Detection of Malingered PTSD in Clinical Practice

8/22/2019 Detection of Malingered PTSD in Clinical Practice

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DETECTION OF

MALINGERED PTSD IN

ROUTINE CLINICALPRACTICE

David Godot, Psy.D.



Purpose of this presentation

There are many different potential malingering

scenarios in mental health, and particularly in

the VA

I’ve 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 betweenthose who seek disability and those who don’t(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-reportingof 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 I’ve 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 aredesigned to detect and manage it)



Differentiation of PTSD sufferers

from PTSD Malingering



Indicators of Potential Malingering(Hall & Hall, 2006; Hall & Hall, 2007)

• Calls attention to symptomsearly and frequently

• More adept at discussingPTSD symptoms than moreordinary worries

• Flashbacks are hallucinatoryin nature and primarily visual

• Claims dissociative amnesia

where none of one’s actionsare remembered

• Initially more reserved aboutdiscussing symptoms

• Preference to discuss day-to-day concerns over PTSDsymptoms

• Flashbacks are dissociative innature and incorporatemultiple senses & emotions

• Claims dissociative stateswhere part of or all actionsare remembered

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 nightmareswith fluctuating

frequency and repeatedthemes

Tends to blame self or share blame for problems

Reports similar levels of difficulty in both workand leisure activities





Exaggerates role in

trauma, often makingself a hero

Denied problems prior

to the trauma

Seeks treatment in thecontext of

compensation-seeking

Tends to minimizeinvolvement in the

traumatic events May use the

existence of prior trauma to explain

current deficits Seeks treatment upon

suggestions fromfriends and family





Reports

nonfluctuatingsymptoms that do

not improve with

time or treatment

Denies psychotic

symptoms

Reports fluctuating

symptoms thatgenerally improve

with time

Reports psychotic

symptoms and

worries about sanity





History of lawsuits andunstable work history

Lack of impulse controlproblems

No survivor guilt

Indignation or laughter when issues of possibledistortion are raised

Relatively stable pre-event work history

Problems withimpulse control

Some degree of survivor guilt

Surprise or blandnessregarding 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 psychologicalassessment instrument, and the best-studiedinstrument for detecting PTSD malingering

• It offers validity scales which have demonstrated utilityin:

– Detecting both coached and uncoached PTSD fakers(Efendov, Sellbom, & Bagby, 2008)

– Detecting faked PTSD by Vietnam combat vets (Eakin et al,2006)

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

• However, the utility of these scales is diminished whenstudy 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-2’s “fake bad” scale,

which indicates an exaggeratedly negative presentation of self & symptoms

– Fp (>=7)• The Fp (Infrequency Psychopathology) scale discriminates

overreported psychopathology from actual seriouspsychopathology

– F-K (>7)• The K (Defensiveness) scale detects attempts to portray

oneself in the best possible way.



Psychological Assessment

Inventory (PAI)

• The PAI offers three primary feigning

indicators:

– Negative Impression scale (NIM)

• The “fake bad” scale -- Elevated score suggests anexaggeration of negative features, or possible

malingering

– Malingering Index

• Uses a pattern detection strategy to associate a PAIprofile with characteristics of simulators

– Rogers Discriminant Function

• Another index with detects unlikely response patterns

to distinguish simulators from patients



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 notcatch 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 SpanSequencing task which shows some ability topredict scores on specific tests of negativeresponse bias (TOMM & MSVT).

– Poor performance on this task relative to generalability may therefore be indicative of a negativeresponse bias

– However, its predictive power is not strongenough 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 likelyto 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 cognitiveperformance 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

I’m unable to find any research relating to theuse of this instrument to detect PTSD

malingering

However, like the WAIS performancescales, 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 compensationseeking. 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 stressdisorder: 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 SymptomInventory 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 stressdisorder. 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 ProcessingSpeed 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 inveterans 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 physiologicalassessment: 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 MSVTfailure? Applied Neuropsychology Adult, 20( 2), 83-94.

http://www.ncbi.nlm.nih.gov/pubmed/16413450




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Detection of Malingered PTSD in Clinical Practice