Determining Whether Service Members Are Malingering Poses Dilemma for Military M.D.s


American military personnel who are discharged because of a service-related disability may be eligible for a lifetime of monthly payments of between 30 percent and 100 percent of their salary as well as health benefits. That may be a temptation to a few who might choose to stretch the truth about an injury or psychiatric disorder, and it is certainly a concern for the medical personnel who evaluate them.

Malingering for secondary gain is nothing new, but Department of Defense’s and Veterans Affairs’ policies on granting disability status—especially for posttraumatic stress disorder (PTSD) and other psychiatric disorders based on self-report—has fluctuated with the political winds. A sharp rise in PTSD claims between 1999 and 2005 led to concern that soldiers and veterans were gaming the system, but when the departments adopted more stringent terms, they were excoriated for denying heroes their due.

Today, in marginal cases at least, the military health system gives the benefit of the doubt to the service member, noted U.S. Army Capt. Erika Zavyalov, D.O., of the Walter Reed National Military Medical Center in Bethesda, Md., speaking along with several colleagues at APA’s Annual Meeting. The extent to which service members or veterans are exaggerating or fabricating symptoms is unclear, said Zavyalov. Little reliable research is available, but the problem is real enough for military and VA medical staff.

Military forensic psychiatrists assigned to evaluate cases should be aware of numerous common patterns, said Army Lt. Col. David Johnson, M.D. (pictured above), also of Walter Reed. “Often there is a vague or conflicting trauma history, with no witnesses, which is hard to prove or disprove,” he said. “There may be some record of difficult personal behavior or some overlap between disability fraud and financial or other fraud.”

Collateral interviews, structured interviews, psychological tests, and forensic assessment instruments may help determine the claimant’s truthfulness, said Johnson.

“Overall, symptoms suggestive of malingering are one piece of data, but often not enough to prove malingering,” said Johnson.

“Malingering goes to motivation, and that can’t be discovered, only approximated,” commented Philip Candilis, M.D., head of the forensic psychiatry residency program at St. Elizabeths Hospital in Washington, D.C., and an adjunct professor at the Uniformed Services University of the Health Sciences in Bethesda, Md. He urged investigators to use standardized interviews, tools, and tests and to set cutoff points in favor of the individual. “If an individual is under the control of an institution—liked the Armed Forces—the individual must come first.”

(Image: David Hathcox)