MILITARY PSYCHOLOGY, 24:397–413, 2012ISSN: 0899-5605 print / 1532-7876 onlineDOI: 10.1080/08995605.2012.695262

Diagnosing PTSD: Lessons FromNeuropsychology

Daniel R. OrmeDepartment of Veterans Affairs Medical Center, Coralville, Iowa

Problematic diagnostic issues related to neurocognitive conditions have been welldocumented in research using neuropsychological instruments. However, due to thenature of differing assessment methods, these issues have not been as clearly estab-lished in the diagnostic assessment of psychiatric disorders that rely on self-report.Nonetheless, they appear relevant. This article summarizes diagnostic-relatedlessons learned based on clinical neuropsychological research and how they areapplicable to the practice of diagnosing psychiatric conditions, post-traumaticstress disorder (PTSD) in particular. Ignoring these lessons raises serious risk formisdiagnosis, inappropriate treatment and services, and iatrogenic illness.

No one has seen post-traumatic stress disorder (PTSD). It cannot be touched anddissected. PTSD is a concept thought to represent a discrete set of subjective,“internal” symptoms that together equate to a psychiatric disorder. The diagno-sis is made based on faith, exclusively on patient self-report. Military medicalproviders sometimes are at a diagnostic advantage in that battlefield electronicmedical records may be available documenting relevant events, initial symptompresentation, and near-term sequelae. This is of considerable assistance to theclinician as it confirms causative events. Nonetheless, most providers do not haveaccess to such information, symptom onset may be delayed, and the diagnosis in

This article not subject to U.S. copyright law.Contents of this article do not represent the views of the Department of Veterans Affairs or the

United States Government.Correspondence should be addressed to Daniel R. Orme, Clinical Neuropsychologist, Mental

Health Service Line, Department of Veterans Affairs Medical Center, 520 10th Avenue, Coralville,IA 52241. E-mail: daniel.orme@va.gov

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any event ultimately relies on self-report. Psychiatric conditions with no biologi-cal markers that are subjectively diagnosed are not uncommon, and their diagnosisand treatment are accepted practice. Depression and schizophrenia are two otherexamples and, even though no one has seen these conditions either, it would behard to argue they do not exist. Yet, the subjective nature of psychiatric conditionsis problematic.

Cognitive sequelae from brain injury and illness similarly cannot be seen butare assumed to exist even without tangible neurologic and radiological evidence.However, it is possible to obtain documentation of the existence and magnitude ofthese neurocognitive problems through neuropsychological evaluation. Thus, anobjective assessment of symptoms associated with brain injury may be under-taken, a distinct advantage over many psychiatric conditions. Because of theability to objectively measure subjective cognitive complaints, much has beenlearned about diagnostic issues related to neurocognitive conditions. What hasbeen learned may be presented as “lessons,” which may be applied to other con-ditions, particularly those that rely on self-report, PTSD in particular. The focusof this article, then, is to present these “lessons” using evidence primarily relatedto toxin exposure during the first Gulf War and to concussion research (the termsmild traumatic brain injury and concussion are synonymous; concussion will beused here). There are six “new” lessons and three that support previous findingsregarding PTSD.

NEW LESSONS

Belief of Having a Medical Condition Influences Subjective Self-Appraisaland Behavior

Could it be that individuals who become convinced they have PTSD interpretphysical and emotional symptoms, respond to questions and questionnaires inclinical settings, and behave as if they do? In other words, is there an illness mind-set that exacerbates, maintains, and in some instances creates PTSD symptoms?The evidence from neuropsychology suggests this is possible.

A good example of this is provided by Mahan, Kang, Dalanger, and Heller(2004). They had a group of 352 Gulf War veterans complete two checklists: onewith 12 items addressing disability status, health care utilization, and selectedmedical conditions; another listing 10 somatic symptoms. Results were contrastedbetween those who reported having received the anthrax vaccine (N = 260) andthose who said they did not receive it (N = 58). Those who reported having hadthe anthrax vaccine endorsed greater difficulties in all 12 areas on the first check-list and 9 of 10 on the other; results were statistically significant. The twist in thisstudy is that all participants had, in fact, received the anthrax vaccine, but 58 of

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them never knew this or forgot. Consequently, greater self-reported health prob-lems were not related to receipt of the anthrax vaccine, but to the reported beliefof having received the vaccine.

