Fake Posttraumatic Stress Disorder (PTSD) Costs Real Money

written by Irena Boskovic & Harald Merckelbach
edited by Reine van der Wal

As a diagnosis, Posttraumatic stress disorder ( PTSD) rests entirely on what people report about their symptoms. Thus, many people, such as Robert, Lisa, and even a Senator, who strive for compensation money or other benefits, falsely report suffering from it. While lying about the PTSD might be easy, detecting those who fabricate PTSD is a real challenge.

One study found that 94% of individuals without prior knowledge about PTSD could successfully act the part. Image from www.pexels.com covered under liscense CC0.

If someone would instruct you to walk into a psychiatric clinic and claim that you suffer from severe psychological consequences of trauma exposure, do you think they would know that you are lying? As shown in a study by Hickling and his colleagues (2002), they probably would not.

The basic idea behind the diagnosis of Posttraumatic Stress Disorder ( PTSD) - that trauma can derange people mentally - exists since the 1880s. There have been many labels to refer to this idea, such as “nervous shock” or “posttraumatic neurosis” (Adamou & Hale, 2003). The terms “shell shock” and “battle fatigue” were used to describe psychological problems related specifically to combat exposure during World War I and World War II. The current term, PTSD, made its first official appearance in the third edition of the Diagnostic and Statistical Manual (DSM III, American Psychiatric Association, 1980) in 1980, describing a psychological disturbance as a consequence of a broader range of trauma experiences (Resnik, West, & Payne, 2008).

Originally, any exposure to a trauma was enough for diagnosing PTSD. However, it later became clear that not everybody with a trauma history develops PTSD. In fact, 10-40% of people will suffer from PTSD after having been confronted with some kind of trauma, as shown by the pioneering work of psychologist George Bonanno (Bonanno, 2005). Whether a victim develops PTSD depends on many factors, such as the nature of trauma and the individual’s personality and background, including previous traumatic experiences. For example, the prevalence of PTSD for people who experienced a sexual assault tends to be close to 80%, while only 15% of people involved in a car accident will develop PTSD (Hall, Hall & Chapman, 2006). When it comes to combat-related PTSD, the proportion of soldiers suffering from PTSD varies as a function of the intensity of violence and torture exposure (McNally, 2003). For example, 70% of people who were prisoners of war and have been tortured suffer from PTSD. In contrast, 18% of veterans who were not captured and not tortured experience PTSD symptoms (Sutker et al., 1993). Unharmed veterans are half as likely to develop PTSD compared with veterans who were wounded (Kulka et al., 1990). Contrary to laypeople’s beliefs, it is not enough to report the experience of trauma in order to be diagnosed with PTSD. The current requirements for the PTSD diagnosis are listed in Table 1.

Table 1. The description of PTSD criteria in the current Diagnostic and Statistical Manual (DSM V, American Psychiatric Association, 2013)
Criterion	Subject	Description
A	Trauma exposure	A direct exposure to a traumatic event, witnessing it, or finding out that a traumatic event happened to a family member.
B	Re-experiencing symptoms	Re-experiencing the trauma through intrusive images and thoughts about it, recurrent dreams related to the event, flashbacks, and high distress when exposed to trauma reminders.
C	Avoidance	Avoidance of thoughts, feelings, people or places related to trauma.
D	Negative cognitions and negative mood	An intense sense of blame (self-blame or blame of others), diminished interest in socializing and participating in previously enjoyed activities.
E	Arousal	A “short fuse”, reckless, self-destructive or violent behaviour, with difficulty to keep their focus and attention.
F	Duration of symptoms	At least for a month.
G	Distress/Functionality	Symptoms create significant distress or functional (occupational, social etc.) impairment.
H	Exclusion of different causes	Symptoms are not caused by medication, alcohol, drug use, or other illness.
Note: In order to be diagnosed with PTSD, a person must have a specific number of symptoms from each criterion (DSM V; American Psychiatric Association, 2013).

PTSD symptoms have become part of the public knowledge through Hollywood movies that depicted traumatized veterans (e.g., The Deer Hunter (1978). Even those who are not familiar with these movies can find detailed information about PTSD on the internet. Hence, individuals do not have to put a lot of effort to obtain the basic information that is needed for receiving the PTSD diagnosis. Even 94% of individuals, without prior knowledge about PTSD but instructed to act as if they suffer from it, are successful in fulfilling the criteria for PTSD on checklists (Burges & McMillan, 2001).

