Apparent symptom overreporting in combat veterans evaluated for ptsd

Clinical Psychology Review, Vol. 20, No. 7, pp. 853–885, 2000 Copyright © 2000 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/00/$–see front matter

PII S0272-7358(99)00015-X

APPARENT SYMPTOM OVERREPORTING IN COMBAT VETERANS EVALUATED FOR PTSD B. Christopher Frueh and Mark B. Hamner Veterans Affairs Medical Center, Medical University of South Carolina

Shawn P. Cahill and Paul B. Gold Medical University of South Carolina

Kasey L. Hamlin Veterans Affairs Medical Center

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 scales 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. © 2000 Elsevier Science Ltd KEY WORDS. PTSD, Combat, MMP1, Symptom Overreporting.

ACCURATE ASSESSMENT AND diagnosis of veterans with combat-related posttraumatic stress disorder (PTSD) is an important step in understanding the clinical syndrome and facilitating effective treatment strategies from both a research and clinical perspective. This assessment is complicate by a number of factors, including disorder

Correspondence should be addressed to B. Christopher Frueh, PhD, Mental Health Service (116), Veterans Affairs Medical Center, 109 Bee Street, Charleston, SC, 29401-5799.

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chronicity, comorbidity, disorder uniqueness and symptom overlap, instrument limitations, somatic and neuropsychological concomitants, and apparent symptom overreporting (Litz, Penk, Gerardi, & Keane, 1991; Oei, Lim, & Hennessy, 1990; Sutker, Uddo-Crane, & Allain, 1991; Watson, 1990). Of these factors, apparent symptom overreporting is perhaps the least understood and dramatically colors our understanding of the disorder. Psychometric studies have consistently shown that combat veterans evaluated for PTSD exhibit (a) extreme and diffuse levels of psychopathology across instruments measuring different domains of mental illness, and (b) extreme elevations on the validity scales of the Minnesota Multiphasic Personality Inventory (MMPI/MMPI-2), in a “fake-bad” direction (e.g., Fairbank, Keane, & Malloy, 1983). The phenomenon of this ubiquitous presentational style significantly complicates accurate assessment for purposes of both diagnostic decision-making and evaluation of treatment outcome. Systemic factors may play a role in that many veterans (e.g., 69– 94% of treatment seeking veterans; Fontana & Rosenheck, 1997a; Frueh, Smith, & Barker, 1996) apply for Veterans Affairs (VA) disability payments for PTSD, introducing prominent financial incentive into the picture. Given that most estimates put the lifetime prevalence of PTSD between 9% and 31% for those expose to combat (Card, 1987; Centers for Disease Control, 1988; Kulka et al., 1990; Southwick, Morgan et al., 1993), over 500,000 veterans in this country alone may suffer from PTSD symptomatology. Thus, the measurement problem posed is relevant to the VA medical system and the large number of veterans seeking treatment within it. In this review we discuss the assessment problem posed by this apparent symptom overreporting, summarize the literature regarding several potential explanatory factors, and address conceptual issues relevant to reaching a better understanding of the phenomenon. In addition, we discuss practical solutions aimed at improving our ability to accurately evaluate combat veterans within both research and clinical settings.

THE PHENOMENON OF APPARENT SYMPTOM OVERREPORTING

Extreme and Diffuse Levels of Psychopathology Endorsed Across Instruments It has been reported consistently for both inpatient and outpatient populations that combat veterans evaluated for PTSD exhibit extreme elevations across a variety of selfreport inventories, especially the Minnesota Multiphasic Personality Inventory (MMPI/MMPI-2). This pattern suggests gross psychopathology and acute distress across multiple dimensions of mental illness. In perhaps the first study to identify this phenomenon, Fairbank, Keane, and Malloy (1983) successfully differentiated a group of Vietnam combat veterans with PTSD from a group of well-adjusted combat veterans and a group of combat veterans with other non-psychotic psychological problems using standardized psychometric measures. On average, the PTSD veterans obtained elevations above a T-score of 70 on 7 of the 10 clinical scales of the MMPI, with a mean two-point code of 8-2 (the “schizophrenia” and “depression” scales). These elevations were significantly higher than those achieved by even the group of veterans with other psychological problems Over the past 2 decades, studies have shown that combat veterans with PTSD, from wars ranging from World War II to the Gulf War, produce similar elevations on the clinical scales of the MMPI and MMPI-2. Most of these studies show veterans obtaining 8-2 two-point codes, with extreme elevations also on scales 7, 4, 6 (the “anxiety,” “antisocial,” and “paranoia” scales) and the validity scales (e.g.,

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Boudewyns & Hyer, 1990; Burke & Mayer, 1985; Cannon, Bell, Andrews, & Finkelstein, 1987; Fairbank, McCaffrey, & Keane, 1985; Frueh, Smith, & Libet, 1996; Hyer et al., 1986; Hyer, Woods, Harrison, Boudewyns, & O’Leary, 1989; Keane, Malloy, & Fairbank, 1984; Koretzky & Rosenoer, 1987; McCormack, Patterson, Ohlde, Garfield, & Schauer, 1990; Munley, Bains, Bloem, & Busby, 1995; Penk et al., 1981, 1989; Roberts et al., 1982; Silver & Salamone-Genovese, 1991; Sutker & Allain, 1995; Sutker, Allain, & Motsinger, 1988; Sutker, Allain, & Winstead, 1993; Sutker, Bugg, & Allain, 1991; Vanderploeg, Sison, & Hickling, 1987; Wilson & Walker, 1990). These elevations typically fall within the T-score ranges of 85–110 for scale 8, 80–100 for scale 2, 75–85 for scales 6 and 7, 75–80 for scales 1 (“hypochondriasis”) and 3 (“histrionic”), and 70–80 for scale 4, and are all well above the T-score clinical cutoff points of 65 for the MMPI-2 (70 for MMPI). In addition to the elevations on MMPI/MMPI-2 clinical scales, combat veterans with PTSD have been shown to produce extreme elevations on a broad range of other nonPTSD measures of acute psychological distress, including scales assessing for depression, anxiety, dissociation, interpersonal problems, anger, guilt, marital maladjustment, and sexual dysfunction. For example, across studies, average scores for combat veterans with PTSD obtained on the Beck Depression Inventory (BDI) range from 18– 29 (e.g., Cooper & Clum, 1989; Fairbank et al., 1983; Frueh et al., 1996; Keane, Fairbank, Caddell, & Zimering, 1989; Orsillo, Weathers, et al., 1996), which indicates severe depression (Beck & Steer, 1987). Mean scores on the Dissociative Experiences Scale have been found to be quite high (Bernstein & Putnam, 1986; Bremner & Brett, 1997; Frueh, Johnson, Smith, & Williams, 1996; Frueh et al., 1996), usually above the cutoff (30) suggested for a diagnosis of Multiple Personality Disorder (Carlson et al., 1993). Combat veterans have also exhibited extreme impairment on the Spielberger State-Trait Anxiety Inventory (Cooper & Clum, 1989; Fairbank, Keane, & Malloy, 1983; Hyer et al., 1986; Keane et al., 1989; Orsillo, Weathers, et al., 1996), Zung Depression Scale (Fairbank, Keane, & Malloy, 1983; Keane et al., 1989), Symptom Checklist-90 (Solomon, Mikulincer, & Bleich, 1988), The Guilt Inventory (Henning & Frueh, 1997), Ways of Coping Checklist-Revised (Blake, Cook, & Keane, 1992; Solomon, Mikulincer, & Flum, 1988), Problem Solving Inventory (Nezu & Carnevale, 1987), Coping Reactions Inventory (Nezu & Carnevale, 1987), Horowitz Interpersonal Problem Inventory (Roberts et al., 1982), Rotter Locus of Control (Hyer, Boudewyns, O’Leary, & Harrison, 1987; Hyer et al., 1986), Profile of Moods Scale (Hyer et al., 1986, 1987), Cook-Medley Hostility Index of the MMPI (Kubany, Gino, Denny, & Torigoe, 1994), Spielberger Anger Expression Scale (Chemtob, Hamada, Roitblat, & Muraoka, 1994; Chemtob, Novaco, Hamada, & Gross, 1997; Frueh, Henning, Pellegrin, & Chobot, 1997), Buss Durkee Hostility Index (Chemtob et al., 1994; Frueh, Henning, et al., 1997), Numbing Scale (Glover et al., 1994a), Vulnerability Scale (Glover et al., 1994b), Hope Scale (Irving, Telfer, & Blake, 1997), Automatic Thoughts Questionnaire and Semantic Function Assessment Measure (measures of maladaptive thinking; Nasby & Russell, 1997), Cloninger Tridimensional Personality Questionnaire (Richman & Frueh, 1997; Wang et al., 1997), Positive and Negative Syndrome Scale for Psychotic Symptoms (Hamner, Frueh, Ulmer, & Arana, 1999; Sautter et al., 1999), Social Phobia and Anxiety Inventory (Crowson, Frueh, Beidel, & Turner, 1998), Dyadic Adjustment Scale and Marital Status Inventory (Riggs, Byrne, Weathers, & Litz, 1998), and Golombok-Rust Inventory of Sexual Satisfaction (Letourneau, Schewe, & Frueh, 1997) among others.

