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Miskey HM, Martindale SL, Shura RD, Taber KH. Distress Tolerance and Symptom Severity as Mediators of Symptom Validity Failure in Veterans With PTSD. J Neuropsychiatry Clin Neurosci 2020; 32:161-167. [PMID: 31266409 DOI: 10.1176/appi.neuropsych.17110340] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Performance validity tests (PVTs) and symptom validity tests (SVTs) are necessary in clinical and research contexts. The extent to which psychiatric distress contributes to failure on these tests is unclear. The authors hypothesized that the relation between posttraumatic stress disorder (PTSD) and validity would be serially mediated by distress tolerance and symptom severity. METHODS Participants included 306 veterans, 110 of whom met full criteria for current PTSD. PVTs included the Medical Symptom Validity Test (MSVT) and b Test. The Structured Inventory of Malingered Symptomatology (SIMS) was used to measure symptom validity. RESULTS MSVT failure was significantly and directly associated with PTSD severity (B=0.05, CI=0.01, 0.08) but not distress tolerance or PTSD diagnosis. b Test performance was not significantly related to any variable. SIMS failure was significantly associated with PTSD diagnosis (B=0.71, CI=0.05, 1.37), distress tolerance (B=-0.04, CI=-0.07, -0.01), and symptom severity (B=0.07, CI=0.04, 0.09). The serial mediation model significantly predicted all SIMS subscales. CONCLUSIONS PTSD severity was associated with failing a memory-based PVT but not an attention-based PVT. Neither PVT was associated with distress tolerance or PTSD diagnosis. SVT failure was associated with PTSD diagnosis, poor distress tolerance, and high symptomatology. For veterans with PTSD, difficulty managing negative emotional states may contribute to symptom overreporting. This may reflect exaggeration or an inability to tolerate stronger negative affect, rather than a "cry for help."
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Affiliation(s)
- Holly M Miskey
- The Salisbury Veterans Affairs Health Care System, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); the Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); and the Wake Forest School of Medicine, Winston-Salem, N.C. (Miskey, Martindale, Shura)
| | - Sarah L Martindale
- The Salisbury Veterans Affairs Health Care System, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); the Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); and the Wake Forest School of Medicine, Winston-Salem, N.C. (Miskey, Martindale, Shura)
| | - Robert D Shura
- The Salisbury Veterans Affairs Health Care System, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); the Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); and the Wake Forest School of Medicine, Winston-Salem, N.C. (Miskey, Martindale, Shura)
| | - Katherine H Taber
- The Salisbury Veterans Affairs Health Care System, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); the Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Salisbury, N.C. (Miskey, Martindale, Shura, Taber); and the Wake Forest School of Medicine, Winston-Salem, N.C. (Miskey, Martindale, Shura)
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Ramanathan-Elion DM, Baydoun HA, Johnstone B. Psychological predictors of functional outcomes in service members with traumatic brain injury. Brain Inj 2020; 34:1183-1192. [PMID: 32683899 DOI: 10.1080/02699052.2020.1793387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PRIMARY OBJECTIVE Research is increasingly demonstrating the significant impact that non-medical factors can have on outcomes of service members (SMs) with mild traumatic brain injury (mTBI). Thus, the current study examined which demographic, TBI-related factors, and psychological variables are most predictive of functional outcomes. RESEARCH DESIGN Retrospective database analysis from medical chart review. METHODS AND PROCEDURES One hundred forty-one patients who received rehabilitation services at an outpatient TBI military treatment facility between 2013 and 2018. Data collected included demographic variables, time since injury, neuropsychological measures, psychological diagnoses, Personality Assessment Inventory (PAI) scores, and Walter Reed Functional Impairment Scale (FIS). Hierarchical linear regression models were used to predict functional outcomes (measured by FIS total, work, social functioning scales). MAIN OUTCOMES AND RESULTS Results indicated that comorbid PTSD diagnosis and PAI Negative Impression Management (NIM) score were predictive of total functional, work, and social outcomes, over and above demographic and TBI-related factors. CONCLUSIONS Current findings confirmed the importance of evaluating and treating psychological factors, as well as exploring one's responding style (NIM), when managing chronic mTBI in SMs. Given ongoing findings of psychological underpinnings to mTBI outcome, there is further need to focus on early interventions to optimize psychological and functional outcomes for SMs.
