Diagnosing PTSD in the Army has changed as a result of a new policy guideline released recently. Although the Army Medicine Policy Guidance is dated 10 April 2012, public awareness of the change was not raised until Hal Bernton of the Seattle Times (who has been on top of this developing story since the beginning) broke the story on 21 April 2012.
The policy change has also been covered by the Los Angeles Times, Wired, and Stars and Stripes.
The two major changes with regard to Army Medicine’s diagnosis of PTSD are:
1. Psychiatrists and psychologists are encouraged to use a flexible definition of Criterion A2 of the DSM-IV PTSD diagnostic criteria.
2. Clinicians are being told that exaggeration or feigning of PTSD is rare and they are being discouraged from assessing for dissimulation during PTSD evaluations.
First Policy Change: Flexible A2 Criterion
I agree wholeheartedly with the first recommendation. The current A2 Criterion for PTSD reads, “The person’s response involved intense fear, helplessness, or horror.” The problem with this criterion for Service Members (and emergency first responders) is that these individuals are trained to control their emotions in the midst of combat or other frightening or horrifying situations. While they might experience fear, soldiers tend to suppress this emotion so that they can respond efficiently and effectively to clear and present danger.
When asked afterwards what they experienced emotionally, many service members will tell you they felt “angry” or even, “nothing, I just acted.” Men and women of the armed forces should not be penalized (not given a PTSD diagnosis when they meet all other diagnostic criteria) simply because they responded to an imminent threat in a manner consistent with their training. My hat is off to Army Medicine for recognizing this problem and taking decisive action to correct it.
Second Policy Change: Discouraging the Assessment of Exaggeration or Feigning
I disagree with the second policy change because it ignores or unfairly discounts psychological research that suggests that some Service Members or Veterans over-report PTSD symptoms when they seek disability benefits. But you wouldn’t know that fact reading the Army Medicine Policy Guidance. Instead, you read this:
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.
The Policy Guidance cites only one document to support this contention. It is an article published in PTSD Research Quarterly, the citation for which is:
Marx, B. P. & Holowka, D. W. (2011). PTSD disability assessment. PTSD Research Quarterly, 22(4), 1-6.
Note that the proper in-text citation for this article is “Marx & Holowka (2011)” but the Army Medicine Policy Guidance refers to it as “Marx (2011).” This isn’t a major error; I simply want to make sure that readers understand which document the Policy Guidance is referencing.
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–also cited by the Army Medicine Policy Guidance–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.
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 doesn’t 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.
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.
This conclusion makes it sound as if maybe the compensation-seeking Veterans weren’t really exaggerating. After all, they were seeking treatment for PTSD so doesn’t that 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.
Those are just three examples. It is widely known in Veteran’s circles that it 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. Those 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.
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.
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 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.
… Continued on the next post – “Lack of Convincing Evidence that Symptom Exaggeration is Rare”
What do you think? Should psychologists and psychiatrists assess for exaggeration when evaluating Service Members or Veterans for PTSD disability compensation? Please leave a comment.
 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.
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:10.1037/1541-15188.8.131.52
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.