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

The Importance of the Morel Emotional Numbing Test Instructions: A Diagnosis Threat Induction Study

OBJECTIVE

Marketed as a validity test that detects feigning of posttraumatic stress disorder (PTSD), the Morel Emotional Numbing Test for PTSD (MENT) instructs examinees that PTSD may negatively affect performance on the measure. This study explored the potential that MENT performance depends on inclusion of "PTSD" in its instructions and the nature of the MENT as a performance validity versus a symptom validity test (PVT/SVT).

METHOD

358 participants completed the MENT as a part of a clinical neuropsychological evaluation. Participants were either administered the MENT with the standard instructions (SIs) that referenced "PTSD" or revised instructions (RIs) that did not. Others were administered instructions that referenced "ADHD" rather than PTSD (AI). Comparisons were conducted on those who presented with concerns for potential traumatic-stress related symptoms (SI vs. RI-1) or attention deficit (AI vs. RI-2).

RESULTS

Participants in either the SI or AI condition produced more MENT errors than those in their respective RI conditions. The relationship between MENT errors and other S/PVTs was significantly stronger in the SI: RI-1 comparison, such that errors correlated with self-reported trauma-related symptoms in the SI but not RI-1 condition. MENT failure also predicted PVT failure at nearly four times the rate of SVT failure.

CONCLUSIONS

Findings suggest that the MENT relies on overt reference to PTSD in its instructions, which is linked to the growing body of literature on "diagnosis threat" effects. The MENT may be considered a measure of suggestibility. Ethical considerations are discussed, as are the construct(s) measured by PVTs versus SVTs.

Subjective Cognitive Dysfunction in Patients With and Without Fibromyalgia: Prevalence, Predictors, Correlates, and Consequences

BACKGROUND

Subjective cognitive dysfunction (SCD) is common in fibromyalgia (FM), where it has been called 'fibrofog.' But its predictors and correlates are not well understood, including the extent to which SCD is present in fibromyalgia and non-fibromyalgia clinical populations. In addition, there are no studies available concerning SCD and fibromyalgia in the general population. We investigated these issues in a longitudinal rheumatic disease research databank and two cross-sectional general population studies.

METHODS

11,150 unselected patients with rheumatoid arthritis completed an assessment of FM and cognitive severity (CS) status using the full 0-3 fibromyalgia 2016 criteria assessment. In addition, CS was dummy coded as present/absent (CS+). Assessments of SCD and fibromyalgia prevalence were available in two German general population studies.

RESULTS

Fibromyalgia was present (FM+) in 2,493 (21.7%) of clinical subjects and absent (FM-) in 9,017 (78.3%) by FM 2016 criteria. Cognitive severity was present in 1,304 (52.3%) of those with fibromyalgia and 1,009 (11.2%) of non-fibromyalgia subjects (FM-). In two general population studies, 42.0% to 52.3% of those with fibromyalgia were CS+ as were 1.4% to 5.5% of FM- subjects. Patients with CS+ had more abnormal scores for every measure of rheumatoid arthritis (RA) severity, fibromyalgia severity, and general health. The presence of CS+ was strongly related to somatic and non-somatic symptoms scores and less strongly to pain variables. The best predictor of CS+ in the clinic and the general population was the symptom severity scale (SSS), a criterion of fibromyalgia.

CONCLUSIONS

Persons with SCD have high counts of somatic and psychological symptoms. Subjective cognitive dysfunction is best predicted by a simple symptoms score, and not by pain extent scores. Although SCD is called fibrofog in patients with FM, 43.6% of CS+ cases occurred in FM- subjects. Fibromyalgia and CS are correlated but appear to be different parts of a symptom severity continuum. 'Fibrofog' as a phenomenon linked only to fibromyalgia is a misnomer because it can be identified in many non-fibromyalgia patients as well.

Consistency does not aid detection of feigned symptoms, overreporting does: Two explorative studies on symptom stability among truth tellers and feigners

Practitioners always want to exclude the possibility that a patient is feigning symptoms. Some experts have suggested that an inconsistent symptom presentation across time (i.e., intraindividual variability) is indicative of feigning. We investigated how individuals with genuine pain-related symptoms (truth tellers; Study 1 n = 32; Study 2 n = 48) and people feigning such complaints (feigners; Study 1 n = 32; Study 2 n = 28) rated the intensity of their symptoms across a 5-day period. In both studies, feigners reported on all 5 days significantly higher symptom intensities than people with genuine complaints, but the two groups did not differ with regard to symptom (in)consistency. Thus, persistently inflated, rather than inconsistent, reports of symptom intensity over time are suggestive of feigning. The implications and limitations of our work are discussed.

