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18 Malingering: Posttraumatic Stress Disorder and Depression KEITH NICHOLSON AND MICHAEL F. MARTELLI

It has long been known that it is possible to feign mental or other disorders and not be detected. Barrows (1971) showed that a wide range of psychiatric, neurologic, pain, fatigue, or other problems, in which there are usually few physical findings, could be readily simulated in the context of teaching or examining medical students. Psychiatric symptoms or syndromes that were readily simulated included depression, agitation, psychosis, neurotic reactions, and thought disorder. Neurologic symptoms that could easily be feigned included paralysis, sensory loss, reflex changes, extensor plantar responses, gait abnormalities, cranial nerve palsy, altered levels of consciousness, coma, seizures, and hyperkinesias. Even after being warned that there were simulators among the examinees, experienced clinicians found it difficult to detect them. Rosenhan (1973) reported that 12 people posing as “pseudopatients” and presenting with some psychiatric symptoms were able to gain admission to psychiatric hospitals in five different states. All but one of the 12 were diagnosed with Schizophrenia and none of the pseudopatients were detected despite hospital stays of from 7 to 52 days. Posttraumatic Stress Disorder (PTSD) and depression are common in the general population, and are also common sequelae following various accidents or injuries that may be an object of medicolegal proceedings (Nicholson & Martelli, 2006). These disorders are heterogeneous, with marked variability in presentation. There is an immense literature concerning their phenomenology, etiology, genetics, neurobiology, course, treatment, and other pertinent factors. The remainder of this section will focus on the differential diagnosis of malingering in the presentation of these psychoemotional problems. Sparr and Pankratz (1983) were the first to document persons simulating PTSD following introduction of this diagnosis into the DSM nomenclature. They described five men who claimed to have been traumatized by the Vietnam War, although four had never been in Vietnam and two had never been in the military. However, it was concluded that these were cases of Factitious Disorder rather than malingering. 501

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Guriel and Fremouw (2003) reviewed the empirical literature pertaining to the assessment of malingered PTSD. They noted that there is widespread concern about the possibility of malingered PTSD, and that PTSD may be one of several disorders that are vulnerable to malingering, as symptoms are subjective and there are often substantial financial or other associated benefits. They suggest that the possibility of malingering, including verification of the traumatic event if possible, be part of all clinical assessments. However, they note that there is no “gold standard” for the assessment of malingered PTSD and, in contrast, suggest that the empirical investigation into malingered PTSD is only in its infancy. Several MMPI (Hathaway & McKinley, 1967) and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) studies, mostly involving simulators but some with differential prevalence designs and some with purported known group designs, were reviewed. It was concluded that results from studies using the earlier MMPI were mixed. Those using the MMPI-2 were suggested to be helpful but not flawless in identifying simulated or malingered PTSD. The MMPI-2 validity scales F, FK, O-S, F-Fb, and Ds2 were considered particularly useful in detecting simulated response styles (see Chapter 16, Malingering: Traumatic Brain Injury, and Chapter 11, Conducting a Psychological Assessment by Andrew Kane, both in this volume, for a description of MMPI and other validity scales). As was discussed in Chapter 16 (Malingering: Traumatic Brain Injury), Rogers et al. (2003) conducted a meta-analysis of the MMPI-2 in the detection of malingering. It was concluded that genuine PTSD patients presumed to be responding honestly produced very extreme elevations on the MMPI-2 Fb validity scale (M  92, SD  25), extreme elevations on F (M  86, SD  22), with slightly higher elevations on other validity scales (i.e., Fp, M  69, SD  21; O-S, M  182, SD  72; DS, M  68, SD  15; FK, M  9, SD  11). As such, there is considerable overlap between the validity scale scores of genuine patients and the scores of those who are feigning (mostly simulators). Guriel and Fremouw (2003) also reviewed the Personality Assessment Inventory (PAI; Morey, 1991), another multiscale self-report inventory, which had only been used in two empirical studies. Results appeared similar to that of the MMPI-2, that is, possibly helpful but not flawless. Guriel and Fremouw (2003) summarized the results of several other techniques to detect malingering or other response sets in PTSD. They noted that although there has been a proliferation of scales to measure PTSD, only the Trauma Symptom Inventory (TSI; Briere, 1995) includes validity scales (Atypical Responses, Inconsistency, Response Level). Although cut-off scores to detect fake-bad response styles in PTSD claimants using this instrument have been developed (Edens et al., 1989), it was suggested that these need to be replicated [and see the study of Elhai et al. (2005) discussed below]. Another technique that has demonstrated capacity in distinguishing suspected PTSD simulators from others is a facial emotion identification task (Morel, 1998), although this also needs further study. The Structured Interview of Reported Symptoms (SIRS; Rogers, 1992, 1997), used extensively in criminal forensic work, is another technique that has some promise but limited study with detection of malingering in PTSD, the only study utilizing