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In addition, combat veterans with PTSD have been shown to elevate a variety of selfreport measures of Axis II personality disorders (e.g., Millon Multiaxial Clinical Inventory, SCID-II Personality Questionnaire) relative to other comparison groups. Data from these studies indicate high levels of borderline, passive-aggressive, schizoid, antisocial, and avoidant features (e.g., Hyer, Davis, Albrecht, Boudewyns, & Woods, 1994; Hyer, Woods, Boudewyns, Bruno, & O’Leary, 1988; Richman & Frueh, 1996; Robert et al., 1985; Sherwood, Funari, & Piekarski, 1990). Furthermore, although the data are somewhat more mixed for studies of neuropsychological and intellectual assessment, there is evidence that combat veterans with PTSD demonstrate reduced cognitive function as compared to their non-PTSD veteran counterparts (e.g., Barrett, Green, Morris, Giles, & Croft, 1996; Wolfe & Charney, 1991). For example, when compared to non-PTSD veterans, PTSD veterans have been shown to perform more poorly on verbal subscales of the Wechsler Adult Intelligence Scale-Revised (Vasterling, Brailey, Constans, Borges, & Sutker, 1997) and on the Trail Making Test (Beckham, Crawford, & Feldman, 1998); IQ estimates from the Shipley Institute of Living Scale scores predicted variance in PTSD symptoms (McNally & Shin, 1995); and combat veterans with PTSD show deficits in areas such as attention and executive functioning (Sutker, Vasterling, Brailey, & Allain, 1995) and memory (Bremner, Krystal, Southwick, & Charney, 1995; Bremner et al., 1993; Sutker, Winstead, Galina, & Allain, 1991; Yehuda, Keefe et al., 1995). Finally, combat veterans have even been shown to change their trauma reports over time, so that they report higher levels of trauma exposure at later dates than they do initially (Southwick, Morgan, Nicolaou, & Charney, 1997). Southwick et al. examined responses of several self-report questionnaires among 59 National Guard reservists at 1 month and 2 years after their return from the Gulf War. They found that a significant number of reservists changed their responses on a 19-item trauma questionnaire, indicating at 2 years after the war a greater degree of exposure to highly traumatic events than they had at 1 month after the war. In addition, there was a significant positive correlation between scores on a PTSD inventory (the Mississippi Scale) and the number of responses changed from “no” at 1 month the “yes” at 2 years on the trauma questionnaire. This indicates that the same veterans who changed their historical description of trauma also reported more PTSD symptoms at follow-up. A similar pattern of findings also were reported in a more recent study with 460 soldiers who served in the peace-keeping mission in Somalia (Roemer, Litz, Orsillo, Ehlich, & Friedman, 1998). Thus, much like “fishing stories,” the tale often seems to grow taller on down the line. In sum, the psychometric profiles typically achieved by combat veterans evaluated for PTSD show a strong tendency to report severe distress and dissatisfaction in virtually every domain related to psychological status. In fact, several studies found that MMPI profiles from this group were indistinguishable from “newly admitted random psychiatric inpatients” (Burke & Mayer, 1985) or veterans with psychotic disorders (Vanderploeg et al., 1987). On the whole, there is (a) a profound lack of symptom discrimination, and (b) a puzzling inconsistency in the obtained psychometric profiles and general clinical presentation (e.g., outpatient status) of many combat veterans evaluated for PTSD (e.g., Frueh, Gold, & de Arellano, 1997; Smith & Frueh, 1996). There is even preliminary data to suggest that self-reported degree of trauma exposure is inflated over time (e.g., Southwick et al., 1997). Thus, the credibility of the clinical presentation of this population is often compromised by an apparent tendency to overreport pathology.

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Extreme Elevations on MMPI/MMPI-2 Validity Scales In addition to high levels of psychopathology endorsed across instruments, combat veterans who served in wars after the Korean War also tend to inflate the validity indices of the MMPI/MMPI-2 in a direction consistent with a “fake-bad” or malingering response set. In their initial paper, Fairbank, Keane, & Malloy (1983) reported a mean T-score elevation of 70 for the F scale (“infrequent” responding), while the mean T-score for the K scale (“defensive” responding) was less than 50. Most other MMPI/MMPI-2 studies have noted elevations of similar or greater magnitude across the full range of validity indices, leading many to question the validity of the obtained scale profiles. For example, mean T-scores for the F scale range from 70–100 (e.g., Frueh, Smith, et al., 1996; Hyer et al., 1986; McCormack et al., 1990; Munley et al., 1995). Prominent elevations have also been found on the F-K index, with mean scores ranging from 5–11 (e.g., Frueh, Smith, et al., 1996; Hyer et al., 1989; Smith & Frueh, 1996) and 49% of all veterans scoring above 7 (Hyer et al., 1989), and on scales Fb, F(p), Es, FBS, Dsr2, Ds2, LW, and O-S (e.g., Frueh, Gold, et al., 1997; Hyer, Boudewyns, Harrison, O’Leary, Bruno, Saucer, & Blount, 1988). These validity scale elevations have been associated with elevations on clinical scales of the MMPI-2 and other self-report measures of acute psychopathology (Smith & Frueh, 1996), increased physiological reactivity to traumatic cues (Orr et al., 1990), and a poorer likelihood of positive treatment outcome results (Perconte & Griger, 1991). Although findings of dramatic validity index elevations in combat veterans do not indicate malingering per se, the extreme patterns obtained resemble those produced by a community sample of normal adults instructed to fake PTSD on the MMPI-2 (Wetter, Baer, Berry, Robison, & Sumpter, 1993). The extreme patterns also greatly exceed validity scale elevations produced by a sample of “pseudo-PTSD” patients who spuriously reported a trauma history (Lees-Haley, 1992). The F, K, and F-K indices have long been used as indicators of test validity on the MMPI/MMPI-2 (e.g., Carson, 1969; Graham, Watts, & Timmbrook, 1991; Hathaway & McKinley, 1967). However, no single cutoff score for any index is sufficient to determine malingering for all populations (Bagby, Rogers, Buis, & Kalemba, 1994; Berry, Baer, & Harris, 1991; Graham, 1993; Rogers, Sewell, & Salekin, 1994; Viglione, Fals-Stewart, & Moxham, 1995). In fact, there is evidence that individuals from other potentially compensation-seeking populations also achieve greater elevations on the validity indices than other normative groups (Rothke et al., 1994). Thus, as suggested by Rothke et al., different norms or cutoff points may be needed for patients seeking some form of disability payment as compared to patients not seeking compensation. Nevertheless, the MMPI/ MMPI-2 validity scores produced by combat veterans evaluated for PTSD are significantly elevated by any standard, and cast serious doubt as to the response validity of a substantial percentage of this population. Interestingly, WWII/Korean War combat veterans and POWs (e.g., Sutker, Winstead, Galina, & Allain, 1990; Sutker et al., 1993) do not seem to show the dramatic F scale elevations found in veterans of later conflicts.

Complications for Diagnostic Decision Making and Evaluation of Treatment Outcome The combination of elevated scores produced on clinical measures of psychopathology and MMPI/MMPI-2 validity scales in combat veterans evaluated for PTSD complicates assessment and treatment of the disorder in several ways. At the level of the individual veteran, it makes differential diagnosis extremely difficult in many cases, frustrating clinicians trying to develop treatment plans. Even when clinicians are in-

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clined to believe that individual veterans are presenting with genuine distress, the symptom reporting pattern described above often leaves well-intentioned therapists confused and overwhelmed as they try to decide where to begin with regard to therapeutic interventions. In other words, when a veteran endorses “everything” at an extreme level, it is almost impossible to know which symptoms to target as priorities. At a broader level, the phenomenon of apparent symptom overreporting leaves many clinicians wondering about the validity of the diagnosis itself, as applied to this population. In fact, personal experience and preliminary results of a survey administered to VA mental health workers (Richman, Frueh, & Libet, 1994, November) suggest that many VA clinical staff inside and outside mental health services are highly skeptical about veterans’ reports of PTSD symptomatology. Such reports are often dismissed out of hand as being “about money,” suggesting a tendency on the part of many VA clinicians to be prejudiced against combat veterans’ symptom reports. Such “stereotyping” from within the VA health-care community may serve only to further alienate a group which already feels misunderstood, unappreciated, and detached from the society they risked their lives to protect. Furthermore, there is a recognized paucity of treatment efficacy data for combatrelated PTSD (e.g., Friedman & Southwick, 1995; Frueh, Turner, & Beidel, 1995; Motta, 1993; Shalev, Bonne, & Eth, 1996; Solomon, Gerrity, & Muff, 1992), which may be at least partially attributed to the overreporting response style. Simply put, the efficacy of any treatment, whether psychosocial or pharmacological in nature, is difficult to assess if psychiatric symptoms cannot be accurately measured at both pre- and posttreatment. Furthermore, because the refinement of treatment technology depends on being able to understand which procedures are efficacious for which symptoms, the development of available treatments is clearly hampered, if not thwarted altogether, by the symptom reporting style of many combat veterans.

