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Pseudo-PTSD
Journal of Anxiety Disorders 21 (2007) 201–210
Pseudo-PTSD Gerald M. Rosen a,*, Steven Taylor b a b
University of Washington, United States University of British Columbia, Canada
Abstract Pseudo-posttraumatic stress disorder (pseudo-PTSD) refers to cases in which a patient’s presentation is but a simulation of the actual clinical syndrome. The problem of pseudo-PTSD has been neglected by many clinicians and researchers, who often rely on the assumption that a patient’s reported symptoms can be accepted as valid. The purpose of this article is to (a) consider the diverse causes of pseudo-PTSD, (b) emphasize the importance of the DSM-IV’s guideline to rule out malingering, and (c) discuss the implications that pseudo-PTSD has for research and clinical practice. # 2006 Elsevier Ltd. All rights reserved. Keywords: Posttraumatic stress disorder (PTSD); Factitious; Malingering; Litigation; Personal injury; Compensationseeking; Veterans
Pseudo or false presentations of posttraumatic stress disorder (PTSD) can arise from diverse causes (Lacoursiere, 1993; Pankratz, 1998). Yet, when the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994) addressed the issue of pseudo-PTSD, it only concerned itself with the concept of malingering. Malingering was defined 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’’ (APA, 1994, p. 739). With regard to PTSD, the DSM-IV provided this cautionary guideline, ‘‘Malingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role’’ (p. 467). The DSM-IV’s guideline to rule out malingering was noteworthy in several respects. First, it directed special attention toward PTSD even though malingering is an issue that can just as well apply to other disorders (e.g., major depression) when issues of compensation are involved. Second, while providing the dictum to rule out malingering, the DSM-IV failed to instruct * Corresponding author at: 117 East Louisa Street, PMB-229, Seattle, WA 98102, United States. E-mail address: [email protected] (G.M. Rosen). 0887-6185/$ – see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2006.09.011
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clinicians and researchers on how they might accomplish the task, if indeed the task is feasible. And third, as previously noted, the DSM-IV’s guideline on malingering ignored other reasons that pseudo-PTSD might occur. In this paper we address these issues and discuss why pseudoPTSD warrants more attention in research, clinical, and forensic settings. 1. DSM-IV’s guideline to rule out malingering 1.1. Why a guideline specific to PTSD? There are several reasons why DSM-IV provides a specific guideline to rule out malingering in the differential diagnosis of PTSD. PTSD was a diagnostic construct that arose by committee decision, largely in response to the interests and mental health needs of Vietnam veterans (Scott, 1990; Shephard, 2001; Yehuda & McFarlane, 1995; Young, 1995). The PTSD diagnosis provided a specific etiology (Meehl, 1977), and so it was particularly beneficial for Vietnam veterans and other groups who might have disability claims. Unlike most other diagnoses, a core assumption underlying PTSD concerned the linkage of a specific class of events (Criterion A) to a specific set of clinical symptoms (Criteria B–D). Slovenko (1994) observed that this feature made PTSD ‘‘a favored diagnosis in cases of emotional distress because it is incident specific’’ (p. 441). Trimble (1985) suggested that PTSD ‘‘would give a great deal of leverage to those seeking compensation and the counting off of symptoms in checklist fashion will become routine practice in many a lawyer’s office’’ (p. 13). Lees-Haley (1986) wryly commented, ‘‘If mental disorders were listed on the New York exchange, PTSD would be a growth stock to watch’’ (p. 17). Additional considerations played a role in the DSM-IV’s provision of a cautionary guideline for PTSD on the issue of malingering. There had been a long history preceding the DSM that considered the problem of malingered posttraumatic disorders (e.g., Lewis & Bombaugh, 1896; Hamilton, 1904; Page, 1891). Issues of disability compensation also influenced policy toward psychological casualties among soldiers in past wars (Jones & Wessely, 2005; Shephard, 2001). In addition to historical considerations, there were contemporary publications in which (a) commentators observed that the symptom criteria were subjective, easily coached, and easily simulated (Eldridge, 1991; Sparr & Atkinson, 1986); (b) case reports documented the reality of feigned PTSD (e.g., Lynn & Belza, 1984; Sparr & Pankratz, 1983); and (c) commentators noted the diverse motives that contributed to people adopting a victim narrative (Hamilton, 1985; Lacoursiere, 1993). In light of these various influences, it was not surprising when the DSM-IV included a cautionary guideline specific to PTSD. The only surprise was that it took three editions to finally recognize the issue: no mention of malingering was made in the PTSD sections of the DSM-III (APA, 1980) or the DSM-III-R (APA, 1987) 1.2. Have mental health professionals heeded the guideline? Despite the DSM-IV’s cautionary guideline to rule out malingering, researchers have mostly ignored the issue. See most every peer reviewed publication on PTSD (1980–2006) to demonstrate this point. Very few studies report that they ruled out malingering, and fewer still describe the methods that were used. This holds true even when litigation or compensation claims apply. To illustrate, Rosen (2004b) observed that Eid, Johnsen, and Thayer (2001) cited two studies as if they demonstrated high rates of PTSD, when in fact both publications (Raphael & Meldrum, 1993; Rosen, 1995) reported on subjects who were involved in litigation. No mention was made by Eid et al. of this important confound. Publications from the Albany Motor Vehicle
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Accident Project (e.g., Blanchard & Hickling, 2003; Blanchard et al., 1996) and a series of papers on survivors of the sinking of the Jupiter (e.g. Yule et al., 2000), included many subjects who were involved in litigation. Yet, no effort to rule out malingering was reported in these publications. Rosen (2006) provided a detailed critique of a paper by Daly and Johnston (2002) that reported a 67% rate of PTSD among litigating survivors of a 3 hour hostage situation at a bar in Northern Island. Although all referrals had been made by plaintiffs’ counsel for the purpose of forensic assessments, no effort was made to rule out malingering. Instead, Daly and Johnston (2002) simply observed that the victims appeared to have been ‘‘genuine, honest people’’ (p. 463). Another example illustrates how researchers and peer review journals have failed to make meaningful attempts to rule out malingering. Murphy and Keating (1995) reported on their evaluation of 27 plaintiffs involved in a class action suit, all of whom had been referred by their counsel. What was the process of assessment used in this study? Murphy and Keating explained that all