Sunday, December 24, 2006

Can Coached PTSD be detected with the MMPI-2?

I often find that the diagnosis of Posttraumatic Stress Disorder (PTSD) has been assigned to claimants in disability, personal injury and worker’s compensations cases. My experience is that many claimed instances of PTSD are genuine though some are exaggerated or faked.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) specifically states that malingering must be ruled out before the diagnosis of PTSD can be made.

Psychologists, aware that some litigants may exaggerate or fake psychological disorders such as PTSD, have developed psychological tests containing special scales or strategies that are used to detect faking. One such test is the Minnesota Multiphasic Personality Inventory, also referred to as the “MMPI-2”. The MMPI-2 contains special “validity scales” that have been scientifically shown to be effective in detecting exaggeration or faking of psychological symptoms. The MMPI-2 is probably the most often used measure of psychopathology that also assesses malingering.

An important question is whether tests, such as the MMPI-2, can distinguish between faked and genuine PTSD when test-takers are given specific information about PTSD and about the MMPI-2.

How do litigants obtain information about PTSD? One way that litigants may learn about PTSD is through exposure to the media. There are more articles in the newspapers and on TV about PTSD today than in past. This may be especially true at the present time, during a war, because combatants may be exposed to severely traumatic situations that can potentially cause mental disorders such as PTSD. In addition, the specific diagnostic criteria for PTSD and a variety of other information about this disorder is available on-line. Some litigants may also learn about PTSD and specific techniques to improve the chances of successful faking PTSD from their attorney. In a study of 70 practicing attorneys and 150 law students conducted in 1995 and published in Professional Psychology: Research and Practice, Wetter and Corrigan found that more than one-third of law students and almost one-half of lawyers believed they were responsible “to inform the client of scales on psychological tests that are designed to detect exaggerated or faked responses”.

Utilizing MMPI-2 scales to distinguish between faked and genuine PTSD among research subjects: Coaching subjects about the symptoms of PTSD or about the validity scales contained within the MMPI-2 has been employed in investigations of whether the MMPI-2 can distinguish between faked and genuine PTSD. Bury and Bagby published such a study in the journal Psychological Assessment in 2002. Investigators in this study randomly assigned 131 research subjects to one of four groups: “uncoached”, “coached about PTSD symptom information”, “coached about MMPI-2 validity scales” and “coached about both symptoms and validity scales”. Following the coaching instructions, subjects were asked to simulate PTSD on the MMPI-2 test. Results from the MMPI-2 tests of coached subjects were then compared to those of individuals who had developed genuine PTSD following workplace accidents. Results of this study were similar to those of previous studies which showed that giving research subjects information about the symptoms of a mental disorder (in this case, PTSD) did not help them to avoid detection as fakers. As in previous investigations, individuals who were taught about the validity scales demonstrated a degree of success in avoiding detection while faking a mental disorder (PTSD in this study).

Conclusions: The MMPI-2 validity scales demonstrate somewhat reduced capacity to identify faking when test-takers are provided with validity scale information. However, the Bury and Bagby study, which provided research subjects with specific information about avoiding detection by the Fp scale of the MMPI-2, showed that Fp remained effective in distinguishing between genuine and faked PTSD.

Recommendations: When insurers and attorneys are concerned that a claimant may be faking PTSD and, especially when there is reason to fear that a claimant may have been coached in techniques for malingering of PTSD, the MMPI-2 can be very helpful in differentiating between faked PTSD and the real disorder. For more information about PTSD and malingering, click on the “articles” button at my website.

Sunday, December 10, 2006

Sailor Malingered Posttraumatic Stress Disorder (PTSD)

Men and women who serve in the US military can be exposed to extremely traumatic situations in combat and, sometimes, in non-combat situations. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), military combat is exactly the type of stressful event that can lead to the development of Posttraumatic Stress Disorder (PTSD). There are several other specific elements that are required in order to meet the diagnostic criteria for this mental disorder.

The DSM-IV specifically states that malingering should be ruled out in situations where an external incentive (such as disability benefits) can be obtained on the basis of PTSD.

