Article

Journal of Interpersonal Violence

Recalled Peritraumatic 26(11) 21862210

The Author(s) 2011
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DOI: 10.1177/0886260510383032
Reported PTSD, and http://jiv.sagepub.com

the Impact of
Malingering and
Fantasy Proneness
in Victims of
Interpersonal
Violence Who Have
Applied for State
Compensation

Maarten Kunst1, Frans Willem Winkel2,

and Stefan Bogaerts2

Abstract
The present study explores the associations between three types of peri-
traumatic reactions (dissociation, distress, and tonic immobility) and post-
traumatic stress disorder (PTSD) symptoms in a sample of 125 victims of
interpersonal violence who had applied for compensation with the Dutch
Victim Compensation Fund (DCVF). In addition, the confounding roles of
malingering and fantasy proneness are examined. Results indicate that tonic

1
Institute for Criminal Law & Criminology, Faculty of Law, Leiden University, The Netherlands
2
International Victimology Institute Tilburg, Faculty of Law, Tilburg University, The Netherlands

Corresponding Author:
Maarten Kunst, Institute for Criminal Law & Criminology, Faculty of Law, Leiden University,
The Netherlands, Building Kamerling Onnes, Room C1.23, P.O. Box 9520, 2300 RA Leiden,
The Netherlands
E-mail: m.j.j.kunst@law.leidenuniv.nl
Kunst et al. 2187

immobility did not predict PTSD symptom levels when adjusting for other
forms of peritraumatic reactions, whereas peritraumatic dissociation and
distress did. However, after the effects of malingering and fantasy proneness
had been controlled for, malingering is the only factor associated with increased
PTSD symptomatology. Implications for policy practice as well as study
strengths and limitations are discussed.

Keywords
interpersonal violence, recalled peritraumatic reactions, PTSD symptoms,
malingering, fantasy proneness

Introduction
Posttraumatic stress disorder (PTSD) appears to be a common disorder in
victims of interpersonal violence who seek compensation from the state for
the damages they suffered, though determinants of PTSD in this specific
subgroup of victims have only recently become subject of empirical study
(e.g., Kunst, Winkel, & Bogaerts, 2010).
Many times the emergence of PTSD and PTSD symptomatology has
been suggested to result from intense peritraumatic reactions. Several meta-
analyses and systematic reviews indicate that peritraumatic dissociation,
which involves the separation of the self from the psychic and physical pain
associated with exposure to traumatic events (Spiegel, 1991), is a strong cor-
relate of PTSD (Breh & Seidler, 2007; Lensvelt-Mulders et al., 2008; Ozer,
Best, Lipsey, & Weiss, 2003; Van der Hart, Van Ochten, Van Son, Steele, &
Lensvelt-Mulders, 2008).
Two distinct but related types of reactions that may occur during or
immediately after trauma exposure are peritraumatic distress and peritrau-
matic tonic immobility. Peritraumatic distress refers to the severity of ini-
tial fear, helplessness, and horror required to fulfill the DSM-IV A2
criterion (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.,
text rev., American Psychiatric Association [APA], 2000; Brunet et al.,
2001), whereas peritraumatic tonic immobility may be considered as the
ultimate response in a series of defense reflexes (i.e., freeze, flight, fight,
tonic immobility1) observed among many animal species [and humans2]
that are elicited by circumstances involving imminent mortal danger where
escape is impossible (Humphreys, Sauder, Martin, & Marx, 2010, p. 359).
An elaborate description of this process is provided by Ratners defensive
2188 Journal of Interpersonal Violence 26(11)

