DETECTION OF MALINGERED PTSD IN ROUTINE CLINICAL PRACTICE

David Godot, Psy.D.

Purpose of this presentation

There are many different potential malingering scenarios in mental health, and particularly in the VA Ive focused on one specific scenario malingering of PTSD to determine the current best practices for clinicians

How much of a concern is malingering of PTSD in the VA?

In the literature

Some have argued that VA disability policies for PTSD reward illness behavior, diminish engagement in treatment, and perversely promote chronic disability (Marx et al, 2008)

However

Mental health service use by Veterans with PTSD tends to increase following successful disability claims (Marx et al, 2008) Treatment outcomes are comparable between those who seek disability and those who dont
(Marx et al, 2008)

Of 2100 service-connected PTSD cases reviewed by the VA inspector general in 2005, only 13 (0.6%) were potentially fraudulent (Marx
et al, 2008)

At least with regard to C&P

Jackson et al (2011) conclude that concerns about PTSD malingering in the VA may be largely unfounded Marx et al (2008) conclude that over-reporting of symptoms by Veterans diagnosed with PTSD is likely as much a sign of severe distress and psychiatric comorbidity as malingering. Frueh (1994) argued that over-reporting symptoms is actually a common feature of PTSD itself

And yet, anecdotally

Most of the VA clinicians Ive personally discussed this issue with have expressed concern, and reported personally dealing with a number of cases of suspected malingering A common discussion centers around the problem of malingerers taking up limited clinical resources and decreasing the morale of treatment teams

Perhaps

PTSD malingering is more of a problem in routine clinical practice (where clinicians may not be as equipped to detect and manage it) than in disability evaluations (which are designed to detect and manage it)

Differentiation of PTSD sufferers from PTSD Malingering

Indicators of Potential Malingering

(Hall & Hall, 2006; Hall & Hall, 2007)

Malingering

True PTSD

Calls attention to symptoms early and frequently More adept at discussing PTSD symptoms than more ordinary worries Flashbacks are hallucinatory in nature and primarily visual Claims dissociative amnesia where none of ones actions are remembered

Initially more reserved about discussing symptoms Preference to discuss day-today concerns over PTSD symptoms Flashbacks are dissociative in nature and incorporate multiple senses & emotions Claims dissociative states where part of or all actions are remembered

Indicators of Potential Malingering

(Hall & Hall, 2006; Hall & Hall, 2007)

Malingering

True PTSD

Reports nightmares that are the same every time, and occur every time one sleeps Overtly and frequently blames others for condition Able to enjoy recreational activities, and may identify them as therapeutic

Reports nightmares with fluctuating frequency and repeated themes Tends to blame self or share blame for problems Reports similar levels of difficulty in both work and leisure activities

Indicators of Potential Malingering

(Hall & Hall, 2006; Hall & Hall, 2007)

Malingering

True PTSD

Exaggerates role in trauma, often making self a hero Denied problems prior to the trauma Seeks treatment in the context of compensation-seeking

Tends to minimize involvement in the traumatic events May use the existence of prior trauma to explain current deficits Seeks treatment upon suggestions from friends and family

Indicators of Potential Malingering

(Hall & Hall, 2006; Hall & Hall, 2007)

Malingering

True PTSD

Reports nonfluctuating symptoms that do not improve with time or treatment Denies psychotic symptoms

Reports fluctuating symptoms that generally improve with time Reports psychotic symptoms and worries about sanity

Indicators of Potential Malingering

(Hall & Hall, 2006; Hall & Hall, 2007)

Malingering

True PTSD

History of lawsuits and unstable work history Lack of impulse control problems No survivor guilt Indignation or laughter when issues of possible distortion are raised

Relatively stable preevent work history Problems with impulse control Some degree of survivor guilt Surprise or blandness regarding issues of distortion

The use of common psychological tests in detection of malingering

Minnesota Multiphasic Personality Inventory (MMPI-2)

The MMPI-2 is the most popular psychological assessment instrument, and the best-studied instrument for detecting PTSD malingering It offers validity scales which have demonstrated utility in:

Detecting both coached and uncoached PTSD fakers

(Efendov, Sellbom, & Bagby, 2008)
2006)

Detecting faked PTSD by Vietnam combat vets (Eakin et al,

Distinguishing compensation-seeking veterans asked to exaggerate from those asked to respond honestly (Arbisi,
Ben-Porath, & McNulty, 2006)

However, the utility of these scales is diminished when study participants are informed about their existence which many malingerers may be (Eakin et al, 2006)

MMPI-2 in the Detection of Malingered PTSD

The scales most predictive of PTSD malingering (Elhai, Gold, Frueh, & Good, 2000) are:

F (>=17)

The F (Infrequency) scale is the MMPI-2s fake bad scale, which indicates an exaggeratedly negative presentation of self & symptoms The Fp (Infrequency Psychopathology) scale discriminates overreported psychopathology from actual serious psychopathology The K (Defensiveness) scale detects attempts to portray oneself in the best possible way.