plaintiffs had been exposed to a sudden and unpredictable torrent of debris and water that swept down a hill in a predawn rainstorm, resulting in neither death nor severe physical injuries. Nonetheless, all plaintiffs were ‘‘exposed,’’ and a class action suit was filed on their behalf. Clinical interviews were conducted using a written protocol that prompted the plaintiffs’ selfreports concerning their emotional status and their current level of functioning. Symptom checklists also were used including the SCL-90-R (Derogatis, 1994) and the Impact of Event Scale (Horowitz, Winler, & Alvarez, 1979). Murphy and Keating noted that medical records were available, but, ‘‘The case attorneys had access to litigants’ medical records, [and] requested that the assessment team submit their report based on data we collected’’ (p. 476). In other words, no attempt was made to look at additional sources of information beyond the plaintiffs’ self-reported problems. Perhaps such attempts were felt to be unnecessary. Murphy and Keating reported, ‘‘We had the opportunity to observe litigants and ask them questions that would be difficult to ‘fake’’’ (p. 480). Based on their findings, Murphy and Keating judged the severity of each case and provided rankings to further a determination of how any group award might be divided. They drew the following conclusion: The process [of assessment] was effective—the case was settled out of court in favor of the litigants. Individual litigants were satisfied with monetary awards received (p. 473). Murphy and Keating’s belief that answers to certain types of questions are difficult to fake, is similar in its optimism to the observation that litigants appear to be trustworthy and sincere (e.g., Blanchard & Hickling, 2003; Daly & Johnston, 2002). As we shall see, there is no particular type of question that reveals feigned presentations of a disorder, nor can clinicians reliably judge a person’s honesty by their aura. 1.3. Is the DSM-IV’s guideline a feasible goal? It should be pointed out the Murphy and Keating publication in 1995 could mean that the assessments were conducted prior to the 1994 introduction of the DSM-IV’s guideline. Nevertheless, the report serves as a striking example of what not to do. Even in years prior to 1994, it was appreciated that forensic experts should not rely solely on an individual’s self-report (Shapiro, 1984), disorders could be easily feigned on symptom checklists (Lees-Haley, 1989, 1990), and mental health professionals were not accurate in judging truthfulness (Ekman & O’Sullivan, 1991; Shapiro, 1984). A decade before the Murphy and Keating publication, Raifman (1983) observed:
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A good poker player probably knows better than a mental health professional whether or not a person is lying. A psychiatrist is a doctor, not a lie-detector (p. 129). Publications over the past 10 years have reinforced these past concerns, demonstrating that (a) individuals involved in civilian personal injury suits can malinger PTSD symptoms (Rosen, 1995), (b) individuals who seek treatment in VA PTSD clinics can over report their symptoms, a pattern accentuated among those who seek VA disability compensation (Frueh, Hamner, Cahill, Gold, & Hamlin, 2000; Frueh et al., 2003), (c) individuals also can misreport the occurrence of traumatic events (Burkett & Whitley, 1998; Sheridan & Blaauw, 2004), and (d) trained clinicians have no particular ability to detect actors who feign PTSD (Hickling, Blanchard, Mundy, & Galovski, 2002; Rosen & Phillips, 2004). At the same time, publications have observed how difficult it can be for clinicians and researchers to fulfill the DSM-IV’s dictum to rule out malingering. There is no single or preferred measure to detect malingering among PTSD patients or claimants (Guriel & Fremouw, 2003), and all instruments have their limitations (Frueh, Elhai, & Kaloupek, 2004). Further, there is the concern that clinicians must be cautious to protect the therapeutic relationship, which might be damaged if the veracity of a patient’s report was somehow questioned (Rosen, 2004a; Taylor, Frueh, & Asmundson, 2007). Reflecting on this situation, M. Miller (personal communication, June 2003) suggested that the DSM-IV should have worded its guideline more realistically, perhaps stating, ‘‘Although necessary, it is often impossible to rule out malingering.’’ Several authors have begun to discuss issues of assessment and how malingering might best be addressed (e.g., Frueh et al., 2004; Rosen, 2004a; Taylor et al., 2007). Still, without a frank confession or convincing findings from videotaped surveillance, the detection of malingering is a probabilistic concern; one in which the probability that symptoms are feigned increases with the amount of convergent information in support of the hypothesis. Examples of methods that may contribute useful data include the PTSD malingering indices from the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; Elhai, Ruggiero, Frueh, Beckham, & Gold, 2002), interview methods such as the Miller Forensic Assessment Screening Test (Miller, 2001), the Structured Inventory of Malingered Symptomatology (Smith, 1997; Smith & Burger, 1997), the Structured Interview of Reported Symptoms (Rogers, Kropp, Bagby, & Dickens, 1992), the Morel Emotional Numbing Test (Morel, 1998), and symptom validity testing (Rosen & Powel, 2003). These methods may enhance the odds of detecting malingered PTSD and they can be employed in forensic assessments. Unfortunately, little is known about their feasibility or accuracy in everyday clinical practice, or in their use for screening people participating in research. 1.4. Recommendations for DSM-V and peer review journals Despite the daunting nature of the task to detect malingered PTSD, it is more precipitous to ignore the matter. As observed by McNally (2003) and Summerfield (1999), feigned cases of PTSD can compromise the integrity of the PTSD database, with the result that tainted findings may be misperceived as sound data. Clinicians and forensic experts are urged to use all available tools in a manner that is informed by current literature. Researchers should only publish in quality peer-reviewed journals if the issue of malingering has been addressed. Rosen (2004b) recommended that journal editors should require a clear disclosure statement from authors that specified the extent to which subjects were involved in litigation, disability applications, or other
