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HISTORY OF THE OFFICE OF MEDICAL HISTORY
Malingering in Combat Soldiers
Major Alfred O. Ludwig (ref 7)
From the military-legal point of view, malingering is punishable under the 96th Article of War. It is usually difficult, if not impossible, to furnish unassailable proof of guilt in such case, and even when the malingerer is convicted and punished he succeeds in his purpose, the evasion of dangerous duty. Practically, the major object in dealing with such cases is to return the malingerer to duty. The primary problem is thus one of proper recognition and disposition of malingerers by medical officers. For the military psychiatrist the detection and management of malingering has an importance much greater than its actual frequency would seem to justify. A few undetected instances of malingering can be highly demoralizing to the troops and destructive of the psychiatrists prestige and effectiveness. Conversely, the psychiatrists role may be strengthened by a realistic but unvindictive management of malingering.
In civil practice malingering is usually seen only in psychopathsinherently unstable persons whose deep exhibitionistic and sadomasochistic trends play a large part in complex psychodynamics of their asocial behavior. While one does see malingerers of this type in the military services, the problem in general is quite different. It is important to remember that the hardships and restrictions of military duty increase the tendency to evade duty by simulation. Combat stress is so great that soldiers with no history of psychopathy may be tempted in this direction. Minor variants of malingering, or "gold-bricking," are often condoned by seasoned soldiers in garrison or on maneuvers. In combat, however, attempts to evade duty by stimulating disability arouse great resentment in line soldiers. Unless malingerers are promptly detected and returned to duty, morale may be impaired and confidence and respect in the Medical Department severely shaken. The detection of malingering, especially in combat soldiers, thus becomes an important duty for every medical officer. Good medical discipline will prevent loss of manpower through the evacuation of soldiers who are not seriously ill or who are malingering
(ref 7) Formerly chief, Fifth Army Psychiatric Center (601st Medical Clearing Co.) psychiatrist, Seventh Army; and psychiatrist, Army Ground Forces.
or merely unwilling. The medical officer must also exercise care in recognizing exaggeration of minor symptoms secondary to actual illness or injury.
The first requisite for the correct diagnosis of malingering is a high degree of alertness. Since psychiatric syndromes are occasionally simulated, it is necessary to be familiar with the various components of the combat neurosis. With sufficient experience it is usually not difficult to differentiate between the atypical behavior of the simulator and the sometimes bizarre reactions of patients with severe anxiety states or hysteria. The simulator is constantly on guard against detection. He makes false or contradictory statements or resorts to easily refuted lies. Sometimes he overplays his hand in an attempt to convince observers that he is really ill. The alarming nature of his actions may sometimes trick the unwary. The patient who is obviously dramatizing should always be suspected. The malingerer is prone to feign emotional disorder, perhaps because he thinks that detection by objective methods is difficult. Amnesia is the most frequently simulated symptom. We have come to look with great suspicion on patients who present themselves with it story of complete amnesia, especially when the usual signs and symptoms of the severe anxiety state are lacking.
CASE 7. A soldier was admitted to a general hospital for psychiatric observation from another military hospital, to which he had been admitted for injuries sustained in all automobile accident in which several unauthorized civilian passengers were killed. He had suffered a minor scalp laceration in this accident. When the wound was healed and he was to return to duty, and also to face serious charges, he complained of complete loss of memory for events both before and after the accident. The circumstances and the atypical onset raised the suspicion of malingering. In the general hospital he aroused much sympathy by dramatically begging for early treatment so that he might be restored to normal. He claimed to know about himself only what he had written in a diary. His reply to all questions was: "I know only what is in this book." Although psychiatrists in the general hospital suspected him of malingering, he was treated with intravenous sodium amytal on two occasions, the first time with 0.5 gm., the second time with 0.8 gm. Under narcosis he was negativistic and refused to answer questions or countered with, "No more questions! Don't ask any more questions!" He denied all knowledge of the accident and of his name, family, military organization, and present location, except in reference to his diary. He was discharged to another hospital before conclusive evidence of malingering could be established. It was learned subsequently that he was persuaded to confess after he had passed through two other hospitals, where he had obstinately stuck to his story.
In this case the onset of amnesia was quite different from that observed in association with anxiety states or hysteria, in which memory loss is usually precipitated by the traumatic incident, which then becomes part of what has been forgotten. Patients with genuine
amnesia would not remember that they had written a diary, nor would they attempt to produce "evidence" for their loss of memory.
The reaction to intravenous sodium amytal is typical and probably diagnostic of malingering. Patients with hysteria or anxiety states are eager to be helped, cooperate well, usually talk freely, and under narcosis display emotional release in relation to recalled material. In contrast, the conscious efforts of the malingerer to maintain his deception defy all attempts to influence his amnesia. He reacts negatively under narcosis, and his conscious control is unshaken. In case 7 the patient malingered in an effort to evade punishment. We were unable to obtain information about his premilitary personality or adjustment. Case 8 illustrates malingering with intent to avoid combat duty.
