Malingering of post-traumatic stress disorder

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Because of the substantial benefits available to individuals with a confirmed PTSD diagnosis, which causes occupational impairment, the distinct possibility of false diagnoses exist, some of which are due to malingering of PTSD. Malingering of PTSD consists of one feigning the disorder. Post-traumatic stress disorder (PTSD) is an anxiety disorder that may develop after an individual experiences a traumatic event. [1] In the United States, the Social Security Administration and the Department of Veterans Affairs each offer disability compensation programs that provide benefits for qualified individuals with mental disorders, including PTSD. Malingering can lead to a decline in research and subsequent treatment for PTSD as it interferes with true studies. Insurance fraud may also come about through malingering, which hurts the economy. [2]

Contents

Motivation

Individuals who malinger PTSD may have several motivations for doing so. First, financial incentives are common. For example, the Department of Veterans Affairs offers substantial annual financial compensation to U.S. veterans who can prove that they have PTSD related to their military service. This potential compensation can create an incentive for veterans to malinger PTSD. [3] Military personnel may avoid their military duty due to malingering PTSD. [4] Furthermore, the U.S. Social Security Administration offers social security disability payments to individuals documenting a disorder such as PTSD that impedes their ability to work, which additionally provides an incentive to malinger PTSD. [5] Additionally, the potential for workers compensation can motivate individuals reporting a traumatic event at their workplace to fabricate PTSD; and finally the potential for personal injury lawsuits can motivate someone to malinger PTSD and sue an individual for causing PTSD as a result of attack, accident or other stressor. [6]

Some individuals are known to malinger PTSD to obtain inpatient hospital treatment. [7] Persons charged in criminal law cases are motivated to malinger PTSD in order to offset criminal responsibility for the crime or mitigate the associated penalties. [8] Some individuals are motivated to malinger PTSD (e.g., related to combat) in order to gain honor and recognition from others. [9]

Prevalence

The prevalence of malingering PTSD varies based on what one may be seeking. Differentiating between forensic and non-forensic evaluations, it has been found that malingering may be attempted in 15.7 percent of forensic evaluations and 7.4 percent of non-forensic evaluations. [10] As mentioned above, personal injury lawsuits can motivate someone to malinger PTSD. It is thought that between 20 and 30 percent of these people seeking settlements have malingered their PTSD results. It is also believed that a minimum of 20 percent of veterans seeking combat compensation have malingered. [11]

Cases within the criminal justice system also vary. A malingering rate between 8 percent and 17.4 percent was found in subjects in competency to stand trial assessments. Of incarcerated subjects seeking psychiatric services, a much higher range between 45 percent and 56 percent were suspected to malinger. Malingering cases were also positively correlated with severity of the crimes for subjects in competency to stand trial assessments. Malingering rates for murderers and robbers are greater than double the rest of subjects seeking incompetency. [12]

Consequences

Malingering can divert resources away from individuals with legitimate PTSD. This can delay or reduce access to treatments and support needed for those with PTSD. [13] Malingering cases can lead to increased skepticism towards individuals claiming to have PTSD and contribute to the stigmatization of those with genuine PTSD. This may cause stress and anxiety due to the suspicion of malingering, thus exacerbating their symptoms. [14] The prevalence of malingering can lead to more stringent criteria for receiving disability benefits, which may negatively impact individuals with legitimate PTSD. Malingering can erode public trust in mental health and disability systems by increasing skepticism and resistance to supporting mental health initiatives. [10]

Individuals who are found to be malingering may face legal consequences, including criminal charges, fines, or imprisonment. [15] Individuals' reputations and credibility can be impacted along with their personal and professional lives. Those found malingering can deal with difficulties when taking legal actions or dealing with future claims. [16]

Malingering assessments consume resources and time that could be allocated to treating genuine cases of PTSD. This can lead to inefficiencies and increased costs in healthcare and mental health systems by consuming resources and time. [16] Money is used when investigating and managing suspected malingering, which can contribute to higher overall healthcare costs. This can increase expenses and impact the availability and quality of mental health services. Malingering can complicate legal cases and insurance claims, which leads to higher litigation costs and delays in settlements. [17]

Psychological assessment findings

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is a self-reported personality test which is the most widely used psychological assessment measure in research to detect malingered PTSD, typically by comparing genuine PTSD patients with individuals trained and instructed to fabricate PTSD on the MMPI-2. [18] Numerous studies using the MMPI-2 have demonstrated a moderately accurate ability to detect simulated PTSD. [19] [20] [21] [22] [23] [24] [25] Validity scales on the MMPI-2 that are reasonably accurate at detecting simulated PTSD include both the Fp scale developed by Paul Arbisi and Yosef Ben-Porath, [26] and the Fptsd scale developed by Jon Elhai for combat survivors. [21] These two scales have shown differing results. The Fp scale is the most helpful malingering predictor in civilian PTSD patients, whereas the Fptsd scale is a better predictor in combat PTSD patients. [10]