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Affiliation(s)
- Deepa M Ramanathan-Elion
- Department of Behavioral Health, Fort Belvoir Intrepid Spirit Center , Fort Belvoir, Virginia, USA
| | - Hind A Baydoun
- Department of Research Programs, Fort Belvoir Community Hospital , Fort Belvoir, Virginia, USA
| | - Brick Johnstone
- Defense and Veterans Brain Injury Center, Fort Belvoir Intrepid Spirit Center , Fort Belvoir, Virginia, USA.,Virginia Crawford Research Institute, Shepherd Center , Atlanta, Georgia, USA
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3
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Herman DS, Weathers FW, Litz BT, Keane TM. Psychometric Properties of the Embedded and Stand-Alone Versions of the MMPI-2 Keane PTSD Scale. Assessment 2016. [DOI: 10.1177/107319119600300409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study investigated the comparability of the embedded and stand-alone versions of the Keane Posttraumatic Stress Disorder scale ( PK scale) of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Participants were 123 Vietnam theater veterans, 68 of whom (55%) were diagnosed with war zone-related posttraumatic stress disorder (PTSD). In separate testing sessions scheduled two to three days apart, all participants first completed the full MMPI-2 followed by the 46 PK scale items administered in a stand-alone format. Sixty participants completed the stand-alone version again in a third session. In addition, all participants were administered the Structured Clinical Interview for DSM-III-R (SCID), including the PTSD module, and completed a number of other questionnaire measures of combat exposure and PTSD. Results indicated that the embedded and stand-alone versions of the MMPI-2 PK scale are quite comparable in terms of mean scores, internal consistency, convergent validity, and diagnostic utility. Use of the standalone version is indicated for assessment applications in which the full MMPI-2 cannot be administered.
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Affiliation(s)
- Debra S. Herman
- Boston Veterans Affairs Medical Center and Tufts University School of Medicine
| | - Frank W. Weathers
- Boston Veterans Affairs Medical Center and Tufts University School of Medicine
| | - Brett T. Litz
- Boston Veterans Affairs Medical Center and Tufts University School of Medicine
| | - Terence M. Keane
- Boston Veterans Affairs Medical Center and Tufts University School of Medicine
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4
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Constans JI, Kimbrell TA, Nanney JT, Marx BP, Jegley S, Pyne JM. Over-reporting bias and the modified Stroop effect in Operation Enduring and Iraqi Freedom veterans with and without PTSD. JOURNAL OF ABNORMAL PSYCHOLOGY 2013; 123:81-90. [PMID: 24274375 DOI: 10.1037/a0035100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The current study investigated in a sample of Operation Enduring and Iraqi Freedom (OEF/OIF) veterans how a symptom overreporting response style might influence the association between PTSD diagnostic status and color-naming response latency for trauma-related stimuli during the Modified Stroop Task (i.e., the Modified Stroop Task effect, MST effect). It was hypothesized that, if an overreporting response style reflected feigning or exaggerating PTSD symptoms, an attenuated MST effect would be expected in overreporters with PTSD as compared with PTSD-diagnosed veterans without an overreporting style. If, however, overreporting stemmed from high levels of distress, the MST effect might be greater in overreporters compared with those with a neutral response style. The results showed that veterans with PTSD and an overreporting response style demonstrated an augmented MST effect in comparison with those with a more neutral style of response. Overreporters also reported greater levels of psychopathology, including markedly elevated reports of dissociative experiences. We suggest that dissociation-prone overreporters may misattribute emotional distress to combat experiences leading to the enhanced MST effect. Other possible explanations for these results are also discussed.
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Affiliation(s)
| | - Timothy A Kimbrell
- Division of Health Services Research, Central Arkansas Veterans Healthcare Center
| | | | - Brian P Marx
- VA National Center for PTSD, VA Boston Healthcare System
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Katsounari I, Jacobowitz J. A Comparative Analysis of MMPI and Rorschach Findings Assessing Combat-Related PTSD in Vietnam Veterans—Analysis of MMPI and Rorschach Findings Assessing PTSD. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/psych.2011.24053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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6
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Rubenzer S. Posttraumatic Stress Disorder: Assessing Response Style and Malingering. PSYCHOLOGICAL INJURY & LAW 2009. [DOI: 10.1007/s12207-009-9045-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hall RCW, Hall RCW. Detection of malingered PTSD: an overview of clinical, psychometric, and physiological assessment: where do we stand? J Forensic Sci 2007; 52:717-25. [PMID: 17456103 DOI: 10.1111/j.1556-4029.2007.00434.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a condition that can be easily malingered for secondary gain. For this reason, it is important for physicians to understand the phenomenology of true PTSD and indicators that suggest an individual is malingering. This paper reviews the prevalence of PTSD for both the general population and for specific events, such as rape and terrorism, to familiarize evaluators with the frequency of its occurrence. The diagnostic criteria for PTSD, as well as potential ambiguities in the criteria, such as what constitutes an exposure to a traumatic event, are reviewed. Identified risk factors are reviewed as a potential way to help differentiate true cases of PTSD from malingered cases. The question of symptom overreporting as a feature of the disease versus a sign of malingering is discussed. We then examine how the clinician can use the clinical interview (e.g., SIRS, CAPS), psychometric testing, and the patient's physiological responses to detect malingering. Particular attention is paid to research on the MMPI and the subscales of infrequency (F), infrequency-psychopathology (Fp), and infrequency-posttraumatic stress disorder (Fptsd). Research and questions regarding the accuracy of self-report questionnaires, specifically the Mississippi Scale (MSS) and the Personality Assessment Inventory (PAI), are examined. Validity, usability, and cutoff values for other psychometric tests, checklists, and physiological tests are discussed. The review includes a case, which shows how an individual used symptom checklist information to malinger PTSD and the inconsistencies in his story that the evaluator detected. We conclude with a discussion regarding future diagnostic criteria and suggestions for research, including a systematic multifaceted approach to identify malingering.
