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Malingering Psychiatric Disorders and Cognitive Impairment in Personal Injury Settings Page 2
Table 3
Many PTSD experts built their reputations by developing checklists or interview schedules to identify PTSD patients and help them fully describe their experiences and symptoms. This focus on "finding" the disorder has helped build a culture in which the validity of a PTSD claim is largely assumed. The program for the 20th annual meeting of the International Society for Traumatic Stress Studies makes no mention of malingering in any one of dozens of trauma symposia. One researcher reported that his efforts to develop a measure of PTSD malingering were met with hostility by one PTSD pioneer.32 Most PTSD diagnostic interviews and self-report scales represent straightforward queries about symptoms and allow any motivated person to present themselves as having the requisite symptoms to meet the diagnostic criteria.33 Few instruments have any means to detect exaggeration or unreliable responding. One such interview schedule, the Clinician Administered PTSD Scale, has a consistency scale to help detect unreliable responding, but one study found it completely ineffective.34 On the other hand, the Atypical Responding Scale on the Trauma Symptom Inventory was able to correctly identify 81% of feigners and 92% of legitimate patients.35 Impressively, these figures were obtained on cross-validation, not just on the original study. The MMPI-2 has two scales, PS and PK, which are designed to assess PTSD symptoms. However, these scales appear highly sensitive to general distress and are not specific to PTSD.36 More useful are the MMPI-2 validity scales, which are capable of distinguishing malingerers from those with PTSD presumed to be legitimate. A recent meta analysis37 concluded that a relatively new scale, (Fp), was superior to traditional indices like the F (Infrequency) scale for two reasons: 1) F(p) contains fewer items that are legitimate symptoms of mental disorder, and 2) the most effective cut score for F(p) has remained fairly stable across studies, unlike those for other scales. A correct classification rate, across studies, of almost 85% was observed.38 A specialized scale designed specifically to identify feigning in personal injury claimants, FBS, was found relatively ineffective at detecting malingered PTSD.39 Lastly, although knowledge of PTSD symptoms may help persuade a claimant present a convincing facade in a face to face interview or on self-report scales, such knowledge does not help evade feigners evade detection on the MMPI-2 validity scales.40 The SIRS appears capable of detecting those who fake PTSD. Unfortunately, no published study has shown it is capable of distinguishing simulators from legitimate PTSD patients. This is a potentially important distinction, because many respected authors have claimed that PTSD patients legitimately experience severe and bizarre symptoms. Thus, they would be at risk for misidentification on typical malingering scales. Empirical demonstration that malingerers and legitimate PTSD patients score differently on the SIRS is needed, but does not currently exist. Another test, specifically developed for distinguishing feigned PTSD, is the Morel Emotional Numbing Test (MENT). Norms are available for legitimate PTSD patients (and other psychiatric groups) and for patients identified as probably exaggerating. None of the former group failed the MENT while 80% of the latter group did. 41 Because PTSD is a psychiatric disorder with few demonstrated cognitive impairments,42 failure on cognitive tests of malingering (such as the TOMM, WMT) can provide strong evidence intentional failure. Poor performance on these cognitive tests requires intentional failure or poor effort, which is distinct from over-reporting or exaggeration. Thus, failure cannot be explained by the claim that dramatization is part and parcel of PTSD.
Psychophysiological Assessment The failure of researchers to identify malingering in diagnosed PTSD patients has one predictable result: The percentage of true patients and malingerers accurately classified will be underestimated. Thus, the accuracy of F(p) and the psychophysiological measures might be considerably better than the 85% and 75% figures cited suggest. For example, if 30% of PTSD patients are malingering, and the PTSD and malingering groups are of equal size, that 30% could account for ALL of the misclassifications for a test with 85% accuracy.
Who Develops PTSD? In Who Does it Persist? Follow up studies of those initially diagnosed with PTSD show that 60% continues to report significant symptoms at six months. The factors listed in Table 4 have been found related to symptom remission or persistence in one or more published studies (number of supportive studies in parentheses). The most reliable findings involve dissociation at the time of the trauma and PTSD-like symptoms in the immediate aftermath. Acute Stress Disorder (ASD) entails the same symptoms as PTSD but does not require the one month delay between the traumatic event and the diagnosis. Not surprisingly, the presence of such symptoms before one month predicts the presence of such symptoms after one month. Table 4
Depression The MMPI-2's newer special malingering scales, particularly F(p) and Ds, appear effective and to produce high correct classification rates in classifying legitimate and feigned depression.50 A newly developed scale, Md (Malingered Depression), appears to provide some additional discrimination when feigners have been coached as to the content of depression scales and the validity indicators used to detect exaggeration.51 However, it is clear that coaching about validity scales does reduce their effectiveness. Persons who are depressed often complain of memory problems and difficulty concentrating. Nonetheless, they typically perform normally on recognition-based memory tests.52 Thus, as with PTSD, failure on cognitive tests like the TOMM or WMT can potentially provide powerful corroborating evidence of intentional failure. 53
Brain Damage Brain injury often leads to emotional distress and problems in function that lead to adjustment problems. Claimants who have suffered a head injury often report bodily symptoms (more so than psychiatric problems), and those that exaggerate tend to maintain the same pattern but to produce more elevated MMPI-2 profiles in general. There have been a number of studies examining the ability of various MMPI-2 scales to distinguish legitimate from feigning brain injury patients. The results indicated that the traditional validity indexes (F, F-K) and even some newer ones (F(p)) do not work very well. This is probably because they contain items that refer to psychosis and major mental illness rather than the image that personal injury claimants seek to portray - that of a good, upstanding person who suffered a very bad injury. However, FBS, a scale developed specifically for assessing malingering in personal injury claimants, has performed well in several studies, achieving 85-90% classification accuracy.54 This is in stark contrast to its failure in assessing malingering in PTSD claimants. Table 5
** Although the MENT has not been specifically researched as a malingering measure for depression, a failure on this would be highly suspect and difficult to explain. *** These measures might still be considered somewhat experimental
A Personality Perspective on PI Litigants
While the author's comments about social context may be valid, there is some reason for caution regarding his other conclusion. Both scale 1 and 3 are elevated by legitimate physical problems and brain damage, so they cannot automatically be viewed as indicating somatization or hysteria. Nor can the personality descriptions that apply to non-traumatized individuals be applied without some reservation and corroboration. Nonetheless, identification of such personality characteristics pre-injury (perhaps through medical records, accounts of family members or acquaintances) could add considerable context to a personal injury claim. Recall that among the predictors of PTSD development are characteristics such as trait neuroticism and previous depression, psychiatric treatment or trauma. Taking these observations together, it seems many legitimate (non-malingering) claimants may be eggshell clients - people who are prone to be intermittently anxious, depressed, moody, and insecure throughout life. The incident may have made things substantially worse for a while, or may be come to be blamed as the cause of one's unhappiness, forgetting the problems that existed before. Conclusion Detecting malingering in a PI context can be difficult, especially if the examinee has been prepared for the examination. It is no longer acceptable practice for those doing forensic assessments to accept a defendant's presentation at face value, and evaluations that do not assess the possibility of malingering (when significant impairment is presented) should be given no weight. Such examiners are opening themselves to being manipulated. Treating professionals are not oriented towards detecting malingering and thus, may come to sincerely support a fraudulent claim. Lastly, there is plenty of room for caution. Despite advancements in instrumentation and procedure, no examiner should presume infallibility. Many examinees may be coached, and some types of coaching can be quite effective. Information from collateral sources, including investigators, will remain a crucial part of a complete defense.
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