Posttraumatic stress disorder (PTSD) and psychosis - Resnick, West & Wooley (2018) - Article

How did the term ‘posttraumatic disorder’ come into existence? 

There have been many different terms for PTSD before it was used in the DSM, such as nervous shock and posttraumatic neurosis in the 1880s, shell shock after WWI, and battle fatigue after WWII. The first DSM used the term gross stress reaction, and the second DSM used the term adjustment reaction to adult life. In the third edition of the DSM the term posttraumatic stress disorder was introduced. 

What changes were made in the criteria of PTSD in the DSM?

These are some of the major changes in the criteria of PTSD in the DSM:

• DSM-III Criteria A described the traumatic event as an event that would be markedly distressing to almost anyone (objective), but was changed in the DSM-IV to an event that the victim found personally distressing (subjective). 

• DSM-IV introduced the term acute stress reaction, a time-limited precursor to PTSD involving dissociative symptoms. 

• DSM-V moved PTSD from the category Anxiety Disorders to a new category Trauma- and Stress Related Disorders. 

• DSM-V replaced the item of physical integrity with sexual violence, specified actual or threatened death of a loved one (where the event must have been violent or accidental), and eliminated the requirement of an extreme emotional response. 

• DSM-V described dreams as being reflective of the content or the affect related to the trauma. Recurrent dreams with invariable content may indicate malingering. 

• The two symptom clusters of avoidance and numbing symptoms in DSM-IV have been divided into Criteria C and D in DSM-V and individuals need to have at least one symptom in each of these categories. 

• Criteria E (hyperarousal) was expanded in DSM-V to include reckless or self-destructive behavior and aggression.

What role does malingering play with regards to PTSD? 

It is easy to malinger posttraumatic stress disorder as the diagnosis is based almost entirely on the individual’s subjective report of symptoms which aren’t easily independently verified. The primary motivation for malingering PTSD is financial gain. It may also be preferable by the participant by not having to admit to more stigmatizing causes of disability (e.g. substance use), and they may also gain sympathy and support. 

Why is it important to detect feigned PTSD?

We can identify four reasons as to why it is important to detect feigned PTSD:

• Feigners misdiagnosed with PTSD may receive unwarranted and harmful therapies. 

• Feigning is disruptive to the therapeutic relationship between malingerers and their therapists, and can cause therapists to become distrustful of all their patients. 

• Malingering has a negative effect on the economy. 

• Malingering creates inaccuracies in the medical database which can impact research regarding PTSD. 

How can psychological tests be used to identify feigned PTSD? 

The use of psychological tests in medicolegal settings has increased as they seem very effective in assessing various forms of response bias. However, it is difficult to distinguish between feigned and genuine PTSD on these tests, because sufferers of PTSD may have intensified symptoms and impairment that elevate clinical and validity scales, and because they often have highly variable symptom profiles. Also PTSD is a highly comorbid disorder and it is difficult to differentiate feigners from genuine PTSD patients due to the complex nature of PTSD. The effectiveness of several popular psychological tests to differentiate between genuine and feigned PTSD are now discussed.

What is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)?

This test uses three main detection strategies to detect feigned PTSD: quasi-rare symptoms, rare symptoms, and erroneous stereotypes. Several studies have examined the effectiveness of this test. These studies show that the F scale is often significantly elevated among individuals with PTSD, often above cutoff scores for feigning. Also for the MMPI-2 Restructured Form the F scale seems to be markedly elevated among individuals with PTSD. Research indicates that the Fp-r scale (rare symptom scales) demonstrates the best results, with genuine PTSD patients scoring relatively low on that scale. 

What is the Personality Assessment Inventory (PAI)?

This test is useful for assessing feigned PTSD due to its response validity scales and ability to assess a variety of symptoms related to the disorder. The most effective scale for differentiating between feigned and genuine PTSD is the Negative Impression Management validity scale, however the NIM score should be viewed together with other data, as NIM scores may be related to high levels of distress or psychopathology. In order to identify feigners with high levels of psychopathology a new scale was created, the Negative Distortion Scale, but further research is necessary to prove its accuracy and effectiveness.

What is the Trauma Symptom Inventory-2?

The Trauma Symptom Inventory is a self-report measure to assess psychological symptoms often associated with traumatic experiences, however it lacks clinical research. The Trauma Symptom Inventory-2 is an updated version with new scales and norms and a revised ATR scale. More research is necessary as the ATR seems susceptible to general distress and other comorbid symptoms. 

What is the Detailed Assessment of Posttraumatic Stress?

This is a self-report measure that measures and evaluates trauma-specific symptoms and posttraumatic stress reactions. It also examines trauma-specific dissociation, substance abuse, and suicidality. It includes a Negative Bias scale to assess the respondents’  tendency to over-endorse unusual or unlikely symptoms, but this scale does not seem effective and more research is necessary. 

What is the Posttrauma Response Set Measure (PRSM)?

This measure includes a diagnostic index to assess genuine PTSD, and also five malingering indices to detect various forms of feigned PTSD. All of the feigning scales on this test have shown to be significantly better at detecting feigned PTSD than the F and Fp scales on the MMPI-2. This test however still needs to be published and undergo peer-review. 

What role does malingering play with regards to other trauma-related disorders?

