Racial differences on psychological measures in combat veterans seeking treatment for PTSD

Affirmative Psychological Testing and Neurocognitive Assessment with Transgender Adults

Neither consensus on best practice nor validated neuropsychological, intelligence, or personality testing batteries exist for assessment and psychological testing on the transgender population. Historically, assessment has been used in a gate-keeping fashion with transgender clients. There are no firm standards of care when considering the content and appropriateness of evaluations conducted presurgically. These evaluations are discussed in the setting of other presurgical evaluations, with a recommendation to move toward a competency to make a medical decisions model. Additional considerations are discussed, such as effects of transition on mood and how to interpret scores in a field where normative data are often gender stratified.

The psychological consequences of combat exposure: the importance of appraisals and post-traumatic stress disorder symptomatology in the occurrence of delusional-like ideas

OBJECTIVE

The aim of the current study is to explore the association between combat experience and the occurrence of delusional-like beliefs. It is hypothesized that negative post-trauma appraisals and positive beliefs about paranoia will be associated with vulnerability to delusional ideas and that veterans who meet criteria for post-traumatic stress disorder (PTSD) will be more likely to hold delusional-like ideas.

DESIGN

A small-scale survey design was employed in order to ensure that detailed information was gathered concerning battle exposure.

METHODS

Forty-one British war veterans completed questionnaires relating to combat experience, delusional ideation, beliefs about paranoia, appraisals of combat trauma and PTSD symptomatology.

RESULTS

Negative post-trauma cognitions and positive and negative beliefs about paranoia were associated with increased predisposition to delusional beliefs; however, the severity of combat experience was not. It was also found that veterans who met criteria for PTSD were more likely to hold delusional-like ideas compared with those who did not. Furthermore, the PTSD group held more negative post-trauma cognitions and more positive beliefs about paranoia.

CONCLUSIONS

These findings suggest that PTSD symptoms may confer vulnerability to delusional beliefs and that this may be mediated by negative appraisals about the self, the world and dysfunctional beliefs about paranoia. However, it is possible that psychotic-like phenomena confer vulnerability to PTSD. The implications of these findings are discussed.

An overview of posttraumatic stress disorder in African Americans

While several studies have found high rates of trauma exposure there is limited information on posttraumatic stress disorder (PTSD) and its relationship to depression in the African American population. The prevalence and/or expression of psychiatric disorders can differ between racial/ethnic groups. The authors review literature addressing trauma exposure, prevalence, and expression of PTSD in the African American population. Risk factors that may be of specific significance to the development of PTSD in African Americans are also reviewed. Additionally, treatment issues and potential directions for future research of PTSD in the African American population are discussed.

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

Psychometric Properties of the Posttraumatic Cognitions Inventory (PTCI): a replication with motor vehicle accident survivors

This study examined the factor structure, internal consistency, concurrent validity, discriminant validity, and discriminative validity of the Posttraumatic Cognitions Inventory (PTCI; E. B. Foa, A. Ehlers, D. M. Clark, D. F. Tolin, and S. M. Orsillo, 1999) in a sample of 112 individuals who had experienced a serious motor vehicle accident. Results generally supported the 3-factor structure of the PTCI: (a) Negative Cognitions About Self, (b) Negative Cognitions About the World, and (c) Self-Blame. Subscales reflecting negative thoughts of the self and world showed adequate internal consistency, as well as good concurrent, discriminant, and discriminative validity. However, difficulties with the subscale representing self-blame emerged, specifically poor concurrent and discriminant validity. Potential reasons for this finding are discussed. The PTCI seems to be a promising measure of negative and dysfunctional posttrauma cognitions, which deserves continuing attention.

Methodological Issues in Cross-Cultural and Multicultural Rorschach Research

Hermann Rorschach researched the utility of his inkblot experiment to understand psychopathology and cultural differences. Contemporary research with the Rorschach has evaluated its utility as a test, although it may more properly represent a clinical method with somewhat different evaluation criteria. Recent controversy regarding the adequacy of the Rorschach as a test and the adequacy of its normative data has at times distorted and oversimplified important methodological issues inherent in the study of cultural difference. Cultural processes remain a central and inadequately examined variable in Rorschach research; an important emergent area of inquiry is the Rorschach's clinical utility as a cross-cultural assessment instrument. We review multicultural and cross-cultural methodological issues intrinsic to contemporary Rorschach research here. Consideration of cultural issues enlarges and enriches the Rorschach clinical utility debate and suggests underexplored research strategies that can contribute to its resolution.

