Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder [1 ed.] 9781616684549, 9781616681449

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Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS

DIFFERENTIAL DIAGNOSIS OF MALINGERING VERSUS POSTTRAUMATIC STRESS DISORDER: SCIENTIFIC

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RATIONALE AND OBJECTIVE SCIENTIFIC METHODS No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

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Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS

DIFFERENTIAL DIAGNOSIS OF MALINGERING VERSUS POSTTRAUMATIC STRESS DISORDER: SCIENTIFIC

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

RATIONALE AND OBJECTIVE SCIENTIFIC METHODS

KENNETH R. MOREL

Novinka Books New York

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher.

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For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Morel, Kenneth R. Malingering versus posttraumatic stress disorder / Kenneth R. Morel. p. ; cm. Includes bibliographical references and index. ISBN 978-1-61668-454-9 (eBook) 1. Post-traumatic stress disorder--Diagnosis. 2. Malingering. I. Title. [DNLM: 1. Stress Disorders, Post-Traumatic--diagnosis. 2. Diagnosis, Differential. 3. Malingering--diagnosis. 4. Military Personnel--psychology. 5. Veterans--psychology. WM 170 M839m 2010] RA1152.P67M67 2010 616.85'21075--dc22 2010002982

Published by Nova Science Publishers, Inc.  New York

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

DEDICATION To my late grandfather, Alfred A. Gagne, my father, Roger R. Morel, my brothers, Glenn A. Morel and David F. Morel, for their honorable service in the U.S. Armed Forces

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—K.R.M.

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

CONTENTS Preface

xi

About the Author Abstract

xv

Part I. Background Issues in Military Psychiatry

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Chapter 1 Chapter 2

xiii

Foundational Issues in the Role of Military Psychiatry in Detecting Malingering

1 3

Problematic Issues in Assessing Malingered PTSD

19

Part II. Statistical Methods and Psychometric Tests to Detect Malingering

41

Chapter 3 Chapter 4 Chapter 5

Rationale and Statistical Methods to Detect Simulated PTSD

43

Psychometric Tests to Differentiate Valid and Invalid Response Patterns for PTSD

57

Conclusion

71

References

73

Index

93

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

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PREFACE No clinical opinion is more problematic, more weighty, or more pressing for a solution in military psychiatric medicine than differentiating malingering from posttraumatic stress disorder (PTSD). During military conflicts, U.S. Armed Forces personnel endure daily harships and life-threatening situations. For service men and women, the nature of war can produce the stress-related psychiatric condition of PTSD or the conscious simulation of symptoms of PTSD for secondary gain. Since malingering has a significant impact on the military and its mission, the importance of differentiating malingering from genuine PTSD makes it relevant that the present state of the art and science of this process be presented in this book.

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

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ABOUT THE AUTHOR KENNETH R. MOREL is a personnel psychologist in the U.S. Navy’s Exam Development Division. He has worked as a psychologist in both the Neuropsychiatry Branch of the National Institutes of Mental Health and for the U.S. Army under the Army Medical Command at Tripler Army Medical Center in Hawaii. He has also worked as a Psychometrist for the Department of Veterans Affairs. His expertise has been utilized as a reviewer for professional journals, such as the Archieves of Clinical Neuropsychology, the Journal of Traumatic Stress, and the Journal of Forensic Psychiatry and Psychology. He is the developer of several psychometric tests, including the Morel Auditory Comprehension Test (MACT) and the Morel Emotional Numbing Test for Posttraumatic Stress Disorder (MENT). The latter psychometric test has been translated into Croatian, German, and Turkish languages and has been used in the U.S., Croatia, Germany, Canada, Switzerland, Great Britain, New Zealand, and Australia. As a Psychometrist, he has evaluated over a thousand active duty military personnel and military veterans for posttraumatic stress disorder (PTSD). His published research has primarily focused on psychological and neuropsychological assessment issues. He received two Public Health Service Citations from the Department of Health and Human Services and various performance citations from the Department of Veterans Affairs, including Excellence in Research in 1995. He is a decorated military veteran of the U.S. Air Force and has also been awarded the Superior Civilian Service Medal by the U.S. Army Medical Command.

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

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ABSTRACT In the Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition-Text Revision (DSM-IV-TR), the American Psychiatric Association specifically advises clinicians to consider a differential diagnosis of malingering in psychiatric assessments for Posttraumatic Stress Disorder (PTSD) when secondary gain may be a factor. This is an important issue in psychiatric evaluations with military personnel, where the nature of war can lead to genuine PTSD or the conscious simulation of symptoms of PTSD for secondary gain. To address this need, this book provides a broad view of the literature to recommend effective methodological techniques in detecting simulated PTSD. First the definition, historical framework, incidence, and impact of malingering are discussed. Next, multiple factors that may influence military psychiatrists’ expertise and attitude toward diagnosing malingering are described. Finally, this book explores the theoretical and practical application of statistical methods and psychometric tests to provide empirically grounded probabilistic evidence of malingering.

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

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PART I. BACKGROUND ISSUES IN MILITARY PSYCHIATRY

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved. Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Chapter 1

FOUNDATIONAL ISSUES IN THE ROLE OF MILITARY PSYCHIATRY IN DETECTING MALINGERING INTRODUCTION

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―People for many reasons pretend to be ill; it is desirable, then, that the physician should be able to arrive at the truth in such cases.‖ – Galen 131 AD to 201 AD

The identification of malingering by physicians extends back over 18 centuries (Lurid, 1941). In military medicine the detection of malingering is a necessary function of mental health practitioners. During military operations in hazardous settings and combat engagements with the enemy, armed forces personnel are placed in life-threatening situations. Exposure to life-threatening events can produce the stress-related psychiatric condition of posttraumatic stress disorder (PTSD). In addition to behavioral health treatment, patients diagnosed with PTSD may also be entitled to convalescence from the hardships of military duty, financial gain through disability pensions, and, in rare circumstances, possible exculpation for crimes by reason of diminished capacity. These benefits entice some military personnel to simulate PTSD. Hence, the nature of war can lead to genuine PTSD or the conscious simulation of symptoms of PTSD for secondary gain. Since malingering has a significant impact on the military and its mission, the importance of differentiating malingering from genuine PTSD makes it relevant that the

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

4

Kenneth R. Morel

present state of the art and science of this process be presented in this book.

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DEFINITION According to Catton (1919) the term malingering, related to the French term malingré (sickly), was originally derived from the words malus (bad, evil or base) and aeger (indisposition, sickness, or illness). Various definitions of malingering are presented in medical science and military law. Dorland's Medical Dictionary-Twenty-seventh Edition (Saunders, 1988) defines malingering as the ―willful, deliberate, and fraudulent feigning or exaggeration of the symptoms of illness or injury, done for the purpose of a consciously desired end‖ (p. 975). The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) identifies malingering as ―the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs‖ (p. 739). The International Statistical Classification of Diseases and Related Health Problems-Tenth Revision-Version 2007 (ICD) identifies malingering as a person feigning illness with obvious motivation (ICD-10 code Z76.5; World Health Organization, 2007). Under military law, the Uniform Code of Military Justice (UCMJ) classifies malingering in U.S. Article 115 as, any person who (1) feigns illness, physical disablement, mental lapse or derangement; or (2) intentionally inflicts self-injury for the purpose of avoiding work, duty, or service. In sum, malingering involves some form of deception, a lie perpetrated by the malingerer, defined as any act or communication with the intent to deceive for secondary gain. Several hierarchical models or classification systems of malingering have been proposed. Lipman (1962) describes four levels of malingering; (1) Invention the patient simulates symptoms that do not exist, (2) Perseveration the patient continues to assert symptoms that have previously existed but have now resolved, (3) Exaggeration the patient falsely inflates the extent of his or her symptoms, and (4) Transference the patient falsely impugns real symptoms to a cause that is unrelated to the symptoms. Similarly, Resnick (1997) identifies three levels of malingering; (1) Full malingering the patient fabricates or grossly exaggerates a mental disorder for secondary gain, (2)

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Foundational Issues in the Role of Military Psychiatry…

5

Partial malingering the patient falsely affirms having symptoms that, in reality, no longer exist, and (3) False imputation the patient attributes genuine symptoms to a non-related etiology. Slick, Sherman, and Iverson (1999) proposed three levels of diagnostic certainty regarding malingering; (1) Definite the patient’s performance on objective tests and clinical interview reveal unambiguous evidence of willful intent to deceive without a reasonable alternative explanation, (2) Probable the patient meets the criteria for ―definite‖ malingering with the exception that the evidence is not unequivocal but still persuasive, and (3) Possible the patient’s presentation is suggestive of negative response bias but a plausible alternative explanation other than malingering may also account for their atypical presentation of symptoms during clinical interview and testing. Rogers, Sewell, and Goldstein (1994) proposed three models to explain the motivational drive of persons to malinger mental illness; (1) Pathogenic model the person’s underlying psychopathology is the primary impetus for malingering, (2) Criminological model malingering is a byproduct of an individual’s antisocial personality characteristics and traits, and (3) Adaptational model person views malingering as a means of meeting personal goal attainment when faced with adverse or hostile circumstances. In addition, research in behavioral attribution and decision-making fields suggests that both knowledge of mental disorders and greater motivational incentives to malinger increases the level of simulated psychopathology (Erdal, 2000).

RESPONSIBILITIES AND DIAGNOSTIC CHALLENGE OF MILITARY PSYCHIATRISTS As officers and medical providers, psychiatrists within the military have a responsibility to provide evidence-based behavioral health treatment to promote, sustain, and enhance the mental health of military members. To do so effectively, psychiatrists must acquire diagnostic skill that utilizes aspects of both clinical and forensic acumen. When a military member voluntarily or through a command referral presents to a Medical Treatment Facility (MTF) for mental health problems, the psychiatrist has the professional task of assessing the patient and determining the best course of treatment. If the patient is unable to perform his or her military duties or a mental health condition precludes worldwide

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Kenneth R. Morel

6

deployment, then the military member is referred to a Medical Evaluation Board (MEB). If the MEB determines that the patient’s mental health condition is unsuitable for continued military service, the case is referred to a Physical Evaluation Board (PEB; see U.S. Code, Title 10-Armed Forces, chapter 61). At this point the Veterans Administration (VA) may become involved in procuring a disability pension for a military member separated from service. Interestingly, 18.9% of patients treated for major psychiatric disorders in the U.S. Armed Forces received VA disability pensions for mental disorders but did not seek medical or psychiatric treatment through from the VA healthcare system (Morel, Rosenheck, Henter, & Wyatt, 1999). Table 1 lists the medical disability regulations for each branch of the U.S. military, the U.S. Coast Guard, and the Department of Veterans Affairs. The psychiatrist's role in this process is straightforward when the veracity of the military member’s presentation is legitimate. In medical situations in which this is not the case, it can be difficult at best for the military physician to differentiate simulated psychopathology from genuine mental disorders. This is especially true in cases of simulated PTSD.

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Table 1. Policies Regarding Fitness for Duty, Medical Discharge, Administrative Separation, and Disability Organization

Regulation

Army

Army Regulation (AR) 40-501 (Standards of Medical Fitness)

Navy

Secretary of the Navy Instruction (SECNAVINST) 1850.4E (Department of the Navy Disability Evaluation Manual)

Air Force

Air Force Instruction (AFI) 36-2902 (Physical Evaluation for Retention, Retirement and Separation)

Marine Corps

Secretary of the Navy Instruction (SECNAVINST) 1850.4E (Department of the Navy Disability Evaluation Manual)

Coast Guard

COMDTINST M1850.2D (Physical Disability Evaluation System)

Veterans Affairs

Veterans Health Administration (VHA) Handbook 1601E.01 (Compensation and Pension Examinations)

Note: The Department of Defense Instruction 1332.38 is the controlling regulation regarding medical disability and retirement. This includes various mental disorders as specified by the American Psychiatric Association in the DSM-IV-TR. The Coast Guard is under the jurisdiction of the U.S. Department of Homeland Security.

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Foundational Issues in the Role of Military Psychiatry…

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BRIEF HISTORICAL FRAMEWORK Psychological trauma from combat-related exposure has been known for centuries (Deahl, 1997). In the late 19th century the psychological consequences of traumatic events was also evident in civilian settings. In 1888, German neurologist Hermann Oppenheim described psychiatric symptoms in survivors of railway accidents as traumatic neurosis (Shorter, 2005). The vast numbers of psychiatric casualties in the First World War (WWI) brought new attention to the psychopathological responses of servicemen to the traumas of war (Micale & Lerner, 2001). The terms often used during WWI in military medicine to describe this mental disorder was shell shock and war neuroses. The medical community was split as to the underlying pathology of war neuroses. One opinion was that psychiatric disturbances seen in war neuroses represent injuries to the central nervous system. Other physicians followed the theory of Sigmund Freud that war neurosis is a functional disturbance more attributable to a specific vulnerability rooted in childhood. During the Second World War (WWII) it became evident, however, that even soldiers who appeared psychologically resilient could develop stress reactions from repeated exposure to the ordeals of war (Jones, 2006). Following the end of the U.S. military involvement in Vietnam in 1975, the American Psychiatric Association (APA) commissioned a task force to examine the issue of classifying symptoms of psychological trauma under one specified mental disorder, PTSD. The formal codification of the constellation of symptoms as PTSD first appeared in the third edition of DSM (APA, 1980). Several political and empirical dilemmas were associated with the formal approval of PTSD in the nomenclature of mental disorders (Baldwin, Williams, & Houts, 2004; McNally, 2003a; Summerfield, 2001). The initial problematic issues regarding the constructs underlying this relatively new diagnostic category are still being debated (Jones et al., 2003; McHugh & Treisman, 2007; North, Suris, Davis, & Smith, 2009; Spitzer, Rosen, & Lilienfeld, 2008). Scott (1990; 1993) and Lembcke (1998) note that antiwar social and political activists were some of the leading proponents of the inclusion of PTSD in the DSM-III (see also Davidson, 1987). It was argued that survivors of other types of traumatic events experienced symptoms similar to survivors of life-threatening trauma in war. In consideration of this fact, the DSM-III task force included an identifiable etiological incident (i.e., exposure

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to a life-threatening event) as a necessary criterion for PTSD, a unique criterion for diagnosing mental disorders. Another distinguishing characteristic of PTSD is that the criteria, as outlined in the DSM, are largely based on the patient’s self-report of symptoms and subjective reaction to the purported life-threatening event(s). When the subjective nature of symptoms is combined with a real or falsified involvement in a life-threatening traumatic event, it is readily apparent that a motivated person could sufficiently feign symptoms of PTSD so as to be given the diagnosis. In fact, Philip Resnick, a noted expert on malingering and past President of the American Academy of Psychiatry and Law, gave the following response when asked what psychiatric disorder is most often malingered:

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Posttraumatic stress disorder is the easiest to malinger because people can be easily coached to report the ―right‖ symptoms. The list of symptoms is readily available on the Internet and they are virtually all subjective, so it is very difficult to ascertain when someone is malingering. (Sussman, 2006, p. 35)

Indeed, some veterans arrive for disability pension examinations for combat-related PTSD with printed lists of the symptoms of PTSD that include real life examples of stressors. This is an important contextual issue in the assessment of PTSD. For example, a search of the Internet using the acronym ―PTSD‖ identified over 5 million sites within one-tenth of a second. Some sites provide step-by-step instructions on how to get a diagnosis of combatrelated PTSD in order to obtain financial compensation. In one inpatient setting a veteran was found with a flyer that outlined the symptoms of PTSD (Thompson, LeBourgeois, & Black, 2004). Incidentally, the flyer misspelled the phrase ―survivor’s guilt‖ as ―survivor’s quilt,‖ which explained why the veteran was insistent on carrying a quilt with him that purportedly bore the names of his fallen comrades in arms. When confronted with documented evidence that he had not been in combat, the veteran admitted that he was feigning symptoms of PTSD for a disability pension. Unfortunately, most mendacious individuals do not admit to malingering, even when confronted with transparent inconsistencies between their account of events and actual documented evidence. Malingering of psychological stress reactions to military trauma is not a new phenomenon. Edward Casey, a British soldier during the WWI, was involved in several attempts to evade the hardships of war by malingering.

