Fabrication of Trauma
Rebecca Wilkinson
Workshop aims
to increase awareness on identification of fabrication within the ex service population and to facilitate reflection
and discussion on the possible reasons people fabricate and underlying
personality processes.
Outline
Brief overview of the service I work in and how I came across the issue
of fabrication
How prevalent is the issue
How is fabrication defined
How can you identify it within the ex military/ military population.
Memory and PTSD
The 7 sins of memory
Personality Disorder
How we assess for PD
Its relevance to fabrication
The different types of PD
Relate to Case study examples
How do you then address this as part of client assessments and
interventions? What might you begin to think about?
Feedback and main group discussion
Questions and close
Fabrication
Humber Traumatic Stress Service
PTSD Service piloted 1996-98
Provide specialist assessment, formulation and intervention for ex-military
personnel affected by exposure to trauma
Psychological intervention, Occupational Therapy, Dual Diagnosis work
Nurse with experience working for the MOD.
links with national and local military.
Work alongside other agencies
Service expanded in 2009 in Hull
Who do we see?
Mainly Complex (multiple or prolonged) type II trauma
On occasions Type I trauma when accompanied with others
factors e.g. self harm, previous treatment ineffective
Comorbidity – alcohol and substance misuse, anxiety and
depression, obsessive traits, personality traits
Mainly army, majority male, late 20’s early 30’s
NI, Falklands, Bosnia, Kosovo, Iraq, Afghanistan
Service Model
Referrer
Military Records
Assessment
Family/ Partner
Dual diagnosis
Team
discussion
Stabilisation
Processing
Integration
Veterans Outreach Pilot Project
Recognition that group of veterans not being reached
PTSD not most common mental health problem in veterans
Evidence shows veterans generally happy with NHS services
once accessed them, problem is getting into services
Potential need to develop different approach to engaging
veterans in mental health services
Pilot to scope need and trial different routes of access
Structure and Staffing
Humber Host Trust
Administrator Band 3
0.8wte
Hull, ER,N Lincs,
York and
North Yorkshire
Leeds, Bradford,
Wakefield
Sheffield, Barnsley,
Doncaster, Rotherham
Veterans Outreach
Post Band 7
Veterans Outreach
Post Band 7
Veterans Outreach
Post Band 7
Humber NHS
Foundation Trust
Leeds Partnerships
NHS Foundation Trust
Sheffield Health and
SC Foundation Trust
Outreach pilot further Highlighted fabrication and its co morbidity with
disorders of the self and addictions
Of 31 cases seen within the outreach service pilot 17 were fabricating
their military history
Of those who fabricated in this population all had served, but less than
the time they stated for example 3 only completed basic training but
reported they had been on operational deployment, many of the cases
reported they had been to on ‘black (secret) ops’; reported they were
members of SAS or Parachute Regiment or had been on operational
tour when they had not..
6 pilot projects: Stafford, Camden & Islington, Cardiff, Tyne Esk & Wear, St
Austell, Lothian. Most have estimated 50%-70% embellished or fabricated in
some way.
Why Fabricate ?
Do Veterans think they need to have PTSD to access treatment?
Or is it a badge of honour?
Or is It something else ?
In general the fabrication for the outreach cases was an exaggeration and
embellishment of the truth in many cases it appeared to be a way to feel they
had achieved something, in others it became a reason for not achieving
significantly where they had sought to find a family in the army structure that
had been lacking previously the army appeared to become the scapegoat and
cause of everything wrong in their life.
“It is rare to find a psychiatric diagnosis that
anyone wants to have, but PTSD seems to be one of them”
(Andreasen, 1995, p. 963).
“Some individuals who never even served in military combat
have successfully acquired service-connected benefits for
PTSD (Burkett & Whitely, 1998). A valuable procedure to
support or refute an account of combat experiences is the
collection of collateral data.”