Assessment of Civilian PTSD with the MMPI/MMPI-2 To place the MMPI/MMPI-2 data for veterans with PTSD in context, a brief description of studies conducted with civilian populations may be helpful (see Wise, 1996, for a comprehensive review). Taken as a whole, the MMPI studies of civilian samples suggest that, as with veteran samples, PTSD is associated with an elevated F scale and elevations across a number of clinical scales, most notably scales 2 and 8 (e.g., Koretzky & Peck, 1990; McCaffrey, Hickling, & Marrazo, 1989). This general pattern is similar to that observed with PTSD veterans, although the magnitude of these elevations does not appear to be as high among civilians. Furthermore, the actual frequency of the 2-8/8-2 codetype appears to be less frequent among civilians than among veterans (Gaston, Brunet, Koszycki, & Bradweijn, 1996) and a decision rule based on the combination of scales F, 2, and 8 (derived from research among veterans) was only modestly successful at correctly identifying the presence of PTSD, although it appeared to be somewhat better at identifying chronic than acute civilian PTSD (Koretzky & Peck, 1990). In addition, optimal cutting scores for civilians on the Keane PTSD (PK) index (Keane et al., 1984) were substantially lower than those recommended for use with veteran samples (19 vs. 30, respectively) and appear to be a somewhat more sensitive indicator of PTSD among civilians than the F-2-8 configuration (Koretzky & Peck, 1990). Interestingly, although only one direct comparison has been made between these two populations, it showed that F-K index scores were found to fall within normal limits among a civilian sample (n ⫽ 7) and to be significantly lower than a veteran

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sample (n ⫽ 9), despite involvement in civil proceedings in which the civilians were seeking compensation (Wilson & Walker, 1990). Finally, data from the Gaston et al. (1996) study provides some suggestions as to what variables may be related to more pathological profiles among civilians with PTSD. These authors found more pathological profiles to be associated with chronic rather than acute PTSD, male gender, comorbid major depression, and comorbid dissociative and/or personality disorders, all factors likely to be present in combat veterans. Taken together, these studies strongly suggest that although civilian PTSD does appear to be associated with high levels of distress across a range of psychological domains on the MMPI, the extreme profiles among veterans are not an inherent component of PTSD, per se.

POSSIBLE EXPLANATIONS FOR THE APPARENT SYMPTOM OVERREPORTING PHENOMENON A variety of explanations for this apparent overreporting response style will now be considered, including psychiatric comorbidity and chronicity, a single global distress factor (e.g., “negative affect”), compensation-seeking incentive, malingering, and sociopolitical issues.

Severity of Actual Illness Genuine psychopathology is one obvious explanation for the extreme symptom reporting pattern described above. That is, the combination of psychiatric comorbidity, interpersonal maladjustment, symptom chronicity, and degree of trauma exposure account for the elevations across clinical measures. In the initial studies examining symptom response patterns on self-report measures (e.g., Fairbank, Keane, & Malloy, 1983; Hyer, Fallon, Harrison, & Boudewyns, 1987; Hyer et al., 1986), the authors explained the symptom reporting patterns as being a natural facet of the clinical syndrome. Fairbank, Keane, & Malloy (1983) concluded that specific self-report measures could be used to accurately discriminate Vietnam combat veterans with PTSD from relevant comparison groups, and could thus be a reliable and valid aid in the diagnostic process. They noted that elevations across clinical scales were likely related to high rates of psychiatric comorbidity and extreme levels of distress. Hyer, Boudewyns et al. (1988) and Hyer (1989) noted the problem of “symptom overreporting” on the MMPI more directly, stating the clear possibility that many veterans were exaggerating their symptomatology, and acknowledged the potential role of financial incentives (i.e., disability compensation). However, Hyer, Boudewyns et al. (1988) ultimately ruled that symptom overreporting was a feature of the disorder, related to the severity and chronicity of the overall syndrome, rather than a purposeful exaggeration for financial incentives. Certainly the above perspective is one that cannot be easily dismissed and must be given full consideration. Based on data from structured clinical interviews, combatrelated PTSD typically is accompanied by multiple current and lifetime comorbid Axis I and II disorders including Substance Abuse (73–91%, lifetime), Major Depression (26–70%), Antisocial Personality Disorder (12–31%), Dysthymia (21–34%), and Borderline Personality Disorder (up to 76%; Barrett, Resnick et al., 1996; Boudewyns, Albrecht, Talbert, & Hyer, 1991; Boudewyns, Woods, Hyer, & Albrecht, 1991; Deering, Glover, Ready, Eddleman, & Alarcon, 1996; Faustman & White, 1989; Keane, Gerardi,

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Lyons, & Wolfe, 1988; Keane & Wolfe, 1990; Orsillo, Weathers, et al., 1996; Sierles, Chen, McFarland, & Taylor, 1983; Southwick, Yehuda, & Giller, 1993). In a similar vein, interpersonal and behavioral problems have also been commonly associated with the clinical syndrome of combat-related PTSD. These problems include social avoidance and anxiety, violence and anger control problems, and numerous other difficulties such as unemployment, impulsive behavior, and family discord (Blum, Kelley, Meyer, Carlson, & Hodson, 1984; B. K. Jordan et al., 1992; Kulka et al., 1990; Nezu & Carnevale, 1987; Orsillo, Heimberg, Juster, & Garrett, 1996; Roberts et al., 1982). Finally, there is strong evidence of symptom chronicity for combat-related PTSD, with many veterans still suffering symptoms from wars fought 30 (Vietnam) or 50 (WWII) years ago (e.g., Bremner, Southwick, Darnell, & Charney, 1996; Johnson, Feldman, Southwick, & Charney, 1994; Long et al., 1989; Oei et al., 1990; Sutker et al., 1990). Given the high rates of concurrent psychiatric disorders, interpersonal difficulties, and disorder chronicity, it makes some intuitive sense that psychological self-report inventories would show high levels of dysfunction across different domains. Providing partial support for the comorbidity explanation of symptom overreporting are studies that suggest MMPI scores may vary as a function of comorbidity (Boudewyns, Albrecht, et al., 1991; Kulka & Schlenger, 1986; Penk et al., 1989; Talbert et al., 1994). In an early report, Kulka and Schlenger (1986) found that veterans with PTSD and other Axis I disorders had higher mean MMPI scores than veterans with PTSD only. Penk et al. (1989) used veterans from two groups that differed on the basis of psychiatric comorbidity (substance abusers, other psychiatric disorders) and found that different MMPI items were necessary to classify PTSD veterans from each group. However, results of this study are limited in two ways: (1) the samples for the two groups were drawn from two separate previous studies and may therefore have contained unknown sources of bias, and (2) comparison of MMPI indices showed relatively minor differences on clinical scales and virtually no differences on validity scales. Talbert et al. (1994) sorted a group of Vietnam veteran inpatients with PTSD into three groups (depression, psychosis, and other) on the basis of psychiatric comorbidity and found statistically significant differences across groups on MMPI clinical, content, and validity indices. However, it was also clear that all groups had the same basic configural pattern on clinical scales (e.g., 8-2 two-point code types) and obtained validity scale scores in a “fake-bad” direction (e.g., mean F scale T-scores ranged from 85–100, and mean K scale T-scores ⬍ 45 for all three groups). In fact, visual inspection of the three-group mean MMPI profiles indicated they were so similar that one must wonder to what extent the statistically significant differences translated into clinically meaningful differences. Smith and Frueh (1996) found affective disorders, but not substance abuse or other anxiety disorders, were overrepresented among a group of combat veterans classified as apparent exaggerators as compared to nonexaggerators (veterans were divided on the basis of F-K ⬎ 13). They concluded that their findings provided partial support for the hypothesis of increased comorbidity among exaggerators, although conclusions from this study were weakened by the fact that diagnoses were based on clinical rather than structured interviews. Finally, several studies have suggested that greater MMPI elevations are associated with longer symptom chronicity (as measured by number of inpatient psychiatric admissions; Long et al., 1989), and greater trauma exposure (e.g., POWs vs. combat-only veterans; Sutker & Allain, 1991; Sutker, Winstead, et al., 1991) in veteran samples, although these studies are not conclusive. Long et al. (1989) attempted to measure the construct of disorder chronicity by counting the number of past inpatient psychiatric

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hospitalizations for a group of veterans, with the idea that higher frequencies of psychiatric hospitalizations indicated greater chronicity. Potential flaws in the logic of this assumption limit the conclusions that may be drawn from the Long et al. study. The data reported by Sutker and colleagues are more compelling, but does not provide a full explanation for the overreporting phenomenon. Although she found that a group of Korean War POWs obtained greater MMPI clinical and validity scale elevations than a group of combat-only Korean War veterans, even the elevations obtained by the POWs are substantially lower than those reported for Vietnam combat-only veterans in other studies. Thus, the studies described above provide only partial support for the notion that clinical and validity scale elevations on self-report measures are a result of higher levels of psychiatric comorbidity, interpersonal maladjustment, symptom chronicity, and trauma exposure in combat veterans.