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This is not entirely surprising considering that trench warfare, common during WWI, often meant living in deplorable conditions that included lice, rats, and the threat of death or disfigurement. In total, 7% of the male population died as a result of WWI. Fearing retribution under military law for being caught feigning medical ailments, Edward Casey stated:

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Those Medical Blokes tell you nothing, for when they carried [out] all their tests, and found I was malingering, I felt certain I would be for the firing squad: it would be ―fini.‖ The solution came that night. (Bourke, 1999, p. 54)

The solution, according to Edward Casey, was to feign psychological stress reactions to the war. He subsequently convinced a military physician that he suffered mental illness by, in his own words, ―telling him lies‖ (Bourke, 1999, p. 54). The physician who examined him stated, ―You may suffer further attacks if frightened or [on] hearing sudden explosions‖ (Bourke, 1999, p. 54). Edward Casey’s deception was successful and he received a temporary reprieve from the warfront. Although malingered stress reactions to war were recognized for centuries among military combatants (Carroll, 2003; Gavin, 1843) and in persons seeking military disability pensions (Collie, 1917; Llewellyn & Jones, 1919; Munson, 1912), malingering was not included in the differential diagnosis section on PTSD in the DSM-III. In the decade following the inclusion of PTSD in the DSM, personal injury lawsuits filed in Federal courts increased 50% (Olson, 1991). In civil compensation cases over a 10-year span there was an 800% increase in stress-related claims, and insurance costs for claims of traumatic stress overtook the total expenditures for all physical injury claims (deCarteret, 1994). From September 1999 to October 2004 there was an 80% rise in the number of veterans receiving disability payments for PTSD not attributable to the war in Iraq or Afghanistan (U.S. OIG, 2005; Levin, 2006). In fact, as early at 1983 published studies reported on the problem of military veterans feigning PTSD for secondary gain (Sparr & Pankratz, 1983). Consequently, later editions of the DSM added a specific caution in the differential diagnosis section on PTSD that, ―Malingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role (p. 467).‖

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INCIDENCE OF MALINGERING The prevalence, incidence, and base rates of malingering in military populations are unknown. This is because military historians and military physicians have been reticent to cite instances of malingering among the armed forces. Malingering is a subject that conjures up social, political, ethical, and legal ramifications that are troublesome. For these and other methodological reasons, malingering is often understated in military populations. For example, out of 6,772,029 admissions to military sick call reported by physicians to their commanding officers and the Surgeon General during the U.S. Civil War and Spanish War (6,454,834 and 317,195, respectively) there was not a single record of malingering (Munson, 1912). Since military personnel can remove themselves from the hardships of war and potential lifethreatening situations by presenting to sick call, it is likely some of the over 6.7 million servicemen presenting to sick call were malingering. Those who do malinger are unlikely to admit to doing so. Consequently, the non-admission of malingering by pseudo-patients along with the non-identification and/or non-reporting by physicians of suspected cases of malingering preclude accurately determining its prevalence. Estimates of the incidence rates of probable malingering in psychiatric examinations for PTSD are also not definitive because they rely on various methods used for detection and the population samples studied. Prior to the inclusion of PTSD in the DSM-III, studies conducted in the 1940’s and 1950’s indicated incidence rates of malingering ranging from 2% to 7% in military personnel being treated or evaluated for psychiatric disorders (Brussel & Hitch, 1943; Flicker, 1956). In a carefully constructed study to improve the external validity of identifying malingerers in active-duty military personnel seen as psychiatric patients in healthcare clinics, the incidence rate was 37.2% (Viglione, Fals-Stewart, & Moxham, 1995). Estimates of probable malingering among military veterans claiming combat-related PTSD vary as well and may underestimate the extent of the problem (Burkett & Whitley, 1998). Lynn and Belza (1984) discovered that 5.6% of inpatients in their study were likely malingering. The U.S. Department of Veterans Affairs’ (VA) Office of Inspector General (U.S. OIG; 2005) reported that 25.1% of the 2,100 case files it reviewed of veterans awarded disability pensions for PTSD were based on inadequate evidence of the occurrence of a traumatic event (DSM Criterion A). Similarly, in a

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retrospective analysis of 116 consecutive disability pension examinations for combat-related PTSD, 25.4% of the 63 claimants who were diagnosed with PTSD were suspected of malingering based on MMPI-2 validity indicators (Morel, 1996a). In a study of veterans diagnosed with chronic PTSD and subsequently referred to a VA residential PTSD treatment clinic, Freeman, Powell, and Kimbrell (2008) found clear evidence of symptom exaggeration on objective testing in 53% of the veterans. Of veterans claiming to be former prisoners of war (POW) in North Vietnam who were members of the American Ex-POW Association, almost 30% were not listed on the DOD’s registry of POWs and had no verifiable records to substantiate their POW claim (Burkett & Whitley, 1998). The simulation of combat-related PTSD is also found among military personnel and veterans of other countries. In England 13% of veterans being treated at a military psychiatric center for PTSD subsequently ―proved to be factitious‖ (Baggaley, 1998). A survey of military physicians in the Israel Defense Forces (IDF) estimated that 25% of the military personnel seen by the IDF physicians were malingering (Iancu, Ben-Yehuda, Yazvitzky, Rosen, & Knobler, 2003). Studies of European and U.S. civilian litigants claiming PTSD revealed high rates of probable malingering. The incidence rate of probable malingering during independent medical examinations for PTSD among a German sample was 51.1% (Merten, Friedel, & Stevens, 2006). Lees-Haley (1997) reported probable malingered PTSD ranged from 20 to 30% in a sample of 492 litigants seeking financial remuneration in U.S. courts. More than 50% of U.S. personal injury claimants from motor vehicle accidents were suspected of malingering psychological symptoms (Hickling, Taylor, Blanchard, & Devineni, 1999).

IMPACT OF MALINGERING In the present context, malingering by military personnel has a detrimental effect on the delivery of effective DOD healthcare, is an economical drain on limited financial resources, and adversely influences the U.S. Armed Forces' ability to carry out its mission. The negative impact of malingering on military operations is significant. Reduction in key military personnel through absenteeism and low morale causes serious concerns for military commanders. Indeed, during WWII enemies of the allied forces routinely dispensed propaganda leaflets to U.S. and British troops that encouraged malingering

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(Pilowsky, 1997). In 1945 the British medical journal The Lancet reported that the dispersed leaflets explained in detail how to feign medical disorders and encouraged allied military personnel to malinger. The goal of the enemy in using the leaflets was to reduce allied fighting forces strength by having military personnel report to sick call rather than perform their duties. Thereby, reducing allied fighting strength. Although military personnel may malinger for any number of reasons, such as the intentional evading of military duties, the primary incentive for military veterans is to obtain monies. The U.S. government expressed concern regarding potential malingering by ex-servicemen as early as the 19th century. On the 18th of March 1818 the Senate and House of Representatives of the U.S. Congress established the ―Pension Fund,‖ a general law to provide for veterans of the War of Independence who were in indigent circumstances. Within two years the U.S. Congress passed what was known as the Alarm Act to confront the growing cases of suspected malingering with regards to the Pension Fund. Lamentably, one U.S. general noted, "It has come to pass that…the malingerers and the deserters all march as veterans of the great conflict upon a parity with the noble men who volunteered and fought to the finish" (cited in Llewellyn & Jones, 1919, p. 13). Similarly, following WWI, England's Ministry of Pensions became concerned about military veterans falsifying or exaggerating psychiatric disorders for financial remuneration. The noted physician Sir John Collie, who was the Director of Medical Service for the British government and considered an expert on malingering, was tasked with leading a special medical board to differentiate military veterans with legitimate neurasthenia and functional nerve disease (i.e., shell shock) from malingerers (Collie, 1917). According to Collie (1917), it was readily apparent that "the thin line which divides genuine functional nerve disease and shamming is exceedingly difficult to define" (p. 375). In recent years, the financial and societal impact of this problem has again come to the attention of the U.S. Congress. The VA’s OIG (2005) reported that the financial costs incurred from unsubstantiated claims of PTSD (i.e., no identifiable stressor) by veterans awarded 50% or greater disability pensions during the year 2002 alone would eventually cost the U.S. treasury 19.8 billion dollars. Additionally, the VA’s OIG noted that the yearly costs of disability awards for PTSD climbed to 4.3 billion dollars a year, an increase of 253%. The increase was not attributable to military conflicts in the Middle East. Two years later, the OIG (2007) detailed several substantiated cases of malingered combat-related PTSD in the Semiannual Report to Congress. None of the

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veterans cited in the report to Congress were detected as malingerers during psychiatric disability pension examinations for combat-related PTSD or during clinical treatment for the disorder. The U.S. OIG cited the following examples: OIG investigators determined that a veteran provided false statements in applying for benefits for post-traumatic stress disorder (PTSD) regarding stressors he claimed exposure to. He also submitted altered letters from VA and Social Security Administration (SSA) to obtain fraudulent Department of Defense and state identification and then used them to commit bank fraud. The loss to VA was $230,000 in healthcare costs and $134,000 in benefits. The veteran was arrested for making false claims, mail fraud, wire fraud, and healthcare fraud. (p. 9-10)

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A veteran was convicted of wire fraud after OIG investigators determined he made false claims to qualify for compensation related for PTSD and collected benefits to which he was not entitled. The loss to VA was approximately $220,000. (p. 12) After a complaint called into the OIG Hotline, a joint investigation with SSA and OIG determined a veteran and his wife submitted false stressor information to VA about his military service. Based on his submission and his wife’s false statements, VA awarded 100 percent PTSD compensation benefits, and SSA awarded disability benefits. The VA loss was $171,082 and the loss to SSA was $111,300. The veteran and his wife were convicted of wire fraud, Social Security fraud, false statements, and theft of Government funds. (p. 13)

Similar reports of fraudulent claims of combat-related PTSD by veterans were detailed in the OIG’s Semiannual Report to Congress in 2008. A veteran was indicted on theft charges after an OIG investigation revealed that he provided false information to the Portland VAMC and to the VA Regional Office in order to fraudulently receive VA benefits. The information included an altered discharge document in support of his PTSD claim, fraudulently claiming 2 ½ years of service in Vietnam and combat stressors he did not experience. The veteran obtained the narrative for the stressors by plagiarizing war stories written by other veterans. The loss to the VA is approximately $193,000.

Based in large part on the fraud perpetrated on the federal government and the general public at large by mendacious individuals, the U.S. Congress enacted new legislation (i.e., The Stolen Valor Act) to combat the growing

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fraud regarding military service. The Stolen Valor Act, signed into law on December 20, 2006, strengthens the provisions of 18 U.S.C.  704 to punish individuals who participate in fraudulent acts regarding any decoration, badge, or medal authorized by Congress for the U.S. Armed Forces. Essentially, this law was enacted as the consequence of the large numbers of persons posing as recipients of military medals that were not actually earned. Numerous persons have been convicted under the Stolen Valor Act, including active duty military personnel (e.g., Petty Officer 2nd Class Dontae L. Tazewell), military veterans (e.g., Jesse MacBeth) and persons with no military service (e.g., Xavier Alvarez). Burkett, a veteran of the Vietnam War, and Whitley (1998) exposed numerous cases of malingered PTSD and phony war heroes in their book, Stolen Valor. Often the imposters used their bogus medals of valor to substantiate disability pension claims for combat-related PTSD. Many cases involved individuals masquerading as heroic war combatants and/or being in the Navy Seals or Army Special Forces. Some mendacious individuals told fabricated tales of abhorrent war crimes against the enemy or civilians. One notable case is Edward Lee Daily who convinced several VA mental health practitioners and members of the media that he was a wounded prisoner of war (POW) who rejoined his unit after escaping from the enemy. He claimed to have been awarded the Distinguished Service Cross, multiple Silver Stars, three Purple Hearts, and a battlefield commission to the rank lieutenant. He received notable coverage by the press after his disclosure that he was ordered to fire on civilians at close range until hundreds were killed (Bateman, 2004). This atrocity reportedly occurred at No Gun Ri during the Korean War in July of 1950. Mr. Daily received $324,911 in disabilities payments and $87,928 in medical care, including years of treatment for combat-related PTSD. Federal investigators later proved that his claims were false. Mr. Daily subsequently admitted to federal agents that he did not receive a battlefield commission to the rank of lieutenant, was not at any time wounded during his enlistment in the military, did not earn the Distinguished Service Cross, Silver Stars, or Purple Heart medals, was not a Korean POW, and had not participated in the alleged massacre at No Gun Ri. On September 13, 2002 Army veteran Edward Lee Daily was convicted in federal court for wire fraud by falsifying military records in order to obtain disability payments for combat-related PTSD. The VA Inspector General’s statement to the U.S. House of Representatives (2003) reported that Mr. Daily was sentenced to 21 months' imprisonment, 36 months' supervised release and ordered to pay back

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$412,839 in fraudulently acquired disability pension payments and medical care. Of note, the clinicians treating Mr. Daily from 1986 to 2001 for his purported combat-related PTSD did not question the authenticity of his extraordinary claims. Conceivably, if an astute diagnostician would have detected Mr. Daily’s deception early on, the fraud perpetrated on the federal government and the general public could have been circumvented. In retrospect, harm to both the federal government and the perpetrator of the fraud himself may have been prevented. Often, the real consequences of malingering are not fully appreciated by either the mental health practitioner or the mendacious patient until played out in a forensic arena.

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PHYSICIAN’S ATTITUDES ON MALINGERING AND A RATIONAL PERSPECTIVE For nearly two millenniums, physicians have echoed the words of Galen and Hippocrates, Primum non nocere, ―First, do no harm.‖ In reality, the practice of psychiatry in military medicine is not so simplistic. Many psychiatrists view a clinical opinion of malingering as depreciatory language that should never be used in describing a military patient. LoPiccolo, Goodkin, and Baldewicz (1999) note that, ―Malingering is a diagnosis that is frequently avoided by physicians‖ (p. 166). The reluctance of physicians and other healthcare practitioners to opine that a patient is malingering is true even when there is significant incentive for the patient to simulate impairment, exaggerate symptom severity, or prolong recovery (Aronoff et al., 2007). At the same time, the mission of the armed forces and the responsibilities of military service require physicians to avoid potential connivance with respect to violating military laws (e.g., UCMJ-115 Malingering; Article 97 Conduct Prejudicial to Good Order and Military Discipline). These competing ideologies can produce cognitive dissonance (see Festinger, 1957). To avoid this, the military psychiatrist should consider a rational discourse on the matter. Foremost, the belief that a clinical opinion of malingering is pejorative may be weighed by the antithetical consequences of an erroneous diagnosis of PTSD. In particular, there are at least eight reasons why undetected malingering in military personnel is a major concern. First, it contributes to prescription errors as a result of malingerers speciously receiving medication

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and medical services for a non-existent mental disorder. This may place the psychiatrist in violation of the Controlled Substances Act for the proper prescribing and dispensing of drugs. Second, it increases the risk of toxicity if greater doses of medication are prescribed due to non-therapeutic benefits from medication (i.e., a patient feigning PTSD is likely to deny therapeutic benefit from medication, which may lead to the physician increasing the dosage). Third, it potentially invalidates research regarding the therapeutic efficacy of pharmacological or behavioral interventions due to contamination of PTSD databases with spurious cases (Levin, 2007; Rosen, 2004; 2006; Rosen & Frueh, 2007). Fourth, it diminishes the military’s personnel capability to engage in war through absenteeism; thereby, potentially resulting in an increase in medical casualties in U.S. Armed Forces (Munson, 1912). Fifth, it undermines good order and discipline of the military (Westphal, 2007). Sixth, it leads to misappropriation of financial resources allocated for medical and psychiatric disability pensions (e.g., U.S. OIG, 2005). Seventh, it wrongly exculpates guilty individuals from being held criminally responsible for their actions (Resnick & Harris, 2002; Nicholas, 2000). And eight, it depletes the Department of Defense’s (DOD) healthcare system of valuable medical resources such as clinic availability, staff hours, and medical supplies (e.g., LoPiccolo et al., 1999). Military psychiatrists may feel the burden of balancing both their oath as a commissioned officer of the Armed Forces and their Hippocratic oath as a physician to humanely treat the patients under their care (e.g., Ludwig, 1949; Marzanski, Coupe, Musunuri, 2006). Munson (1912) offered the following counsel to military physicians: Fortunately, however, there need, in practice, be no conflict between these two obligations—for the soldier actually in need of serious medical care is, by the very fact of such need, physically unable to bear arms and support the vicissitudes of campaign; and while his military obligations are thus necessarily suspended he may and should, in his [or her] own person, become the legitimate object of such humanitarian effort and personal interest and sympathy as will most contribute to his [or her] early recovery. But it must be emphasized that the element of humanitarianism is secondary…than as the happy relief from suffering of a professional patient [i.e., malingerer]. (p. 490)

The challenge for the military physician is to maintain the appropriate ethical and fiduciary responsibility regarding medical treatment for patients under their care while also following the lawfully mandated requirements of

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the U.S. Armed Forces (Malone & Lange, 2007). No sensible physician wants to deny proper treatment to a patient with a genuine mental condition. Nevertheless, a military physician, as an officer of the Armed Forces, has a duty as a conserver of military strength to identify persons who are suspected of malingering (Ludwig, 1949; see also 5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army and E.O. 9397). Munson (1912) stated, ―Malingering is undoubtedly one of the most important factors contributing to unnecessary depletion of forces and inefficiency in time of war‖ (p. 626-627). According to Ranson (1949), when encountering a malingerer who does not have an underlying psychiatric disorder or physical impairment that would preclude him or her from fulfilling their military duties, the psychiatrist should persuade the person to return to duty. This protects the perpetrator of the fraud from punishment under the UCMJ, and also helps the Armed Forces reduce absenteeism and maintain trained military personnel in needed capacities. Furthermore, identifying potential malingering may provide the psychiatrist with an opportunity to explore the underlying reasons for the patient’s deception, which could lead to appropriate psychiatric interventions. Garriga (2007) stated, ―it can be argued that the physician has an obligation to the malingerer, at least when in a therapeutic relationship, not to perpetuate and reinforce maladaptive behavior.‖ Similarly, a clinical opinion of malingering does not necessarily preclude that the mendacious patient could not benefit from appropriate healthcare services (Morel, 1996b). A patient’s genuine psychiatric or medical symptoms apart from those symptoms that are simulated might warrant treatment by a healthcare practitioner. It should be noted, nonetheless, that the military physician has a duty to provide appropriate restorative treatment for their patients with the goal to return patients to optimal functioning, which may lead to their return to military service and being placed in harm's way. It is the inevitable consequence of war. Of equal consideration for the military physician, is that a reduction of key military personnel—through deliberate malingering or the exaggeration of symptoms—can reduce the effectiveness of a military unit to engage in battle, which can lead to an increase in medical casualties. The paradox for the military diagnostician is that an incorrect clinical judgment in either direction—PTSD or malingering—carries substantial consequences. As described in the preceding paragraphs, undetected malingering can negatively impact both the perpetrator of the deception and the military healthcare system. Likewise, an incorrect clinical opinion of malingering when a more plausible explanation of the patient’s presenting

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symptoms is warranted, could lead to disciplinary action against the accused malingerer. Under the punitive articles of the UCMJ, a conviction for violating Article 115—Malingering carries various maximum punishments depending on the particular circumstances involved as follows:

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1. Feigning illness, physical disablement, mental lapse, or derangement. Dishonorable discharge, forfeiture of all pay and allowances, and confinement for 1 year. 2. Feigning illness, physical disablement, mental lapse, or derangement in a hostile fire pay zone or in time of war. Dishonorable discharge, forfeiture of all pay and allowances, and confinement for 3 years. 3. Intentional self-inflicted injury. Dishonorable discharge, forfeiture of all pay and allowances, and confinement for 5 years. 4. Intentional self-inflicted injury in a hostile fire pay zone or in time of war. Dishonorable discharge, forfeiture of all pay and allowances, and confinement for 10 years. In summary, the military physician has the professional obligation not only to provide appropriate restorative treatment to military personnel in need but to also assist when necessary with differentiating malingering from legitimate psychiatric disorders. Failure to do so may result in a loss of credibility for psychiatry and have negative consequences for the DOD’s healthcare system and the U.S. Armed Forces. Although the DSM-IV-TR recommends differentiating malingering from genuine PTSD, it does not specify how this is to be done. Furthermore, forensic military psychiatric skills are needed but academic training for physicians in this area may be lacking (Turner & Neal, 2003). This book proposes that the best practice parameter is to study assessment methods to detect unauthentic PTSD that is based on rational scientific evidence and to avoid decisions that are anchored in unempirical perception. Concerning the latter, the following chapter describes some of the problematic issues in assessing malingered PTSD.