“Those malingering PTSD may state that their records do not reflect their
covert missions or ‘black ops’; hence no evidence of their experiences
exists. If there is no written record of one of these events, look for the
special training required for these missions. The terms Selection,
specialist courses passed, classified training/mission will appear with
dates (Burkett & Whitely, 1998). “
“Although fabricated stories that are as vivid and horrifying as the experiences of true
combat veterans (Burkett & Whitely, 1998; Hamilton, 1985) they may reveal their
fabrication by incorrectly identifying certain details, including geography and culture of
the area, military terminology used at the time and dates related to specific events”
(Burkett & Whitely, 1998)
Genuine PTSD
Malingered PTSD
Minimise relationship of symptoms to
combat
Emphasize relationship of symptoms to combat
Blame themselves
Blame others
Dream themes of helplessness
Dream themes of grandiosity or power
Deny emotional impact of combat
“Act out” alleged feelings
Are reluctant to tell combat memories
“Relish telling combat memories
Have survivor guilt related to specific incidents
Have generalized guilt over surviving the war
Avoid environments that resemble combat
Do not avoid environments that resemble combat
Show anger at helplessness
Show anger at authority
Case Study
Client referred by GP showing symptoms of PTSD, Client
reports that he was a Chef in the RLC. He reports to have
witnessed been exposed to various contacts with the Taliban
when he was selected to go out on operations with special
forces.
Investigations of records and Confidential reports show that
this client is telling the truth – born in the UK with heritage from
Pakistan he was fluent in Pashto and Dari (amongst other
languages) and he was able to act as an interpreter when
operational circumstances meant normal channels broke
down, he was reliable and given positive reports for his
adaptability.
Be Aware sometimes it may not sound real but is true
and other times it sounds very real but is fabricated!
Memory
Memory
The 7 sins (D.Schacter
2001)
There are genuine mistakes in memory recollection. It is worth
considering these possibilities in our assessment of authenticity or
fabrication
Omission: (Involves forgetting)
the result is a failure to recall an idea, fact, or
event
1. Transcience - the general deterioration of a specific memory over time.
2. Absent mindedness - memory breakdown involves problems at the point
where attention and memory interface
3. Blocking - when the brain tries to retrieve or encode information, but
another memory interferes with it
Commission:
(Distorted or unwanted
recollections) there is a form of memory
present, but it is the desired fact, event, or ideas
4. Misattribution
Misattribution entails correct recollection of information with incorrect recollection
of the source of that information.
Example: A soldier who witnessed a shooting just after attending a training
course may blame the shooting on someone who was at the training course.
5. Suggestibility
Memories of the past are often influenced by the manner in which they are
recalled, and when subtle emphasis is placed on certain aspects of the event
those emphasized aspects are sometimes incorporated into the recollection,
whether or not they actually occurred.
Example: A sergeant witnesses three hostages being kidnapped, a woman and
two men. He later reads in the newspaper that two women and one man were
kidnapped and he remembers it as two women and one man.
6. Bias
One's current feelings and worldview distort remembrance of past events. This
can pertain to specific incidences and the general conception one has of a
certain period in one's life.
This occurs partly because memories encoded while a person was feeling a
certain level of arousal and a certain type of emotion, come to mind more
quickly when a person is in a similar mood.
Example: An ex-army officer, retired from the service is getting married and
really enjoying the experience. He get’s into conversation with some members
of his squadron at the wedding and talks about his experiences in Iraq with
enjoyment and pleasure. This is not representative of the actual experience in
which he witnessed a great deal of death and destruction. His colleagues who
are not in the same present state of mind may feel confused at his response.
7. Persistence
(A thought you can’t get rid of)
This failure of the memory system involves the unwanted recall of
information that is disturbing. The remembrance can range from a blunder
on the job to a truly traumatic experience, and the persistent recall can
lead to formation of phobias, post-traumatic stress disorder, and even
suicide in especially disturbing and intrusive instances. (The body
remembers)
For example: The body physically reacts to a loud bang in the present in
the same way it would have been on alert to explosions etc in the war
zone.
In summary - The significance of memory
Memory can be commissioned out of the clients awareness. It may
serve a purpose for the client but has not been intentionally distorted.
