Malingered Posttraumatic Stress Disorder (PTSD) and the Effect of Direct Versus Indirect Trauma Exposure on Symptom Profiles and Detectability

Posttraumatic stress disorder (PTSD) is arguably prone to malingering due to its subjective and heterogeneous nature. Various factors can influence PTSD symptom profiles including trauma type and trauma exposure. However, it is unknown whether trauma exposure influences malingered PTSD symptom profiles. We used a malingering simulation design with trauma type controlled to compare (1) PTSD symptom profiles (Posttraumatic Stress Checliklist-5; PCL-5) at the syndrome, symptom cluster, and individual symptom levels and (2) symptom validity profiles (Structured Inventory of Malingered Symptomatology; SIMS) at the overall and subscale level, as a function of direct and indirect trauma exposure. Seventy-three participants were randomly assigned to either the direct (“witnessed” trauma) or indirect (“learned about” trauma) condition. Participants were coached about symptoms and instructed to simulate PTSD. PCL-5 profile analyses revealed that simulators in the direct exposure group reported greater overall PTSD severity. Significant differences were found on cluster D (changes in cognition and mood) and individual symptoms including intrusive thoughts, amnesia, difficulty experiencing positive emotions, and risk-taking. No differences were identified for any other symptom scores nor for the symptom validity profile, except for the SIMS total score (direct: M?=?33.0, SD?=?12.8, indirect: M?=?26.5, SD?=?13.9, t(71)?=?2.06, p?=?.043, d?=?.48). These findings indicate that trauma exposure can influence malingered PTSD profiles at the syndrome, symptom cluster, and individual symptom levels (small effects), but, with one exception for a summary score, it does not produce a detectable difference on symptom validity testing. This study may provide insight for clinicians into the how malingered PTSD profiles can manifest as a result of direct and indirect trauma exposure; however, further research is strongly indicated.     

Detection of Malingered PTSD: An Overview of Clinical,Psychometric, and Physiological Assessment: Where Do We Stand?

ABSTRACT: Posttraumatic stress disorder (PTSD) is a condition that can be easily malingered for secondary gain. For this reason, it is important for physicians to understand the phenomenology of true PTSD and indicators that suggest an individual is malingering. This paper reviews the prevalence of PTSD for both the general population and for specific events, such as rape and terrorism, to familiarize evaluators with the frequency of its occurrence. The diagnostic criteria for PTSD, as well as potential ambiguities in the criteria, such as what constitutes an exposure to a traumatic event, are reviewed. Identified risk factors are reviewed as a potential way to help differentiate true cases of PTSD from malingered cases. The question of symptom overreporting as a feature of the disease versus a sign of malingering is discussed. We then examine how the clinician can use the clinical interview (e.g., SIRS, CAPS), psychometric testing, and the patient's physiological responses to detect malingering. Particular attention is paid to research on the MMPI and the subscales of infrequency (F), infrequency-psychopathology (Fp), and infrequency-posttraumatic stress disorder (Fptsd). Research and questions regarding the accuracy of self-report questionnaires, specifically the Mississippi Scale (MSS) and the Personality Assessment Inventory (PAI), are examined. Validity, usability, and cutoff values for other psychometric tests, checklists, and physiological tests are discussed. The review includes a case, which shows how an individual used symptom checklist information to malinger PTSD and the inconsistencies in his story that the evaluator detected. We conclude with a discussion regarding future diagnostic criteria and suggestions for research, including a systematic multifaceted approach to identify malingering.     

A Commentary on the MND Model and the Boone Critique: “Saying It Doesn’t Make It So”

We appreciate Boone’s (2011, this issue) critique of Rogers, Bender, and Johnson’s (2011, this issue) analysis of the Malingered Neurocognitive Dysfunction (MND) criteria. She raised good points and appeared in general agreement regarding several crucial limitations of the MND model. However, Boone remained mostly silent on several issues including the compelling results from our methodological review of MND studies and Criteria A through D. When provided, her comments tended to be very selective and were often presented with little or no empirical support. This contrasting pattern of strong statements and weak evidence appears to unintentionally parallel the MND model, which was documented in our original analysis. As a result of her criticism, however, we clarified our point regarding methodological limitations in establishing levels of TBI and its potential relevance to determinations of feigned cognitive impairment. We hope that these spirited discussions will stimulate a much-needed review and a fundamental revamping, if not replacement, of the MND model.     

