Abstract
Introduction
There is a dearth of research on the impact of pre-treatment assessment effort and symptom exaggeration on the treatment outcomes of Veterans engaging in trauma-focused therapy, handicapping therapists providing these treatments. Research suggests a multi-method approach for assessing symptom exaggeration in Veterans with posttraumatic stress disorder (PTSD), which includes effort and symptom validity tests, is preferable. Symptom exaggeration has also been considered a “cry for help,” associated with increased PTSD and depressive symptoms. Recently, research has identified resilience as a moderator of PTSD and depressive symptom severity and an important predictor of treatment response among individuals with PTSD. Thus, it is important to examine the intersection of symptom exaggeration, resilience, and treatment outcome to determine whether assessment effort and symptom exaggeration compromise treatment response.
Materials and Methods
We recruited Veterans, aged 18–50 who served during the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) era, from mental health clinics and fliers posted in a large Veterans Affairs Medical Center. Veterans met inclusion criteria if they were diagnosed with PTSD via a clinician-administered assessment. Sixty-one Veterans consented to participate and self-selected into a cognitive processing therapy (CPT) group or treatment-as-usual. We offered self-selection because low recruitment rates delayed treatment start dates and were consistent with a Veteran-centered care philosophy. Veterans were assessed before and after treatment to determine the impact of assessment effort and symptom exaggeration scores on measures of PTSD and depressive symptoms and resilience. This study examined whether assessment effort failure and symptom exaggeration were associated with compromised psychotherapy outcomes in Veterans with PTSD undergoing CPT group. We hypothesized that a pattern of responding consistent with both effort and symptom exaggeration would result in higher (ie, more severe) pre- and post-treatment scores on PTSD and depressive symptom outcome measures and lower resiliency when compared to Veterans providing good effort and genuine responding. Hypotheses were evaluated using bivariate correlation analyses, analysis of variance, and chi-square analyses.
Results
Pre-treatment scores on measures of PTSD and depressive symptoms were higher among Veterans whose pattern of responding was consistent with poor assessment effort and symptom exaggeration; these Veterans also scored lower on a measure of resiliency. At post-treatment, there were no differences between Veterans displaying good and failed effort testing on measures of PTSD and depressive symptoms or in whether they completed treatment. Post-treatment resiliency scores remained significantly lower in those with failed effort testing.
Conclusion
These results suggest that Veterans with PTSD whose validity testing scores are indicative of poor effort and symptom exaggeration may be less resilient but may still complete a CPT group treatment and benefit from treatment at a rate comparable to Veterans who evidence good assessment effort and genuine symptom reporting pre-treatment. These findings also challenge the assumption that pre-treatment assessment effort failure and symptom exaggeration accurately predict poor effort in trauma-focused psychotherapy.
INTRODUCTION
Research and clinical folklore in the Veterans Affairs (VA) healthcare system has suggested that the results of trauma-focused treatment of many Veterans with posttraumatic stress disorder (PTSD) may be confounded by the amount of effort these Veterans put forth during treatment. For example, some Veterans with PTSD may put forth less effort in PTSD treatment and exaggerate their symptoms in hopes of obtaining disability benefits.1–3 Therapists providing trauma-focused treatment with such Veterans are handicapped because there is limited research on effort failure and symptom exaggeration and Veterans’ response to treatment for PTSD. Moreover, it is unclear how Veterans who exaggerate their symptoms differ from those who do not. To our knowledge, there is no research examining how assessment effort impacts trauma-focused treatment outcomes. Consequently, therapists lack guidance about whether effort and symptom exaggeration should regularly be assessed prior to initiating treatment to improve effectiveness when working with Veterans or whether a Veterans’ lack of pre-treatment effort or symptom exaggeration will compromise treatment outcomes.
Previous research on symptom exaggeration and malingering has utilized objective psychometric testing,3–6 clinical interviewing, and corroboration of Veterans’ combat and/or trauma history7 to ascertain whether a Veteran might be exaggerating their symptoms. Consequently, research has emphasized the need for a multi-method approach, including effort testing.8 Effort testing, defined as the examinee’s effort in performing well on a test,9 has well-established reliability and validity in measuring symptom exaggeration on neuropsychological tests10,11 and complements symptom validity testing in establishing symptom exaggeration.