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situations involving compensation claims. When feasible, comparisons on measures of interest should be made between subjects unaffected and possibly affected by compensation concerns. Editors of journals that contribute to the PTSD scientific literature are encouraged to consult with each other for the purpose of drafting a set of requirements that provide minimal standards for assessing and reporting on the status of research subjects. An example of this type of enterprise is provided by the CONSORT (Consolidated Standards of Reporting Trials) guidelines, a document that has provided standards for those reporting clinical trials in medicine (Begg et al., 1996; Rennie, 1996). As observed by Rosen (2006), ‘‘Until researchers and journal editors heed the DSM, the PTSD data base remains at risk’’ (p. 534). 2. Factitious PTSD Diverse motives can lead people to take on a victim role and present with the symptoms of PTSD (Lacoursiere, 1993). Not every case of pseudo-PTSD is malingered. In support of this point are numerous cases reported in the literature in which people feign symptoms of PTSD to assume the sick role (e.g., Fear, 1996; Lynn & Belza, 1984; Neal & Rose, 1995; Newmark, Adityanjee, & Kay, 1999; Sparr & Pankratz, 1983). To illustrate, Fear (1996) described a case in which a young male claimed to have been involved in a fishing disaster and feigned PTSD symptoms primarily to gain admission to hospital. Factitious PTSD may be associated with bizarre claims of satanic ritual abuse, UFO abductions, or memories of past-life abuse recovered during age regression therapies. Baumeister and Sommer (1997) conducted a review of cases involving some of these purported forms of abuse. They concluded that some people seem to adopt a patient role to transcend and transform their identities and to cultivate relationships with powerful, and often desirable others. Another mechanism to account for at least a subset of patients presenting with PTSD-like symptoms after recovered memories of sexual abuse or bizarre events (e.g., space alien abductions) has been proposed by McNally and Clancy (2005a,b). Here it is proposed that episodes of sleep paralysis, accompanied by hallucinations upon awakening and an inability to move, may lead the person to misinterpret their experience. This raises the fascinating question of whether a presentation of posttraumatic reactions after what may be a falsely perceived event can be construed as PTSD. Such events do not appear to meet the first condition of Criterion A (experiencing, witnessing, or being confronted with an event involving actual or threatened death or serious injury), although they certainly could fulfill the second and subjective component that defines a traumatic stressor (a person’s response is characterized by intense fear, helplessness, or horror). Perhaps with the ever expanding definition of Criterion A and resulting concerns with conceptual bracket creep (McNally, 2003; Rosen, 2005), such distinctions will no longer matter. In that case, PTSD will be considered a clinical syndrome that can result from any event, real or imagined, as long as it is traumatic in the eye of the beholder. Logically, that position would do away with Criteria A entirely, a position that was considered by the DSM-IV subcommittee (Kilpatrick et al., 1998) and continues to be recommended by some (Maier, 2006). 3. Is PTSD itself a pseudo disorder? Most psychiatric disorders are hypothetical constructs devised to help clinicians and researchers better understand and treat psychopathology. In this regard, PTSD is no different from other psychiatric disorders. What distinguishes PTSD from other disorders is the construct’s underlying core assumptions or ‘‘inner logic’’ (Young, 2004). As previously discussed, one of the
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distinctive assumptions underlying PTSD is the assumption of specific etiology (Meehl, 1977); PTSD is conceptualized as a unique clinical syndrome that can arise only after a defined traumatic event (Criterion A in the DSM). If the field of traumatology were to do away with Criterion A, would PTSD stand on the merits of its symptom criteria? There are reasons to think not. First, PTSD does not represent a discrete disorder with a distinctive etiology. Research using a statistical method called latent class analysis (LCA) suggests that there may be three distinct classes or groups of individuals; no PTSD, partial PTSD, and full PTSD (Breslau, Reboussin, Anthony, & Storr, 2005). However, ‘‘LCA provides no formal test of whether the resulting classes differ in severity or qualitatively’’ (Breslau et al., 2005, p. 1350). Research using taxometric statistical methods, which are designed to distinguish dimensional from categorical methods, suggests that posttraumatic stress symptoms fall on a continuum of severity, ranging from everyday symptoms of stress (e.g., tension, headaches, irritability) to symptoms characteristic of what we currently call PTSD (Ruscio, Ruscio, & Keane, 2002). Consistent with this, behavioral genetic (twin studies) indicates that PTSD symptoms arise, in part, from additive genetic factors; that is, genes that quantitatively contribute to the risk for developing PTSD symptoms (Stein, Jang, Taylor, Vernon, & Livesley, 2002). Other behavioral genetic studies raise the possibility that PTSD, like other anxiety and mood disorders, arises from a combination of non-specific genetic and environmental factors (influencing many disorders) along with comparatively smaller contributions from disorderspecific factors (Hettema, Prescott, Myers, Neale, & Kendler, 2005). That traumatic events are likely to be non-specifically linked to psychopathology is indicated, for example, by research showing that childhood sexual abuse is associated with an increased risk for all kinds of disorders, including PTSD, panic disorder, major depression, and bulimia nervosa (for reviews, see Taylor (2000, 2006)). Also, non-criterion A events can give rise to the PTSD clinical syndrome (e.g., Gold, Marx, Soler-Baillor, & Sloan, 2005; Mol et al., 2005), a further demonstration that core assumptions are fatally flawed. Posttraumatic stress symptoms also overlap with other diagnostic constructs that may just as well account for the symptom criteria of PTSD (e.g., depression, panic disorder, specific phobia; Young, 1995). In fact, the overlap of symptoms for the combination of major depression and specific phobia is absolutely complete with PTSD to fulfill criteria for the latter diagnosis. Consider as just one example that Symptom criteria C-4 for PTSD is defined as ‘‘markedly diminished interest or participation in significant activities,’’ while symptom 2-A for major depression is defined as ‘‘markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly everyday.’’ McHugh (1999) extended these considerations to a discussion of unusual or delayed forms of PTSD: More likely, the culprit will be a separate and complicating condition like major depression, with its cardinal symptoms of misery, despair, and self-recrimination. In this condition, memories of past losses, defeats, or traumas are reawakened, giving content and justification to diminished attitudes about oneself. But such memories should hardly be confused with the cause of the depression itself, which can and should be treated for what it is. The possibility that PTSD is itself a pseudo-diagnosis is apart from concerns regarding malingered and factitious presentations of the hypothesized disorder. Nevertheless, any discussion of pseudo-PTSD would be incomplete without considering this long-standing (March, 1990), yet unresolved issue.