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Affiliation(s)
- Ryan C W Hall
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 North Wolfe Street/Meyer 113, Baltimore, MD 21287-7113, USA
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8
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Chen CH, Tan HKL, Liao LR, Chen HH, Chan CC, Cheng JJS, Chen CY, Wang TN, Lu ML. Long-term psychological outcome of 1999 Taiwan earthquake survivors: a survey of a high-risk sample with property damage. Compr Psychiatry 2007; 48:269-75. [PMID: 17445522 DOI: 10.1016/j.comppsych.2006.12.003] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Severe natural disasters can cause long-term psychological impact on the survivors. This study aimed to examine the prevalence and risk factors of posttraumatic stress symptoms and psychiatric morbidity among survivors of the severe earthquake that occurred in Chi-Chi, Taiwan, in September 21, 1999. METHODS A total of 6412 earthquake survivors whose houses were destroyed by earthquake were recruited about 2 years after the disaster. They completed a self-report questionnaire assessing posttraumatic stress symptoms, psychiatric morbidity, and information of demographics, trauma exposure, and current living status. RESULTS The estimated rates of posttraumatic stress disorder caseness and psychiatric morbidity were 20.9% and 39.8%, respectively. Psychiatric morbidity occurred mainly in survivors who were female, older, with low education level, and currently living in a prefabricated house. The risk factors for posttraumatic stress disorder caseness were female sex, currently living in a prefabricated house, low education level, and experienced complete destruction of property. CONCLUSION These results showed that severe earthquake can cause long-term psychological impact in the survivors. The findings of risk factors suggest avenues for targeting postdisaster interventions.
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Affiliation(s)
- Chin-Hung Chen
- Department of Psychiatry, Tsao-Tun Psychiatric Center, Nantou, Taiwan
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9
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Hall RCW, Hall RCW. Malingering of PTSD: forensic and diagnostic considerations, characteristics of malingerers and clinical presentations. Gen Hosp Psychiatry 2006; 28:525-35. [PMID: 17088169 DOI: 10.1016/j.genhosppsych.2006.08.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Revised: 08/25/2006] [Accepted: 08/30/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This paper aims to study the detection of individuals malingering posttraumatic stress disorder (PTSD) in criminal and civil situations. METHOD A brief history of PTSD and its rise to prominence in legal circles are discussed. The characteristics of individuals who malinger and particularly those who fake PTSD are discussed. Diagnostic dilemmas inherent to the condition, such as the definition of a traumatic exposure, what constitutes a PTSD flashback and the potential for normal symptom exaggeration, are explored. RESULTS The typical presentation of malingered symptoms is presented to help clinicians detect commonly seen malingering patterns. Suggestions for interview techniques, Minnesota Multiphasic Personality Inventory test values and sources of collateral information to help detect malingering are reviewed. CONCLUSION The paper concludes with a review of the typical presentations of malingered PTSD symptoms and a reminder that physicians need to distinguish legitimate symptoms from faked or embellished presentations.
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Affiliation(s)
- Ryan C W Hall
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, 600 N. Wolfe Street/Meyer 113, Baltimore, MD 21287-7113, USA.
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10
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Mozley SL, Miller MW, Weathers FW, Beckham JC, Feldman ME. Personality Assessment Inventory (PAI) Profiles of Male Veterans With Combat-Related Posttraumatic Stress Disorder. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2005. [DOI: 10.1007/s10862-005-0634-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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11
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Abstract
This article is a critical examination of the current state of the literature regarding the assessment of malingered posttraumatic stress disorder (PTSD). First, published empirical studies that examine the assessment of malingering in PTSD claimants using the American Psychiatric Association's Diagnostic and Statistical Manual criteria are summarized. Next, conceptual and methodological strengths, weakness, and limitations of existing research are outlined. Currently, there is no method or single instrument that is universally recognized as being the best tool to detect malingering in PTSD claimants. Lastly, recommendations for future investigations are provided.
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Affiliation(s)
- Jennifer Guriel
- Department of Psychology, West Virginia University, Morgantown, WV 26506-6040, USA.