Consideration of substance use in compensation and pension examinations of veterans filing PTSD claims

Veterans filing claims that service-induced PTSD impairs them worry that claims examiners may attribute their difficulties to conditions other than PTSD, such as substance use. Substance use commonly co-occurs with PTSD and complicates establishing a PTSD diagnosis because symptoms may be explained by PTSD alone, PTSD-induced substance use, or by a substance use condition independent of PTSD. These alternative explanations of symptoms lead to different conclusions about whether a PTSD diagnosis can be made. How substance use impacts an examiner’s diagnosis of PTSD in a Veteran’s service-connection claim has not been previously studied. In this study, we tested the hypothesis that mention of risky substance use in the Compensation & Pension (C&P) examination would result in a lower likelihood of service-connection award, presumably because substance use reflected an alternative explanation for symptoms. Data were analyzed from 208 Veterans’ C&P examinations, medical records, and confidentially-collected research assessments. In this sample, 165/208 (79%) Veterans’ claims were approved for a mental health condition; 70/83 (84%) with risky substance use mentioned and 95/125 (76%) without risky use mentioned (p = .02). Contrary to the a priori hypothesis, Veterans with risky substance use were more likely to get a service-connection award, even after controlling for baseline PTSD severity and other potential confounds. They had almost twice the odds of receiving any mental health award and 2.4 times greater odds of receiving an award for PTSD specifically. These data contradict assertions of bias against Veterans with risky substance use when their claims are reviewed. The data are more consistent with substance use often being judged as a symptom of PTSD. The more liberal granting of awards is consistent with literature concerning comorbid PTSD and substance use, and with claims procedures that make it more likely that substance use will be attributed to trauma exposure than to other causes.

Neural correlates of response bias: Larger hippocampal volume correlates with symptom aggravation in combat-related posttraumatic stress disorder

The diagnosis of posttraumatic stress disorder (PTSD) is vulnerable to the simulation or exaggeration of symptoms as it depends on the individual's self-report of symptoms. The use of symptom validity tests is recommended to detect malingering in PTSD. However, in neuroimaging research, PTSD diagnosis is often taken at face validity. To date, no neuroimaging study has compared credible PTSD patients with those identified as malingering, and the potential impacts of including malingerers along with credible patients on results is unclear. We classified male patients with combat-related PTSD as either credible (n = 37) or malingerers (n = 9) based on the Morel Emotional Numbing Test and compared structural neuroimaging and psychological questionnaire data. Patients identified as malingerers had larger gray matter volumes in the hippocampus, right inferior frontal gyrus and thalamus, and reported higher PTSD symptoms than credible PTSD patients. This is the first structural neuroimaging study to compare credible PTSD patients and malingerers. We find evidence of structural differences between these groups, in regions implicated in PTSD, inhibition and deception. These results emphasize the need for the inclusion of SVTs in neuroimaging studies of PTSD to ensure future findings are not confounded by an unknown mix of valid PTSD patients and malingerers.

Patient, Therapist, and System Factors Influencing the Effectiveness of Prolonged Exposure for Veterans With Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury

In contrast to concerns that cognitive limitations and neurobehavioral symptoms (NBS) associated with traumatic brain injury (TBI) may inhibit treatment effectiveness, a recent study found prolonged exposure (PE) led to large reductions in posttraumatic stress disorder (PTSD) symptoms among Iraq-Afghanistan veterans with a range of TBI severity (article by Wolf, Kretzmer, Crawford, Thors, Wagner, Strom, Eftekhari, Klenk, Hayward, and Vanderploeg [J Trauma Stress 28:339-347, 2015]). We further examined this sample of 69 veterans to determine whether system, veteran, and therapist factors predicted clinically significant responses. Results of hierarchical, logistic regressions revealed that therapist training in PE and lower service connection were associated with increased odds of large decreases in PTSD symptoms after adjusting for the robust effect of PE sessions completed. Other patient-level factors including age, time since injury, and baseline NBS were unrelated to significant improvements. Findings emphasized the impact of PE dosage, indicated greater mastery of the protocol was beneficial, and showed that service connection could impede self-reported, clinically significant change during PE in this important cohort.