This phenomenon is also seen in actual performance on neurocognitive testsand has been called “diagnosis threat” (Suhr & Gunstad, 2002). For example,Suhr and Gunstad (2002) administered neurocognitive tests to 36 undergradu-ate college students with history of concussion. Half (the “threat” group) wereinformed that: they were selected for this evaluation because of their historyof concussion; studies have shown many individuals have cognitive sequelaefrom concussion; the purpose of the study was to examine the relationshipbetween concussion and cognitive functioning. The others (the “neutral” group)were only given a description of the kinds of tests they were to take and wererequested to give their best effort. The “threat” group performed poorer on testsof immediate and delayed memory and general intellect than the “neutral” group.Another study (Suhr & Gunstad, 2005) supported these findings and also notedthat effort, anxiety, and depression symptoms did not explain the differences inscores between the groups. Neurocognitive test differences between the groups inthese studies, then, appear related to the expectation of the examinees.

Symptoms Are Highly Suggestible

PTSD receives high visibility from the media, government and military leaders,and medical professionals. For example, Armstrong and Olatunji (2009), utiliz-ing a Lexis-Nexis search, found a “staggering” (p. 57) increase in the number ofPTSD-related articles in U.S. news media in recent years, particularly since thesecond Gulf War and the 2008 elections. Whereas there were less than 100 arti-cles noted per year from 1988 to 2004, the number increased to approximately200 in each of 2006 and 2007 and to greater than 600 in each of 2007 and 2008.With such bombardment of PTSD-related information, the possibility of PTSDacquisition through suggestion is raised. Analogous conditions but with largelysomatic and neurocognitive complaints are well-known.

There are well-documented instances where individuals complain of physical(including neurocognitive) symptoms, yet no medical cause or objective evi-dence of illness is found, and psychological factors are often suspected. In someinstances, these are called “functional somatic syndromes” and include multiplechemical sensitivity, sick building syndrome, effects of silicone breast implants,chronic fatigue syndrome, and fibromyalgia. Gulf War illness may be anotherexample of this (Barsky & Borus, 1999; Ismail & Lewis, 2006, Orme, 2010).

Mass psychogenic illness is a variant of functional somatic syndromes (Barsky& Borus, 1999). With this, groups of individuals complain of a range of unex-plained, generally somatic symptoms, with nausea, vomiting, headache, and dizzi-ness predominating; it occurs anywhere individuals comingle but most frequently

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in schools, employment settings, and communities (Boss, 1997). The afflictedoften attribute their ills to specific sources, such as presumed but undocumentedexposure to toxins or a virus, while medical investigation reveals no identifiablecause. These situations most likely are sociological, not medical, events.

A brief example of mass psychogenic illness may be helpful (Vasterman,Yzermans, & Dirkzwager, 2005). On October 3, 1992, a Boeing 747 cargo jetcrashed into two apartment buildings in Amsterdam. Thirty-nine residents andfour crew members were killed. The cause was quickly determined to be badlocking pins, causing two engines to break away. Subsequently, there developedspeculation and rumors particularly involving potential hazardous cargo, includ-ing sarin, in the plane, and a government cover-up, all unfounded. There werenumerous media hypes with each new rumor. Soon, individuals in the communitybegan complaining of a wide range of symptoms: rashes, respiratory difficulty,sleeplessness, fatigue, and concentration and memory difficulties. Initially, onlyrescue workers and residents in the vicinity of the crash complained of thesesymptoms. However, with each new media blitz, increasing numbers reportedsymptoms and, over several years, the number of claims rose from over a fewdozen to in excess of 6,000. There was concern this was a new disease. Still, med-ical examination found no objective evidence of illness, and it was concluded thatmost of the concerns individuals reported were related to misattribution of eventsand symptoms associated with “normal” living.