Single Global Distress Factor Hypothesis Another possible explanation for the phenomenon of apparent symptom overreporting is that a single factor (e.g., “negative affect”) is driving symptom reporting patterns. According to this explanation, acute levels of perceived global distress lead veterans to overestimate their actual level of psychopathology across multiple domains, and may even account for the high levels of psychiatric comorbidity described above. In contrast to the comorbidity explanation, it suggests that high scores on measures of different domains (e.g., depression, anxiety, thought disturbance, anger) are a result of a single global distress factor, not multiple distinct problem areas. In a study which points toward this conclusion, Shalev, Freedman, Peri, Brandes, and Sahar (1997) examined the utility of several different psychometric instruments to predict PTSD symptomatology in a sample of civilian trauma victims. Although not conducted with veterans, results of this study indicated that specific PTSD measures (e.g., Impact of Events Scale, Mississippi Scale) were no better at predicting PTSD symptoms than general measures of distress (e.g., State Trait Anxiety Inventory) were. One way to evaluate the issue of single versus multiple factors more thoroughly is to examine data from factor analytic studies conducted with combat veterans. Unfortunately for our purposes, most of the factor analytic studies with combat veterans have been conducted using measures specifically designed for assessing symptoms of PTSD. Nevertheless, these studies can be highly informative given that the diagnosis of PTSD itself involves three hypothetically distinct components (intrusion, avoidance and emotional numbing, and hyperarousal). Several studies have examined the factor structure of the Mississippi Scale for Combat-Related PTSD, a 35-item, 5-point Likert scale designed to assess for the presence and severity of PTSD symptomatology (Keane, Caddell, & Taylor, 1988), with mixed results taken as a whole. In their initial validation paper, Keane et al. (1988) reported that a principal components analyses resulted in six factors with eigenvalues greater than 1.00 in a sample of treatment-seeking veterans. McFall, Smith, MacKay, and Tarver (1990) reported three factors in a sample of PTSD-positive and PTSD-negative veterans treated for substance abuse. However, King and King (1994) suggested that the item-total correlations reported in the two studies noted above (.58 and .64, respectively), as well as those reported by Hyer, Davis, Boudewyns, and Woods (1991) for PTSD-positive veterans assessed on two occasions (.54 and .47), is evidence of a large degree of homogeneity across the 35 items of the Mississippi Scale. This finding, in combination with the fact that the scoring of the scale involves a single total sum score, is suggestive of unidi-

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mensionality. King and King (1994) conducted a common-factor analysis using data collected from a large community-based national sample of Vietnam theater and era veterans from the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990). Their results initially produced two factors, with the first accounting for 34% of the variance, with an eigenvalue over eight times larger than the eigenvalue of the second factor (which accounted for 4.1% of the variance). Examination of a hypothesized higher order solution led to the conclusion that “the Mississippi Scale is characterized by an organizing higher-order factor that accounts for four subdimensions” (p. 286), a finding that was cross-validated in a second subset of the data. Finally, Engdahl, Eberly, and Blake (1996) used confirmatory factor analyses to simultaneously examine the factor structure of three PTSD self-report measures (Mississippi Scale, Impact of Events Scale, and the Keane MMPI-2 subscale). They concluded that only a one-factor model produced an acceptable fit of the data to the model, suggesting convergence among the three measures on a single underlying factor. Factor analytic studies conducted on other measures of PTSD have also shown similarly mixed results regarding the factor solutions generated. Silver and Iacono’s (1984) common-factor analysis of 33 symptom ratings resulted in four factors. Watson et al.’s (1991) common-factor analysis of the 17-item PTSD Interview obtained five factors. King, Leskin, King, and Weathers’ (1998) confirmatory factor analysis of the 17item Clinician Administered PTSD Scale, a structured interview for PTSD, found that the model of best fit was a four-factor, first-order solution, containing correlated yet distinct first-order factors corresponding to reexperiencing, avoidance, emotional numbing, and hyperarousal dimensions. Gold et al.’s (in press) principal components analysis of 20 PTSD-related items extracted from the Cornell Medical Index administered to WWII POWs in 1965, as well as their clustering of SCID items (collected from the same sample of POWs in 1990) in two-dimensional space, provided support for a threefactor solution, King, King, Leskin, and Foy’s (1995) common-factor analysis of the 43item Los Angeles Symptom Checklist generated a dominant first factor accompanied by two secondary factors. As noted by King and King (1994) this variance in the factor solutions generated by various studies may be partially explained by the use of different measures, as well as different types of samples. For example, results obtained from the NVVRS might understandably be quite different from those obtained in more homogeneous samples, such as veterans seeking treatment for PTSD or substance abuse. In fact, the phenomenon of extreme and diffuse elevations across clinical measures and validity indices may only be relevant to the subset of veterans seeking evaluation within the VA system, where the possibility of financial and other systemic/economic factors may come into play. In other words, factor structures may be different for veterans seen within the VA system that for those evaluated outside of it. Another way to consider the phenomenon of apparent symptom overreporting on psychometric measures is to examine the psychometric distinctiveness of different measures in a sample of combat veterans evaluated for PTSD. Although this research has been attempted with the general constructs of anxiety and depression in a variety of clinical samples, the results have been mixed (e.g., Clark, Steer, & Beck, 1994; Cox, Swinson, Kuch, & Reichman, 1993; Watson et al., 1995; Zinbarg & Barlow, 1991). To the best of our knowledge similar studies have not been attempted with veteran PTSD populations. Taken as a whole, the data from factor analytic studies are far from conclusive. Al-

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though there is some evidence to suggest that a dominant single factor drives much of the symptom reporting on measures of PTSD, and possibly depression, these data do not provide a full explanation for the apparent symptom overreporting phenomenon. Furthermore, even a successful single factor explanation does not necessarily state what that factor might be.

Compensation-Seeking Status Consistent with a single-factor explanation, many researchers have speculated that apparent symptom overreporting may reflect motivation of veterans to present themselves as disabled by military experiences in order to obtain service-connected status (i.e., disability compensation) from the VA (e.g., Atkinson, Henderson, Sparr, & Deale, 1982; Lees-Haley, 1989). In fact, one sample of VA clinicians recognized compensation-seeking as one of the most serious obstacles to successful evaluation and treatment of PTSD patients within the VA system (Richman, Frueh, & Libet, 1994, November). Several studies have examined the issue of compensation-seeking status on symptom reporting using psychometric methods. Schneider (1979) found that psychiatric disability payments to veterans (in a non-PTSD sample) were significantly correlated with elevations on the F and 8 scales of the MMPI. In a sample of veterans evaluated between 1981 and 1985, Quinn, Knight, Weathers, Keane, and Ireland (1993, October) used a 2 (PTSD vs. non-PTSD) ⫻ 2 (compensation-seeking vs. non-compensation-seeking) design to analyze symptom-reporting patterns on the MMPI. They found that only the non-PTSD noncompensation-seeking group produced significantly lower profile elevations than the other three groups, which were not different from each other, and concluded that intent to seek compensation did not appear to effect reporting style in veterans with PTSD. However, Quinn et al. (1993, October) cautioned that their data was collected in the early 1980s, at a time when the rate of PTSD disability claims filed fell below more recent rates. Thus, they conceded that compensation-seeking status might currently be a greater factor in the psychometric profile patterns produced by veterans. Results from another study found that two groups of combat veterans differentiated on the basis of F-K index scores above and below 13 did not differ significantly in compensation-seeking status (Smith & Frueh, 1996). Specifically, compensation-seeking was not statistically over-represented among veterans with F-K index scores of ⱖ 13 (80%) as opposed to those with F-K indices of ⬍ 13 (65%), although there was a trend in that direction. Because the range of veterans’ scores above and below this cutoff were not examined, it was not determined whether compensation-seeking status could be differentiated at other F-K cut-off points (e.g., ⬎ 20). Thus, it is possible that compensation-seeking status may be overrepresented at other cut-off points, and therefore these results are not fully informative with regard to this issue. R. G. Jordan, Nunley, and Cook (1992) analyzed the psychometric profiles of psychiatric inpatient Vietnam veterans with PTSD classified into three groups on the basis of their service-connection status. Groups included veterans compensated for PTSD, compensated for physical or other mental problems, or not compensated at all. Analysis of responses to the MMPI and Mississippi Combat Scale revealed no differences in endorsement patterns among the three groups, leading the authors to conclude that disability status did not correlate with symptom reporting on these selfreport inventories. However, their conclusions may be somewhat problematic due to the manner in which they grouped veterans for the analyses. Because the modal disability