Moral transgression during the Vietnam War: a path analysis of the psychological impact of veterans' involvement in wartime atrocities

BACKGROUND AND OBJECTIVES

Involvement in wartime combat often conveys a number of deleterious outcomes, including posttraumatic stress disorder (PTSD), depression, hostility, aggression, and suicidal ideation. Less studied is the effect of engagement in wartime atrocities, including witnessing and perpetrating abusive violence.

DESIGN AND METHODS

This study employed path analysis to examine the direct effects of involvement in wartime atrocities on hostility, aggression, depression, and suicidal ideation independent of combat exposure, as well as the indirect effects via guilt and PTSD symptom severity among 603 help-seeking male Vietnam War veterans.

RESULTS

Involvement in wartime atrocities was predictive of increased guilt, PTSD severity, hostility, aggression, depressive symptoms, and suicidal ideation after controlling for overall combat exposure. Combat-related guilt played a minor role in mediating the effect of atrocity involvement on depression and suicidal ideation. PTSD severity had a larger mediational effect. However, it still accounted for less than half of the total effect of involvement in wartime atrocities on hostility, aggression, and suicidal ideation.

CONCLUSIONS

These findings highlight the heightened risk conveyed by involvement in wartime atrocities and suggest that the psychological sequelae experienced following atrocity involvement may extend well beyond guilt and PTSD.

The Incremental Validity and Clinical Utility of the MMPI-2 Infrequency Posttraumatic Stress Disorder Scale

The incremental validity and clinical utility of the recently developed Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Infrequency Posttraumatic Stress Disorder Scale (Fptsd) was examined in relation to the family of MMPI-2 F scales in distinguishing feigned post-traumatic stress disorder (PTSD) from disability claimants with PTSD. Research participants instructed to feign PTSD when completing the MMPI-2 scored significantly higher on the MMPI-2 family of F scales and the Fptsd scale compared with their responses when completing the MMPI-2 under standard instructions and the sample of claimants with PTSD. Although comparable in magnitude, effect sizes derived from mean group differences and hierarchical logistic regressions for the Fptsd scale never exceeded those for F B , and F P , F, F B , and F P added incrementally to Fptsd in the prediction of feigned PTSD. These results suggest that the Fptsd scale does not afford any incremental predictive utility for detecting feigned PTSD relative to the complement of the existing family of F scales.

An MMPI-2 Scale to Detect Malingered Depression (Md Scale)

A specialized Minnesota Multiphasic Personality Inventory–2 (MMPI–2) validity scale was constructed to detect individuals who are knowledgeable about either depression or MMPI-2 detection strategies and who subsequently attempt to malinger depressive symptoms on the MMPI-2. The Malingered Depression (Md) scale consists of 32 items that discriminated college students who feigned depression from those who were genuinely depressed. Further information about the incremental validity and the utility of the Md scale was obtained in a cross-validation study with additional college students who feigned depression and a sample of students with clinically significant depressive symptoms. The results indicate that the Md scale possesses promising value in detecting malingered symptoms of depression.

Detecting feigned postconcussional and posttraumatic stress symptoms with the structured inventory of malingered symptomatology (SIMS)

The Structured Inventory of Malingered Symptomatology (SIMS) is a standalone symptom validity test (SVT) designed as a screening measure to detect a variety of exaggerated psychological symptoms. A number of studies have explored the accuracy of the SIMS in litigious and clinical populations, yet few have examined the validity of the SIMS in detecting feigned symptoms of postconcussional disorder (PCD) and posttraumatic stress disorder (PTSD). The present study examined the sensitivity of the SIMS in detecting undergraduate simulators (N = 78) feigning symptoms of PCD, PTSD, and the comorbid presentation of both PCD and PTSD symptomatologies. Overall, the SIMS Total score produced the highest sensitivities for the PCD symptoms and PCD+PTSD symptoms groups (.89 and .85, respectively), and to a lesser extent, the PTSD symptoms group (.69). The Affective Disorders (AF) subscale was most sensitive to the PTSD symptoms group compared to the PCD and PCD+PTSD symptoms groups. Additional sensitivity values are presented and examined at multiple scale cutoff scores. These findings support the use of the SIMS as a SVT screening measure for PCD and PTSD symptom exaggeration in neuropsychological assessment.