Many Reported Symptoms Simply Reflect Normal Functioning

Self-report of PTSD symptoms is subjective, and it is difficult to discern nor-mal responses to bad events from those that constitute a psychiatric condition.Some suggest that at least on occasion, report of symptoms associated with PTSDreflect normal reaction to horrific events or symptoms associated with daily living(Dobbs, 2009; McHugh & Treisman, 2007; Spitzer, First, & Wakefield, 2007).If neuropsychological research may be generalized to PTSD, such suggestionsmerit consideration.

Symptoms associated with brain dysfunction are fairly commonly reported inthe general, nonclinical population. This is evident, for example, with controlgroup data in studies examining self-report of neurocognitive sequelae of trau-matic brain injury (TBI). For example, Paniak et al. (2002) found the followingsymptoms endorsed by from 39% to 60% of their normal control group, con-sisting of staff and students from university, hospital, and government offices:anxiety, headache, sleep problems, irritability, forgetfulness, word-finding diffi-culties, distractibility, restlessness, and lack of initiative. Iverson, Lange, Brooks,and Rennison (2010) found 58.2% of their control group endorsed two ormore symptoms on the 16-item British Columbia Post-Concussion SymptomInventory, while 22.6% reported experiencing six or more symptoms. Most

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frequently endorsed were problems with: fatigue (39%), sleep (32.8%), con-centration (27.1%), headache (26.6%), temper (23.7%), and memory (23.7%).A somewhat different approach was used by Mittenberg, DiGiulio, Perrin, & Bass(1992) and Ferguson, Mittenberg, Barone, and Schneider (1999). Their 30-iteminventory addressed activities of daily living that may be impaired in individu-als who have sustained significant head trauma. Their control groups consistedof community volunteers (Mittenberg et al., 1992) and nonhead-injured athletes(Ferguson et al., 1999). In both instances 20% to 41% complained of such thingsas forgetting: where are the car keys, groceries they are to get, where a walletwas placed, why s/he went into a room, directions while driving, where the caris parked, and contents of daily conversations. In summary, report of symptomsassociated with TBI does not indicate one has TBI sequelae, as these symptomsare commonly endorsed in the general population.

Self-Perception/Self-Report Is Often Inaccurate

Can individuals who are generally psychiatrically normal, well-meaning, andsincere believe information that is untrue and be convinced they have medicalconditions that are not supported by objective fact? This cannot be researchedwith PTSD, as those symptoms are subjective and not verifiable. However,neuropsychological and other research suggests the answer is “yes” to both,raising concern regarding PTSD as well.

Two areas of study are presented to demonstrate that self-report is often inac-curate. Both involve military veterans. The first examines self-report of exposureto toxins during the first Gulf War and their presumed cognitive sequelae, whilethe other addresses symptoms associated with concussion related to service duringOperation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF).

McCauley et al. (1999) contrasted Gulf war era veterans’ self-report of expo-sure to various toxins with Department of Defense documentation. Nearly 6% ofveterans who were not deployed to combat reported having had the botulinum vac-cine, as did 17.8% of those in combat; however, records indicate less than 5% ofcombat troops received this vaccine, and most of these were in a specific MarineCorps unit that was not well represented in the McCauley et al. (1999) sample.Additionally, 28% and 47% of veterans who were deployed only during precom-bat or postcombat periods, respectively, reported exposure to chemical warfareagents, although there is no data to suggest the presence of chemical warfareagents during this conflict.

