Assessment of Malingering among Servicemembers with a Focused Examination of Explanatory Models

Explanatory Models of Malingering

Umbrasas takes a mostly fresh viewpoint in exploring two explanatory models for military malingering. First, acute distress malingering is viewed in the context of disciplinary actions as “adaptive behavior in a high-stake adversarial situation” (Ref. 1, p 188). Second, disability malingering is conceptualized as an exit strategy via medical retirement that is motivated by the “potential for monetizing increased disability” (Ref. 1, p 189). Our commentary adopts a more conservative approach than Umbrasas. It introduces long-standing explanatory models, setting the stage for examining their applicability to military malingering.

More than three decades ago, Rogers⁴ first postulated three explanatory models of malingering (i.e., pathogenic, criminological, and adaptational), based largely on the scattered literature of the time, to directly address the question “why does malingering occur?” (Ref. 4, p 184). Thus, these three models considered the primary motivation for engaging in malingering as an intentional response style.⁵ With some success, these models have also been applied to the denials and dissimulations of sex offenders,^6,7 as well as factitious presentations (i.e., Munchausen by proxy⁸ and factitious psychological presentations⁹). As the earliest paradigm, the pathogenic model postulated that an underlying mental disorder was the primary force in the formation of malingering behavior.² As the impairment worsened, it predicted that voluntary fabrication of symptoms would gradually devolve into involuntary production, eventually to the point that malingering no longer occurred. In sharp contrast to the pathogenic paradigm, a highly influential criminological model was inferred directly from the DSM-III’s four indicators for when malingering should be strongly suspected.¹⁰ As observed by Rogers,⁴ the common theme of the criminological model is “badness”; specifically “a bad person (APD [antisocial personality disorder]), in bad circumstances (legal difficulties) who is performing badly (uncooperative)” (Ref. 11, p 7). For the criminological model, malingering is conceptualized as a goal-driven deception by antisocial persons seeking undeserved gains, such as the avoidance of criminal or administrative sanctions.

Most recently, Rogers⁵ developed the adaptational model typically applied to high-stakes settings, which were viewed or experienced by examinees as adversarial. Using a cost–benefit analyses, malingering may have been seen as the best alternative in terms of both potential outcome and likelihood of success. Depending on the individual’s level of insight, a decision to malinger could be complex and may even include factors such as the would-be malingerer’s estimation of an evaluator’s assessment skills.¹² The adaptational model has been applied in several diverse professional contexts, including medical practice¹³ and jail detainees.¹⁴

Across the three explanatory models, Rogers and colleagues³ provided systematic prototypical analysis (i.e., independent expert ratings regarding the importance of specific descriptors to a particular construct) of malingering for both forensic and nonforensic malingerers. The prototypical data concerned three major domains: feigned mental disorders, feigned cognitive impairment, and feigned medical presentations. Overall, the pathogenic model consistently proved the least prototypical, failing to produce any average ratings in the moderate range (i.e., 4 to 5 on a 7-point scale). In contrast, Rogers et al.³ found that cost–benefit analysis (a core component of the adaptational model) produced the highest level of prototypicality across three domains with forensic referrals. For referrals of servicemembers,¹ military evaluators may wish to query suspected malingerers about the likelihood of different outcomes should they respond candidly, malinger, or deny symptoms or impairment. Such examinations may help to reveal persons’ motivations and their corresponding decisions via a cost–benefit analysis.

A central question involves how to assess a cost–benefit analysis based on interactions with examinees when malingering is suspected. It would likely be helpful to consider different response styles for cost–benefit analysis, perhaps beginning with denials, before moving on to malingering, and genuine responding. This order makes sense given the frequency of denial and defensiveness in adversarial contexts,¹⁵ such as administratively initiated military evaluations.¹⁶ It also provides a balanced perspective of under-reporting and over-reporting. For under-reporting, practitioners may wish to begin with a nonjudgmental comment followed by three questions. Consider the following statement, “Some persons we evaluate do not want to share emotional concerns and deny their psychological problems.” To delve into the cost–benefit analysis, questions for the examinee might include: What are your thoughts about that approach? If someone like yourself were to try it, what would be the chances of succeeding? Or, alternatively, the chances of getting caught and being in more trouble? The same process and questions could also be applied to over-reporting: “Some persons we evaluate want a good outcome for their emotional and mental problems, even if they need to report fake symptoms and greatly exaggerate their impairment.” Our advice is simply to ask examinees about their motivations rather than rely solely on our own suppositions.

