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.     

Sevoflurane concentrations in blood, brain, and lung after sevoflurane-induced death

Sevoflurane concentrations in blood, brain, and lung were measured in an individual apparently dying from sevoflurane inhalation. Sevoflurane is a volatile nonflammable fluorinated methyl isopropyl ether inhaled anesthetic, chemically related to desflurane and isoflurane. The incidence of abuse of sevoflurane is lower than that of other drugs of abuse possibly due to its inaccessibility to the general public and less pleasurable and addicting effects. The dead subject was an anesthetist found prone in bed holding an empty bottle of sevoflurane (Ultane). Serum, urine, and liver were screened for numerous drugs and metabolites using enzyme immunoassays and gas chromatography-mass spectrometry. Analysis did not reveal presence of any drug, including ethanol, other than sevoflurane. Sevoflurane was determined by headspace gas chromatography and revealed concentrations of 15 microg/mL in blood and 130 mg/kg in brain and lung. Autopsy revealed pulmonary edema and frothing in the lung, pathological findings associated with death by sevoflurane or hypoxia. The cause of death was ruled as sevoflurane toxicity and the manner of death as accident.     

The fate of the chemical warfare agent during DNA extraction

Forensic laboratories do not have the infrastructure to process or store contaminated DNA samples that have been recovered from a crime scene contaminated with chemical or biological warfare agents. Previous research has shown that DNA profiles can be recovered from blood exposed to several chemical warfare agents after the agent has been removed. The fate of four toxic agents, sulfur mustard, sodium 2-fluoroacetate, sarin, and diazinon, in a lysis buffer used in Promega DNA IQ extraction protocol was studied to determine if extraction would render the samples safe. Two independent analytical methods were used per agent, selected from GC-MS, 1H NMR, 19F NMR, (31)P NMR, or LC-ES MS. The methods were validated before use. Determinations were carried out in a semi-quantitative way, by direct comparison to standards. Agent levels in the elution buffer were found to be below the detectable limits for mustard, sarin, sodium 2-fluoroacetate or low (<0.02 mg/mL) for diazinon. Therefore, once extracted these DNA samples could be safely processed in a forensic laboratory.     

The role of environmental factors in the causation of sudden death in infants: two cases of sudden unexpected death in two unrelated infants who were cared for by the same babysitter

We report two cases of sudden unexpected death in two unrelated African American female infants, 2 months and 4 months old. Both infants were attended to by the same babysitter in the same apartment and died 39 days apart in the same bed and in the same bedroom. The autopsy of the first infant revealed sudden unexplained death in an infant. Toxicologic analysis for carbon monoxide (CO) was not performed because it was not suspected. When the second infant died, investigation into the ambient air quality within the apartment revealed high levels of CO emanating from a poorly ventilated and defective hot water heater, which was located across a hallway from the bedroom where the two babies died. CO saturation levels in the postmortem blood samples of the two babies were elevated and were similar (13% and 14%). Nicotine and cotinine were not detected in the blood sample of the two infants. Cherry-red livor mortis was absent. Acute CO intoxication was determined to be the underlying cause of these two unexpected deaths. These two cases underscore the need to integrate ambient air analysis and postmortem CO analysis as routine components of the comprehensive death investigation of infants who die suddenly and unexpectedly.     

Forensic dental training in the dental school curriculum

This article reviews the literature regarding forensic education in the dental school curriculum and describes an exercise in forensic identification of victims of a mass casualty. Radiographs were made of dentate human cadavers in the gross anatomy laboratory at the Southern Illinois School of Dental Medicine. The jaws were then removed to provide "wet specimens" for the exercise. Several restorations were performed on the cadaver teeth, after which radiographs of the dissected jaws were made. One author wrote up mock dental records for each of the victims. These records included the first set or "premortem" radiographs. Students participating in the exercise were provided with a plane crash scenario, the dental records of the passengers on the manifest, the dissected jaws, and the second set or "postmortem" radiographs. Students were expected to form three teams. The first two teams evaluated the ante-mortem and postmortem dental records. The third team compared the ante-mortem and postmortem records to arrive at identification. The purpose of the exercise was twofold. It introduced dental students to forensic dentistry and emphasized the need for complete and accurate record keeping in the dental office. Several factors lessened the realism of the exercise and made it difficult to reproduce in the future. These included the uniformity of the dental records and the destruction of cadaver material following the exercise.     