Fp (>=7)

F-K (>7)

Psychological Assessment Inventory (PAI)

The PAI offers three primary feigning indicators:

Negative Impression scale (NIM)

The fake bad scale -- Elevated score suggests an exaggeration of negative features, or possible malingering Uses a pattern detection strategy to associate a PAI profile with characteristics of simulators Another index with detects unlikely response patterns to distinguish simulators from patients

Malingering Index

Rogers Discriminant Function

PAI in the Detection of Malingered PTSD

These indicators do a fair job of detecting PTSD malingering

However,

Negative Impression is somewhat affected by the presence of trauma Therefore, the Malingering and Discriminant Function scales should be relied on where the PAI is employed (Rogers, Gillard, Wooley, & Ross, 2012)

PAI vs MMPI-2

PAI is not nearly as well-studied for this purpose as MMPI-2 A comparison study found that MMPI-2 substantially outperformed PAI, but did not catch all fakers (Eakin et al, 2006)

Furthermore, this study examined non-treatment seeking individuals Treatment-seeking patients would be more likely to report distress, making differentiation of malingerers less reliable in clinical settings

WAIS-IV

The Wechsler Adult Intelligence Scales, 4th Edition (WAIS-IV) contains a new Digit Span Sequencing task which shows some ability to predict scores on specific tests of negative response bias (TOMM & MSVT).

Poor performance on this task relative to general ability may therefore be indicative of a negative response bias However, its predictive power is not strong enough for detection of malingering in isolation. (Whitney, Shephard, & Davis, 2013)

Other aspects of the WAIS

Studies performed using the WAIS-III indicate that WMI and PSI are generally good clinical indicators of poor effort or deliberate misrepresentation (Etherton, Bianchini, Heinly, & Greve,
2006; Etherton, Bianchini, Ciota, Heinly, & Greve, 2006)

These scales have changed somewhat since the release of the updated WAIS-IV, but the prognostic attributes of these scales are likely to remain useful in the context of a complete evaluation

Cognitive Assessment of mTBI & PTSD

In cases where Mild Traumatic Brain Injury (mTBI) is being claimed concurrently with PTSD
One

study found no difference between cognitive performance of patients with mTBI and PTSD or another psychiatric illness, versus those with mTBI alone (Roger, Gillard, Wooley, & Ross, 2012) Using the Trail Making Test, Stroop, Rey Complex Figure, and California Verbal Learning Test

Test of Memory Malingering (TOMM)

A 50-item visual recognition test designed to distinguish genuine memory impairments from malingered ones. Takes 15-20 minutes to administer. Consists of 2 learning trials, with each trial yielding a simple performance score.

More than 5 errors on the second trial indicates a very high probability of malingering, except where dementia may be present

TOMM Procedure

Subjects are shown 50 drawings, and then asked to distinguish the drawing they were shown from drawings they were not shown

TOMM with TBI & PSTD

TOMM is insensitive to a wide range of neurological impairments, and so is reliable with TBI patients Im unable to find any research relating to the use of this instrument to detect PTSD malingering
However,

like the WAIS performance scales, it may be that TOMM could provide a good general indicator of feigned impairment

References

Arbisi, P.A., Ben-Porath, Y.S., & McNulty, J. (2006). The ability of the MMPI-2 to detect feigned PTSD within the context of compensation seeking. Psychological Services, 3(4), 249-261. Eakin, D.E., Weathers, F.W., Benson, T.B., Anderson, C.F., & Funderburk, Brandice (2006). Detection of feigned posttraumatic stress disorder: a comparison of the MMPI-2 and PAI. Efendov, A.A., Sellbom, M., & Bagby, R.M. (2008). The utility and comparative incremental validity of the MMPI-2 and Trauma Symptom Inventory validity scales in the detection of feigned PTSD. Psychological Assessment, 20(4), 317-326. Elhai, J.D., Gold, P.B., Frueh, B.C., & Gold, S.N. (2000). Cross-validation of the MMPI-2 in detecting malingered posttraumatic stress disorder. Journal of Personality Assessment, 75(3), 449-463. Etherton, J.L., Bianchini, K.J., Ciota, M.A., Heinly, M.T., & Greve, K.W. (2006). Pain, malingering and the WAIS-III Working Memory Index. The Spine Journal, 6(1), 61-71. http://www.ncbi.nlm.nih.gov/pubmed/16413450 Etherton, J.L., Bianchini, K.J., Heinly, M.T., & Greve, K.W. (2006). Pain, malingering, and performance on the WAIS-III Processing Speed Index. Journal of Clinical & Experimental Neuropsychology, 28(7), 1218-37. http://www.ncbi.nlm.nih.gov/pubmed/16840247 Frueh, C. (1994). The susceptibility of the Rorschach Inkblot Test to malingering of combat-related PTSD. Journal of Personality Assessment, 62(2), 280-298. Gordon, S.N., Fitzpatrick, P.J., & Hilsabeck, R.C. (2011). No effect of PTSD and other psychiatric disorders on cognitive functioning in veterans with mild TBI. The Clinical Neuropsychologist, 25(3), 337-347. Hall, R.C.W., & Hall, R.C.W. (2007). Detection of malingered PTSD: An overview of clinical, psychometric, and physiological assessment: Where do we stand? Journal of Forensic Science, 52(3), 717-725. Marx, B.P., Miller, M.W., Sloan, D.M., Litz, B.T., Kaloupek, D.G., & Keane, T.M. (2008). American Journal of Public Health, 98(5), 773.

Rogers, R., Gillard, N.D., Wooley, C.N., & Ross, C.A. (2012). The detection of feigned disabilities: The effectiveness of the Personality Assessment Inventory in a traumatized inpatient sample. Assessment, 19(1), 77-88.
Whitney, K.A., Shepard, P.H., Davis, J.J. (2013). WAIS-IV digit span variables: Are they valuable for use in predicting TOMM and MSVT failure? Applied Neuropsychology Adult, 20(2), 83-94.