Bogus PTSD

As we previously presented, PTSD is a well-known, self-reported diagnosis that is relatively easy to simulate. Still, the question may arise – why would people want to have the PTSD diagnosis? Well, traumatic events often have a legal dimension: victims may be entitled to financial compensation for their psychological injuries. Furthermore, in courts of law, perpetrators of violent crimes may stress their PTSD as a strategy to reduce criminal responsibility or to mitigate sentences. If an assessment of PTSD symptoms is largely based on self-reports – which is the case with a diagnosis of PTSD – then malingering becomes an option to be considered. Malingering is defined as the intentional production of falsely or grossly exaggerated physical or psychological complaints with the goal of receiving an external incentive (DSM V, 2013). The M-word is often avoided because it is a painful topic: clinicians and lawyers do not want to run the risk of misclassifying a victim of trauma as a malingerer. Still, several studies have come up with alarming numbers. For example, one US study found evidence for malingering or symptom exaggeration in half of 74 veterans seeking treatment for PTSD (Freeman, Powell, & Kimbrell, 2008). Feigned PTSD has also been found to occur during civil procedures in which people try to obtain compensation for alleged injuries or service-connected disability pensions (Knoll & Resnick, 2006; Briere, 2004). Unfortunately, the exact prevalence rates of such cases are not known, because successful malingerers go undetected (Guriel & Fremouw, 2003). Also, people who feign PTSD often do have some form of traumatic background (Guriel & Fremouw, 2003). Thus, they are familiar with the symptoms they need to report in order to appear genuine.

A recent study found that forensic professionals are skeptical about their own ability to detect those who malinger, with only 4% reporting being certain they could successfully do so. Hickling’s study proved the ground for skepticism. He instructed actors to attend a clinic specialized in the treatment of PTSD and to present bogus PTSD symptoms. None of the actors was detected (Hickling, Blanchard, Mundy, & Galovski., 2002).

With a diagnosis that is relatively easy to malinger, and professionals that are timid to confront feigners, there are good reasons to assume that PTSD is over-diagnosed, especially in forensic settings (Cohen & Appelbaum, 2016). Looking into general statistics, there is another strange trend occurring in PTSD diagnoses. The top five countries with the highest prevalence rate of lifetime PTSD are Canada, the Netherlands, Australia, the United States, and New Zealand, which are the most developed countries and considered to be the least vulnerable to traumatization (Duckers, Alisic, & Brewin, 2016). This could mean that standards for diagnosing PTSD differ across countries, which has been recognized in another diagnosis as well, such as depression (Kessler & Bromet, 2013). However, another likely cause for national differences in PTSD prevalence is that highly developed countries have more incentives to offer for people who are diagnosed with PTSD, compared with poor countries that have the lowest prevalence of lifetime PTSD, such as Nigeria and Romania (Duckers et al., 2016).

Who is more “vulnerable” to fake PTSD and why?

As we previously explained, the exact prevalence of malingering is not known. However, certain populations might be more prone to feigning, considering their likelihood of receiving a financial compensation, or avoiding criminal charges by claiming PTSD. For example, financial gain might be especially important in combat-related PTSD. Of the total number of US veterans receiving compensation for a mental disorder, 75% are compensated for PTSD and this percentage tends to go up each year¹ (McNally & Frueh, 2013). Croatia changed its policy regarding veteran compensation in 2001, allowing veterans with delayed PTSD to apply. Intriguingly, before the new regulation, 58% of a sample (225 veterans) who were referred to a military hospital for psychiatric evaluation exhibited symptoms of PTSD. After 2001, this number increased up to 91% (Kozaric-Kovacic et al., 2004). In the US, the estimated proportion of people feigning PTSD symptoms so as to receive a financial compensation ranges between 20% and 30% (Lees-Haley, 1997). A survey of 2,100 veterans who were receiving PTSD disability compensation noted that 25% of them was misdiagnosed and did not fulfill the criteria for benefits. Extrapolating these results to all benefit-receiving veterans, that is a loss of approximately $19.8 billion (Department of Veterans Affairs Office of the Inspector General, 2005; Resnick, West, & Payne, 2008). Veteran Robert Warren²is just one of many examples. He had received over 200k dollars before it was revealed that he has never seen combat. Another example is ex-soldier Felton Lamar Gray³, who fabricated a terrifying story of his best friend being blown to pieces in front of him, an experience that entitled him to 100% disability ratings. Once his story was checked, it was discovered that his “best friend” was very much alive and barely knew Gray. Maybe the most “successful” fraud was performed by a veteran named David Clark⁴, who obtained over 1.4 million dollars, by creating a scheme of generating fraudulent documentation, such as psychiatric and military reports, for himself and others.

