Posttraumatic stress disorder (PTSD) is a serious psychiatric disorder that has adverse health implications for the patients and their family members. PTSD occurs after exposure to a terrifying event; an individual may experience or witness the traumatic event (Mayo Clinic, 2018). According to Matto et al. (2019), service members, especially those returning from Iraq and Afghanistan, report higher cases of PTSD. Similarly, Fogger et al. (2016) report that the rate of PTSD in veterans returning from war zones, Iraq or Afghanistan, to be 18.5%. Moreover, most of the U.S. military service members have been subjected to multiple deployments, which increases their risks of suffering from PTSD by 50% (Korb, 2019). Consequently, recognizing the need to care for military veterans, the federal government created the U.S. Department of Veterans Affairs (V.A.). The federal government invests financial resources to ensure these veterans’ health is taken care of. For instance, in the fiscal year 2020, V.A. received $220.2 billion (Korb, 2019) . Shockingly, as stated by Fogger et al. (2016), “ there are over 23 million military veterans in the United States, yet only around 8.9 million (38%) of the veterans are receiving any portion of their health care inside a Veterans Health Administration facility” (p.598). These statistics reveal that most of these war veterans receive care outside the V.A., which calls for practitioners to be competent in managing their care. This will help the practitioners identify genuine and false PTSD cases.
Traumatic exposure does not necessarily lead to PTSD, as revealed in the National Comorbidity Survey. This survey revealed that “although 61 percent of men and 51 percent of women were exposed to a traumatic experience at some point in their lives, the lifetime prevalence of PTSD was8 percent and 20 percent, respectively” (Matto et al., 2019, p.2). The major challenge faced by practitioners while diagnosing PTSD is that they rely on patient reports, which has made it difficult for practitioners to determine the constituents of a traumatic stressor (Matto et al., 2019). This reliance on patients' reports has created loopholes for patients to consciously and unconsciously fake the diagnosis of PTSD. Ali et al. (2015) state that the reliance on self-reporting makes malingering possible. Malingering of PTSD is defined by Ali et al. (2015) as the “intentional production of false or grossly exaggerated physical and/or psychological symptoms associated with the diagnosis of PTSD to obtain external incentives” (p.12). Out of fear of stigmatizing the patients or losing rapport, practitioners find it hard to question the authenticity and validity of the PTSD symptoms with the patients (Matto et al., 2019). Tracy & Rix (2017) several reasons why diagnosing genuine PTSD cases is difficult. Firstly, according to the author, an individual may have real PTSD symptoms but exaggerate them. Secondly, a person may fake PTSD for external gains, such as financial compensation. In fact, Ali et al. (2015) assert that “14% of all occupational injury claims are based on PTSD” (p.12). Moreover, the use of the same diagnostic criteria in given groups and the generalization of the results have also made it difficult to distinguish between fake and genuine PTSD cases.
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Statement of the Problem
While it cannot be denied that war veterans are exposed to traumatic events that lead to PTSD, it is imperative for practitioners to distinguish between fake and genuine PTSD cases. Boskovic & Merckelbach (2018) notes that although the prevalence of PTSD malingering is undetermined, several populations are more prone to feigning given their professions. For instance, service members stand to gain financial compensations for combat-related PTSD, which increases their likelihood of faking PTSD diagnosis. In the U.S., 75% of all veterans receiving compensations fall in the category of PTSD-related mental disorder (Boskovic & Merckelbach, 2018). The diagnosis of PTSD is easy to malinger. Likewise, practitioners are reluctant to confront these fakers due to litigation consequences (Walczyk et al., 2018). Therefore, it can be confidently suggested that PTSD is over-diagnosed. Malingered PTSD and factitious PTSD have been on the rise in the military, which calls for change in diagnosing PTSD approaches. Despite the occurrence of fake PTSD diagnoses, there is limited literature that focuses on distinguishing between fake and genuine PTSD cases. Most of the existing literature focuses on the effectiveness of establishing methods to identify and treat PTSD mental disorders among veterans.