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4. Discussion Regardless of whether PTSD represents a distinct disorder, it has served at least one useful function; to promote research and advance our understanding of how individuals react to severely adverse events. Unfortunately, the utility of the PTSD construct is undermined to the extent that pseudo presentations of the disorder are prevalent and go undetected. Some authorities may feel these issues are trivial, noting that the base rate of malingering is low. Here the argument goes that because malingering rarely occurs there is no need to detect it (e.g., D.G. Kilpatrick, personal communication, 23 March 2005). In actuality, the true base rate of malingering is not known, with estimates ranging as high as 50% (Resnick, 2003). Even less is known about base rates for factitious presentations of PTSD. A recent study found that among veterans claiming Vietnam combat-related PTSD, military records did not corroborate reports of combat exposure in almost 40% of cases (Frueh et al., 2005). Findings such as these reinforce the position that pseudo-PTSD should not be ignored. References American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baumeister, R. F., & Sommer, K. L. (1997). Patterns in the bizarre: common themes in satanic ritual abuse, sexual masochism, UFO abductions, factitious illness, and extreme love. Journal of Social and Clinical Psychology, 16, 213– 223. Begg, C., Cho, M., Eastwood, S., Horton, R., Moher, D., Olkin, I., et al. (1996). Improving the quality of reporting of randomized controlled trials: the CONSORT statement. Journal of the American Medical Association, 276, 637–639. Blanchard, E. B., & Hickling, E. J. (2003). After the crash: assessment and treatment of motor vehicle accident survivors (2nd ed.). Washington, DC: American Psychological Association. Blanchard, E. B., Hickling, E. J., Taylor, A. E., Loos, W. R., Forneris, C. A., & Jaccaard, J. (1996). Who develops PTSD from motor vehicle accidents? Behaviour Research & Therapy, 34, 1–10. Breslau, N., Reboussin, B. A., Anthony, J. C., & Storr, C. L. (2005). The structure of posttraumatic stress disorder: latent class analysis in 2 community samples. Archives of General Psychiatry, 62, 1343–1351. Burkett, B. G., & Whitley, G. (1998). Stolen valor: how the Vietnam generation was robbed of its heroes and its history. Dallas, TX: Verity Press. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Minnesota multiphasic personality inventory-2 (MMPI-2): manual for administration and scoring. Minneapolis, MN: University of Minnesota Press. Daly, O. E., & Johnston, T. G. (2002). The Derryhirk Inn incident: the psychological sequelae. Journal of Traumatic Stress, 15, 461–464. Derogatis, L. R. (1994). Symptom checklist-90-R administration, scoring, and procedures manual (3rd ed.). Minneapolis, MN: National Computer Systems. Eid, J., Johnsen, B. H., & Thayer, J. F. (2001). Post-traumatic stress symptoms following shipwreck of a Norwegian Navy frigate—an early follow-up. Personality and Individual Differences, 30, 1283–1295. Ekman, P., & O’Sullivan, M. (1991). Who can catch a liar? American Psychologist, 46, 913–920. Eldridge, G. (1991). Contextual issues in the assessment of posttraumatic stress disorder. Journal of Traumatic Stress, 4, 7–23. Elhai, J. D., Ruggiero, K. J., Frueh, B. C., Beckham, J. C., & Gold, P. B. (2002). The infrequency-posttraumatic stress disorder scale (Fptsd) for the MMPI-2: development and initial validation with veterans presenting with combatrelated PTSD. Journal of Personality Assessment, 79, 531–549. Fear, C. F. (1996). Factitious post-traumatic stress disorder revisited. Irish Journal of Psychological Medicine, 13, 116– 118.
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Mol, S. S. L., Arntz, A., Metsemakers, J. F. M., Dinant, G.-J., Vilters-van Monfort, P. A. P., & Knottnerus, J. A. (2005). Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study. British Journal of Psychiatry, 186, 494–499. Morel, K. R. (1998). Development and preliminary validation of a forced-choice test of response bias for posttraumatic stress disorder. Journal of Personality Assessment, 70, 299–314. Murphy, S. A., & Keating, J. P. (1995). Psychological assessment of postdisaster class action and personal injury litigants: a case study. Journal of Traumatic Stress, 8, 473–482. Neal, L. A., & Rose, M. C. (1995). Factitious post-traumatic stress disorder: a case report. Medicine, Science, and the Law, 35, 352–354. Newmark, N., Adityanjee, & Kay, J. (1999). Pseudologia fantasica and factitious disorder: review of the literature and a case report. Comprehensive Psychiatry, 40, 89–95. Page, H. W. (1891). Railway injuries: with special reference to those of the back and nervous system, in their medico-legal and clinical aspects. London: Charles Griffin & Co. Pankratz, L. (1998). Patients who deceive: assessment and management of risk in providing health care and financial benefits. Springfield, IL: Charles C Thomas. Raifman, L. (1983). Problems of diagnosis and legal causation in courtroom use of posttraumatic stress disorder. Behavioral Sciences and the Law, 1, 115–130. Raphael, B., & Meldrum, L. (1993). The evolution of mental health responses and research in Australian disasters. Journal of Traumatic Stress, 6, 65–89. Rennie, D. (1996). How to report randomized controlled trials: the CONSORT statement. Journal of the American Medical Association, 276, 649. Resnick, P. J. (2003). Guidelines for evaluation of malingering in PTSD. In: R. I. Simon (Ed.), Posttraumatic stress disorder in litigation: guidelines for forensic assessment (2nd ed., pp. 187–205). Washington, DC: American Psychiatric Press. Rogers, R., Kropp, P. R., Bagby, R. M., & Dickens, S. E. (1992). Faking specific disorders: a study of the Structured Interview of Reported Symptoms (SIRS). Journal of Clinical Psychology, 48, 643–648. Rosen, G. M. (1995). The Aleutian Enterprise sinking and posttraumatic stress disorder: misdiagnosis in clinical and forensic settings. Professional Psychology: Research and Practice, 26, 82–87. Rosen, G. M. (1996). Posttraumatic stress disorder, pulp fiction, and the press. Bulletin of the American Academy of Psychiatry and the Law, 24, 267–269. Rosen, G. M. (2004a). Malingering and the PTSD database. In: G. M. Rosen (Ed.), Posttraumatic stress disorder: issues and controversies (pp. 85–99). Chichester, England: John Wiley & Sons. Rosen, G. M. (2004b). Litigation and reported rates of posttraumatic stress disorder. Personality and Individual Differences, 36, 1291–1294. Rosen, G. M. (2005). Traumatic events, criterion creep, and the creation of pretraumatic stress disorder. Scientific Review of Mental Health Practice, 3, 39–42. Rosen, G. M. (2006). DSM’s cautionary guideline to rule out malingering can protect the PTSD database. Journal of Anxiety Disorders, 20, 530–535. Rosen, G. M., & Phillips, W. R. (2004). A cautionary lesson from simulated patients. Journal of the American Academy of Psychiatry and the Law, 32, 132–133. Rosen, G. M., & Powel, J. H. (2003). Use of a symptom validity test in the forensic assessment of posttraumatic stress disorder. Journal of Anxiety Disorders, 17, 361–367. Ruscio, A. M., Ruscio, J., & Keane, T. M. (2002). The latent structure of posttraumatic stress disorder: a taxometric investigation of reactions to extreme stress. Journal of Abnormal Psychology, 111, 290–301. Scott, W. (1990). PTSD in DSM-III: a case in the politics of diagnosis and disease. Social Problems, 37, 294–310. Shapiro, D. (1984). Psychological evaluation and expert testimony. New York: Van Nostrand Reinhold. Shephard, B. (2001). A war of nerves: soldiers and psychiatrists in the twentieth century. Cambridge, MA: Harvard University Press. Sheridan, L. P., & Blaauw, E. (2004). Characteristics of false stalking reports. Criminal Justice and Behavior, 31, 55–72. Slovenko, R. (1994). Legal aspects of post-traumatic stress disorder. Psychiatric Clinics of North America, 17, 439–446. Smith, G. P. (1997). Assessment of malingering with self-report instruments. In: R. Rogers (Ed.), Clinical assessment of malingering and deception (pp. 351–370). New York: Guilford. Smith, G. P., & Burger, G. K. (1997). Detection of malingering: validation of the Structured Inventory of Malingered Symptomatology (SIMS). Journal of the Academy of Psychiatry and Law, 25, 183–189. Sparr, L. F., & Atkinson, R. M. (1986). Post-traumatic stress disorder as an insanity defense: medico-legal quicksand. American Journal of Psychiatry, 143, 608–613.