Etiology of depression comorbidity in combat-related PTSD: a review of the literature

Posttraumatic stress disorder is often diagnosed with other mental health problems, particularly depression. Although PTSD comorbidity has been associated with more severe and chronic symptomology, relationships among commonly co-occurring disorders are not well understood. The purpose of this study was to review the literature regarding the development of depression comorbid with combat-related PTSD among military personnel. We summarize results of commonly tested hypotheses about the etiology of PTSD and depression comorbidity, including (1) causal hypotheses, (2) common factor hypotheses, and (3) potential confounds. Evidence suggests that PTSD may be a causal risk factor for subsequent depression; however, associations are likely complex, involving bidirectional causality, common risk factors, and common vulnerabilities. The unique nature of PTSD-depression comorbidity in the context of military deployment and combat exposure is emphasized. Implications of our results for clinical practice and future research are discussed.

Attentional functioning in patients with posttraumatic stress disorder: a preliminary study

OBJECTIVE

To compare patients with posttraumatic stress disorder (PTSD) to patients without psychiatric or cognitive disorders on neuropsychological measures of attention.

METHODS

The sample included 19 patients with PTSD and 22 participants with no cognitive or psychiatric diagnosis. All had been referred for clinical neuropsychological evaluation at a VA Medical Center. None were diagnosed with dementia, delirium, or current substance dependence except nicotine or caffeine, and none had a history of stroke or of traumatic brain injury with loss of consciousness. Patients were excluded if they failed to exert adequate effort on testing.

RESULTS

PTSD patients performed significantly more poorly than patients without psychiatric diagnoses on Digit Span.

CONCLUSION

PTSD patients were impaired relative to participants without psychiatric diagnoses on a measure of focused attention. Several factors, including the small sample size, suggest that the results should be considered preliminary.

Compensation and treatment: disability benefits and outcomes of U.S. veterans receiving residential PTSD treatment

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma-related symptoms in addition to providing service-connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.

A Latent Growth Mixture Modeling Approach to PTSD Symptoms in Rape Victims

The research literature has suggested that longitudinal changes in posttraumatic stress disorder (PTSD) could be adequately described in terms of one universal trajectory, with individual differences in baseline levels (intercept) and rate of change (slope) being negligible. However, not everyone who has experienced a trauma is diagnosed with PTSD, and symptom severity levels differ between individuals exposed to similar traumas. The current study employed the latent growth mixture modeling technique to test for multiple trajectories using data from a sample of Danish rape victims (N = 255). In addition, the analysis aimed to determine whether a number of explanatory variables could differentiate between the trajectories (age, acute stress disorder [ASD], and perceived social support). Results concluded the existence of two PTSD trajectories. ASD was found to be the only significant predictor of one trajectory characterized by high initial levels of PTSD symptomatology. The present findings confirmed the existence of multiple trajectories with regard to PTSD symptomatology in a way that may be useful to clinicians working with this population.

A qualitative study of U.S. veterans' reasons for seeking Department of Veterans Affairs disability benefits for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is the most prevalent compensable mental disorder within the U.S. Department of Veterans Affairs disability system and the number of veterans with PTSD service-connected disability has increased steadily over the past decade. An understanding of the reasons veterans apply for PTSD disability status may inform interpretation of this increase and policies and interventions to assist veterans with military-related PTSD. The authors conducted an exploratory qualitative study to describe the reasons veterans seek PTSD disability benefits and explored differences between those who served in different military service eras. They gathered data through in-depth interviews with 44 purposefully selected U.S. veterans, and conducted content analysis of transcribed interviews using inductive and deductive analysis with constant comparison. Participants described 5 interrelated categories of reasons for seeking PTSD disability benefits, including 3 internal factors (tangible need, need for problem identification or clarification, beliefs that justify/legitimize PTSD disability status) and 2 external factors (encouragement from trusted others and professional assistance). There were no major differences by service era. Findings may help policy makers, providers, and researchers understand what veterans hope to achieve through PTSD disability and the instrumental role of social networks and government systems in promoting the pursuit of PTSD disability status.

