from individuals close to the patient, but it is necessary to make sure those individuals do not stand to gain from the litigation.

Psychological test for detecting the malingering of PTSD

The most important concern with tests which claim to detect malingering, is the misclassification of genuine PTSD as malingered PTSD. It is therefore necessary to always use multiple data sources and not only feigning scales in order to come to a conclusion.

The Minnesota Multiphasic Personality Inventory (MMPI-2) is a useful tool to determine response styles. The test consists of multiple detection strategies, of which rare symptom and erroneous stereotype detection strategies are best in differentiating genuine PTSD from malingering.

The Personality Assessment Inventory (PAI) is an inventory which consists of multiple scales that assess a variety of psychological domains, including psychopathology, response styles, interpersonal functioning and treatment needs. It uses rare symptoms and spurious patterns of pathology to detection strategies for malingering. Unfortunately, research has shown that all PAI validity indicators were relatively ineffective at identifying PTSD malingerers. Therefore, the MMPI-2 is currently preferred when evaluating feigned PTSD.

The Trauma Symptom Inventory (SPI) is a self-report questionnaire, of which the Atypical Response Scale (ARS) is the most effective in detecting malingering. The scale screens for overreporting symptoms by using a quasi-rare symptom detection strategy. Unfortunately, current research has shown great limitations when utilizing the ARS within genuine trauma patients.

A specialized, structured interview for assessing feigning and response styles is the Structured Interview of Reported Symptoms(SIRS). Although the SIRS has shown to be very useful, there is only limited research that focuses on PTSD specifically. Further research is necessary, although upcoming research regarding SIRS and PTSD seems promising.

Psychophysiological Assessment measure body responses in order to confirm or disconfirm criteria B of the DSM diagnosis: the re-experiencing of the trauma by physical reactions. An example of these measures is the use of battlefield sounds, and comparing the bodily reactions of veterans and a control group. This can also be done with genuine PTSD patients and suspects of malingering. Even though, a physiological response cannot confirm nor disconfirm the presence of PTSD. Because of conflicting evidence coming from several studies, psychophysiological assessments may or may not be admitted as evidence in court.

Clinical Decision Model for Establishing Malingered PTSD

In order to make a clear decision about whether or not someone is malingering, all kinds of evidence must be gathered. The Clinical Decision Model for Establishing Malingered PTSD requires the following:

1. The clinician understands the individual’s motive for feigning symptoms

2. There is strong collateral information confirming the malingering behavior

3. There are at least two symptoms

Sometimes individuals fail to recover from their traumatic injuries, which does not necessarily mean they malinger. This may also be caused by the regression of coping strategies , which leads to less mature defense mechanisms like blaming others. Furthermore, depression, low-back injury, old age and loss of libido are also associated with a poor prognosis. Finally, not being able to return to work at the conclusion of the settlement also results in a poor prognosis.

Malingered PTSD in Combat Veterans

There are three common motives for malingering PTSD in veterans:

1. Financial compensation. Once veterans have qualified for a PTSD diagnosis, there is an ongoing financial motive to remain disabled regardless of their true state.

2. Obtain admission to a veterans hospital

3. Reducing criminal culpability. It is important to assess the relationship between the crime and PTSD. Also, evaluators should consider whether the crime scene recreated a traumatic event and if the veteran experienced dissociative symptoms at the time the crime was committed.

In order to determine whether a veteran truly suffers from PTSD, clinician should look in to their files with great care. The common files, like military records and discharge papers, can easily be forged. It is therefore important to cooperate with the Veterans Affairs and experienced combat veterans in order to elucidate false claims.

The presence of an antisocial personality disorder does not mean you cannot have PTSD. Caution is needed though, because they have a lot of DSM-criteria in common. An antisocial personality should however increase a clinician’s suspicion for malingering.

In order to notice malingered PTSD, one should pay attention to how the veteran attributes blame for their symptoms and stressors. Veterans with genuine PTSD often feel very guilty and perceive themselves as the cause of their problems. They often suffer from survivor’s blame, and mostly seek help as a result of insisting family members. Genuine PTSD veterans are more likely to downplay their combat experiences and their symptoms, even by trying not to call any attention to for instance their hyper-alertness or suspicious eye movements.

Finally, true combat veterans often have nighttime flashbacks: nightmares in which they relive the combat stressor. These dreams may proceed in an almost identical fashion for years, and mostly contain a theme of helplessness. In contrast, malingerers often report heroic dreams about their combat battles.