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Sparr, L. F., & Pankratz, L. (1983). Factitious post-traumatic stress disorder. American Journal of Psychiatry, 140, 1016– 1019. Stein, M. B., Jang, K. L., Taylor, S., Vernon, P. A., & Livesley, W. J. (2002). Genetic and environmental influences on trauma exposure and posttraumatic stress disorder symptoms: a general population twin study. American Journal of Psychiatry, 159, 1675–1681. Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science & Medicine, 48, 1449–1462. Taylor, S. (2000). Understanding and treating panic disorder: cognitive-behavioural approaches. New York: Wiley. Taylor, S. (2006). Clinician’s guide to PTSD: a cognitive-behavioral approach. New York: Guilford. Taylor, S., Frueh, B. C., & Asmundson, G. J. G. (2007). Detection and management of malingering in people presenting for treatment of posttraumatic stress disorder: methods, obstacles, and recommendations. Journal of Anxiety Disorders, 21, 22–41. Trimble, M. (1985). Post-traumatic stress disorder: history of a concept. In: C. Figley (Ed.), Trauma and its wake (pp. 5– 14). New York: Brunner/Mazel. Yehuda, R., & McFarlane, A. C. (1995). Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis. American Journal of Psychiatry, 152, 1705–1713. Young, A. (1995). The harmony of illusions: inventing post-traumatic stress disorder. Princeton, NJ: Princeton University Press. Young, A. (2004). When traumatic memory was a problem: on the historical antecedents of PTSD. In: G. M. Rosen (Ed.), Posttraumatic stress disorder: issues and controversies (pp. 127–146). Chichester, England: John Wiley & Sons. Yule, W., Bolton, D., Udwin, O., Boyle, S., O’Ryan, D., & Nurrish, J. (2000). The long-term psychological effects of a disaster experienced in adolescence. I. The incidence and course of PTSD. Journal of Child Psychology & Psychiatry, 41, 503–511.
Pseudo-PTSD Gerald M. Rosen a,*, Steven Taylor b a b
University of Washington, United States University of British Columbia, Canada
Abstract Pseudo-posttraumatic stress disorder (pseudo-PTSD) refers to cases in which a patient’s presentation is but a simulation of the actual clinical syndrome. The problem of pseudo-PTSD has been neglected by many clinicians and researchers, who often rely on the assumption that a patient’s reported symptoms can be accepted as valid. The purpose of this article is to (a) consider the diverse causes of pseudo-PTSD, (b) emphasize the importance of the DSM-IV’s guideline to rule out malingering, and (c) discuss the implications that pseudo-PTSD has for research and clinical practice. # 2006 Elsevier Ltd. All rights reserved. Keywords: Posttraumatic stress disorder (PTSD); Factitious; Malingering; Litigation; Personal injury; Compensationseeking; Veterans
Pseudo or false presentations of posttraumatic stress disorder (PTSD) can arise from diverse causes (Lacoursiere, 1993; Pankratz, 1998). Yet, when the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994) addressed the issue of pseudo-PTSD, it only concerned itself with the concept of malingering. Malingering was defined 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’’ (APA, 1994, p. 739). With regard to PTSD, the DSM-IV provided this cautionary guideline, ‘‘Malingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role’’ (p. 467). The DSM-IV’s guideline to rule out malingering was noteworthy in several respects. First, it directed special attention toward PTSD even though malingering is an issue that can just as well apply to other disorders (e.g., major depression) when issues of compensation are involved. Second, while providing the dictum to rule out malingering, the DSM-IV failed to instruct * Corresponding author at: 117 East Louisa Street, PMB-229, Seattle, WA 98102, United States. E-mail address: [email protected] (G.M. Rosen). 0887-6185/$ – see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2006.09.011
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clinicians and researchers on how they might accomplish the task, if indeed the task is feasible. And third, as previously noted, the DSM-IV’s guideline on malingering ignored other reasons that pseudo-PTSD might occur. In this paper we address these issues and discuss why pseudoPTSD warrants more attention in research, clinical, and forensic settings. 1. DSM-IV’s guideline to rule out malingering 1.1. Why a guideline specific to PTSD? There are several reasons why DSM-IV provides a specific guideline to rule out malingering in the differential diagnosis of PTSD. PTSD was a diagnostic construct that arose by committee decision, largely in response to the interests and mental health needs of Vietnam veterans (Scott, 1990; Shephard, 2001; Yehuda & McFarlane, 1995; Young, 1995). The PTSD diagnosis provided a specific etiology (Meehl, 1977), and so it was particularly beneficial for Vietnam veterans and other groups who might have disability claims. Unlike most other diagnoses, a core assumption underlying PTSD concerned the linkage of a specific class of events (Criterion A) to a specific set of clinical symptoms (Criteria B–D). Slovenko (1994) observed that this feature made PTSD ‘‘a favored diagnosis in cases of emotional distress because it is incident specific’’ (p. 441). Trimble (1985) suggested that PTSD ‘‘would give a great deal of leverage to those seeking compensation and the counting off of symptoms in checklist fashion will become routine practice in many a lawyer’s office’’ (p. 13). Lees-Haley (1986) wryly commented, ‘‘If mental disorders were listed on the New York exchange, PTSD would be a growth stock to watch’’ (p. 17). Additional considerations played a role in the DSM-IV’s provision of a cautionary guideline for PTSD on the issue of malingering. There had been a long history preceding the DSM that considered the problem of malingered posttraumatic disorders (e.g., Lewis & Bombaugh, 1896; Hamilton, 1904; Page, 1891). Issues of disability compensation also influenced policy toward psychological casualties among soldiers in past wars (Jones & Wessely, 2005; Shephard, 2001). In addition to historical considerations, there were contemporary publications in which (a) commentators observed that the symptom criteria were subjective, easily coached, and easily simulated (Eldridge, 1991; Sparr & Atkinson, 1986); (b) case reports documented the reality of feigned PTSD (e.g., Lynn & Belza, 1984; Sparr & Pankratz, 1983); and (c) commentators noted the diverse motives that contributed to people adopting a victim narrative (Hamilton, 1985; Lacoursiere, 1993). In light of these various influences, it was not surprising when the DSM-IV included a cautionary guideline specific to PTSD. The only surprise was that it took three editions to finally recognize the issue: no mention of malingering was made in the PTSD sections of the DSM-III (APA, 1980) or the DSM-III-R (APA, 1987) 1.2. Have mental health professionals heeded the guideline? Despite the DSM-IV’s cautionary guideline to rule out malingering, researchers have mostly ignored the issue. See most every peer reviewed publication on PTSD (1980–2006) to demonstrate this point. Very few studies report that they ruled out malingering, and fewer still describe the methods that were used. This holds true even when litigation or compensation claims apply. To illustrate, Rosen (2004b) observed that Eid, Johnsen, and Thayer (2001) cited two studies as if they demonstrated high rates of PTSD, when in fact both publications (Raphael & Meldrum, 1993; Rosen, 1995) reported on subjects who were involved in litigation. No mention was made by Eid et al. of this important confound. Publications from the Albany Motor Vehicle
