Distinguishing PTSD From ‘False’ PTSD: Tips for Clinicians

A 45-year-old man experiencing irritability, anxiety, and mood swings also claims he experiences flashbacks and nightmares from a traumatic auto collision that happened three years earlier. Seeking a disability payment, he believes he has posttraumatic stress disorder (PTSD) and wants a health care professional to confirm it.

How does the evaluating psychiatrist know when the patient’s symptoms are really related to the trauma and not to anxiety or another disorder? How does one confirm a trauma that may have occurred years before? And what is the nature of the nightmares and flashbacks he reports? Is the patient truly reliving the experience of the collision?

David Hathcox

PTSD is a serious mental illness that causes significant disability and suffering. And no clinician wants to doubt a patient’s symptoms. But the diagnosis depends on patient self-report, which may be clouded in ways that other self-reported psychiatric symptoms may not be.

In a paper in the June Journal of the Academy of Psychiatry and the Law, past APA President Renée Binder, M.D., a professor of psychiatry at the University of California, San Francisco (UCSF), joined UCSF colleagues Mikel Matto, M.D., and Dale McNiel, Ph.D., in addressing the difficult and sensitive topic of “false PTSD.” Binder is also founder and director of UCSF’s Psychiatry and Law Program.

In the paper, they described false PTSD variants, including “malingered PTSD (for external gain, such as receiving a disability pension or evading criminal consequences), factitious PTSD (for internal gain, such as assuming the victim or hero/veteran role), and misattributed PTSD (legitimate psychopathology misdiagnosed as PTSD).” They also outlined steps to more accurately ascertain the validity of a PTSD diagnosis.

“Something we want to be clear about is that PTSD is very real and very serious,” Binder told Psychiatric News. “It is associated with a high level of social, occupational, and physical disability. Often people with the disorder are unable to work and experience serious psychological and/or medical illness. Accurate diagnosis is essential so that patients get the treatment they need and is crucial for good research so that we can develop better, more effective treatments.”

Binder said she and her co-authors were prompted to write the article when they were consulted by a psychiatrist who reported that a patient had explicitly sought advice on how to feign PTSD for the purposes of receiving a pension. Binder emphasized, however, that the problem of false diagnosis is more complicated than malingering or feigning an illness. “Some people who aren’t going to get any financial gain may seek out the diagnosis for some other kind of reward, or they may have a variety of symptoms that they misattribute to a trauma,” she said.

In the paper, Binder and colleagues wrote, “Patients may have conscious and unconscious motivations to feign a diagnosis of PTSD. These can include legal (e.g., reducing or avoiding criminal liability), personal (e.g., justifying relationship strife and occupational problems), financial (e.g., acquiring money from civil lawsuits, disability, and veteran pensions), shelter (e.g., securing inpatient or [emergency department] admission), and social (e.g., gaining sympathy or respect from peers).”

They added, “Clinicians may be reluctant to question the validity of self-reported trauma and related symptoms. They may worry about loss of rapport, stigmatizing patients, and the moral responsibility to veterans or patients as victims deserving additional services.”

Binder and colleagues noted that trauma does not always or even typically result in PTSD. They cited the National Comorbidity Survey, which showed that even though 61% of men and 51% of women were exposed to a traumatic experience at some point in their lives, the lifetime prevalence of PTSD was 8% and 20%, respectively.

“Experiencing symptoms after a trauma (e.g., intrusive thoughts, nightmares, insomnia, avoidance of reminders of the event, exaggerated negative beliefs, irritability, and hypervigilance that do not spontaneously resolve within months after trauma) is the exception to the norm,” they wrote. “Such symptoms become less exceptional, however, as cumulative trauma burden increases.”

How can mental health professionals ensure an accurate PTSD diagnosis? Binder and colleagues provided this guidance:

• Review collateral information and relevant records. This means gathering objective evidence wherever possible from multiple sources—work, school, family, medical and psychiatric records, and military, police, or court records—to compare against the patient’s subjective report.

• Conduct a thorough evaluation. Beyond the formal evaluation interview, this also means observing how the individual interacts with his or her environment and holding casual conversations with the individual prior to the formal evaluation interview, both of which can help uncover potential PTSD symptoms. It is also crucial to ask for details about the nature of self-reported symptoms and traumatic events and to validate these with third parties and collateral reports, when possible.

• Consider misattributed PTSD. Accurate evaluation of potential PTSD requires completing a broad differential diagnosis to rule out non–PTSD psychopathology. Binder and colleagues recommend following the simple mnemonic, STAMP, which represents the domains to evaluate when assessing self-reported symptoms:

  S – Substance abuse

  T – Trauma

  A – Anxiety

  M – Mood/Medications/Medical

  P – Psychosis/Personality disorders

  “Even in cases in which PTSD is genuine, it is still important to screen for missed diagnoses,” they wrote. “PTSD is rarely seen as a stand-alone disorder.

• Consider malingered or factitious PTSD. Patients feigning PTSD symptoms often give vague or nonspecific answers to direct questions and describe symptoms using stereotypical information or “dramatic, heroic, or cinematic” language.

  The authors described signs of feigned symptoms: rare symptoms, improbable or absurd responses, unlikely symptom combinations, contradictory symptoms, and exaggeration of symptom severity.

• Consider performing psychological testing. The authors cited several validated scales that can be helpful in assessing patients and discerning the validity of reported symptoms. These include the Structured Interview of Reported Symptoms-2, the Minnesota Multiphasic Personal Inventory-2, and the Personality Assessment Inventory, among others.

In comments to Psychiatric News, Binder emphasized that accurate diagnosis is crucial so that resources can be allocated to those genuinely disabled by a serious mental disorder and to ensure the integrity of research: Investigators seeking biomarkers for PTSD need to know that their clinical samples are representative of true diagnosis.

She and her fellow authors wrote: “A methodical approach can help clinicians and forensic evaluators rule out several types of false PTSD prior to arriving at an accurate diagnosis of genuine PTSD. Consideration of the data described in this paper can help ensure that more valid research occurs, and that clinical and financial resources are allocated to individuals with genuine PTSD, while evaluees presenting with false PTSD can be approached intentionally, compassionately, and tactfully.” ■