CASE 8. A medical officer entered the Seventh Army Psychiatric Treatment Center with alleged loss of memory. He had left his unit on the previous day, wandered into a medical installation, and was tagged and sent in for psychiatric observation. He had visited the center a short time before, when he brought in a patient. It was known that, some weeks before, he had been transferred from it general hospital to become battalion surgeon in a combat unit. His superiors stated that he had lost weight and was known to be apprehensive about his new duty. When interviewed he mumbled: "Won't anyone do something for me? I can't stand those shells." It was known that he had not been exposed to shelling. He denied knowing the interviewing officer, whom he had met earlier. When asked to multiply 2 times 2, he did so correctly, but when asked to multiply 9 times 8, he first answered 70, then 72. He claimed complete amnesia. His behavior and his assumed confusion had a forced character, which, with his obviously untruthful statement about exposure to shelling, made it clear that he was malingering. He was told that he was simulating and was warned that failure to give up his symptoms could result in serious charges. By evening of the same day he asked to see the examiner, stated that he had regained his memory except for the period of hospitalization, and asked to return to duty. There was no evidence of anxiety and no history of civilian neurosis. He was returned to duty.
In some instances malingering is secondary to a moderate anxiety state, as illustrated in case 9.
CASE 9. An infantry lieutenant was admitted to the Fifth Army Psychiatric Center because of a panic reaction in combat. He was somewhat confused from sedation, but showed the usual manifestations of an anxiety state. He was further sedated for two days. It was then reported that he had developed amnesia. When addressed by name he answered: "I don't remember my name, but that is what they call me here." In an interview he continued to claim total amnesia and produced letters, papers, and identification cards, saying that he knew about himself only what he could learn from them. Under sodium amytal he was unproductive. He remembered only some heavy shelling. Under narcosis he was found to be very sensitive to noise. It was pointed out that there was a discrepancy between this reaction and his alleged amnesia, which included the period he had spent in combat. He was told that it was clear that he was feigning amnesia and that he would be court-martialed unless he promptly gave
up this symptom. Soon after going back to the ward he reappeared and tearfully confessed. He had had extreme anxiety in combat from the start, but nevertheless stuck to his post for 6 weeks. Just before his admission a shell killed some of his men. He recalled running around, shouting, and weeping. In the hospital he became utterly terrified at the thought of returning to combat and decided to feign amnesia.
This officer had a moderate anxiety state, with insomnia, anorexia, noise sensitivity, and marked tremor. For reasons of individual treatment, but particularly for disciplinary purposes, it was necessary to detect and curb the simulation. This man was evacuated to the rear after a stern warning. It was felt that his underlying anxiety was of sufficient severity to make further combat duty impossible.
This type of malingering is quite different from that described in cases 7 and 8. The two types may be classified as primary, premeditated, and without essential underlying psychiatric or physical illness and secondary, superimposed on an existing acute psychiatric disorder. The primary type resembles that seen in the civilian malingerers. It is usually obstinately maintained by the patient. The secondary type is usually much more easily uncovered and removed. Cases 7 and 8 were both of the primary type, though case 7 more closely resembled the malingering seen in civil life. In case 8 there was no underlying psychiatric disorder of significance. The reaction appeared in response to anticipatory apprehension. In case 9 malingering was secondary to a moderate anxiety state. The relative ease with which the deception was uncovered in cases 8 and 9 is the rule in dealing with malingering in combat troops.
Occasionally one sees attempts to simulate a psychotic disorder as in case 10.
CASE 10. An infantry private was brought into the Seventh Army Treatment Center in a highly disturbed state. He staged a most dramatic performance. He waved his arms around, made incoherent noises, blew out his cheeks, blew his nasal secretions over his face and clothes, appeared utterly unresponsive. After a night of this behavior, which disturbed the entire ward, he was given intravenous pentothal. At first he resisted violently and muttered "Never, never!" but then fell asleep. When awakened by supraorbital pressure and aware of what was going on, he resumed his bizarre behavior on an even more exaggerated scale. The whole reaction was forced and resembled no known psychiatric syndrome. He was warned to give up this obvious simulation lest charges be preferred. When returned to an empty ward he continued to resist. He was unruly, untidy, and noisy. On the following morning he still clung to a partial deception by assuming confusion. Further admonition served to remove this symptom as well. This man gave a history of familial psychopathy. His father was an alcoholic. His mother had been insane. After giving up his simulation, he said that he had been afraid from the first moment in combat. He had stayed 3 months until he had become shaky after another soldier was wounded near him on the day of admission. When he wept his lieutenant sent
him to the aid station, where he began the bizarre behavior that caused his referral to the center. He was returned to duty.