Although the exact number of military service people who are not honest about their exposure to severe traumas is not known, it is reasonable to assume that the great majority of American servicemen and servicewomen honestly represent their exposure to traumas and the psychological symptoms which can result. However, servicemen or servicewomen may occasionally engage in malingering, the deliberate exaggeration or faking of psychological symptoms, in order to obtain external incentives.

One such incident of apparently malingered PTSD was reported by Brad Wong in the Seattle Post-Intelligencer on December 8, 2006. In this case, a former sailor acknowledged that he had purposefully faked symptoms of PTSD in order to obtain federal benefits in the amount of $174,000. The sailor admitted he was not being honest when he said he had seen a non-military worker drown after falling from a ship, that he had seen a member of the military die on the Golden Gate Bridge in San Francisco and that he had been thrown into deep water during his basic training and was unable to swim.

On the basis of these claims the Department of Veterans Affairs had awarded him about $134,000 and he had received an additional $40,000 in benefits from the Social Security Administration.

According to this article, the sailor is scheduled to be sentenced in 2007.

Standard psychological tests, such as the Minnesota Multiphasic Personality Inventory (MMPI-2) have been scientifically demonstrated to be useful in determining if an individual is engaging in exaggeration or faking of psychological symptoms, such as PTSD. The Trauma Symptom Inventory (TSI), another psychological test, was specifically designed to identify the pattern of symptoms that is consistent with PTSD and, like the MMPI-2, has validity scales that can be helpful in distinguishing between genuine and exaggerated symptoms of PTSD.

For more information about malingering, PTSD and psychological tests used to identify PTSD and malingering, please click on the "Articles" button on my website.

Saturday, December 9, 2006

Malingering: A Growing and Costly Problem

The Diagnostic and Statistical Manual of Mental Disorders ("DSM-IV) defines "malingering" as "...the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs."

In my practice as a clinical and forensic psychologist, I am often asked to consider whether examinees may have malingered psychological symptoms, such as PTSD or Major Depressive Disorder, in disability, worker's compensation and personal injury claims.

Malingering of psychological symptoms is a big and growing problem for those who pay for monetary benefits and treatment. The expansion of malingering and its associated unnecessary costs may be related to several factors such as decreased stigmatization resulting from acknowledging mental illness, increased availability of coverage for various forms of treatment for mental disorders and to an aversion by some mental health treating doctors to identify malingering by their patients.

Admitting to having a psychological problem does not appear to have the stigma attached to it that existed decades ago when treatment took place primarily in mental hospitals. As a graduate student in clinical psychology in the 1960s, I sometimes met patients who had been "locked up" in mental hospitals continuously for ten, twenty or thirty years or more. Receiving a diagnosis of a mental illness at that time could be, literally, a life sentence as a pariah. Psychiatric hospitals in those days were dark, noisy places with heavy locked doors. The keys to those locked doors were huge and often worn around staff members' necks. Forty years ago, psychiatric hospitals physically resembled prisons and there was little available in the way of what we now call "treatment".

Beginning in the 1960s, the Community Mental Health movement led the way to a major downsizing of mental hospital populations and the closing of many psychiatric hospitals altogether in the US. Instead of being treated in an inpatient setting, individuals needing mental health services would be treated in community mental health centers and often times in outpatient clinics.

In the 21st century, when psychiatric hospitalization is required because an individual is suicidal or dangerous to others as a result of a mental illness, the length of inpatient treatment is often measured in days or weeks rather than in months or years. The movement towards community mental health treatment centers "democratized" mental health treatment, placing treatment facilities within the communities they served rather than "up on a hill", far away from population centers. Most people today know of someone who is being treated for a mental disorder, or has had this treatment himself or herself. Acknowledging that one is being treated for a psychological disorder is, mostly, no longer a cause for shame. Today, in many circles it is considered acceptable or even fashionable to mention that one has a therapist or analyst. In my practice I occasionally see people who self-diagnose mental disorders for various reasons, one of which is to obtain benefits for which they might not otherwise be eligible. The personal costs, such as stigmatization, of making a claim for psychological damages in a disability, Worker's Compensation or personal injury case is not nearly as high as it would have been forty years ago.