Similarly, large numbers of veterans of the first Gulf War complain of med-ically unexplained cognitive decline related to their deployment; this is part ofwhat has come to be called Gulf War illness. However, the overwhelming andrather robust research literature suggests normal cognitive functioning in theseindividuals. This is well detailed in a number of comprehensive reviews of relevant

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research (Axelrod & Milner, 2000; Committee on Gulf War and Health, 2009;Vasterling & Bremner, 2006; Wessely, 2006). As an aside, the findings of thosereviews are in contrast to conclusions offered by the congressionally mandatedResearch Advisory Committee on Gulf War Veterans’ Illnesses (2008, p. 1) whoflatly stated Gulf War illness is “real,” due to exposure to neurotoxins, affects 25%of those deployed, and includes a large number of symptoms, including “persistentmemory and concentration problems.” However, serious reservation regarding thecommittee’s conclusions is indicated due to issues related to over-interpretationof data and potential conflict of interest involving committee members (Cardwell,2005; Orme, 2010; Orme, 2012).

Regarding concussion and protracted cognitive sequelae, the literature is exten-sive and reveals that complaint of symptoms is highly unlikely to be related toneurological insult (Belanger, Curtis, Demery, Lebowitz, & Vanderploeg, 2005;Binder, 1997; Binder et al., 1999; Iverson, 2005; Jungwirth et al., 2004; Lebowitz,Vassallo, Vanderploeg, & Curtiss, 2006; Liik, Vahter, Gross-Paju, & Haldre, 2009;Marino et al., 2009; Meares, et al., 2011; Rohling, Larrabee, & Millis, 2012;Suhr, 2003; Tsanadis et al., 2008). There are few dissenting opinions. Notableis Ruff (2005), who writes of the “miserable minority” (10–20% of concussionpatients presumed to have lingering sequelae). He posits that neuropsychologicalresearch largely misses this group due to small sample sizes or the use of groupeddata. Still, Rohling et al. (2012) dismiss these arguments through use of statisti-cal modeling, taking into account possible effects of relatively small but clinicallysignificant groups within larger samples.

While a comprehensive review of the literature is not practical for thepurposes of this paper, two recent studies with veterans of Operation IraqiFreedom/Operation Enduring Freedom (OIF/OEF) are presented here as exam-ples. Brenner et al. (2010) administered neuropsychological tests to 45 soldierswho reported a history of concussion during deployment. Results were contrastedbetween those reporting (N = 27) and not reporting (N = 18) enduring concussionsymptoms. The tests produced 25 variables, primarily assessing attention, ver-bal memory, and executive functioning. In spite of the large variable-to-subjectratio, none of these variables demonstrated a significant difference between thetwo groups. Similarly, a sample of 105 veterans, all screening positive for con-cussion, underwent a 45-minute neuropsychological evaluation assessing a rangeof cognitive skills; they also completed self-report symptom checklists (Spencer,Drag, Walker, & Bieliauskas, 2010). Again, data analysis revealed that self-report of symptoms was poorly correlated with objective neuropsychological data,although it was related to self-reported affective difficulties. Interestingly, clini-cians (i.e., physicians, nurses, physical therapists, social workers, and others) wereasked to estimate the expected relationship between symptom complaint and testperformance. Their prediction of a strong relationship was not supported.

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Premorbid Functioning Is Often Reported As Better Than It Was

The “good old days” bias refers to the notion that individuals with health-relatedconcerns often report their premorbid health as better than it was (Iverson, Langeet al., 2010; Lange, Iverson, & Rose, 2010). Consequently, they attribute greateradverse effects to their perceived ill health than is realistic. “Good old days” biashas been demonstrated with concussion patients, but there are no known analo-gous studies involving those with PTSD; however, this is worth consideration andmay be clinically relevant with this group as well. Presented here is representative“good old days” research related to concussion research.

An early, much-cited study (Mittenberg et al., 1992) provides evidence of this.Patients seen at an outpatient clinic complaining of sequelae from concussionoccurring approximately 1.7 years previously and a control group completed a30-item checklist addressing affective, somatic, and memory issues. Participantscompleted the checklist twice. The concussion group rated how they are currentlyand how they were before their injury; the control group rated how they are cur-rently and as they imagined they would be 6 months after a head injury. There wasessentially no difference between how the concussion group rated their currentsymptoms and the control groups predicted post-TBI symptoms. In contrast, theconcussion group reported considerably fewer preinjury symptoms than the nor-mal controls current functioning. Under-reporting of premorbid symptoms for theconcussion group is suggested. Self-report of lasting sequelae from concussion,then, may reflect an erroneous judgment of the difference between self-appraisedpremorbid functioning and current status.