Attempts to simulate psychosis are usually easy to uncover. Even well-educated persons who practice this form of deception usually fall so far short of the mark that diagnosis is not difficult. They behave according to the lay concept of insanity, with such bizarre dramatization that the result becomes ridiculous. The features of known psychoses are missing, and it is apparent that contact with reality is maintained. Case 10 illustrates the striking attempts to attract attention and sympathy and the negative reaction to barbiturates. This patient also had an underlying anxiety state, but not of incapacitating degree.
Case 11 illustrates an attempt to simulate a hysterical symptom.
CASE 11. A soldier was referred to a station hospital for treatment of hysterical paralysis of the left wrist following a mild injury during training. A median nerve injury was suspected at another hospital, and neurolysis was attempted. After this procedure the patient complained of numbness of the entire left hand, and said that he could not extend his fingers. Examination at the station hospital showed apparent loss of sensation to pinprick and light touch over a glove distribution on the left hand. The fingers were held partly flexed and returned slowly to their former position after passive straightening. Sodium amytal was given intravenously to relieve what was thought to a hysterical symptom. The patient resisted this treatment and under narcosis reacted with negativism. He resorted to echolalia as a counter to questions. He then began to dramatize and rolled on the floor, but took great care to avoid injury. This unexpected but typical response to narcosis firmly established the diagnosis of malingering. Conclusive proof was furnished when the soldier was seen to use his "paralyzed" hand when he thought himself unobserved.
The differential diagnosis between hysteria and malingering may be very difficult, for the evaluation of hysterical symptoms depends largely on the patient's own statements. The symptoms in this case were consistent with a diagnosis of conversion hysteria. The soldier's objection to barbiturate narcosis, which he feared might lead him to tell the truth, should have led to suspicion. The negativistic reaction to narcosis clinched the diagnosis. In doubtful cases of this sort the use of barbiturate narcosis is often helpful in making the correct diagnosis.
The problem of self-inflicted wounds must also be discussed under the subject of malingering. Since these men are evacuated through surgical channels, our experience with this group is limited. Such soldiers invariably claim that the wound was accidental. There are never witnesses, and it is usually impossible to prove deliberate intent. In one such case, in which it appeared likely that the wound had been inflicted with deliberate and premeditated intent to evade duty, we had an opportunity to employ intravenous barbiturate narcosis.
The soldier reacted negativistically in the same manner as other malingerers. It is possible that this method may prove useful in differentiating the deliberate from the accidental in this difficult group. In one overseas group the Inspector General's Department routinely investigated all self-inflicted wounds. This policy served as a partial deterrent to this form of evasion. It is axiomatic that, unless residual disability prevents it, soldiers with self-inflicted wounds should be returned to duty with their units as soon as the injury is healed. When deliberate intent can be proved, court-martial procedures should be initiated. In suspected cases the proper investigation should be conducted before the soldier is evacuated from the army area.
Soldiers who exaggerate physical symptoms ("goldbricking" or "riding the sick book") are guilty of a minor variety of malingering. Usually it is unnecessary to regard such offenses with the same seriousness as the premeditated efforts already described. Soldiers are usually easily discouraged from continuing such behavior, and they should then be returned to duty. Inexperienced medical officers play into the hands of such soldiers when they evacuate them for further study or treatment under such vague labels as "ill-defined condition" or "not yet diagnosed."
Since the object of treatment is to detect the malingerer and return him to duty, morale is impaired if such cases are evacuated to the rear unrecognized. The offenders must be discouraged by firm handling. The malingerer, once revealed, is told that his deception is known and that court-martial charges will follow promptly unless the simulation is dropped or if the offense is repeated. Usually this approach is followed by confession. Only two of the cases treated in this way refused to relinquish their symptoms. Charges were preferred against these men but both decided to return to duty before their cases were tried. To our knowledge, none of those returned to duty after a warning attempted to malinger a second time.
Although malingering is rare among combat troops, such cases occur and must be detected. Every medical officer who has practiced combat psychiatry has missed some malingerers before his suspicions were sufficiently aroused. Once the needed experience has been gained, the medical officer readily develops a keen intuition in uncovering these cases. Intravenous barbiturates are often of great help in making the diagnosis. The response of the malingerer to narcosis is negativistic and unproductive. Amnesia is a favorite
subterfuge of the simulator. The atypical nature of the symptoms, the contradictory or inconsistent statements of the patient, and their forced or dramatic behavior are all diagnostic leads. Court conviction is difficult to obtain. The correct procedure is to return the soldier to duty. This measure acts as a deterrent both to the offender and to other soldiers who may be tempted to use such methods to evade duty.