The advent of modern psychiatric and psychological techniques may also be a factor in the increase of unnecessary costs paid for remediation or compensation for mental disorders. In my office in Boston I frequently conduct psychological evaluations of individuals receiving monetary or psychological treatment benefits who are suspected by the referral source of no longer having a disabling mental disorder or of having reached end result (maximum medical improvement) and are thought to be unlikely to obtain benefits, in the form of improved functioning, from additional psychological and psychiatric treatment. In Massachusetts, as in some other states, there is a mandated mental health benefit included in health insurance plans. If an individual has been in a motor vehicle accident, for example, and has become aware or has been advised that such a trauma can cause psychological symptoms, the accident victim may seek mental health treatment for those symptoms. Psychological symptoms alleged by the accident victim, such as nervousness or depression, may or may not be related to the accident. However, an individual may may attribute the emotional symptoms to the accident and seek treatment for those symptoms in order to substantiate or enhance a later claim for treatment and/or monetary benefits.

The ease with which an individual can access the mental health treatment system leads to consideration of a third factor that may contribute to the expansion of unnecessary costs for feigned mental disorders: the aversion apparently felt by some psychotherapists (psychologists, psychiatrists and social workers) to suggest that their patient may be malingering a mental disorder.

I have written several articles which discuss various aspects of the treating doctor's antipathy towards writing in their treatment notes the terms "faking", "exaggerating" or "malingering" in describing their patients. These documents can be found by clicking on the "Articles" button on my website. I spend a large proportion of my work day reviewing other doctor's psychological treatment records as a part of a psychological evaluation I am conducting. It is very rare to find a reference to exaggeration, faking or malingering in the psychotherapy treatment notes I review as a part of my evaluation. The reasons why references to "exaggeration", "faking" or "malingering" are nearly non-existent in treatment records seems to be rather straightforward. Psychotherapists tend to "bond" with their patients. Many psychotherapists proceed with treatment based on the idea that part of the psychotherapy treatment process is to empathize with the patient. Further, many psychotherapists attempt to enter into or acknowledge the patient's inner psychological world, no matter how distorted that world might be (think of a delusional patient) in order to treat that patient. Many psychotherapists believe that a suggestion that their patient may be malingering is a breach of the trust that is inherent in the psychotherapeutic relationship that would damage the relationship and impair the treatment process. As a result, a psychotherapist may unwittingly become a part of the process by which an patient, motivated to exaggerate or fake psychological symptoms, attempts to enhance the credibility of a claim of a mental disorder and the the likelihood of receiving compensation in the form of monetary benefits, avoidance of work or change in responsibilities.

With the advent of the internet and the resulting free flow of information about psychological tests, independent medical exams and information about how to fake believable mental disorders on psychological tests, the problem of malingering of mental disorders may grow worse. The appropriate response to suspected malingering of psychological symptoms by a litigant is a comprehensive forensic examination by a psychologist that contains the following elements: (1) a robust review of a litigant's psychological history; (2) a complete review of a litigant's functioning in such areas as interpersonal relationships, daily activities and ability to cope with stress, to concentrate and to make appropriate judgments; (3) a comprehensive mental status exam in which the psychologist maintains a degree of skepticism while attempting to document or rule out all alleged mental disorders according to the criteria available in the Diagnostic and Statistical Manual of Mental Disorders and (4) the use of psychological tests such as the Minnesota Multiphasic Personality Inventory (MMPI-2), Trauma Symptom Inventory (TSI) and Miller Forensic Assessment of Symptoms Test (M-FAST) which have built-in "Validity" scales which have been scientifically shown in published studies to be useful in identifying malingered psychological symptoms.

Tuesday, December 5, 2006

Three Types of Inadequate Documentation of PTSD

The diagnosis of PTSD occurs regularly in records I review in my forensic psychology practice. Typically, these are the records of psychological evaluation and treatment services that were provided to an individual (the litigant) in a personal injury, disability or worker's comp case in which a treating doctor or therapist has assigned a diagnosis of Posttraumatic Stress Disorder (PTSD) to a patient.