Additional studies have largely replicated and augmented the findings ofMittenberg et al. (1992). For example, Ferguson et al. (1999) found that althoughathletes with and without histories of concussion endorsed similar frequency ofpostconcussive symptoms, those with such a history underestimated preinjurysymptoms by 97%. Lange et al. (2010) found that while concussion participantsreported fewer preinjury symptoms than controls regardless of litigation status,more current symptoms were reported for those with versus those without pend-ing litigation. Nonlitigant concussion participants in a study by Hilsabek, Gouvier,and Bolter (1998) also endorsed fewer preinjury symptoms than controls, and theyalso reported having sought treatment for more symptoms postinjury than con-trols, participants with back injuries, and those who have experienced a sudden,significant life stressor; an increase in number of symptoms over time was alsoreported, inconsistent with what is known regarding recovery from concussion.

Assessment Method Influences Conclusions

There is a commendable and extensive effort to ensure that military activeduty and veteran populations are regularly screened for a number of conditions,

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including PTSD, and to secure appropriate treatment for those in need of care.Regarding PTSD, military members are screened within 30 days and againbetween 3 and 6 months following deployment; and VA medical centers havebuilt-in reminders in the computerized patient record system that require healthcare providers to screen for PTSD (Brenner, Vanderploeg, & Terrio, 2009). Thesetake the form of questionnaires in that they ask about specific symptoms diagnos-tic for PTSD. Additionally, it is common for clinicians to regularly have patientscomplete PTSD questionnaires to assist with diagnosis and to monitor treatment.While laudable and understandable, could the very well-intentioned effort to pro-vide help contribute to PTSD symptom presentation and/or exacerbation? In thiscase, could the assessment method result in false positives or, as discussed above,acquisition through suggestion?

Concussion studies have shown that symptom reporting varies dependingupon the assessment method. For example, Villemure, Nolin, & Le Sage (2011)assessed sequelae of concussion with a sample of 354 individuals. Each wasassessed 1 week, 4 weeks, and 3 months postinjury. Two methods of assess-ment were used on each occasion: “spontaneous method,” involving open-endedquestioning; and “suggested method,” whereby the participants responded tostandardized symptom checklists. On each occasion, participants reported sig-nificantly more symptoms with the “suggested method.” For example, memoryproblems were noted by 29.4%, 27.7%, and 22.6% of the participants at eachof the three times, respectively, using the “suggested method.” However, only6.5%, 7.3%, and 6.8% noted this to be an issue at these three times using the“spontaneous method.” In a similar study, Iverson, Lange et al. (2010) foundthat when compared with interview, checklists resulted in: approximately threetimes more symptom endorsement; greater percentage of participants reporting4 or more of 13 symptoms (44.4% versus 91.8%); and all 13 symptoms endorsedat a significantly greater rate.

LESSONS SUPPORTED

Reported Symptoms May Reflect Those Associated With a DifferentCondition

PTSD frequently co-occurs with other conditions, and it is difficult to differenti-ate one from another. Rosen and Lilienfeld (2008) summarize the literature on theco-occurrence of PTSD with conditions such as depression, panic disorder, gener-alized anxiety disorder, obsessive-compulsive disorder, and substance abuse. Theyalso note the overlap of diagnostic criteria. The clinical dilemma is to tease outthe contributions of these various conditions and to ensure that what looks likePTSD is not another condition. This problem is not unique to PTSD and is wellevidenced in concussion research as well.

