¿Es la simulación de trastorno mental en militares un diagnóstico estereotipado?

García Silgo, M.; García Silgo, M.

doi:10.4321/s1887-85712019000300004

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Sanidad Militar

versão impressa ISSN 1887-8571

Sanid. Mil. vol.75 no.3 Madrid Jul./Set. 2019 Epub 20-Jan-2020

https://dx.doi.org/10.4321/s1887-85712019000300004

REVIEW

Is malingering mental disorder a stereotyped diagnosis in the military?

M. García Silgo¹

^¹Capitán Psicólogo. Doctora en Psicología. Inspección General de Sanidad de la Defensa (España).

ABSTRACT

From the beginning of Western culture, malingering mental problems has been described as a method used to avoid military recruitment or escape from war. For centuries, the association between malingering and the military has persisted, creating in the 20th century a specific criterion in the main manuals of psychiatric classification, albeit having no objective evidence to support members of the military as more prone to malinger than other professionals. Is the diagnosis of malingering mental disorder stereotyped in the military?

Objective:

To reflect on whether or not the current classification of malingering mental disorder is based on scientific evidence.

Method:

After carrying out bibliographical searches the following constructs were analysed: the historical evolution of the concept, the methodology of its detection, the consequences suffered by the military when they were labelled as malingerers. Finally, prevalence studies were examined.

Results:

Military contexts do not present high rates of malingering nowadays and yet it seems that malingering-military stereotype remains in the forensic perspective.

Conclusion:

There is no empirical justification to include a specific malingering criterion for military personnel in psychiatric diagnosis manuals. However, this criterion contributes to stigmatizing military personnel who present real psychological problems. In addition, it encourages dissimulation or faking good. Hopefully, the present article will help include psychosocial factors in the biological model of malingering, fight against double stigma associated with mental problems in the military, dignify the invisible wounds of war and restore the honour of those who have been condemned or executed in the past for suffering mental disorders.

KEYWORDS: Malingering; military; double stigma; mental disorder diagnosis; dissimulation

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 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.

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 tag (see the Madigan Army Medical Center controversy or the Brannan vs. Humphrey controversy in Weiss & Van Dell⁹⁴).

The consequences of being suspected of malingering in the military

Reflecting on malingering in military contexts requires, necessarily, including the consequences of being labelled as a faker. Because, regardless of whether the armies were voluntary, or forced, or whether or not there were better detection methods for malingering, the truth is that those in the military have been treated unfavourably when, supposedly, were faking. Persecution and severe punishment of malingering in the military have been constant throughout History. For example,² in Sparta, soldiers were condemned with capital punishment until Charondas imposed public shaming, like exposing them dressed as women. On the other hand, Augustus sold them as slaves and, in the reigns of the emperors Constantine, Valens and Valentinian, they were marked with a red iron, without prejudice of being used later as soldiers. Later, in the Crusades, a spinning wheel and a spindle (as feminine symbols) were hung from their clothes. In the Modern Age, in particular, in Spain from 1730 to 1789, the so-called «lazy» were forced into regiments of veterans who were later sent to Italy, North Africa or the Indies⁹⁵.

As for the most severe punishment that could be applied for supposed malingers - execution - used since the Ancient Age, it remained in force in the Napoleonic army,⁷ in the Great War on the British front¹²^,¹³ and in the Second World War in the Unified Armed Forces of Nazi Germany¹¹ and in the United States.¹⁰ Only four years ago (on 13 January 2015), in the United States, a former Vietnam veteran was executed for committing a crime in 1998 under the influence of mental problems that, according to Weiss and Van Dell⁹⁴, were trivialized and classified as malingering during the trial.

The penalties now received by the military are, fundamentally, deprivation of liberty. In Spain, for example, malingering illness or an injury or causing injury to oneself or another with the aim of exempting oneself from service or duty are crimes against the duties of the service (Articles 52 and 59 of the Military Penal Code, MPC). Malingering is also contemplated in the MPC (Article 55) by means of falsification of documents (such as providing forged medical documents or with modified dates). The minimum punishment is from six months to three years and, the maximum, from four to ten years, depending on the national situation (times of peace, armed conflict, state of siege or critical circumstances). Other crimes related to malingering in the military are abandonment of destination or residence (Article 56), desertion (Article 57) and the special breach of the duty of presence (Article 58). In these cases, malingering could appear after the crime, either to justify the criminal behaviour, or to avoid the penalty of imprisonment.

The attempt of suicide could also be a crime if its intent is to avoid service (Article 59) because it is interpreted as disloyalty. In the United States of America, the Uniform Code of Military Justice punishes malingering and attempted suicide in Article 115. In addition, if the attempt of malingering - or suicide - could harm order and discipline, the interpretation would fall under Article 134. An example of this⁹⁶ is the case of a US soldier who had returned from Saudi Arabia four months previously, when he was redeployed for six months in South Korea. The soldier made a suicide attempt by ingesting twenty pills of Benadryl^®. His superior, worried about the morale of his battalion if this soldier was allowed to «just go home», consulted with the Military Justice and charges by both Articles 134 and 115 were brought against him. The soldier was found hanged in his room the day before the war council hearing.