Purpose of the Study
The purpose of this study is to identify the best approach that practitioners can use to differentiate between genuine and fake PTSD cases during diagnosis. This study is important since fake PTSD cases amongst veterans have been on the rise in recent years. In fact, PTSD is the only mental condition the Diagnostic and Statistical Manual (DSM-5) of Mental Disorders identifies as easier to fake (Tracy & Rix, 2017). The DSM-5 contains all literature, including the symptoms necessary for a person to be considered to suffer from PTSD. This information is readily accessible to the public, making it easier to fake the PTSD symptoms, especially given that practitioners rely on self-reports for diagnosis. Evidence suggests that PTSD disability payments have been a burden to the U.S. Matto et al. (2019) note some interesting statistics with a strange trend: between 1999 and 2004, these payments increased by 149% compared to 42% for other disability payments. During this same period, "the number of veterans receiving Veterans Affairs (V.A.) disability for PTSD rose by 80 percent (versus 12% for other disabilities)" (p.2). By 2010, this figure had increased by 222%. In fact, by 2013, "6.8 percent of all veterans receiving any V.A. disability payments were receiving compensation for PTSD" (p.2). Thus, Matto et al. (2019) concluded that this increasing surge in the number of veterans diagnosed with PTSD is unclear. Consequently, these statistics shed light on the existence of discrepancies in identifying the actual number of veterans who have genuine PTSD. Therefore, this study aims at identifying effective methods that can be used to distinguish between fake and genuine PTSD cases.
Social Significance of Study
This study has a social significance that extends beyond the clinical settings. Firstly, identifying methods that can accurately lead to diagnosing PTSD cases ensures that the patient receives appropriate treatment. Likewise, accurate diagnosis also ensures that the patients are not subjected to inappropriate or harmful treatments. Further, accurate PTSD diagnosis could lead to the elimination of misdiagnosis when they have other conditions. Patients could suffer from stigmatization when termed as feigners when their cases are genuine (Walczyk et al., 2018). Socially, accurate diagnosis of PTSD will lead to reduced usage of clinical resources. As Matto et al. (2019) asserted, societies have limited resources to treat PTSD; therefore, fake PTSD diagnosis may deprive others of the resources' genuine cases. Further, accurately diagnosing PTSD will lead to reduced inaccuracies in medical research, especially in clinical trials leading to improved healthcare delivery to veterans.
This study also has economic implications for societies. Boskovic & Merckelbach (2018) state that PTSD financial compensation due to malingering cases in the U.S. ranges between 20% and 30%. This costs the nation over $19.8 billion in losses (Boskovic & Merckelbach, 2018). Although most malingering cases are not known, several veterans have been caught. For instance, Veteran Robert Warren was awarded $200k as PTSD compensation, only to be discovered later that he was not in combat. Likewise, Felton Lamar Gray, ex-soldier, fabricated a traumatizing story that subjected him to 100% disability ratings losses only to be discovered later (Boskovic & Merckelbach, 2018). Therefore, given the unusual increasing trend of veterans suffering from PTSD, this study will propose effective methods that can be used to alienate genuine and fake cases.
In summary, despite ongoing advances in malingering detection, many individuals successfully malinger mental, cognitive, and physical disorders to gain financial compensation, avoid work, gain access to medications, and avoid prison. This places a large financial burden on society, negatively impacts the healthcare system's efficient operation, and increases medical costs. The creation or discovery of new and effective malingering detection methods can significantly reduce the burden of malingering on the criminal justice system and society. According to Walczyk et al. (2018), if malingering is not detected in criminal justice, it could lead to delayed prosecution. Likewise, malingerers stand a chance to be moved to comfortable prison facilities, where they can easily escape (Walczyk et al., 2018). Moreover, when convicted, individuals may feign psychiatric or cognitive symptoms, where they may stand to gain more benefits than the others. Therefore, this research will propose effective malingering assessment techniques that could help detect fake PTSD symptoms.
Research Question and Hypothesis
For the purpose of this study, the following question was addressed:
What are the impacts of false PTSD on Veterans?