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12
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MMPI-2 Validity and Award of Service Connection for PTSD During the VA Compensation and Pension Evaluation. Psychol Serv 2004. [DOI: 10.1037/1541-1559.1.1.56] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Elhai JD, Ruggiero KJ, Frueh BC, Beckham JC, Gold PB, Feldman ME. The Infrequency-Posttraumatic Stress Disorder scale (Fptsd) for the MMPI-2: development and initial validation with veterans presenting with combat-related PTSD. J Pers Assess 2002; 79:531-49. [PMID: 12511019 DOI: 10.1207/s15327752jpa7903_08] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Researchers have identified difficulties associated with the use of traditional Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) validity scales with survivors of traumatic events. A new scale, the Infrequency-Posttraumatic Stress Disorder scale (Fptsd), was created from MMPI-2 items that were infrequently endorsed by 940 male combat veterans presenting for treatment at the posttraumatic stress disorder (PTSD) clinics of 2 Veterans Affairs Medical Centers. A variety of statistical methods were implemented that preliminarily established Fptsd's validity with a validation sample of 323 additional PTSD-diagnosed combat veterans. Results indicate that, relative to previously established validity and overreporting scales (F, Fb, and Fp), Fptsd was significantly less related to psychopathology and distress and better at discriminating simulated from genuinely reported PTSD. Clinical implications are discussed concerning the use of Fptsd to assess disability-seeking veterans suspected of overreporting PTSD symptoms.
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Affiliation(s)
- Jon D Elhai
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina and Veterans Affairs Medical Center, Charleston, South Carolina 29401, USA
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14
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Franklin CL, Repasky SA, Thompson KE, Shelton SA, Uddo M. Differentiating overreporting and extreme distress: MMPI-2 use with compensation-seeking veterans with PTSD. J Pers Assess 2002; 79:274-85. [PMID: 12425391 DOI: 10.1207/s15327752jpa7902_10] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
This purpose of this study was to examine overreporting on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) in compensation-seeking veterans with posttraumatic stress disorder (PTSD). A sample of veterans tested during a V.A. hospital compensation and pension exam were given the MMPI-2 and measures of PTSD, depression, and combat exposure. Veteran's MMPI-2s were only included in the analyses if their profile was extremely exaggerated, as measured by an F scale T score above 80, did not elevate the MMPI-2 VRIN and TRIN scales, and had a primary diagnosis of PTSD (n = 127). Using the Infrequency-Psychopathology, F(p), scale to distinguish overreporting from distress, it was found that 98 veterans elevated profiles due to distress, whereas 29 elevated due to overreporting, F(p) below and above 7, respectively. Differences between groups on MMPI-2 clinical scales and the other measures were assessed. Implications of these findings for assessing veteran response style and using the MMPI-2 with a PTSD population are discussed.
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15
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Elhai JD, Gold PB, Frueh BC, Gold SN. Cross-validation of the MMPI-2 in detecting malingered posttraumatic stress disorder. J Pers Assess 2000; 75:449-63. [PMID: 11117156 DOI: 10.1207/s15327752jpa7503_06] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We attempted to cross-validate findings from a previous study (Elhai, Gold, Sellers, & Dorfman, in press) using a clinical sample of combat-related war veterans to distinguish genuine from malingered posttraumatic stress disorder (PTSD) on the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). The MMPI-2 scores of 124 male combat war veterans at the PTSD outpatient treatment program of a Veterans Affairs Medical Center were compared with those of 84 adult college students instructed and trained to malinger PTSD. MMPI-2 overreporting variables examined were F, F-Fb, F-K, F(p), Ds2, O-S, OT, and FBS. A stepwise discriminant analysis identified F. F-Fb, F-K, Ds2, O-S, and OT as the best malingering predictors. A predictive discriminant analysis yielded good hit rates for the model with impressive cross-validation results. We assessed cutting scores for the predictors of the model. We discuss clinical implications for using the MMPI-2 to distinguish malingered PTSD from combat-related PTSD.
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Affiliation(s)
- J D Elhai
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, USA
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16
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Calhoun PS, Earnst KS, Tucker DD, Kirby AC, Beckham JC. Feigning combat-related posttraumatic stress disorder on the personality assessment inventory. J Pers Assess 2000; 75:338-50. [PMID: 11020148 DOI: 10.1207/s15327752jpa7502_11] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
This study examined whether individuals who were instructed on the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) criteria for posttraumatic stress disorder (PTSD) could feign PTSD on the Personality Assessment Inventory (PAI; Morey, 1991). The study also investigated whether PAI indexes of symptom exaggeration, the Negative Impression Management (NIM) scale and the Malingering index, could identify individuals feigning PTSD. The diagnostic rule for PTSD (Morey, 1991, 1996) was applied to the profiles of a group of 23 veterans with combat-related PTSD and 23 male undergraduates instructed to malinger PTSD. Seventy percent of the student malingerers produced profiles that received diagnostic consideration for PTSD. The NIM cutting score (> or = 8) was highly effective in detecting simulation of PTSD but resulted in the misclassification of a large number of true PTSD cases. There were no significant differences in the overall efficiency of the test with various validity criteria. We discuss the implications of these findings for the use of the PAI in the diagnosis of combat-related PTSD.