Assessment of response style in combat veterans seeking compensation for posttraumatic stress disorder

This study examined response styles of veterans seeking compensation for PTSD (N = 204). Veterans were classified as having a valid or overreporting response style based on their scores on three MMPI-2 validity scales that measure overreporting F, F(p), F-K. Sixteen percent of veterans had valid scores on all three scales. The number of veterans classified as having an overreporting response style differed depending on which scale was used. This finding highlights the importance of using multiple validity scales to measure response style. Veterans who were and were not classified as overreporters were compared on measures of combat exposure, PTSD, and depression.

Racial differences in psychotic symptoms among combat veterans with PTSD

We tested the hypothesis that race may influence clinical presentation and symptomatology in combat veterans with posttraumatic stress disorder (PTSD). African-American and Caucasian veterans were administered the Psychotic Screen Module of the Structured Clinical Interview for DSM, Minnesota Multiphasic Personality Inventory-2 (MMPI-2), and other psychometric measures at a Veterans Affairs outpatient PTSD clinic. Subjects were consecutive referrals who were not matched for level of combat trauma or preexisting trauma; however, there were no group differences in other relevant demographic or diagnostic variables. Significant racial differences, with modest effect sizes, were found on clinician ratings of psychotic symptoms, MMPI-2 scale 6 ("paranoia"), and a measure of dissociation. No significant differences were found for the MMPI-2 scale 8 ("schizophrenia"), or on measures that might suggest comorbid depression or anxiety. African-Americans with PTSD endorsed more items suggesting positive symptoms of psychosis, without higher rates of primary psychosis, depression, or anxiety than Caucasians.

Replication and expansion of findings related to racial differences in veterans with combat-related PTSD

Racial differences in those seeking treatment at a Veterans Affairs Medical Center (VAMC) outpatient posttraumatic stress disorder (PTSD) treatment program were examined. One hundred eleven (71 Caucasian and 40 African American) veterans were compared on both self-report measures and interview measures of PTSD, depression, dissociation, and general psychopathology. Participants completed the following self-report measures: the Beck Depression Inventory, the Dissociative Experiences Scale, the Mississippi Combat PTSD Scale, and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Participants also completed the Clinician Administered PTSD Scale (CAPS-1), which is a structured interview for PTSD, and completed a non-structured clinical interview. The two groups did not differ on measured demographic variables, nor were there significant differences on self-report or interview measures of anxiety, depression, or PTSD symptomatology. Contrary to expectation, groups did not differ on self-report measures of dissociation, paranoia, or schizophrenia. African Americans were significantly more likely to endorse items of bizarre mentation from the MMPI-2. These results suggest that African American and Caucasian veterans with combat-related PTSD do not differ with regard to manifestation or severity of psychopathology.

Differentiating overreporting and extreme distress: MMPI-2 use with compensation-seeking veterans with PTSD

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.

A comparison of MMPI-2 validity in African American and Caucasian psychiatric inpatients

This study investigated ethnic differences on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) in 229 African American and 1,558 Caucasian psychiatric inpatients. Mean differences were found on several MMPI-2 validity and clinical scales. These were generally consistent with differences between the groups, indicated by the available extratest criterion data. To identify potential bias, the authors conducted 65 step-down hierarchical multiple regression analyses, predicting conceptually relevant clinical criteria from either MMPI-2 clinical or content scales for each gender. A number of MMPI-2 scales evidenced bias reflecting minor underprediction of psychopathology in African Americans. It is important to note that, in almost all cases, the magnitude of these differences was small and not clinically significant.

An ethnocultural study of posttraumatic stress disorder in African-American and white American Vietnam War veterans

This study examined the intensity of Posttraumatic Stress Disorder (PTSD) symptoms as measured by the Mississippi Scale, the Keane (PK), and the PTSD (PS) Scales of the MMPI-2 in a sample of 34 African-American and 34 White American Vietnam War Veterans who sought treatment in a Specialized Inpatient PTSD Unit. The scores of the two groups on the Beck Depression Inventory and the clinical scales of the MMPI-2 were also compared. The ethnoculturally different sample was matched on intensity of combat exposure, marital status, employment status, age, and education. No significant differences on the measures of PTSD symptoms were noted and no significant differences were found on the Beck scale or the MMPI-2 clinical scales.

