This is the second of two blog posts critiquing an article published in PTSD Research Quarterly by Marx & Holowka (2011), PTSD Disability Assessment.
Update: Since I wrote this post, Dr. Marx and the National Center for PTSD have moderated their view on these issues – a great example of top-notch scientists remaining open to new ideas and perspectives, and forming their opinions based on empirical evidence rather than ideology or personal preferences. For example, see this seminal research article:
Marx, B. P., et al. (2017). The influence of veteran race and psychometric testing on Veterans Affairs posttraumatic stress disorder (PTSD) disability exam outcomes. Psychological Assessment, 29(6), 710-719.
Also note that Professor Marx & colleagues’ research have moderated my views too.
Having reviewed the research studies that Marx & Holowka (2011) misconstrued (see the previous post), I will now turn to an analysis of the two studies on which they–and the 2012 Army Medicine Policy Guidance–relied on to support their claim that Service Members and Veterans rarely exaggerate or feign PTSD symptoms.
Lack of Evidence that Symptom Exaggeration is “Rare”
Here is what Marx & Holowka (2011) wrote:
In what may be the strongest evidence regarding the validity of estimates of military-related PTSD, an internal study conducted in 2005 by the VA Office of the Inspector General (OIG) showed that, out of 2,100 reviewed service-connected PTSD cases, only 13 (0.6%) were potentially fraudulent. The results of this study by the VA suggest that malingered PTSD is not nearly as prevalent as what others have suggested. These VA findings were corroborated by Dohwenrend et al. (2006), who found no evidence of malingering and virtually no evidence of attempts to inflate disability claims.
2005 VA Office of the Inspector General (OIG) Report
Citing the IOG Report as evidence for an exceptionally low exaggeration rate, as Marx & Holokwa (2011) did, compares apples to oranges. In this case the comparison is between:
1) a potential crime (fraud); and
2) symptom exaggeration during PTSD treatment evaluations or disability examinations.
It stands to reason that potential fraud, a federal crime, occurs significantly less often than symptom exaggeration, which is not a crime. Thus, to cite a 0.6% potential fraud detection rate as if it represents the symptom exaggeration rate is disingenuous. Instead of extrapolating from potential fraud cases, an accurate assessment of the exaggeration rate should involve the direct measurement of the behavior in question (symptom exaggeration) while the Service Member or Veteran is seeking compensation. And this is precisely the research method employed by the studies that Marx & Holokwa (2011) attempt to dismiss. Contrary to the impression of relative rarity that Marx & Holokwa (2011) seek to convey, the appropriately conducted research suggests exaggeration rates from 23% (Franklin, et al., 2002) to 53% (Freeman, et al., 2008). I believe the 23% figure is probably closest to the true rate because the Franklin, et al. (2002) study:
- Determined this rate based on a validity scale (Fp) with very good specificity (Arbisi, et al., 2006; Tolin, et al., 2010).
- Used a fairly conservative criterion for exaggeration (Fp ≥ 7).
- Analyzed results obtained from actual PTSD disability examinations (C&P PTSD exams).
While one might argue that not all of the veterans with MMPI-2 Fp scores at or above 7 were significantly exaggerating or feigning mental disorder symptoms, one must also consider that the researchers (Franklin, et al., 2002) used only one validity scale to identify “overreporters” as they referred to this group. If they had used additional validity scales to identify significant exaggeration or feigning, particularly scales most likely to identify dissimulation of non-psychotic symptoms, e.g., the MMPI-2 Gough Dissimulation Scale (Ds), they would have undoubtedly found even more veterans who had significantly exaggerated or feigned symptoms.
Dohwenrend, et al. (2006)
This study was primarily a reanalysis of data from the National Vietnam Veterans Readjustment Study (Kulka, et al., 1988), with additional information about combat exposure culled by the researchers from military personnel records and historical archives. The section of the Dohwenrend, et al. (2006) article upon which Marx & Holokwa (2011) base their assertion of “…no evidence of malingering and virtually no evidence of attempts to inflate disability claims” is this one:
To investigate questions about the possible falsification of symptom reporting, we reasoned that if some NVVRS veterans exaggerated their PTSD symptoms by outright lying or more subtle retrospective distortions (26), these veterans should be overrepresented among veterans who reported experiencing high war-zone stress despite having record-based MHMs indicating low or moderate severity of exposure. Using questionnaire measures of dissembling (27–31) and self-reported symptoms, we found no indication of dissembling and little evidence of exaggeration (SOM text).The possibility of receiving disability compensation might motivate falsification of symptoms and exposure reports (16). Compensation-seeking for psychiatric disability was reported by 9.3% of the veterans. However, there was no elevation of compensation-seeking among veterans discordant on the exposure measures; for example, only 3.0% of those who reported high exposure in the context of low MHM exposure sought compensation compared with 15.6% who were high on both exposure measures.
I have no problem accepting the conclusion that the Veterans evaluated for the National Vietnam Veterans Readjustment Study (NVVRS) were not exaggerating their symptoms. But there is a major problem with extrapolating from this conclusion to an assertion that Service Members seeking compensation rarely exaggerate during clinical PTSD evaluations or disability examinations (C&P PTSD exams): The Veterans enrolled in the NVVRS knew that it was a research study and that their answers to questions would never be used to determine if they qualified for compensation benefits. On the other hand, Service Members or Veterans seeking compensation know that when they receive a treatment evaluation or a disability examination that their answers to questions will “count”, i.e., their responses and any resulting diagnoses will be reviewed by adjudicators to determine if they qualify for compensation benefits. The evaluation context matters. There is no incentive during a confidential research study–that has nothing to do with compensation benefits–for individuals to exaggerate or feign symptoms. However, some Service Members or Veterans, who have applied for disability compensation or plan to do so soon, will be tempted to embellish the nature and extent of the symptoms they report when undergoing contemporaneous PTSD treatment evaluations or, certainly, during VA compensation and pension examinations for PTSD. Again, as I emphasized above, I believe that such exaggeration or feigning occurs in a minority of cases (probably somewhere between 20% and 25% of claimants), which means that the majority of Service Members and Veterans do not exaggerate or feign their symptoms. Nonetheless, a 20-25% exaggeration/feigning rate is hardly “rare” and should not be ignored by policy-makers, administrators, and disability examiners. What do you think? Is exaggeration among Service Members or Veterans seeking disability compensation “rare”? Should disability examiners assess for exaggeration or feigning? Please comment below. References Department of Veterans Affairs. Office of the Inspector General. (2005). Review of state variances in VA disability compensation payments. (#05-00765-137). Washington, DC: Author. Dohrenwend, B. P., Turner, J. B., Turse, N. A., Adams, B. G., Koenen, K. C., & Marshall, R. (2006). The psychological risks of Vietnam for U.S. veterans: A revisit with new data and methods. Science, 313(5789), 979-982. doi: 10.1126/science.1128944 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. Kulka, R. A., et al. (1988). Contractual report of findings from the National Vietnam Veterans Readjustment Study, Volume I. Washington, DC: Veterans Administration. Marx, B. P. & Holowka, D. W. (2011). PTSD disability assessment. PTSD Research Quarterly, 22(4), 1-6.