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Affiliation(s)
- P S Calhoun
- Department of Psychology, Vanderbilt University, USA.
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Frueh BC, Hamner MB, Cahill SP, Gold PB, Hamlin KL. Apparent symptom overreporting in combat veterans evaluated for PTSD. Clin Psychol Rev 2000; 20:853-85. [PMID: 11057375 DOI: 10.1016/s0272-7358(99)00015-x] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Psychometric studies have consistently shown that combat veterans evaluated for posttraumatic stress disorder (PTSD) appear to overreport psychopathology as exhibited by (a) extreme and diffuse levels of psychopathology across instruments measuring different domains of mental illness, and (b) extreme elevations on the validity scale of the MMPI-MMPI-2, in a "fake-bad" direction. The phenomenon of this ubiquitous presentational style is not well understood at present. In this review we describe and delineate the assessment problem posed by this apparent symptom overreporting, and we review the literature regarding several potential explanatory factors. Finally, we address conceptual and practical issues relevant to reaching a better understanding of the phenomenon, and ultimately the clinical syndrome of combat-related PTSD, in both research and clinical settings.
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Affiliation(s)
- B C Frueh
- Veterans Affairs Medical Center, Medical University of South Carolina, USA
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18
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Fontana A, Rosenheck R. Effects of compensation-seeking on treatment outcomes among veterans with posttraumatic stress disorder. J Nerv Ment Dis 1998; 186:223-30. [PMID: 9569890 DOI: 10.1097/00005053-199804000-00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The desire to acquire or increase financial compensation for a psychiatric disability is widely believed to introduce a response bias into patients' reports of their symptoms and their work performance. The hypothesized effects of compensation-seeking in inhibiting improvement from treatment are examined. Data from outpatient (N = 455) and inpatient (N = 553) programs for the treatment of posttraumatic stress disorder and associated disorders in the Department of Veterans Affairs were used to compare outcomes for veterans who were and were not seeking compensation. Outcome was measured as pre/post improvement in symptoms and work performance over the course of 1 year after the initiation of treatment. No compensation-seeking effect was observed among outpatients, but a significant effect was found for some inpatients. The effect for inpatients was manifested essentially by patients in a program type which was designed to have an extremely long length of stay, thus triggering a virtually automatic increase in payments. Like outpatients, inpatients in programs with a moderate length of stay did not manifest a compensation-seeking effect on improvement. Although not permitting a definitive explanation, the preponderance of the evidence favors the overstatement of symptoms rather than either the severity or the chronicity of the disorder as the most likely explanation for the compensation-seeking effect that was observed. For patients treated in standard outpatient and short-stay inpatient programs, compensation does not seem to affect clinical outcomes adversely.
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Affiliation(s)
- A Fontana
- Northeast Program Evaluation Center (182), VA National Center for PTSD, VA Connecticut Healthcare System, West Haven 06516, USA
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19
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Abstract
It is clear from the existing data that PTSD often occurs in the context of other major psychological conditions. Evidence to support this comes from clinical studies, epidemiological studies, and studies of PTSD among substance abusers. Clearly, probably several different subgroups of PTSD patients exist including those who had psychological or behavioral problems before exposure to traumatic events (e.g., substance abuse), those who developed other problems concurrent with exposure to the traumatic events, and those who developed problems secondary to the development of PTSD, perhaps in efforts to cope with the intensely debilitating symptoms of PTSD. With this knowledge, research on PTSD must begin to contend with the comorbidity issue in systematic ways. The use of comparison groups that are carefully selected is one key way in which conclusions about PTSD can be most conservatively drawn. The use of statistical procedures to control for difference in levels of comorbidity is another responsible way in which to approach the problem. Finally, efforts to employ global measures of functioning such as the Global Assessment of Functioning to equate subjects within a study on minimally this characteristic may be the most economical method for trying to rule out the role of comorbidity and severity of condition in conclusions drawn in research studies. All these solutions presuppose the careful measurement of comorbidity in studies of PTSD, a recommendation that requires serious consideration for researchers operating in this field.