There are numerous examples of people who fabricated PTSD for other reasons than financial gain⁵, such as legal benefits, or just popularity and public attention. To name a few US examples: Lisa Weiszmiller⁶, who faced drug charges, used the PTSD excuse in court, despite the fact that she had been discharged from the army after just a few months. Similarly, drug smuggler Saleem Sharif⁷ said that he would had never gone into the drug business if he hadn’t previously been enrolled in service, which, he claimed, resulted in PTSD. Even a plagiarized college thesis of US senator John Walsh⁸ was “a result of his severe PTSD at the time”. Some, for example Jesse MacBeth and Simon Buckden, went one step further and spoke in the public domain about their misfortune in the battlefield and about their (also invented) cancer struggles, gaining popularity worldwide. They were both found guilty of fraud in 2005 and 2012.

How to detect bogus cases?

There are limited ways to detect whether people faking PTSD and, as the example of the Hickling study illustrates, the intuitive clinical impression is certainly not one of them. In rare cases, people might confess that they faked PTSD, or there might be solid evidence, such as a video of a bogus victim performing activities previously stated as undoable. More commonly, however, clinicians have to rely on psychometric evidence to rule in or out malingering (Resnick et al., 2008). According to the DSM V, clinicians should suspect malingering when a patient is involved in legal procedures, or if a patient’s symptom report does not fit his behaviour or objective findings or lacks details. Furthermore, suspicion should be raised if a person is reluctant to undergo medical testing, refuses to cooperate, or shows characteristics of antisocial personality disorder (Niesten et al., 2015). However, when clinicians rely on these rules of thumb, they will detect only 20% of the malingerers (Rogers, 1990). Recent research showed that people who feign their symptoms actually provide very long stories, full of vague details (Boskovic et al., 2017), and that the connection between malingering and antisocial traits is very weak, if existing at all (Demakis et al., 2015; van Impelen et al., 2017). Also, the DSM V assumes that a person is either malingering or not (Berry & Nelson, 2010), when in fact malingering is a dimensional phenomenon. Some people might fabricate their symptoms, others might exaggerate existing complaints, and still others might misattribute genuine symptoms to a traumatic cause (Resnick, 1997). All three types of malingering can be seen in feigned PTSD (Guriel & Fremouw, 2003), but people feigning PTSD are more likely to exaggerate rather than to fabricate symptoms (Resnick, 1997).

There are numerous instruments that can help to detect potential malingering. These instruments are collectively known as Symptom Validity Tests (SVT). They usually include absurd, implausible symptoms (e.g., “My headache are so strong sometimes that my feet hurt”), and many feigners tend to endorse such symptoms. Besides the SVT’s, so-called Performance Validity Tests (PVT’s) are effective in the detection of malingering. These types of tests consist of simple memory or perception tasks that are combined with a two–alternative, forced-choice procedure. In the Morel Emotional Numbing task, for example, a patient is presented with pictures of faces depicting emotional expressions (e.g., anger). After each picture, the patient is asked to indicate which of two emotions the depicted person expresses (e.g., anger vs happiness). Even people with serious neurological problems can do this task very well. Just by guessing, a person can obtain a correct score of 50%. Therefore, if an individual fails this test by having less than 50% correct, it is highly likely that a person is providing wrong answers intentionally (Morel & Marshman, 2008).

SVTs and PVTs have their limitations. There is, indeed, the risk of false positives (classifying genuine patients as malingerers), but that should be an impetus to carry out a systematic evaluation with multiple instruments. By combining several SVTs and PVTs, and by using the criterion that a patient is only suspected of over-reporting symptoms when he fails two or more tests, the risk of false positives drops below 5%. Not using such tests can obscure many aspects of clinical and forensic psychology, can lead to low-quality assessments, and might give a wrong impression about the prevalence of PTSD.

