Distinguishing false post-traumatic stress disorder (PTSD) from the real thing can be very tricky, but it's necessary in order both to help patients and to make sure treatment resources are allocated correctly, according to , assistant clinical professor of psychiatry at the University of California San Francisco.
"There is a very finite number of psychiatrists who are well-qualified to treat PTSD, and if they're spending time on [false] PTSD cases, they're not able to treat the people who need help the most, " Matto said in a phone interview.
At last month's annual meeting in Portland, Ore., Matto laid out a framework for assessing potential PTSD cases. Matto is a captain in the California Army National Guard and chief mental health officer for the Joint Force Headquarters.
The framework delineates five possible types of PTSD diagnoses:
- Misattributed PTSD: Symptoms that are consistent with PTSD but are actually more attributable to a co-morbidity such as anxiety. Misattributed PTSD is fairly common, since 92% of patients with a primary PTSD diagnosis have at least one other psychiatric diagnosis, according to Matto.
- Malingered PTSD: Symptoms are being deliberately falsified by the patient in order to achieve some sort of external gain, such as pension or disability payments, or dismissal from a lawsuit.
- Factitious PTSD: Symptoms are being deliberately falsified by the patient for intrinsic gain, such as respect from peers or using the "victim" role to justify a poor level of functioning, like failed relationships or legal problems.
- Elevated PTSD: Symptoms are consistent with PTSD but seem exaggerated.
- Genuine PTSD: Symptoms are real and are consistent with a diagnosis of PTSD.
Misattributed PTSD
To spot misattributed PTSD, "The first thing you look to see is whether or not someone who is misidentified as having PTSD when there's a set of symptoms that are better explained by another diagnosis," he said.
For example, "Misattribution is very common in victims of trauma. You have a clinician bias -- 'Oh, they were in a war' -- that leads to an early PTSD diagnosis, when in fact the most common response to trauma is depression or anxiety. If it does [turn out to be] misattributed, you can address the underlying pathology instead of progressing down the PTSD treatment path, which is inappropriate and won't get optimal results."
Once misattributed PTSD is ruled out, the clinician should look at the symptoms and say, 'Are they being volitionally produced or not?'" Matto continued. If they are being intentionally produced, "Physicians in the past have attributed it to malingering PTSD," but clinicians should dig deeper and see whether it's being produced for primary or secondary gain.
Only if it's produced for secondary gain -- external rewards such as getting out of legal responsibility in a criminal case -- is it actual malingering, according to Matto. For example, a patient might decide, "I was assaulted by an employee at WalMart; I'll sue WalMart and claim that I have PTSD as a result of the assault."
This is a common strategy in civil cases as well, he said. "The most accurate data seem to be that in 20%-30% of personal civil injury lawsuits, PTSD is falsely claimed." In the case of the Veterans Affairs health system, PTSD was the third most common disability claim by 2012.
How to Treat Malingering
As for malingering, "I get called in for challenging or diagnostically unclear cases, so probably see more of it than most," said Matto. Although it can be hard to address, "If someone's malingering it's because they want something. [For example] I have folks malingering for the sake of getting a pension, so I will say, 'You do not have PTSD but I can tell you're suffering; if it's because of financial need, let's see what resources I have to help with that.'"
If the patient is producing the symptoms for primary gain -- an intrinsic reason like getting to play the role of a sick person -- that's known as factitious PTSD. "This is very common in primary care physician offices -- people want the sort of sympathy that comes from being sick; they want to be pampered. They will inject insulin -- or even inject feces to make themselves septic."
"The main difference between factitious PTSD and malingered PTSD is that malingered PTSD is not a mental illness, while factitious PTSD is a psychopathology. Factitious disorder is recognized in the DSM, whereas malingering is not." The treatment for factitious PTSD is longitudinal psychotherapy, since one of the main motivations is unmet social need, he added.
There is real danger in not recognizing malingered PTSD, Matto noted. "If malingered PTSD isn't caught, then you get the stereotype of it being violent, since people are using it to get out of responsibility for committing crimes. "
"Also, not catching it calls into question legitimacy of the research database," he said. "That's because if you take a look at people's response rates to therapy or pharmaceutical interventions for PTSD, [those who malinger] never claim to get better. That makes the efficacy rates for different treatment modalities look worse than they are and people might be more reluctant to enter treatment."
Then there are the cases of elevated PTSD, in which patients have PTSD but appear to be volitionally producing symptoms. "Sometimes when you do psychological testing, the symptoms can appear amplified; that's something we need to be very cautious about," he said.
"Studies have found that a certain number of veterans seem to be overreporting their claims, but when you look a little deeper, they're not doing so for the sake of malingering; they're doing it as a cry for help ... One study showed that of the evaluated claims, 23% appeared to be intentionally exaggerating their symptoms but 77% were actually a sign of distress. This requires careful calibration of neuropsychiatric testing to make sure we're not missing folks."
The Devil is in the Details
Matto suggests people depart from the traditional way of thinking about PTSD. "The traditional way has been to look [first] for signs and symptoms of malingered PTSD; I'm saying go the other way around -- look for genuine PTSD and if there's a deviation, see whether it's false PTSD or not."
This involves carefully going through the patient's medical records and look very closely at progress notes, rather than at case summaries, he said. "You really want to look at progress notes because you can get a day-by-day accounting of symptoms and create logs yourself to see how people are doing over time, and compare it with testing that may occur on particular days, or with symptom logs you give the patient."
He also recommended looking at military records, in particular the DD-214 discharge form from the military. "It's a one-pager; it's not hard to fake," Matto said. "I recommend people request it directly from the [military's] National Personnel Records Center."
Also, when you're talking to patients about their about military service, try to get as much detail as possible, he said. "One stereotype physicians have about individuals with PTSD is that they don't want to talk about their military experience. They may not want to talk about traumatic experiences, but they should be able to talk about other details. if they were in the Navy, you can ask, 'What sort of boat were you on and where did you stop?'" Or you can ask about their uniform; if the response is "I wore my greens," the physician can ask what was on their utility belt. "We should ask for a lot of details."
In addition, "I always recommend they take a look for inconsistencies in their story between what they're describing and what they're demonstrating," said Matto. For example,"I'll [position] patients with their back to a door and while I'm talking to them" because a common sign of PTSD is being uncomfortable with having one's back to a door.
If the patient genuinely has PTSD, "they'll [immediately] see where the chair is and ask to move it," whereas a patient with false PTSD may seem fine until you start asking about their symptoms, and then they may remember about that being a symptom and will ask to move the chair.
Or they may say that their memory is terrible and they can't remember what happened the day of their trauma, but if you ask what day they filed a lawsuit they'll know the exact day and year. "Look for those inconsistencies," but also give them a chance to explain them because there may be a good reason for it, he said.