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rating for the compensated groups was low (only 10%, based on a possible continuum of 0–100% for each veteran), partially compensated, as well as non-compensated veterans, might have been strongly motivated to seek increases in disability benefits and therefore inclined to exaggerate on self-report inventories. Frueh and colleagues (Frueh, Gold, et al., 1997; Frueh, Smith, et al., 1996) argued that accurately understanding the role of compensation-seeking status on response patterns on psychological measures requires a definition of “compensation-seeking” which maximally differentiates individuals with financial incentives from those without. Such differentiation is complicated by the fact that financial incentives do not necessarily vary directly with current level of disability status. The relationship between disability payments and disability ratings (on 0–100% basis) are curvilinear, and many benefits (e.g., college education for children, some forms of medical coverage) do not begin until a rating of 100% is awarded. Therefore, a veteran who is rated as 90% disabled stands to benefit from an increase to 100% almost as much as a veteran service-connected at only 10%. Taking financial incentive into account, Frueh, Smith, et al. (1996) examined scores on psychological measures in a group of veterans divided into two groups: (1) those currently seeking, or planning to seek, government disability payments (i.e., service connection) or increases in existing disability payments (i.e., a rating increase) for combat-related PTSD (compensation-seeking [CS] veterans), and (2) those not intending to seek compensation for their symptoms of PTSD at the time of testing (noncompensation-seeking [NCS] veterans). Sixty nine percent (69%) of the veterans were classified as compensation-seeking. This group produced significantly more pathological scores on all measures (selected MMPI-2 clinical and validity scales [F, K, F-K] and other measures of severity for PTSD, depression, and dissociative experiences). Although the authors acknowledged that greater levels of actual psychopathology in CS veterans could account for scale elevations, the two groups did not differ in frequency of PTSD diagnoses. In addition, the CS veterans markedly elevated the MMPI-2 validity indices of F (T ⫽ 104) and F-K (12.9) compared to NCS veterans (F ⫽ 82, F-K ⫽ 3.7), implying that CS veterans’ approach to psychological testing reflected a fake-bad response set. These results have been replicated and extended in a follow-up study which found significant differences between CS and NCS veterans on a broad range of self-report measures (e.g., Beck Depression Inventory, Mississippi Scale, Dissociative Experiences Scale) and MMPI-2 validity indices (F, F(p), Fb, F-K, O-S, Ds2, Dsr2, LW, FBS) in a sample of 165 combat veterans (Frueh, Gold, et al., 1997). For example, CS veterans had significantly higher MMPI scales F (T ⫽ 107), 2 (T ⫽ 87), 8 (T ⫽ 94), and BDI scores (mean ⫽ 32) compared to NCS veterans (F [T ⫽ 70], 2 [T ⫽ 78], 8 [T ⫽ 74] and BDI [mean ⫽ 22]). 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 (GAF), and clinician-rated severity of PTSD were controlled for. Finally, Rouhbakhsh, Drescher, Pivar, and Greene (1996, November) examined the relationship between financial incentive and patterns of MMPI-2 overreporting in a group of 164 combat veterans evaluated in an inpatient PTSD treatment program. They divided patients into two groups based on their compensation-seeking intentions (CS vs. NCS). Although they did not find a significant difference across MMPI-2 clinical or validity scales between the two groups at entry into or exit from the program, their results indicated that NCS veterans showed significant change in their F scale scores during treatment while CS veterans did not. The authors concluded that

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the continued endorsement of distress on the F scale by CS veterans, despite lowering of symptoms on several measures, suggested a relationship between compensationseeking status and symptom reporting patterns. Although results of studies examining compensation-seeking are somewhat mixed, recent studies using a definition of “compensation-seeking” which maximizes financial incentives indicate that there is a strong association between compensation-seeking and elevated scores on MMPI clinical and validity scales, as well as other self-report measures of psychological distress. While not evidence of malingering per se, these data suggest that the specter of available disability benefits does influence the way in which veterans describe their difficulties, leading them to exaggerate symptoms either consciously or unconsciously. Nevertheless, even the mean scores for non-compensation-seeking veterans were generally quite high, suggesting that compensation-seeking status also is only a partial explanation for the apparent overreporting phenomenon.

Malingering The compensation-seeking explanation suggests that the symptom reports of many veterans are driven by unconscious reporting biases, however, a substantial subset of the population has been thought to be intentionally faking (i.e., malingering) their clinical presentation of psychiatric symptoms (e.g., Resnick, 1997). Therefore, we will consider the issue of malingering separately from “compensation-seeking” even though financial disability payments are likely the primary motivation for dissimulators. At this point, the true extent of malingered combat-related PTSD is not known, although cases of factitious and malingered PTSD have been well documented in the literature. Early reports noted the increase of malingering of all types of physical and mental disorders during wartime (Ossipov, 1944) and in military settings where there were a variety of secondary gain incentives (Lorei, 1970; Rogers, 1990a; Schretlen, 1988). More recently, others have presented case histories of malingering veterans (Lynn & Belza, 1984; Sparr & Pankratz, 1983), many of whom were shown to have never even served in combat. Gold, Frueh, Chobot, and Brady (1996, August) examined distributions of MMPI-2 validity scale scores and estimated the base rate of malingering in VA PTSD outpatient clinics at about 20%. They noticed that a sharp drop in frequency scores occurred at a cumulative frequency of approximately 80%, and scores above this point resembled those obtained by experimental malingering groups in analogue studies. Nevertheless, while perhaps common, the full extent of this problem is not well understood at this point. Research on the detection of malingered PTSD is scant, and has focused primarily on self-report measures. Fairbank et al. (1985) compared the MMPI profiles of 15 Vietnam veterans with PTSD to the profiles of two groups of role-informed malingerers (15 well-adjusted Vietnam veterans, and 15 mental health professionals) instructed to fake the symptoms of PTSD. A discriminant function analysis successfully classified over 90% of the subjects, and the authors concluded that the MMPI and the Keane PTSD subscale are valuable psychometric instruments for detection of malingered PTSD. This study and its results have been replicated in another sample of combat veterans (McCaffrey & Bellamy-Campbell, 1989). The conclusions reached by Fairbank et al. (1985) are also supported by another study that found role-informed malingerers scored significantly higher on MMPI-2 validity indices (F, F-K) than a comparison group of veterans with PTSD (Frueh & Kinder, 1994), and by research supporting the use of the MMPI in other populations where there is clear financial incentive for psy-

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chiatric disturbance (e.g., Roman, Tuley, Villanueva, & Mitchell, 1990; Schretlen, 1988; Walters, 1988). The conclusion that the MMPI can detect malingered PTSD is not accepted by all. Lees-Haley (1989) found that untrained role-informed subjects were able to successfully fake PTSD (in response to a civilian accident) on the MMPI Keane PTSD subscale. Although this study may be of limited value because it does not deal with combat veterans, it does suggest that a structured measure, where most items have some degree of face validity, may be susceptible to malingering. In a study more relevant to combat-related PTSD, Perconte and Goreczny (1990) attempted to replicate the findings of Fairbank et al. (1985) using a sample of Vietnam combat veterans divided into three categories: PTSD, psychiatric disorders other than PTSD, and PTSD fabricators. Statistical comparisons between the groups showed that the identified fabricators were not statistically different from the PTSD group on most MMPI scales (e.g., both groups had mean F scales of about 81), and actually scored lower than the PTSD group on those scales where differences were found (scales 5, 6, 7). Furthermore, discriminant function analyses correctly classified only 17 of 39 (43.6%) veterans in the study, little better than change. Perconte and Goreczny concluded that the MMPI is of little value in discriminating real from fabricated symptoms of PTSD in the clinical setting, stating that problems of external validity (e.g., use of nonclinical samples) likely account for the initial findings of Fairbank et al. (1985). Two studies have examined the ability of role-informed malingerers to fake PTSD on the Mississippi Scale, a measure of PTSD symptomatology which has a high degree of face validity (Frueh & Kinder, 1994; Lyons, Caddell, Pittman, Rawls, & Perrin, 1994). The results from each of these studies show that role-informed malingerers were able to achieve scores on the Mississippi that were equal to or greater than those obtained by veterans with PTSD. Thus, this measure, designed specifically to assess PTSD-related symptoms, appears to be highly vulnerable to dissimulation. One study has examined the susceptibility of the Rorschach inkblot, a projective instrument, to malingering of combat-related PTSD. Frueh and Kinder (1994) found that role-informed malingerers (undergraduate volunteers) differed significantly from a group of combat veterans diagnosed with PTSD on a number of theoretically relevant variables. Malingerers typically gave responses that were overly dramatic (Dramatic) and less complicated (Lambda), less emotionally restrained (SumC), and indicated an exaggerated sense of impaired reality testing (X⫺%, X⫹%, M⫺) compared to the veteran PTSD group. However, the two groups did not differ on many other important variables of interest, such as the Depression Index. This inconsistency of results, in combination with methodological limitations related to external validity, suggests that these results should be considered highly tentative at this point. There is also good evidence that psychophysiological assessment (e.g., heart rate, blood pressure, skin conductance), which has been shown to have good sensitivity and specificity in the diagnosis of combat-related PTSD (e.g., Blanchard, Kolb, & Prins, 1991; Orr et al., 1990; Pitman, 1993), may be less vulnerable to dissimulation. Gerardi, Blanchard, and Kolb (1989) compared the physiological reactivity of 18 veterans with PTSD to 18 combat veterans without PTSD. Half (n ⫽ 9) of the non-PTSD veterans were educated about the physiological reactivity associated with PTSD and were asked to “fake” that reactivity in response to a standardized audiotape of combat sounds. In addition, half (n ⫽ 8) of the veterans with PTSD were asked to “fake good,” or control their physiological reactivity when presented with the audiotape of combat sounds. The other half of the subjects in each group were given no additional instructions