For Example
A young woman remembers being abused by her
father when it was not her but her sister that was abused (she may
sub-consciously be protecting her sister)
The client may not remember the facts exactly as they happened but in a
distorted way. This could be due to trauma through PTSD or
developmental dysfunction (PD) and does not mean they are fabricating
in a purposeful way. (it may be that they have sub consciously worked
out a way to get help)
For example . a soldier who was present at an incident in which a fellow
soldier described witnessing a traumatic event. The soldier related the
event to others subsequently as if he had witnessed it and believed this
to be the case.
Small Group Task One
Think about the clients you have assessed or had contact with in
relation to their shared memories. Discuss the relevance of
comissioning memories and whether this could be relevant to some of
your clients.
Consider how you clarify whether you believe your client is fabricating
or genuinely believes his experience?
Case studies are also available should you need or prefer to use these
Personality
Disorder
What is Personality disorder?
How do we assess whether the
PTSD client is personality
disordered and or fabricating?
(Berne 1966)
Historical
Behavioural
Social
Phenomenological
Historical
We spend time with them talking. Invite them to tell us their story
(what’s their narrative?)
We find out about their families, histories, attachment patterns.
Check quality of story. Do we have evidence? Is it true?
Behavioural
We evaluate their behaviour in certain situations (as mindful and without
judgement as possible, not easy when their behaviour invites judgement
and reactions in others)
Do they behave in ways that are demanding, aggressive, destructive,
dependent, arrogant, abusive, idealising, denegrating etc?
Behavioural cont;
In telling their narrative check;
Their Manner - Are they vague, confusing, illogical?
Quantity of story. Can they be succinct. Is there a beginning middle and end?
The coherence of their story
The more coherent their narrative, the more secure their attachment style
(less potential for PD)
The less coherent the narrative, the more likelihood of developmental issues
(more potential for PD)
Social
We listen to their thinking about their life and events. Are they self
blaming or blaming of others?
We assess their adult relationship patterns. This will provide us with
information about their personality structure
Phenomenological
We see how we feel in response to them. i.e. do we feel over-involved,
deskilled, devalued, angry, hurt, conned etc?
Do we feel like the most significant person in the world to this client or
could we be anybody as long as we are there for them?
What is our gut response to their story (the best tool we have for
assessment).
Do we believe it or are we unconvinced?
Can they tell their story and remain in relationship.
Do I feel connected to them and their story, do I question their
authenticity, Are they interested in me and what I think?
Small Group Task two
Using one of the case studies or a case of your own reflect on the information
within the assessment
Looking at the Historical, Behavioural Social and Phenomenological
Discuss whether the client may be fabricating and why this might be in light of
the information gained at the assessment?
What might need to be taken into account as part of the care plan?
Discuss the information found from the Military records how does this fit with
your initial opinions from the assessment what does this make you feel?
In summary - Assessment of an underlying PD with
a PTSD presentation
With your earlier discussion what were some of the words that were used
in reference to your response to your clients?
This is your counter transference response – counter-transference is
when we respond from the place invited by our clients (they expect us to
be irritated with them and we find ourselves being irritated with them) or
the client may generate something familiar in us from our own experience
(I may recognise some passivity in them which is an aspect of my own
personality that I don’t like so I react to their passivity in a critical or
negative way).
Considering our own response is essential in assessing whether something
feels fabricated or authentic.
Remember our GUT (phenomenological) responses are our most
significant resource but needs to be supported by our Historical, Social and
Behavioural assessment.
Small Group Task Three
Discuss your counter-transference responses to some of the clients you have
heard about today or one of your own clients you see as complex
Why Fabricate?