PTSD is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 4th Ed.). The DSM-IV criteria for PTSD require that the individual has experienced a severe traumatic stressor. There are examples in DSM-IV of the kinds of stressors that could reasonably meet the criterion for this disorder. It must also be established that the victim of the trauma experienced a specific emotional state as a result of the trauma. The individual must re-experience the traumatic event, defensively avoid exposure to reminders of the traumatic event and experience symptoms of increased arousal. The DSM-IV is specific on the the kinds and combinations of symptoms that must be present in order to substantiate a diagnosis of PTSD.

In addition, the DSM-IV indicates that malingering must be ruled out in those situations in which an external incentive (such as financial benefits) might play a role.

In many treatment records I review, but not all, the treating doctor does not adequately document all of the required criteria before assigning the diagnosis of PTSD. I say this, realizing that there may always be other records I haven't seen that may contain better documentation, and I always reserve the right to change my opinion should new information from a source be discovered. It not known to me why there is not more comprehensive documentation of PTSD in mental health treatment records. One reason may be that there is limited time to provide treatment and there are waiting lists. Preparation of comprehensive diagnostic notes is seen as a poor use of treatment time. Also, in a treatment setting, additional information about the patient and the diagnosis can be accrued as treatment progresses so there is no necessity for documenting all the criteria of a diagnosis at once. Many or most clinicians feel there is no need to assess for malingering and, further, that assessing for malingering could impair the crucial trust inherent in the doctor-patient alliance that is so important in psychotherapy treatment. In most cases there is no need to assess for malingering within the context of psychotherapy treatment and this is not a significant issue in the treatment record while the treatment record remains in the treatment setting.

However, incomplete documentation of PTSD and failure to rule out malingering can and does become a significant issue in legal cases when the doctor's treatment record is brought into the legal process. Recently, while reviewing mental health records in a disability case, I identified the following three types of inadequate documentation of PTSD.

Minimalist Type: This progress note is often one page in length or less and describes treatment with psychotherapy or psychopharmacology. The diagnosis of PTSD is often prominently noted at the top of the page. In the body of the report there is a discussion of an issue the patient is having, such as marital conflict or depression. There is no or almost no documentation of PTSD in the note. Treatment notes that list a diagnosis should, in my view, substantiate the diagnosis in the notes within a reasonable time after treatment begins.

Compliant Type: In this type of treatment progress note, the diagnosis of PTSD appears to be substantiated, but a closer look reveals that the documentation consists of a listing in the treatment notes of the criteria for DSM-IV as they appear in the DSM-IV. This, in my opinion, does not support a diagnosis of PTSD. Simply reiterating the criteria for PTSD, without elaboration with details from an examinee's history, current mental status data and psychological test results, does not suffice, in my opinion, to confirm a diagnosis. Compliant documentation seems designed to meet the letter of the law but lacks any indication of the treating doctor's knowledge of the patient's symptoms.

Teetering Type: In this kind of treatment note, the clinician discusses only one or two symptoms of PTSD but does not document all the required criteria for the disorder. For example, I might find a comprehensive discussion of the victim's accident and resulting emotional reaction that completely confirms that the individual meets the first set of criteria for the disorder. However, there is no subsequent attempt by the clinician to confirm the remaining required elements needed to confirm the diagnosis of PTSD. This diagnosis is "teetering" because it is like a four-legged table that only has two extended.

Conclusions: Treatment records are created for the purposes of documenting and improving treatment. When these records are moved into the legal arena in a personal injury, worker's compensation or disability case, they do not perform as well and can fail as proof of PTSD. In these kinds of cases, it can be helpful to consult with a psychologist who can conduct a forensic evaluation of the litigant which includes an assessment of malingering.

Stuart Clayman, Ph.D. practices forensic and clinical psychology in Boston, Massachusetts, USA. Tel: 617 782-8355. For more information, click on the "Articles" button on my website.

Wednesday, November 29, 2006

Forensic Psychology Experts

Nearly every day, in my work as a forensic psychology expert, I am asked to review the medical records of litigants who are claiming mental impairments in Worker's Comp, Personal Injury and Disability cases. Sometimes, the request for me to review records is made by an attorney, although I am also referred litigants and their medical records for evaluation by insurance companies and Independent Medical Exam companies. While studying these medical records, I see a number of errors being made in determining the authenticity of the mental impairment claim that can have a significant impact on the outcome of the claim.