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other than to listen to the audiotape. Results showed that when subjects were instructed to alter their physiological responses to the combat stimuli, the veterans with PTSD were unable to. However, non-PTSD veterans were able to increase certain physiological responses (e.g., heart rate, EMG) so as to appear more similar to the PTSD veterans. Nevertheless, PTSD and non-PTSD subjects were still discriminated at a moderate rate (6 of 9, or 66%, were identified in a discriminant analyses), suggesting that psychophysiological assessment may show some promise in identifying those who are attempting to feign the disorder. Similar results were obtained in a study comparing the physiological reactivity of 25 Vietnam veterans with PTSD and 18 Vietnam veterans without PTSD. It was found that veterans without PTSD were unable to simulate the physiological response patterns of PTSD subjects even when imaging their own personal combat experiences (Orr & Pitman, 1993). As noted by Perconte and Goreczny (1990), most of the extant malingering studies are limited by the analogue nature of their designs, which place significant restrictions on external validity (e.g., making generalizations from nonclinical to clinical samples). In perhaps the most comprehensive psychometric study to date, Gold et al. (1996) utilized data from a variety of sources to evaluate malingering within a clinical setting. They used retrospective clinical ratings (using the diagnostic scheme proposed by Rogers, 1990b) to sort veterans into three criterion groups on a continuum of malingering (“Malingering,” “Indeterminant,” and “Honest”) based on veterans’ observed behavior in the clinic over time. Results showed these groups differed dramatically on demographic variables, diagnoses, and MMPI-2 response patterns. Although the capacity of MMPI-2 validity indices to accurately classify veterans into criterion groups was relative poor, extreme scores on the Infrequency indicators (F, Fb, F-K, and Fp) did strongly predict at least exaggeration of psychological difficulties. It merits comment that the definition of malingering, as a construct, is complicated and may vary somewhat across clinical settings or along a severity continuum (Gold et al., 1996; Rogers, 1988). Thus, our knowledge on this crucial subject is truly in its infancy at this point. Before we can fully understand the role that malingering plays in the phenomenon of apparent symptom overreporting, more research is needed regarding base-rates and detection of malingering among combat veterans evaluated for PTSD in various clinical settings.

Sociopolitical Considerations A sociopolitical perspective may also provide some valuable insights into symptom overreporting among combat veterans. It has been well documented that Vietnam veterans, who comprise the subjects in the bulk of the studies described above, experienced unique pressures and traumas while in a war zone (e.g., atrocities; Laufer, Gallops, & Frey-Wouters, 1984), and were caught in a period of social transition and stress upon return from the war. In explaining their results Hyer, Boudewyns et al. (1988) offered: One reason might be that Vietnam combat veterans are just now “learning” to respond to years of dormant thoughts and feelings about their condition. During this dissonance reduction process they are “seduced” into exaggeration, overreports, and even factitious reports when confronted with their pathology. In a sense they must make an effort to “really” be a Vietnam veteran again and must sell themselves and their helpers. Given that many other veterans are also involved in this process, this can become a “cathartic or contagion process,” where facts and fiction are interchangeable (pp. 484–485).

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Thus, there is the suggestion that for many veterans the manifestation of “PTSD” may be a sociological phenomenon (e.g., Vietnam Veteran Syndrome) as opposed to psychiatric disorder. In an eloquent discussion of socio-political considerations among Vietnam veterans, Fleming (1985) stated that PTSD “has become the trendy political diagnosis used by some to explain anything and everything a Vietnam veteran does. A few veterans use the psychiatric label to legitimize their acting out” (p. 136). Indeed, it is possible that many of the patient behaviors typically associated with attempts to obtain disability benefits may be motivated by factors other than financial reward. In this sense, the original meaning of the psychoanalytic term “secondary gain” may be applicable. In other words, veterans may be motivated by a range of factors associated with the granting of disability status, including a desire for recognition, acceptance, or status from their country, government, or society. Certainly, this perspective is potentially valuable clinically; however, no empirical data exist currently to support this perspective as an explanation for the overreporting phenomenon. Thus, little can be said about the role of socio-political factors until empirical research is conducted on the issue.

CONCEPTUAL ISSUES AND FUTURE DIRECTIONS Before reaching any conclusions regarding apparent symptom overreporting, a number of conceptual and practical issues relevant to reaching a better understanding of the phenomenon in both research and clinical settings merit discussion.

Validity of Clinical Diagnoses The issue of diagnostic validity is of prominent concern in the clinical studies presented above. Inherent in virtually every study on the assessment of PTSD is the potential problem of circularity involved in evaluating results from self-report inventories and clinical diagnoses. Put another way: how can we be confident of the diagnostic classification of veterans in the above studies, given the apparent tendency to overreport psychiatric symptoms on self-report measures? Most of the above studies utilized structured interviews to reach diagnoses of PTSD and other Axis I disorders, although many also relied on the consensus of clinical staff. Nevertheless, it seems reasonable to think that the tendency to overreport pathology, or respond with a negative reporting bias, on pencil and paper self-report inventories would have a carryover effect to clinical interviews. This suggests that diagnostic decision-making is particularly difficult with this population, and special care is called for in any studies dealing with aspects related to comorbid psychiatric disorders.

Predisposing Factors At present, our understanding of predisposing factors for PTSD is quite underdeveloped. However, there is a compelling pair of studies suggesting that there may be certain premorbid factors that account for a significant amount of the variance among combat veterans who do and do not develop PTSD associated with their combat trauma. Specifically, lower precombat intelligence (Macklin et al., 1998) and precombat academic weakness, absenteeism, and tardiness in secondary school (Watson, Davenport, Anderson, & Mendez, 1998) have been found to be risk factors for developing

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PTSD, even after adjusting for the extent of combat exposure. Also, several of the studies that have examined Axis II features in veterans with PTSD have suggested that preexisting personality disorders may be a risk factor for PTSD (e.g., Richman & Frueh, 1997). If this is the case, then actual current psychopathology and functional deficits may be partially related to preexisting vulnerabilities, and not the ravages of combat trauma and subsequent PTSD symptoms alone. Further investigation of potential predisposing factors will greatly enhance our understanding of this syndrome.

Evaluating Treatment Efficacy As noted earlier, the accurate evaluation of treatment outcome results is an issue of serious concern. There is a recognized lack of treatment efficacy data for combatrelated PTSD (e.g., Foa & Meadows, 1997; Motta, 1993; Shalev et al., 1996), which may be at least partially attributed to the overreporting response style and the reluctance of many patients to acknowledge therapeutic gains. Although there has been little empirical investigation of this hypothesized association, several studies have presented results which merit comment. Perconte and Griger (1991) examined treatment outcome data for 45 combat veterans who completed at least 6 weeks of treatment in a partial hospitalization program. They found that veterans who were found to have improved immediately following treatment and at 18 months posttreatment obtained lower scores at pretreatment on the MMPI PTSD subscale, global indices of the SCL90-R, and seven of the nine individual symptom scales of the SCL-90-R as compared to those veterans who did not improve. They also noted that the subjects who evidenced improvement were found to have lower rates of alcohol consumption and greater participation in the treatment program than those who did not improve. Perconte and Griger concluded veteran symptom overreporters have poorer treatment outcomes, even though observing clinicians in their study did not report them to be any more dysfunctional than veterans who did not overreport their symptoms and subsequently evidenced treatment improvement. In another study, Frueh, Turner, Beidel, Mirabella, and Jones (1996) examined the treatment efficacy of a multicomponent behavioral treatment program for PTSD in 15 combat veterans. They found that although veterans, most of whom were seeking disability, showed no evidence of improvement on any of three self-report measures used (including the Beck Depression Inventory), they did evidence significant improvement on clinician ratings (e.g., CGI, Hamilton Anxiety Rating Scale), psychophysiological measures of cued reactivity, and daily symptom frequency counts (daily patient ratings). The authors concluded that self-report inventories might not provide valid indication of treatment progress in this population because of their vulnerability to the response bias of veterans. Similar results and conclusions were reached in another behavioral treatment outcome study (Pitman et al., 1996), and results from psychopharmacological treatment outcome studies also demonstrate similar inconsistencies between clinician ratings and self-report measures (e.g., Reist et al., 1989). Finally, Fontana and Rosenheck (1997a) recently examined the influence of compensation-seeking status on treatment outcome in a large sample of inpatient (n ⫽ 553) and outpatient (n ⫽ 455) veterans treated for PTSD within the VA system (subjects were drawn from other treatment outcome studies; see Fontana & Rosenheck, 1997b, and Rosenheck & Fontana, 1996 for additional details). Data from their sample indicate that 84% of the outpatients and 96% of the inpatients were classified as compensation-seeking (CS). Their results indicate that CS status had a significant ef-

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fect for inpatient veterans. Specifically, they found that CS inpatient veterans, from programs with long lengths of stay (⬎ 21 days), were likely to evidence less pre- to posttreatment improvement on a battery of self-report measures (e.g., Mississippi, Brief Symptom Inventory), clinician ratings of PTSD (e.g., CAPS), and work performance over the course of 1 year following the initiation of treatment. Interestingly, no such effect was found for veterans treated in the outpatient setting, although visual inspection of the data suggests that CS veterans exhibited much greater pathology at the initiation of treatment than NCS veterans. One caveat to these results is that veterans were classified as “compensation-seekers” if they were already service connected, so that this group included veterans who were already receiving a disability rating of 100%. Thus, by including these veterans, financial incentive was conceivably not maximized in the CS group, possibly masking a significant effect for those truly in the hunt for disability payments. Furthermore, neither group of veterans (CS vs. NCS) in either the inpatient or outpatient groups showed much evidence of improvement at 1 year after the start of treatment, and the authors concluded that both CS and NCS veterans showed a tendency to overstate their level of psychopathology. Since the development and refinement of treatment technology depends on being able to understand which procedures are efficacious and under what conditions, this process is seriously jeopardized by the phenomenon of symptom overreporting among combat veterans. Future treatment outcome studies will need to take steps to deal with this problem, and additional research is necessary to provide a better understanding of how this ubiquitous response style plays out within the context of assessing treatment change.