The Symptom Validity Test (SVT) is two different measures that can help diagnose malingering PTSD and assess the credibility of reported PTSD symptoms. These reported means are self-report measures, response patterns, and symptom profiles. [27] Studies show that SVTs are effective in distinguishing between genuine and feigned symptoms in various settings. The Performance Validity Test (PVT) evaluates the credibility of an individual's performance on cognitive or neuropsychological tests. PVTs are particularly useful for identifying cases where individuals might be fabricating or exaggerating cognitive impairments, including those related to PTSD. PVTs are widely validated and used in various assessments by complimenting other assessments tools by providing additional evidence. [28]

Other psychological test instruments have been investigated for PTSD malingering detection ability, but have not approached the accuracy rates of the MMPI-2. These tests include the Personality Assessment Inventory [29] [30] and Trauma symptom inventory. [25] [31] [32] The current literature modestly supports the effectiveness of the Personality Assessment Inventory or PAI at detecting malingering of post-traumatic stress disorder or PTSD.  Although results are mixed, the validity indicators of the PAI have been found to be effective at differentiating malingered PTSD from a diagnostically supported diagnosis of PTSD. Specifically, the negative impression management or NIM scale, the malingering index scale or MAL, and the negative distortion validity scale or NDS of the PAI are interpreted in detecting malingering of PTSD. [33] [34]

It is important to use multiple assessments when determining malingering of PTSD and not only rely on one test. [35] A preliminary test which can be used is the Miller-Forensic Assessment of Symptoms (M-FAST). It can find 78 percent of test-takers asked to feign results and only takes between 5 and 10 minutes. [36] Interviews hosted by clinicians are sometimes preferred over self-reported tests. These include the Clinician-Administered PTSD Scale (CAPS) or the Structured Interview of Reported Symptoms-2 (SIRS-2). [37] [38] Each of these include and interviewer who asks an interviewee a series of questions. The CAPS asks interviewees to rate items on a scale while the SIRS-2 may ask questions that could elicit a response that would expose malingering. The SIRS-2 has high accuracy in general malingering and PTSD malingering. [11]

Limitations

Many studies on malingering PTSD focus on specific populations, mostly being veterans, which does not allow this to be generalized to more diverse groups. Most studies and research on malingering PTSD are concentrated in Western countries, specifically the United States. This overlooks other cultures and ethnicities. [39]

Assessment tools for malingering like the MMPI-2, PAI, and other tests, vary in levels of accuracy depending on the context and population. The effectiveness of these tests differs, thus leading to potential inconsistencies in malingering detection. [40] Some tools used to assess malingering PTSD may be outdated and some of the research articles have used these outdated tools for their research. These malingering PTSD assessments involve subjective elements with self-reporting items. This subjectivity can impact the reliability and validity of malingering assessment. [41]

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

Psychological testing refers to the administration of psychological tests. Psychological tests are administered or scored by trained evaluators. A person's responses are evaluated according to carefully prescribed guidelines. Scores are thought to reflect individual or group differences in the construct the test purports to measure. The science behind psychological testing is psychometrics.

Malingering is the fabrication, feigning, or exaggeration of physical or psychological symptoms designed to achieve a desired outcome, such as personal gain, relief from duty or work, avoiding arrest, receiving medication, and mitigating prison sentencing. It presents a complex ethical dilemma within domains of society, including healthcare, legal systems, and employment settings.

The Minnesota Multiphasic Personality Inventory (MMPI) is a standardized psychometric test of adult personality and psychopathology. A version for adolescents also exists, the MMPI-A, and was first published in 1992. Psychologists and other mental health professionals use various versions of the MMPI to help develop treatment plans, assist with differential diagnosis, help answer legal questions, screen job candidates during the personnel selection process, or as part of a therapeutic assessment procedure.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples include violence, rape, or a terrorist attack.

Dissociative disorders (DDs) are a range of conditions characterized by significant disruptions or fragmentation "in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior." Dissociative disorders involve involuntary dissociation as an unconscious defense mechanism, wherein the individual with a dissociative disorder experiences separation in these areas as a means to protect against traumatic stress. Some dissociative disorders are caused by major psychological trauma, though the onset of depersonalization-derealization disorder may be preceded by less severe stress, by the influence of psychoactive substances, or occur without any discernible trigger.

Reduced affect display, sometimes referred to as emotional blunting or emotional numbing, is a condition of reduced emotional reactivity in an individual. It manifests as a failure to express feelings either verbally or nonverbally, especially when talking about issues that would normally be expected to engage emotions. In this condition, expressive gestures are rare and there is little animation in facial expression or vocal inflection. Additionally, reduced affect can be symptomatic of autism, schizophrenia, depression, post-traumatic stress disorder, depersonalization derealization disorder, schizoid personality disorder or brain damage. It may also be a side effect of certain medications.

Robert Michael Bagby is a Canadian psychologist, senior clinician scientist and director of clinical research at the Centre for Addiction and Mental Health (CAMH). He is a full professor in the Department of Psychiatry, University of Toronto. He became a full professor of psychology at the University of Toronto Scarborough campus in July 2011.