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It has been well-established that there is a strong overlap between symp-toms associated with concussion and other medical conditions. For example, in areview of the literature, Iverson, Brooks, Ashton, and Lange (2010) noted similarsymptoms between individuals reporting concussion symptoms and symptoms ofthose with outpatient psychological care, minor medical problems, PTSD, ortho-pedic injuries, and chronic pain. Fear et al. (2009) found an association betweenself-reported blast exposure while deployed on military duty to Iraq and postcon-cussive symptoms, but the same association with these symptoms was found forthose reporting possible exposure to depleted uranium, aiding the wounded, otherhealth outcomes, and PTSD.

Additionally, the definition of “probable TBI” for war veterans often includes:“injury during deployment that resulted in an alteration of consciousness immedi-ately following the injury—e.g., being confused, experiencing memory loss, beingunconscious” (Tanielian & Jaycox, 2008, p. 93). However, “alteration of con-sciousness,” and so on, can be attributed to causes other than TBI, such as stress,fear, and the fog of war. Elliott (1997), for example, determined that of those whoviewed combat injuries, 38% noted at least partial amnesia for the event(s).

History Reporting Varies Over Time

A PTSD diagnosis requires that the afflicted has experienced an emotionally trau-matic event. As straightforward as that appears, research shows that reporting ofsuch events is not static. Accuracy and reliability of self-report of stressful eventslinked with PTSD has been shown to vary over time, and increased reportingfrom one time to the next has been associated with reporting of PTSD symp-toms (Engelhard, van den Hout, & McNally, 2008; Heir, Piatigotrsky, & Weisaeth,2009; Koenen, Stellman, Dohrenwend, Sommer, & Stellman, 2007; Roemer, Litz,Orsillo, Ehlich, & Friedman, 1998; Southwick, Morgan, Nicolaou, & Charney,1997). The cause of this is unclear, but what other research reveals is thatrecollections of significant events vary over time even when PTSD is not an issue.

Wessley et al. (2003), for example, addressed the stability of military hazardrecall with Gulf War era veterans. Using checklists, these veterans were queried in1997 and again in 2000–2001 regarding potential toxin exposure during that con-flict. They were divided into three groups based on their location during the war:Persian Gulf Region (Gulf cohort), Bosnia (Bosnia cohort), and not deployed (Eracohort). Their findings were mixed. At least moderate reliability was noted forreported exposure to obvious events such as oil fire smoke and hearing Scud mis-siles detonate. Belief of exposure to chemical attack was fairly reliable, althoughthere is no reason to believe there were such attacks during that war (McCauleyet al., 1999). Poor reliability was associated with exposure to chemicals (i.e.,chemical agent-resistant coating [CARC] paint, solvents, pesticides), local water,and depleted uranium. An increase in exposure reporting was noted with the Gulf

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cohort and associated with poor health perception, but not with psychologicalmorbidity or physical health. On the other hand, recalling fewer exposures overtime was associated with better health perception.

Another study (VanDyke, Axelrod, & Schutte, 2010) examined consis-tency of self-report related to battlefield brain trauma in OIF/OEF veterans.Specifically, they examined consistency of response to the Traumatic Brain InjuryScreening Instrument (TBISI). This is a screening instrument used in VeteransAdministration facilities and relies on self-report to items addressing four issues.These are whether the veteran experienced: (1) an event while deployed that couldresult in brain injury; (2) immediate sequelae from that event; (3) continuationor worsening of symptoms over time; (4) symptoms occurring within the weekpreceding completing of the TBISI. Participants were administered this question-naire twice: upon initial screening and then during second-level evaluation, withthe time between administrations averaging 6 months. There were 21 total items.Only six were considered to have “good/fair” reliability, with consistency rangingfrom 69% to 91%. Noteworthy is that the most consistency was found for report ofsymptoms experienced within the week prior to completing the TBISI, accountingfor three of the six “good/fair” reliability items; this is counter to the expectationthat “current problems” items were most likely to fluctuate with time.