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Chapter 2

PROBLEMATIC ISSUES IN ASSESSING MALINGERED PTSD

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LIMITATIONS IN DETECTING MALINGERING BY CLINICAL INTERVIEW ALONE The clinical interview has been the mainstay of psychiatric examinations going back nearly two centuries (Marneros, 2008). The role of the clinical interview in military psychiatry is that of obtaining information about the patient in order to describe the patient’s present mental condition, to enable reasonable predictions to be made about the patient’s future behavioral functioning, and to determine the etiology of any mental disorder and the best course of treatment. In psychiatric evaluations for PTSD in which the patient provides a valid description of their symptoms and a lucid and frank history of relevant information, an assessment by a skilled practitioner can, in principle, be made sufficiently precise by a clinical interview alone. In contrast, in assessing unreliable or mendacious patients based on clinical interview alone, the diagnostic accuracy of mental health practitioners is less then certain (Ekman & O’Sullivan, 1991; Hickling, Blanchard, Mundy, & Galovski, 2002; Hobel, 2005; Samuel & Mittenburg, 2005). Lynn and Belza (1984) note, ―So adept are factitious PTSD patients at their deception that even the most experienced physicians can find themselves fooled by the presenting complaints‖ (p. 699). It has become increasingly clear that the ability of practitioners to differentiate patients with legitimate symptoms of PTSD from those feigning symptoms of PTSD, without objective collateral evidence, is problematic.

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Ekman and O’Sullivan’s (1991) research demonstrated that psychiatrists could accurately detect lying in little more than half of cases (57.1%) based on clinical observations alone. Samuel and Mittenberg's (2005) study revealed that clinicians are unable to differentiate between genuine, contrived, or exaggerated complaints solely on the basis of the patient’s demeanor. Rosen and Taylor (2007) note that "there is no particular type of question that reveals feigned presentations of a disorder, nor can clinicians reliably judge a person's honesty by their aura" (p. 203). Overall, the detection of liars seldom exceeds 60% in experimental settings (Vrij, 2000). In fact, diagnostic errors in differentiating honesty from deception falls in the direction of believing that individuals are more likely telling the truth than lying (Nicholson & Martelli, 2007). This can be problematic as public opinion surveys suggest that purposeful misrepresentation for financial gain in medicolegal settings is often viewed as acceptable behavior (Insurance Resource Council, 1992; 1993). Consequently, the detection of malingering by clinical interview alone is improbable (Reid, 2000). The utilization of structured clinical interviews to assess patients who may simulate PTSD is also problematic. Many structured clinical interviews for PTSD are highly regarded and are useful when the interviewee is lucid and honest in their responses. For example, the Clinician Administered PTSD Scale (CAPS; Blake et al., 2001) is described by the National Center for PTSD as the ―gold standard‖ for PTSD assessment and diagnosis. Yet, a study by Freeman et al. (2008) in which the clinicians were blinded regarding previous diagnostic testing results, revealed that PTSD symptom severity in veterans as measured by the CAPS correlated significantly with a measure assessing clear symptom exaggeration suggestive of malingering. The same is true with other structured interviews. Lees-Haley, Price, Williams, and Betz (2001) note that the use of the Structured Clinical Interview for DSM Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2000) without additional data to support the authenticity of the patient’s claims is problematic at best. Without special training and interest in detecting lies, many psychiatrists may misinterpret stereotypic behavioral cues as evidence of honesty or deception on the part of the patient. Leal, Vrij, Fisher, and van Hooff ’s (2008) study revealed that mendacious individuals with high anxiety concerning whether or not their deception will be detected, in fact, do not display the stereotypical signs of nervous behaviors (i.e., tonic arousal and blinking). A review of over 110 published studies indicates that there are no consistent behavioral cues of lying, either verbal or nonverbal, that can be detected by clinical interview (DePaulo et al., 2003). Reid (2000) stated that malingerers

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do not ―reliably fidget or blink more, avoid eye contact, or use less detail in their explanations‖ (p. 227). Frank and Ekman's (1997) research suggest, however, that psychiatrists may improve their ability to detect deception with training in recognizing emotional rather than stereotypical signs usually associated with lying. As noted above, the detection of simulated PTSD based solely on the clinical interview is exceeding difficult. Frequently a definite verification of the life-threatening event and the direct presence of the patient at the exact time and place of the event in question cannot be obtained. Consequently, psychiatrists often rely on the patient’s self-report of events. Typical signs to look for in detecting deception are inconsistencies in a patient's behavior, factual errors in the chronology or events in the patient's military history, and reporting of symptoms that do not match the known constellation of symptoms associated with PTSD. In addition, malingerers may overstate symptoms of nightmares and flashbacks to impress the examiner. It is typical for a malingerer to report experiencing exactly the same dream repeatedly, which is rare in true cases of PTSD. The major problem with reliance on this method of detection is that it is common for malingerers to be well versed in the symptoms of PTSD, have predetermined examples of everyday behavioral manifestations of the disorder, and have researched knowledge of actual military events that would qualify as a traumatic stressor. Indeed, it is not uncommon for malingerers to arrive at a clinical interview with a planned deceptive narrative. The present author has discovered within the possession of a veteran who was undergoing a disability examination for combat-related PTSD, detailed printed notes that included all of the information necessary with which to simulate PTSD. In another case, the examiner had a revealing conversation with a claimant seeking a disability pension for combat-related PTSD. The patient, not acquainted with the present author, asked about his military service and the present author, having served in the U.S. Air Force, acknowledged being a military veteran. The disability claimant then asked, ―Do you know how I can find out about any combat operations just outside of Saigon? I tried looking it up at the library last night but could not find any. I need this [information] so I can have a stressor for my PTSD claim.‖ As is readily apparent from these compensation cases, reliance on the authenticity and completeness of the patient’s historical recall of pertinent information during the clinical interview can lead to diagnostic errors.

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Although it is also not unusual for an examinee to provide inaccurate statements during the clinical interview, the practitioner should not merely conclude that the patient is malingering. Military patients could communicate inaccurate information as the result of pathological processes (e.g., blast induced concussion, closed head injury, penetrating missile wounds, lack of sufficient quality sleep, etc.) or psychological factors (e.g., source monitoring errors, depression, easily suggestible, hindsight bias, acquiescence response bias). A patient with these conditions or predispositions should not be considered malingering based solely on their erroneous account of the purported traumatic event. In sum, information derived from clinical interview alone cannot reliably either negate or confirm malingering.

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LACK OF ADHERENCE TO, AND VERIFICATION OF, CRITERION A AND CRITERION F Diagnostic errors in the verification of a traumatic stressor among veterans are not uncommon (U.S. OIG, 2005). By definition, a diagnosis of PTSD requires exposure to an etiological event of traumatic nature, such as military combat. However, Burkett and Whitley’s (1998) book exposed numerous exservicemen who had not been in combat but who pretend to be traumatized combat veterans. Many of the malingerers identified by Burkett and Whitley were successful in simulating PTSD during psychiatric examinations for disability pensions by the VA. Frueh et al. (2005) reported that 59 of 94 Vietnam veterans diagnosed with combat-related PTSD at a specialized VA PTSD clinic had no objective evidence of ever being in combat. McGrath and Frueh (2002) state that fraudulent self-reports of combat experience among veterans are a frequent problem. To avoid diagnostic errors in differentiating persons with simulated PTSD from those with genuine PTSD, psychiatrists should augment thorough history-taking from the patient with corroborative data to support the patient’s self-report of the traumatic stressor. Confidence in meeting DSM-IV-TR Criterion A (1) can be weighed by utilizing the following hierarchical schema: High confidence—Verification of patient’s direct involvement in a life-threatening event; Moderately-high confidence—Verification of patient’s presence when event occurred (i.e., patient saw firsthand the event occur); Moderate confidence—Verification that the patient was informed of a family member or close comrade who was involved in a traumatic event of an extreme nature; Low confidence—Unable

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to verify presence of the patient when the event took place; Low confidence— unable to verify the occurrence of the stressor; Extremely low confidence— Patient not present when stressor occurred and was not informed of a family member or close comrade involved in traumatic event; Extremely low confidence—stressor did not occur. Another related problem regarding Criterion A (1) for diagnosticians is the expanding pathway by which one calls a traumatic stressor. McNally (2003a) noted that the conceptual classification of what constitutes fulfillment of PTSD Criterion A (1) has expanded beyond the specified standard delineated in the DSM-IV-TR (see also Rosen, 2004-2005). Gaughwin (2008) recommends that psychiatrists closely follow Criterion A (1) for PTSD to ensure ―that merely unpleasant events, irrespective of how subjectively upsetting they may be, do not qualify for the diagnosis of PTSD‖ (p. 109). In effect, a range of normal human emotions to a specific non-life threatening or non-physically perilous event does not constitute a psychiatric disorder. Perhaps the most overlooked criterion for a diagnosis of PTSD is Criterion F. Mental health practitioners often fail to note that in order to give a diagnosis of PTSD, the disorder has to be the primary causal factor of significant impairment in social and occupational functioning in the patient (e.g., Solomon & Horesh, 2007). Many individuals experience horrific traumatic events in their lives and have subsequently met one or more of the PTSD criteria B, C, D, and E but are still able to function reasonably well in social and occupational settings. Thus, if an individual has symptoms of PTSD that do not significantly interfere with social and occupational functioning, that individual would not meet the threshold specified in the DSM-IV-TR for the diagnosis of PTSD even though various symptoms of PTSD are present.

RELIANCE ON THE ACCURACY OF PATIENTS’ MEMORIES OF TRAUMATIC EVENTS Reliance on the historical accuracy of patients’ memories of traumatic events is problematic. Although patients are the main source of clinical data in psychiatric examinations for PTSD, physicians should note that memories of traumatic events are not immutable (Bremner, Shobe, & Kihlstrom, 2000; McNally, 2003b). Neural evidence (i.e., fMRI) suggests that realitymonitoring errors –mistaking an imagined event as a real event– can lead to false memories in patients who are otherwise responding honestly (Gonsalves

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et al., 2004). Furthermore, reconstruction of autobiographical memories is affected by the patient’s current clinical condition (Harvey & Bryant, 2000; Schwarz, Kowalski, & McNally, 1993; Southwick, Morgan, Nicolaou, & Charney, 1997). Southwick et al. (1997) found that historical data of observable traumatic events obtained from veterans of Operation Desert Storm within one month of being in war varied from their self-report regarding the same events at twoyears post. In sum, 88% of the veterans recalled the information differently at 2-years post and 70% reported traumatic events that they failed to mention when reporting their war experiences 2-years prior on the same objective questionnaire. In this latter group, an increase in reported traumatic events was associated with an increase in self-report of traumatic stress symptoms. The researchers note that inconsistencies in the recall of objective traumatic events ―raise doubts about the reliability of memory for combat‖ (p. 175). Accordingly, Armstrong and High (1999) caution practitioners that, ―There is no connection between the vividness and emotional impact of a trauma story and its truthfulness‖ (p. 47).

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FALSE BELIEFS REGARDING MILITARY PROTOCOLS AND PROCEDURES FOR DOCUMENTING COMBAT OPERATIONS Perceptions and stereotypical beliefs by the general public regarding military protocols and procedures for assigning personnel to combat missions and documenting those operations are often erroneous. This is also true for some physicians treating veterans in VA healthcare facilities. For example, Henderson (2002) stated that for military personnel involved in ―covert activities, the records are frequently falsified to conceal those activities‖ (p. 1328). This statement is not supported by the facts or proper military protocols and procedures for documenting military training, occupation, and duty assignments. While the military takes necessary steps to protect confidential information from disclosure to the enemy, it does not falsify documents regarding individual personnel records. Furthermore, consistent with and perhaps surpassing other large organizations, the U.S. Armed Forces maintain detailed records of personnel files and operational and institutional missions. For example, the Army documents and records activities at all levels–armies, corps, divisions, brigades, and battalions. At no time is an individual’s professional military

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training, duty assignments, and other personnel records classified. On the contrary, accurate records are necessary for the resourceful use of servicemen and women. Vietnam veteran Burkett’s 15-year extensive investigation of military personnel records did not reveal a single personnel record among the thousands reviewed that were falsified by the U.S. Government to conceal covert missions (Burkett & Frueh, 2002). Access to these declassified military records can be obtained through the National Military Personnel Records Center, 9700 Page Avenue, St. Louis, Missouri 63132-5100. Indeed, the U.S. Armed Forces have a long tradition of keeping military records regarding individual servicemen and women. On August 7, 1782 George Washington signed a general order establishing the nation's first military decoration:

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The name and regiment of the person with the action so certified are to be entered in the 'Book of Merit,' which will be kept at the orderly office. Should any who are not entitled to these honors have the insolence to assume the badges of them, they shall be severely punished.

FALSE BELIEFS REGARDING HOW MILITARY PERSONNEL ARE ASSIGNED JOB CLASSIFICATION AND SPECIAL OPERATIONS Mental health practitioners should view cautiously any discordance between a patient’s statement regarding their military job and combat activities and actual military records (i.e., personnel file or DD-214). The military does not entrust special operations and expensive equipment to carry out such missions without careful due diligence and accountability. Military commanders, under the Department of Defense, have a legal obligation under the oath of their commission to execute U.S. Code Title 10–Armed Forces directives, to include organizing, equipping, and training forces for the conduct of prompt and sustained combat operations (see http://www.army. mil/info/organization). Contrary to popular portrayals in some movies of a lack of military decorum and gross organizational negligence, in reality the U.S. Armed Forces is a highly structured organization that has over 200 years of experience in carrying out its mission effectively. This includes extensive research to determine what career field a military person is best suited for and is assigned to.

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There are 142 military career fields. The assignment to each of these military occupations is a multistep process that includes; (a) Application with pertinent background information, (b) Standard security clearance, (c) Physical examination and psychological screening, (d) Drug testing, (e) Armed Services Vocational Aptitude Battery (ASVAB) testing, (f) Basic military training school or officer candidate training, (g) Technical and professional training school(s), (h) Security clearance consistent with military occupation and duties, which may include a rigorous Single Scope Background Investigation (SSBI) and special adjudication process mandatory for a Top Secrete clearance involving Secret Compartmental Information (SCI), and (i) Further professional military training and security checks as warranted. Although military applicants can choose particular career fields, they must meet all of the minimum requirements for the chosen career and the decision on career placement is solely at the discretion of the military. Certain sensitive career fields cannot be chosen by a military applicant but must be selected by military commanders who are authorized to make such decisions. Even in these cases, the selected enlistee or officer candidate must meet all of the requirements for the military job and any additional training for special mission operations. Thinking in terms of how a major law firm conducts business, a first year law associate is not suddenly assigned to preside over a multi-million dollar corporate merger. Likewise, an enlisted soldier who has a confidential security clearance, lower quartile ASVAB score, and no specialized military reconnaissance training will not be assigned a military mission that requires an SCI security and completion of highly competitive specialized reconnaissance training requiring both exceptional physical and intellectual capabilities. Hence, when a patient claims they were a ―Navy Seal‖ assigned to a ―special covert mission‖ but official military records do not corroborate their selfreport, this is not consistent on any level with how the military operates. When such unsubstantiated and dubious claims occur during disability pension evaluations for combat-related PTSD, without a frank psychosis, one can only conclude the that statements are questionable and the clinical assessment of malingering is warranted.

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FALSE BELIEF THAT MILITARY RECORDS OF VIETNAM VETERANS WERE DESTROYED IN A FIRE

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Statements by Vietnam era veterans that the ―fire in St. Louis‖ destroyed their military records that would have verified their combat in Vietnam are false. Since only 15% of the servicemen in Vietnam were assigned to combat units (Dean, 1997, p. 209), some mendacious persons seeking life-time disability pensions from the VA for combat-related PTSD have justified a lack of documented combat exposure in their military records by claiming their ―real‖ records were destroyed by a fire. On July 12, 1973 a fire damaged the National Personnel Records Center (NPRC) at Overland, Missouri. Federal records of U.S. Army personnel discharged from the military from November 1, 1912 to January 1, 1960 and U.S. Air Force personnel discharged from September 25, 1947 to January 1, 1964 were affected (Stender & Walker, 1974). The first U.S. combat troops deployed to Vietnam began in 1965 and ended with the U.S. troop withdrawal in 1975. The fire at NPRC did not affect records of military personnel serving in combat in Vietnam. Furthermore, several Federal agencies working together reconstructed 94% of the damaged records (McNally, 2003a). Mental health practitioners have, however, fallen prey to this common myth regarding the destruction of military records of Vietnam era veterans.

