Assessing symptom validity of PTSD in veterans
The PTSD diagnosis may help veterans obtain valuable rehabilitation resources that will aid them in their transition from military to civilian life. These resources may lead veterans to have direct (e.g. jail diversion programs) or indirect (e.g. compensation and disability evaluations) contact with the legal system. The ability of practitioners to validly diagnose PTSD is central to ensuring that resources go to the veterans who need them most.
Given the potential secondary gains in psycholegal settings, we cannot validly (or ethically) diagnose PTSD without assessing for the presence of overreporting (APA, 2000; Rogers & Bender, 2003). Yet, our current lack of understanding about the nature and practical implications of overreported PTSD among veterans impedes our ability to validly assess the diagnosis altogether. It also leaves this valuable diagnosis on tenuous legal ground via its potential inadmissibility under Frye and Daubert (Koch, O'Neill, & Douglas, 2005).
By elucidating the gaps in our empirical understanding of PTSD overreporting in veterans, this article seeks to illustrate the need to improve our ability to validly diagnose PTSD among veterans in psycholegal settings.
However, there is still disagreement about the prevalence of overreported PTSD in veterans. Some researchers have reported that symptom exaggeration is virtually non-existent and extremely rare (Lande & Williams, 2013; Marx, Miller, Sloan, Litz, Kaloupek, & Keane, 2008), while others have reported rates of approximately 20 to over 50 percent (Benjamin & Virginia, 2007; Freeman, Powell, Kimbrell, 2008; Frueh, Hamner, Cahil, Gold, & Hamlin, 2000). This lack of agreement suggests that the actual prevalence of PTSD overreporting among veterans is largely unknown. While concerning, this is not surprising given the current state-of-the-art of assessment for overreported PTSD; a review of which first requires an understanding of some contextual issues with which many veterans live.
The importance of context
Given the unknown prevalence of exaggerated PTSD among veterans, it is increasingly important that the methods used to evaluate PTSD in this group are considerate of the unique contextual issues common to the veteran experience. For instance, the presumption that Criterion A traumatic military events are based on "objective fact" and "easily corroborated" (First, 2010, p. 257) ignores the realities of government record keeping. For example, veterans may experience combat situations, such as witnessing a nearby explosion, without the event being recorded or the veteran being classified as being "in combat." Also, classified assignments may be sparsely documented given their sensitive nature. These problems with inaccurate or incomplete records may result in Criterion A events that are less objective and more difficult to corroborate than clinicians expect.
Another consideration is whether the reported symptoms actually stem from a Criterion A stressor that is "military" or "combat" in nature. Different stressors carry different stigma among veterans. Sexual trauma experienced during military service, for instance, may be perceived as more stigmatizing and more difficult to discuss than combat trauma (Weaver, Trafton, Walser, & Kimerling, 2007). Thus, a veteran's (even intentional) misattribution of symptoms from a sexual trauma to a combat trauma, a type of manipulation that Resnick (1997) referred to as "false imputation," does not negate the authenticity of the traumatic event or the subsequent symptoms. In fact, such reluctance to disclose the true traumatic event may support the diagnostic symptom of avoidance. Therefore, problems corroborating Criterion A events should be considered within the context of potential obfuscation stemming from a stigmatized trauma.
Additional considerations surround the challenges many veterans face in obtaining treatment. Media reports supported by data from the Department of Veterans Affairs (VA; e.g. Rabaino & Glantz, 2013) are full of stories about long wait times to receive services, with estimates ranging from an average of one to two years. In spite of the President's 2012 order to improve access to mental health services for veterans (White House, 2012), the VA's previous practices would presumably influence current resource-seeking veterans. For example, it has been suggested that a veteran's perception of the system as slow or unresponsive may lead him/her to exaggerate symptoms (Lande & Williams, 2013). Paradoxically, veterans may also overreport as a way to combat perceptions that assessing clinicians question the validity of their symptoms (Mossman, 1996; Sayer & Thuras, 2002). Although this type of exaggeration has been described as "partial malingering" (Resnick, 1997), these contextual issues suggest that it may be more appropriate to conceptualize such symptom exaggeration as a "cry for help," particularly if it occurs in the context of a perceived obstacle. Collectively, these contextual issues illustrate the potential for veterans with PTSD to adopt symptom exaggeration and/or false imputation strategies to cope with challenges unique to veterans. Thus, it would seem appropriate to consider such exaggerations within an adaptational model of overreporting (see Rogers, 1997). The potential for adaptive exaggerations of actual symptoms illustrates the need for empirical methods and measures that differentiate exaggerated and/or falsely imputed symptoms of actual PTSD from purely malingered symptoms.