To belong or be accepted (as with the forces)
Resort to an earlier developmental stage in a fearful situation
A symptomatic presentation to acquire and maintain relationship (out of
awareness)
Provides a quality of attachment (in their frame of reference)
May be a false memory response to an authentic trauma of service or life
trauma
To repair an unmet developmental need
For financial gain
Anti-social tendencies
Relational Response Model
Extension of Relational Response Model
MODEL C
SOME
RESPONSIVENESS TO
TREATMENT BUT
OTHER BEHAVIOURS
PRESENT
LACK OF AUTHENTICITY
AND STAFF FEEL
UNCONVINCED OF PTSD
NO EVIDENCE/RECORDS
TO SUPPORT
PRESENTATION
HIGH POSSIBILITY OF REPRESENTATION
ELSEWHERE TO MAINTAIN
FINANCIAL GAIN
DISCHARGE
CONFRONTATION
OF PRESENTATION
Small Group Task four
Again focus on your own experience of clients or the available case studies and
what you feel are their reasons for being in the service with you.
Discuss in your groups your experiences of working with what you believe to be a
genuine symptomatic presentation, a client with a relationship gain and those that
you believe to be there for financial gain.
Think about your responses to each of these and compare your experiences. What
helps you in being clearer about authenticity versus fabrication.
The Main Personality
Disorder Types and
why they may fabricate
Borderline
Issues of abandonment, separation and dependency
Moves between idealising and devaluing others (usually in response to what
they experience as not “good enough” care)
Identity disturbance
Impulsive behaviours
Easily bored and feelings of emptiness
Intense feelings of anger
Most likely to be relationship gain. Can be effectively worked with in
therapy. Responds well to confrontation
Schizoid
A sense of power over others, can live in a fantasy world. Lack of
connectedness
A sense of separateness, as if rejecting the rest of the world (withdrawal)
non-sensical or over-detailed dialogue
Dilemma of wanting to be in relationship but not tolerating the closeness
Most likely to fabricate from a place of managing relationship. Fantasy
can be more tolerable than reality. Interpretation more effective than
confrontation which could invite withdrawal. Long term
Narcissistic
Grandiose, superior, having a sense of specialness, self love
Insists on having the “top” person (doctor, lawyer etc)
Devaluing of others, blaming
Sense of entitlement
Lacks empathy
Narcissist - Validate experience (whatever the narcissistic preoccupation i.e. what a hard time they have had). Gradually introduce
confrontation in a subtle way but gratification in the relationship can
be paramount, whether this is for financial or relationship gain
Anti-social
Failure to conform to social norms
Repeated lying, use of aliases, or repeated conning
No regard for the impact on others
Impulsivity, irritability or aggressiveness
Reckless disregard for safety of self and others but mainly others
Lack of remorse
Approach- Most likely to be financial gain. Behaviour needs
confronting as relationship difficult to establish other than in a
reward and punish environment.
In summary - Forming a picture
Fabrication does not necessarily mean financial gain. It is
important to integrate all the relevant information gathered in
our assessment with the factual evidence and our experience
of the client before making this judgement
Small Group Task Five
Using the information from the day talk about how you may use this theory
to support your approach to some of the clients discussed earlier either in
the case presentations or in your own practice. Which aspects of the
theory do you find helpful in working with fabrication
Pick two key points per group and feedback as part of full group
discussion
Any Questions ?
Service Contact Details
01482 617771
[email protected] – Service Administrator
Humber Traumatic Stress Service
Victoria House
Park Street
Hull
My Contact details
[email protected]
References
American Psychiatric Association, (1980). Diagnostic and statistical
manual of mental disorders (3rd ed). Washington, DC.
Andeaasen, N. C, (1995). Postraumetic stress disorder:
Psychology, biology, and the Manichaean warfare between false
dichotomies. American Journal of Psychiatry, 152, 963-965.
Baggaley,M. (1998) ‘Military Munchausen’s’: assessment of
factitious claims of military service in psychiatric patients. Psychiatric
Bulletin, 22,153-154.
Burkett, B.G. & Whitley,G. (1998) Stolen Valor: How the Vietnam
Generation Was Robbed of its Heroes and its History.Dallas,TX:Verity
Press.