RELIANCE ON PUBLISHED RESEARCH THAT IS BIASED, PROBLEMATIC, OR INCOMPLETE Choi and Pak (2005) identified 65 types of bias in health research, of which, selection bias is the most common type. Selection bias is a problem in studies published in peer-reviewed journals on combat-related PTSD (Frueh et al., 2005; Rosen, 1995; 2004). An essential variable in PTSD research, in terms of establishing legitimate population samples, is the identification and exclusion of persons who are simulating PTSD from being included in the authentic PTSD samples. If unrecognized or undetected, such inclusion seriously threatens the validity of PTSD databases (Rosen, 2006; Rosen & Frueh, 2007; Rosen & Taylor, 2007). In spite of these concerns, and the DSMIV (APA, 1992) and DSM-IV-TR's (APA, 2000) specific caution to rule out malingering, Rosen and Taylor’s (2007) examination of peer-reviewed studies published from 1980 to 2006 revealed that many researchers did not take

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practical steps to exclude persons who may be simulating PTSD. Vallverdu (2008) stated that peer-reviewed journal editors who ―control the communication channels‖ (p. 9) could also contribute to bias in published research. Another bias is expectancy bias. Although it is accepted as the best standard practice in medicine to conduct double-blind studies whenever possible, this has generally not taken place in assessment studies in PTSD research. Baldwin et al. (2004) state, ―we have been unable to locate a study that indicated that experimenters were blind to participants’ diagnostic status when performing intake assessments and preparing participants to experience the trauma-related stimuli‖ (p. 47). In PTSD investigations, often both the researchers and the participants know the diagnostic status of the participants prior to the study. This leads to expectancy effects and other biases (e.g., LaGuardia, Smith, Francois, & Bachman, 1983). Gerardi, Blanchard, and Kolb (1989) suggest that expectancy bias can even affect psychophysiological measures. If fact, the researchers found that participants without PTSD could sufficiency change their physiological responses to traumatic imagery to statistically match participants with a clinical diagnosis of PTSD. Essentially, practitioners should review with caution any studies in which the diagnosis of combat-related PTSD is based exclusively on the patients’ subjective complaints during clinical interview, structured interview, or on face-valid self-report measures of PTSD. Freeman et al. (2008) found that more than 50% of Vietnam veterans diagnosed with chronic PTSD had scores on symptom validity tests in the range consistent with persons who feign psychiatric symptoms. In another study, well over half of the Vietnam veterans diagnosed with combat-related PTSD at a specialized VA clinic for PTSD had no objective evidence in their military records of ever being in combat (Frueh et al. 2005). One plausible hypothesis is that the patients were fabricating symptoms of PTSD to either maintain disability pensions for combat-related PTSD, increase their disability rating, or to support a future disability claim for PTSD. For that reason, Charney et al. (1998) recommend that clinical trials should exclude patients that are receiving financial benefits for PTSD or who may seek such benefits in the future. As has been stated, PTSD is easily simulated and is a compensable disorder in disability pensions and civil litigation; therefore, researchers must exercise every precaution in distinguishing between patients with legitimate PTSD from those who may be simulating PTSD. The following safeguards should be considered in PTSD research; (a) use of multiple reliable sources to determine the authenticity of a diagnosis of PTSD, (b) inclusion of symptom

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validity tests to identify persons simulating PTSD, (c) strict adherence to Criterion A of direct exposure to an extreme (e.g., life-threatening) traumatic event, and (d) following the recommendation of APA’s Board of Scientific Affairs Task Force on Statistical Inference to be precise when naming a variable or describing cohorts used in a study (Wilkinson, 1999). On this latter point, Lees-Haley (2004) proposed that imprecise labels hinder empirical falsification of questionable findings. For example, one study identified participants as "bona fide PTSD claimants" when a more accurate description would be "self-reported claims of PTSD from compensation-seeking claimants" (Lees-Haley, 2004, p. 95). Another problematic issue is the reliance on studies that do not correct for measurement errors. When studies rely on psychological tests to assess PTSD, the sensitivity and specificity of the psychometric instruments should be considered in correcting for measurement errors. For example, the Presidential Advisory Committee on Gulf War Veterans' Illnesses (Lashof et al., 1996) determined that the prevalence rates of PTSD among military personnel who served in the Gulf War were 0% to 36% with a mean of 9%. This rate seemed arbitrarily high given that the coalition ground assault began on February 24, 1991 and ended 4-days later on February 28, 1991. When the data was reexamined based upon the sensitivity and specificity of the psychological tests utilized in the studies, the prevalence rates dropped to a range of 0% to 18% (0% in 18 of the 20 reported rates; Haley, 1997). According to Haley, "virtually all of the PTSD reported in Gulf War veterans was due to false positive errors of measurement and that the true prevalence rates of PTSD were near zero" (p. 699).

OVERCONFIDENCE IN PHYSIOLOGICAL OR MEDICAL NEUROIMAGING TEST RESULTS Physicians are apt to place more weight on data from physiological measures, biological markers, and neuroimaging scans relative to other sources of information about a patient (e.g., Kihlstrom, 2002; Warner, 1992). This may lead to diagnostic errors in some PTSD cases. Although increases in physiological reactions (e.g., heart rate, respiratory, sweat secretions) are cited as a ―valid index of reactivity to trauma-related memories or stimuli‖ in military veterans purporting symptoms of PTSD (Schlenger, Jordan, Caddell, Ebert, & Fairbank, 2004, p. 244), the seemingly logical inference that

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physiological reactivity is—as a matter of fact—evidence of PTSD is not so unequivocal. McNally et al. (2004) demonstrated that physiological measures of reactivity to audio-taped descriptions of combat-related trauma purported by military veterans claiming PTSD were remarkably similar to persons tested under similar conditions who claimed to have been abducted by space aliens. As noted earlier in this paper, Gerardi et al. (1989) found no significant difference in psychophysiological measures between veterans diagnosed PTSD and participants instructed to feign PTSD. For this reason, McNally and colleagues caution that physiological reactivity ―cannot be taken as evidence of the memories authenticity‖ (McNally et al., 2004, p. 496). Biological markers for PTSD, other physiological tests, and neuroimaging studies are also inconclusive. The Institute of Medicine (IOM) of the National Academy of Sciences (2006) reviewed existing data on the efficacy of biological markers in the diagnosis and assessment of PTSD. The IOM report noted variable and, by inference, inconclusive results to support genetic predispositions utilizing serotonin (5-HTT) and dopamine (DRD2, DAT). The IOM further reported ―hypothalamic pituitary adrenal (HPA) axis and brain imaging abnormalities appear contradictory and not necessarily specific to PTSD‖ (North, Suris, Davis, & Smith, 2009, p. 35). One study found a potential vulnerability to PTSD but not a diagnostic marker of PTSD. Specifically, smaller hippocampi has been noted in some persons who report being exposed to trauma but it is not evidence that the purported trauma is the causal factor in lower hippocampal volume. In a study of monozygotic twins, in which one twin had PTSD from combat in Vietnam and the other twin had not served in combat nor had any history or diagnosis of PTSD, there was no difference in hippocampal volume between individual sets of monozygotic twins (Gilbertson et al., 2002). Furthermore, the same data revealed that severity for PTSD symptoms in the twin with combat trauma was negatively correlated with hippocampal volume but instead closely matched the hippocampal volume of their non-exposed twin (Gilbertson et al., 2002). Hence, smaller hippocampal volume cannot be taken as evidence of PTSD but may suggest a specific vulnerability to developing symptoms of PTSD. Although further research is needed to advance our understanding of the physiological and genetic markers of PTSD, there are four medical tests that physicians should consider when assessing PTSD. First, in view of the high comorbidity of substance-related disorders and PTSD, drug screenings are advisable. Second, sleep studies may be warranted in patients presenting with both symptoms of PTSD and poor quality sleep (e.g., restlessness, insomnia,

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excessive daytime sleepiness, loud snoring, and autonomic hyperactivity). Third, research suggests that elevated levels of serum total and free triiodothyronine (T3) with no elevations of free thyroxine (T4) and thyrotropin (TSH) are found in patients with combat-related PTSD (Wang & Mason, 1999). Thus, laboratory tests for hormones may be indicated given the relationship between traumatic stress and thyroid function. Fourth, the frequent use of improvised explosive devices (IED) by the enemy has led to an increase in military patients with complaints of psychological symptoms and cognitive dysfunction. Hence, computed tomography (CT) and magnetic resonance imaging (MRI) scans along with neuropsychological testing can aid in an accurate diagnosis of CNS dysfunction resulting from physical trauma to the brain.

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USE OF FACE-VALID SELF REPORT MEASURES OF PTSD The process by which physicians make a diagnosis is similar to that of mental heath practitioners. That is, physicians typically conduct a clinical examination, take the patient’s health history, and utilize objective medical tests to assess pathology. Likewise, mental health practitioners approach the diagnostic process in much the same way, namely conducting a clinical examination, taking the patient’s history, and employing the use of objective psychometric tests to assess psychopathology. Just as certain medical tests vary in their diagnostic accuracy and may not be suitable for all patients, so to, the sensitivity and specificity of psychological tests are diminished in various settings with particular patients. Many of the psychological tests developed to measure the emotional impact of traumatic stress are face-valid self-report measures, such as the Impact of Event Scale (IES; Horowitz, Winler, & Alvarez, 1979), PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993), and Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1994). Subsequent studies revealed that face-valid self-report measures are ineffective in distinguishing between persons with genuine PTSD from persons who simulated PTSD (Burges & McMillian, 2001; King & Sullivan, 2009; Lees-Haley, 1990; Lees-Haley, Price, Williams, & Betz, 2001; McGuire, 2002; Sullivan & King, in press). Studies indicate that, on average, 90% of naïve persons instructed to simulate PTSD without the benefit of coaching or specific knowledge of the DSM criteria scored in the positive

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diagnostic range for the disorder on face-valid self-report measures (Burges & McMillan, 2001; Lees-Haley & Dunn, 1994; Slovenko, 1994). Furthermore, the utilization of Maercker and Schützwohl’s (1998) regression-based formula to data from face-valid self-report measures yielded poor results in detecting false claims of PTSD (Merten & Lorenz, 2009). Face-valid self-report tests specifically developed to assess combat-related PTSD are also ineffectual in distinguishing legitimate PTSD and simulated PTSD. For example, the Mississippi Scale for Combat-Related PTSD (Keane, Caddell, & Taylor, 1988) is a test that is recommended by the VA "for inclusion in disability evaluations for PTSD" (Watson et al., 2002, p. 20), however, it is particularly vulnerable to false positives in persons who simulate PTSD symptoms. In fact, several studies have provided empirical evidence that the Mississippi Scale for Combat-Related PTSD cannot distinguish between persons with genuine PTSD and persons who simulated PTSD (Calhoun, Earnst, Tucker, Kirby, & Beckham, 2000; Dalton, Tom, Rosenblum, Garte, & Aubuchon, 1989; Frueh & Kinder, 1994; Lyons, Caddell, Pittman, Rawis, & Perrin, 1994; Marcario, & Perconte, 2005; Morel, 2008a). Moreover, the raw test items of this psychological instrument can be viewed by anyone with access to the Internet (http://www.istss.org/sigs/ documents/MississippiScale. pdf), a serious breach of test security (Morel, 2008b; 2009).

FAILURE TO ACKNOWLEDGE OR IDENTIFY INVALID TEST PERFORMANCE A failure by mental health practitioners to acknowledge or identify invalid test performance subverts two fundamental purposes of objective psychological testing when secondary gain is a factor; (a) accurately identifying true psychopathology (Morel, 1996b) and, (b) differentiating persons with genuine mental disorders from persons simulating mental disorders. Retrospective analyses by Arbisi, Murdoch, Fortier, and McNulty (2004) and Morel (1996a) of 813 VA Compensation and Pension disability claims for PTSD (n = 699 and 114, respectively) revealed that these two fundamental principles were not followed. Both studies found no difference in awards of lifetime disability pensions for combat-related PTSD between credible disability claimants and disability claimants with objective evidence of negative response bias (i.e., simulated PTSD) on the MMPI-2.

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More revealing was the fact that the no mention was made in the psychological reports that the questionable claimants had failed one or more symptom validity measures on the MMPI-2. This occurred even when the diagnostician utilized other aspects of the invalid MMPI-2 profile to support a diagnosis of PTSD. Conversely, the diagnosticians were much more apt to report when a claimant’s response style was valid. Ignoring symptom validity data that suggests the patient is simulating a psychiatric disorder could be warranted in particular cases of extremely low intellectual abilities (Hurley & Deal, 2006) or active psychosis but this should be a rarity rather than standard practice.

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REALISTIC PROFESSIONAL AND INTRINSIC NEEDS OF PHYSICIAN When malingering is suspected, physicians may be reluctant to diagnose malingering because they believe it would interfere with the doctor-patient relationship (Binder, 2007). Psychiatrists value the doctor-patient relationship as necessary to make an accurate diagnosis, to enhance patient compliance with the treatment plan, and in some cases therapeutic in and of itself. Other physician concerns are the potential for legal liability for slander and/or a physical or verbal confrontation with the patient. These are all legitimate issues that have to be dealt with. A review of Shomaker and Ashburn (2000a; 2000b) may be helpful to psychiatrists with these concerns.

ALTRUISM Medical professionals are primarily entrusted to promote the wellbeing of their patients. The altruistic nature of the profession can lead to both overt and covert diagnostic bias against malingering or non-compensable mental disorders and in favor of PTSD. During a clinical examination for a disability pension for combat-related PTSD the psychiatrist may learn that the claimant has limited income and resources (e.g., poor education, limited vocational skills, etc.). In some instances the psychiatrist may interpret their fiduciary responsibility as that of helping the patient acquire the necessary financial resources. It has been the present author’s experience on more than a few occasions to hear a mental health professional state, following a disability

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examination, ―I gave the patient a diagnosis of PTSD because he really needs the money.‖ While such motives are admirable, they can nevertheless interfere with the purpose of the diagnostic examination; which is to make a sound medical opinion on the patient’s genuine mental health. To help patients with limited financial resources, referral to a vocational specialist and or social services is a more appropriate practice than a pseudo-diagnosis. Medical professionals should not lose sight of the fact that work and self-reliance are powerful healers too and can have a positive impact on patients and their families.

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RESTRICTED CLINICAL EXPERIENCE AND CONFIRMATORY BIASES From a practical perspective, physicians rely on clinical experience in formulating diagnostic decisions. Medical expertise is thus related to how broad or narrow the range of clinical experience is. In military medicine the physician may be confronted with the daily casualties of war. While this provides the physician with experience in treating traumas, it may also create subtle predispositions. This can take the form of reliance on idiosyncratic beliefs, confirmatory bias, inadequate consideration of alternative diagnoses, and failure to assess the extent of actual impaired functioning necessary to fulfill criterion F for PTSD (Koch, 2001; see also Tversky & Kahneman, 1973). According to Van Atta (1999), the psychiatric diagnosis of PTSD is often the due to practitioners’ assumption that combat-exposure automatically results in PTSD. Consider the following hypothetical scenario. The majority of a military psychiatrist’s caseload is related to stress reactions to war (i.e., limited range of clinical experience). The psychiatrist begins to form the clinical impression that PTSD is the inevitable consequence of war (i.e., reliance on idiosyncratic belief). With this belief, and limited time in seeing a large volume of patients—many of whom are referred with a provisional diagnosis of PTSD, the psychiatrist focuses his or her questions during the clinical examination to assess symptoms of PTSD (i.e., confirmatory bias). Since other diagnostic alternatives were not assessed, the data acquired only pertains to PTSD (i.e., failure to consider alternative diagnoses). Finally, assuming that positive symptoms of PTSD are disabling, the psychiatrist does not formally determine whether or not the patient has symptoms that cause ―clinically significant

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distress or impairment in social, occupational, or other important areas of functioning‖ (APA, 2000, p. 468) as specified by the DSM-IV-TR (i.e., failure to critically assess criterion F necessary for PTSD).

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NONCRITICAL ACCEPTANCE OF PREVIOUS DIAGNOSIS Achenbach (1995) stated, "the term diagnosis has acquired an aura of clinical authority" (p. 269). When a patient's medical records cite a diagnosis of PTSD, physicians as well as other healthcare providers will generally accept the diagnosis as accurate. Often there is a reluctance to change the provisional diagnosis, even when there is compelling evidence to do so. This can perpetuate a diagnosis that has changed over time or was inaccurate to start with (see Rosen, 1995). Indeed, mendacious persons who simulate PTSD rarely have their diagnosis challenged in certain medical settings. For example, the Inspector General for the VA Healthcare System reported several instances of persons simulating PTSD that, apparently, were not detected or reported by healthcare practitioners examining or treating the malingerers (U.S. OIG, 2007). In some cases there may be institutional or professional pressure to maintain a questionable diagnosis of PTSD. In one case, a well-known PTSD researcher within the VA Healthcare System referred a veteran of the Vietnam War with a diagnosis of combat-related PTSD for a Compensation and Pension examination. When it was subsequently pointed out that the particular disability-seeking claimant in question was never in Vietnam, had not seen any combat, and, in fact, was removed from military service for gross insubordination within hours of arriving for his first day of basic training, the response from the referring source was, "When I say someone has PTSD, they have PTSD." Obviously, objective science and diagnostic accuracy should take precedent over research objectives and political considerations. In best practice, constructive clinical acumen utilizing hypothetical-deductive reasoning in evidence-based medicine should be weighed when either accepting or rejecting a provisional diagnosis of PTSD (see Bergman, 2009).

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FAILURE TO CONSIDER ALTERNATIVE DIAGNOSES THAT MAY RESULT FROM TRAUMA A principal hindrance in clinical decision-making is considering all the alternative diagnostic possibilities in a particular patient (Baue, 1977). Disproportionate exposure to PTSD literature relative to other mental disorders can result in diagnostic bias. There are numerous pamphlets, journal articles, books, conference presentations, Internet sites, and training seminars on the topic of PTSD. The VA Healthcare System, in particular, designates enormous resources directly for PTSD. Conversely, the amount of emphasis and information on other mental disorders that may be related to trauma is relatively diminutive in comparison (Davidson, 1993). Given this fact, practitioners are more likely to overestimate the risk of PTSD associated with an exposure to trauma and to underestimate the risk of other mental disorders associated with trauma or which have some overlapping symptoms of PTSD. Table 2 lists several DSM-IV-TR disorders associated with trauma or which have behavioral features similar to patients with PTSD.

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Table 2. Additional Differential Disorders to Rule Out before Diagnosing PTSD Condition

Trauma related behavioral features

Acute Stress Disorder

Similar signs of PTSD but lasting not more than 1 month

Adjustment Disorder

Psychological response to stressor

Agoraphobia

Avoidance

Borderline Personality Disorder

Hypersensitivity to environmental circumstances

Delirium

Paranoia, irritability

Dissociative Disorders

Emotional numbing, feeling detached

Generalized Anxiety Disorder

Hyper arousal

Major Depressive Episode following trauma Withdrawal, emotional numbing, avoidance of trauma Manic Episodes with irritable mood

Hyper arousal, irritability, non-compliance

Nightmare Disorder

Recurrent terrifying dreams of danger that provoke anxiety

Obsessive Compulsive Disorder

Recurrent intrusive thoughts

Panic Disorder

Panic associated with trauma

Sleep Terror Disorder

Nightmares, intense fear

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Problematic Issues in Assessing Malingered PTSD Specific Phobia

Avoidance

Substance Induced Disorder

Interpersonal problems

37

Note. Careful attention to current diagnostic criteria (e.g., DSM-IV-TR) should be utilized to assist the clinician in differentiating between these disorders.

DIFFERENTIAL DIAGNOSES: SEPARATING MALINGERING FROM FACTITIOUS AND SOMATOFORM DISORDERS

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Reliance on the most commonly recognized criterion for diagnosing malingering—false or grossly exaggerated physical or psychological symptoms—could lead to diagnostic errors. Practitioners may not always give careful attention to ruling out other possible differential diagnoses when a patient presents with false or grossly exaggerated physical or psychological symptoms. The general algorithm for differential diagnoses in the DSM-IV-TR is simple; (a) the motivation of malingerers is external incentives as opposed to internal incentives for persons with Factitious Disorder, and (b) malingerers intentionally produce (fabricate) their symptoms and persons with Somatoform Disorders such as Conversion Disorder do not consciously simulate symptoms. The simplicity of the DSM-IV-TR’s differential diagnosis for malingering, however, is deceptive in psychiatric examinations for PTSD. Table 3. Differential Disorders to Rule Out before Diagnosing Malingering Condition

Intentional Feigning

Incentive

Conversion Disorder

No

None. Symptoms preceded by stressors.