The need for improved methods & measures
Unfortunately, we do not currently have the empirical support that we so desperately need in psycholegal settings. The current "gold standard" PTSD assessment instruments, the PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) and Clinician Administered PTSD Scale (CAPS; Weathers, Keane, & Davidson, 2001), were developed and validated for purely treatment-oriented settings and were not created with symptom report validity in mind (Elhai, Ford, & Naifeh, 2010). These measures rely heavily on the self-report of face valid and inherently subjective items (Koch et al., 2005), and are readily available to the public online in their entirety. While the MMPI-2 has more psycholegal utility, studies have found that upwards of one-half of veterans produced elevations on the MMPI-2 suggestive of exaggeration or malingering (Elhai, Frueh, Davis, Jacobs, & Hamner, 2003; Elhai, Ruggiero, Frueh, Beckham, Gold, & Feldman, 2002; Freeman, Powell, Kimbrell, 2008). It seems that a cautious, spectrum-based approach to interpreting such elevations is advisable, given the unknown prevalence rates and high rates of comorbidity among veterans with PTSD (see Elhai et al., 2003; Elhai et al., 2002; Freeman et al., 2008). This type of approach should continue at least until we generate more empirical support for our ability to validly assess PTSD in veterans, which includes our ability to differentiate between different levels of overreporting.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Benjamin J. S. & Virginia A. S. (Eds.). (2007). Kaplan & Sadock's Synopsis of Psychiatry, 10th Ed. Philadelphia, PA: Lippincott Williams & Wilkins.
Elhai, J. D., Ford, J. D., & Naifeh, J. A. (2010). Assessing trauma exposure and posttraumatic morbidity. In G. M. Rosen & B. C. Frueh (Eds.), Clinician’s guide to posttraumatic stress disorder (pp. 119–151). Hoboken, NJ: John Wiley& Sons, Inc.
Elhai, J. D., Ruggiero, K. J., Frueh, B. C., Beckham, J. C., Gold, P. B., & Feldman, M. E. (2002). The Infrequency-Posttraumatic Stress Disorder scale (Fptsd) for the MMPI-2: Development and initial validation with veterans presenting with combat-related PTSD. Journal of Personality Assessment, 79, 531–549.
Elhai, J. D., Frueh, B. C., Davis, J. L., Jacobs, G. A., & Hamner, M. B. (2003). Clinical presentations in combat veterans diagnosed with posttraumatic stress disorder. Journal of Clinical Psychology, 59, 385–397.
First, M. B. (2010). The PTSD stressor criterion as a barrier to malingering: DSM-5 draft commentaries. Psychological Injury and Law, 3, 255-259.
Freeman, T., Powell, M., & Kimbrell, T. (2008). Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder. Psychiatry Research, 158, 374–380.
Frueh, B. C., Hamner, M. B., Cahil, S. P., Gold, P. B., & Hamlin, K. L. (2000). Apparent symptom overreporting in combat veterans evaluated for PTSD. Clinical Psychology Review, 20, 853-885.
Koch, W. J., O’Neill, M., & Douglas, K. S. (2005). Empirical limits for the forensic assessment of PTSD litigants. Law & Human Behavior, 29(1), 121-149.
Lande, R., & Williams, L. (2013). Prevalence and characteristics of military malingering. Military Medicine, 178(1), 50-54.
Marx, B. P., Miller, M. W., Sloan, D. M., Litz, B. T., Kaloupek, D. G., Keane T. M. (2008). Military-related PTSD, current disability policies, and malingering. American Journal of Public Health, 98(5), 773-774.
Mossman, D. (1996). Veterans Affairs disability compensation: A case study in counter therapeutic jurisprudence. Bulletin of the American Academy of Psychiatry and Law, 24, 27-44.
Rabaino, L., & Glantz, A. (2013, March). Infographic: Veterans waiting longer. Center for Investigative Reporting. Retrieved April 24, 2013.
Resnick, P. J. (1997). Malingering of posttraumatic stress disorders. In R. Rogers (Ed.), Clinical assessment of malingering and deception, 2nd Ed. New York, NY: Guilford Press.
Rogers, R. (Ed.). (1997). Clinical assessment of malingering and deception (2nd ed.). New York, NY: Guilford Press.
Rogers, R. & Bender, S. D. (2003). Evaluation of malingering and deception. In A. Goldstein & I. B. Weiner (Eds.), Handbook of Psychology: Volume 11 Forensic Psychology (pp. 109-129). Hoboken, NJ: John Wiley & Sons, Inc.
Sayer, N. A., & Thuras, P. (2002). The influence of patients’ compensation-seeking status on the perceptions of Veterans Affairs clinicians. Psychiatric Services, 53, 210-212.
The White House, Office of the Press Secretary. (2012). Executive order – Improving access to mental health services for veterans, service members and military families. [Press release].
Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician administered PTSD scale: A review of the first ten years of research. Depression and Anxiety, 13, 132–156.
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies (ISTSS), San Antonio, Texas.
Weaver, C. M., Trafton, J. A., Walser, R. D., & Kimerling, R. E. (2007). Pilot test of seeking safety treatment with male veterans. Psychiatric Services, 58, 1012-1013.