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.

Reading the Expert’s Psychological/Psychiatric Report

As a part of my independent psychological evaluation of a claimant in a disability, worker’s comp or personal injury case, I am usually asked to review an examinee’s medical records as well as to conduct my own examination. The purpose of reviewing the medical records is to identify objective findings that I can use, along with my interview and tests, as the basis for my opinion about whether an examinee has a mental disorder or not and how severe that mental disorder might be. Because benefits may be available if a claimant is found to have a mental disorder, I also use tests that can identify whether or not an examinee has exaggerated or minimized psychological symptoms.

By “medical records” I mean treatment progress notes as well as reports that are based on psychological or psychiatric evaluations.

The purpose of this entry is to provide you with a few tips that will help you to evaluate the authenticity of diagnoses found in psychological and psychiatric medical records in disability, worker’s comp and personal injury suits.

Mental disorders are defined by specific criteria which are found in the DSM-IV. Doctors don’t always document the full criteria of the mental disorder they diagnose. I notice this is especially true in psychotherapy and psychopharmacology notes. For instance, a doctor might indicate in the treatment notes that the patient was involved in an accident and presents with nightmares and, on the basis of this information alone, assign a diagnosis of PTSD. Although the patient may in fact meet the full diagnostic criteria for PTSD, the problem is that these symptoms, by themselves, do not meet all the diagnostic criteria for PTSD and the diagnosis can be challenged on that point.

Doctors sometimes draw conclusions that are not supported by their interview or test findings. This is related to point #1. I recently reviewed a report in which the psychiatrist administered a psychological test measuring depression, found the results to be normal, yet, despite this test finding, assigned a diagnosis of depression to the examinee. When there is a discrepancy between test findings and the diagnosis, there should be an explanation for that discrepancy. This doctor did not provide an adequate explanation. I would challenge the credibility of the diagnosis in my written review of these medical records.

Who did the actual psychological testing? Psychological testing, unlike psychotherapy treatment, is the unique skill of clinical and forensic psychologists. Other professionals, even within the field of mental health, rarely conduct psychological tests. Occasionally, other professionals will administer or utilize psychological testing and this will sometimes result in errors in test selection, administration and in the use of the test results. For instance, I was retained by a lawyer to examine an individual and review the reports of two psychiatrists who had previously evaluated the same individual. I noted that one psychiatrist had administered the MMPI-2 test and sent the test sent to a lab for scoring and interpretation. The lab then produces a narrative (text) report. The narrative report from most labs is clearly identified as consisting of “hypotheses” to be tested against the data from the clinical exam. The narrative report does not provide information pertaining only to the individual who took the test and is not considered to be data. The psychiatrist, perhaps unaware of the nature of the narrative report, then incorporated large sections of the narrative MMPI-2 report into his own report. The second psychiatrist read the laboratory produced narrative report of the MMPI-2 test administered by the first psychiatrist, also incorporated large sections of text from the narrative report and did not make it clear that he had not, himself, administered the report. When a professional who is not trained or not well-experienced in the use of a psychological test uses that test, the risk of error in the administration or interpretation of the results of that test is increased.

The expert fails to consider malingering: Posttraumatic Stress Disorder (PTSD) is diagnosed in some disability, worker’s compensation and personal injury claims when the claimant has experienced a stressful event. According to the DSM-IV, malingering must be ruled out in those situations involving financial incentives. Yet, I very rarely see any mention of malingering or an attempt to assess for malingering in psychotherapy treatment notes even when the psychotherapist has diagnosed PTSD and is aware the patient has a legal claim in which PTSD is an issue. More surprising to me is when a psychologist or psychiatrist, conducting an IME within the context of a legal case, fails to mention or attempt to determine if there if exaggeration, faking or malingering. A PTSD diagnosis in a legal case should be challenged if malingering has not be ruled out.

Stuart J. Clayman, Ph.D. is a licensed psychologist who conducts forensic and clinical examinations in disability, worker’s compensation, employee-employer and personal injury claims. Dr. Clayman can be reached at jay@braindoctor.org or at 617 782-8355. More information is available at Dr. Clayman’s website: www.braindoctor.org

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.

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, 4^th 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.