Dementia with frontal lobe dysfunction

No

None

Factitious Disorder

Yes

Assume sick role

Hypochondriasis

No

None

Munchausen syndrome by proxy

Yes

Attention of medical staff

Pain associated with psychological factors

No

No conscious incentive

Somatization Disorder

No

None

True medical or psychiatric illness related to presenting complaints*

No

Relief of suffering

Note: *Patients with genuine medical or psychiatric disorders can exaggerate the extent of social or occupational impairment or severity of symptoms for secondary gain.

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The complexity in determining a patient’s motivation and the intentionality of their presenting symptoms cannot be overemphasized, especially during PTSD examinations. The clinical presentation of patients with Factitious Disorder may be quite similar to malingerers. A patient can intentionally feign or exaggerate symptoms of PTSD to either assume the sick role (Factitious Disorder) or to seek medical documentation to support a planned future application for a disability claim for PTSD (malingering). Another complication in differential diagnoses is that somatic complaints in the absence of positive laboratory findings have been noted both in military veterans with PTSD (Shalev, Bleich, & Ursano, 1990) and in patients with Somatoform Disorders. Table 3 lists DSM-IV-TR differential disorders to consider when formulating a clinical opinion of malingering.

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MISUNDERSTANDING OF HOW MALINGERING IS INFERRED The clinical picture of how malingering is inferred by mental health practitioners is a frequent problem. Four general errors are common; failing to identify an external incentive, use of one validity indicator in isolation, misinterpreting atypical symptom endorsement, and misunderstanding how to deduce intent. First, a positive score on a test of negative response bias in the absence of an external incentive is insufficient evidence for a clinical opinion of malingering. Second, the assessment of malingering should incorporate multiple sources of evidence rather than relying solely on one indicator. Third, a positive score on a measure of negative response bias is seldom found in patients with genuine mental disorders who are responding honestly, but this does not mean that it is never found in legitimate patients. Fourth, intent is best inferred from a combination of multiple, highly improbable events that are quite atypical in patients with legitimate mental disorders but are found in persons who are known to be malingering. This is discussed later in this book.

BINARY CLASSIFICATION OF NON-EXCLUSIONARY DATA An erroneous assumption by some healthcare practitioners is that patients with real medical and/or psychiatric symptoms do not malinger. Similarly, a

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person who is malingering is not by default free of medical or psychiatric problems. In reality, malingering and genuine medical or psychiatric conditions are not mutually exclusive. Iverson (2006) stated ―It would be extraordinarily naïve‖ to assume patients presenting with genuine psychiatric disorders or objectively verified brain injuries could not malinger (p. 78). Malingering is, by definition, a goal directed behavior that patients with mental disorders as well as healthy persons can engage in. Studies reveal that even patients with well-documented medical evidence of physical pathology (e.g., traumatic brain injuries) can and do malinger (Bianchini, Greve, & Love, 2003; Greve, Bianchini, & Ameduri, 2003; Iverson, 2003). In fact, a patient with somatization disorder can also malinger (Ben-Porath, Greve, Bianchini, & Kaufmann, 2009). A related false assumption is that a patient who has symptoms associated with PTSD cannot or does not malinger. In reality, a patient with genuine symptoms that is not significantly interfering with social or occupational functioning could willfully and rationally produce a false impression of disability for secondary gain (Morel, 1998). According to the DSM-IV-TR, deliberate exaggeration of psychological symptoms for secondary gain raises the suspicion of malingering. In one court case the reason for rejection of a claim for psychological injuries (i.e., PTSD) was the result of ―a very considerable degree of exaggeration in her [the claimant’s] account of her disabilities‖ (Ormsby vs. Chief Constable Strathclyde Police [2008] CSOH 143, a decision of Lord Malcolm issued 10 October 2008). Nevertheless, an interdisciplinary task force of physicians and neuropsychologists stated that treating healthcare providers seldom consider that a patient is malingering, even when secondary gain incentives are evident (Aronoff et al., 2007).

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PART II. STATISTICAL METHODS AND PSYCHOMETRIC TESTS TO DETECT MALINGERING

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Chapter 3

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RATIONALE AND STATISTICAL METHODS TO DETECT SIMULATED PTSD The preceding chapter discussed the challenges in military psychiatry of differentiating persons who simulate PTSD from those who do not. Although diagnostic certitude can rarely be achieved in psychiatric medicine, confidence in the reliability of a clinical opinion can be increased. The best practice is to use a multimodal approach to acquire convergent evidence to support a psychiatric diagnosis for a patient as follows: (a) review of medical, educational, vocational, judicial, and military records, (b) behavioral observations before, during, and after the examination, (c) clinical interview (open-ended and structured), (d) collateral interviews, (e) psychological test data, including symptom validity testing, and (f) professional consultation, especially with practitioners who have forensic experience. In the shift to evidence-based practices in behavioral medicine, psychological testing is a fundamental and objective means of providing a scientific basis for clinical decisions. It is not surprising, therefore, that psychological testing to assess the veracity of a patient’s presentation of symptoms comprise a major and indispensable part of the diagnostic process in assessing malingering. Since the diagnosis of PTSD relies heavily on the veracity and historical accuracy of a patient’s subjective self-report, Van Atta (1999) states, ―it is prudent to compare diagnostic impressions to results of psychological testing‖ (p. 20). A basic knowledge of statistical methodology underlying the inferences that one can make regarding the efficacy of symptom validity tests (i.e., psychometric tests to assess simulated impairment) are necessary, however. This is central in evaluating the diagnostic weight a practitioner can place on the data derived

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from testing, particularly since clinical decisions can easily become forensic evidence. In the present chapter, a brief overview of the main types of study designs to assess malingering is presented. The remaining discussion covers statistical procedures that can be applied in the detection of malingering. It is hoped this chapter will represent a step forward in the reasoned application of advanced statistical methods that is essential to the detection of deception. Having a basic understanding of statistical methods to detect malingering can also be beneficial in reviewing published research (see IV.A.6.c. Statistics in the International Committee of Medical Journal Editors’ Uniform Requirements for Manuscripts Submitted to Biomedical Journals at http://www.icmje.org).

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DIFFERENCES BETWEEN ANALOG AND KNOWN-GROUPS DESIGN IN DETECTING DECEPTION Most of the studies that have assessed the efficacy of psychometric instruments to differentiate patients who give a legitimate effort on testing from those who feign symptoms have utilized an analog design (i.e., simulation design). Typically, analog studies compare honest response styles of clinical samples or non-clinical participants to that of naïve or coached participants instructed to respond as if they had PTSD. Extremely poor performance on a psychometric test of negative response bias in comparison to simulated malingerers, provides evidence that the patient’s presentation of symptoms is likely not accurate. The reported sensitivity and specificity attributable to analog studies may not generalize to actual malingerers, however. In essence, since analog studies frequently use undergraduate university students or mental health professionals to simulate a mental disorder, the findings may not adequately generalize to other specific populations. There are two main factors that could confound the results of analog studies. First, analog studies lack comparable secondary gain incentives. For example, a 23-year-old married veteran with children would receive over $2,000,000 dollars in disability benefits over the course of an average life expectancy if rated by the VA as 100% disabled from combat-related PTSD. Additional monies can be acquired from Social Security disability payments for PTSD. Second, although a test score similar to the norm reference (i.e., simulated malingerers) has been used to substantiate the clinical opinion of

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malingering, it is potentially problematic with specific patient populations. For example, patients with a dementia or extremely low IQ may produce atypically poor performance on symptom validity tests (Hurley & Deal, 2006), and analog studies may not have adequately controlled for these potentially mediating variables. Thus, findings from analog studies may well be considered as provisional evidence when diagnostic decisions are made. In cases where results from analog studies may not be sufficient to enable comparisons to specific populations, other research methods must be considered. Studies using known-groups samples may provide significant improvement over analog studies but only if the criteria to identify suspected malingerers utilize multiple indicators (e.g., discrepancies in self-report and documented records, symptom validity measures, endorsement of non-credible symptoms, etc.) of negative response bias (i.e., simulated impairment). The use of multiple indicators to identify suspected malingerers in known-groups studies is necessary because of the "methodological problems inherent in identifying a subject group that is, by definition, intent on escaping detection" (McClain, 2003, p. 24).

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STATISTICAL METHODS TO AUGMENT THE USE OF PSYCHOMETRIC TESTS Symptom validity tests provide clinicians with empirical data to differentiate simulated PTSD from genuine PTSD but how that data is interpreted relies, in part, on the mathematical functions of various statistical methods. It is important, therefore, that physicians who utilize data derived from psychological testing referrals have at least a basic understanding of statistical methods and their usefulness in describing such data and what types of conclusions can be reasonably drawn from particular statistical methods. Obviously it would be advantageous if there were total agreement in the scientific literature on the validity of various statistical methods and their inferences. Unfortunately, that is not the case. Therefore, the present discussion will focus on statistical methods that have particular application in differentiating persons who simulate impairment from those who do not. It should be noted that these statistical methods are not necessarily mathematically independent of each other and, additionally, methods from one statistical approach can augment the efficacy of another statistical technique (e.g., Tang, Sindler, & Shirven, 1987).

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The underlying principle of utilizing particular statistical methods in psychometric testing is to present data in a format that allows the clinician to make informed diagnostic decisions. Statistical methods to quantify psychological phenomena is a tool that clinicians use to confirm or deny hypothesis formulated during clinical interview, to augment other sources of information gathered about the patient, and to make weighty deductions based on clinical experience. It should be noted that although the mathematics behind it may be computationally accurate, no statistical method is perfect. It necessitates ample common sense and scientific aptitude to determine when even the best statistics have led to a valid diagnostic answer. McFall and Treat (1999) stated, ―Beneath every clinical application of a valid psychological test lies an extensive foundation of scientific theory, empirical research, and quantitative modeling‖ (p. 215).

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Sensitivity and Specificity It would be a serious error if physicians believe that psychological tests are 100% diagnostically accurate or that a particular score derived from testing is an absolute indication of a patient’s ability. Therefore, one purpose of statistics is to quantify the degree of confidence in test results. In medical diagnostics, the terms sensitivity and specificity are commonly used to describe the accuracy of test data, expressed as a range from 0 to 1. Sensitivity refers to the proportion of true positives of the total number of patients with the target disorder (e.g., simulated PTSD). Specificity refers to the proportion of true negatives identified from all the patients without the target disorder (e.g., not simulating PTSD). Figure 1 illustrates the general logic for deriving sensitivity and specificity in a contingency table to detect simulated PTSD. The basic formula for calculating sensitivity and specificity are as follows: Sensitivity = TP/(TP+FN) Specificity = TN/(FP+TN) Where TP = true positives, FN = false negatives, TN = true negatives, and FP = false positives. Errors in diagnostic accuracy in this model are termed as Type 1 (αerrors, false positive) and Type II (ß errors, false negative) errors. 1 – Specificity = Type I (α) error = FP/(FP+TN) 1 – Sensitivity = Type II (ß) error = FN/(TP+FN)

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If a patient’s score is negative on a test with very high sensitivity, then it lends support that the patient is legitimate (i.e., not simulating symptoms). Conversely, if a patient has a positive score on a test with very high specificity, then it suggests the patient is simulating symptoms (i.e., malingering when external secondary gain is the motive). Although sensitivity and specificity are often stated in medical science to describe the diagnostic value of a given test, they may not be as informative as other methods that build on these statistical principles.

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Figure 1. Contingency table illustrating sample of predictions of simulated PTSD model logic for deriving sensitivity, specificity, positive predictive value, and negative predictive value.

Positive Predictive Value and Negative Predictive Value In military medicine it is particularly important for psychiatrists to determine the probability that a patient with a positive result on a test to detect simulated PTSD is being correctly diagnosed. This can be accomplished, in part, by determining the positive predictive value (PPV). Thinking in terms of the post-test probability of potential malingered PTSD, the PPV is the proportion of patients with positive test results who are correctly diagnosed as simulating PTSD. The negative predictive value (NPV) refers to the probability that the patient’s presentation is legitimate (i.e., not simulating PTSD) when the test is negative. As can be seen from the Figure 1, PPV and NPV is a statistical extension of data used to calculate sensitivity and specificity. The basic formula for calculating PPV and NPV are as follows: PPV = TP/(TP+FP) NPV = TN/(TN+FN)

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PPV = SensitivityPrevalence/(TP+FP) It may be hard to estimate the PPV when the prevalence of simulated PTSD in a population is unknown or not well represented in the original normative sample for a given psychological test. However, even a test with high sensitivity and specificity may be of little value if the prevalence of simulated PTSD is low.

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Likelihood Ratios Likelihood ratios (LR) are a powerful statistical alternative to using sensitivity and specificity or PPV to describe the diagnostic properties of a psychological test (Deeks & Altman, 2004). In assessing potential malingering, likelihood ratios are the ratio of the probability of a particular test result in patients who are simulating PTSD to the probability in patients who are legitimate (i.e., not simulating symptoms of PTSD). In actual clinical practice, the prevalence of malingering in a military setting is likely to change based on numerous factors, such as an increase in intense prolonged combat engagements, age, gender, education level, financial incentives, etc. These dynamic factors contribute to diagnostic uncertainty in clinical practice. Moayyeri and Soltani (2004) point out that likelihood ratios provide a statistical method that is not bound to a predefined threshold of the prevalence of a disorder (e.g., simulated PTSD). Likelihood ratios, as a statistical tool in detecting deception, integrate both the sensitivity and specificity of a test and provide a direct estimate of how much a test result will change the odds of simulating impairment. If an examinee's test results show a likelihood ratio greater then 1, then the examinee is more likely a malingerer than a non-malingerer. The farther the likelihood ratio is from 1, the stronger the evidence of malingering. In other words, the likelihood ratio not only tells you that the person is simulating impairment on the test, but how much more likely it is that this person is a malingerer than that he or she is in fact not a malingerer. In contrast, if an examinee's test results show a likelihood ratio less than 1, there is evidence suggesting that the person is not simulating impairment; the farther below 1, the smaller the odds of simulating impairment. One formula to conceptualize calculating the positive and negative likelihood ratios are as follows:

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LR+ = sensitivity / (1 - specificity) LR- = (1 - sensitivity) / specificity The post-test odds are calculated by multiplying the pre-test odds by the likelihood ratio as follows:

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oddspost = oddspre X likelihood ratio As can be seen from the formulae above, the pre-test odds (i.e., the likelihood of a positive or negative test) utilize information about the sensitivity and specificity of a diagnostic test. The drawback with using likelihood ratios is in deriving the information for calculating the pre-test odds. This involves, in part, knowing the prevalence of simulating impairment in a population (i.e., the probability (p) of malingering). Statistical analysis of test data from samples of suspected malingerers sometimes reveal a large standard deviation (SD) around the mean (M), however. This suggests that there may not be a constant p for all malingerers (Morel & Shepherd, 2008a). Another caveat of using likelihood ratios, as opposed to merely using statistical output in the form of sensitivity and specificity, is the experience of the physician in making use of the data to formulate diagnostic interpretations. Puhan, Steurer, Bachmann, and Ter Riet (2005) found that the use of likelihood ratios did not enhance physicians’ diagnostic accuracy above that of using sensitivity and specificity.

Receiver Operating Characteristic Curve Another statistical tool to detect malingering is based on signal detection theory. Signal detection theory was originally developed to optimize the difference between a signal and background noise in radar transmissions during WWII (Pierce, 1980). A graphical representation of signal detection theory utilized in medical decision making to assess the efficacy of a diagnostic test is the receiver operating characteristic (ROC; also called the relative operating characteristic or isosensitivity curve; Macmillan & Creelman, 2005). The advantage of an ROC curve is that it permits researchers to determine the optimum cutting score on psychometric tests and display the information in a figure (see Figure 2).

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Figure 2. Receiver Operating Characteristic curve (ROC) showing a hypothetical symptom validity test’s cutting score (represented by double circles) to balance true positive (sensitivity) versus false positives (1 – specificity) in a binary classifier system (see Swets, 1996).

The ROC curve incorporates both the sensitivity and specificity of a diagnostic test. In simplistic terms, the ROC curve is a visual plot comparing the fraction of true positives (i.e., simulated PTSD) verses the fraction of false positives or Type 1 error (α) (i.e., genuine presentation misdiagnosed as simulating PTSD). The area under the curve (AUC) can be stated in a single number from 0.5 (no predictive value) to positive 1 (perfect predictive value). The advantage of the ROC curve analysis is that it allows one to increase either the sensitivity or specificity of a diagnostic test by modifying the cutting score of the test. It should be noted, however, that if one were to lower the cutting score for a positive score on a test to detect simulated PTSD it would increase the sensitivity of the measure but reduce its specificity. Conversely,

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raising the cutting score would lower the sensitivity of the test and increase its specificity. A useful way of conceptualizing a ROC curve is to visualize distinct distributions of test scores from two separate groups on a test to detect simulated PTSD (see Figure 3). One distribution represents the scores of patients who are simulating PTSD. The other distribution represents the scores of patients who are genuine (i.e., not simulating PTSD). The area of overlap between the two bell curves represents false positives (i.e., genuine patients who had a positive test scores) and false negatives (i.e., mendacious patients whose test score was negative). A test with high sensitivity and high specificity would have very little overlap between the two bell curves. This would be graphically shown in a ROC curve by a curved line well above the straight diagonal line between the lower left side of the figure and the upper right side. Conversely, a test with low sensitivity and low specificity would have a large overlap between the two distributions of test scores. In a ROC curve this would appear as a curved line very close to the diagonal line, which signifies that the test has poor diagnostic ability to distinguish between patients who simulate impairment and those who do not. As noted in the previous paragraph, changing the cutting score for a positive test will either increase or decrease the sensitivity and specificity of the measure.

Figure 3. Hypothetical distributions of test scores from two independent samples, persons simulating PTSD and persons not simulating PTSD.