In Certain Situations, the Incidence of Inaccurate Patient PresentationIs High

Of concern here is when the self-report of patients, or performance onneuropsychological tests, is inaccurate due to intentional incorrect reporting orissues related to effort on testing. In these instances, findings are considered“noncredible” and, as pertains to neuropsychological testing, have been definedas “poor performance that is unrelated to brain dysfunction and is accompaniedby compelling evidence that effort is a major influence” (Greiffenstein, 2010,p. 81). “Effort” is further described as either not trying hard enough or tryingto appear impaired. For example, disinterest and fatigue may result in not tryinghard enough; on the other hand, individuals with factitious disorders and malin-gerers may try to appear impaired, while others may overemphasize their bonafide problems to make a case, such as to obtain care. Self-report of symptoms andhistory may also be noncredible, and sometimes this is identified through objec-tively identified historical inaccuracies or reporting of inconsistent or medicallyimplausible symptoms. However, self-report often cannot be verified.

Recognizing that intentional false reporting of PTSD symptoms may occurfor a variety of reasons, false reporting for financial benefit (i.e., malingering)is noted here as an example of the nature of this problem. In some situations,a diagnosis of PTSD can result in substantial sums of money and other bene-fits. A military veteran who is declared 100% disabled due to PTSD receives

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approximately $2,300 tax-free dollars per month for life, adjusted annually forcost of living, plus other Veteran’s Administration and military benefits includinghealth care (Satel, 2011). Putting this into perspective, someone who retired fromthe military after attaining the highest enlisted rank (E-9) and serving 20 yearswould receive $2,381 per month, pretaxes (Office of the Secretary of Defense,2012). This should not be misunderstood: military veterans certainly are deserv-ing of compensation and a way to obtain a livelihood in the face of service-relateddisabling injury or illness. However, the temptation to stretch the truth for per-sonal gain may be too great for some, particularly when diagnostic criteria areeasily accessible for review and diagnosis is confirmed based on one’s word. Forexample, Hall and Hall (2007) reported that the incidence of symptom exaggera-tion or those who “outright malingered” (p. 717) psychological symptoms rangesfrom 1% to greater than 50% in personal injury litigation, and as many as 75%of Vietnam veterans applying for compensation for PTSD. Interestingly, Arbisi,Murdoch, Fortier, and McNulty (2004) found no significant difference in VA com-pensation amounts awarded when contrasting those whose psychological testingwas valid versus invalid (suggesting a false presentation). There is a rich body ofresearch literature that examines intentional incorrect patient self-report relatedto PTSD. The interested reader may wish to consult the following reviews ofrelated practice and research issues (Frueh, Hamner, Cahill, Gold, & Hamlin,2000; Guriel & Fremouw, 2003; Hall & Hall, 2006; Hall & Hall, 2007; Taylor,Frueh, & Asmundson, 2007).

Verifiability remains a significant challenge to assessing the accuracy of patientself-report, such as with PTSD. Neuropsychology, on the other hand, standstall among other mental health professions in its ability to objectively addressnoncredible neurocognitive presentations through use of specialized tests andstatistical methods (see Bush et al., 2005, for review). Neuropsychology, then,might provide a model for the issue of noncredible self-report in PTSD. Throughneuropsychological methods, it is possible to assess the validity of responses ofindividuals with cognitive complaints in the clinical setting and also gauge themagnitude of the problem in the field as a whole. Regarding the latter, the evi-dence is striking. Mittenberg, Patton, Canyock, and Condit (2002), for example,surveyed members of the American Board of Clinical Neuropsychology and foundthe following “probable malingering and symptom exaggeration” (p. 1094) baserates by referral concern: disability (30%); personal injury (29%); criminal (19%);medical (8%). Research concerning patient effort on neuropsychological testingis extensive and cannot be comprehensively reviewed here; the interested readermay wish to consult Larrabee (2007) for more detailed information and litera-ture review. Suffice it to say, however, that high rates of effort-related concernshas been repeatedly documented, particularly when there may be secondary gain.Larrabee (2003), for example, found failure rates on tests of effort to average40% for individuals undergoing neuropsychological evaluation when secondary

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gain was at issue. More focused studies found frequency of failure on at least onetest of effort to be: 40%–46% of individuals claiming neurocognitive sequelaefrom long-term occupational exposure to toxins (Greve et al., 2006; van Hout,Schmand, Wekking, Hargman, & Deelman, 2003); 43% of applicants for com-pensation based on claimed work-related pain or psychological injury (Gervais,Rohling, Green, & Ford, 2004); 79% of individuals applying for Social Securitydisability based on low intellectual functioning (Chafetz, 2008); and 89% ofthose undergoing criminal pretrial or presentencing evaluations (Ardolf, Denny,& Houston (2007).