The Need for Assessment Data from Other Sources Because of the overreporting problem described above, clinicians and researchers evaluating combat veterans for PTSD and associated features should acquire assessment data from a variety of sources. In the section that follows, we will discuss a number of assessment strategies that may bypass potential self-report biases, and may therefore represent valuable sources of additional information. Psychophysiological reactivity. The prominence of autonomic symptoms in combat veterans with PTSD has been consistently documented via studies of psychophysiological responding, which show clear evidence of heightened reactivity in combat veterans with PTSD (e.g., Blanchard et al., 1991; Keane et al., 1998; McFall, Murburg, Roszell, & Veith, 1989; Orr et al., 1990; Pitman, 1993). In these studies, standardized combatrelated cues (e.g., combat sounds and pictures) or individually developed scripts are presented while physiological reactivity is measured via blood pressure (BP), heart rate (HR), forehead electromyogram (EMG), or galvanic skin response (GSR). Combat veterans with PTSD have significantly larger BP and HR responses during traumatic cue exposure than do combat veterans without PTSD, although EMG and GSR have proven to be less reliable for purposes of differentiation (e.g., Blanchard, Kolb, Pallmeyer, & Gerardi, 1982; Blanchard, Kolb, Gerardi, Ryan, & Pallmeyer, 1986; Blanchard et al., 1991; Orr et al., 1990; Orr, Pitman, Lasko, & Herz, 1993; Pallmeyer, Blanchard, & Kolb, 1986; Pitman et al., 1990; Pitman, Orr, Forgue, de Jong, & Claiborn, 1987; Shalev, Orr, & Pitman, 1993). Sensitivities and specificities for the studies cited above ranged from 70–90 and 80–100, respectively. Furthermore, as mentioned earlier, there is evidence to suggest that measurement of psychophysiological reactivity

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may provide relatively good discrimination even when individuals are attempting to exaggerate or disguise their responses (Gerardi et al., 1989; Orr & Pitman, 1993). Thus, this assessment modality is less susceptible to the negative reporting bias (conscious or unconscious) potentially found with self-report measures. Structured interviews. A variety of structured interviews have been used with this population, the two most commonly used ones are the Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams, Gibbon, & First, 1990) for evaluating the range of Axis I pathology and the Clinician Administered PTSD Scale (CAPS; Blake et al., 1990) for assessing PTSD symptomatology. The CAPS-1 is a 17-item clinical rating scale designed specifically to rate frequency and severity of PTSD symptomatology according to DSM-III-R (American Psychiatric Association, 1987) criteria. The scale has been shown to have strong interrater reliabilities (.92–.99) for each of the three PTSD symptom clusters, a high degree of internal consistency (.73–.85), to be highly correlated with the Mississippi Scale (.70–.91) and MMPI-2 PK scale (.77–.84), and to have a good diagnostic utility when compared to the SCID PTSD module (Weathers & Litz, 1994). Although the CAPS-1 may not be quite as vulnerable to exaggerated/malingered symptoms as self-report inventories because the format calls for clinician judgement in the formation of clinical ratings, this measure relies heavily on the verbal symptom reports of veterans. Furthermore, despite inviting clinicians to circle items of “questionable validity,” it does not contain any quantifiable or reliable validity checks. Thus, structured interviews are also likely to be affected by the symptom overreporting phenomenon. More research is needed to clarify the utility of these instruments with patients who may be exaggerating their symptom reports. In particular, research is needed which incorporates the Structured Interview of Reported Symptoms (SIRS; Rogers, Bagby, & Dickens, 1992), an interview of malingered psychiatric symptoms, into studies of exaggerated and malingered symptom reports. Other structured interview instruments, such as the Positive and Negative Syndrome Scale (e.g., Sautter et al., 1999) or Object Relations Clinician Rating (Ford, Fisher, & Larson, 1997), among others, may offer information relevant for treatment planning or patient matching. Self-monitoring. Very little is known about the use of self-monitoring or patient ratings with combat veterans. Frueh, Turner, et al. (1996) used this assessment modality as an outcome measure in evaluating the efficacy of a multicomponent behavioral treatment package. They asked patients to keep a daily log of relevant symptoms (e.g., nightmares, flashbacks) and social activities for 1-week periods at three separate assessment points (pre-, mid-, and posttreatment). Interestingly, their results showed that patients reported significant symptom reductions, such as fewer nightmares, and increased social activities, despite the fact that no such changes were noted on more global self-report inventories (e.g., Beck Depression Inventory, Mississippi Scale) administered at the same assessment points. Frueh et al. concluded that daily patient ratings may be a promising behavioral assessment modality for use with this population, and may be less vulnerable to symptom overreporting than self-report inventories. Similar results and conclusions were noted in another recent study. Pitman et al. (1996) reported decreased symptoms of intrusive thoughts in 20 Vietnam veterans with chronic PTSD, even though the sample reported no symptom improvement on measures such as the Impact of Events Scale, SCL-90, and the CAPS-1 interview. Specifically, they noted that when patients counted and recorded the number of intrusive

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combat memories for carefully timed intervals, they showed a 26% symptom reduction at posttreatment. However, those same veterans reported a 14% increase in these symptoms on posttreatment interviews! Thus, there is clear evidence to suggest that patient daily ratings of symptoms provide very different information than more global, retrospective measures. Behavioral assessment. As with patient ratings, little is known about the use of other forms of behavioral assessments to evaluate the functioning of combat veterans evaluated for PTSD. Behavioral assessment can be multifaceted, including a variety of strategies, and may be used to evaluate both psychiatric symptoms and social/occupational functioning. A functional assessment conducted with veterans and/or collateral others could provide valuable information for the development of behavioral treatment plans. In addition, social skills have been successfully evaluated in a variety of clinical populations (e.g., schizophrenics) via behavioral assessments, such as the Simulated Social Interaction Test (Curran, 1982). This type of evaluation requires patients to respond to a variety of role-played social situations while the clinician makes ratings of the quality of social skills exhibited (e.g., assertiveness, anger expression). Although this strategy does not provide information about how well or how often an individual uses appropriate social behaviors outside of the clinic setting, it does allow for assessment of an individual’s repertoire of social behaviors. This strategy may require more time and resources than is available for most clinical evaluations, but it could serve as a valuable outcome measure in treatment studies seeking to evaluate change in social skills. To the best of our knowledge this strategy has not yet ben employed in any published studies of combat veterans with PTSD. Other behavioral assessment techniques (e.g., functional analysis, facial coding) are worthy of further investigation with regard to their assessment utility with combat veterans. For example, in an early single case study Fairbank, Gross, and Keane (1983), successfully evaluated treatment outcome for exposure therapy with a Vietnam combat veteran using observer ratings of the patient’s inarticulate utterances, gross and fine motor movements, and facial tension. Objective indicators of functioning. Another way to consider patients’ level of psychopathology is to examine data from a variety of objective sources that may serve as proxies for quality of life or level of functioning. For example, public and private agency records regarding medical problems and treatment, employment status, legal involvement, marital status, etc. can be compiled to provide a valuable picture of a veteran’s level of functioning. This has been done with a large sample of combat veterans via an archival analysis of data from the NVVRS, where it was found that difficulties on a broad range of variables were inversely correlated with treatment outcome efficacy (Zatzick et al., 1997). Again, further research with similar methodologies or variables of interest would be valuable. Projective measures. In contrast to the large body of data compiled on the use of the MMPI/MMPI-2 with PTSD patients, research with the Rorschach is limited. However, there has recently been increased interest in its utility with Vietnam veterans (Frank, 1992; van der Kolk, & Ducey, 1989). The appeal of projective measures is that they are, by nature, less face-valid than objective inventories, and may therefore be less vulnerable to overreporting. Two studies have presented structural summary data from Rorschach protocols of hospitalized Vietnam veterans with PTSD indicating impaired