Recalled peritraumatic reactions, self-reported PTSD, and the impact of malingering and fantasy proneness in victims of interpersonal violence who have applied for state compensation

The present study explores the associations between three types of peritraumatic reactions (dissociation, distress, and tonic immobility) and posttraumatic stress disorder (PTSD) symptoms in a sample of 125 victims of interpersonal violence who had applied for compensation with the Dutch Victim Compensation Fund (DCVF). In addition, the confounding roles of malingering and fantasy proneness are examined. Results indicate that tonic immobility did not predict PTSD symptom levels when adjusting for other forms of peritraumatic reactions, whereas peritraumatic dissociation and distress did. However, after the effects of malingering and fantasy proneness had been controlled for, malingering is the only factor associated with increased PTSD symptomatology. Implications for policy practice as well as study strengths and limitations are discussed.

Prevalence and predictors of posttraumatic stress disorder among victims of violence applying for state compensation

Many studies have focused on the predictive value of victims' emotions experienced shortly after violence exposure to identify those vulnerable for development of posttraumatic stress disorder (PTSD). However, many victims remain unidentified during the initial recovery phase, yet may still be highly in need of psychological help after substantial time since victimization has passed. Professionals involved in the settlement of civil damage claims filed by victims of violence may play an important role in referring victims with current psychological problems to appropriate treatment services, as they are likely to maintain relations with victims until all compensation possibilities have been exhausted. As an exploratory examination of this topic, the current study investigates the potential utility of file characteristics as predictors of chronic PTSD among 686 victims of violence who had applied for state compensation with the Dutch Victim Compensation Fund (DVCF) in 2006. Identification of significant predictors is preceded by estimating prevalence rates of PTSD. Results indicate that approximately 1 of 2 victims applying for state compensation in the Netherlands still have PTSD many years after victimization and claim settlement. Age, female sex, time since victimization, acquaintance with the perpetrator, violence-related hospitalization, and compensation for immaterial damage prove to be predictive of PTSD, although female sex and immaterial damage compensation fail to reach significance after adjusting for recalled peritraumatic distress severity. Implications for policy practice as well as strengths and limitations of the study are discussed.

Detecting faked psychopathology: a comparison of two tests to detect malingered psychopathology using a simulation design

Malingered psychopathology has the potential to be a costly social problem and there is a need for studies that compare the malingering detection capabilities of tests of psychopathology. This study investigated the capacity of two measures to detect simulated psychopathology. Forty-one first-year psychology students were randomly allocated to experimental groups that included malingering and control conditions. Analogue malingerers were given a financial incentive to simulate believable psychological impairment. Controls received standardised test instructions and the prize incentive, contingent on good effort. In a between-group simulation design, group differences on the Personality Assessment Inventory (PAI) and the revised Symptom Checklist-90 (SCL-90-R) were assessed. Group comparisons revealed elevation of the majority of clinical index scores among malingerers and a consistent pattern of results across tests. Analysis of the test operating characteristics of the malingering indices for these measures revealed superior detection of simulated malingering using the PAI, particularly Rogers' Discriminant Function, although classification accuracy of all malingering indexes was improved when adjusted cut-offs were used. Overall, results from this study demonstrate the vulnerability of the PAI and (SCL-90-R) to simulated psychopathology, but also the capacity of these measures to detect such performance when specific indexes are used.

Giving context to post-deployment post-concussive-like symptoms: blast-related potential mild traumatic brain injury and comorbidities

In the military and Veterans Administration systems, individuals with potential MTBI are presenting with symptoms in excess of what would be expected based on initial injury characteristics and/or at unexpected time periods based on current research findings. This article investigates factors that might account for the discrepancy between current research expectations and some occurrences in clinical practice. The physics of blast waves, as well as animal and human research, relevant to explosions are reviewed. Additional factors that occur within the military blast exposure milieu are also explored because the context in which an injury occurs can potentially impact symptom severity and course of recovery. Differential diagnoses, iatrogenic illness, diagnosis threat, and symptom embellishment are also considered.

Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder

Veteran subjects with chronic, combat-related posttraumatic stress disorder (PTSD) are frequently used as research subjects in the study of PTSD. However, questions have consistently been raised regarding PTSD symptom exaggeration in veteran populations due to the relationship between PTSD symptoms and disability payments within the Veterans Affairs (VA) system. We used a variety of standardized forensic instruments frequently utilized in measuring symptom exaggeration - including the MMPI-2, the Structured Interview for Reported Symptoms (SIRS), the Structured Inventory of Malingered Symptomatology (SIMS), and the Miller Forensic Assessment Test (MFAST) - to examine symptom report in a group of veterans presenting for treatment at a VA residential PTSD treatment program. The majority of Vietnam veteran subjects in our study (53%) exhibited clear symptom exaggeration by SIRS criteria. Within the entire subject group, total SIRS scores correlated significantly with reported PTSD symptom severity as measured by the Clinician Administered PTSD Scale (CAPS).