When there is no clinical evidence that supports a physiological cause of neurological symptoms, they may be the by-product of the unintentional (conversion disorder) or intentional (malingering) production of symptoms. Tests that detect malingering in organic disease are invalid in conversion disorder. Also, a person with conversion disorder may also malinger. It is thus very important for clinicians to distinguish between the two disorders by assessing the patients’ consciousness. 

How can we differentiate between conversion disorder and malingering?

The clinician should pay attention to the unconscious gain associated with the patients’ symptoms, which they may reveal by accident or they may not be aware of them themselves. Also, patients with conversion disorder tend to willingly engage in evaluations because they want an explanation for their symptoms, whereas malingerers are worried about getting caught. 

Can depression and psychosis be malingered?

Depression is common after a traumatic accident and can be related to both physical harm and emotional loss. The symptoms are easy to fake as most tests rely on self-report. PTSD requires a careful differentiation between diagnosis and comorbid diagnosis in addition to feigning. Psychosis is not often malingered, as it is not easy to do, may require inpatient hospitalization, and the person may need to keep up the act for many months or even years. 

How can malingering of PTSD be assessed?

Persons with antisocial and psychopathic traits more often malinger. Malingerers often have poor social and occupational functioning prior to the trauma. This can be seen in sporadic employment with long absences from work or previous incapacitating injuries. Amnesia can play a role in PTSD, but it can easily be feigned as well, however it tends to be more obvious when it is feigned as malingerers tend to overplay their memory problems by forgetting overlearned data. Procedural memory however is rarely impaired and it is unlikely that sufferers from PTSD would forget their name or forget how to ride a bike or drive a car. 

What behavioral clues can be seen in malingerers of PTSD?

Malingerers may over-act and give dramatic reports of their symptoms. They may be evasive and not want to discuss returning back to work or the money they may gain. They may avoid being specific and give vague answers to specific questions. Sometimes they may get more aggressive and intimidate the interviewer and accuse them of suggesting malingering. There may be internal and external inconsistencies. With internal inconsistencies they will contradict themselves (e.g. saying they have memory problems, but then remember very specific things). With external inconsistencies the persons symptoms are contrasting what is observed (e.g. a discrepancy between the individual’s report and hospital or police records). 

How can collateral information help detect malingering of PTSD?

Collateral information is necessary to validate the individual’s reported symptoms and the traumatic event. This information can be gathered through police reports, witness accounts, medical records, employee files, school records, and tax returns. Information can also be gathered from people who are close to the individual, but cannot gain from the litigation (for example about work habits, sleep habits, presence of symptoms). 

What clues during the interview can show malingering of PTSD?

Interviewers should adopt an open-ending questioning style and avoid leading questions that give clues to correct responses. They should insist on a detailed account of the specific symptoms, as the criteria for PTSD are quite well known (for example to discuss the content of nightmares, not simply accept someone is experiencing nightmares). Details such as circumstances, severity, frequency, and context must be discussed. Nightmares with PTSD often show variations on the theme of the trauma, malingerers are less likely to report these variations. Posttraumatic nightmares are often accompanied by body movement, fear of the dark and of going to sleep, and talking or shouting during sleep. People with genuine PTSD often withdraw from work and recreational activities, whereas malingerers state they are incapable of working but keep participating in hobbies. 

How can psychophysiology help detect malingering in PTSD?

One of the few objective methods of distinguishing genuine from malingered PTSD is the measurement of the body’s responses to indicators of trauma (heart rate, blood pressure, muscle tension). Research however indicates that there is a lack of accuracy and some individuals with PTSD do not show physiological reactivity, whereas some without PTSD do. 

What clinical decision model for establishing malingered PTSD can be offered?

The following model is presented to help clinicians determine the existence of malingered PTSD: 

1) establish known motivation for malingering

2) characteristics of the malingerer (two or more of the following criteria: irregular employment/job dissatisfaction, prior insurance claims, capacity for recreation but not work, lack of nightmares/nightmares inconsistent with presentation, antisocial personality traits, evasiveness/contradictions, unwillingness to cooperate/hostile behavior)

3) confirmatory evidence of malingering (one of more of the following criteria: admission of malingering, incontrovertible proof of malingering, psychometric evidence of malingering, corroborative evidence of malingering). 

Why do veterans malinger PTSD?

Three main factors can motivate veterans to malinger PTSD. First, to obtain financial compensation. Second, to reduce criminal culpability. Third, to obtain admission to a VA hospital. Collection collateral data is very important in verifying a veteran’s story. This can be done through military records, collaboration with VA-employees and ex-veteran’s, family and friends. 

What are the differences between genuine and malingered PTSD in veterans?

Veterans with genuine PTSD tend to attribute blame to themselves and appear withdrawn. They look for help because they were encouraged by others or repeatedly lose their jobs. They downplay their combat experiences and are reluctant to discuss their current symptoms. In their nightmares they more often feel overwhelmingly helpless. They also tend to avoid environmental cues that remind them of the trauma. Malingerers of PTSD however are more assertive and often present themselves as victims and attribute different problems directly to their experience in the army. They emphasize their combat experiences and often tell heroic stories. Their nightmares are often about being in power and having control, but they often say that they fear they may lose control and hurt others.