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Affiliation(s)
- T M Keane
- Department of Veterans Affairs Medical Center, Boston, Massachusetts 02130, USA
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20
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Frueh BC, Smith DW, Libet JM. Racial differences on psychological measures in combat veterans seeking treatment for PTSD. J Pers Assess 1996; 66:41-53. [PMID: 8576834 DOI: 10.1207/s15327752jpa6601_3] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In this article, we examined racial differences in psychometric data on 4 commonly used self-report inventories administered to a group of 206 combat veterans evaluated at a Veterans Affairs Medical Center outpatient posttraumatic stress disorder (PTSD) treatment program. Patients completed the Beck Depression Inventory, Mississippi Scale for Combat-Related PTSD, Dissociative Experiences Scale (DES), and Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Black veterans showed greater elevations than White veterans on the DES, and the F-K index and Scales 6 and 8 of the MMPI-2. In addition, normative data are presented for the entire sample on each measure. Results suggest that, consistent with studies using the original MMPI, these patients endorse severe levels of psychopathology across a broad range of symptoms, including depression and disturbed thinking. Implications for clinical practice and future research are addressed.
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Affiliation(s)
- B C Frueh
- Psychology Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401-5799, USA
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Munley PH, Bains DS, Bloem WD, Busby RM, Pendziszewski S. Posttraumatic stress disorder and the MCMI-II. Psychol Rep 1995; 76:939-44. [PMID: 7568611 DOI: 10.2466/pr0.1995.76.3.939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study investigated the MCMI-II profile characteristics of 39 veterans diagnosed with Posttraumatic Stress Disorder. Characteristics of the mean group profile were similar to prior findings reported in the literature on the MCMI and Posttraumatic Stress Disorder with highest mean elevations found on the Avoidant, Passive-Aggressive, Schizoid, and Antisocial basic personality scales, the Borderline and Schizotypal pathological personality scales, and with elevations on the Anxiety, Dysthymia, Alcohol Dependence, Drug Dependence, and Major Depression clinical syndrome scales. A multivariate analysis of variance comparing the group with Posttraumatic Stress Disorder with a non-PTSD comparison group of 39 on the basic personality, pathological personality, and the clinical syndrome scales of the MCMI-II was not statistically significant. Nonetheless, univariate analyses of variance comparing the two groups on the individual modifier scales and the individual personality and clinical syndrome scales of the MCMI-II using a Bonferroni adjusted probability indicated significant differences on the Desirability and Histrionic scales. Response-style bias as a possible factor in MCMI-II profiles for the group with Posttraumatic Stress Disorder is also discussed.
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Affiliation(s)
- P H Munley
- Psychology Service, VA Medical Center, Battle Creek, MI 49016, USA
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22
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Hovens JE, van der Ploeg HM, Bramsen I, Klaarenbeek MT, Schreuder JN, Rivero VV. The development of the Self-Rating Inventory for Posttraumatic Stress Disorder. Acta Psychiatr Scand 1994; 90:172-83. [PMID: 7810340 DOI: 10.1111/j.1600-0447.1994.tb01574.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In this study a newly developed Self-rating Inventory for Posttraumatic Stress Disorder (PTSD) is presented. The instrument consists of 47 items, reflecting DSM-III-R criteria, associated features and items corresponding to the disorder of extreme stress not otherwise specified. All items are phrased in a trauma-independent way and are measured on an intensity scale. The instrument was validated on 76 subjects with war-related trauma and 59 psychiatric outpatients, one third of whom were traumatized. Test-retest for the scale was 0.90. The coefficient alpha appeared to be 0.96 for the 47-items scale and 0.92 for the 22 DSM-III-R subscale. The scale correlated significantly with the Clinician Administered PTSD Scale, the Mississippi Scale for Combat-related PTSD, the MMPI PTSD subscale and the Impact of Event Scale. The overall efficiency of the Self-rating Inventory for PTSD was comparable to the overall efficiency of the Mississippi Scale and superior to the MMPI PTSD subscale. Factor analysis on the 22 DSM-III-R items showed 4 factors, representing numbing, intrusion, avoidance and sleeping problems. It is concluded that the Self-rating Inventory for PTSD is a powerful instrument for diagnosing PTSD in survey research. The instrument appears to be capable of differentiating not only between PTSD and non-PTSD subjects but also between traumatized non-PTSD subjects and non-traumatized psychiatric patients.
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Affiliation(s)
- J E Hovens
- Centre 45, National Center for the Treatment of WW II Victims, Oegstgeest, The Netherlands
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23
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Abstract
A cluster analysis was used to identify groups of inpatients with confirmed post-traumatic stress disorder (PTSD) due to combat. In Study 1 the MCMI was administered to 256 subjects, in addition to the MMPI, PTSD measures, and background variables. Three clusters resulted: a Traumatic Personality (8-2), Schizoid Influence (8-2-1), and Antisocial Influence (8-6). Comparison on the MCMI symptom scales, MMPI, and PTSD scales showed that the Antisocial Influence cluster was "healthier" on all measures. The Schizoid Influence was most psychopathological. In Study 2 the MCMI-II was administered to 136 new subjects who met the same criteria as in Study 1. Four clusters resulted: Global (1-2-6A-6B-8A-8B), Subclinical (1), Aggressive (6A-6B-8A), and Detached/Self-defeating (1-2-8A-8B).