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Accident Project (e.g., Blanchard & Hickling, 2003; Blanchard et al., 1996) and a series of papers on survivors of the sinking of the Jupiter (e.g. Yule et al., 2000), included many subjects who were involved in litigation. Yet, no effort to rule out malingering was reported in these publications. Rosen (2006) provided a detailed critique of a paper by Daly and Johnston (2002) that reported a 67% rate of PTSD among litigating survivors of a 3 hour hostage situation at a bar in Northern Island. Although all referrals had been made by plaintiffs’ counsel for the purpose of forensic assessments, no effort was made to rule out malingering. Instead, Daly and Johnston (2002) simply observed that the victims appeared to have been ‘‘genuine, honest people’’ (p. 463). Another example illustrates how researchers and peer review journals have failed to make meaningful attempts to rule out malingering. Murphy and Keating (1995) reported on their evaluation of 27 plaintiffs involved in a class action suit, all of whom had been referred by their counsel. What was the process of assessment used in this study? Murphy and Keating explained that all plaintiffs had been exposed to a sudden and unpredictable torrent of debris and water that swept down a hill in a predawn rainstorm, resulting in neither death nor severe physical injuries. Nonetheless, all plaintiffs were ‘‘exposed,’’ and a class action suit was filed on their behalf. Clinical interviews were conducted using a written protocol that prompted the plaintiffs’ selfreports concerning their emotional status and their current level of functioning. Symptom checklists also were used including the SCL-90-R (Derogatis, 1994) and the Impact of Event Scale (Horowitz, Winler, & Alvarez, 1979). Murphy and Keating noted that medical records were available, but, ‘‘The case attorneys had access to litigants’ medical records, [and] requested that the assessment team submit their report based on data we collected’’ (p. 476). In other words, no attempt was made to look at additional sources of information beyond the plaintiffs’ self-reported problems. Perhaps such attempts were felt to be unnecessary. Murphy and Keating reported, ‘‘We had the opportunity to observe litigants and ask them questions that would be difficult to ‘fake’’’ (p. 480). Based on their findings, Murphy and Keating judged the severity of each case and provided rankings to further a determination of how any group award might be divided. They drew the following conclusion: The process [of assessment] was effective—the case was settled out of court in favor of the litigants. Individual litigants were satisfied with monetary awards received (p. 473). Murphy and Keating’s belief that answers to certain types of questions are difficult to fake, is similar in its optimism to the observation that litigants appear to be trustworthy and sincere (e.g., Blanchard & Hickling, 2003; Daly & Johnston, 2002). As we shall see, there is no particular type of question that reveals feigned presentations of a disorder, nor can clinicians reliably judge a person’s honesty by their aura. 1.3. Is the DSM-IV’s guideline a feasible goal? It should be pointed out the Murphy and Keating publication in 1995 could mean that the assessments were conducted prior to the 1994 introduction of the DSM-IV’s guideline. Nevertheless, the report serves as a striking example of what not to do. Even in years prior to 1994, it was appreciated that forensic experts should not rely solely on an individual’s self-report (Shapiro, 1984), disorders could be easily feigned on symptom checklists (Lees-Haley, 1989, 1990), and mental health professionals were not accurate in judging truthfulness (Ekman & O’Sullivan, 1991; Shapiro, 1984). A decade before the Murphy and Keating publication, Raifman (1983) observed:
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A good poker player probably knows better than a mental health professional whether or not a person is lying. A psychiatrist is a doctor, not a lie-detector (p. 129). Publications over the past 10 years have reinforced these past concerns, demonstrating that (a) individuals involved in civilian personal injury suits can malinger PTSD symptoms (Rosen, 1995), (b) individuals who seek treatment in VA PTSD clinics can over report their symptoms, a pattern accentuated among those who seek VA disability compensation (Frueh, Hamner, Cahill, Gold, & Hamlin, 2000; Frueh et al., 2003), (c) individuals also can misreport the occurrence of traumatic events (Burkett & Whitley, 1998; Sheridan & Blaauw, 2004), and (d) trained clinicians have no particular ability to detect actors who feign PTSD (Hickling, Blanchard, Mundy, & Galovski, 2002; Rosen & Phillips, 2004). At the same time, publications have observed how difficult it can be for clinicians and researchers to fulfill the DSM-IV’s dictum to rule out malingering. There is no single or preferred measure to detect malingering among PTSD patients or claimants (Guriel & Fremouw, 2003), and all instruments have their limitations (Frueh, Elhai, & Kaloupek, 2004). Further, there is the concern that clinicians must be cautious to protect the therapeutic relationship, which might be damaged if the veracity of a patient’s report was somehow questioned (Rosen, 2004a; Taylor, Frueh, & Asmundson, 2007). Reflecting on this situation, M. Miller (personal communication, June 2003) suggested that the DSM-IV should have worded its guideline more realistically, perhaps stating, ‘‘Although necessary, it is often impossible to rule out malingering.’’ Several authors have begun to discuss issues of assessment and how malingering might best be addressed (e.g., Frueh et al., 2004; Rosen, 2004a; Taylor et al., 2007). Still, without a frank confession or convincing findings from videotaped surveillance, the detection of malingering is a probabilistic concern; one in which the probability that symptoms are feigned increases with the amount of convergent information in support of the hypothesis. Examples of methods that may contribute useful data include the PTSD malingering indices from the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; Elhai, Ruggiero, Frueh, Beckham, & Gold, 2002), interview methods such as the Miller Forensic Assessment Screening Test (Miller, 2001), the Structured Inventory of Malingered Symptomatology (Smith, 1997; Smith & Burger, 1997), the Structured Interview of Reported Symptoms (Rogers, Kropp, Bagby, & Dickens, 1992), the Morel Emotional Numbing Test (Morel, 1998), and symptom validity testing (Rosen & Powel, 2003). These methods may enhance the odds of detecting malingered PTSD and they can be employed in forensic assessments. Unfortunately, little is known about their feasibility or accuracy in everyday clinical practice, or in their use for screening people participating in research. 1.4. Recommendations for DSM-V and peer review journals Despite the daunting nature of the task to detect malingered PTSD, it is more precipitous to ignore the matter. As observed by McNally (2003) and Summerfield (1999), feigned cases of PTSD can compromise the integrity of the PTSD database, with the result that tainted findings may be misperceived as sound data. Clinicians and forensic experts are urged to use all available tools in a manner that is informed by current literature. Researchers should only publish in quality peer-reviewed journals if the issue of malingering has been addressed. Rosen (2004b) recommended that journal editors should require a clear disclosure statement from authors that specified the extent to which subjects were involved in litigation, disability applications, or other
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situations involving compensation claims. When feasible, comparisons on measures of interest should be made between subjects unaffected and possibly affected by compensation concerns. Editors of journals that contribute to the PTSD scientific literature are encouraged to consult with each other for the purpose of drafting a set of requirements that provide minimal standards for assessing and reporting on the status of research subjects. An example of this type of enterprise is provided by the CONSORT (Consolidated Standards of Reporting Trials) guidelines, a document that has provided standards for those reporting clinical trials in medicine (Begg et al., 1996; Rennie, 1996). As observed by Rosen (2006), ‘‘Until researchers and journal editors heed the DSM, the PTSD data base remains at risk’’ (p. 534). 2. Factitious PTSD Diverse motives can lead people to take on a victim role and present with the symptoms of PTSD (Lacoursiere, 1993). Not every case of pseudo-PTSD is malingered. In support of this point are numerous cases reported in the literature in which people feign symptoms of PTSD to assume the sick role (e.g., Fear, 1996; Lynn & Belza, 1984; Neal & Rose, 1995; Newmark, Adityanjee, & Kay, 1999; Sparr & Pankratz, 1983). To illustrate, Fear (1996) described a case in which a young male claimed to have been involved in a fishing disaster and feigned PTSD symptoms primarily to gain admission to hospital. Factitious PTSD may be associated with bizarre claims of satanic ritual abuse, UFO abductions, or memories of past-life abuse recovered during age regression therapies. Baumeister and Sommer (1997) conducted a review of cases involving some of these purported forms of abuse. They concluded that some people seem to adopt a patient role to transcend and transform their identities and to cultivate relationships with powerful, and often desirable others. Another mechanism to account for at least a subset of patients presenting with PTSD-like symptoms after recovered memories of sexual abuse or bizarre events (e.g., space alien abductions) has been proposed by McNally and Clancy (2005a,b). Here it is proposed that episodes of sleep paralysis, accompanied by hallucinations upon awakening and an inability to move, may lead the person to misinterpret their experience. This raises the fascinating question of whether a presentation of posttraumatic reactions after what may be a falsely perceived event can be construed as PTSD. Such events do not appear to meet the first condition of Criterion A (experiencing, witnessing, or being confronted with an event involving actual or threatened death or serious injury), although they certainly could fulfill the second and subjective component that defines a traumatic stressor (a person’s response is characterized by intense fear, helplessness, or horror). Perhaps with the ever expanding definition of Criterion A and resulting concerns with conceptual bracket creep (McNally, 2003; Rosen, 2005), such distinctions will no longer matter. In that case, PTSD will be considered a clinical syndrome that can result from any event, real or imagined, as long as it is traumatic in the eye of the beholder. Logically, that position would do away with Criteria A entirely, a position that was considered by the DSM-IV subcommittee (Kilpatrick et al., 1998) and continues to be recommended by some (Maier, 2006). 3. Is PTSD itself a pseudo disorder? Most psychiatric disorders are hypothetical constructs devised to help clinicians and researchers better understand and treat psychopathology. In this regard, PTSD is no different from other psychiatric disorders. What distinguishes PTSD from other disorders is the construct’s underlying core assumptions or ‘‘inner logic’’ (Young, 2004). As previously discussed, one of the