Changes in psychiatric status and service use associated with continued compensation seeking after claim determinations for posttraumatic stress disorder

This study examined changes in psychiatric status and use of VA mental health services after the adjudication of Department of Veterans Affairs (VA) disability claims for posttraumatic stress disorder (PTSD) in a sample of 101 veteran claimants. Hypotheses were based on the premise that the claims process may create incentives for veterans to demonstrate illness. After the PTSD claim determination, half the sample had filed or planned to file a claim for a rating increase or an appeal and thus remained compensation seeking. Contradicting the authors' hypotheses, psychiatric status did not improve and treatment drop-out rates did not increase among veterans who were no longer compensation seeking after the claim determination. Results have implications for the design and direction of future research.

Validity Rates of the Personality Assessment Inventory and the Minnesota Multiphasic Personality Inventory–2 in a VA Medical Center Setting

In this study, we compared protocol validity rates between the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and the Personality Assessment Inventory (PAI; Morey, 1991) in a veteran population. Veterans (N=472) were administered both instruments as part of routine psychological evaluations. Profile validity was based on previously published criteria. When applying primary validity indicators, inpatients produced significantly fewer invalid PAI profiles (37%) than MMPI-2 profiles (63%). We found similar results among outpatients for which we considered 47% of MMPI-2 profiles invalid compared to only 21% of PAI profiles. When applying both primary and supplementary validity indicators, both inpatients and outpatients continued to produce fewer invalid PAI profiles than MMPI-2 profiles. We discuss factors that may be related to the differences in validity rates.

Does posttraumatic stress disorder (PTSD) affect performance?

Research has increasingly identified alarming levels of traumatic stress symptoms in individuals working in emergency services and other high stress jobs. This study examined the effects of prior critical incident exposure and current posttraumatic symptoms on the performance of a nonpatient population, police recruits, during an acutely stressful event. A stressful policing situation was created through the use of a video simulator room that was responsive to actions of participants. The performance of participants to the simulated emergency was evaluated by 3 independent blinded raters. Prior exposure to critical incidents was measured using the Critical Incident History Questionnaire and current level of traumatic stress symptoms was measured using the Impact of Events Scale-Revised. Neither previous exposure to critical incidents nor trauma symptoms correlated with performance level. Recruits with high or severe levels of trauma symptoms did not demonstrate impairments in judgment, communication, or situation control compared with their colleagues with lesser or no trauma symptoms. On the basis of these findings, there is no reason to believe that police recruits with PTSD are prone to making errors of communication or judgment that would place them or others at increased risk.

Absence of renal sequelae after childhood Escherichia coli O157:H7 gastroenteritis

Although a quarter of children who survive diarrhea-associated hemolytic uremic syndrome develop long-term renal sequelae, the prognosis of acute, self-limited Escherichia coli O157:H7 gastroenteritis has never been previously studied. Four years after a drinking water outbreak of E. coli O157:H7, we examined the risk of high blood pressure (>95th percentile expected for age, sex, and height), reduced kidney function, and microalbuminuria among previously healthy children and adolescents. Of the 951 participants, 313 were asymptomatic during the outbreak, 305 had moderate symptoms of acute gastroenteritis, and 333 had severe symptoms that necessitated medical attention. An additional 23 children who developed hemolytic uremic syndrome during the outbreak were excluded from this analysis. There were no differences in mean systolic blood pressure between those who had no, moderate, or severe symptoms of acute gastroenteritis during the outbreak (109, 110, and 107 mm Hg). Similarly, there were no group differences in diastolic blood pressure, estimated glomerular filtration rate, or random urine albumin to creatinine ratio (P ranged from 0.14 to 0.52), or in the adjusted relative risk of high blood pressure, a glomerular filtration rate <80 ml/min per 1.73 m(2), or microalbuminuria (P ranged from 0.23 to 0.89). Patients who presented to medical attention with gastroenteritis during this E. coli O157:H7 outbreak had an absence of renal sequelae 4 years later. With no existing data to support screening after self-limited E. coli O157:H7 gastroenteritis, we recommend that only those children who develop recognized features of hemolytic uremic syndrome be followed for long-term renal health.