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this technique not having any patients with PTSD in the comparison group (Rogers et al., 1992). Guriel and Fremouw (2003) reported that there have been mixed results utilizing the Rorschach projective technique to detect simulated PTSD. Finally, although psychophysiological assessment may accurately identify PTSD symptomatology, there has been limited study in detecting malingerers, and the utility of such measures in separating malingered from genuine responses remains controversial. Guriel and Fremouw (2003) eventually concluded that it is difficult to differentiate between malingered and genuine PTSD because an apparent “over-reporting” of symptoms is typical of many actual or legitimate PTSD cases. It was noted that there is a high comorbidity of PTSD with several other clinical or personality disorders, and that PTSD, like other severe pathologies, may include a myriad of symptoms resulting in elevated scales on various measures. There have been conflicting results on the effect of compensation status on presentation in PTSD. For example, Frueh et al. (2003), utilizing archival data from assessment of 320 adult male combat veterans, concluded that compensationseeking veterans reported significantly more distress and that they were much more likely to overreport or exaggerate their symptoms than were noncompensationseeking veterans. In contrast, DeViva and Bloem (2003), in an archival study of 141 combat veterans, found that compensation seeking was not related to psychometric assessment scores or indices of exaggeration. Neither compensation seeking nor indices of exaggeration were related to treatment outcome. However, it was noted that combat veterans seeking treatment for PTSD tend to report high levels of psychopathology on self-report instruments. On review of the literature, Elhai et al. (2004) also concluded that elevations on the MMPI-2 F scale were confounded with the effects of psychopathology and distress among psychiatric patients generally, and that F scale elevations in PTSD may be misleading as, rather than suggesting malingering, these have been associated with severe trauma exposure history, depression, dissociation, actual PTSD, increased somatic complaints as well as chaotic family-of-origin environments. It was noted that the Fp scale had been used in few studies with conflicting results. Elhai et al. (2004) reported on the utility of the newly created InfrequencyPosttraumatic Stress Disorder scale (Fptsd), which had previously been shown to demonstrate incremental validity over other MMPI-2 scales in detection of malingered PTSD with combat-exposed PTSD patients (Elhai et al., 2002). Elhai et al. (2004) studied the effectiveness of the Fptsd scale in addition to F and Fp in discriminating genuine civilian PTSD among 41 adult victims of child sexual abuse from a group of 39 students instructed to simulate PTSD. Analyses demonstrated Fptsd’s incremental validity over F but not over Fp. Based on the two studies examining Fptsd and other validity scales (Elhai et al., 2002, 2004), it was suggested that the Fptsd scale may be more appropriate for combat trauma victims, and the Fp scale may be more appropriate for civilian trauma victims. Greiffenstein et al. (2004) reported that the MMPI-2 Fake Bad Scale (FBS; Lees-Haley et al., 1991; see Chapter 16, Malingering: Traumatic Brain Injury) distinguished between litigants reporting “implausible symptoms” long after “minor

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frights or soft tissue injuries” and nonlitigants clinically-referred following severe stressors with “probable posttraumatic syndrome.” The F, Fp and FK scales showed poor utility in discriminating between these groups. Some of the “implausible” symptoms in the litigating sample were that there were multiple diagnoses (93.5% with three or more comorbid diagnoses), delayed symptom onset of one month or more, claims of both mild TBI and PTSD, and symptoms being nonresponsive to psychotropic medications. We would question how improbable such symptoms are. Moreover, although there was little specific information concerning pain problems, it appeared that at least 50 of 57 of the litigating sample had some significant pain problems. Of the nonlitigating sample, it appeared that robbery was the most common stressor and that there were few, if any, participants with significant pain problems. It was also noted that the mean FBS score for the nonlitigating trauma patients was above that initially suggested by Lees-Haley et al. (1991) as a cut-off. FBS cutting scores derived from logistic regression were applied to a third group made up of litigants with histories of undeniably severe trauma. A substantial number of this third group scored above cutoffs for exaggeration, and it was acknowledged that interpretation of this result was ambiguous, that is, higher scores may have been due to effects associated with trauma vs. exaggeration associated with compensation seeking status. Indeed, we do not think that this study provides any useful information concerning the utility of the FBS scale to distinguish between individuals presenting with sequelae associated with actual trauma (especially when this involves pain and related problems) and individuals who may be exaggerating associated with compensationseeking status. Elhai et al. (2005) recently examined the Trauma Symptom Inventory’s (TSI) ability to discriminate between student simulators and genuine PTSD outpatients. Whereas results demonstrated between-group differences on several TSI clinical scales, few were in the expected direction, that is, the PTSD patients scored higher than simulators on several scales. The Atypical Response validity scale was found to be inadequate in correctly classifying simulators and patients. It was noted that this scale was not developed as a measure of malingering but, instead, was intended to be a general validity screen. Noting the problem of the applicability of simulation studies for real-world clinical and forensic settings, and that simulators may be better able to avoid detection when informed about validity scales (Walters & Clopton, 2000), Eakin et al. (2006) studied the utility of the MMPI-2 and the PAI in distinguishing between students meeting criteria for PTSD and students who had been exposed to a traumatic event in the past three years but who did not screen positive for PTSD and who were either responding honestly or simulating. All subjects were coached about the presence of validity scales, and simulators were provided with detailed information about PTSD. Results indicated that the validity scales and selected clinical scales of the MMPI-2 and PAI were generally comparable in their ability to distinguish PTSD subjects from healthy controls. However, the PAI was not nearly as effective in discriminating between simulators and PTSD cases. In contrast, all of the MMPI-2 fake-bad validity scales (the FBS scale was not used