There are three main limitations in using signal detection theory. First, researchers need to consider the ecological validity of the specified cutoff score of the test. That is, the optimum cutting score for one patient population

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may not necessarily be the best criterion for a different patient population. Second, the optimal cutting score that balances true positive (sensitivity) versus false positives (1 – specificity) may not be ideal depending on the goal of the clinician using the test. For example, in a military setting a clinician may want to reduce false positives, especially considering that malingering is punishable under the UCMJ. Conversely, in determining whether a military veteran is assigned to limited space available individual psychotherapy for PTSD versus group therapy that has many more openings for inclusion, the clinician may want to maximize true positives. This would reserve slots in costly individual psychotherapy for genuine patients, and also allow for pseudo patients to be uncovered in group therapy where their deception may come to light. Third, signal detection theory relies on the quality of the criterion measure. That is, the test being evaluated should be as free from measurement error as possible. Another limitation is that ROC curves are composed of sensitivity and specificity, which may not be as relevant as the PPV and NPV, which can only be computed from the ROC curve if the prevalence of malingering is known.

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Binomial Distribution The binomial distribution, known as early as the 3rd century BC (Bag, 1966), is an effective statistical tool that can be applied in the detection of negative response bias (i.e., simulated impairment). When a symptom validity test utilizes a two-alternative forced-choice paradigm, statistical probabilities of the chance of an examinee choosing to answer the question in a given way can be calculated and compared to normative samples of various clinical patient populations and persons suspected of simulating psychopathology. A symptom validity test needs to have four underlying characteristics for a binomial analysis; (1) the symptom validity test includes several trials, (2) each trial has only two possible outcomes, correct (i.e., success) or incorrect (i.e., failure), (3) the probability that a particular outcome will occur on any given trial is constant, and (4) all of the trials in the symptom validity test are independent of all other trials, meaning that performance on one trial is not dependent on performance of any other trial. When a symptom validity test has the characteristics listed above, the theoretical probability of obtaining a particular score on the test can be derived from the binomial distribution. The basic rationale is as follows. When each individual test item on a symptom validity test is independent of all other test

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items, they are referred to Bernoulli trials. The binomial probability formula for calculating the probabilities for n Bernoulli trials is: Pr(k successes in n trials) = (n!/((k!)(n - k)!))pkqn-k, where n = number of trials, k = number of correct responses, n – k = number of incorrect responses, p = probability of a correct response, and q = 1 – p = probability of an incorrect response. To get the probability (p) of getting k successes or less in n trials based on the normal distribution, the following formula can be used (note that a correction factor of 0.5 added to the numerator adjusts the calculation when n is small):

z

k  np  0.5 npq

Some assumptions in utilizing the binomial distribution are that each of the items on symptom validity test are independent of all other items on the test  an equal probability of being answered correctly. Not and that all items have all two-alternative forced choice tests meet this latter assumption. When this is the case, the following formula can be adapted to calculate the probabilities as follows:

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P(k successes) =

n1! n 2! k k p1 1 (1 p1 ) n1 k1 p2 2 (1 p2 ) n 2 k2 k 2!(n 2  k2 )! 1  k1 )!

 k !(n 1

For a further review of the application of the binomial distribution to symptom validity tests utilizing a two-alternative forced-choice paradigm, please refer to  Morel and Shepherd (2008a).

Statistical Averaging in the Use of Multiple Tests to Improve Detection of Malingering Clinical experience suggests that combining multiple tests of negative response bias improves the detection of malingering. To meet the diagnostic criteria of probable malingering as defined by Slick, Sherman, and Iverson (1999), multiple indicators of invalid performance on testing are necessary. The efficacy of this approach is that sensitivity to detect probable malingering is increased, while also maintaining specificity (i.e., without a concomitant

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increase in the false positive rate). Several studies have demonstrated the beneficial effect of combining data from multiple symptom validity tests (e.g., Larrabee, 2008; Victor, Boone, Serpa, & Buehler, 2006). Intuitively, it makes sense that positive findings from several symptom validity tests are more diagnostically persuasive than data from a single test. In a practical sense, how then do we combine positive results from several different symptom validity tests derived from the same patient? If the symptom validity measures are not significantly inter-correlated with each other, a sequential linking of likelihood ratios can be calculated. This is referred to as chaining likelihood ratios. With symptom validity tests that are independent of each other, one can use the post-test odds from one test to be used as the pre-test odds for a second test and so forth by using the formula: odds/odds + 1 (Larrabee, 2008). Larrabee (2008) demonstrated that the statistical probability of detecting malingering increases when utilizing chaining of likelihood ratios from multiple positive test scores. The study further demonstrated that when three symptom validity tests were failed, the ―posterior probabilities of malingering derived from chaining of likelihood ratios closely approximated those obtained by direct computation of Positive Predictive Power‖ (Larrabee, 2008, p. 666). Other statistical approaches, such as Bayesian model averaging (BMA) for combining several symptom validity tests can also be applied (Hoeting, Madigan, Raftery, & Volinsky, 1999; Mills & Volinsky, 2001)

Bayesian Analyses Thomas Bayes (ca. 1702–1761) proposed a mathematical model whereby one can determine the conditional and marginal probability of two outcomes. With the promotion of evidence-based practices in medicine, Bayesian analysis is becoming a more common statistical tool for researchers. Bayes’ theorem is as follows: Pr(AB) = Pr(BA)Pr(A)/P(B), where Pr(AB) denotes the probability of A occurring given B. In fact, the computation of PPV from sensitivity and prevalence estimates employed Bayes’ theorem: PPV = Pr(true positivetest positive) = Pr(test positive true positive)Pr(true positive)/P(test positive) = sensitivityprevalence/(false positive + true positive). Bayes’ theorem is applicable in more settings then simply computing PPV. It is often used to statistically calculate posterior probabilities based on

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given observations and prior beliefs. In other words, this method combines previous base rate information on malingering with current test data to estimate the probability of malingering given the patient’s score on a test. For example, a patient achieves a positive score on a symptom validity test to assess negative response bias, utilizing Bayesian analysis one can compute the probability that a proposed clinical opinion of malingering is correct, given that observation (i.e., the patient’s test score). Mossman (2000a) points out that test results used to detect negative response bias ―have the same effect as results of medical diagnostic tests‖ (p. 777). That is, they influence the clinician’s beliefs about the certitude of a particular diagnosis. Bayesian analysis is a tool that provides a framework to prevent a practitioner from over or under interpreting the significance of a particular test score achieved by a patient (Mossman, 2000b; Mossman & Hart, 1996). The pragmatic use of Bayesian analysis affords several advantages in diagnostic testing. First, diagnostic tests are seldom, if ever, perfect. The use of Bayesian analysis offers a method for practitioners to communicate the probability, which can be expressed as a percentage, that a patient is malingering as opposed to merely stating the patient had a score consistent with or similar to malingerers. A second and related point is in risk analysis. A clinical opinion of malingering in military psychiatric practice also has forensic implications. Bayesian analysis can provide a mathematical degree of certainty in one clinical opinion over another (e.g., malingering or credible patient). Third, Bayesian analysis provides a method to adjust for sources of uncertainty in studies. The potential drawback to the Bayesian model is that one must specify prior beliefs, which are often unknown, and results can change depending on the prior belief.

SUMMARY OF STATISTICAL METHODS TO DETECT MALINGERING A brief description of the various applications of statistics for making inferences regarding malingering was discussed. As can be seen from the discussion, the clinical suppositions that one can derive from the output vary depending on the statistical method utilized. In addition, the efficacy of the statistical methods to aid in the differentiation of malingering from genuine PTSD depends in large measure on the psychometrics properties of the particular psychological tests that are administered to the patient. A key

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question for the practitioner is whether the tests selected adequately differentiate persons simulating PTSD from those who are not. The next chapter addresses this issue.

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Chapter 4

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PSYCHOMETRIC TESTS TO DIFFERENTIATE VALID AND INVALID RESPONSE PATTERNS FOR PTSD The substantial weight of published research on the scientific rationale of the methodological tools for differentiating between valid mental disorders and malingering is in the field of applied neuropsychology (e.g., Sbordone, Saul, & Purisch, 2007). After reviewing the scientific literature on malingering, the National Academy of Neuropsychology’s (NAN) conclusion is that the administration of symptom validity tests (SVTs) are ―medically necessary‖ during comprehensive psychological examinations (Bush et al., 2005, p. 419). The official policy statement from NAN notes that in any assessment where secondary gain is an issue or where the practitioner suspects the patient’s presentation is not reliable, the practitioner ―must utilize symptom validity tests and procedures‖ (Bush et al., 2005, p. 426). Moreover, Schretlen (1988) states, ―it is probably indefensible to render expert testimony regarding the likelihood of malingering without psychological test data bearing on this question‖ (p. 451). The decision of which symptom validity tests constitutes best practice, however, was left to individual practitioners to determine themselves. In effect, NAN’s official policy statement, viewed in the context of DSMIV-TR’s caution to rule out malingering in assessments for PTSD, underscores the need for mental health practitioners to be knowledgeable about various objective psychometric tests to assess simulated PTSD. The psychometric properties and diagnostic utility of psychological tests employed to detect simulated psychopathology are discussed in this chapter. Particular emphasis

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was made to include symptom validity measures that are utilized in assessments for PTSD. Before proceeding, a word of caution regarding the interpretation of psychological test data should be noted. The requirements of Federal or State law on who is qualified to interpret particular assessment products might necessitate a referral by the psychiatrist to a clinical psychologist or neuropsychologist for diagnostic testing. In Downs v. Perstorp Components, Inc., 126 F. Supp. 2d 1090, (E. D. Tenn. 1999) the court held that psychological evaluations fall under the scope of licensed psychologists with professional training and expertise in psychometric testing. The court excluded the testimony of a physician who had administered particular tests to the plaintiff, because the physician did not meet Daubert standards as an expert witness in the interpretation of such tests (see also brief of American Psychological Association as amicus curiae to Georgia Supreme Court in Chandler v. Morris, S91C1591, June 1992). Furthermore, some clinical diagnostic cases in military psychiatry will eventually become forensic psychiatric cases. In these situations, it should be recognized that state and federal laws vary on expert testimony regarding interpretation of psychological test data (see United States v. Houser, 36 M.J. 392 (1993)). Also, the courts can exclude expert testimony, even in situations where the expert has the professional credentials requisite to purchase psychological tests as specified by test distributors’ user qualification websites (e.g., http://www.pantesting.com/auth_users.asp). By and large, the Military Rules of Evidence follow the Federal Rules of Evidence (see http//www.au.af. mil/au/awc/awcgate/law/mil-evidence-155.pdf). Therefore, in military settings it is useful for psychiatrists to consult with clinical psychologists or neuropsychologists when malingering is an issue, thereby optimizing the use of their expertise. In cases where the psychiatrist needs to refer a patient for clinical diagnostic testing to rule out malingering, the referral question should note why symptom validity testing is being requested.

STRUCTURED CLINICAL INTERVIEWS Miller Forensic Assessment of Symptom Test The Miller Forensic Assessment of Symptom Test (M-FAST; Miller, 2001) is a 25-item structured interview to screen for feigning of psychiatric

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illness. The purpose of the M-FAST is to provide an estimate of the likelihood that an examinee is malingering psychopathology and to elucidate how the respondent is malingering. The M-FAST includes the followings scales; Reported versus Observed symptoms (RO), Extreme Symptomatology (ES), Rare Combinations (RC), Unusual Hallucinations (UH), Unusual Symptom Course (USC), Negative Image (NI), and Suggestibility (S). Analyses show that negative response bias (i.e., simulating impairment) is responsible for over 50% of the variance in M-FAST scores (Miller, 2001; Vitacco et al., 2008). In two analog studies specifically assessing the efficacy of the M-FAST to detect participants instructed to simulate symptoms of psychological trauma, the sensitivity was 68% (Guriel et al., 2004) and 78% (Messer & Fremouw, 2007). In forensic examinations a cutting score of ≥6 yielded PPV ranging from .74 to .78 and NPV of .89 to .91 (Jackson, Rogers, & Sewell, 2005; Guy & Miller, 2004). In a study combing the M-FAST with the Morel Emotional Numbing Test-Revised the correct classification rate to detect malingered PTSD was increased to over 90% (Messer & Fremouw, 2007).

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Structured Interview of Reported Symptoms The Structured Interview of Reported Symptoms (SIRS; Rogers, Bagby, & Dickens, 1992) is a 172-item structured interview to detect malingering and other types of problematic response styles in psychiatric evaluations. The SIRS includes 13 subscales and provides information to quantify definite or probable simulated mental impairment, as well as, credible responders. Interrater reliability estimates range from .89 to 1.0. The internal consistency reliability coefficients for the SIRS subscales range from .66 to .92 with an average of .85. Rogers, Payne, Berry, and Granacher’s (2008) research indicate that the SIRS is an effective test to detect negative response bias in compensation and disability settings. Comparisons of 569 persons involved in forensic examinations for worker’s compensation, personal injury litigation, or disability proceedings revealed that the SIRS reliably distinguished between claimants with simulated mental illness and those with genuine disorders (Cohen’s d = 1.94). Two general concerns with the SIRS are noted. First, similar to personality inventories that include measures of validity, administration time for the SIRS is lengthy; which in some cases exceeds an hour (Green, Rosenfeld, Dole, Pivovarova, & Zapf, 2008). Several abbreviated versions of the SIRS have been created to address this issue. Norris and May (1998)

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produced an abbreviated version of the SIRS as a screening instrument consisting of 40-items. This version had a sensitivity of 87% and specificity of 73% in a correctional setting. Story (2000) developed a 71-item version of the SIRS that had a sensitivity of 78.9% and specificity of 90% in a sample of 49 pre-trial forensic patients. Green et al. (2008) created a 69-item abbreviated version of the SIRS (SIRS-A). A comparison of non-psychiatric participants instructed to simulate psychiatric symptoms to psychiatric patients instructed to respond honestly on the SIRS-A produced a sensitivity of 86.2% and specificity of 85.1%. The sensitivity of the SIRS-A in a psychiatric sample instructed to malinger symptoms was markedly lower (50%), however. This is the second concern with the SIRS. According to Green et al. (2008) review of published data, the sensitivity of the SIRS to detect simulated impairment is low (i.e., 48.5%).

VALIDITY SCALES WITHIN TESTS OF PSYCHOPATHOLOGY

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Trauma Symptom Inventory The Trauma Symptom Inventory (TSI; Briere, 1995) is a 100-item selfreport test that measures acute and chronic PTSD symptomatology. The examinee rates each symptom item according to its frequency of occurrence over the prior six months, using a four-point scale ranging from 0 (never) to 3 (often). The TSI includes 10 clinical scales and three measures of validity, Response level (RL), Atypical response (ATR), and Inconsistent response (INC). The ATR is used to assess patients who may simulate PTSD symptoms, as it measures exaggeration and/or the attempt to appear grossly impaired (i.e., impairment that is atypical of genuinely impaired clinical samples). The correlation of TSI with the F scale of the MMPI-2 is .50 (Briere, 1995). The TSI manual conservatively recommends a T-score of ≥90 to detect feigned trauma symptoms. This cutoff score seems high, especially considering the mean and standard deviation of the TSI (i.e., M = 50 and SD = 10). The efficacy of the TSI’s ATR scale to differentiate simulated psychopathology from persons with legitimate PTSD is not given in the test manual, however. To address this need, Edens, Otto, and Dwyer (1998) utilized an analog design and identified an ATR T = 61 as the optimal cutoff score to differentiate honest

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responders (non-PTSD) and simulated malingerers (sensitivity = .84, specificity = .92, and an overall correct classification of .87). Additional studies raise questions regarding the efficacy of the TSI’s ATR scale to detect malingerers. In a follow-up study comparing a clinical sample of actual patients diagnosed with PTSD to a cohort instructed to simulate PTSD, the ATR overall classification rate was .61, with a PPV of .66 and NPV of .54 (Elhai et al., 2005). The ATR failed to detect 52% of those simulating PTSD (i.e., participants posing as malingerers). In a youth study, Carmody and Crossman (2005) found that 66% of those in the deception condition (i.e., simulate PTSD) were not detected on the ATR. Efendov, Sellbom, & Bagby (2008) found that the ATR did not add incremental validity to the F scales of the MMPI-2. Efendov and colleagues’ study further revealed that the ATR could not distinguish coached participants instructed to simulate PTSD from claimants diagnosed with PTSD. Consistent with previous research (Viglione et al., 2001), Elhai et al. (2007) found that examinees can alter their presentation on the ATR when simple cautionary instructions about endorsing credible symptoms are provided prior to testing. In addition to potential false negatives (Type II, ß errors) with the optimal cutoff score on the ATR, Rosen et al. (2006) found an increased risk for false positives (Type 1, α errors). Similarly, in an analog study on the impact of coaching in PTSD evaluations, Guriel et al. (2004) stated that the ―TSI was generally not useful in discriminating between honest responders and coached malingerers‖ (p. 50). Therefore, practitioners should use caution when interpreting the TSI in settings where secondary gain may be a factor (Rosen et al., 2006).

Minnesota Multiphasic Personality Inventory-2nd Edition The Minnesota Multiphasic Personality Inventory-2nd Edition (MMPI-2; Butcher et al., 1989) is the most widely used measure to assess adult psychopathology. The test consists of 567 true/false statements. The MMPI-2 includes several validity scales; Variable Response Inconsistency (VRIN), True Response Inconsistency (TRIN), Lie (L), Correction (K), Infrequency (F), Back F (FB), Infrequency–Psychopathology (FP; Arbisi & Ben-Porath, 1995), Fake Bad Scale (FBS; Lees-Haley, English, & Glenn, 1991), Dissimulation Scale (DS; Gough, 1954, 1957), Dissimulation Index (F-K; Gough, 1950), Obvious minus Subtle items (O-S; Wiener, 1948; Greene, 1991), InfrequencyPosttraumatic Stress Disorder (FPTSD; Elhai et al., 2002), Response Bias Scale (RBS: Gervais, Ben-Porath, Wygant, & Green, 2007), and Superlative Self-

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Presentation (S). The primary validity scales to detect simulated psychiatric impairment in assessments for PTSD are the F, FB, FP, FBS, DS, O-S, FPTSD, and F-K scales. The practitioner should note that the items comprising these validity scales overlap with some items on the clinical scales of the MMPI-2 and with each other (Nelson, Sweet, & Demakis, 2006). The majority of published research on MMPI-2 validity scales utilized multiple validity scales rather than a single indicator to detect simulated psychopathology. This approach follows conventional recommendations in forensic practice. Studies utilizing stepwise discriminant analysis found the F, F-FB, F-K, DS, O-S, and OT as the best indictors of malingered combat-related PTSD (Elhai, Gold, Frueh, & Gold, 2000) and FP, F-K, and O-S as the best predictors of malingering for non-veterans (Elhai, Gold, Sellers, & Dorfman, 2001). In a study with the MMPI rather than the MMPI-2, stepwise logistic regression analyses found DSR400 (a shortened version of the DS), F, F-K, and S as the most sensitive and specific measures of malingering among active duty enlisted Marine Corps and Navy military personnel (p 80%). Conversely, in clinical samples with known-groups, the RDF was significantly less effective relative to the NIM or the MAL (Boccaccini, Murrie, & Duncan, 2006; Kucharski et al., 2007; Wang et al., 1997). There is also a potential for false positives depending on the cutoff score applied. Bowen and Byrant (2006) found that 17% of patients seeking treatment for acute stress disorder were misclassified as malingerers. Therefore, a degree of caution should be used when interpreting the PAI validity indicators of persons who may simulate PTSD.