What causes veterans to fake PTSD symptoms?
How can practitioners distinguish between genuine and fake PTSD diagnoses?
As part of this study, the investigation included one research hypothesis:
The more war veterans learn that they stand to gain more combat-related compensations, the more they are likely to fake PTSD diagnoses.
Definition of Key Terms
Posttraumatic stress disorder (PTSD)- a psychiatric disorder that occurs after exposure to a traumatic event.
Malingering of PTSD - “is the intentional production of false or grossly exaggerated physical and/or psychological symptoms associated with the diagnosis of PTSD in order to obtain external incentives” (Ali et al., 2015, p.12).
Literature Review
No doubt, participating in military service increases the risk of service members suffering from mental health complications. However, the unusual increase in the number of veterans diagnosed with PTSD symptoms suggests that not all cases are genuine. In fact, it has been found that malingering in the military has been on the rise, the major motivations for malingering being financial compensations. Despite malingering of PTSD being a prevalent problem among the service members, there is limited literature to probe the causes. Most literature in this field focuses on treating PTSD to veterans to increase their quality of life. Therefore, this study seeks to review the limited literature on malingering of PTSD amongst the veterans to identify the motivations behind fabricating the symptoms, the impacts of malingering, and how practitioners can effectively distinguish between genuine and fake PTSD cases.
The limited literature that exists points out that malingering of PTSD symptoms among veterans has been on the rise. Given that PTSD diagnosis is subjective, it is possible for the symptoms to be faked. Fox & Vincent (2019) noted that regardless of the psychological knowledge or the depth of PTSD symptoms, people still fake PTSD diagnoses. This literature review will also focus on the existence of fake PTSD diagnoses among veterans.
Ineffectiveness of PTSD Assessment Tools
Fox & Vincent (2019) investigated the existence to which people malinger psychological symptoms, especially personal injury, for civil litigation. According to the authors, most practitioners utilize Symptom validity tests (SVTs) and performance validity tests (PVTs) to detect the prevalence of feigned psychological illness and neurocognitive impairments. To investigate malingering's depth, Fox & Vincent (2019) used a simulated personal injury paradigm, a simulated motor vehicle accident, to evaluate how symptom-based and performance-based measures of malingering relate. Four hundred eleven undergraduate participants were recruited for the research and were asked to complete four malingered symptomatology measures. These measures were to be completed as if the participants were experiencing similar PTSD symptoms.
The researcher used a multi-trait multi-method matrix (MTMM) to find the correlations between malingering assessment tools and the symptom validity measures. It was found that there was a weak correlation between the malingering assessment tools; however, the symptom validity measures had a significant correlation. Fox & Vincent (2019) malingering of PTSD symptoms results from multiple factors. Likewise, the authors also concluded that the malingering assessment methods are disassociated. Therefore, for effective assessment and detection of malingered PTSD symptoms, the evaluators should not rely on one assessment tool; rather, they should use multiple tools.
Some of the limitations of this research include lack of a control group; thus, the researchers lacked a group of participants to compare the characteristics with. Therefore, the accuracy of the results cannot be conclusively determined. Likewise, the use of simulation design makes it difficult to have certainty in group membership.
Monaro et al. (2018) also investigated the effectiveness of the existing evaluation tools. According to the authors, people can easily fake or exaggerate major depression symptoms since the symptoms are not difficult to emulate. The authors also state that most people are driven by financial incentives from health insurance companies while faking PTSD symptoms. Further, the authors assert that although several tools are available for detecting malingered PTSD symptoms, most, such as the M-Test and the Structured Inventory of Malingered Symptomatology (SIMS), rely on self-reports from the patients. This is a major limitation with these tools since PTSD symptoms can be easily faked through coaching. This could make it difficult for practitioners to identify feigned psychiatric symptoms. Thus, more sophisticated tools are required for patient assessments.