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in this study) and PTSD-relevant clinical scales significantly discriminated simulators and PTSD cases. The MMPI-2 scales demonstrated very good specificity, that is, not identifying a true PTSD case as a simulator, but poor sensitivity using established cutting scores, that is, many of the simulators avoided detection. Importantly, it was noted that whereas students meeting criteria for PTSD had been well diagnosed using the CAPS (Blake et al., 1995) or other criteria, these were not a treatment seeking group and were all undergraduate university students who were likely not as severely affected as may be the case with many others with PTSD. Depression is another disorder or psychoemotional difficulty that is common not only in the general population but, also, in medicolegal claims or disability assessments, and which may be especially vulnerable to feigning given that most people have some familiarity with symptomatology or ready access to such information (Bagby et al., 2000; Griffin et al., 1996; Nicholson & Martelli, 2006; Steffan et al., 2003). Several studies, most all of which have utilized the MMPI-2, have attempted to determine whether those feigning depression can be detected. Bagby et al. (1997) compared the MMPI-2 profiles of college students simulating depression or Schizophrenia with profiles produced by actual patients, and found that the MMPI-2 F and Fp validity scales were better able to detect feigned schizophrenia than depression, whereas Fb was better at identifying simulated depression. Bagby et al. (2000) subsequently studied the ability of mental health professionals (psychiatrists, nurses, social workers) with advanced degrees and considerable clinical experience in assessing or treating depression to feign depression while completing the MMPI-2. It was concluded that the clinical experts were unable to successfully simulate depression although they were better than were the student simulators in the Bagby et al. (1997) study. Bagby et al. (2000) found that the Fb validity scale best discriminated between groups, followed closely by F. Neither the Ds nor the FBS scales contributed uniquely to explaining the variance. The feigners also scored higher than clinical cases on six of the nine MMPI-2 clinical scales. Other studies have found that knowledge of depression or questionnaire validity scales has an effect on the ability of simulators to escape detection. Walters and Clopton (2000) found that simulators who were provided with information about depression or the MMPI-2 validity indices were significantly more successful in simulating depression than participants who were not provided with such information. Viglione et al. (2001) found that subjects simulating depression who had been cautioned to avoid grossly exaggerating their responses produced smaller elevations on MMPI-2 scales and, therefore, had more realistic profiles than simulators who were not so cautioned. None of the validity indices adequately identified simulators who had been cautioned. It was suggested that many real-life malingerers are likely cautious, so that real-life malingering effect sizes may be much smaller than those in simulation studies. Crawford et al. (2006) compared the MMPI-2 records of (1) sophisticated student simulators who had been presented with a scenario about a worker who suffered facial trauma and who were to then feign depression, with (2) the archival records of depressed in-patients.

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They found that the FBS scale was the only validity scale that successfully discriminated between groups. Rogers et al. (2003), as discussed in Chapter 16, conducted a meta-analysis of MMPI-2 studies involving malingering or feigning of mental disorder with an emphasis on distinguishing real from feigned disorder. With respect to depression, it was found that those with genuine depression may have extreme elevations on scales F and Fb. Ds appeared to provide the best discrimination between those who were genuinely depressed and all feigners, but none of the existing MMPI-2 validity scales provided very good discrimination. Steffan et al. (2003) developed the Malingered Depression (Md) scale from 32 MMPI-2 items that distinguished between college students who feigned depression and those who reported at least mild to moderate depression. A cross-validation study with sophisticated (i.e., provided with information about MMPI-2 validity scales) and naive simulators, and a sample of students in counseling (and presumably depressed) indicated that the Md scale was well able to discriminate between those who were feigning and those who were not, and that this scale provided incremental validity in differentiating sophisticated simulators from depressed persons. However, it was noted that a higher cut-off score may be necessary with patients who are more depressed. Bagby et al. (2005) subsequently examined the incremental validity of the Md scale in comparison with the F, Fb, and Fp scales to detect feigned depression. Although the Md scale did successfully discriminate cases of feigned depression from patients with bona fide mild–moderate or severe depression, the Fb scale and the F/Fp scale combination were the best single predictors. It was suggested that the Md scale may not provide incremental validity over the existing MMPI-2 F, Fb, and Fp scales. Again, there was large overlap between the validity scale scores of the genuine patients and simulators. Mogge and Lepage (2004) have recently developed the Assessment of Depression Inventory (ADI), which assesses both depression and response bias. In studies that have included cross-validation of the initial findings, it has been found that the measure of depression correlates with other well-validated measures, and that the feigning scale discriminates between simulators and actual patients. One other technique that has begun to be explored in the detection of malingered depression is that of computerized content analysis of speech (Cannizzaro et al., 2004). Although this technique needs further study and development, as do various electrophysiological or other neuroimaging techniques, it may become very useful in many clinical endeavors in the future.

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