TWO-ALTERNATIVE FORCED-CHOICE PARADIGM TO DETECT SIMULATED PTSD Morel Emotional Numbing Test for Posttraumatic Stress Disorder The Morel Emotional Numbing Test for Posttraumatic Stress Disorder (MENT; Morel, 1995, 1998) is a 60-item symptom validity test to detect negative response bias in assessments for PTSD. In a review of the literature on detecting malingered PTSD, Rubenzer (2009) recommended use of the MENT (see also Geraerts, 2009). The MENT is composed of three sets of 20items each. Normative data is available on various patient groups, including patients with PTSD and suspected malingerers. The total error score on the MENT can be compared to cutting scores provided in the test manual. In addition, the total number of errors on the MENT can be converted to z scores for comparisons with the normative data. The reliability of the MENT, as

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measured by internal consistency equivalences, ranged from .87 to .94 (p < .0001). Initial validation of the MENT found a sensitivity of .82 and specificity of 1.0. The PPV, NPV, and overall efficiency or hit rate were 1.0, .94, and .96, respectively. The correlation of the MENT to the MMPI-2 F-K index in a regression model was 50%, r = .71, p < .0001, d = 2.0 (Morel, 1998). The correlation of the MENT to a well validated symptom validity measure utilized in neuropsychological evaluations, the Word Memory Test (WMT; Green, Allen, & Astner, 1996), was 68% in a linear model, r = .83, p < .0001, d = 2.9 (Morel, 2008c). Unlike other validity measures, the MENT does not assess exaggerated or non-credible symptom endorsement by the patient in a self-report format, Likert scale questionnaire, or structured clinical interview. Rather the MENT is distinctive in that it builds on the two-alternative forced-choice paradigm primarily utilized in forensic and clinical neuropsychological examinations (Morel & Shepherd, 2008a). Specifically, each test item on the MENT simultaneously displays the target stimuli and two possible choices, one correctly matches the target stimuli and the other does not. The design of the test does not lend itself to overstating or overestimating symptoms, as the correct and incorrect responses are present and easily discernable. Therefore, the test measures deliberate distortion rather than merely exaggeration. In addition, the MENT has three other practical advantages over conventional methods to detect simulated PTSD (see Morel & Marshman, 2008). First, selection of facial affect recognition as a pathognomonic sign of emotional numbing in the test stimuli in the MENT has particular significance in detecting simulated PTSD. In contrast to other symptom validity measures that use atypical and bizarre symptom endorsement to assess simulated psychopathology, the MENT utilizes emotional numbing as a plausible symptom of PTSD. This increases the sensitivity of the MENT as both naïve and knowledgeable malingerers are more likely to simulate symptoms they believe are associated with the condition they are trying to emulate (Morel & Marshman, 2008). Although emotional numbing is one criterion of PTSD, facial affect recognition is a cognitive ability that is; (a) present almost from birth and endures intact throughout most of the human life cycle, (b) generally culturally free, (c) highly resistant to the majority of neurologic disorders apart from word recognition deficit (decoding) and extremely poor visual acuity, and (d) with the exception of patients schizophrenia and autistic disorder, not associated with most psychiatric disorders. In fact, disability claimants with authentic combat-related PTSD average 96% correct responses on the MENT.

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Therefore, errors on this task most plausibly represent a volitional choice to suppress actual abilities patients. Second, unique in the development of symptom validity measures, the normative data for the MENT is entirely composed of known-group samples. The selection of the known-group design follows Rogers’ (2008) advice regarding methodological issues that need to be addressed in such research. To avoid criterion contamination the researchers did not pre-select group classification of the normative sample. Instead, the researchers conducted post-hoc analyses of archival data of 100 consecutive Compensation and Pension examinations for combat-related PTSD that included the MENT as part of a battery of tests. Claimants with neurologic disorders, non-compliance with examination procedures, and incomplete psychological testing were eliminated. From the remaining records, four groups were identified; (a) credible claimants diagnosed with PTSD, (b) credible claimants not meeting criteria for PTSD, (c) older credible claimants (i.e., ≥63 years of age), PTSD and non-PTSD, and (d) claimants suspected of malingering. To reasonably support the ecological validity of the study, only persons who fulfilled all of the specified criteria as listed in Table 4 were placed in the malingering cohort. In addition, two clinical samples of military veterans not applying for disability pensions were included in the normative database. The clinical comparison samples were composed of veterans who had already been diagnosed by practitioners unfamiliar with the study objectives. This included; (a) veterans being treated for chemical dependency in a VA medical center inpatient program and (b) veterans with a diagnosis of schizophrenia who were unable to function independently in the community and were institutionalized in a VA medical domicile facility. Inclusion of these groups provides diagnostic information regarding co-morbid factors (i.e., chemical dependency or substance abuse) and a baseline of genuinely poor performance on the MENT on a patient population with know deficits in affect recognition (i.e., patients with schizophrenia; see Morel, 1998). Additional normative data is available on two groups of military veterans referred for neuropsychological evaluations, (a) elderly patients with cognitive complaints consistent with dementia and (b) outpatients with a range of neurologic disorders or cognitive complaints.

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Table 4. Criteria to Classify Disability Claimants in the Malingering Cohort for the MENT Normative Study 1.

Veteran was applying for Compensation and Pension for combat-related PTSD.

2.

Veteran had no documented medical history of neurologic or neurocognitive dysfunction and was not referred for a pending neurology or neuropsychological examination.

3.

The patient was not actively psychotic during the examination and did not have a history of psychosis.

4.

(a) Veteran’s stated military occupation specialty (MOS) did not match the MOS documented on their DD-214 (e.g., professing to be a Navy Seal or Army Special Forces when their DD-214 indicated their occupation was a clerk, cook, tire mechanic, etc.), or (b) Veteran claimed to be a prisoner of war (POW) but was not listed on the DOD official database of POWs.

5.

Veteran’s claimed stressor was combat in Vietnam (i.e., DSM Criterion A) but official military documents did not corroborate that the veteran was ever in combat, or (b) The veteran claimed combat with an award of a Purple Heart or other military medals but no evidence of combat engagements and specific award of military medals relating to combat were documented in the veteran’s DD-214.

6.

Veteran’s VRIN score was in the valid range on the MMPI-2 but their F-K index score was ≥15.

7.

Veteran endorsed highly improbable and non-credible symptoms (i.e., ≥17) on the Quick Test of Posttraumatic Stress Disorder (Q-PTSD; Morel, 2008a).

8.

Failure of the disability claimant to adequately account for any of the above mentioned discrepancies on follow-up clinical interview.

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Note: All criteria had to be satisfied to classify disability claimants in the malingering cohort.

Third, one of the main challenges in malingering research is that the incentives to successfully simulate PTSD are far greater in real life settings (e.g., disability pensions, worker’s compensation, criminal law defenses, personal injury jurisdictions) than what can be offered to volunteers instructed to simulate PTSD in analog designed studies. In general, greater incentives produce higher levels of motivation to simulate PTSD. Since the initial validation of the MENT was derived from archival data on military veterans seeking financial remuneration in the form of lifetime disability pensions for combat-related PTSD, it seems reasonable that this research model enhances the ecological validity of this instrument to provide evidence of malingering. Studies indicate the MENT is effective at distinguishing patients who simulate symptoms and those who do not. Meta-analyses of the MENT revealed a sensitivity of 79.0% (CI = 65.6 to 88.1) and specificity of 95.9% (CI = 85.4 to 98.9; Morel & Shepherd, 2008-b, 2008c). Pooled estimates of several studies on the MENT indicate that credible patients correct response rate is 94.5% and malingerers average 71.1% correct responses. On average, malingerers had over 5-times the error rate on the MENT relative to credible

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respondents (M = 17.33, CI = 16.1 to 18.5, and M =3.3, CI = 2.6 to 4.1, respectively). The design of the MENT in using affect recognition, makes the test useful for a variety of cultures and ethnic groups. The MENT has been translated into Dutch, Croatian, German, Turkish languages. For example, in a study on the effectiveness of a German version of the MENT to detect four independent groups of motivated simulated malingerers (i.e., naïve, informed, warned, and informed and warned), the sensitivity of the MENT ranged from 65% to 95% (Merten & Lorenz, 2009). In a prospective study of 61 disability claimants alleging PTSD, the correlation of the German version of the MENT to the WMT was Spearman’s Rho (rs) = .66 (Merten, Thies, Schneider, & Stevens, 2009). Claimants failing the WMT produced 3.5 times more errors on the German MENT relative to disability claimants who passed the WMT. Another study examined the efficacy of a Croatian version of the MENT to differentiate between compensation seeking and non-compensation seeking combat veterans of the Croatian War (Geraets et al. 2009). The sensitivity and specificity of the instrument was 91.8 and 95.7, respectively. One caution regarding use of the MENT is the potential for false negatives. Similar to the WMT, the MENT is an exceedingly easy task for honest test-takers, even for patients with neurologic or psychiatric disorders. Credible disability claimants diagnosed with PTSD had a mean correct response rate of 96% on the MENT (M total error rate = 2.41, SD = 1.66). Conservatively, the MENT manual indicates a cutoff score for total errors of ≥8 for adults 18 to 59 years of age and ≥9 for adults over 59 years of age. This original criterion or cutting score was calculated to reduce false positives in a patient population prone to over-report psychopathology (e.g., Hyer, Fallon, Harrison, & Boudewyns, 1987). Yet, a total error score of 7 on the MENT falls below the cutting score but is still poorer than 99.72 of the of credible disability claimants diagnosed with PTSD. Therefore, a lower cutoff score may be warranted to increase sensitivity of the MENT in particular settings where there is significant incentive to malinger. Alternatively, it may be more efficacious to compute z-score comparisons to the criterion groups (i.e., normative samples for the MENT) that are provided with the MENT test package.

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GENERAL CAUTIONS IN THE USE OF SYMPTOM VALIDITY MEASURES OF MALINGERED PSYCHOPATHOLOGY Before making diagnostic inferences from data derived from symptom validity testing, it is essential to consider four important general principles. First, no test has perfect sensitivity and specificity. Similar to medical tests, psychometric tests rarely achieve absolute diagnostic precision (e.g., Meyer et al., 2001). Second, psychometric tests, like medical tests, require the practitioner to use specific standardized procedures as approved for their use. Violations of standardized procedures can result in arbitrarily skewed results. Third, the practitioner needs to consider the appropriateness of the selected tests for particular patient populations. For example, some psychometric tests designed to assess negative response bias (i.e., simulated impairment) may not be appropriate for patients with extremely low intellectual faculties (Hurley & Deal, 2006), who are actively psychotic, or who are otherwise unable to respond to test demands (e.g., Franklin, 2008). Fourth, a major limitation to the usefulness of psychometric tests as diagnostic tools is when the integrity of the test has been violated. In physical medicine, for example, a patient may use a masking agent to thwart the results of a urine or serum blood tests. Likewise, the diagnostic utility of psychometric tests is severely diminished when a patient has prior knowledge of the content or underlying constructs of the tests, which can enable the patient to alter their presentation on testing (Morel, 2009).

SUMMARY OF PSYCHOMETRIC PROCEDURES TO DETECT SIMULATED PTSD Along with a thorough review of relevant medical and ancillary military records and clinical interview, symptom validity testing is a practical necessity to differentiate simulated PTSD from genuine presentation of symptoms. Just as medical laboratory tests are used to assist the physician in making a clinical diagnosis, mental health practitioners utilize psychological tests in making diagnostic decisions. Mossman (2000a) stated that, similar to medical diagnostic tests, the results of tests to detect simulated impairment influence the examiner’s decision process as to whether or not the patient is malingering. The synthesis of diagnostic tools to detect malingering provides practitioners an efficient means to arrive at a rational, object, and evidence-based diagnostic

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decision. The accuracy of a clinical opinion of malingering should be based on the practitioner’s skill, experience, and ability to select and/or incorporate data from appropriate empirically grounded symptom validity tests.

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Chapter 5

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CONCLUSION The clinical picture of what constitutes simulated PTSD versus genuine PTSD is a frequent problem in military medicine. When secondary gain is a potential issue, ruling out malingering requires close examination and often presents an intriguing diagnostic challenge to the physician. An accurate diagnosis may be achieved in a majority of patients after a thorough records review is performed, a reliable history via clinical interview has been taken, and symptom validity testing obtained. Standard symptom validity measures can provide empirically-grounded probabilistic evidence to aid the psychiatrist in the appropriate confirmation of the clinical impression of malingering. Conversely, diagnostic opinions on malingering are incomplete without symptom validity testing and open to challenge, especially in forensic cases. Forensic involvement is always a potential concern in the assessment of malingering in the military but a viable doctor-patient relationship can still benefit the patient. The best practice for the physician when malingering is detected is to; (1) state clearly that malingering is suspected, (2) take steps to bring to an end the malingering, including discussing the underlying reason for the malingering, (3) provide treatment for any legitimate physical or mental illnesses that the patient may have, and (4) educate the patient and reinforce alternative coping mechanisms to prevent future malingering attempts. Successful intervention with malingerers may increase retention in the military and render more severe punitive judgments under the UCMJ as unnecessary. For these reasons, abrupt discharge of a clinical diagnostic case because of suspected malingering should be avoided. It is especially important that clinical vigilance is taken not to prematurely discharge a patient who is admitted for a self-inflicted injury or apparent parasuicide; even if it becomes

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evident the patient was seeking secondary gain. Since 10% of clinically suspected parasuicides eventually commit suicide, all appropriate behavioral precautions should be taken. In conclusion, the differentiation between malingering and PTSD is problematic at best, and requires clinical expertise, rational deductive reasoning, and a degree of mettle. Undeniably, war is a mechanism in which prolonged hardships and the threat of death can produce stress reactions in combatants or the conscious simulation of symptoms of PTSD for secondary gain. During war, malingering may be seen as a ―solution‖ to relieve oneself from the burdens of duty and perilous situations. The ease with which one can simulate symptoms of PTSD along with financial incentives in the form of medical disability pensions provides additional motivations for malingering. The difficulty of making a differential diagnoses between malingering and PTSD in military medicine does not, however, exempt the psychiatrist from his or her responsibility to do so. As military officers and physicians, psychiatrists have a task of consummate importance and difficulty. This is not new to modern military medicine. Concerning the challenge for military physicians to determine the authenticity and extent of impairment, Llewellyn and Jones (1919) acknowledged almost a century ago, ―Let us be frank – recognize clear-eyed our limitations– our inability to appraise even approximately the full consequences of disease or injury a terra incognita, bristling with obstacles to overcome, pitfalls to avoid and withal gravid with potentialities for good or ill‖ (p. v).