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reality testing, ineffective coping strategies, and high levels of situational stress (Hartman et al., 1990; Swanson, Blount, & Bruno, 1990). Two other studies have presented data supporting the utility of the Rorschach in assessing PTSD symptomatology and psychological distress in veterans of the Gulf War (Sloan, Arsenault, Hilsenroth, Handler, & Harvill, 1996; Sloan, Arsenault, Hilsenroth, Harvill, & Handler, 1995). As mentioned previously, Frueh and Kinder (1994) examined the susceptibility of the Rorschach to malingered PTSD symptomatology, comparing profiles obtained from treatment-seeking veterans with combat-related PTSD to undergraduate role-informed malingerers. Although they acknowledged significant limitations with regard to external validity (e.g., comparing combat veterans to undergraduate volunteers), they concluded that the Rorschach shows promise as an assessment tool for the detection of malingerers. Additional research is needed to further our understanding of the utility of projective measures for evaluating overreporters in this population, including the use of other forms of projective measures (e.g., the Thematic Apperception Test, Hand Test). Neurobiological markers. There is a growing body of recent research which points towards a distinct set of neurobiological markers, (e.g., the hypothalamic-pituitary-adrenal axis) which differentiate PTSD from other affective and anxiety disorders (Bremner et al., 1997; Charney, Deutch, Krystal, Southwick, & Nagy, 1993; Hamner & Gold, 1998; Krystal et al. 1989; Yehuda, Boisoneau, Lowy, & Giller, 1995; Yehuda, Giller, Levengood, Southwick, & Siever, 1995). This line of research is still in its infancy, even relative to other areas of PTSD inquiry. As with psychophysiological assessment, it may hold promise for providing objective measures of PTSD severity that are not vulnerable to simulation or exaggeration. Neuropsychological measures. Along with changes in neurobiological markers, there is a growing awareness that cognitive dysfunction appears to be significant among many PTSD sufferers (e.g., Barrett, Green, et al., 1996; McNally & Shin, 1995; Vasterling et al., 1997; Wolfe & Charney, 1991). In addition to poorer verbal intellectual functioning (e.g., Vasterling et al., 1997), symptoms of cognitive disorganization (e.g., dissociation; Bremner et al., 1992), impaired attention and executive functioning (Sutker, Vasterling, et al., 1995), and memory impairment (Bremner et al., 1993, 1995; Sutker, Winstead, et al., 1991; Yehuda, Keefe, et al., 1995) have recently been documented in veterans with PTSD. However, the interface of cognitive dysfunction and symptom overreporting is not well understood. There is some evidence to suggest that level of IQ and symptom reporting are inversely correlated on at least one measure (the Dissociative Experiences Scale, with a visual analogue response format; Dunn, Paolo, Ryan, & Fleet, 1993; Frueh, Johnson, et al., 1996). More research is needed on neuropsychological testing in combat veterans with PTSD, including studies examining malingering on neuropsychological measures which operate on different principles (e.g., whether an individual scores worse than would be expected given random chance) than validity scales of personality measures. Information processing. Recent research indicates that clinically significant emotional states affect information processing, including the interpretation of ambiguous stimuli as threat-relevant, an attentional bias for threat-relevant information among anxious individuals, and a memory bias for negative information among depressed indi-

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viduals (see Dalgeish & Watts, 1990; or Logan & Goetsch, 1993, for reviews). The most commonly studied preparation in this class of measures is a variation of the Stroop test. A consistent result has been that individuals with anxiety disorders exhibit delayed color-naming of threat-relevant words in comparison to either a control list of neutral words, or a control group of nonanxious individuals (e.g., MacLeod & Rutherford, 1992; Mogg, Bradley, Williams, & Mathews, 1993). This emotional Stroop effect has been found for both combat-related (McNally, Amir, & Lipke, 1996; McNally, Kaspi, Riemann, & Zeitlin, 1990) and civilian PTSD (Cassiday, McNally, & Zeitlin, 1992; Foa, Feske, Murdock, Kozak, & McCarthy, 1991). In addition, the effect appears to be “dose-sensitive” in that, although a group of sexual assault victims with PTSD displayed longer color-naming latencies for threat-related words than a group of sexual assault victims without PTSD, the latter group also displayed greater color-naming interference for threat words than a non-victimized control group (Cassiday et al., 1992). As of yet, such measures of information processing have not been included as outcome measures in treatment studies with PTSD. However, they have been utilized in the investigation of treatment outcome with other anxiety disorders with promising results. For example, Mathews, Mogg, Kentish, and Eysenck (1995) found that cognitive-behavioral treatment significantly reduced the emotional Stroop effect in a group of patients with generalized anxiety disorder (GAD) and abolished the differences between the GAD group and a non-anxious comparison group. Mattia, Heimberg, and Hope (1993) found that treatment responders among social phobics randomly assigned to receive either cognitive-behavioral treatment, the monoamine oxidase inhibitor phenelzine, or a pill placebo, displayed a significant reduction in color-naming latencies for social threat words while treatment non-responders did not. Finally, Thorpe and Salkovskis (1997) found that a single session of graduated in vivo exposure therapy significantly reduced phobic avoidance, self-reported fear, and colornaming latencies for spider-related words in comparison to a no-treatment control group. Investigations of information processing in emotional disorders have led to significant advances in our theoretical understanding (see Litz & Keane, 1989, for a discussion of the relevance of such research in understanding PTSD). More importantly for the present discussion is the possibility that such measures may have utility in assessing treatment outcome because they may be less susceptible to exaggeration or faking. Although studies of simulated responding have yet to be conducted with the emotional Stroop or other measures of information processing, they intuitively would seem less vulnerable to distorted responding. This is because there is no face validity to these measures and the magnitude of the differences between the threat-related and neutral words are literally measured in terms of either seconds (when words are presented in lists) or milliseconds (when words are presented individually).

Assessment of Social Functioning The evaluation of social functioning in combat veterans with PTSD has been a neglected area of the clinical literature and represents a special area of assessment (Frueh, Turner, Beidel, & Cahill, in press). Perhaps more so than with other psychiatric disorders, broad-based assessment strategies are needed to fully capture the severity and complexity of the disorder. However, instruments for evaluating the complex

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domains of social functioning are generally lacking, and no measures have been developed specifically for combat-related PTSD. Therefore, the lack of reliable and valid assessment procedures represents a significant gap in our knowledge base. A variety of assessment measures, mostly self-report inventories (listed above), have been used to evaluate social functioning. Without exception, each of these inventories was found to show extreme levels of dysfunction in veterans with combat-related PTSD. Thus, the overreporting phenomenon appears to extend to this area of assessment. Further, there is no general consensus as to the best way to evaluate this important and complex domain. Because social skills and functioning likely comprise a complex set of multidimensional domains, it seems improbable that any single measure will be sufficient to provide a comprehensive evaluation. An array of assessment strategies, including behavioral measures, likely are necessary to fully and accurately assess social functioning. Development of a multimodal index, incorporating data from a variety of method sources, may prove less susceptible to symptom overreporting. This has been accomplished successfully for the evaluation of other psychiatric populations. For example, the Social Phobia Endstate Functioning Index (Turner, Beidel, & Jacob, 1994; Turner, Beidel, Long, Turner, & Townsley, 1992) utilizes data from a variety of sources (e.g., self-report inventory, clinician rating, performance on a behavioral task, patient ratings of distress), and has been shown to be a valid and reliable measure of endstate social functioning in those treated for social phobia. Construction of such an index for PTSD sufferers would represent a significant advancement in our ability to accurately evaluate the social functioning of veterans treated for PTSD because it would be less vulnerable to symptom overreporting, and veterans’ functioning could then be compared to that of normals.

Practical Implications for Clinicians This review has practical implications for clinicians conducting evaluations with combat veterans. First and foremost, clinicians should be aware of the response bias often seen in this population and should not rely only on self-report inventories or other assessment procedures which may be vulnerable to symptom overreporting. Rather, comprehensive assessment of PTSD, associated symptoms, and social functioning in combat veterans should consist of a multi-method approach, including: (1) self-report measures, to assess veterans’ perceptions of their symptomatology; (2) structured interviews, to allow for clinician ratings of relevant symptoms; (3) patient ratings (e.g., daily diaries), to obtain a specific assessment of symptoms and social behaviors; (4) psychophysiological assessment of reactivity to traumatic cues; (5) other behavioral assessments, including facial coding, functional analysis, and performance tasks (e.g., social skills role-plays) in the clinic setting to provide an evaluation of social skill strengths and deficits; and (6) external sources of information such as agency records, medical charts, military records, and collateral reports. Clinicians might consider relying on the “funnel” metaphor of assessment (see Hawkins, 1979). The global assessment provided by self-report inventories and clinical interviews may be helpful in identifying (or “funneling”) general domains of relative psychopathology and interpersonal maladjustment, but more narrow functional (behavioral) assessments, patient ratings, or other assessment strategies are then necessary to identify specific deficits, needs, or psychopathology.

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CONCLUSIONS Psychometric studies have consistently shown that combat veterans evaluated for PTSD apparently overreport psychopathology as exhibited by (a) extreme and diffuse levels of psychopathology across a variety of instruments (e.g., MMPI/MMPI-2, Beck Depression Inventory) measuring different domains of mental illness, and (b) extreme elevations on the validity scales of the MMPI/MMPI-2, in a “fake-bad” direction. The phenomenon of this ubiquitous presentational style is not well understood at present. In the current review we described and delineated the assessment problem posed by this apparent symptom overreporting and reviewed the literature regarding several potential explanatory factors, including features of the clinical syndrome (e.g., comorbidity, interpersonal maladjustment, chronicity, and degree of trauma exposure), a single response factor (e.g., “negative affect”), compensation-seeking status, malingering, and sociopolitical factors. Consideration of a number of conceptual and practical issues are necessary to reach a better understanding of the phenomenon in both research and clinical settings. This includes more research on assessment sources other than self-report inventories, including psychophysiological recordings, functional indicators, behavioral assessments, projective and neuropsychological measures, neurobiological markers, and subliminal processing, as well as further research on aspects of assessment related to comorbidity, compensation-seeking status, malingering, and sociopolitical factors.

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