distance model (1967). According to this model, prey organisms cease all
body movements once a predator has been detected. This freeze response
prepares them to action. If the proximity of the predator increases, a mixture
of defense reflexes will be set into motion. Initially, most preys will attempt
to escape from the approaching threat and will not fight or resist until fleeing
has proven to be unsuccessful. Tonic immobility is an autonomic outcome of
successive failures in both responses or when neither fleeing nor fighting is
deemed appropriate (Gallup, 1977). Contrary to peritraumatic dissociation
and distress, tonic immobility is primarily a physical state that is character-
ized by motionless body posture and unresponsiveness to painful stimuli
(Gallup & Rager, 1996; Marx, Forsyth, Gallup, Fus, & Lexington, 2008).3
During a state of tonic immobility, the organism involved is hyperaltert and
prepared to flee in a moment of opportunity (Bracha, 2004). Just as dissocia-
tion, both peritraumatic distress (e.g., Birmes, Brunet, Coppin-Calmes et al.,
2005) and tonic immobility (e.g., Heidt, Marx, & Forsyth, 2005) have been
found to be highly predictive of PTSD. This is not an irrefutable finding,
given that many previous studies relied on retrospective data and, therefore,
may have been susceptible to varying types of self-report biases.
The nature of the interrelationships between different types of peritrau-
matic reactions in predicting PTSD remains subject of ongoing debate (e.g.,
Bryant, 2007). In line with Janets (1907) classic theoretical conceptualiza-
tion of dissociation, several scholars have argued that peritraumatic dis-
sociation protects against overwhelming levels of peritraumatic stress
(e.g., Spiegel, Hunt, & Dondershine, 1988; Van der Kolk & Van der Hardt,
1989), but prevents adequate processing of trauma-related information.
Consequently, trauma representations are poorly integrated into autobio-
graphical memory and are likely to result in intrusions and flashbacks char-
acteristic of PTSD (e.g., Brewin, Dalgleish, & Joseph, 1996; Ehlers & Clark,
2000). Others have posited that peritraumatic dissociation is an epiphenom-
enon of peritraumatic distress that occurs in a subset of trauma victims who
experienced extreme levels of peritraumatic distress during trauma exposure
(e.g., Bernat, Ronfeldt, Calhoun, & Arias, 1998; Fikretoglu et al., 2006;
Friedman, 2000). Tonic immobility, on the other hand, has been suggested to
represent a behavioral or somatoform manifestation of peritraumatic disso-
ciation (Abrams, Hons, Carleton, Taylor, & Asmundson, 2009; Hagenaars,
Van Minnen, & Hoogduin, 2007). Conversely, some authors have argued
that peritraumatic dissociation entails a byproduct of peritraumatic tonic
immobility (Heidt et al., 2005). Finally, it has been argued that tonic immo-
bility operates as a mediator between peritraumatic distress and PTSD
Kunst et al. 2189

(Bovin, Jager-Hyman, Gold, Marx, & Sloan, 2008; Rocha-Rego et al., 2009).
However, many of these speculations require further empirical validation.
Given the aforementioned findings, the current study attempted to contrib-
ute to the state of the art in two ways. First, the independent associations
between the three discussed types of peritraumatic reactions and PTSD symp-
tom severity were studied. A substantial number of studies have examined the
predictive power of two of these constructs (e.g., Birmes et al., 2003; Bovin
et al., 2008; Dyb et al., 2008; Rizvi, Kaysen, Gutner, Griffin, & Resick, 2008)
and other risk factors for PTSD simultaneously, particularly initial symptoms
of PTSD (e.g., Hagenaars et al., 2007) and acute stress disorder (Bryant,
2003). However, previous research has never examined the predictive value
of peritraumatic dissociation, peritraumatic distress, and peritraumatic tonic
immobility concurrently. Unraveling their independent contributions is
important to determine whether these risk factors merely act as a proxy for
one another (Birmes, Brunet, Coppin-Calmes et al., 2005). A proxy risk
factor is a variable that is strongly correlated with a given outcome only
through its relationship with another variable that is highly correlated with
that outcome (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001).
Second, inspired by the discussion in Candel and Merckelbachs (2004)
critical review of studies into the relationship between peritraumatic disso-
ciation and PTSD, two sources of self-report bias were investigated as poten-
tial confounders in the link between recalled peritraumatic reactions and
current PTSD symptom severity: malingering and fantasy proneness.
Malingering has been formally defined in the revised fourth edition of the
DSM-IV-TR as the intentional production of false or grossly exaggerated
physical or psychological symptoms, motivated by external incentives such
as avoiding military duty, avoiding work, obtaining financial compensation,
evading criminal prosecution, or obtaining drugs (p. 739) and should be
ruled out in those situations in which financial remuneration, benefit eligibil-
ity, and forensic determinations play a role (p. 467). Rosen (2006) also
advocated the routine assessment of malingering in empirical studies that
include participants who seek compensation.
The core problem in malingering research is that no reliable methods are
available to detect malingering. Tests developed to measure malingering
typically infer malingering from test scores above a predetermined cutoff
score. Three designs have been used in previous studies to establish cutoff
scores: (1) (quasi-)experimental simulations, (2) known-groups comparisons,
and (3) differential prevalence designs. All these designs suffer from serious
methodological limitations. Simulation studies typically administer vignettes
that instruct study participants to fill out self-report questionnaires as if they
2190 Journal of Interpersonal Violence 26(11)