The three explanatory models of malingering have less prototypicality when applied to nonforensic domains (which may include many military evaluations).⁸ Nonetheless, two pronounced features were mostly present in nonforensic settings: an unwillingness to accept any personal responsibility for their malingering presentations, and thus, no feelings of guilt at these concerted deceptions. In such cases, the malingering appeared to be situationally driven for persons generally lacking in long-term general life goals.¹⁷

Umbrasas’s Military Malingering

Umbrasas¹ tackled two explanatory models of military malingering by contrasting two ends of the career spectrum. Acute distress malingering was applied to junior servicemembers with generally less than five years in the service and with a history of re-occurring disciplinary problems. In contrast, disability malingering was applied to medical retirements, which may occur at any time in military service but appeared in this article to be limited to less than 15 years (see Table 5 in Ref. 1). As a result, the models do not capture other salient reasons for military malingering (e.g., avoiding the rigors of deployment, and, especially, serious combat risks) and they do not apply to military careerists exceeding 15 years.

Aligned with the adaptational model, Umbrasas’s most consistent theme involved the potentially adversarial nature of the military structure and provision of health care to servicemembers. Addressing the latter, Umbrasas acknowledged a nonbeneficent role intentionally adopted by some mental health providers who “may have idiosyncratic motives or experience organizational pressure to refrain from making certain diagnoses” (Ref. 1, p 182). Viewed from an interactional perspective, any modeling of deception by evaluators may substantially contribute to nonforthcoming communications by examinees. This point is exemplified in correctional settings where the correct diagnosis of certain disorders (e.g., impaired sleeping) are administratively disallowed because of institutional concerns regarding medication-seeking motivations.¹⁸

Stigmatization has continued to play a central role in creating an adversarial context for mandatory evaluations of servicemembers. In a systematic review of 111 investigations, Hom and her colleagues¹⁹ detailed a range of stigma-related reasons for active servicemembers not to seek treatment. As a result of the military structure, substantial percentages of active-duty servicemembers expressed multiple perils of seeking mental-health treatment (each ranging from 16.2 to 49.9%), which included harming their military careers, being blamed for their disorders, and diminishing the confidence of leaders in their service capabilities. Of a more personal nature, they were also motivated by self-stigmas such as embarrassment or being seen as weak. Such external risks as damages to military careers and direct blame from leaders are compelling examples of major adversarial consequences in high-stakes contexts.²⁰ As previously noted, however, the motivation would likely eliminate malingering (i.e., simulated impairment) in favor of defensiveness (i.e., simulated adjustment).

Citing the Army Profession and Leadership Policy,²¹ Umbrasas noted toxic leadership as a common military stressor related to inexperienced, indifferent, or abusive leaders. Under such stress, servicemembers might well be highly motivated to use malingering adaptively as the best short-term alternative to extremely adversarial circumstances. Umbrasas cited only the Army Profession and Leadership Policy on this crucial point.²¹ Although the manual described destructive leadership, it did not delve into the depth and breadth of this potentially catastrophic problem, nor did it offer data about its prevalence. As a result, it is not clear to what appreciable extent, if any, poor leadership may motivate military nongenuine responding in light of severe adversarial contexts.

We categorize Umbrasas’s military models differently for acute distress malingering and disability malingering. The acute phase appears to have merged elements of the criminological and adaptational models. Regarding the former, disciplinary problems were stressed, even to the point that a punitive administrative discharge may be considered, which demonstrably underscored the cumulative effects of military misconduct. On this point, Umbrasas described acute-phase malingerers on several occasions as serving “the functional purpose of frustrating the military justice process” (Ref. 1, p 188). This choice of terminology with its antisocial intent is clearly aligned with the criminological model. At other times, however, Umbrasas favored the adaptational model of malingering at the acute phase. He described acute malingering “as a type of adaptive behavior in a high-stakes adversarial situation where servicemembers have no other viable options to exercise” (Ref. 1, p 188) with a cite to Rogers’s early work.²² With these two divergent explanatory models, one reasonable assessment approach might be to consider both, with the relative emphasis being identified on a case-by-case basis.

For disability malingering, the adaptational model undoubtedly predominated for military malingering. In the context of military retirement, the functional purpose was described as maximizing benefits by increasing the disability ratings until 100 percent disability is achieved. As insightfully noted by Umbrasas,¹ however, this cost–benefit analysis might well deter potential malingerers. He provided the following analysis if malingering were detected: “Servicemembers seeking secondary gain in this situation would conceivably jeopardize their lucrative and certain pension for an uncertain gambit related to disability” (Ref. 1, p 190). Thinking more broadly, Umbrasas elaborated on long-range goals that could be jeopardized with unsuccessful military malingering. Some career servicemembers may have further professional aspirations, because of their highly sought security clearances, to work as civilians for the Department of Defense.

