¿Es la simulación de trastorno mental en militares un diagnóstico estereotipado? Sanid. mil. 2019; 75(3) 151 In conclusion, it could be said that, in contrast to decisions based on scientific evidence, in the past, decisions were made under the influence of stereotypes and stigma since health professionals are not exempt from stigma towards mental problems, 111,123 especially when decisions are made under pressure from the chain of command7 in the face of a manpower crisis due to casualties in combat13,45 and with the endorsement of some professionals13-15. Thus, psychological problems of the soldiers became easily associated with weakness, cowardice or malingering9 12. To a greater or lesser extent, this double stigma persists nowadays in the military, just as the criterion of suspected malingering specific to the military is still maintained in the main psychiatric classification manuals and in the forensic perspective. Prevalence of malingering mental problems in the military The study of the prevalence of malingering is complex and controversial. First, because fakers actively seek not to be detected, which makes it difficult or impossible to know their real incidence. 124 Second, the diagnostic criteria that operationally define malingering in the manuals has been recently established125 but are still limited and not reliable as a detection method, because they can easily lead to create false positives126. Third, clinicians are reluctant to make favourable malingering reports127 because a large number of diagnoses must be discarded before being diagnosed126, or a misclassification of malingering can lead to the stigmatization and subsequent disqualification from receiving adequate treatments25 or because by labelling someone as a malinger, clinicians face the possibility of being sued for defamation and even be physically assaulted127. Fourth, because the expectation of finding this pattern is more common in the forensic area than among clinicians, although this is not always true10,124,130-133, causing professionals who evaluate psychopathology in non-forensic contexts to ignore it. Fifth, because malingering presents a variable rate depending on the context analyzed.131,134 Finally, because it is a complex evaluation pattern that requires its own methods and empirically validated strategies, for which not all professionals who evaluate mental health are trained. Despite the above, as has frequently been pointed out, military malingering is rare. For instance, alleged self-mutilations for the avoidance of conscription in Napoleon’s army, in fact, were accidents due to inexperience7. More examples are found among soldiers of the Soviet Union,135 the First World War or interwar period56,134-139, in the Spanish Civil War2, in both soldiers10 and sailors142 of the United States in World War II and in Vietnam143, whose psychological problems were considered faked but, in reality, were true. Recent studies of the military population reflect this same reality. Lande and Williams10 conclude that, of the 28,065,568 visits made by the US military to health centres, between 2006 and 2011, only 985 (1·074) were malingering and factitious cases. In another study132 of active duty servicemen in the United States, which analyzed the incidence of malingering over 15 years (from 1998 to 2012), an incidence of 4·456 primary diagnoses is reflected (annual rate of 2·08 cases per 10,000 military personnel) and 2·308 secondary diagnoses (annual rate of 1·08 per 10,000 military personnel). Of these, only 164 primary diagnoses (0·08 x 10,000) and 65 secondary diagnoses (0·03 x 10,000), also including factitious disorder, occurred during deployments. From the point of view of Military Justice, the crime of malingering or voluntary disablement in Spanish soldiers was recorded seven times, between 2000 and 2016, out of a total of 4.089 military crimes144. Even when military service was compulsory in Spain, for example, between 1976 and 1986, there were only 9 cases out of a total of 6.286 crimes145. On the other hand, from the point of view of the Military Health, conclusive data cannot be extracted because the professionals who evaluate mental health in the military – even in forensic contexts – do not evaluate within the legal sphere146, so it is very difficult to classify a soldier with a malingering mental disorder code. For example, in Spain, the Psychiatric Expert Medical Board (PEMB – that evaluates the veracity, causes and consequences of mental disorders of the Spanish military) determined that between 2000 and 2018 there were approximately 400 military personnel out of a total of 2.040 that were classified as «useful and fit» (information provided by the PEMB). Therefore, all that is known, on the one hand, is the number of soldiers who are discharged for an objectively demonstrated mental disorder and, on the other, those who, after a period of medical leave, return to service. When countries have a mandatory recruitment system, the estimated malingering rate is between 5% and 25%147. For example, Vetter et al.91 found a rate of 4·72% in recruitment phases in the Swiss army in 2003 and Iancu et al146. recorded 25% in soldiers requiring health services in the Israeli army. But none of the instruments used by both studies have high specificity149 and neither have reliable malingering detection scales. In particular, PST scale (from SCL-90-R) is made with the number of items rated higher than zero, so it is an exaggeration scale of multiple symptoms. But exaggeration is not equivalent to fake bad. In fact, exaggeration may be due to many reasons, such as, anguish towards the evaluation itself, distrust in showing real psychopathology, (doubting if it willbe enough to require a sick leave or help), or hopelessness before the circumstance to which they are subjected (compulsory conscription). On the other hand, the criteria for suspicion of malingering on which Iauncu et al.148 were based -inconsistencies, extravagant complaints, exaggeration of symptoms and secondary gain-, are stereotyped clues. Against intuition, different authors have pointed out that recognition of lies is not a simple task for evaluators134,150 153 and, also, signals such as exaggeration or inconsistencies, taken alone, do not necessarily imply malingering133,154,155 nor the existence of a genuine disorder156. It seems obvious that the type of recruitment (mandatory or voluntary) is a variable to be considered by the evaluators, but this should not lead to identifying more suspects when compulsory conscripsts, because this would not be a helpful criterion when making an empirical and fair decision, however, it could lead to making stereotyped decisions. CONCLUSION Even though the incidence of malingering in the military is unknown157, some authors indicate very low rates. In addition, studies find high malingering rates in different civil contexts158-165.
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