were malingering and then compare their scores to those in a nonsimulating

control group (e.g., Rogers & Cruise, 1998). A large disadvantage of simula-
tion designs is that they lack external validity (Guriel & Fremouw, 2003).
Known-group comparisons look for differences in symptom response levels
between known malingerers and those of whom it is known that they have the
disorder under investigation (Hall & Hall, 2006). An advantage of this
method over simulation is that it provides better external validity than a simu-
lation design. The weakest methodology is used by differential prevalence
designs. Such studies compare groups presumed to differ symptom ratings,
such as war veterans who seek PTSD-related compensation and those who
dont (e.g., Fontana & Rosenheck, 1998; Frueh et al., 2003; Frueh, Gold, &
De Arellano, 1997; Frueh, Smith, & Barker, 1996; Gold & Frueh, 1999). The
biggest problem, however, is that none of these methods can be used to be
absolutely sure whether participants in the supposed malingering condition
were actually malingering or not. Consequently, cutoffs for malingering can-
not reliably distinguish malingering from feigning symptoms among people
not motivated by financial interests or other external motives, such as those
with factitious disorders, hysterical pathology (e.g., Guriel & Fremouw,
2003; Rogers, Jackson, & Kaminski, 2005; Rosen, 2006; Rosen & Taylor,
2007; Taylor, Frueh, & Asmundson, 2007; Vitacco, Rogers, Gabel, &
Munizza, 2007), and those otherwise not malingering (e.g., Vrij, 2000, 2008;
Vrij & Mann, 2003). Finally, it cannot be excluded that that extreme symp-
tom scores are characteristic of PTSD (see Elhai, Gold, Frueh, & Gold, 2000;
Elhai, Gold, Sellers, & Dorfman, 2001). Participants test scores thus provide
an indication of possible or probable malingering at best.
The second potential confounderfantasy pronenesshas been suggested
to covary with malingering (Merckelbach & Smith, 2003) but conceptually
differs from malingering in that it is not influenced by external motives.
Rather, it is a personality trait that involves the nondeliberate tendency to
become engaged in imagination (Lynn & Rhue, 1988) and to give exaggerated
interpretations of ambiguous perceptions or sensations (Candel & Merckelbach,
2004; Spanos, Cross, Dickson, & DuBreuil, 1993). It has been suggested to
bias retrospective reports of peritraumatic reactions (Candel & Merckelbach,
2004; McNally, Clancy, Schacter, & Pitman, 2000; Merckelbach, Muris,
Horselenberg, & Stougie, 2000). Thus, scholars studying the associations
between peritraumatic reactions and PTSD symptom severity in individuals
involved in claim settlement should adjust for the potentially confounding
effects of both malingering and fantasy proneness (see Candel & Merckelbach,
2004). However, to date, previous studies have failed to do so.
Kunst et al. 2191

In sum, the first purpose of the current study was to explore the relative
contributions of recollections of peritraumatic dissociation, distress, and
tonic immobility in the explanation of current PTSD symptom severity in
victims of interpersonal violence who had sought state compensation. Based
on the literature, we expected that each type of peritraumatic reactions would
be associated with PTSD symptom severity in bivariate analyses. We did not
have any expectations about their relative contributions to PTSD symptom
severity in multivariate analyses, because they have never been investigated
concurrently in previous research. The second purpose was to determine
whether associations between peritraumatic reactions and posttraumatic
stress levels were confounded by malingering and fantasy proneness. As this
topic has been neglected too, we did not have any prior expectations in this
regard either.

Methods
Procedure and Participants

The current study was part of a larger study into the psychosocial aftermath
of violent victimization (see also Kunst, Bogaerts, Wilthagen, & Winkel,
2010; Kunst et al., 2010). Participants had claimed financial compensation
from the Dutch Victim Compensation Fund (DVCF) between January 1 and
December 31, 2006. Recruitment took place among those who had partici-
pated in a previous study in May-June 2008 (see Kunst et al., 2010) and had
agreed to fill out an additional set of questionnaires (n = 203). The follow-up
survey was sent to them by mail in the first week of February 2009. A total
of 128 victims (63.1%) responded. Three respondents were excluded from
statistical analyses, for they had too many missing values on any of the scales
included in the questionnaire to allow two-way imputation of missing data
(i.e., <60% completed).
As the author availed of information on age, gender, time elapse since
victimization (in years), type of violence (sexual violence, severe physical
assault, moderate physical assault, theft with violence, and other4), and level
of compensation for pain and suffering for victims who had filed a claim with
the DVCF in 2006,5 the representativeness of the study sample with regard to
these background variables could be assessed. Study participants were more
often females (79/125, 63.2% vs. 1,755/3,596, 48.8%; p < .01) and substan-
tially older (M = 48.34, SD = 15.30 vs. M = 40.82, SD = 15.53; p < .001)
than applicants who did not participate in the study. They also had
2192 Journal of Interpersonal Violence 26(11)