An Ethnocultural Study of Posttraumatic Stress Disorder in African-American and White American Vietnam War Veterans

This study examined the intensity of Posttraumatic Stress Disorder (PTSD) symptoms as measured by the Mississippi Scale, the Keane (PK), and the PTSD (PS) Scales of the MMPI-2 in a sample of 34 African-American and 34 White American Vietnam War Veterans who sought treatment in a Specialized Inpatient PTSD Unit. The scores of the two groups on the Beck Depression Inventory and the clinical scales of the MMPI-2 were also compared. The ethnoculturally different sample was matched on intensity of combat exposure, marital status, employment status, age, and education. No significant differences on the measures of PTSD symptoms were noted and no significant differences were found on the Beck scale or the MMPI-2 clinical scales.

Apparent symptom overreporting in combat veterans evaluated for PTSD

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.

Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder

BACKGROUND

Psychotic symptoms may be present in up to 40% of patients with combat-related posttraumatic stress disorder (PTSD). In this study, we hypothesized that severity of psychotic symptoms would also reflect severity of PTSD symptoms in patients with well-defined psychotic features.

METHODS

Forty-five Vietnam combat veterans with PTSD but without a primary psychotic disorder diagnosis underwent a Structured Clinical Interview for DSM-III-R with Psychotic Screen, and the Clinician Administered PTSD Scale (CAPS). Patients identified as having psychotic features (PTSD-P), (n = 22) also received the Positive and Negative Syndrome Scale (PANSS) and the Hamilton Depression Rating Scale (HDRS).

RESULTS

There was a significant positive correlation between the CAPS and PANSS global ratings (p < .001) and the HDRS and PANSS (p < .03) in the PTSD-P patients. Many CAPS and PANSS subscales also demonstrated significant intercorrelations; however, the CAPS-B subscale (reexperiencing) and the PANSS positive symptom scale were not correlated, suggesting that psychotic features may not necessarily be influenced or accounted for by more severe reexperiencing symptoms. Fifteen (68%) of the PTSD-P patients had major depression (MDD). Both CAPS and PANSS ratings were significantly higher in the PTSD-P patients with comorbid MDD.

CONCLUSIONS

As postulated, patients with more severe psychosis ratings are likely to have more severe PTSD disease burden if psychotic features are present. This study further documents the occurrence of psychotic features in PTSD that are not necessarily due to a primary psychotic disorder, suggesting that this may be a distinct subtype; however, a significant interaction likely exists between PTSD, depression, and psychotic features.

Racial differences in combat-related PTSD: empirical findings and conceptual issues

We critically review the empirical literature on racial differences in epidemiology, psychopathology, and treatment outcome in combat veterans with posttraumatic stress disorder (PTSD). Although there is a body of literature pertaining to various aspects of race and combat-related PTSD, much of the writing is conceptual in nature and based on single case or anecdotal reports, and there is a striking paucity of rigorous empirical findings. Furthermore, despite the prevailing zeitgeist and clinical lore, the limited extant empirical evidence suggests that veterans of different races are more similar to each other than they are different when it comes to the clinical manifestation and response to treatment of combat-related PTSD and associated features. The one area where clear differences exist is in epidemiological rates of PTSD, where minority combat veterans (i.e., Blacks and Hispanics) have been shown to have higher absolute rates of the disorder. However, secondary analyses within the existing epidemiological studies suggest that differential rates of PTSD between racial groups may be a function of differential rates of traumatic stressors and other pre-existing conditions. This finding, in combination with the general paucity of empirical data and certain methodological limitations, significantly moderates the conclusions that should be reached from this body of literature. Further research is needed before we can consider our knowledge in this area complete. A number of conceptual and methodological issues are discussed in order to highlight future research directions.

Symptom overreporting in combat veterans evaluated for PTSD: differentiation on the basis of compensation seeking status

We examined the role of compensation-seeking status on response patterns to self-report inventories of acute psychopathology and psychological distress in a group of 165 combat veterans evaluated for posttraumatic stress disorder (PTSD) at a Department of Veteran Affairs (VA) Medical Center. Veterans completed the Minnesota Multiphasic Personality Inventory-Revised, Beck Depression Inventory, Mississippi Scale for Combat-Related PTSD, a fixed-response format version of the Dissociative Experiences Scale, and Impact of Events Scale as part of a standard assessment battery. Results showed that compensation-seeking veterans endorsed dramatically higher levels of psychopathology across measures and produced sharply elevated "fake-bad" validity indices as compared to non-compensation-seeking veterans. Differences between the two groups on most scales and indices exceeded effect sizes of 1.0, even when effects of income, global assessment of functioning, and clinician-rated severity of PTSD were controlled for. It is suggested that the availability of VA disability compensation for combat-related PTSD impedes accurate initial assessment of veterans presenting for treatment and may impair estimation of long-term therapeutic outcome in this population.