How do individuals whose scores on measures of effort and symptom validity testing are indicative of exaggeration differ from individuals whose scores on measures of effort and symptom validity testing are not? Studies employing objective psychometric testing have suggested that compared to individuals whose pattern of responding is within normal limits, individuals whose pattern of responding on measures of effort and symptom validity testing is indicative of exaggeration are more symptomatic and depressed.12–14 Previous research has identified baseline resilience as a predictor of response to treatment among people with PTSD seeking medication with or without cognitive behavioral therapy and indicated that treatment of PTSD improved resilience among these individuals.15 Another study found that evidence based treatment for PTSD and substance abuse, which included providing CPT, increased resilience.16 However, we found no research examining the impact of validity testing and resilience. Therefore, we were interested in whether validity testing was associated with resilience.
We found no studies assessing effort testing and treatment outcomes and only one study13 examining symptom exaggeration and treatment outcomes in Veterans with PTSD. This study did not find a significant relationship between these two factors. Consequently, the impact of poor pre-treatment assessment effort and psychiatric symptom exaggeration on clinical outcomes remains unclear.
This study sought to address these gaps in the literature, by examining whether assessments indicating effort failure and symptom exaggeration were associated with compromised treatment outcomes in Veterans with PTSD undergoing cognitive processing therapy (CPT) group. We hypothesized that both effort and symptom validity test failure would result in higher (eg, more severe) pre- and post-treatment scores on symptom outcome measures of PTSD and depression and lower resiliency when compared to Veterans providing good effort and genuine responding. We also hypothesized that Veterans with PTSD whose testing indicated effort failure and symptom exaggeration would be less likely to complete treatment.
METHOD
Research Design
All recruitment, informed consent, and study components were conducted in compliance with the affiliated university’s institutional review board as part of a study examining treatment effectiveness for PTSD using functional magnetic resonance imaging in Veterans.
Recruitment and Participants
Recruitment occurred from September 2011 through February 2013. Participants were Veterans referred from general and specialty mental health clinics at a large VA Medical Center because of trauma-related symptoms. Veterans were eligible for participation if they were between 18 and 50 years old and met current criteria for PTSD per the Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV).18 All interested participants were administered additional diagnostic interviews to determine whether they met criteria for co-occurring psychiatric diagnoses or exclusionary conditions. Veterans were excluded from participation if they had dementia or a neurological disorder, active drug or alcohol abuse, contraindications to MRI, moderate to severe traumatic brain injury (TBI), acute psychological instability, and concurrent diagnosis of a psychotic spectrum disorder.
We had aimed to randomize Veterans between the CPT group and treatment-as-usual (TAU) conditions. However, the recruitment rate for the current study averaged one Veteran per week; thus randomizing participants between the CPT group treatment and the TAU condition would have resulted in some Veterans waiting as long as 8–10 weeks to begin treatment. As a result, we relied upon a Veteran-centered care philosophy, and Veterans self-selected into a CPT group or TAU. Veterans were provided with group cohort start dates to aid their decision-making. Eight CPT groups were conducted (six for males, two for females), averaging 4 to 5 Veterans per group. Treatment completion (TC) required attending nine out of twelve CPT sessions. Veterans in the TAU condition were informed they should continue attending their usual VA services including medication management, when applicable, and were encouraged to complete CPT group at the end of the 12-week TAU period.
The sample consisted of 50 male and 11 female Veterans, all of whom served during the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) era. The average length of military service in the sample was 8.69 years. Thirty-six Veterans (59%) had served during multiple service eras. All participants were between 24 and 50 years old (Mage = 33.9, SD = 6.35). The sample was largely identified as Caucasian (62.3%) and Black or African American (31.1%). Additionally, many of the participants were married (47.5%) or in a long-term dating relationship (16.9%). More than half of participants had completed some college or an Associate’s degree (57.4%). Lastly, 52 Veterans (85.2%) were diagnosed with a co-occurring depressive disorder. See Table I for complete demographic characteristics.
TABLE I.