The double stigma

Given the suspicion of malingering, there is another punishment that is not regulated by the Military Justice but by organizational variables in the culture and climate of the armies, such as stigma (understood according to Crocker, Major & Steele,⁹⁷ Goffman,⁹⁸ Jones et al⁹⁹. and Link and Phelan¹⁰⁰) associated with real mental problems (in line with: Corrigan,¹⁰¹ Corrigan & Kleinlein,¹⁰² Mak, Poon, Pun & Cheung¹⁰³ and Pascoe & Smart Richman¹⁰⁴) or with the supposedly malingered ones²³^,²⁴^,¹⁰⁵^,¹⁰⁶ in military contexts.²¹^,²²^,¹⁰⁷^,¹⁰⁸ The fear of the effects of stigma for supposed rejection and the negative impact on the military career has been found in militaries from Israel,¹⁰⁹ Germany,¹⁰⁶ the United States,²¹^,²² the United Kingdom¹¹⁰ and Canada¹¹¹^,¹¹².

In military culture, mental problems are synonymous of weakness²²^,¹⁰⁶^,¹¹³ and suspected malingering²³^,²⁴^,¹⁰⁶ in equal parts, and can even lead to derogatory labels such as⁹⁴ shirker, slacker, idler, layabout, dead-beat, gold brick,⁹⁴ scum, or, in Spanish, «jeta».¹¹⁴ An example of the effects of stigma on soldiers in times of war is the episode known as The Slapping Incident, which occurred in the Campaign of Sicily in August 1943, between General George S. Patton and two soldiers. The double stigma, therefore, leads a member of the military with real psychological problems to have as much fear of being perceived as a malinger (shirker, slacker, idler, layabout, dead-beat, gold brick) as to be perceived as weak, since both labels are equally pejorative, going against the moral principles of military culture.

Approximately 60% of the military who experience mental health problems do not seek help¹¹⁶, so they will be forced to disguise their disorder (understood in line with Baer, Rinaldo & Berry¹¹⁷ and Paulhus¹¹⁸. Although the incidence of dissimulation of psychopathology in the military environment is unknown, its use is frequent to avoid the stigma that accompanies the diagnosis of mental disorder with the corresponding negative impact on the career.¹¹⁹ Although some authors have drawn attention to the importance of contemplating dissimulation in the military³⁶^,⁶⁵^,⁶⁶^,⁶⁸^,¹¹⁹^-¹²¹ all efforts were always directed to detecting malingering. However, concealment can also lead to serious negative consequences for the soldier, his/her unit, his/her family, and even, his/her country. For instance, on March 11^th 2012 in Afghanistan, NCO Robert Bales murdered 17 Afghan civilians, including nine children, four women and three men, and wounded six others. This fact, known in the media as the Kandahar Massacre, has been explained, among others, as a problem of dissimulation and stigma¹²². Therefore, the phenomenon of dissimulation caused by the fear of double stigma should not be left out of the debate.

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 al.¹⁴⁶ 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. Yet, the diagnostic criterion of being a member of the military is still included in the main psychiatric classification manuals when there is no other occupation or profession tagged as suspected of malingering.

Although prevalence studies in other contexts indicate higher rates of malingering than in the military, the criterion of being in the military remains a reason for suspicion in the diagnostic manuals. Why aren’t other occupations like teachers, lawyers, policemen, firemen, electricians, waiters, etc. not suspected of malingering so as not to be included among the criteria of suspicion? Why is this suspicion only attributed to military personnel? Who benefited from this criterion when it was included and why is it still maintained? Is there any fear about eliminating it? What is the relationship between, on the one hand, the invention of Post Traumatic Stress Disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders³⁷ together with the inclusion, the same year and in this same manual, the criterion of being military in the diagnosis of malingering and, on the other hand, the Vietnam war veterans of the United States? Could the presence of this criterion really encourage defeatism in times of low morals?

It seems that suspected malingering is not related to occupation or profession, but to the complexity of the biopsychosocial context in which the person finds him or herself. While the criteria for suspected malingering continue to be based on a stereotyped criminological model and not on empirical criteria, these criteria will continue to promote stereotypes and stigma, which does not help to reduce the fear of double stigma associated with mental health problems in the military population.

Judicial decisions about mental illness have sometimes been criticized for their simplicity. However, Finkel and Handel¹⁶⁶ showed that the simplicity did not reside with the judges, but in the medical tests with which they had to decide. Even now that experts have empirical evaluation procedures, psychodiagnosis remains a delicate task. Thus, nowadays there are validated instruments, there is some recognition to the stigma associated with mental problems and there is independence between mental health professional and the chain of command. All that remains is to develop and validate a biopsychosocial model of mental health problems and malingering separate from the illness model, as proposed, by Wade and Halligan⁴⁶ and Bass and Halligan⁴⁷. This model would be broad enough to differentiate between contexts and include a wide range of psychosocial variables, in which no occupation or profession should be stereotyped.

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Received: March 21, 2019; Accepted: June 25, 2019