The pathogenic model of malingering was not examined in Umbrasas’s explanatory approach to military malingering. It is conceivable that panic reactions of combat posttraumatic stress disorder may become overwhelming when a further deployment has been ordered considering that high perceived threat has been reported among servicemembers.²³ Rather than evoking the pathogenic model of malingering, however, such severe reactions might better be conceptualized as genuine responding to extreme stressors. As a result, we concur with the article’s de-emphasis of the pathogenic model.

Delayed Reporting of Symptoms

Umbrasas¹ cited a 1984 literature review by Rogers²⁴ to conclude a “sudden onset” was a key feature “in classic models of malingering” (Ref. 1, p 184) but tempered that conclusion by affirming that “weighing a delayed report of symptoms too heavily as a sign of malingering can result in an erroneous clinical decision” (Ref. 1, p 184). This view of sudden onset as a key feature was likely overstated because this early review by Rogers found only a few case studies (the weakest type of empirical research) to support this notion. Moreover, subsequent research on the Structured Interview of Reported Symptoms²⁵ (SIRS) found that the suddenness of presentation (onset and resolution) was much less effective at detecting malingering than other scales and detection strategies, resulting in its being dropped from the SIRS²⁶ and being excluded from its second edition, the SIRS-2.²⁷

Commonsensically, the equating of delayed symptom reporting with a sudden onset seemed highly problematic at best. It may be true in occasional cases when examinees improbably claimed an “overnight” appearance of symptoms of considerable severity.²⁸ With unhurried, open-ended questions, it would be much more likely that symptoms were present for some time but not reported until circumstances or priorities had changed. Umbrasas helpfully provided examples for genuine symptom delay, such as dysfunctional coping mechanisms, repression, and an understandable reluctance to self-disclose.¹

Denial of both symptoms and psychological impairment should be considered from an adaptational model,¹¹ but logically, as evidence of defensiveness which has been viewed as the polar opposite of malingering for more than three decades.^11,29,–,31 As a practical result, defensiveness with its minimization of psychological difficulties has continued to be completely at odds with efforts to malinger. Rather than alleviating suffering, defensiveness would result in further exposure to trauma and other stressors.³² Within the general category of “simulated adjustment,” defensiveness refers to “the concealment of psychological impairment” (Ref. 31, p 7).

To provide a broader context, it should be observed that other authors have already tried for several decades to apply past evidence of defensiveness to current conclusions about malingering.¹⁶ For example, the standards for malingered neurocognitive dysfunction (MND) included denials of past psychiatric history as current criteria of feigned cognitive impairment.³³ More recently, the MND criteria^34,35 were tightened, apparently in response to scholarly criticism.³⁶ Based on this revision, past defensiveness can only be used as an indicator of current malingering when the denials were documented in medical records despite a “long-standing history of mental health problems” (Ref. 35, p 754). On this point, Umbrasas did not provide any specific guidance on how past defensiveness should be documented to be considered as a factor in assessing current acute distress malingering. If the current MND standards were applied to military presentations, then many cases would not be applicable because they were characterized by only brief periods of active service and limited mental health treatment. It is our view that any consideration of past defensiveness must seriously consider the MND and other relevant literature.

Delayed symptom reporting should not be utilized either as an indicator or even a screen for military malingering for three important reasons. First, sudden onset (an ineffective indicator of malingering) is very different from delayed symptom reporting. Second, defensiveness (i.e., the minimization of psychological symptoms and impairment) is the complete opposite of malingering and obviously lacks the same external motivation. Rather than avoiding trauma and stressors (e.g., potential motivation to malinger), defensiveness prolongs them (e.g., further deployments). Third, it requires inferential leaps across time (i.e., the extended past to the present) and often domains (e.g., feigned mental disorders to feigned cognitive impairment).

Concluding Thoughts

Umbrasas¹ should be credited for shining a light on largely unseen matters of malingering as applied to active and retired servicemembers. He clearly understands the nonaccepting views of mental disorders in the military, even when entirely genuine and fully consistent with the rigors of deployment, captured in the common phrase “suck it up.” Moreover, when malingering is strongly suspected because of an atypical presentation, he highlights the need to remain open to the possibility of genuine explanations for such presentations. These insights alone have made this article a valuable contribution.

We have examined Umbrasas’s two explanatory models of military malingering in the light of established explanatory models of malingering. The adaptational model of malingering was the strongest fit with its cost–benefit analysis when faced with adversarial circumstances. In contrast, the criminological model offered peripheral insights, whereas the pathogenic model was essentially noncontributory. Em-pirically, the next step would be to systematically evaluate prototypical ratings by experts in military malingering that would build from these established models as well as the insightful contributions offered here by Umbrasas.