experienced severe physical assault less often than nonparticipants (7/125,

5.6% vs. 408/3,596, 11.3%; p < .05) and had received higher levels of
compensation for pain and suffering (M = 2.42, SD = 1.85 vs. M = 2.01,
SD = 1.83, p < .025). No differences between participants and nonpartici-
pants were observed for time since victimization (M = 6.72 years, SD = 5.03
vs. 5.28 years, SD = 3.55; p = ns), the number of sexual violence acts (19/125,
15.2% vs. 451/3596, 12.5%), moderate physical assaults (34/125, 27.2% vs.
1214/3596, 33.8%), thefts with violence (40/125, 32% vs. 899/3596, 25.0%),
and other types of violence (25/125, 20% vs. 624/3596, 17.4%).
Furthermore, participants personal files were checked by hand to compute
the number of material losses they had claimed with the DVCF. Material
losses may include costs for medical assistance, (psycho)therapy, dental assis-
tance, hospital stay, medical aids/prostheses, special dietary requirements,
home help, diminished income due to work disability, study delay, change of
address or installation of home security, travel and transport costs, legal assis-
tance, clothing, telephone and postage costs, and other costs (Schadefonds
Geweldsmisdrijven, 2007). This variable was created to serve as a global indi-
cator of participants interest in financial compensation. On average, victims
had claimed 2.77 (SD = 2.34) types of material losses. Approval for the study
was obtained from the DVCF Committee.

Measures
Peritraumatic Reactions
Peritraumatic dissociations. The Dutch translation of the Peritraumatic Dis-
sociative Experiences Questionnaire-10 Self-Report Version (PDEQ-10
SRV; Kleber & Van der Hart, 1998; Marmar, Weiss, & Metzler, 1997) was
used to measure peritraumatic dissociation. Its items are to be completed on
a 5-point Likert-type scale (1 = not at all true, 2 = slightly true, 3 = somewhat
true, 4 = very true, 5 = extremely true). Factor analytic research on the
Dutch PDEQ-10 SRV suggests that it represents a unidimensional construct
(Van der Velden et al., 2006). The PDEQ-10 SRV appears to be a psycho-
metrically sound research instrument, with satisfactory internal consistency
and testretest reliability and moderate to strong convergent validity (e.g.,
Birmes, Brunet, Benoit et al., 2005). In the current study, internal consistency
reliability of the PDEQ was Cronbachs = .90.
Peritraumatic distress. A Dutch translation of the 13-item Peritraumatic
Distress Inventory (PDI; Brunet et al., 2001; Kunst et al., 2010) was used
to record peritraumatic distress. The PDI uses a 5-point Likert-type scale
Kunst et al. 2193

(0 = not at all, 1 = slightly, 2 = somewhat, 3 = very true, 4 = extremely true).

The psychometric properties of the PDI have been investigated in a sample of
police officers exposed to critical incidents, which included both victims of
physical and sexual assault. The PDI has been found to be internally consis-
tent, with good testretest reliability and good convergent and divergent
validity (Brunet et al., 2001). Brunet et al. suggest the existence of a 2-factor
structure, yet most previous studies have used the PDI as a unidimensional
construct (e.g., Birmes, Brunet, Coppin-Calmes et al., 2005; Fikretoglu et al.,
2006). In the current study, internal consistency reliability of the PDI was
Cronbachs = .86.
Peritraumatic tonic immobility. The Tonic Immobility ScaleAdult Form
(TIS-A; Forsyth, Marx, Fus, Heidt, & Gallup, 2000) was translated into
Dutch by the first author prior to administration. As several of its items have
large similarities with those of the PDEQ-10 SRV and the PDI, only items
pertaining to the motor aspects of tonic immobility (froze or felt paralyzed
during the event, unable to move though not restrained during the event,
and unable to call out or scream during the event) were used for statistical
analyses (see Rocha-Rego et al., 2009). The TIS is to be answered on a
7-point Likert-type scale (0-6). In the current study, internal consistency reli-
ability of the TIS motor scale was Cronbachs = .88.
Malingering. The Dutch version of Structured Inventory of Malingered
Symptomatology (SIMS; Merckelbach, Koeyvoets, Cima, & Nijman, 2001;
Smith, 1997; Smith & Burger, 1997) was used to screen for malingering.
The SIMS consists of 75 true/false items that measure malingered symp-
toms in 5 different areas (psychosis, amnesic disorders, neurological
impairment, affective disorders, and low intelligence). However, as its sub-
scales lack sufficient internal consistency reliability, the SIMS is particu-
larly suitable to be used as a unidimensional instrument. An advantage of
the SIMS is that it requires low reading ability and uses a paper-and-pencil
mode of administration (Smith, 2008). Candel and Merckelbach, (2004)
have suggested to use the SIMS as a screener for symptom overreporting
when investigating the association between peritraumatic dissociation and
PTSD. The SIMS has been administered among individuals with history of
childhood sexual abuse (Geraerts, Jelicic, & Merckelbach, 2006). SIMS
total scores of 17 or more indicate probable malingering (e.g., Merckelbach,
Koeyvoets et al., 2001; Rogers, Hinds, & Sewell, 1996). In the current
study, internal consistency reliability of the SIMS total score was Cronbachs
= .93.
2194 Journal of Interpersonal Violence 26(11)

