García Silgo, M. lo? ¿Que relación hay entre, por un lado, la invención del Trastorno de Estrés Postraumático en la tercera edición del Manual Diagnóstico y Estadístico de los Trastornos Mentales (APA, 1980) junto con la inclusión, ese mismo año y en este mismo manual, del criterio de ser militar en el diagnóstico de simulación y, por otro lado, los veteranos de guerra de Vietnam de los Estados Unidos? ¿De verdad este criterio alentaría el derrotismo en tiempos de baja moral? La simulación no está relacionada con la ocupación o profesión, sino con la complejidad del contexto biopsicosocial en el que se encuentre la persona. Mientras los criterios de sospecha de simulación se sigan basando en un modelo criminológico estereotipado y no en criterios empíricos, dichos criterios seguirán fomentando los estereotipos y el estigma, lo cual no ayuda a reducir el miedo al doble estigma en población militar, con el impacto negativo que ello conlleva. Las decisiones judiciales sobre enfermedad mental han sido a veces criticadas por su simpleza, sin embargo, Finkel y Handel166 demostraron que la simpleza no residía en los jueces, sino en las pruebas médicas con las que éstos tenían que decidir. Incluso, ahora que los expertos cuentan con procedimientos empíricos de evaluación, el psicodiagnóstico sigue siendo una tarea delicada. Así, existen instrumentos de medida validados, hay cierto reconocimiento al estigma asociado a los problemas mentales e independencia entre el profesional de la salud mental y la cadena de mando, por lo que tan solo falta desarrollar y validar un modelo biopsicosocial de los problemas mentales y de su simulación, como han propuesto, respectivamente, Wade y Halligan46 o Bass y Halligan47. Este modelo sería suficientemente amplio como para diferenciar entre contextos e incluir un amplio abanico de variables psicosociales, en el que ninguna ocupación o profesión debería estar estereotipada. Is malingering mental disorder a stereotyped diagnosis in the military? INTRODUCTION Malingering mental disorders is a phenomenon that appears throughout history, occurring in all social spheres. The Bible narrates a case of malingering insanity in Book I of Samuel (21:14, Bible of Jerusalem) and there are documents recording cases of malingering for political purposes and personal gain from ancient Athens and Rome1,2. However, it is in military contexts where malingering has been most associated, although there have been no empirical methods employed to detect malingering mental problems nor any prevalence studies that confirmed what everyone seems to take as true. From the origin of Western culture to the present day, malingering is described as a constant method among soldiers to avoid military conscription or escape from war. There are many historical references, starting with the famous malingering madness of Ulysses to avoid going to the Trojan War3 or the comments in the Treaty of the Air, the Waters and the Places of Hippocrates2. Even the etymology of malingering originated from military contexts4 and today the psychiatric classification manuals themselves still include the condition of 148 Sanid. mil. 2019; 75 (3) being a member of the military among the criteria for suspecting malingering. This malingering-military association occurred naturally as a consequence of a set of factors. In first place, it cannot be denied that war has been intrinsic to the history of humanity, especially until the Long Peace5 and the New Peace.6 Because of this past, armies needed to recruit thousands of men, for their end and, the end, consisted, not infrequently, in dying. Thus, malingering was associated with the militia intuitively, because it was assumed that it would be used by many. This was helped by the fact that experts in the past classified soldiers with the difficulty that accompanies the diagnosis of «invisible» health problems, without having objective evidence and, as Vautier, Andruetan, Clervoy and Payen7 point out, being subjected to a role conflict as experts due to the pressure exerted by the chain of command. Secondly, governments had an explicit interest in classifying psychological problems caused by wars as malingering8, because it is synonymous of cowardice or disloyalty9-12 and, in addition, they could always find prestigious professionals who defended this option as, for example, the neurologist Gordon Holmes13, the doctors who were part of the Research Committee of Southborough13 or Sir John Collie.14,15 Third, military culture has entrenched stereotypes about masculinity16-19 strength, honour and loyalty, which even mattered at national level17,20 and are incompatible with mental problems – real or malingered. Thus a double stigma originated: one associated with the mental problem itself21,22 and the other associated with being suspected of malingering.23-25 This double stigma led to the fact that, in the absence of objective evidence and the impossibility of finding organic harm in psychological problems, individuals were easily classified as weak, cowardly, disloyal or malingerers, since all these terms were perceived as voluntary and intentional acts of duty avoidance. Lastly, the exclusion of the psychosocial perspective from the understanding of mental health problems26 and the inclusion of psychosocial problems in the category of physical illness27-30 did not help to make the malingering debate multidisciplinary and to integrate non-medical factors in the model. Thus, the military malingering hypothesis –which was biased from the start due to the difficulty of diagnosing invisible health problems, the role conflict of medical experts, the stereotypes, the double stigma, the biological view of mental disorders and the own interests of governments and some professionals – ended up being endorsed by many experts31-36 and by the psychiatric diagnosis manuals themselves.37-41 There are also exceptions, such as the denunciation by Sigmund Freud into the war crimes Commission at the end of the First World War42 or the reflections of some other authors7,8,13,15,43-45. It seems necessary, therefore, to explore malingering mental disorders in the military, in order to recognize the invisible wounds of war and restore the honour of thousands of soldiers stigmatized, condemned or executed in the past for suffering real mental disorders. In addition, double stigma associated with mental problems in military contexts must be combated. Last but not least, the study of malingering in the military also serves to include non-medical factors in the biological model of mental disorders and malingering, in line with Wade and Halligan46 and Bass and Halligan,47 respectively.
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