Do Motivations for Malingering Matter? Symptoms of Malingered PTSD as a Function of Motivation and Trauma Type

Psychological disorders associated with traumatic events, such as post-traumatic stress disorder (PTSD), may be prone to malingering due to the subjective nature of trauma symptomology. In general, symptoms tend to be inflated when an external reward (i.e., compensation) is associated with the claim. The present study was designed to test whether malingered claims of PTSD symptoms differed as a function of the type of trauma being malingered (accident, disaster, sexual assault) and the motivation for malingering (compensation, attention, revenge, no motivation). Participants were randomly assigned into conditions, given malingering instructions, and then asked to complete three measures of trauma symptoms (Impact of Event Scale??Revised; Post-Traumatic Stress Disorder Checklist; Trauma Symptom Inventory). Results indicated that participants in the sexual assault condition produced higher symptom reports on nearly all scales. Revenge and compensation motivations yielded elevated symptom scores. Further, individuals rated high in fantasy proneness and dissociation produced elevated scores on atypical responding and most clinical scales. More research is needed to examine the extent to which different motivations and trauma types influence symptom reporting.     

Differentiating Factitious from Malingered Symptomatology: the Development of a Psychometric Approach

Psychometric symptom validity assessment is becoming increasingly part and parcel of psychological and neuropsychological assessments. An unresolved and rarely addressed issue concerns the differentiation between factitious and malingered symptom presentations: present-day symptom validity tests can assess whether an examinee presents with noncredible symptomatology, but not why an examinee does so. We explored this issue by developing the Symptom and Disposition Interview (SDI); a symptom validity test that incorporates strategies intended to gauge internal incentives associated with factitious disorder. The merits of the SDI were explored and compared to a traditional symptom validity test (the Structured Inventory of Malingered Symptomatology) in two analogue studies, each with factitious and malingering conditions (n = 24–30 per condition) and a clinical control group (n = 34, n = 40). Overall, the results were positive: The SDI was as effective in detecting feigned symptom presentations as a traditional symptom validity test and superior in differentiating factitious from malingered symptom presentations. We conclude that the SDI is not ready for clinical use, but that psychometric approaches to the assessment of factitious symptomatology, such as the SDI, appear sufficiently promising to warrant future research.     

Symptom Validity Testing in Claimants with Alleged Posttraumatic Stress Disorder: Comparing the Morel Emotional Numbing Test, the Structured Inventory of Malingered Symptomatology, and the Word Memory Test

In independent medical examinations, unjustified claims of posttraumatic stress disorder (PTSD) are to be expected at an increased rate. In a prospective study, consecutive cases of patients claiming PTSD who underwent independent neuropsychiatric evaluation were analyzed. For 61 adult patients, results of three symptom validity tests (Morel Emotional Numbing Test, Structured Inventory of Malingered Symptomatology, and Word Memory Test) were available. Seventy percent of all claimants showed probable negative response bias in at least one of the three tests, 25% in all three tests. High probability of negative response bias was associated with symptom overreporting and demonstration of cognitive deficits in performance tests. The results indicate that high rates of uncooperativeness must be expected in civil forensic patients with claimed PTSD. A multi-method approach to the assessment of response distortion in PTSD claimants is indicated.     

The Relationship Between Psychopathic Personality Features and Malingering Symptoms of Major Mental Illness

This study examined the relationship between psychopathy and malingering in a subsample of male prison inmates (n = 55) participating in a larger study of the clinical utility of various assessment measures in correctional settings. Participants' capacity to feign major mental illness successfully was evaluated using standard cutoff scores for the detection of malingering on a variety of instruments, including the Structured Inventory of Malingered Symptomatology (SIMS; G. P. Smith & G. O. Burger, 1997), the Structured Interview of Reported Symptoms (SIRS; R. Rogers, R. M. Bagby, & S. E. Dickens, 1992), and the Personality Assessment Inventory (PAI; L. Morey, 1991). Psychopathic traits were assessed via the Psychopathic Personality Inventory (PPI; S.O. Lilienfeld & B. P. Andrews, 1996). Correlations between the malingering indices and the PPI were low (–.14 to .14) and not statistically significant. These findings fail to support the clinical intuition that individuals with higher levels of psychopathy are likely to be more adept at malingering.     

Investigating Differences in Truthful and Fabricated Symptoms of Traumatic Stress over Time

False allegations of victimization typically are accompanied by malingered emotional symptomology to corroborate claims. This analog study was designed to compare truthful and fabricated symptom profiles on measures of post-traumatic stress (i.e., Revised Impact of Event Scale, Post-Traumatic Stress Disorder (PTSD) Checklist, Trauma Symptom Inventory) and levels of symptom consistency over time. Participants (undergraduate students) described their mental health symptoms for both traumas at time 1 (N?=?291), time 2 (N?=?252, 3 month), and time 3 (N?=?181, 6 months). Results indicated that fabricated traumas were associated with inflated symptom profiles. Validity scales were not effective at discerning symptom veracity, although reports could be discriminated somewhat by atypical responding and clinical scales. PTSD symptoms in malingerers also were reported more consistently over time. This research offers applicable information for identifying feigned traumatic stress.     