Fantasy Proneness. The Dutch version of the Creative Experiences Ques-

tionnaire (CEQ; Merckelbach, Muris, Schmidt, Rassin, & Horselenberg,
1998) was used to evaluate fantasy proneness. The CEQ contains 25 yes/no
statements. The total number of yes answers needs to be summed to obtain
a score of fantasy proneness, with higher scores indicating higher levels of
fantasy proneness. The CEQ appears to have good psychometric properties
(Merckelbach, Horselenberg, & Muris, 2001). In the current study, internal
consistency reliability of the CEQ was Cronbachs = .80.
PTSD Symptom Severity. The Dutch version of the PTSD Symptom Scale,
Self-Report version (PSS-SR; Arntz, 1993; Foa, Riggs, Dancu, & Rothbaum,
1993) was used to measure PTSD symptom severity. The PSS-SR has been
used as a screening instrument for PTSD symptomatology among victims of
crime (e.g., Andrews, Brewin, Rose, & Kirk, 2000; Dunmore, Clark, &
Ehlers, 1999; Rose, Brewin, Andrews, & Kirk, 1999). For each of the 17
items, respondents had to indicate to what extent they have experienced the
corresponding symptom during the past week on a 4-point Likert-type scale
(0 = never, 1 = once, 2 = 2-4 times, 3 = 5 times or more). The psychometric
properties of the PSS-SR have been found to be satisfactory in crime victim
samples (Foa et al., 1993; Wohlfarth, Van den Brink, Winkel, & Ter Smitten,
2003). In the current study, internal consistency reliability of the PSS-SR was
Cronbachs = .95.

Statistical Analyses
Data management. Prior to analyzing the research questions, missing val-
ues were dealt with using two-way imputation. Two-way imputation first
calculates the overall mean (OM) of a certain scale across available scores,
the sample mean for item j (IM), and the mean for person i (PM), and then
imputes the missing value of respondent i on Item j by substracting OM from
the sum of PM and IM (Bernaards & Sijtsma, 2000). Two-way imputation is
useful when scales assess unidimensional psychological states or traits
(Sijtsma & Van der Ark, 2003; Van Ginkel & Van der Ark, 2008; Van
Ginkel, Van der Ark, & Sijtsma, 2007). As time since victimization and
SIMS total scores were highly positively skewed, a log transformation was
required to normalize their distribution (see Tabachnick & Fidell, 2007).
Information on participants number of material damages had to be dichoto-
mized by median number of damages claimed (low 2). All other variables
were reasonably normally distributed.
Kunst et al. 2195

Research questions. Means, standard deviations, and bivariate correlations

between variables of interest were calculated to describe the study sample. For
anecdotal purposes, the number of probable malingerers (i.e., total SIMS
scores 17) was computed. Next, to investigate the independent associations
between the different types of peritraumatic reactions and PTSD symptom
severity, several partial correlations were computed. In each analysis, the
correlation between one type of peritraumatic reactions and PTSD symptom
severity was calculated while adjusting for the other two. Subsequently, par-
tial correlations between peritraumatic reactions and PTSD symptom severity
were computed when controlling for total malingering and fantasy proneness
scores. Finally, a hierarchical multivariate regression analysis was conducted
to test whether the different types of peritraumatic reactions were indepen-
dently associated with PTSD symptom severity above and beyond back-
ground variables (age, gender, time since victimization, type of violence,
compensation level for pain and suffering, and the number of material dam-
age categories claimed) and to see whether model parameters would change
if total scores for malingering and fantasy proneness were controlled for.
Background variables were entered on Step 1. Peritraumatic dissociation,
distress, and tonic immobility were included in Step 2. In the final step, total
scores for malingering and fantasy proneness were added to the model. Prior
to analyses, data were checked for violations of assumptions (i.e., multicol-
linearity, outliers, normality, linearity, homoscedasticity, and independence
of residuals). Tolerance values were well above .2 for all variables, indicating
that multicollinearity was not an issue (Hutcheson & Sofroniou, 1999). Other
assumptions of regression analyses were not violated either. The alpha level
was set at .05 in all statistical tests. We did not adjust for multiple testing, as
this is not required for exploratory research (Bender & Lange, 2001). All
computations were performed using the software package SPSS 16.0 for
Windows (SPSS Inc., Chicago, Illinois).