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distinctive assumptions underlying PTSD is the assumption of specific etiology (Meehl, 1977); PTSD is conceptualized as a unique clinical syndrome that can arise only after a defined traumatic event (Criterion A in the DSM). If the field of traumatology were to do away with Criterion A, would PTSD stand on the merits of its symptom criteria? There are reasons to think not. First, PTSD does not represent a discrete disorder with a distinctive etiology. Research using a statistical method called latent class analysis (LCA) suggests that there may be three distinct classes or groups of individuals; no PTSD, partial PTSD, and full PTSD (Breslau, Reboussin, Anthony, & Storr, 2005). However, ‘‘LCA provides no formal test of whether the resulting classes differ in severity or qualitatively’’ (Breslau et al., 2005, p. 1350). Research using taxometric statistical methods, which are designed to distinguish dimensional from categorical methods, suggests that posttraumatic stress symptoms fall on a continuum of severity, ranging from everyday symptoms of stress (e.g., tension, headaches, irritability) to symptoms characteristic of what we currently call PTSD (Ruscio, Ruscio, & Keane, 2002). Consistent with this, behavioral genetic (twin studies) indicates that PTSD symptoms arise, in part, from additive genetic factors; that is, genes that quantitatively contribute to the risk for developing PTSD symptoms (Stein, Jang, Taylor, Vernon, & Livesley, 2002). Other behavioral genetic studies raise the possibility that PTSD, like other anxiety and mood disorders, arises from a combination of non-specific genetic and environmental factors (influencing many disorders) along with comparatively smaller contributions from disorderspecific factors (Hettema, Prescott, Myers, Neale, & Kendler, 2005). That traumatic events are likely to be non-specifically linked to psychopathology is indicated, for example, by research showing that childhood sexual abuse is associated with an increased risk for all kinds of disorders, including PTSD, panic disorder, major depression, and bulimia nervosa (for reviews, see Taylor (2000, 2006)). Also, non-criterion A events can give rise to the PTSD clinical syndrome (e.g., Gold, Marx, Soler-Baillor, & Sloan, 2005; Mol et al., 2005), a further demonstration that core assumptions are fatally flawed. Posttraumatic stress symptoms also overlap with other diagnostic constructs that may just as well account for the symptom criteria of PTSD (e.g., depression, panic disorder, specific phobia; Young, 1995). In fact, the overlap of symptoms for the combination of major depression and specific phobia is absolutely complete with PTSD to fulfill criteria for the latter diagnosis. Consider as just one example that Symptom criteria C-4 for PTSD is defined as ‘‘markedly diminished interest or participation in significant activities,’’ while symptom 2-A for major depression is defined as ‘‘markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly everyday.’’ McHugh (1999) extended these considerations to a discussion of unusual or delayed forms of PTSD: More likely, the culprit will be a separate and complicating condition like major depression, with its cardinal symptoms of misery, despair, and self-recrimination. In this condition, memories of past losses, defeats, or traumas are reawakened, giving content and justification to diminished attitudes about oneself. But such memories should hardly be confused with the cause of the depression itself, which can and should be treated for what it is. The possibility that PTSD is itself a pseudo-diagnosis is apart from concerns regarding malingered and factitious presentations of the hypothesized disorder. Nevertheless, any discussion of pseudo-PTSD would be incomplete without considering this long-standing (March, 1990), yet unresolved issue.
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4. Discussion Regardless of whether PTSD represents a distinct disorder, it has served at least one useful function; to promote research and advance our understanding of how individuals react to severely adverse events. Unfortunately, the utility of the PTSD construct is undermined to the extent that pseudo presentations of the disorder are prevalent and go undetected. Some authorities may feel these issues are trivial, noting that the base rate of malingering is low. Here the argument goes that because malingering rarely occurs there is no need to detect it (e.g., D.G. Kilpatrick, personal communication, 23 March 2005). In actuality, the true base rate of malingering is not known, with estimates ranging as high as 50% (Resnick, 2003). Even less is known about base rates for factitious presentations of PTSD. A recent study found that among veterans claiming Vietnam combat-related PTSD, military records did not corroborate reports of combat exposure in almost 40% of cases (Frueh et al., 2005). Findings such as these reinforce the position that pseudo-PTSD should not be ignored. References American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baumeister, R. F., & Sommer, K. L. (1997). Patterns in the bizarre: common themes in satanic ritual abuse, sexual masochism, UFO abductions, factitious illness, and extreme love. Journal of Social and Clinical Psychology, 16, 213– 223. Begg, C., Cho, M., Eastwood, S., Horton, R., Moher, D., Olkin, I., et al. (1996). Improving the quality of reporting of randomized controlled trials: the CONSORT statement. Journal of the American Medical Association, 276, 637–639. Blanchard, E. B., & Hickling, E. J. (2003). After the crash: assessment and treatment of motor vehicle accident survivors (2nd ed.). Washington, DC: American Psychological Association. Blanchard, E. B., Hickling, E. J., Taylor, A. E., Loos, W. R., Forneris, C. A., & Jaccaard, J. (1996). Who develops PTSD from motor vehicle accidents? Behaviour Research & Therapy, 34, 1–10. Breslau, N., Reboussin, B. A., Anthony, J. C., & Storr, C. L. (2005). The structure of posttraumatic stress disorder: latent class analysis in 2 community samples. Archives of General Psychiatry, 62, 1343–1351. Burkett, B. G., & Whitley, G. (1998). Stolen valor: how the Vietnam generation was robbed of its heroes and its history. Dallas, TX: Verity Press. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Minnesota multiphasic personality inventory-2 (MMPI-2): manual for administration and scoring. Minneapolis, MN: University of Minnesota Press. Daly, O. E., & Johnston, T. G. (2002). The Derryhirk Inn incident: the psychological sequelae. Journal of Traumatic Stress, 15, 461–464. Derogatis, L. R. (1994). Symptom checklist-90-R administration, scoring, and procedures manual (3rd ed.). Minneapolis, MN: National Computer Systems. Eid, J., Johnsen, B. H., & Thayer, J. F. (2001). Post-traumatic stress symptoms following shipwreck of a Norwegian Navy frigate—an early follow-up. Personality and Individual Differences, 30, 1283–1295. Ekman, P., & O’Sullivan, M. (1991). Who can catch a liar? American Psychologist, 46, 913–920. Eldridge, G. (1991). Contextual issues in the assessment of posttraumatic stress disorder. Journal of Traumatic Stress, 4, 7–23. Elhai, J. D., Ruggiero, K. J., Frueh, B. C., Beckham, J. C., & Gold, P. B. (2002). The infrequency-posttraumatic stress disorder scale (Fptsd) for the MMPI-2: development and initial validation with veterans presenting with combatrelated PTSD. Journal of Personality Assessment, 79, 531–549. Fear, C. F. (1996). Factitious post-traumatic stress disorder revisited. Irish Journal of Psychological Medicine, 13, 116– 118.
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