PTSD symptom reporting and persistent malingering in recipients of state compensation for violent crime victimization: an exploratory study

Previous research suggests that victims of violent crime who have applied for state compensation may persist in malingering after conclusion of the application process. To further explore this topic, the current study investigated differences in PTSD symptomatology between violent crime victims who had received compensation from the Dutch state and those who had been denied such compensation. Potential participants were approached through the Dutch Violent Offences Compensation Fund. Eventually, 125 victims agreed to participate and filled out a set of paper-and-pencil questionnaires. Both univariate and multivariate analyses revealed that recipients of compensation had reported higher symptom levels, than non-recipients but only when they could be qualified as probable malingerers. If compensation recipients could not be qualified as probable malingerers, they had reported lower symptom levels than non-recipients. This suggests that some victims will emotionally benefit from compensation, while others will unconsciously accept it as a validation of initially malingered symptoms. Results were discussed in terms of directions for future research and study limitations.     

Psychological Injury: Systems, Change Processes, Development

This paper presents a model of chronic pain [Young and Chapman (Pain, affect, nonlinear dynamical systems, and chronic pain: Bringing order to disorder. In G. Young, A. W. Kane, & K. Nicholson (Eds.), Causality of psychological injury: Presenting evidence in court (pp. 197–241). New York: Springer, 2007)]. It includes extensive coverage of the systems perspective. The paper expands the model to medically unexplained symptoms and provides a developmental model of how these may unfold and influence adult presentation after events such as accidents. Similarly, the model is examined for the developmental roots of personality disorder. The paper examines other threats to validity of diagnosis in cases of psychological injury.     

Discrepancy between Mother and Child Perceptions of Their Relationship: II. Consequences for Children Considered within the Context of Maternal Physical Illness

Discrepancies between parent and child perceptions of parenting have been well established. The current study addressed whether discrepancies in one dimension of parenting, the parent-child relationship, are associated with child adjustment difficulties concurrently and longitudinally. In particular, it was hypothesized that greater discrepancies in mother and child perceptions of parenting would be associated with child adjustment difficulties. Furthermore, it was hypothesized that families experiencing a stressor—in this case, maternal infection with the human immunodeficiency virus (HIV)—would experience larger discrepancies than families in which the mother is noninfected and that maternal HIV infection would moderate the association between discrepant views and child adjustment. Participants were 183 African-American women (61 HIV infected; 122 noninfected) and one of their noninfected children. All participants were from the inner-city area of New Orleans. Results indicated that discrepancies in mother and child perceptions of their relationship was associated with mother and child reports of externalizing behavior problems concurrently and longitudinally. In addition, discrepancies were significantly higher in families experiencing maternal HIV infection than in the noninfected group. However, with one exception, maternal HIV status failed to moderate the relationship between discrepancies in perception and child adjustment, indicating that discrepancies play a similar role in both types of families. Clinical implications of the present results are discussed.     

Detection of Malingered ADHD Using the MMPI-2-RF

This study examined the utility of the Minnesota Multiphasic Personality Inventory—2 Restructured Form (MMPI-2-RF) validity scales for detecting feigning and exaggeration of attention-deficit/hyperactive disorder (ADHD) among college students. Under a simulation study design, participants with and without ADHD were assigned to perform honestly or to feign or exaggerate deficits related to ADHD while completing self-report symptom inventories. Participants instructed to feign produced symptom profiles similar to honest clinical profiles and more severe than honest nonclinical profiles. Participants with ADHD instructed to exaggerate produced less severe profiles than those instructed to feign and more severe profiles than clinical controls. MMPI-2-RF scale Fp-r showed potential for use in malingered ADHD detection at a revised cut score, which was significantly lower than the cut score suggested in the test manual; use of the revised cut score will require further validation. Scales F-r, Fs, and FBS-r did not classify well, but should be assessed in future studies of malingered ADHD. Detection of exaggeration was consistently poorer than detection of feigning.     

Medicalization and social justice

Most social justice critiques of medical care focus upon the allocation of extant, but scarce, resources. In contrast to that focus, this article explores the preallocative arena of factors which shape the supply and availability of medical care. We identify four such factors: (1)medicalization — the tendency to regard as biologically caused various human problems which were in earlier eras ignored or attributed to other causes; (2)social inclusion — the bringing of economically deprived and socially marginal groups into participation in the medical care system; (3)biomedical transcendence — the elevation of biomedically derived concepts of human function into a social and personal world view; and (4)health absolutism — the ideology which holds individuals accountable for their own health and which, contrary to the thrust of the other factors, deemphasizes access and social equity for professionally provided medical care. While these forces all enhance the place of health as a social value, it is by no means certain that they will lead to a society which is more medically just. The article concludes with an appeal for critical analysis of the processes which shape both the medical care system and the broad social concern with medical care.     

