User:Enicklas/Malingering of PTSD

Malingering
Malingering involves the intentional fake or exaggeration of physical or psychological symptomology associated with a medical or psychiatric diagnosis for external incentives. Feigning and malingering are commonly misused by the general public as interchangeable terms. Feigning, while it does involve faking or exaggerating symptoms of a medical or psychiatric diagnosis, is done without any motivation for external incentives. Neither is considered a diagnosis according the DSM-IV, but rather a clinically relevant condition that might warrant further clinical attention.

Psychiatric Diagnosis of PTSD
Post-traumatic stress disorder or PTSD is a psychiatric disorder characterized by intrusion, avoidance, and hyperarousal symptoms. The clinical presentation of PTSD is dependent upon the type of traumatic event or stressor, intensity and frequency of traumatic exposure, and other underlying neurobiological and individualized personality factors. (APA, 2013; Matto et al., 2019; Peace et al., 2011; ) A diagnosis of PTSD is complex and there is little research to provide a strong understanding of the construct of PTSD within the field of psychology, leading to decreased diagnostic accuracy and clarity (Ingram et al., 2012). Of the psychiatric diagnoses recognized by the Diagnostic and Statistical Manual of Mental Disorder-5 or DSM-V, the symptom criterion is highly subjective for PTSD. In fact, PTSD has been referred to as the “diagnosis of choice” regarding civil litigation. (Ali et al. 2015; Matto et al., 2019).

The diagnostic criterion for PTSD has changed from the DSM-IV-R to the DSM-5 to include the addition of a dissociative specifier and a revision to criterion A, by including simply learning of a traumatic event occurring to a close family member or friend. These changes have legal implications (Zollener et al., 2020) Regarding the dissociative subtype, individuals experiencing true dissociation might experience cognitive impairment related to attention and memory issues. Studies have found that malingering for disability or financial gain is easier and more commonplace with the inclusion of the dissociation subtype as individuals might claim difficulty remembering events or fabricate memories without having to validate or corroborate the events. (Ellickson-Larew et al., 2020; Zollener et al., 2020) The inclusion of learning about a traumatic event or stressor also increases the ease of malingering and confusion over what constitutes a traumatic event or stressor (Kerig et al., 2020). For instance, a veteran, from simply being in the military, qualifies as meeting criterion A for PTSD or having exposure to a traumatic event or stressor. While the trauma exposure in this population is potentially legitimate, it increases rates of malingering of PTSD for financial gain. (Freuh et al., 2000; McNally & Frueh, 2012). For these reasons, the DSM-5 criteria for PTSD has been criticized for both its reliability and validity. (Kerig et al., 2020Zoellner et al., 2013; Matto et al., 2019; Peace et. al., 2011)

Motivation for Malingering of PTSD
The motivation for malingering of PTSD is typically found in cases of civil law including psychological injury cases, workers' compensation and disability claims. There is also an increased motivation to malinger PTSD in the veteran population for those seeking disability services connection. (Freuh et al., 2000; McNally & Frueh, 2012). Individuals involved in criminal court cases with malingering PTSD seek to evade criminal responsibility and sequential/consequential punishment. Therefore, motivation to malinger PTSD is centered around potential financial. (Zoellner et al., 2013; Matto et al., 2019; Peace et. al., 2011)  The prevelance rates for malingering are largely unknown, although some studies have found approximately 15 percent of forensic evaluations for the courts involve cases of malingering and 50 percent of personal injury lawsuits, involve instances of malingering of PTSD. (Ali et al. 2015’ Ingram et al., 2012; Peace et al., 2011)

Assessment for Detecting Malingering of PTSD
Conducting an evaluation with the aim of detecting malingering, typically includes performing a clinical interview and implementing use of formal psychology assessment instruments. The Structured Interview for Reported Symptoms or SIRS is a clinically-administered interview that is considered to be to the “gold standard” when assessing for malingering (Rogers, Sewell, & Gillard, 2010 *Look up; Wolf et al., 2020).

Several formal psychology assessment instruments are available to detect malingering of PTSD, including the Minnesota Multiphasic Personality Inventory-2 or MMPI-2, the Personality Assessment Inventory or PAI, and the Miller Forensic Assessment of Symptoms Test or M-FAST. The MMPI-2 is the most widely used formal psychology instrument to detect malingering of PTSD. The MMPI-2 is a 567 item, self-report questionnaire, designed to assess for general psychopathology. Numerous studies have found the MMPI-2 to render strong to modest accuracy at detecting the malingering of PTSD (SEE BELOW). Specifically, the FB or infrequent symptoms, the Obvious-Subtle or obvious symptom validity subscales, have been found to be statistically significant in their usefulness at identifying those with exaggerated or fabricated symptomology (Agrusti et al., 20??; Nijdam-Jones et al., 2020).

Although other psychological test instruments, such as the PAI and M-FAST have been investigated for PTSD malingering detection ability, they have not approached the accuracy rates of the MMPI-2. The PAI is a 344 item, self-report questionnaire, designed to measure psychopathology, in particular, personality psychopathology. The anxiety-related disorders subscale of the PAI was designed to capture potential symptoms of PTSD. The current literature modestly supports the effectivenss of the Personality Assessment Inventory or PAI at detecting malingering of posttraumatic stress disorder or PTSD. Although results are mixed, the validity indicators of the PAI have been found to be effective at differentiating malingered PTSD from a diagnostically supported diagnosis of PTSD. (Russell & Morey, 2019). Specifically, the negative impression management or NIM scale, the malingering index scale or MAL, and the negative distortion validity scale or NDS of the PAI, are interpreted in detecting malingering of PTSD.

The M-FAST was originally developed for the purposes of assessing symptom exaggeration within the forensic inpatient psychiatric setting (Wolf et al., 2020; Miller, 2001*find). This assessment instrument includes a series of questions about uncommon symptoms and is used alongside a formal clinical interview. This measure has been found to have strong psychometric properties, including strong test-retest reliability and internal consistency. The M-FAST has been normed for use with the psychiatric inpatient and the incarcerated population. The M-FAST has more recently been used with the trauma exposed veteran population in detecting symptoms exaggeration or feigned and malingered PTSD. Wolf et. al. (2020) examined the M-FAST for use of selecting symptom over-reporting with veterans in a psychiatric inpatient setting and found that the instrument was no better than a formal clinical interview alone. However, other studies have found the M-FAST effective at detecting malingering amongst the veteran population (Ahmadi et al., 2013).