One significant error is made, in my opinion, when the notes of treating doctors' are relied upon as a database for decision-making in legal cases.

Treating doctor's notes are just that: they are the record of the conceptualizations, diagnoses, treatment plans and prognoses. The problem begins when the treatment notes of the psychologist, psychiatrist or social worker are brought into the legal system because the legal system has different rules with which the treating mental health professional may not be familiar.

Take the example of a patient who is being treated for the psychological aftereffects of a motor vehicle accident. I may be provided with psychotherapy treatment notes covering a period of six months or more for review. I might also be retained to conduct a face-to-face examination of the litigant, but for the purposes of this discussion I will focus only on the review of the medical records.

The purpose of my review of the medical records is usually to determine the following:
1. Does the litigant have a mental impairment?
2. What is the severity of the impairment?
3. To what extent is the impairment related to the trauma in question (an MVA, for example)?
4. Does the impairment result in disability for work or other severe loss of capacity to function?
5. What is the prognosis? Is the litigant still exhibiting mental impairment now?

Treating doctors (and I include psychologists, psychiatrists, social workers and other types of mental health professionals) have a tendency to bond with their patients. This is normal and is a useful part of the treatment process. Mental health professionals may, in fact, usefully enter into the psychic world of their patients in order to better understand and treat their patients. This means that treating mental health professionals have a tendency to accept what their patients say as true in an uncritical manner. I think that most treating mental health professionals would consider this attempt to understand their patient to be a critical part of the healing process. I also believe that most psychotherapy patients would find this caring and empathetic approach to be a necessary characteristic of their doctor and would probably consider dropping out of treatment if they felt their doctor did not make an attempt to understand and accept them and their symptoms.

The treatment process comprised of, among other elements, empathy, uncritical acceptance and bonding can work well in psychotherapy treatment. Yet, there are implications of this approach and the written process or progress notes that the treating doctor enters into the record that are problematical once the patient moves into the legal arena of the personal injury, Worker's comp or disability claim.

Treating doctors tend to see many patients in a day. Notes of the treatment process and progress must be made in order to document that treatment has occurred. Time taken to make these notes must be subtracted from the treatment hour, resulting in the traditional 50 minute psychotherapy session. One implication of this time crunch is that treating psychotherapist may not have or take the time to carefully document the full criteria of the mental disorder which is the focus of treatment. Mental disorders, despite the myth, are carefully defined in the "Bible" of mental disorders which is also known as the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV. Yet, I frequently note that treating mental health professionals use a kind of shorthand when documenting, for example, Posttraumatic Stress Disorder (PTSD). Rather than carefully recording in the notes how the patient meets each of the requirements for PTSD, the treating mental health professional may save time by noting that the patient experienced a stressful event, avoids the place where the trauma occurred and now has some problems with sleep. Although this formulation may be found in treating mental health professional's progress notes, it absolutely does not document the full criteria of the PTSD and, therefore, is subject to critical analysis within the context of a forensic psychological exam and in cross-examination should the case proceed to deposition or trial.

Another common mistake of the treating mental health professional is to fail to rule out malingering. Malingering is defined in the DSM-IV as "...the intentional production of false or greatly exaggerated physical or psychological symptoms, motivated by external incentives...".
In some mental disorders, according to the DSM-IV, including PTSD, malingering must be ruled out before a diagnosis can be made. I rarely see any attempt to rule out malingering documented in a mental health professional's progress notes. As I noted in article I published on my website entitled "The Importance of Using Psychological Tests to Identify Faked, Exaggerated or Malingered Symptoms in Litigation: An Introduction for Attorneys", an interview alone is not a robust method of accurately identifying or ruling out malingering. A much better method of doing so involves the use of psychological tests designed for this purpose. Yet, it is rare for treating mental health professionals to employ psychological testing as a part of the typical treatment process.

More information about the issues raised in this post are available at my website.