Risk of hypertension and reduced kidney function after acute gastroenteritis from bacteria-contaminated drinking water

BACKGROUND

The long-term health consequences of acute bacterial gastroenteritis remain uncertain. We studied the risk of hypertension and reduced kidney function after an outbreak of acute gastroenteritis due to contamination of a regional drinking water supply with Escherichia coli O157:H7 and Campylobacter species.

METHODS

A total of 1958 adults with no known history of hypertension or kidney disease before the outbreak participated in a long-term follow-up study. Of the participants, 675 had been asymptomatic during the outbreak, 909 had had moderate symptoms of acute self-limited gastroenteritis, and 374 had had severe symptoms that necessitated medical attention. The outcomes of interest were a diagnosis of hypertension or the presence of reduced kidney function and albuminuria during the follow-up period.

RESULTS

After a mean follow-up of 3.7 years after the outbreak, hypertension was diagnosed in 27.0% of participants who had been asymptomatic during the outbreak and in 32.3% and 35.9% of those who had had moderate and severe symptoms of acute gastroenteritis respectively (trend p = 0.009). Compared with the asymptomatic participants, those with moderate and severe symptoms of gastroenteritis had an adjusted relative risk of hypertension of 1.15 (95% confidence interval [CI] 0.97-1.35) and 1.28 (95% CI 1.04-1.56) respectively. A similar graded association was seen for reduced kidney function, defined as the presence of an estimated glomerular filtration rate below 60 mL/min per 1.73 m2 (trend p = 0.03). No association was observed between gastroenteritis and the subsequent risk of albuminuria.

INTERPRETATION

Acute bacterial gastroenteritis necessitating medical attention was associated with an increased risk of hypertension and reduced kidney function 4 years after infection. Maintaining safe drinking water remains essential to human health, as transient bacterial contaminations may have implications well beyond a period of acute self-limited illness.

Response style and posttraumatic stress disorder (PTSD): a review

Response style is an important issue that is often not addressed when assessing or treating patients with posttraumatic stress disorder (PTSD). In this paper, various response styles are discussed along with their relevance to clinical work and research with PTSD patients. Two of the most prevalent measures of response style, the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Structured Interview of Reported Symptoms (SIRS) scales are evaluated for use in assessing for PTSD. In addition, the Trauma Symptom Inventory's potential for use in evaluating response style is briefly discussed. Implications for future work and directions for future investigation are outlined.

Veterans seeking disability benefits for post-traumatic stress disorder: who applies and the self-reported meaning of disability compensation

Assumptions about the characteristics and motivations of individuals pursuing disability status are well known. However, policy, programming and interventions need to be based on information about the actual sociodemographic characteristics of disabled individuals, as well as their goals in seeking disability status. In this study, we focus on veterans seeking disability compensation for post-traumatic stress disorder (PTSD) from the United States Department of Veterans Affairs. We present information on their life circumstances and their self-reported reasons for valuing the obtainment of veterans' disability status on the basis of PTSD. There was considerable variability in the background of veterans seeking disability status on the basis of PTSD. Of concern, only about half of these individuals were receiving any mental health treatment at the time of application. Most claimants reported seeking disability compensation for symbolic reasons, especially for acknowledgement, validation and relief from self-blame. Reasons having to do with improved finances were less frequently endorsed, although the importance of obtaining improved solvency through disability status decreased as income increased. The sense of investment in obtaining a sense of self-acceptance and acceptance from others through disability status varied by sociodemographic variables. Overall, findings suggest that individuals seeking disability benefits may have unmet mental health care needs, and that policy makers, investigators and providers should consider material benefit as one of many possible reasons for engaging in a disability compensation system.

Toxic mold and mycotoxins in neurotoxicity cases: Stachybotrys, Fusarium, Trichoderma, Aspergillus, Penicillium, Cladosporium, Alternaria, Trichothecenes

Presented is the argument that psychologists and neuropsychologists have no scientific basis for rendering opinions about causation given the current state of the literature. The critical question is whether in a residence or office inhalation of mold spores or mold metabolites, including mycotoxins, causes neuropsychological impairment or mental and emotional disorders. There has not been sufficient research to support such conclusions. Nonetheless, in the context of litigation, speculative opinions are rendered in lieu of scientifically well-founded conclusions. Resources for recognizing and coping with pseudoscientific arguments are suggested.