Military and veteran populations are not immune. Armistead-Jehle (2010)found a 58% failure rate on tests of effort for veterans seen for neuropsychologicalevaluation following positive screening for concussion. A similar sample(Whitney, Shepard, Williams, Davis, & Adams, 2009) found failure rate to be17%, a smaller frequency but still approaching one out of five individuals. Finally,Nelson et al. (2010) compared samples of National Guard members, all of whomreported a history of concussion, based on whether they were seen clinically orfor research purposes. Insufficient effort accounted for 20.3% to 33.6% of testvariance for the clinical group but only 1.0% to 8.4% for the research group.

CLOSING THOUGHTS

In neuropsychology the general rule tends to be: “assume untrue until proven.”For example, although an individual may complain of memory problems relatedto head trauma, the prudent neuropsychologist would not suppose this to be truewithout valid supporting psychometric and clinical data. While appearing cynical,there is good reason for this position, as reflected throughout the body of thispaper. Although untested, in general mental health practice the rule often appearsto be: “assume true unless proven otherwise.” The risk of false positives in thiscase must be quite large based on what we know from neuropsychology and runsthe significant risk of inappropriate treatment and services, and iatrogenic illness.

Consequently, there is good reason to tread lightly, cautiously, and perhapscynically when assessing for PTSD. Lange et al. (2010) essentially suggest thatpostconcussive syndrome should be a diagnosis of exclusion, given only afterother diagnoses and factors that may cause and/or maintain the reported symp-toms are ruled out. Should PTSD be a diagnosis of exclusion? This argumentcould well be made.

Please note that the literature cited in the body of this report is not exhaus-tive but thought to be representative of the issues raised. Also, while PTSD isspecifically noted, these issues are relevant for any diagnosis that relies primarilyon self-report. PTSD was selected because, unlike most other psychiatric diag-noses, it has been controversial from the start, it remains the subject of hot debate,

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it has evolved substantially over the brief 32 years since it was first placed inthe Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) (AmericanPsychiatric Association, 1980), and it cannot be easily separated from personaland political forces that contributed in part to its creation/discovery and modifi-cations over the years (Baldwin, Williams, & Houts, 2004; Dobbs, 2009; McHugh& Treisman, 2007; McNally, 2009; Rosen & Lilienfeld, 2008; Rosen, Spitzer, &McHugh, 2008; Scott, 1990; Spitzer et al., 2007; Spitzer, Rosen, & Lilienfeld,2008; Summerfield, 2001). It is hoped that mental health clinicians criticallyappraise patient self-report when making diagnostic decisions, taking into accountthe numerous divergent pathways that may arrive at the same place: meetingdiagnostic criteria.

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Arbisi, P. A., Murdoch, M., Fortier, L, & McNulty, J. (2004). MMPI-2 validity and award of serviceconnection for PTSD during the VA compensation and pension evaluation. Psychological Services,1(1), 56–67.

Ardolf, B. R., Denny, R. L., & Houston, C. M. (2007). Base rates of negative response bias andmalingered neurocognitive dysfunction among criminal defendants referred for neuropsychologicalevaluation. The Clinical Neuropsychologist, 21, 899–916.

Armistead-Jehle, P. (2010). Symptom validity test performance in U.S. veterans referred for evaluationof mild TBI. Applied Neuropsychology, 17, 52–59.

Armstrong, T., & Olatunji, B. (2009). PTSD in the media: A critical analysis of the portrayal ofcontroversial issues. The Scientific Review of Mental Health Practice, 7(1), 55–60.

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