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A Certain Symptom of PTSD May Suggest an Element of Malingering

The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) describes a formula clinicians can use to screen plaintiffs in lawsuits for malingering of mental disorders. This formula is composed of four elements, one of which is the failure of an individual to cooperate with prescribed treatment. According to the DSM-IV, the clinician should "strongly suspect" malingering when any combination of the four elements is noted.

Clinicians should be careful in concluding there may be malingering even if a recommendation of treatment has not been implemented and even when the individual being assessed has two or more of the four elements described in DSM-IV. There may be alternative reasons why an individual has not followed a recommendation for treatment that have nothing to do with malingering of psychological symptoms.

One of the defining symptoms of Post-traumatic Stress Disorder (PTSD) is a pattern of avoidance of situations that are associated with a trauma. If an individual has been severely traumatized or witnessed the severe injury or death of another person in, for example, an automobile accident, the individual may avoid conversations about that accident because those conversations would be likely to arouse bothersome memories or frightening nightmares about the trauma or other forms of severe emotional distress. Avoiding conversations about an extremely emotionally-charged subject may be one way a traumatized individual may attempt to protect himself or herself from the futher experience of trauma.

A clinician, however, may misinterpret the unwillingness of a plaintiff to participate in treatment as an indicator of malingering.

If malingering is suspected, the clinician should obtain several sources of information, such as data from an interview, psychological tests designed to identify malingering and information from collateral contacts.

What appears to be a sign of malingering may be a genuine symptom of a mental disorder.

For more information on this subject, please visit my Forensic Psychology Services website and click on the button labeled "Articles".

Psychological Symptoms are easily exaggerated or faked

Exaggeration or faking of psychological symptoms is a serious problem in Worker's Compensation, disability or personal injury cases because the accuracy of information provided by the plaintiff (injured person) is critical in determination of psychological damages resulting from injury. This is particularly so when damages include psychological symptoms or mental disorders because, unlike physical injuries, there are no x-rays or other tests that can definitively show that an individual is in fact suffering from emotional distress.

Some scientific studies have shown that untrained individuals can easily exaggerate or fake symptoms, such as anxiety or depression, on psychological tests. The reason this can be done by individuals who have little knowledge of psychological matters is that most psychological tests in common use today lack any kind of mechanism to determine that an individual has not responded honestly to a psychological test.

Because of a number of factors, such as time and money limitations, psychologists and psychiatrists often do not utilize the more comprehensive tests that have demonstrated effectiveness in determining that an individual has exaggerated or faked psychological symptoms. Typically, mental health professionals who are providing treatment to an injured person do not engage in efforts to identify exaggeration or faking of psychological symptoms because exaggeration or faking are believed to be relatively rare phenomena in such settings or because the skeptical attitude on the part of the treating doctor suggested by his or her evaluation of exaggeration or faking can be construred by the patient as evidence of mistrust by the psychotherapist. This perceived lack of trust in what the patient is telling the doctor can be harmful in a treatment relationship because trust by the patient in the doctor may be one necessary and important element of successful treatment.

However, individuals who are already in treatment or who begin treatment for psychological problems after a personal or work accident, sometimes seek legal redress for their injuries. Subsequently, the treating doctor can be called upon to provide written reports or courtroom testimony about their treatment. Because the treating doctor had no way of knowing that a legal case was forthcoming, he or she did not have a reason to administer time-consuming and expensive psychological tests designed to identify exaggeration or faking. In this situation, the testimony that can be offered by the treating doctor is based on clinical interviews or notes of treatment sessions. If the treating doctor's patient has been exaggerating or faking psychological symptoms in the treatment setting for the purpose of enhancing a future legal claim, this may be unknown to the treating doctor.

Most research shows that clinical interview alone, without specialized psychological testing, is not an effective method for identifying exaggeration or faking of psychological symptoms or mental disorders.

Only specialized tests such as Minnesota Multiphasic Personality Inventory (MMPI-2), SIRS and M-FAST have been shown to be effective in identifying exaggerated or faked psychological symptoms.

Identify Malingerers or Pay the Price

It is very likely that insurance companies are needlessly paying large sums of money to claimants with exaggerated or faked psychological symptoms such as exaggerated PTSD (Posttraumatic Stress Disorder). Unfortunately, exaggerated PTSD is only one example of the many kinds of exaggerated psychological symptoms that might be exhibited by a personal injury, Worker’s Compensation or disability claimant in order to secure financial benefits or to avoid work.

Exaggeration and faking of mental disorders are not rare occurrences especially now that many litigants can find information on the Internet that may assist them in their attempts to report genuine-sounding, though false or exaggerated, psychological symptoms.