Military Service Records: Searching for the Truth

In conducting Compensation and Pension (C&P) examinations, one of the most significant sources of evidence supporting a veteran’s claim for service connection are found in the veteran’s service medical records and service personnel records. Although specific numbers are unknown, a majority of mental health providers who conduct C&P examinations are not veterans and have limited knowledge and understanding of the records they are being asked to review. In cases of an initial posttraumatic stress disorder (PTSD) examination, the Federal Register requires C&P examiners to determine if the veteran’s claim is consistent with the places, types, and circumstances of the veteran’s service. This article reviews specific data within personnel records to help verify those elements. Additionally, perhaps one of the most difficult types of evaluations faced by any C&P examiner is a PTSD claim for personal assault (e.g., military sexual trauma). This article reviews the types of information within the records to help identify specific “Markers” associated with personal trauma.     

Neuropsychological and Psychological Aspects of Malingered Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is an anxiety disorder that is frequently encountered in litigation, and as such, there is an increased risk for poor effort on cognitive tests, symptom exaggeration, or frank malingering. These are particularly problematic for accurate diagnosis. This article is divided into four sections. First, we address why individuals malinger PTSD as well as the challenges in detecting an invalid PTSD symptom presentation. Second, we discuss issues of cognitive functioning in PTSD and then the prevalence of and common patterns of poor effort on neuropsychological testing among individuals feigning PTSD. Third, we discuss psychological functioning in PTSD and then the prevalence and patterns of functioning on psychological measures of malingering in this population. Finally, recommendations for detecting invalid PTSD symptom presentations are provided.     

A report of the 2002–2008 paternity testing workshops of the English speaking working group of the International Society for Forensic Genetics

The English Speaking Working Group (ESWG) of the International Society for Forensic Genetics (ISFG) offers an annual Paternity Testing Workshop open to all members of the group. Blood samples, a questionnaire and a paper challenge are sent to the participants. Here, we present the results of the 2002–2008 Paternity Testing Workshops with the objective to evaluate the uniformity of DNA-profiling and conclusions of the participating laboratories as well as to clarify tendencies in typing strategies and biostatistical evaluations of the laboratories. The numbers of participating laboratories increased from 46 in 2002 to 68 in 2008. The results showed an increasing degree of concordance concerning methods and DNA systems used and a high degree of uniformity in typing results with discrepancies in 0.1 and 0.3 % of all submitted PCR-based results. The paper challenges showed uniformity in the calculation of the weight of evidence for simple cases with straight-forward genetic constellations. However, a high degree of variation existed in complex scenarios with rare genetic constellations such as genetic inconsistencies/possible silent alleles, rare alleles and haplotypes.     

Economics and Law of Works of Art in the Single European Market

This paper is concerned with the economic analysis of the European rules on the circulation of works of art. After reviewing the relevant literature, an economic framework of the international circulation of works of art is provided (social goals, efficiency and distributive aspects, an economic rationale for a general free trade rule integrated by selective protectionism). Using this framework the European system of circulation of works of art—resulting from the combination of the Maastricht Treaty with Regulation 3911/92 and Directive 93/7—is analysed. The main results of the analysis are: 1) the general free trade principle ruling the Single European Market is strongly limited by rules protecting national artistic heritages of member states; 2) this protectionism—working towards countries both outside and inside the European Union—is applied according to the national laws of each member state, while, contrary to what the Maastricht Treaty would call for, an artistic heritage of European significance is not defined and no autonomous role is recognized in this field to European Institutions; 3) this system shows some inconsistencies with economic theory, as strict limits to trade are not provided when they should be required by the preservation of the physical or artistic integrity of works of art, while in other cases an unduly restrained trade may derive from highly protectionist national laws and export-licencing policies of member states. Enforcement provisions are also analysed and some proposals to improve the system are advanced.     

Paternity testing in a kidnapping case

A case of kidnapping involving the concept of paternity testing is described. The couple arrested and charged with kidnapping stated the child in their possession was their biological daughter. Serological tests were performed on liquid blood samples in an effort to determine if the couple could have been the biological parents of the child. Two genetic inconsistencies were discovered in the 15 blood marker systems analyzed.     

Innovation in the U.S. Service Sector

This paper contributes to ard a better understanding of innovation in the service sector by focusing on the disparate nature of R&D in the U.S. service sector as learned through case studies of the U.S. telecommunications, financial services, systems integration services, and research and development testing services industries. Based on this understanding of the nature and scope of R&D therein, a new policy-oriented model of innovation specific to the service sector is posited. Also, policy recommendations are offered with regard to the public sector’s collection and interpretation of R&D data related to the service sector.