Deahl M, Klein S, and Alexander D (2011)The costs of conflict: Meeting
the mental health needs of serving personnel and service veterans
International Review of Psychiatry, Vol. 23, No. 2 : Pages 201-209
.
Frueh, B.C., Elhai, J.D.,Grubaugh, A.L., et al (2005)
Documented combat exposure of US veterans seeking treatment for
combat-related post-traumatic stress disorder. British Journal of
Psychiatry, 186, 467-472
Frueh C, Hamner M, Cahill S, Gold P, Hamlin K (2000) Apparent
symptom over reporting in combat veterans evaluated for ptsd Clinical
Psychology Review, Volume 20, Issue 7, , Pages 853-885
Hamilton , J.D. (1985), Pseudopost-traumatic stress disorder. Mil Med
150:353-356
Kashdan T. Elhai J, Frueh C (2007)Anhedonia, emotional numbing, and
symptom overreporting in male veterans with PTSD Personality and
Individual Differences, Volume 43, Issue 4, , Pages 725-735
Knoll J. Resnick P (2006), The Detection of Malingered Post-traumatic
Stress Disorder Psychiatric Clinics of North America, Volume 29, Issue 3,
Pages 629-647
Lynn, E.J. and Belza, m. (1984), Factitious post-traumatic stress
disorder: the veteran who never got to Vietnam. Hosp Community Psychiatry
35:697-701
Mccullum smith C, and Ford C (2011) Simulated Illness: The Factitious
Disorders and Malingering Psychiatric Clinics of North America, Volume 34,
Issue 3, , Pages 621-641
Mcdermott B (2012), Psychological Testing and the Assessment of Malingering
Psychiatric Clinics of North America, Volume 35, Issue 4, Pages 855-876
Mcnally R (2012), Psychiatric disorder and suicide in the military, then and now:
Commentary on Frueh and Smith Journal of Anxiety Disorders, Volume 26,
Issue 7, Pages 776-778
Miller L (2012) Posttraumatic stress disorder and criminal violence: Basic
concepts and clinical-forensic applications Aggression and Violent Behavior,
Volume 17, Issue 4, Pages 354-364
Pankratz, L. (1985). The spectrum of factitious post-traumatic stress disorder.
Paper presented at the annual meeting of the American Psychiatric
Association, Dallas, TX, May 18-24.
Peace K., Porter S. and Cook B. (2010) Investigating differences in truthful and
fabricated symptoms of traumatic stress over time. Psychol.inj. And law 3 118129
Resnick, P. J. (2003). Guidelines for evaluation of malingering patients in
PTSD. In R. I. Simon (Ed). Posttraumatic Stress Disorder in Litigation:
Guidelines for Forensic Assessment, 2nd ed, pp. 187-205. Washington, D.C.:
American Psychiatric Publishing Inc.
Rosen G, Taylor S (2007) Pseudo-PTSD Journal of Anxiety Disorders, Volume
21, Issue 2, , Pages 201-210
Rogers, R (2008), Clinical assessment of malingering and deception
Ryan C.W. Hall, Richard C.W. Hall (2006) Malingering of PTSD: forensic
and diagnostic considerations, characteristics of malingerers and clinical
presentations General Hospital Psychiatry, Volume 28, Issue 6, Pages
525-535
Scott, J. (1993) The Politics of Readjustment: Vietnam Veterans Since the
War.NewYork:De Gruyter.
Sparr, L. & Pankratz, L. (1983) Factitious post traumatic stress disorder.
American Journal of Psychiatry,140,1016-1019.
Taylor S., Frueh C. and Asmundson G (2007) Detection and management
of malingering in people presenting for treatment of posttraumatic stress
disorder: Methods, obstacles, and recommendations Journal of Anxiety
Disorders Volume 21, Issue 1, Pages 22–41
Wessely, Simon. 2005, War stories: Invited commentary on . .
.Documented combat exposure of US veterans seeking treatment for
combat-related post-traumatic stress disorder BRITISH JOURNAL OF
PSYCHIATRY, 18 6 , 4 73 - 4 7 5