How frequently does faking or exaggeration of PTSD and other psychological symptoms occur? A 1994 study reported that that almost 16% of examinees malingered psychological symptoms in forensic (court) settings and 7% of examinees malingered psychological symptoms in non-forensic settings. In 1996 a follow-up study by some of the same authors showed that malingered psychological symptoms occurred slightly more frequently than indicated by the 1994 study. A study conducted in 2000 showed that 29% of personal injury litigants, 30% of disability claimants, 19% of criminal cases and 8% of medical cases likely involved some degree of symptom exaggeration and malingering of psychological or medical symptoms. Clearly, exaggeration, faking or malingering of psychological symptoms on the part of litigants is relatively common.

How can insurance companies avoid losses due to exaggerated or faked psychological symptoms? One critical technique that can prevent or reduce such losses is to require that the psychologist conducting an IME or psychological evaluation of the tort claimant fully evaluates the likelihood of exaggeration or malingering. The psychologist usually accomplishes this by using sophisticated psychological tests that can reliably detect faking, even when a litigant has learned techniques to assist him or her in efforts to deceive the examiner.

However, based on my 30 years of experience as a clinical and forensic psychologist, during which time I have conducted thousands of psychological evaluations of tort claimants, I have found that many mental health professionals conducting such examinations have failed to utilize effective procedures to identify exaggerators, fakers and malingerers. Astoundingly, I have found that some mental health professionals, including psychologists and psychiatrists, apparently fail to even consider the idea that an examinee may have exaggerated or faked psychological symptoms. This is evident when there is no mention in the written psychological or psychiatric report that such a consideration was made. This is a major failure, in my opinion, especially in those cases (such as with a diagnosis of PTSD) in which the Diagnostic and Statistical Manual of Mental Disorders specifically states that malingering must be ruled out before such a diagnosis can be made.

I can assist you in determining whether exaggeration, faking or malingering of psychological symptoms may have occurred. My procedures include a review of existing medical records, a clinical or face-to-face interview of the litigant and the administration of specialized psychological tests that have been scientifically demonstrated to be useful in making such a determination.

More information about the procedures and tests I utilize when conducting forensic psychological evaluations can be found on my website by clicking on the Articles button on the left side of your screen. In addition, citations to studies reported in today’s blog entry are available upon request.

A COMBINATION OF GENUINE AND EXAGGERATED DEPRESSION THAT RESULTS IN DISABILITY FOR WORK

Not long ago, I was retained to conduct a psychological evaluation of an employee who was alleging severe depression resulting in disability for work. Her employer believed she may have had a mild non-disabling depression but that she was presenting with a more severe, possibly exaggerated depression.

The examinee, a female, was age 49 when I met with her in my office in Brighton, Massachusetts, and reported to me that she first experienced depression while in college around 30 years earlier. Her initial symptoms of depression included difficulty arising in the morning, increased appetite, crying and missing classes at college.

Upon clinical interview, the examinee reported that her current symptoms of depression included sad mood, loss of interest in previously preferred activities, decreased appetite, insomnia, fatigue, low energy level, worthlessness and concentration problems. She denied recurrent thoughts of death or suicidal ideas. Her current treatment plan includes psychotherapy and antidepressant medications. She had never been treated for depression in a psychiatric hospital setting.

In addition to a clinical interview, I also administered psychological tests including the reading subtest from the Wide Range Achievement Test, the Miller Forensic Assessment of Symptoms Test (M-FAST) and the Minnesota Multiphasic Personality Inventory (MMPI-2). I used these tests to (a) determine that her reading skills were strong enough that she could respond to the other psychological tests I administered (b) to confirm findings from the clinical interview and (c) to determine if the claimant is exaggerating or faking (malingering) psychological symptoms. Clinical interview without psychological testing is not a reliable indicator of malingering.

On the basis of my examination of this individual, I concluded that she met all the diagnostic criteria for Dysthymic Disorder, a chronic type of depression. However, I noted on the basis of the clinical interview that she appeared to exaggerate some of the symptoms of her depression when she described them to me during the interview. She seemed able to perform usual daily activities in a way that seemed inconsistent with her claim of severe depression. In addition, I found that her claim of severe fatigue and concentration difficulties was not consistent with her ability to cooperate with a four-hour examination. In addition, I found that her scores on the “validity” scales of the MMPI-2 and her score on the M-FAST were consistent with exaggerated depression.

Although I found that she exaggerated some symptoms of depression, my opinion was that she had genuine symptoms of depression that were significant enough at the time I met with her to interfere with her ability to meet some requirements of her job description. I concluded that , despite some exaggeration of depressive symptoms, she was unable to work at her job due to a genuine, chronic depression.