Due to such limitations, several sophisticated tools, such as those involving hand-motor responses, have been developed to detect deceptions during PTSD evaluations. Therefore, in their research, Monaro et al. (2018) investigated the effectiveness of machine-learning algorithms, a double-choice computerized task, to detect deceptions. According to the authors, this tool's main advantage over the others is that kinematic movement, which the subjects cannot consciously control. Therefore, this tool is extremely difficult to deceive. To investigate the effectiveness of this tool, the authors recruited two groups of participants. The first group consisted of 60 subjects, while the second one comprised 27 subjects. Participants from both groups were randomly assigned to two groups, liars and truth-tellers, and were required to conduct some Machine-learning tasks. The researchers found that individuals with malingered depression recorded higher depressive and non-depressive symptoms compared to genuinely depressed participants. Likewise, the researchers also found that the genuinely depressed participants took more time to complete mouse-based tasks compared to the rest. Therefore, the authors concluded that Machine-learning models have a 96% in identifying genuine and fake PTSD cases.
Despite the accuracy of this model, there were several limitations. Firstly, small sample size was used in the research; thus, the results could not be used for generalization. Likewise, the machine learning model's accuracy was not compared to that of the clinicians, which makes the research inconclusive. However, regardless of the limitations, Monaro et al. (2018) propose a tool that could be useful in detecting deceptions during the diagnosis of PTSD.
Ineffectiveness of Malingering Documentation
In a study by Lande & Williams (2013), the authors investigated the effectiveness of the available assessment tools in identifying PTSD malingering among veterans. The authors noted that although the assessment tools, such as the Minnesota Multiphasic Personality Inventory-2, may be effective in detecting malingering cases, they are ineffective in identifying the subject’s motivation. Therefore, the authors investigated the “prevalence and characteristics of medical malingering in the military” (p.50). With analysts' help, the authors used the DOD’s electronic database, The Military Health System Management Analysis and Reporting Tool (M2), for data collection and analysis.
DOD’s spending on military medical was analyzed from financial years 2006 to 2011, during which Iraq and Afghanistan wars were at their peak. The medical records of over 20 million military members were obtained. The authors found an increasing trend in the number of service members diagnosed with psychological disorders. However, Lande & Williams (2013) found that the number of malingering cases was small. Several reasons were noted that hinder practitioners from documenting malingering cases. Firstly, practitioners avoid documenting malingering cases as they will subject the feigner to prosecution. Likewise, the practitioners avoid such documentation since they do not like testifying against the prosecuted. Furthermore, making such documentations would affect the subject’s medical claims from the Department of Veterans Affairs (V.A.) . Moreover, Lande & Williams (2013) claimed a high likelihood of the ‘genuinely’ documented diagnoses in the military databases being actually fake but awarded due to biases rather than rigorous assessments. Therefore, such factors make it hard to document the actual prevalence of malingering among the military.
Building on these findings, Schnellbacher (2016) investigated military health practitioners' perceptions of military malingering. The author asserts that even though the rate of malingering in the U.S. military is undetermined, the problem is greatly undiagnosed. Therefore, Schnellbacher (2016) sought to investigate the factors leading to this malingering being undiagnosed. Using n observational epidemiologic mixed-methods cross-sectional study, Schnellbacher (2016) surveyed military health providers who attend to Active-Duty Soldiers. Online surveys were conducted, where 502 subjects responded. On average, each respondent stated that they encounter 8.34 cases of malingering or factitious conditions per year, but only 0.68 cases are diagnosed. Likewise, the analysis revealed that these practitioners did not diagnose 7.698 cases of intentional deception. This leads to over 14,500 Soldiers malingering cases in the Army medical system.
Some of the factors that contributed to the increasing diagnosis gap included “increased burnout scores, lack of evidence/difficulty proving, policy and pressure from above, being unsure of the diagnosis, and fears of a negative impact on the provider” (Schnellbacher, 2016, p.4). Therefore, the researcher concluded that army behavioral health providers play a role in the increasing number of undiagnosed malingering and factitious cases.
