Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder
Introduction
The study of combat-related trauma has been instrumental in conceptualizing and defining posttraumatic stress disorder (PTSD). This is primarily due to the large number of studies investigating the epidemiology, treatment and pathophysiology of PTSD that have utilized combat-related PTSD subjects. In some specific areas of PTSD research, such as structural and functional neuroimaging, a majority of studies have enrolled only combat-related PTSD subjects (Hull, 2002). Despite the extensive use of this subject group, a panel of PTSD research experts has recommended that combat-related PTSD subjects enrolled in clinical trials be reported separately from civilian-trauma subjects (Charney et al., 1998). This same expert panel also recommended that “patients whose continued receipt of financial benefits is contingent upon maintaining PTSD symptoms, or who are awaiting a decision concerning the possibility of receiving financial benefit, should be excluded from clinical trials” (Charney et al., 1998). These are unusual recommendations at first glance, given the extensive use of combat-related PTSD subjects in numerous scientific studies. However, the recommendation is supported by findings that reveal that subjects with combat-related PTSD frequently demonstrate extensive comorbidity (Hryvniak and Rosse, 1989, Brady et al., 2000), poor response to standard psychosocial interventions (Johnson et al., 1996, Schnurr et al., 2003) and pharmacological treatments (Hertzberg et al., 2000), and tendency to exaggerate symptoms (Frueh et al., 1997). Except for a small number of studies examining treatment outcome (Fontana and Rosenheck, 1998, DeViva and Bloem, 2003), information regarding financial compensation for PTSD symptoms is not typically included in research work using veteran populations so it is difficult to assess the relationship between financial benefits and symptom presentation in the overwhelming majority of published studies.
The relationship of financial compensation to symptom presentation of veteran subjects with combat-related PTSD has not been ignored, however. Previous investigations of reports of symptomatology by individuals with combat-related PTSD have consistently found evidence of symptom over-reporting of psychopathology as measured by validity scales of the Minnesota Multiphasic Personality Inventory (MMPI) and the MMPI-2. Hyer et al., 1989, Hyer et al., 1988, using validity measures of the MMPI, showed that combat-related Vietnam Era PTSD subjects over-report symptoms to a high degree and that increasing over-reporting is associated with higher MMPI–PTSD scores. These authors hypothesized that over-reporting of symptoms may be secondary to increasing monetary compensation provided by the VA system for report of more severe PTSD symptoms. Frueh and associates (Frueh et al., 1997, Frueh et al., 2000, Gold and Frueh, 1999) have investigated exaggeration of PTSD symptoms in combat-related PTSD subjects in a series of studies using the MMPI-2 and other instruments, and have reported that compensation-seeking veterans with combat-related PTSD over-report psychopathology more than non-compensation-seeking PTSD veterans. Other investigations using the MMPI-2 have found extreme elevations of reported psychopathology in combat-related PTSD to be unrelated to compensation seeking (Franklin and Thompson, 2005, DeViva and Bloem, 2003).
Guriel and Fremouw (2003) summarized the current state of research into the assessment of symptom exaggeration in PTSD patients. They noted the limited use of structured interviews for PTSD symptom assessment in studies done to date; in addition, they observed that no clear single method or instrument has been universally recognized as the best tool to detect exaggeration in PTSD claimants. The authors suggested the use of instruments designed to detect symptom exaggeration, such as the Structured Interview of Reported Symptoms (SIRS) (Pollock et al., 1997), and the use of standardized clinical interviews for PTSD symptoms, such as the Clinician Administered PTSD Scale (CAPS), for assessment of symptom exaggeration in PTSD populations.
To investigate symptom exaggeration in veterans with chronic PTSD, we utilized several standardized forensic instruments designed to detect symptom exaggeration in a group of veterans presenting for PTSD treatment in a VA residential setting.
Section snippets
Participants
The sample comprised 74 veterans with chronic PTSD presenting to a 7-week, referral-based VA residential PTSD treatment program serving a four-state area. The majority of the sample (n = 67) were Vietnam war veterans, while the remainder were World War II (n = 1), Korean Conflict (n = 1), Gulf War (n = 4), or Iraqi War (n = 1) veterans. All subjects reported combat exposure, and military discharge forms (DD214) were used to validate their claims of having served in the military in the conflicts they
Results
The sample comprised 74 male veteran subjects. The average age for all subjects was 54.9 ±8.1 years, and subjects reported an average of 12.7 ± 2.2 years of education. The racial breakdown in the sample was as follows: Caucasians, 64%; African-Americans, 36%. Seventy of the participants (94.6%) reported that they were unemployed, and only four participants (5.4%) reported being employed either full- or part-time.
Fifty-nine (80%) of the participants reported that they were currently seeking to
Discussion
To our knowledge, this study is the first to use the SIRS, the CAPS-2, and self-report measures to study symptom reporting in a veteran population with PTSD. The most important findings are the significant levels of symptom exaggeration in a subset of our veteran subject group; over half of our veteran subjects demonstrated clear and significant symptom exaggeration on the basis of categorical SIRS criteria. As noted, not all of our potential subjects chose to participate. We cannot say how our
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