It is also important to use all available data that could support or falsify the presence of PTSD. The clinicians should look into a person’s history of symptoms, obtain information about his social and occupational functioning from other sources, and compare this to the patient’s report. Also, any military or/and medical record should be checked, although military record can be easily forged (Burkett & Whitely, 1998). Clinicians often believe that “secret operations” are not documented, but that is a myth. At a minimum, training for this type of military job is recorded, and usually only date and location are left out (McNally, 2003). Additionally, knowing the risk factors (e.g., prior exposure to trauma, Davidson et al., 1991; social factors, gender, age, Bremner et al., 1993, etc.) for developing PTSD, and if they are present in a particular case, may help in the assessment of possible malingering. Recently, some authors argued that PTSD should be considered as a biopsychosocial condition that includes specific biological markers, such as genetics and certain pattern of activity in different brain regions (Young, 2017). However, the utility of these risks factors or markers is questionable because the absence of any risk factor or biological marker does not disprove the presence of PTSD. Furthermore, certain researchers believe that using tasks that rely on the reaction time, rather than tasks that rely on self-report, may help in detection of malingering (e.g., Buckley, Galovski, Blanchard, & Hickling, 2003). The reasoning behind using the reaction time measures is that malingerers would have difficulties in recognizing the response patterns typical for genuine patients. The Modified Stroop task (MST) is a good example. This task includes presentation of disorder-related and neutral words in different colors. An examinee is asked to name the colors as quickly as possible while ignoring the meaning of the words. It is assumed that the examinee with a certain psychological disorder would exhibit a prolonged reaction time (RT) in color-naming words related to his/her disorder, compared to the RT when neutral words are presented, so called the MST effect. Thus, if this effect is absent, the person might be fabricating his/her complaints (Buckley et al., 2003). However, others studies showed that the MST effect is easily produced by malingerers (e.g., Boskovic et al., 2018), and that results of the Modified Stroop task are highly unreliable (Kimble, Frueh, & Marks, 2009).

Relevance of fake PTSD and its consequences

There are many misconceptions about malingering that still have a strong influence, not just in psychiatric and psychological circles, but in society at large. For example, some psychologists (e.g. Jackson et al., 2011; Yelin, 1986) state that there is no reason to be concerned about malingering of PTSD because simulated PTSD is rare. There is also a widespread idea that it is easy to recognize people who malinger PTSD. However, both of these assumptions have been disproved by scientific research (e.g., Freeman et al., 2008; Hickling et al., 2002). From a political point of view, it does not sound good if veterans who fought for their country, or people who might have been victims, are screened for malingering. However, the price of a policy that bans SVTS and PVTs may amount to millions of dollars or euros given to people who may not even have a history of trauma. Eventually, this may jeopardize the legitimacy of health care funding for patients with genuine problems (Poyner, 2010). On the other hand, having a “tunnel vision” and overclaiming the prevalence of malingering is also dangerous. It can lead to a raised threshold for obtaining a legitimate diagnosis, resulting in underdiagnosed genuine PTSD cases. This would be especially pronounced in mild forms of PTSD. Therefore, both trivializing or overestimating the issue of malingering undermines the quality of clinical assessment, but it also carries political and legal risks with it.

Reference

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Notes

1 In the USA, individuals who receive a 100% service related disability compensation due to PTSD can receive up to $40k (tax-free) each year for their entire lifetime (Burkett & Whitley, 1998).

2 http://www.breachbangclear.com/ptsd-fakers/

3 http://www.dailyherald.com/article/20100502/news/305029890/

4 https://www.justice.gov/usao-md/pr/six-veterans-plead-guilty-fraudulentl...

5 For all types of benefits that veterans are eligible for see https://benefits.va.gov/BENEFITS/derivative_sc.asp?utm_source=fb&utm_medium=social&utm_campaign=Derivative_SC&utm_content=20170912.

6 http://havokjournal.com/culture/ptsd-trauma-is-not-drama/

7 http://www.vocativ.com/usa/uncategorized/kabul-connection-soldier-west-p...

8 https://www.stripes.com/news/us/senator-i-had-ptsd-when-i-wrote-war-coll...