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Affiliation(s)
- L Hyer
- Veterans Administration, Augusta, Georgia
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24
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Frueh BC, Kinder BN. The susceptibility of the Rorschach Inkblot Test to malingering of combat-related PTSD. J Pers Assess 1994; 62:280-98. [PMID: 8189337 DOI: 10.1207/s15327752jpa6202_9] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The ability of subjects to alter their responses on the Rorschach and self-report measures to fake the symptoms of combat-related Posttraumatic Stress Disorder (PTSD) was investigated. Subjects were 40 White male undergraduates, randomly assigned to either a control or role-informed malingerer group, and 20 White Vietnam veterans with PTSD. Subjects were administered the Rorschach, MMPI-2 validity scales, and Mississippi Scale for Combat-Related PTSD. Results indicated that malingerers were able to achieve scores similar to the PTSD patients on the Mississippi Scale and some Rorschach variables. However, they evidenced significant differences on the MMPI-2 validity scales and several important Rorschach variables. Malingerers typically gave responses that were overly dramatic and less complicated, less emotionally restrained, and indicated an exaggerated sense of impaired reality testing as compared to PTSD patients. Behavioral differences were also noted between the groups. Findings are discussed in the context of the study's limitations and the practical detection of malingered PTSD in clinical settings.
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Affiliation(s)
- B C Frueh
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC 29401-5799
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25
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Abstract
MMPI profiles for 87 PTSD veteran inpatients were classified and studied according to MMPI F Scale elevation. Mean MMPI profiles and frequency of high two-point code types were studied for different levels of F Scale elevation. Similar mean profile configurations were found for subgroups with F > or = 70 with Scales 2 and 8 appearing as the two highest clinical scales. For F < 70 the configuration was different in that Scale 8 was not one of the two highest scales. The 2-8/8-2 high two-point code was the modal high two-point code for the total sample but the relative frequency of high two-point codes did vary somewhat within and across levels of F Scale elevation.
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Affiliation(s)
- P H Munley
- VA Medical Center, Battle Creek, MI 49016
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26
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Hyer LA, Albrecht JW, Boudewyns PA, Woods MG, Brandsma J. Dissociative experiences of Vietnam veterans with chronic posttraumatic stress disorder. Psychol Rep 1993; 73:519-30. [PMID: 8234605 DOI: 10.2466/pr0.1993.73.2.519] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Interest in dissociation has been renewed, and its relationship to Post-traumatic Stress Disorder is especially intriguing. In this study 57 consecutively admitted chronic, combat-related Posttraumatic Stress Disorder sufferers were grouped by scores on a dissociative scale (Dissociative Experiences Scale). The three groups (high, medium, and low) were compared on personality measures (MMPI basic scales and subscales, and Millon's MCMI), Posttraumatic Stress Disorder measures, and a psychophysiological index of heart rate under baseline trauma conditions. The results showed that the survivors with more dissociative experiences show distinctive and higher symptom levels--excessive fearfulness, symptoms of strange experiences, and high tonic psychophysiological states--as well as greater severity of ratings of Posttraumatic Stress Disorder (on the Mississippi Scale). The discussion addressed the possible role of dissociation in Posttraumatic Stress Disorder.
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Affiliation(s)
- L A Hyer
- Veterans Affairs Medical Center, Augusta, GA 30910
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27
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Elwood RW. The clinical utility of the MMPI-2 in diagnosing unipolar depression among male alcoholics. J Pers Assess 1993; 60:511-21. [PMID: 8336266 DOI: 10.1207/s15327752jpa6003_8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The correspondence between Scale 2 elevations on the MMPI-2 and SCID-diagnosed unipolar depression (major depression and dysthymia) and alcohol-induced depression was evaluated among 106 consecutive male admissions to an inpatient alcohol treatment unit. Valid profiles were obtained from 87 subjects, 15% of whom were diagnosed with unipolar depression and another 4.5% with presumed alcohol-induced depression. The sensitivity of Scale 2 (the probability that a depressed subject would obtain an elevated score) ranged from .19 to .42. Positive predictive power (the probability that a subject who obtained an elevated score had a depressive disorder) ranged from .23 to .38. Neither Scale 2 alone nor Scale 2 paired in 2-point code types predicted the presence or absence of comorbid depressive disorders among male alcoholics.
