This post provides a critique of an influential 2011 article by two prominent VA PTSD researchers:

Marx, B. P. & Holowka, D. W. (2011). PTSD disability assessment. PTSD Research Quarterly, 22(4), 1-6.

I refer to the article as influential because it appeared in a widely circulated newsletter published by the VA’s National Center for PTSD. The National Center rightly enjoys a worldwide reputation as the premier institution conducting research and providing education to the public, patients, and professionals about PTSD. Therefore, it is reasonable to assert that an article in its newsletter for professionals (PTSD Research Quarterly), influences opinion among VA and other mental health professionals and policy makers.

In fact, the U.S. Army promulgated a new policy in 2012 discouraging its psychologists and psychiatrists from screening for possible exaggeration or malingering during PTSD disability evaluations citing only the Marx & Holowka (2011) article as justification for the change.

Army Medicine’s Policy Guidance on the Treatment and Assessment of Post-Traumatic Stress Disorder (PTSD) [OTSD/MEDCOM Policy Memo 2012-035] states:

Although there has been debate on the role of symptom exaggeration or malingering for secondary gain in DoD and VA PTSD Disability Evaluation System (DES) processes, there is considerable evidence that this is rare and unlikely to be a major factor in the vast majority of disability determinations. [emphasis added]

This statement could not be further from the truth, and it is a shame that a National Center for PTSD publication provided the justification for such an inaccurate assertion by Army Medicine.

Despite the inestimable contributions of National Center for PTSD, if they have a weak spot it is their penchant for minimizing or denying the extent to which veterans engage in misattribution, exaggeration, or feigning of PTSD symptoms during VA Compensation and Pension examinations (C&P exams) for posttraumatic stress disorder. The Marx & Holowka (2011) article exemplifies this denial and minimization.

The problem with the Marx & Holowka (2011) article is that it:

• Misconstrues (or incompletely reports on) research that suggests higher-than-average rates of symptom exaggeration among Veterans seeking PTSD disability benefits.
• Cites two studies in support of their claims, which when examined closely, do not provide convincing evidence that symptom exaggeration or feigning is rare when service members or veterans seek PTSD disability benefits.

This blog post addresses the first problem and a subsequent post will tackle the second problem with the Marx &  Holowka (2011) article.

Misconstruing Relevant Research Studies

This section will review four research studies that Marx & Holowka (2011) try to discredit.

Misconstruing Research: Study #1

With regard to misconstruing research, the first study I will examine does not involve misconstrual per se, it is simply incomplete. Here is the quote from the Marx & Holowka (2011) article:

Higher scores on the MMPI-2 F scale, an indicator of exaggerated response, have also been associated with increased (actual) symptomatology. For instance, a study by Franklin, Repasky, Thompson, Shelton, and Uddo (2002) found that compensation-seeking Veterans with elevated MMPI-2 F scores were not purposely exaggerating their symptoms, or attempting to deceive assessors, but rather were experiencing extreme distress. (p. 2)

That statement is correct up to a point. Franklin, et al. (2002) demonstrated that some compensation-seeking Veterans elevate standard MMPI-2 validity scales when further analysis suggests that they were not engaging in wholesale exaggeration for the purposes of receiving compensation benefits but were, instead, simply distressed. Franklin, et al. (2002) were not the first researchers to suggest this pattern (see Frueh, et al., 2000, for example), however, their research is an important contribution. And, subsequent research (Resnick, West, & Payne, 2008) has confirmed this phenomenon with PTSD patients in general. However, Marx & Holowka (2011) don’t tell the whole story about the Franklin, et al. (2002) study. Specifically, they fail to mention that 22.8% of the Franklin, et al. (2002) sample did not fit into the “extreme distress” group and, in fact, there was a strong indication that those Veterans significantly exaggerated their symptoms (Fp ≥ 7).

Misconstruing Research: Study #2

The next research study to examine is described by Marx & Holowka (2011) as follows:

Grubaugh, Elhai, Monnier, and Frueh (2004) observed higher scores on the MMPI-2 F scale among compensation-seeking Veterans, but no differences in healthcare utilization among the compensation-seeking and non-compensation-seeking groups. This suggests that even if some Veterans exaggerated claims, they were also motivated to obtain treatment for their difficulties. (p. 2)

This conclusion makes it sound as if maybe the compensation-seeking Veterans were not really exaggerating. After all, they were seeking treatment for PTSD so does that not suggest that they actually have the disorder? Perhaps. But another possibility exists, namely that the compensation-seeking Veterans might have sought PTSD treatment to establish their claim for disability benefits. Consider the following advice offered to Veterans contemplating a PTSD disability claim:

There is 1 major thing that you need in order to get a PTSD claim approved. This is a diagnosis of Post Traumatic stress disorder from a medical professional. The diagnosis can come from a private physician or from a VA physician.

Or this advice:

What you need to do is to build support for your claim by never missing a doctors appointment. Always be on time and be extremely careful of what you say and/or don’t say. When you go to the doctor follow these simple rules: When you see a medical doctor or any nurse, you should respond to How are you today? by saying “my nightmares bother me, the flashbacks are nearly unbearable ” then discuss what else bothers you. This issue is first and foremost, then you can complain about other things that bother you. You always respond with your service connected issue first. Never say fine, never say OK.