Evaluating False PTSD
There are several strategies that can be used to detect malingering of PTSD symptoms. According to Walczyk et al. (2018), these strategies can be categorized into unlikely and amplified presentations. Effective use of these strategies can help identify a common thread with malingers. In more detail, these strategies help identify symptoms and trends that deviate from the typical ones.
Collateral Information and Records
The first step is to compare the subjective report given by the patient and outside evidence (Matto et al., 2019). According to Ali et al. (2015), this information collection should be done before the evaluation, to determine discrepancies with the patient’s reports. The data collected could involve reports by the commanders at combat zones and other witnesses.
Interview Techniques
Interviews may also be conducted to determine instances of malingering with veterans. Ali et al. (2015) recommend the use of open-ended questions at the start of the evaluation. Several interviewing tools are available for practitioners, including Structures Interview of Reported Symptoms (SIRS), the Structured Inventory of Malingered Symptomology (SIMS), the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Miller Forensic Assessment of Symptoms (M-FAST), and the Millon Clinical Multiaxial Inventory MCMI-II. These tools are used to detect psychiatric malingering; however, some of these tools are time-consuming, making them ineffective (Walczyk et al., 2018).
Due to the ease of availability of DSM literature on PTSD symptoms, feigners may be able to recite with ease these symptoms during evaluations. However, according to Ali et al. (2015), feigners may not be able to relate those symptoms with personal life accounts convincingly. Likewise, the responses to fabricated symptoms lacks quality. Therefore, the use of interview techniques is effective in identifying fake PTSD symptoms.
Findings
Evidence suggests that PTSD can have adverse effects on veterans. As Korb (2019) asserted, most of the service members in the U.S. military have been subjected to multiple deployments, which increases their risks of suffering from PTSD by 50%. Therefore, it is important to detect and treat PTSD in service members to improve their quality of life. However, it has also been noted that faking PTSD symptoms has also been on the rise, which could have detrimental effects on individuals and societies. Moreover, evidence also suggests that there is limited literature on the impacts of fake PTSD on veterans. Therefore, there is a need to identify effective methods to accurately diagnose fake PTSD symptoms.
Based on the reviewed literature, if there is no admission from the patients, practitioners rely heavily on reports from several sources to detect fake PTSD instances. However, as noted by Fox & Vincent (2019), there may be inconsistencies with the evaluation techniques used; therefore, practitioners need to seek extra information to have a clear picture. That said, using all assessment tools during the evaluation can be time-consuming and cost-intensive. Therefore, evaluators may start with less time-consuming techniques, such as M-FAST, which takes 5-10 minutes, followed by a diagnostic interview (Ali et al., 2015). Further, collateral data need to be reviewed to determine discrepancies. If hints of malingering are detected, tools, such as SIRS, MMPI-2 may be used for in-depth psychometric evaluations (Ali et al., 2015). Moreover, if these tools prove insufficient, practitioners may go for the advanced psycho-physiologic methods of evaluation. Such strategies could help detect instances of malingering of PTSD symptoms.
Conclusions
Malingered PTSD is a highly controversial issue in the military since the identification of PTSD symptoms relies heavily on subjective self-reports. Considering the increasing unusual trends of veterans diagnosed with PTSD or under PTSD-compensation scheme, it is evident that malingering PTSD is on the rise. Evidence from the existing literature reveals that most veterans fake PTSD symptoms for financial incentives. However, it cannot be denied that the effects of genuine PTSD cases on service members have been dire. Therefore, fake PTSD diagnosis hinders those with genuine cases from accessing the limited societal and clinical resources, increasing government expenditure, and the implications being felt more on the tax-payers. Further, fake PTSD diagnoses also affect the criminal justice system as justice is not often served. Therefore, it is clear that fake PTSD diagnoses can have detrimental impacts on the nation.
References
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Boskovic, I., & Merckelbach, H. (2018). Fake Posttraumatic Stress Disorder (PTSD) Costs Real Money Www.in-Mind.org. https://www.in-mind.org/article/fake-posttraumatic-stress-disorder-ptsd-costs-real-money
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