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Affiliation(s)
- R W Elwood
- Department of Veterans Affairs Medical Center, Tomah, WI
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Hovens JE, Falger PR, Op den Velde W, Meijer P, de Groen JH, van Duijn H. A self-rating scale for the assessment of posttraumatic stress disorder in Dutch Resistance veterans of World War II. J Clin Psychol 1993; 49:196-203. [PMID: 8486800 DOI: 10.1002/1097-4679(199303)49:2<196::aid-jclp2270490210>3.0.co;2-n] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The present study reports on the development of a Dutch PTSD scale based on the DSM-III criteria for PTSD. Test-retest reliability was .91. The scale showed an internal consistency with a coefficient alpha of .88. Factor analysis on a large sample of Resistance veterans (N = 967) yielded six factors, which represent intrusive thoughts, physiological reactions, detachment, rage, active confrontation, and guilt.
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Affiliation(s)
- J E Hovens
- Centrum 45, National Center for the Treatment of WW II Victims, Oegstgeest and Psychiatric Hospital Het Christelijk Sanatorium, Zeist, The Netherlands
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Hyer L, Davis H, Woods G, Albrecht JW, Boudewyns P. Relationship between the Millon Clinical Multiaxial Inventory and the Millon-II: value of scales for Aggressive and Self-defeating personalities in Posttraumatic Stress Disorder. Psychol Rep 1992; 71:867-79. [PMID: 1454937 DOI: 10.2466/pr0.1992.71.3.867] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This study addressed two issues, the interrelationship between the Millon Clinical Multiaxial Inventory (MCMI) and the Millon II (MCMI-II) and the value of the new personality scales, Aggressive and Self-defeating, in a sample with diagnoses of combat-related Posttraumatic Stress Disorder. 100 confirmed cases of combat-related Posttraumatic Stress Disorder were given a battery of measures including both Millon inventories and the Minnesota Multiphasic Personality Inventory (basic scales and selected subscales). They were rated on discharge status during a structured treatment program. Basic treatment and background information were also obtained. Analysis showed scores on the MCMI-II scales were higher but generally reflective of MCMI scales and that the Self-defeating personality style tends to be reflective of greater psychopathology, suicidal problems, treatment/disposition difficulties, overreporting of symptoms, and intensity of problems. Discussion encouraged the use of the MCMI-II with special emphasis given to the Self-defeating style in this group with Posttraumatic Stress Disorder.
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Affiliation(s)
- L Hyer
- Department of Veterans Affairs Medical Center, Augusta, GA 30910
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30
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Litz BT, Penk WE, Walsh S, Hyer L, Blake DD, Marx B, Keane TM, Bitman D. Similarities and differences between MMPI and MMPI-2 applications to the assessment of posttraumatic stress disorder. J Pers Assess 1991; 57:238-53. [PMID: 1955973 DOI: 10.1207/s15327752jpa5702_4] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The purpose of this study was to address the question: Is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) comparable to the original MMPI in its applicability to the assessment of posttraumatic stress disorder (PTSD) among Vietnam combat veterans? The question was addressed by administering both the original MMPI and MMPI-2 to 29 subjects classified as meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R) criteria for PTSD and comparing MMPI and MMPI-2 scores in terms of: degree of association, code-type congruence, diagnostic hit rates (when compared to two other clinical samples, and one normal sample), and congruence of the Keane PTSD Scale (PK). Results reveal highly significant correlations between MMPI and MMPI-2 basic scales for the PTSD sample as well as congruence in 2-point codes comparable to previous studies. The MMPI-2 was found to identify effectively PTSD subjects from the other groups. Results also showed a high degree of association between the MMPI and MMPI-2 in regard to PK scores, although minor differences were found in PK raw scores between the two tests. Overall, the findings suggest a high degree of comparability between the MMPI and MMPI-2 in the assessment of PTSD.
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Affiliation(s)
- B T Litz
- Boston Veterans Administration Medical Center
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31
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Abstract
Suicidal behavior among Vietnam veterans with chronic Post-traumatic Stress Disorder (PTSD) was evaluated. Sixty chronic PTSD vets admitted to a Specialized PTSD Unit were divided into two groups based on the presence of suicidal behavior: 29 patients in a Suicide Group and 31 in a Non-suicide Group. Subjects were evaluated on symptoms, psychometric measures, military variables, adjustment factors, and pre-military parental patterns of discipline. Results showed that the Suicide Group possessed problems in paternal child-rearing patterns, current adjustment difficulties, and the PTSD symptoms of survival guilt and crying. In a regression analysis, paternal inconsistency of love, survivor guilt, and tendency to cry, in addition to age and sex, accounted for the significant variance of suicidal behavior.
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Affiliation(s)
- L Hyer
- Veterans Administration Medical Center, Augusta, Georgia
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32
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Hyer L, Boudewyns P, Harrison WR, O'Leary WC, Bruno RD, Saucer RT, Blount JB. Vietnam veterans: overreporting versus acceptable reporting of symptoms. J Pers Assess 1988; 52:475-86. [PMID: 3210120 DOI: 10.1207/s15327752jpa5203_9] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- L Hyer
- Veterans Administration Medical Center, Augusta, GA
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