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INDEX

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A abduction, 111 abnormalities, 41 academic, 24 accident victims, 109 accidents, 8, 14, 107 accountability, 35 accuracy, 27, 33, 43, 48, 58, 61, 65, 91, 114 acute, 79, 84, 106 acute stress, 84, 106 Acute Stress Disorder, 49 adjudication, 36 administration, 75, 78, 100, 102 adult, 81, 83, 90, 116 age, 63, 86, 90, 112 agents, 19, 91 aggression, 119 aid, 42, 73, 93 air force, xviii, 7, 30, 37 algorithm, 50 aliens, 41, 111 alternative, 5, 46, 47, 48, 63, 69, 70, 85, 93 American Psychiatric Association (APA), xix, 4, 8, 9, 38, 39, 47, 97, 103 American Psychological Association, 76, 108 analog, 58, 59, 77, 80, 83, 88

antisocial personality, 6 anxiety, 29, 49, 109, 111, 112, 113, 115 anxiety disorder, 109 application, xix, 51, 58, 60, 61, 70, 114 archivist, 117 armed forces, xi, xv, 3, 6, 7, 12, 15, 18, 20, 21, 22, 24, 34, 35, 118 army, xvii, 7, 18, 19, 22, 34, 37, 88, 101, 110, 114 arousal, 29, 49, 109 assault, 40 assessment, xvii, 10, 24, 27, 28, 36, 38, 41, 52, 75, 76, 93, 97, 100, 105, 106, 108, 109, 110, 111, 112, 114, 115 assignment, 35 assumptions, 69 attacks, 11 Attention Deficit Hyperactivity Disorder, ii attitudes, 119 attribution, 6 aura, 28, 47 authenticity, 19, 29, 30, 39, 41, 94 authority, 47, 119 availability, 21 averaging, 71, 107 avoidance, 49

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Index

94

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B background information, 35 background noise, 65 bank fraud, 17 base rate, 12, 72, 109 base rate information, 72 base rates, 12, 109 battery, 86 Bayesian analysis, 71, 72 Bayesian estimation, 117 behavior, 23, 28, 29, 53 behavioral manifestations, 30 behavioral medicine, 57 beliefs, 34, 46, 71, 72 beneficial effect, 70 benefits, 4, 16, 17, 21, 39, 59 bias, 5, 31, 37, 38, 44, 45, 46, 47, 48, 52, 58, 59, 68, 70, 72, 77, 78, 82, 84, 90, 100, 101, 111, 112, 113 binomial distribution, 68, 69, 70, 113, 117 biological markers, 40, 41 birth, 86 blood, 91 BMA, 71 Borderline Personality Disorder, 49 brain, 41, 42, 53, 99, 109 brain injury, 99, 109

C case study, 98 category a, 9 central nervous system (CNS), 8, 42, 101 channels, 38 childhood, 8, 99 childhood sexual abuse, 99 children, 59 Civil War, 12, 102 civilian, 8, 14, 82, 103 classification, 5, 32, 78, 80, 83, 86 clinical approach, 110

clinical assessment, 36, 111 clinical diagnosis, 38, 91 clinical examination, 43, 45, 47 clinical judgment, 23 clinical presentation, 51 clinical trial, 39 clinically significant, 47 clinician, 50, 60, 68, 72, 99 clinics, 13 coast guard, 7, 8 cognitive ability, 86 cognitive dissonance, 20, 103 cognitive dysfunction, 42 cohort, 80, 82, 87, 88 collateral, 28, 57 communication, 5, 38 community, 8, 87, 105 comorbidity, 42, 116 compensation, 4, 10, 12, 17, 30, 39, 78, 88, 89, 97, 98, 102, 115, 118, 119 competency, 108 complexity, 51 compliance, 45, 49, 86 computation, 71 computed tomography, 42 concussion, 30 confidence, 31, 57, 61 confinement, 24 confirmatory factor analysis, 118 conflict, 15, 22, 101 confrontation, 45 congress, ix, 15, 16, 17, 18, 118 consensus, 101 construct validity, 100, 105 contamination, 21, 86 contingency, 61 control, 38 Controlled Substances Act, 21 conviction, 23 correlation, 79, 85, 89 costs, 12, 16, 17 counsel, 21 courts, 11, 14, 76, 113

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Index CRC, 116 credentials, 76 credibility, 24 creep, 115 crimes, 4, 18, 109

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D danger, 49 database, 87, 88, 115 death, 11, 94 decision making, 65 decisions, 24, 36, 46, 57, 58, 59, 60, 91 decoding, 86 deductive reasoning, 48, 94 defendants, 109 defense, 82, 88, 101, 115 deficit, 86, 87 definition, xix, 31, 53, 60 dementia, 59, 87 Department of Defense, 8, 16, 21, 35, 113 Department of Health and Human Services, xviii Department of Homeland Security, 8 depression, 31, 109 depressive disorder, 113 Desert Storm, 33, 117 destruction, 37 detection, 3, 13, 28, 29, 30, 58, 60, 65, 68, 70, 102, 103, 106, 109, 111, 117 deviation, 64, 79 diabetes, 110 Diagnostic and Statistical Manual of Mental Disorders, 4 diagnostic criteria, 50, 70, 110, 117 differential diagnosis, xix, 11, 50 differentiation, 73, 94 directives, 35 disability, 4, 7, 8, 10, 11, 13, 16, 17, 18, 19, 21, 30, 31, 36, 37, 39, 44, 45, 48, 51, 53, 59, 78, 82, 83, 86, 87, 88, 89, 94, 112, 116, 118

95

disaster, 117 discipline, 21 disclosure, 18, 34 discordance, 35 discourse, 20 discriminant analysis, 81, 115 discrimination, 106 distress, 47, 100, 110 distribution, 67, 68, 69, 70, 113, 117 doctor-patient, 45, 93 dopamine, 41 dosage, 21 dream, 30 drug screenings, 42 drugs, 4, 21 DSM, xix, 4, 8, 9, 11, 13, 24, 29, 31, 32, 38, 43, 47, 49, 50, 52, 53, 75, 88, 103, 107, 108, 115, 116 DSM-II, 9, 11, 13, 116 DSM-III, 9, 11, 13, 116 DSM-IV, xix, 4, 8, 24, 31, 32, 38, 47, 49, 50, 52, 53, 75, 103, 107 duties, 6, 15, 22, 36 dynamic factors, 63

E ecological, 68, 87, 89 elderly, 87 emotional, 29, 33, 43, 49, 85, 100, 110 emotional distress, 100, 110 emotions, 32 ethnic groups, 89 etiology, 5, 27 evidence-based practices, 57, 71 exaggeration, 4, 14, 23, 29, 53, 79, 82, 85, 104, 108 examinations, 10, 13, 14, 16, 27, 31, 33, 50, 51, 75, 77, 78, 85, 86, 98, 119 exclusion, 38 exercise, 39 expenditures, 12

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Index

96

expertise, xvii, xix, 46, 76, 77, 94 explosions, 11 exposure, 3, 8, 9, 16, 31, 37, 39, 47, 48, 100, 104, 106, 109 external validity, 13, 118 eye contact, 29

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F fabricate, 50 factor analysis, 118 failure, 44, 46, 47, 69, 118 false negative, 61, 67, 80, 84, 89 false positive, 40, 44, 61, 66, 67, 68, 70, 71, 80, 84, 90, 115 false statement, 16, 17, 81 family, 31, 106 faults, 108 fear, 49 federal government, 18, 19 federal law, 76 Federal Rules of Evidence, 77 financial resources, 15, 21, 46 fire, 18, 24, 37, 117 First World, 8 flashbacks, 30 forensic, 6, 12, 19, 24, 57, 58, 72, 76, 77, 78, 79, 81, 85, 93, 99, 104, 107, 108, 109, 111, 114, 115, 117, 118 forensic patients, 79 forensic settings, 115 forfeiture, 24 fraud, 17, 18, 19, 22, 118 free recall, 109 frontal lobe, 51 fulfillment, 32 funds, 17

G gender, 63 general practitioner, 107

generalizability, 115 generalized anxiety disorder, 49, 109 generation, 100 genetic marker, 42 goal attainment, 6 gold, 28 gold standard, 28 government, 15, 16, 18, 19 graduate students, 107 group therapy, 68 groups, 59, 67, 83, 84, 86, 87, 89, 90 guidelines, 112, 113 guilt, 10 guilty, 21 Gulf War, 40, 106, 109

H hardships, 4, 11, 12, 94 harm, 19, 20, 23 head injury, 30, 112 health, 3, 6, 18, 19, 27, 32, 35, 37, 43, 44, 46, 52, 59, 76, 91, 101, 107, 111, 113, 116, 119 health care professionals, 116 health problems, 6 health services, 119 healthcare, 7, 13, 15, 17, 20, 21, 23, 24, 34, 47, 52, 53, 116 hearing, 11 heart, 19, 40, 88 heart rate, 40 heuristic, 117 hippocampal, 41, 105 Homeland Security, 8 honesty, 28, 29 hormones, 42 house, 15, 19, 118 HPA, 41 human, 32, 86 humanitarian, 22 hyperactivity, 42

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Index hpochondriasis, 51 hypothalamic, 41 hypothesis, 39, 60

J

I

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97

ICD, 4 identification, 3, 13, 16, 38 idiosyncratic, 46, 47 IES, 43, 109 imagery, 38, 41, 42, 111 imprisonment, 19 in situ, 76 incentives, 4, 6, 15, 20, 50, 51, 52, 53, 59, 63, 88, 90, 94, 102 incidence, xix, 12, 13, 14 inclusion, 9, 11, 13, 38, 39, 44, 68 income, 46 Indian, 98 indication, 61 indicators, 14, 59, 70, 84, 109 indices, 103 inefficiency, 22 inferences, 58, 60, 73, 90 injury, ix, 4, 5, 8, 11, 14, 24, 30, 53, 78, 82, 88, 94, 98, 99, 109, 110, 112 inmates, 119 insomnia, 42 Inspector General, 13, 19, 48, 118 instruments, 40, 58, 107 insurance, 12 integrity, 90 intentionality, 51 interdisciplinary, 53 internal consistency, 78, 85 Internet, 10, 44, 48 intervention, 94 interview, 5, 27, 28, 29, 30, 38, 57, 60, 77, 78, 85, 88, 91, 93 inventories, 78 irritability, 49 isolation, 52

judge, 28, 82 judgment, 23 jurisdiction, 8, 88

K Korean, 19 Korean War, 19

L language, 20 law, 4, 5, 11, 15, 18, 20, 36, 76, 77, 88, 107, 118 lawsuits, 11 legislation, 18 lice, 11 life cycle, 86 life expectancy, 59 life-threatening, xv, 3, 9, 13, 29, 31, 39 lifetime, 44, 88 likelihood, 63, 64, 71, 75, 77, 109 Likert scale, 85 limitation, 68, 90, 94 linear, 85 linear model, 85 litigation, 39, 78, 114, 115 longitudinal studies, 117 lying, 28, 29, 109, 118

M magnetic resonance, 42 magnetic resonance imaging (MRI), 42 mail fraud, 17 major depression, 109 major depressive disorder, 113 maladaptive, 23 Marine Corps, 7, 81

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Index

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98

masking, 91 mathematics, 60 measures, 38, 40, 43, 44, 59, 68, 71, 76, 78, 79, 81, 82, 83, 85, 86, 93, 111 media, 18 medical care, 19, 22 medical diagnostics, 61 medical services, 20 medicine, xv, 3, 8, 20, 38, 46, 48, 57, 62, 71, 91, 93, 94, 119 memory, 33, 110, 111, 116, 117 men, xv, 15 mental disorder, 5, 6, 7, 8, 9, 21, 27, 44, 45, 48, 52, 53, 59, 75, 97, 109, 115, 116 mental health, 3, 6, 18, 19, 27, 43, 44, 46, 52, 59, 76, 91, 107, 111, 119 mental health professionals, 59 mental illness, 6, 11, 78, 83, 93, 108 mental impairment, 78 mental retardation, 107 mental state, 115 Middle East, 16 military occupation, 35, 88 misappropriation, 21 misconceptions, 105 misleading, 110 missions, 34, 35 misunderstanding, 52 models, 5, 6, 61, 115 modernity, 111 monozygotic twins, 41 morale, 15 MOS, 88 motivation, 4, 50, 51, 88, 103 motives, 46 motor vehicle accident (MVA), 14, 106

N naming, 39 nation, 35 National Academy of Sciences, 41, 114

navy, xvii, 7, 18, 36, 81, 88 negative consequences, 24 negligence, 35 nerve, 16 nervous system, 8 neurasthenia, 16 neuroimaging, 40, 41 neurologic disorders, 86, 87 neurologist, 8 neuropsychology, 75, 108, 112, 113 neuroscience, 103 neuroses, 8 neuroticism, 105 nightmares, 30 noise, 65 non-clinical, 58 nonverbal, 29 normal, 32, 69 normal distribution, 69 North America, 117

O objective tests, 5 obligation, 22, 23, 24, 35 observations, 28, 57, 71 occupational, 32, 47, 51, 53 oral, 105 outpatients, 87, 105

P pain, 116 paradox, 23 parameter, 24 pathognomonic sign, 85 pathology, 8, 43, 53, 108 patients, 3, 7, 13, 21, 22, 23, 27, 28, 30, 33, 38, 39, 42, 43, 45, 47, 49, 51, 52, 58, 59, 61, 62, 63, 67, 68, 79, 80, 84, 86, 87, 89, 90, 93, 98, 113 peer, 37

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Index pensions, 4, 7, 10, 11, 13, 16, 18, 19, 21, 30, 31, 36, 37, 39, 44, 46, 87, 88, 94, 98, 119 perception, 25 personality, 6, 78, 83, 115 personality characteristics, 6 personality inventories, 78 petroleum, 82 pharmacological, 21 physicians, 3, 8, 12, 14, 20, 21, 24, 28, 33, 34, 40, 42, 43, 45, 46, 47, 53, 60, 61, 65, 94, 114 physiological, 38, 40, 41, 42 pilot study, 119 pituitary, 41 pituitary adrenal, 41 play, 12 politics, 116 poor, 42, 43, 46, 58, 59, 67, 86, 87, 108 poor performance, 58, 59, 87 population, 11, 13, 37, 63, 64, 68, 87, 90, 118 posttraumatic stress, ix, xv, xvii, 3, 16, 98, 99, 100, 101, 102, 103, 104, 105, 106, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118 pragmatic, 72 prediction, 82, 83 predictors, 81 pressure, 48 priming, 109 prior knowledge, 91 prisoners, 14 prisoners of war, 14 probability, 62, 63, 64, 69, 70, 71, 72, 114, 117 production, 4 program, 87 propaganda, 15 protocols, 34 proxy, 51 pseudo, 13, 46, 68 psychiatric diagnosis, 47, 57

99

psychiatric disorder, 7, 10, 13, 16, 22, 24, 32, 45, 51, 53, 86, 89, 109 psychiatric illness, 51, 77 psychiatric patients, 13, 79, 98 psychiatrist, xix, 6, 7, 20, 21, 22, 23, 28, 29, 31, 32, 45, 46, 47, 62, 76, 77, 93, 94 psychoanalysis, 110 psychological injury, 114 psychological phenomena, 60 psychological stress, 11 psychologist, xvii, 76 psychology, ix, 117, 118, 119 psychometric properties, 76 psychopathology, 6, 7, 43, 44, 69, 76, 77, 79, 81, 83, 86, 90, 97, 98, 102, 106, 108, 117 psychosis, 36, 45, 88 psychosomatic, 107, 118 psychotherapy, 68 psychotic, 88, 90 public, 18, 19, 28, 34, 101 public health, 101 public opinion, 28 public opinion surveys, 28 punishment, 22 punitive, 23, 94

Q quartile, 36 questionnaire, 33, 85

R radar, 65 range, 18, 32, 39, 40, 43, 46, 47, 61, 78, 83, 87, 88 rats, 11 reactivity, 40 reality, 5, 20, 33, 35, 53 reasoning, 48, 94 recall, 30, 33, 109

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Index

100 recognition, 85, 87, 89 reconstruction, 33 recovery, 20, 22 regression, 43, 81, 82, 85 regulations, 7, 8 rejection, 53 relationship, 23, 42, 45, 93 reliability, 33, 57, 78, 85, 108, 119 resources, 15, 21, 46, 49 respiratory, 40 responsibilities, 20 retardation, 107 retention, 94 retirement, 8 retribution, 11 risk, 21, 49, 72, 80, 119

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S safeguards, 39 sample, 14, 62, 63, 78, 80, 86, 99, 109 schizophrenia, 86, 87, 113 school, 36, 116 scientific theory, 61 scientific validity, 82 scores, 39, 67, 68, 71, 77, 83, 84, 112 Second World War, 8 security, 35, 36, 44, 112, 113 self-report, 9, 29, 31, 33, 36, 38, 39, 43, 58, 59, 79, 85, 99, 111 senate, 15 sensitivity, 40, 43, 59, 61, 62, 63, 64, 66, 67, 68, 70, 71, 77, 78, 80, 82, 85, 86, 89, 90 serotonin, 41 serum, 42, 91, 118 services, ix, 23, 46, 119 severity, 20, 28, 41, 51 sexual abuse, 99 shock, 8, 16 signal detection theory, 65, 68, 111 signs, 29, 49, 85 simulation, xv, xix, 4, 14, 58, 94, 117

single test, 70 sites, 10, 48 skills, 24, 46 sleep, 30, 42 Social Security, 16, 17, 59 social services, 46 somatic complaints, 51, 82 somatic symptoms, 97 somatization, 53 somatization disorder, 53 Somatoform, 50, 52 specific knowledge, 43 specificity, 40, 43, 59, 61, 62, 63, 64, 66, 67, 68, 70, 78, 80, 82, 85, 89, 90 standard deviation, 64, 79 standards, 7, 76, 116 statistics, 61, 73 stereotypical, 29, 34 strategies, 118 strength, 15, 22 stress, ix, xv, xvii, 3, 9, 10, 11, 16, 33, 42, 43, 47, 84, 94, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118 stress reactions, 9, 11, 47, 94, 110 stressors, 10, 16, 17, 51 stress-related, xv, 3, 12 students, 59, 107 subjective, 9, 10, 38, 58, 107 subjective stress, 107 substance abuse, 87 suffering, 22, 51 suicide, 94, 119 supervised release, 19 Supreme Court, 76 surgeon general, 12 surgeons, 101 surgery, 98 survivors, 8, 9 susceptibility, 104 suspects, 75 sympathy, 22 syndrome, 51

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,

Index synthesis, 91 systems, 5

Copyright © 2010. Nova Science Publishers, Incorporated. All rights reserved.

T target stimuli, 85 task force, 9, 53 taxonomy, 97 test data, 57, 61, 64, 72, 75, 76 test items, 44, 69, 83 test scores, 67, 68, 71 testimony, 75, 76, 82, 114 theft, 17 therapeutic benefits, 21 therapeutic relationship, 23 therapy, 68 threatening, 3, 9, 10, 11, 32, 94 threshold, 32, 63 thyroid, 42 thyrotropin, 42 time, 19, 20, 22, 24, 29, 34, 37, 47, 78, 109, 111 tolerance, 116 tonic, 29, 109 total expenditures, 12 toxicity, 21 traffic, 107 training, 24, 29, 34, 35, 36, 48, 76, 102 transparent, 10 trauma, 8, 9, 11, 33, 38, 40, 41, 42, 49, 77, 79, 82, 105, 106, 107, 108, 111, 112, 116 traumatic brain injuries, 53, 99 traumatic events, 8, 9, 32, 33, 117 trial, 69, 78, 108, 114 triiodothyronine, 42 TSH, 42

U U.S. military, 7, 9 uncertainty, 63, 72

101

undergraduate, 59 Uniform Code of Military Justice (UCMJ), 5, 20, 22, 23, 68, 94 university students, 59

V veterans, xvii, 10, 12, 13, 14, 15, 16, 17, 18, 29, 31, 33, 34, 37, 39, 40, 52, 81, 82, 87, 88, 89, 101, 103, 104, 105, 107, 109, 112, 117, 118 Veterans Health Administration (VHA), 8 victims, 109 Vietnam, 9, 14, 17, 18, 31, 34, 37, 38, 41, 48, 88, 100, 102, 105, 107, 109, 110, 116, 118 Vietnam War, 18, 48 visual acuity, 86 vocational, 46, 57 vulnerability, 8, 41, 105

W war, xv, xix, 4, 8, 9, 11, 12, 14, 17, 18, 21, 22, 23, 24, 33, 46, 47, 88, 94, 99, 101, 104, 114, 116 war crimes, 18 war hero, 18 warfare, 11 websites, 76 wellbeing, 45 wire fraud, 17, 19 withdrawal, 37 women, xv, 34, 35, 99 word recognition, 86 workplace, 109 World Health Organization, 5, 119 World War, 8, 118 World War I, 118 World War II, 118

Morel, Kenneth R.. Differential Diagnosis of Malingering Versus Posttraumatic Stress Disorder, Nova Science Publishers,