¿Es la simulación de trastorno mental en militares un diagnóstico estereotipado? Sanid. mil. 2019; 75(3) 149 METHOD Bibliographical searches with key words «malingering AND (military OR soldier OR veteran)» were done in the most important scientific databases. Results were –from 1847 to 2018– PsycINFO with 134, MEDLINE with 109, Psychology and Behavioral Sciences Collection with 7 and PsycARTICLES also with 7. Those papers which showed significant contributions and empirical data on the malingering history, malingering detection and prevalence of malingering were selected. RESULTS Detecting malingering in armies No other organization has ever needed to mobilize such large groups of men for such bloody ends as armies. Therefore, the history of detecting malingering has its origin in wars. The military doctors always found themselves with the problem of discriminating between those who drop out due to real illnesses and those who escape injury or death by faking them. In the Ancient Age, Galen developed the first treaty of simulated diseases based on observations of slaves, where he listed the most frequent types of malingering in his time and gave rules to differentiate real pains from feigned ones.2 During the Middle Ages, the decision on those who claimed not to be fit for recruitment resided in the Church, while, in the Modern Age, this decision was professionalized in the figure of the doctor and systematized through the development of guides on detecting malingering. The authors of this period devoted great efforts to the detection of feigned diseases, studied the role that was reserved to the doctor in the discovery of fraud, set out general precepts to discover it and analyzed the diseases that used to be feigned. The most outstanding authors of this time were Ambrosio Paré – considered the father of military health-, Paolo Zacchias – the father of forensic medicine- and, in Spain, Cristóbal Pérez de Herrera. In the Modern Age, the psychophysical evaluation of military personnel is carried out in a more objective way. Not only did the first exhaustive guides for detecting malingering appear, but also the concept of the expert report, the first tribunals of experts and the observational methodology. In the 17th century, the first psychiatric military expertise was established48 and, in the 18th century, Dominique Larrey – a physician known for introducing the principles of modern military health – asked to create a committee of experts to study cases (in Napoleon’s army) classified as voluntary self-licenses, determining, according to the Court, that the mutilations were due to the inexpertise of the recruits, which led to exempting 3,000 soldiers from execution7. The confinement of the «crazy» in specific centres or hospitals was ordered in those years to observe them for several weeks or months. This measure had an obvious intention of detecting malingering48. In the Contemporary Age, this methodology became entrenched and generalized. Guides continued to be written, such as1: Belloc, Stier, Golbert, Marc, Fodere, Souville, Borie, Fallot, Kirchoff, Marshall, Devergie, Orfila, Taylor and Bernard. In Spain, according to Lozano et al.,49 the most complete work was that of Díaz Alcrudo in 1850, although there were many prominent authors, such as Merino Delgado50, Arguello51 and Slocker52 –a medical physician whose treatise on simulated diseases served as a guide to the Spanish military doctors of his time and later. 2 The first systematic guide in English written for the military context was that of Hector Gavin,53 who received the Professor of Military Surgery award from the University of Edinburgh in April 1835.54 For its part, the observational methodology used in the Modern Age continued to be used in Contemporary times. The Regulation of Military Hospitals in Spain in 1884 specified that the «insane» should be treated in specific departments where their acts could be observed and the pretence or truth of their disorders discovered.55 In the 20th century, soldiers suspected of malingering continued being observed, for example, those of the Great War,56 those of the Spanish Civil War2 and those of World War II57. In this way, detection accuracy was improved in wars of that time, such as the American Civil War58 and the First World War on the British front.45 In the Second World War, the publications on malingering mental problems in the military stand out, characterized by classifying the different types of malingering, comparing them with the psychopathological pictures described in those years and giving advice or keys for its detection and diagnosis.59-68 In these years, they began to develop other detection techniques. Some showed doubtful efficacy, such as the Rorschach test,35,69 electroencephalograms69 or drug use24,70-72 – a technique already used in the mid-nineteenth century.-43 Meanwhile, scientific psychology achieved better results. Hunt and Older65 pointed out the possibility of using a psychometric test with statistical reliability to compare malingering with the mentally weak. For their part, Meehl and Hathaway73 convinced of the need to differentiate between fakers and dissimulators, introduced several detection methods in the Minnesota Multiphasic Personality Inventory.74 In addition, different authors began to evaluate suspected malingering in controlled trial investigations with objective indicators. 65,75-78 In the following years, the three fundamental areas of research in malingering detection were consolidated: detection rates, controlled trial and statistical methodology.79 Detection rates were developed by using strategies of implausibility of symptoms and amplification of reported symptoms.80 On the other hand, controlled trial, which had been developed in the middle of the 20th century, were confirmed in the 90s81-85 and consolidated at the beginning of the 21st century through the use of specific designs for the detection of malingering, such as analogue groups,86-90 known groups,91 bootstrapping comparisons84,92 and differential prevalence.93 Finally, the statistical methodology applied to the detection of malingering, focused on three types of data analysis:79 the classification precision by analyzing the area under the curve or ROC curves, correlations with other indicators and the analysis of statistically significant differences in between groups by means of ANOVAs or MANOVAs including the size of the effect. In conclusion, the precision in malingering detection improved from the Modern Age, was enhanced during Contemporary times and completed with empirically validated procedures in the late 20th Century and early 21st. However, we must not forget that this methodology is not exempt from error and may also lead to the creation of controversies by using the malingering
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