Perceptions of Malingering or Factitious Disorder by Army Behavioral health Providers

Thesis (Master's)--University of Washington, 2016-06Abstract Introduction: The topic of malingering or factitious disorder in the military population generates strong opposing viewpoints within the military medical community. As a result, the estimated frequency of malingering in this population ranges widely from “rare” to a “majority of claimants seeking disability compensation.” Even though we do not know the specific rate of malingering in the United States Military, there is evidence that malingering is significantly underdiagnosed in this population. The reason for this potential under-diagnosis is unknown. Objective: This study explored this topic by examining the perceptions of military behavior health providers on malingering within the military healthcare community. Greater understanding potential factors contributing to the thoughts and diagnosis of malingering can potentially prevent provider burnout, identify potential need for additional training, and provide improved medical care to service members diagnosed with malingering or factitious disorder. Methods: We surveyed all military health providers who see Active Duty Soldiers. From December 2015 to Jan 2016 emails were sent to the each installation behavioral health representative who forwarded a link of the survey to all individual behavioral health providers at their installation. These surveys collected demographics including the type of behavioral health professional, active duty status, training level, location, type of practice, and history of deployment. They also included the ProQOL burnout scale and measured the perceptions of malingering and factitious disorder. Results: 502 subjects responded with a response rate of 42%. On average each behavioral health provider estimates seeing 8.34 cases of malingering or factitious disorder each year but diagnoses only 0.68 cases. Additional analysis reveals that each provider provider does not diagnose 7.698 cases of conditions involving intentional patient deceptionin the last year (95% CI 6.32-9.08, p-value <0.001). Multivariate analysis shows that factors associated with increased diagnosis of malingering/factitious disorder include inpatient setting (β 4.411, 95% CI 0.019-8.802), p-value 0.049), and increased burnout scores on the ProQOL instrument (β 0.406, 0.203-0.610, p-value <0.001). No differences were seen between different types of behavioral health professional, active duty status, deployment history, training level, location, or type of practice (other than inpatient). Lack of evidence/difficulty proving, policy and pressure from above, being unsure of the diagnosis, and fears of a negative impact on the provider made up 2/3 of the qualitative open-ended responses that explain the diagnostic gap but only the perception of policy and pressure from above (β 8.659, 95% CI (4.77-12.55), p-value <0.001) and politics (β 8.975, 95% CI (2.54-15.41), p-value 0.006) were significantly associated with this outcome. Conclusions: Our findings support the current literature that the diagnosis of malingering and factitious disorder is minimized by Army behavioral health providers. This study estimates that up to 14,500 Soldiers are not accurately diagnosed with malingering or factitious disorder every year in the Army medical system.. Inpatient setting and increased burnout are all associated with greater rates of perception and diagnosis. Perceptions of politics and policy/pressure from above were factors that were significantly associated with a diagnostic gap. As this is the first study that has examined this finding in the United States Military, we strongly suggest additional studies to examine the effect that this diagnostic gap can have on the system, on other patients, the iatrogenic impact on the Soldiers themselves, and overall military readiness