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Posttraumatic Stress Disorder: Assessing Response Style and Malingering

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Abstract

Posttraumatic stress disorder (PTSD) may form the basis for disability or worker’s compensation claims or a personal injury lawsuit. While now achieving widespread acceptance among treating professionals and the public, PTSD is the subject of several controversies and the possibility of faking in a compensation context. There appears to be a dramatic split among mental health professionals who write primarily from a treatment or plaintiff perspective and those who take a more skeptical approach. This article reviews recent developments in the assessment of malingering, including symptom validity measures, and applies them to the assessment of PTSD. Recommendations for current practice are provided.

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Notes

  1. A recent meta-analysis (Pole 2007) found small to moderate effects of PTSD on psychophysical measures such as resting heart rate and changes in physiological measures to standard and idiographic trauma-related stimuli.

  2. The WMT effort indicators do not correlate with IQ or age above age 10, and even modest decrements in performance from normative levels are associated with depressed scores on other measures.

  3. I include all available studies in this table, as one of two simulation studies that used unscreened veterans as their genuine PTSD sample reported statistics comparable to the better-controlled studies.

  4. Although Rogers described his study as a bootstrapping design, the measures used are well validated; conservative cutoff scores were used, and only extreme groups were compared. This is a strong design comparable to, for example, classification based on the SIRS, which Rogers has cited as an example of a known group design.

  5. It is unfortunate that the SIMS and M-FAST authors described their measures as screening tests, as this may artificially constrain their use: with higher cutoff scores, both may well provide positive predictive power/specificity statistics comparable to other response-style instruments.

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Appendix

Appendix

Summary of Trauma Symptom Inventory studies

Scale or Index

Study

Simulators (unless indicated)

Comparison

Validity Control for PTSD?

Instructed to avoid detection?a

Sens

FP

LR

Cohen’s d

ATR>58b

Elhai et al. (2005)

Students

PTSD diagnosed outpatients

N

N

0.70

0.57

1.2

0.48

ATR ≥ 61

Edens et al. (1998)

Students

Students

N, LR

Y

0.78

0.08

9.8c

-

ATR ≥ 61

Edens et al. (1998)

20 Students with trauma and one TSI elevation (feign)

20 Students with trauma and one TSI elevation

N, LR

Y

-

0.15

-

-

ATR > 61b

Elhai et al. (2005)

Students

PTSD - diagnosed outpatients

N

N

0.65

0.45

1.4

-

ATR ≥ 61

Guriel-Tennant and Fremouw (2006)

Students with recent trauma, neg on PCL (naïve)

Students with recent trauma, pos on PCL and CAPS

N, LR

Y

0.82

-

-

-

Students with recent trauma, neg on PCL (coached)

Students with recent trauma, pos on PCL and CAPS

N, LR

Y

0.32

-

-

-

ATR ≥ 61

Rosen (2006)

Students

Students

N, LR

N

0.68

0.20

3.4c

1.00c

ATR > 61

Guriel et al. (2004)

Students (uncoached)

Students

N, LR

Y

0.84

-

-

1.60c

Students (coached symptoms)

Students

N, LR

Y

0.83

-

-

1.46c

Students (coached Sxs and strategies)

Students

N, LR

Y

0.81

-

-

1.28c

ATR > 61d

Edens et al. (1998) reanalysis by Rosen (2006)

Students with two elevations on TSI

Students with two elevations on TSI

N, LR

Y

0.86

0.42

2.0

-

ATR ≥ 61

Efendov et al. (2008)

Remitted trauma, valid MMPI and TSI (uncoached)

PTSD claimants, assessed if suspected

P, HRe

Y

0.72

0.51

1.4

0.74

ATR ≥ 61

Efendov et al. (2008)

Remitted trauma, valid MMPI and TSI (coached)

PTSD claimants, assessed if suspected

P, HRe

Y

0.55

0.51

1.1

0.14

ATR > 61

Edens et al. (1998)

 

Various clinical groups

?

?

-

0.23f

-

-

ATR > 63

Rosen (2006)

Students with two elevations on TSI

Students with two elevations on TSI

NA

N

0.65

0.36

1.8

-

ATR > 63b

Elhai et al. (2005)

Students

PTSD diagnosed outpatients

N

N

0.52

0.30

1.7

-

ATR > 64

Edens et al. (1998)

 

Various clinical groups

?

?

-

0.17f

-

-

ATR > 70

Edens et al. (1998) reanalysis by Rosen (2005)

Students with two elevations on TSI

Students with two elevations on TSI

Y

Y

0.74

0.21

3.5

-

ATR ≥ 90

Edens et al. (1998)

Students

Students

Y

Y

0.27

0.01

48.0

-

ATR ≥ 90

Efendov et al. (2008)

Remitted trauma, valid MMPI and TSI (Uncoached)

PTSD claimants, assessed if suspected

P, HRe

Y

0.34

0.87

0.4

-

ATR ≥ 90

Efendov et al. (2008)

Remitted trauma, valid MMPI and TSI (Coached)

PTSD claimants, assessed if suspected

P, HRe

Y

0.16

0.87

0.2

-

ATR > 90

Elhai et al. (2005)

Students

PTSD diagnosed outpatients

N

Y

0.22

0.40

0.6

-

ATR > 90g

Porter (2007)

Students with trauma since age 16

Students with trauma since age 16

NA

N

0.19

0.10

1.9

0.61

HR = high risk; LR = low risk; P = partial.

aIncludes warnings about validity scales.

bArticle does not specify whether cutoff score was inclusive of feigning or not. Identified cutoff rule presumed from use of > 90 in other part of article.

cEffect size figure is computed from comparing an honest responding, non trauma-exposed group to a simulating group.

dOriginal cutoff score used by Eden et al. was ≥ 61, not > 61.

eFigures shown derived from weighted average of various clinical groups (n = 659).

fCutoff score actually used is not specified, but is presumed from context and figures for sensitivity and specificity.

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Rubenzer, S. Posttraumatic Stress Disorder: Assessing Response Style and Malingering. Psychol. Inj. and Law 2, 114–142 (2009). https://doi.org/10.1007/s12207-009-9045-4

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