Results
Sample characteristics are described in Appendix A, Table 1. The magni-
tude of the correlation coefficients between the three types of peritraumatic
reactions suggested that they were highly interconnected. As expected,
each type of peritraumatic reactions correlated substantially with PTSD
symptom severity. Total scores for malingering and fantasy proneness cor-
related with all measures of recalled peritraumatic reactions and current PTSD
symptom severity, indicating the appropriateness of examining their
2196 Journal of Interpersonal Violence 26(11)

confounding potential in subsequent analyses. A total of 23 (18.4%) par-

ticipants could be classified as probable malingerers. Partial correlation coef-
ficients revealed that the associations between peritraumatic dissociation
and PTSD symptom severity decreased in size from large to small after
adjusting for peritraumatic distress and tonic immobility (r = .24, p < .01).
The correlation between peritraumatic distress and PTSD symptom sever-
ity remained medium in size when partialing out participants peritrau-
matic dissociation and tonic immobility scores (r = .31, p < .001). The
correlation between peritraumatic tonic immobility and PTSD symptom
severity became slightly negative and no longer remained significant after
adjusting for peritraumatic dissociation and distress (r = .06, p = ns), pre-
liminarily indicating that peritraumatic tonic immobility is merely a proxy
for other types of peritraumatic reactions.
The coefficients for the correlations between peritraumatic reactions and
PTSD symptom severity substantially decreased after total scores for malin-
gering and fantasy proneness had been controlled for, providing initial sup-
port for the confounding role of these two factors. Each measure of
peritraumatic reactions remained correlated with PTSD symptom severity
though, with r = .35 (p < .001) for the partial correlation between peritrau-
matic dissociation and PTSD symptom severity, r = .32 (p < .001) for the
partial correlation between peritraumatic distress and PTSD symptom sever-
ity, and r = .22 (p < .025) for the partial correlation between peritraumatic
tonic immobility and PTSD symptom severity.
Finally, hierarchical multivariate regression analyses revealed that theft
with violence and compensation for pain and suffering were related to lower
and higher PTSD symptom severity in the first step, respectively. Peritraumatic
dissociation and peritraumatic distress predicted PTSD symptom severity
above and beyond background variables before total scores for malingering
and fantasy proneness were entered into the model. The association between
tonic immobility and PTSD again failed to reach significance. However, after
inclusion of total scores for malingering and fantasy proneness, neither peri-
traumatic dissociation nor peritraumatic distress remained significantly asso-
ciated with PTSD symptom severity. The total score for malingering was the
only predictor that was significantly associated with PTSD symptom severity
in the final regression step. Thus, the final model suggested that associations
between victims recollections of peritraumatic reactions in the context of
claim settlement were mainly due to participants scores on the SIMS. The
full model explained 57.1% of the variance in PTSD symptom severity
(Appendix B, Table. 2).
Kunst et al. 2197

Discussion
The current study explored the relationships between PTSD symptom sever-
ity and recollections of three types of peritraumatic reactions often discussed
in traumatic stress studies: peritraumatic dissociation, peritraumatic distress,
and peritraumatic tonic immobility. In addition, it intended to test whether
associations between peritraumatic responses and PTSD symptoms were
confounded by malingering and fantasy proneness, as was proposed by Candel
and Merckelbach, (2004).
Results indicated that tonic immobility functions as a proxy for peritrau-
matic dissociation and peritraumatic distress. Although the latter two
remained significantly associated with PTSD symptom severity when partici-
pants scores on other measures of peritraumatic reactions were controlled
for, the relationship between tonic immobility and PTSD symptom severity
failed to reach significance. Findings also suggested that malingering and
fantasy proneness may act as confounders in the associations between peri-
traumatic reactions and PTSD symptom levels. Total scores for malingering
and fantasy proneness correlated both with measures of peritraumatic reac-
tions and PTSD and accounted for a large part of their intercorrelations.
Multivariate analyses indicated that total scores for malingering were the
only predictor of PTSD symptom severity.
The failure to find significance for the association between peritrau-
matic tonic immobility and PTSD symptom severity prior to adjustment
for malingering and fantasy proneness total scores in the multivariate
model may not only have been due to concurrent levels of peritraumatic
dissociation and distress. Alternatively, it may also indicate that the
adverse impact of tonic immobility depends on conditions that adversely
affect the impact of tonic immobility on PTSD symptoms, but which were
not measured, such as (behavioral) self-blame and guilt for not fighting
back (see Heidt et al., 2005; Rizvi et al., 2008). Several studies have sug-
gested that self-blame is associated with persistent distress (e.g., Frazier,
2003; Koss, Figueredo, & Prince, 2002), and others have found that com-
plete immobility is predictive of later self-blame (Galliano, Noble, Travis,
& Puechl, 1993). These results provide reason to believe that tonic immo-
bility is only associated with increased symptom levels if it leads to self-
blame attributions. Unfortunately, the studys design prevented us from
dealing with this issue.
Although the number of participants who qualified for probable malinger-
ing according to their SIMS scores was rather low compared to several other
2198 Journal of Interpersonal Violence 26(11)