Y-STRs in forensic medicine: DNA analysis in semen samples of azoospermic individuals

ABSTRACT: The incidence of rape has increased, especially in metropolitan areas, such as the city of São Paulo. In Brazil, studies about it have shown that the majority of this type of crime is committed by the relatives and persons close to the victim. This has made the crime more difficult to be denounced, as only 10% of the cases are reported to competent police authorities. Usually, cytological exams are carried out in sex crime investigations. The difficulty in showing the presence of spermatozoa is frequent, but it does not exclude the presence of male DNA. The absence of spermatozoa in material collected from rape victims can be due to several factors, including the fact that the agressor suffers from azoospermia. This condition can be the result of a successful vasectomy. As the majority of DNA in the ejaculation sample is from spermatozoa, there is much less DNA to be analyzed. This study presents the application of Y‐STRs (DYS19, DYS389I, DYS389II, DYS390, DYS391, DYS392, and DYS393) in DNA analysis of sperm samples from 105 vasectomized men. The study demonstrated a great variation in DNA concentration. DNA extraction and amplification was possible in all sperm samples even in the absence of spermatozoa. The same profile was observed, for each individual, from DNA extracted from blood, pre‐ and postvasectomy semen samples. The use of markers specific for Y chromosome in sex crime cases, especially in the absence of spermatozoa, is very important, mainly because in most situations there is a small quantity of the agressor's DNA in the medium and a large quantity of the victim's DNA.     

Taphonomic changes to blunt force trauma: a preliminary study

This study examines the effects of taphonomic processes on blunt force trauma (BFT) through an experimental study involving pig heads. Of particular concern is the possibility that taphonomic changes can create pseudo-trauma and/or conceal evidence of actual trauma. BFT was inflicted on 10 pig skulls using a hammer. The skulls were subsequently exposed to the environment for 12 months. Seven taphonomic changes were evaluated: the freeze-thaw cycle; rodent gnawing; carnivore scavenging; presence/weight of soil; presence/weight of rain and snow; movement/displacement of bones; and discoloration due to sun bleaching and grass staining. Taphonomic effects varied between cancellous, compact, fresh, and degreased bone. Freezing and thawing, exposure to rain and snow, movement of the skulls, and soil erosion altered and, in some cases disguised, pre-existing trauma. Rodent and carnivore activity did not obliterate evidence of BFT. Recommendations for evaluating BFT on remains affected by taphonomic processes are presented. As each taphonomic process outlined by this study has the potential to disguise antemortem injury, the authors propose that one must carefully examine large, circular openings in the skull that may represent the remnant evidence of BFT.     

Evaluation of the Suchey-Brooks method for aging skeletons in the Balkans

This study has been carried out to examine whether the Suchey-Brooks (S&B) methods could be successfully applied in age assessment of populations from the Balkans. The known-age sample consists of 33 females and 52 males pairs of pubic bones collected from the autopsy cases. Age estimation by S&B method showed an accuracy of 89.74% in males and 72.0% in females. Statistical analysis showed a positive correlation between the actual age of the investigated individuals and age phases obtained by the S&B method, although the mean values of the sixth age category differed significantly compared with the original model. The most reliable indicators in both sexes were the relief of the symphyseal surface, lipping, symphyseal rim, and dorsal margin. The discriminating power of these indicators was the least reliable in distinguishing S&B phases 2 and 3. Based on these results, the appropriate recommendations for aging Serbian populations are made. There was a good agreement between two observers (kappa=0.726).     

Mole guns in Turkey in 2003-2005

This study describes the frequency of mole guns in Turkey by examining the cases sent to the Council of Forensic Medicine of Turkey between 2003 and 2005. In total, 11 mole guns were examined. Mole guns are manufactured to be used as a trap against detrimental animals. Although they are not meant to be used as a firearm, they are able to cause death. Mole guns appearing in regular casework were evaluated in terms of type of the gun, number of barrels, size and caliber, rifling, design, mechanism, fitness for use, legality, and geographical distribution. Ninety-one percent of the guns were 12 gauge. Most commonly they originate from Inner Anatolia. Mole guns are typically handmade. Some examples of injuries and deaths caused by mole guns are also offered.     

Waxing grave about adipocere: soft tissue change in an aquatic context

When postmortem environmental conditions are "just right," according to the "Goldilocks Phenomenon," soft tissues (and associated fatty acids) are converted into and preserved as adipocere. To better understand this conversion process and the development of adipocere three human cadavers were immersed in outside, water-filled pits for over 3 months to observe adipocere formation in an underwater context simulating actual field conditions. Recordings of environmental conditions showed that temperatures were between 21 degrees C and 45 degrees C, a range sufficient for the growth of Clostridium perfringens. Chemical analysis of liquid and tissue samples revealed an increase in palmitic acid and decrease in oleic acid. This study tracked the remarkable gross morphological changes that can occur in human bodies subjected to an aquatic postmortem environment. The results support the "Goldilocks Phenomenon" and substantiate previous findings that the presence of bacteria and water is crucial for adipocere to form.