Symptom exaggeration and compensation seeking among combat veterans with posttraumatic stress disorder

Combat veterans seeking treatment for posttraumatic stress disorder (PTSD) tend to report high levels of psychopathology on self-report instruments. The purpose of the current archival study was to replicate research on the relationships among symptom exaggeration, attempts to obtain compensation, and treatment outcome on the Beck Depression Inventory, the Mississippi Scale for Combat-Related PTSD, and selected MMPI-2 and MCMI-II subscales. Results indicated that symptom exaggeration as defined by an MMPI-2 F-K index over 13 was related to higher scores on all scales examined. Compensation seeking was not related to assessment scores or exaggeration. Neither compensation seeking nor exaggeration was related to treatment outcome. Limitations of the study and implications for future research are discussed.

Refinement of the MMPI-2 F(p) scale is not necessary: a response to Gass and Luis

Gass and Luis (2001) reported that four MMPI-2 Lie scale items contained on the F(p) scale do not measure symptom exaggeration but measure defensiveness. They hold that elimination of the four Lie scale items improves the utility of the F(p) scale in the identification of exaggeration in VA samples. To directly address the assertion that removal of the L scale items from the F(p) scale enhances the predictive validity of F(p), data derived from a previously published study where 74 psychiatric inpatients were asked to retake the MMPI-2 and either feign psychopathology or respond in an honest manner were reanalyzed. The intact F(p) scale demonstrated a stronger correlation with group membership, increased incremental validity, and superior classification rates compared with the F(p) scale without the 4 Lie scale items. Consequently, the F(p) refinement recommended by Gass and Luis is unnecessary.

A cluster analysis of symptom patterns and adjustment in Vietnam combat veterans with chronic posttraumatic stress disorder

This study investigated whether a subgroup of veterans with malignant posttraumatic stress syndrome, as described by Rosenheck (1985) and Lambert et al. (1996), could be identified via cluster analysis within two samples of Vietnam veterans with combat-related posttraumatic stress disorder (PTSD). In the initial subsample (n = 157), four clusters were identified, including a subgroup that scored consistently higher on measures of interpersonal violence and current physical problems. Similar results were found in the cross-validation subsample (n = 156). These results provide support for the theoretical concept of malignant PTSD and suggest that veterans with chronic PTSD are not homogenous. Whereas some manifest extreme levels of both functional impairment and PTSD symptomatology, others exhibit markedly less functional impairment despite manifesting clinically significant levels of PTSD. Clinicians can consider this heterogeneity in their treatment decisions.

The Infrequency-Posttraumatic Stress Disorder scale (Fptsd) for the MMPI-2: development and initial validation with veterans presenting with combat-related PTSD

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.

Violence and hostility among families of Vietnam veterans with combat-related posttraumatic stress disorder

The current study provides a portrait of emotional-behavioral functioning within a small sample of Vietnam veterans with combat-related posttraumatic stress disorder (PTSD), their partners, and older adolescent and adult children. Veterans, their partners and children reported moderate-low to moderate-high levels of violent behavior. In addition, partner and veteran hostility scores were elevated relative to gender and age matched norms. Partners also reported heightened levels of psychological maltreatment by veterans. Veterans' combat exposure was positively correlated with hostility and violent behavior among children but unrelated to partner variables. Veterans' reports of PTSD symptoms were positively associated with reports of hostility and violence among children, and hostility and general psychological distress among partners. Veterans' violent behavior was also positively correlated with children's violent behavior, but did not yield significant correlations with other child or partner variables. Findings are discussed in relation to prior work and directions for future research are addressed.

Partners' ratings of combat veterans' anger

Spouse reports may serve as an important source of collateral information in the assessment of posttraumatic stress disorder (PTSD) and associated behavioral problems. This study examined the concordance of anger reports among 94 combat veterans and their partners. Veterans' scores on subscales of the Multidimensional Anger Inventory were compared with scores on a parallel version completed by partners to assess veterans' anger symptomatology. The study examined whether the concordance between veteran and partner-reported anger is moderated by whether the veteran suffers from PTSD. There was moderate agreement between veterans and their partners on reports of anger and little evidence to suggest that PTSD diagnosis affected the convergence between partner and veteran scores.