studies (e.g., Stevens, Friedel, Mehren, & Merten, 2008), the high correlations
observed between malingering total scores and measures of peritraumatic
distress and PTSD symptom severity suggest that victims reportings of past
and present psychological suffering may be biased by exaggeration or misat-
tribution of symptom levels, possibly driven by incentives to gain financial
compensation. To prevent inequality of justice between those with malinger-
ing symptoms and those without such symptoms, victim compensation funds
might consider screening for symptom overreporting when compensation for
PTSD is claimed (see Merckelbach, Koeyvoets et al., 2001). However, before
screening is introduced as a standard procedure, the psychometric properties
of existing measures of malingering need to be investigated in victims eligible
for state compensation. Preferably, this should be followed by the develop-
ment of a new screener suitable for quick administration during the application
process.
Several study limitations need to be mentioned when interpreting the
data. First, the cross-sectional nature of the study prevents determination
of cause and effect. Second, regression parameters may have been biased
due to unmeasured confounders, such as previously experienced trau-
matic events and the rather low number of participants in the study
(Tabachnick & Fidell, 2007). This cannot refute though that, according to
the rules of thumb provided by Green (1991), the data were able to detect
medium effect sizes. Third, the study largely relied on retrospective self-
report measures. Recollections of peritraumatic dissociation, distress, and
tonic immobility may have been affected by memory bias and misattribu-
tion. More precisely, those who do not suffer from high symptom levels
may simply have forgotten initial trauma reactions, whereas those who do
probably ascribe their current state of distress to past emotional states
(e.g., Candel & Merckelbach, 2004). Fourth, the psychometric properties
of our tonic immobility scale are unknown. Fifth, the SIMS is merely a
general self-report measure of malingering rather than a specific symp-
tom validity test for PTSD, such as the Morel Emotional Numbing Test
for PTSD (Morel, 1995, 1998) and the Miller Forensic Assessment of
Symptoms Test (Miller, 2001). However, this was not deemed problem-
atic, because SIMS scores were primarily used to be entered as continu-
ous covariates in statistical analyses and not to differentiate between
malingerers and nonmalingerers. Sixth, since all participants had com-
pleted the application procedure with the DVCF prior to study entry, their
responses may no longer have been biased by their motivation to gain
financial compensation. We do not consider this to be very likely though,
Kunst et al. 2199

since potential participants were approached through the DVCF and not
directly by the authors themselves. Thus, they still may have felt an urge
to report consistent with previous symptom reports. In addition, previous
research has shown that malingering remains present after completion of
compensation procedures (e.g., Nicholson & Martelli, 2007). Seventh, we
do not know whether participants SIMS scores were indicative of their
tendency to malinger or not. In the introduction it was explained that all
measures of malingering suffer from this shortcoming. We attempted to
partly overcome this issue by adjusting for fantasy proneness and the num-
ber of losses claimed with the DVCF. The former has been suggested to
confound the relationship between measures of malingering and symptom
severity (Candel & Merckelbach, 2004). The latter may be assumed to be
indicative of participants interest in compensation. Eighth, due to the fact
that participants were recruited among respondents to a previous study, the
study sample may not have been representative of the general population
of victims applying for state compensation with the DVCF. Of particular
relevance in this respect is that study participants differed in age from
nonparticipants, whereas no difference was observed on time since victim-
ization. This indicates that participants were older than nonparticipants at
the time of victimization. Consequently, the average age difference
between victim and perpetrator for participants is likely to be smaller than
for nonparticipants. If so, tonic immobility scores in our sample may have
been lower than that in the general population of DVCF applicants, because
previous research indicates that the age difference between perpetrator and
victim is positively associated with tonic immobility (Heidt et al., 2005).
Despite these limitations, the current study was the first to investigate the
contributions of peritraumatic dissociation, distress, and tonic immobility to
PTSD symptom severity simultaneously and to account for the potentially
confounding influences of malingering and fantasy proneness in a sample of
victims of violence with a history of compensation seeking. Future studies
should particularly consider prospective investigation of defensive response
patterns in humans to determine under what conditions which peritraumatic
response prevails in the development of PTSD and other psychiatric disor-
ders. Studies focusing on malingering in victims should preferably employ a
longitudinal design that allows them to differentiate between victims who
claim compensation and those who dont and to assess symptom levels both
pre- and post-application for compensation.
2200 Journal of Interpersonal Violence 26(11)

Appendix A
Table 1. Means (M), Standard Deviations (SD), and Bivariate Correlations
(n = 125)

M SD 1 2 3 4 5 6
1.Peritraumatic 28.31 11.22 1.00
dissociation
2.Peritraumatic 28.90 11.87 0.71** 1.00
distress
3.Peritraumatic tonic 10.91 6.28 0.52** 0.61** 1.00
immobility
4. Malingering 0.87 0.37 0.41** 0.54** 0.24* 1.00
5. Fantasy proneness 6.04 4.06 0.41** 0.34** 0.25* 0.40** 1.00
6.PTSD symptom 14.47 14.04 0.54** 0.57** 0.34** 0.67** 0.43** 1.00
severity
Note: PTSD = posttraumatic stress disorder.Values for malingering represent log transformed
values.
*p < .01. **p < .001.