I am a licensed psychologist in Massachusetts and I conduct psychological evaluations for insurance companies and lawyers in connection with Workers Compensation, Disability and Personal Injury claims. More information about my services is available at my website.

Some Implications of Failure to Rule out Malingering

I recently conducted a medical records review of a Worker's Compensation in order to determine if the injured worker in fact suffered from PTSD and Pain Disorder as a result of an industrial accident.

There was only one report in the file I was given for review that contained a clinical psychiatric examination of the injured worker. In that report, based on the clinical interview, the psychiatrist diagnosed Posttraumatic Stress Disorder but did not address or rule out the question of malingering. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), malingering should always be ruled out prior to assigning a PTSD diagnosis.

Several months later, the same injured worker was sent to another psychiatrist who conducted a medical records review without a clinical interview. The second psychiatrist agreed with the earlier diagnosis of PTSD and added a diagnosis of Pain Disorder Associated with both psychological factors and a general medical condition.

As a result of the first psychiatrist's failure to rule out malingering, and the second psychiatrist's assignment of a Pain Disorder diagnosis without any assessment of malingering in the file, I wrote in my report that I could not be sure the PTSD or Pain Disorder diagnoses could be substantiated.

The lessons here are as follows:

1. Plaintiff's attorneys should be careful not to accept, without some scepticism, the notion that their client's diagnosis of PTSD is genuine and adequately documented when malingering has not been ruled out. I have written elsewhere that psychological testing rather than interview is needed to rule out malingering. Failure to obtain a clinical exam in which malingering has been ruled out can help to avoid unpleasant surprises at deposition or trial.

2. Personal Injury and Worker's Compensation defense attorneys and insurance companies should require that an assessment of malingering be conducted as an essential element of all psychological evaluations and especially those in which diagnoses such as PTSD and Pain Disorder are alleged. Failure to do so may result in unnecessary awards and benefits for mental disorders that have not be adequately documented.

For additional information on these topics, please visit my website and click on the "Articles" button on the left side.

When Documentation Fails to Support Psychological Disability

I often review medical records as a part of my evaluation of an individual claiming mental impairment in disability cases involving mental disorders such as Panic Disorder, Posttraumatic Stress Disorder and Major Depressive Disorder . The purpose of this post is to discuss one type of error, made by doctors who examine or treat disability claimants, that can lead to incorrect conclusions. This error involves an assumption that if an individual reports psychological symptoms, that individual is disabled and cannot work, even in the absence of corroborating evidence of the symptoms and impairment of the claimant’s functioning.

It is, unfortunately, quite common for me to review reports that will contain statements like the following as sole corroboration of a mentally disabling condition:

• She has nightmares
• He is struggling with significant symptoms of depression and anxiety
• The claimant made several errors on a “Serial Sevens” task

Having nightmares does not necessarily preclude an individual from working. When I met with this claimant, I learned that the nightmares had been occurring only once per two months and that the claimant last had a nightmare six months before I met with her. I also learned that the nightmares did not prevent the claimant from sleeping 8 hours per night.

Symptoms of depression and anxiety are common manifestations of a variety of mental disorders. But, symptoms of depression and anxiety can also be expressed by individuals with mild mental disorders and by those with no mental disorder at all. In reviewing records in a disability claim, I often read psychotherapy progress notes indicating that the claimant was observed to be anxious or that he exhibited symptoms of depression. The psychotherapist may then conclude that the claimant is disabled and cannot work at all at his usual occupation or any occupation. Yet, the report did not provide examples of behaviors exhibited by the claimant demonstrating that the symptoms interfere with usual functioning in such areas as daily activities or social relationships, or that the symptoms precluded work.

In order to identify mental processing problems, some mental health professionals utilize a task in which the claimant is asked to subtract numbers from another number or spell certain words backwards. On the basis of errors on such tasks, a claimant was described as totally disabled for all work because of impairments of attention, concentration and memory. Yet, this claimant’s cognitive functioning was normal, except for the problems noted, and was not precluded from working as a result of cognitive impairments. Clearly, a problem in counting backwards or spelling a word backwards does not prevent an individual from working in all occupations.

CONCLUSIONS: I often note that medical documents purportedly demonstrating disability do not include objective findings that substantiate mental impairments that preclude work. It is not enough to describe the claimant’s subjective report of psychological symptoms or to state that a claimant is anxious or depressed. In order to prove that a claimant cannot work in any occupation, treating or examining doctors must provide up-to-date clinical findings, backed-up by behavioral observations or psychological test data that document mental impairments that result in significant loss of capacity to function.

Dr. Clayman practices forensic and clinical psychology in Boston, MA, USA. He can be reached at 617 782-8355. More information about Dr. Clayman's areas of expertise can be found at his website by clicking on the Articles button.