Or this suggestion on a HadIt.com forum (by a Moderator with over 21,000 posts on the forum):

Welcome to Hadit. You need three things to establish your claim for PTSD. You have to have a current diagnosis of PTSD that is linked to your service and you need to show a stressor that can be proved that happened when you served. Spending some time in a VA hospital can help your claim.[1]

Those are just three examples. It is widely known in Veteran’s circles that it is usually a good idea to seek PTSD treatment to help “establish your claim” for PTSD. I am not asserting that this is necessarily a bad thing. Veterans suffering from PTSD certainly deserve top-notch treatment and the VA is a good place to receive it. However, one should not assume that compensation-seeking Veterans pursue VA PTSD treatment only for clinical reasons; sometimes they seek treatment to help establish their PTSD disability claim, either in addition to or exclusive of a desire to receive clinical assistance.

Misconstruing Research: Study #3

The next research study is described in part by Marx & Holowka (2011) as follows:

Arbisi, Murdoch, Fortier, and McNulty (2004) compared Veterans undergoing C&P exams with high and low scores on the MMPI F(p) scale, detecting no difference in award decisions or healthcare utilization, and although available, these scores were not routinely considered in the final determination of PTSD compensation. (pp. 2-3)

The whole point of that article is that VA psychologists failed to interpret, integrate, or even comment on high scores on the MMPI-2 Fp scale, a finding that should trigger a concern that the test-taker may very well be exaggerating his or her symptoms. The fact that the psychologists overlooked the Fp score is an indictment of their clinical acumen not evidence that MMPI-2 Fp scores are irrelevant, as Marx & Holowka seem to imply.

Misconstruing Research: Study #4

The last study which Marx & Holowka misconstrue is described in their article as follows:

Finally, Freeman, Powell, and Kimbrell (2008) reported that 53% of treatment-seeking (especially compensation-seeking) Veterans exaggerated symptoms or malingered on psychological tests. The tendency to exaggerate symptoms, as assessed by an interview measure, was associated with elevated PTSD symptoms but not with elevations in other forms of psychopathology among Vietnam Veterans. Freeman et al. suggested that, even among other decidedly subjective mental disorders, PTSD is a condition that is especially likely to be exaggerated. Importantly, though, service-connected PTSD was no more common among Veterans who exaggerated symptoms than it was among Veterans who did not exaggerate. This finding is inconsistent with the hypothesized negative impact of VA psychiatric disability policies. (p. 3)

However, Freeman, Powell, & Kimbrell (2008), noted in their article that:

Fifty-nine (80%) of the participants reported that they were currently seeking to either establish or increase their service-connected disability (SCD), while 15 participants (20%) reported that they were not seeking to increase their SCD. All of our study subjects without current SCD reported that they were actively seeking SCD. (Freeman, Powell, & Kimbrell, 2008, p. 377)

Thus, all of the subjects in the Freeman, Powell, & Kimbrell (2008) study were either already service-connected for PTSD or were seeking service-connection for PTSD. Comparing currently SC (Service-Connected) with currently NSC (Non-Service-Connected) groups is confounded by the fact that all of the NSC group was compensation-seeking. Thus, you would expect to find no difference between the SC and NSC groups because each group contained a large number of compensation-seeking Veterans.

Consequently, the Freeman, Powell, & Kimbrell (2008) results remain: 53% of Veterans in an inpatient PTSD treatment program, who were either already SC or were seeking compensation, showed clear signs of symptom exaggeration or feigning.

Footnote
[1] Be sure to read that post in context. The author was not advocating deception of any kind. My point is simply that it is standard advice that a Veteran can (and in some cases, should) establish a basis for their disability claim by seeking PTSD treatment. In most cases, a Veteran seeks treatment both because they need to establish an evidentiary basis for their claim and because they genuinely want help.

References
Arbisi, P. A., Murdoch, M., Fortier, L. & McNulty, J. (2004). MMPI-2 validity and award of service connection for PTSD during the VA compensation and pension evaluation. Psychological Services, 1(1), 56–67. doi:10.1037/1541-1559.1.1.56

Franklin, C., Repasky, S., Thompson, K., Shelton, S. & Uddo, M. (2002). Differentiating overreporting and extreme distress: MMPI-2 use with compensation-seeking veterans with PTSD. Journal Of Personality Assessment, 79(2), 274–285.

Freeman, T., Powell, M. & Kimbrell, T. (2008). Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder. Psychiatry Research, 158(3), 374–380.

Grubaugh, A. L., Elhai, J. D., Monnier, J., & Frueh, B. C. (2004). Service utilization among compensation-seeking veterans. Psychiatric Quarterly, 75(4), 333-341. doi: 10.1023/B:PSAQ.0000043509.18637.3b

Marx, B. P. & Holowka, D. W. (2011). PTSD disability assessment. PTSD Research Quarterly, 22(4), 1-6.

Resnick, P. J., West, S. & Payne, J. W. (2008). Malingering of posttraumatic disorders. In R. Rogers (Ed.), Clinical assessment of malingering and deception (3rd Ed.). (pp. 109–127). New York: Guilford Press.

What do you think? Please comment below!