Appendix B
Table 2. Multivariate Regression Analysis Predicting Current PTSD Symptom
Severity

R2 change
B SE B (%)
Variables
Step 1 17.7**
Age 0.08 0.08 .09
Gender 4.77 2.73 .17
Time since victimization 11.98 6.39 .18
Sexual assault 0.49 4.25 .01
Moderate physical 4.28 3.30 .14
assault
Theft with violence 7.14 3.35 .24*
Compensation for pain 1.56 0.74 .21*
and suffering
MNMDC (2) 0.10 2.58 .00
Step 2 23.9***
Age 0.09 0.07 .09

(continued)
Kunst et al. 2201

Table 2. (continued)

R2 change
B SE B (%)
Gender 1.63 2.40 .06
Time since victimization 8.37 5.60 .12
Sexual assault 3.37 3.72 .09
Moderate physical 3.18 2.83 .10
assault
Theft with violence 3.00 2.92 .10
Compensation for pain 1.18 0.64 .16
and suffering
MNMDC (2) 1.42 2.22 .05
Peritraumatic dissociation 0.28 0.14 .23*
Peritraumatic distress 0.49 0.14 .42**
Peritraumatic tonic 0.08 0.14 .06
immobility
Step 3 15.5***
Age 0.02 0.06 .03
Gender 0.89 2.12 .03
Time since victimization 5.23 4.91 .08
Sexual assault 0.53 3.24 .01
Moderate physical 3.27 2.45 .10
Assault
Theft with violence 2.12 2.53 .07
Compensation for pain 0.79 0.56 .10
and suffering
MNMDC (2) 0.06 1.93 .00
Peritraumatic dissociation 0.20 0.13 .16
Peritraumatic distress 0.16 0.14 .14
Peritraumatic tonic 0.02 0.12 .02
immobility
Malingering 17.31 3.10 .45***
Fantasy proneness 0.36 0.25 .10

Note: Number of participants studied, n = 125. MNMDC = Median Number of Material

Damages Claimed; Tonic Immobility ScaleAdult Form (TIS-A). Gender is coded as male = 1
and female = 0.Values for time since victimization and malingering represent log-transformed
values. Additional analyses with TIS total scores included (i.e., with all items retained) did not
change results. Also note that severe physical assault could not be adjusted for due to the low
number of participants in this category (<10; Tabachnick & Fidell, 2007).
*p < .05. **p < .01. ***p < .001.
2202 Journal of Interpersonal Violence 26(11)

Acknowledgment

The authors thank the Dutch Victim Compensation Fund for its financial and organi-
zational support with the data collection.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the authorship
and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this
article.

Notes
1. Tonic Immobility.
2. To date, some anecdotal evidence exists regarding the occurrence of this defense
pattern in humans (e.g., Bradley, Codispoti, Cuthbert, & Lang, 2001; Cuthbert,
Bradley, & Lang, 1996; Schmidt, Richey, Zvolensky, & Maner, 2008).
3. Note that many studies interchangeably use the terms freezing and tonic immo-
bility, which is incorrect. Freezing refers to ceasement of movement in order to
enable consideration of possible defense strategies. Tonic immobility, on the other
hand, reflects an ultimate defense strategy when fighting and flighting have failed
to be successful (Marx, Forsyth, Gallup, Fus, & Lexington, 2008).
4. The DCVF (Dutch Victim Compensation Fund) categorizes type of violence
according to their legal classification used in the Dutch Penal Code (DPC). To
enable statistical testing, the number of different categories was reduced from
30 to 5 (see Kunst, Winkel, & Bogaerts, 2010). Severe and moderate physical
assault and theft with violence corresponded to the original file categorization.
Sexual violence included all individuals who had experienced an offence falling
under Book 2, Title XIV of the DPC. The remainder of the sample is a mixture of
offences that were too low in number to form a category of their own.
5. Compensation level for pain and suffering (ranging from 0 to 8) served as an indi-
cator of compensation for PTSD (posttraumatic stress disorder) symptomatology
and the total amount of compensation awarded (up to 22.700).

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2210 Journal of Interpersonal Violence 26(11)

Bios

Maarten Kunst, PhD, LLM, studied Criminal Law and Psychology and Mental
Health at Tilburg University, the Netherlands. In May 2010 he finished his PhD thesis
on the psychosocial consequences of violent victimization. Currently, he works as an
assistant professor in Criminology at Leiden University.

Frans Willem Winkel, PhD, LLM, is professor in victimological psychology at

Tilburg University. He is author and co-author of many journal articles and chapters
in edited volumes. His research focuses on victims of domestic violence.

Stefan Bogaerts, PhD, is professor in forensic psychology at Tilburg University. He

has published in many peer-reviewed journals and edited books. His research inter-
ests include a broad range of issues in forensics, psychology, and criminology.