Memory and trauma is the deleterious effects that physical or psychological trauma has on memory.

<span class="mw-page-title-main">Veterans benefits for post-traumatic stress disorder in the United States</span> VA disability compensation for PTSD

The United States has compensated military veterans for service-related injuries since the Revolutionary War, with the current indemnity model established near the end of World War I. The Department of Veterans Affairs (VA) began to provide disability benefits for post-traumatic stress disorder (PTSD) in the 1980s after the diagnosis became part of official psychiatric nosology.

Trauma Screening Questionnaire abbreviated as (TSQ) is a questionnaire developed for screening of posttraumatic stress disorder. The TSQ was adapted from the PTSD Symptom Scale – Self-Report Version (PSS-SR). This self-reported assessment scale consists of 10 items, which cover one of the main signs of PTSD. Each item is answered with binary yes or no responses. Overall assessment is done by total score, and the total score higher than 5 indicates on likelihood of PTSD. The TSQ is considered as a valid assessment scale for screening of posttraumatic stress disorder.

A psychological injury is the psychological or psychiatric consequence of a traumatic event or physical injury. Such an injury might result from events such as abusive behavior, whistleblower retaliation, bullying, kidnapping, rape, motor vehicular collision or other negligent action. It may cause impairments, disorders, and disabilities perhaps as an exacerbation of a pre-existing condition.

Jon Elhai is Distinguished Professor of clinical psychology at the University of Toledo. Elhai is known for being an expert in the assessment and diagnosis of Posttraumatic stress disorder (PTSD), forensic psychological assessment of PTSD, and detection of fabricated/malingered PTSD; as well as in internet addictions.

The Trauma Symptom Inventory (TSI) is a psychological evaluation/assessment instrument that taps symptoms of Posttraumatic stress disorder and other posttraumatic emotional problems. It was originally published in 1995 by its developer, John Briere. It is one of the most widely used measures of posttraumatic symptomatology.

<span class="mw-page-title-main">Loren Pankratz</span> American psychologist (born 1940)

Loren Pankratz is a consultation psychologist at the Portland VA Medical Center and professor in the department of psychiatry at Oregon Health & Science University (OHSU).

The Lees-Haley Fake Bad Scale (FBS) or MMPI Symptom Validity Scale is a set of 43 items in the Minnesota Multiphasic Personality Inventory (MMPI), selected by Paul R. Lees-Haley in 1991 to detect malingering for the forensic evaluation of personal injury claimants. It was endorsed by the MMPI publishers in 2006 and incorporated into the official scoring keys. A 2008 Wall Street Journal article noted that a few psychologists argued that it was controversial because they felt that some individuals with legitimate injuries would be categorized as faking bad.

The University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index for DSM-5 is a psychiatric assessment tool used to assess symptoms of PTSD in children and adolescents. This assessment battery includes four measures: the Child/Adolescent Self-Report version; the Parent/Caregiver Report version; the Parent/Caregiver Report version for Children Age 6 and Younger; and a Brief Screen for Trauma and PTSD. Questions may differ among the indexes depending on the target age, however the indexes are identical in format. The target age groups for this assessment are children and adolescents between 7-18 and children age 6 and younger. Versions of the UCLA PTSD Reaction Index for DSM-5 have been translated into many languages, including Spanish, Japanese, Simplified Chinese, Korean, German, and Arabic. The DSM-IV version of the UCLA PTSD Reaction Index Index has been updated for DSM-5.

The Clinically Administered PTSD Scale (CAPS) is an in-person clinical assessment for measuring posttraumatic stress disorder (PTSD). The CAPS includes 30 items administered by a trained clinician to assess PTSD symptoms, including their frequency and severity. The CAPS distinguishes itself from other PTSD assessments in that it can also assess for current or past diagnoses of PTSD.

The Structured Inventory of Malingered Symptomatology (SIMS) is a 75-item true-false questionnaire intended to measure malingering; that is, intentionally exaggerating or feigning psychiatric symptoms, cognitive impairment, or neurological disorders.

The Child PTSD Symptom Scale (CPSS) is a free checklist designed for children and adolescents to report traumatic events and symptoms that they might feel afterward. The items cover the symptoms of posttraumatic stress disorder (PTSD), specifically, the symptoms and clusters used in the DSM-IV. Although relatively new, there has been a fair amount of research on the CPSS due to the frequency of traumatic events involving children. The CPSS is usually administered to school children within school boundaries, or in an off-site location to assess symptoms of trauma. Some, but not all, people experience symptoms after a traumatic event, and in serious cases, these people may not get better on their own. Early and accurate identification, especially in children, of experiencing distress following a trauma could help with early interventions. The CPSS is one of a handful of promising measures that has accrued good evidence for reliability and validity, along with low cost, giving it good clinical utility as it addresses a public health need for better and larger scale assessment.

References

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