Demographics Information and Other Sample Characteristics
| N | % | |
|---|---|---|
| Gender | ||
| Male | 50 | 82% |
| Female | 11 | 18% |
| Ethnicity | ||
| Hispanic | 16 | 26.2% |
| Race | ||
| Caucasian | 38 | 62.3% |
| Black or African American | 19 | 31.1% |
| Native Hawaiian or Pacific Islander | 1 | 1.6% |
| Unknown race/not reported | 3 | 4.9% |
| Educational attainment | ||
| Less than high school | 1 | 1.6% |
| High school/GED | 10 | 16.4% |
| Some college, associate’s degree, or vocational training | 35 | 57.4% |
| Bachelor’s degree | 11 | 18% |
| Some graduate school or advanced degree | 4 | 6.6% |
| Marital status | ||
| Married | 28 | 47.5% |
| Single | 8 | 13.6% |
| Divorced | 7 | 11.9% |
| Long-term dating | 10 | 16.9% |
| Other | 6 | 10.2% |
| Service Era Joined * | ||
| Post-Vietnam | 6 | 9.8% |
| Persian Gulf War | 30 | 49.2% |
| OEF/OIF/OND | 23 | 37.7% |
| Missing/did not report | 2 | 3.3% |
| Co-occurring disorders/conditions | ||
| Major depressive disorder | 43 | 69.4% |
| Dysthymia | 4 | 6.5% |
| Multiple depressive disorder diagnoses | 5 | 8.1% |
*Categories are not mutually exclusive, all Veterans served during the OEF/OIF/OND era.
Procedures
Once consented, Veterans participated in pre-treatment assessments at Time 1 (T1) (N = 61) and were reassessed (N = 46) at post-treatment or an equivalent Time 2 (T2) for Veterans who self-selected into TAU. At pre-treatment, but not at post-treatment, subjects completed a measure of symptom validity (the Word Memory Test (WMT)) and a measure of symptom exaggeration (the Miller Forensic Assessment Test (M-FAST)). See Figure 1 for participant flow and participation throughout the study. There were no differences in age, race, gender, marital status, or level of education between participants enrolled in the CPT groups or TAU or participants who dropped out of treatment.
Figure 1.
Participant flow and participation in study.
Intervention
CPT is an evidence-based, cognitive behavioral treatment for PTSD.19 All group therapists were certified VA CPT providers. Treatment adherence to the CPT protocol was evaluated by a member of the study staff trained in CPT. Approximately 25% of sessions were randomly evaluated for treatment fidelity (ie, inclusion of essential session elements, exclusion of off-task) by a study staff member trained in CPT. Results suggested 100% of all unique and essential session elements were addressed and 93% of group sessions were on-task.
Measures
Primary outcomes were changes in PTSD and depressive symptoms, representing treatment response. Secondary outcomes included change in resilience and TC. All measures have good20 to excellent psychometric properties.18,21–24
CAPS-IV
The CAPS-IV is a semi-structured interview assessing the severity and frequency of 17 diagnostic criteria to determine current or lifetime PTSD diagnosis and a total PTSD severity score18. The CAPS-IV was administered pre- and post-treatment.
Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-IV)
The SCID-IV is a semi-structured clinician-administered interview to assess a range of psychiatric diagnoses21. Clinicians ask an entry question for each disorder and, based on Veteran response, utilize follow-up questions to further assess or discontinue. The SCID-IV was used to identify co-occurring disorders and exclusionary diagnoses.
PTSD Checklist-Military Version (PCL-M)
The PCL-M is a 17-item self-report measure of posttraumatic stress symptoms based on the DSM-IV-TR.22 Per the CPT protocol, we administered the PCL-M weekly and utilized the last completed PCL-M score for analyses.
Beck Depression Inventory-II (BDI-II)
The BDI-II is a 21-item measure used to evaluate depressive symptoms.23
Connor Davidson Resilience Scale (CD-RISC)
The CD-RISC is a 25-item measure of resilience (ie, the ability to cope with adversity) in those with depression, anxiety, and stress reactions.20
WMT
The WMT is a test of effort and verbal memory.10 It was selected because of its sensitivity and specificity to detect actual abilities or impairments versus deliberate symptom exaggeration or poor effort, especially among individuals with a history of brain injury. That is, research on the WMT found that individuals with mild brain injuries were most likely to have low effort scores because of exaggeration of impairment, whereas those with more severe of brain injury had higher WMT effort scores.11 The recommended clinical cutoff of 82.5% was employed; subscales scores below this benchmark suggest effort failure.
M-FAST
The M-FAST is a 25-item clinician-administered measure that assesses the likelihood that an individual is exaggerating psychiatric illness based on a total score and behavioral observations.24 A cutoff score ≥ 6 on the M-FAST is suggestive of significant symptom exaggeration in Veterans with PTSD.25
The M-FAST was included in the research design 90 days after recruitment for the study commenced; therefore, 10 participants did not complete the M-FAST.
RESULTS
First, we ran correlations to determine whether effort and symptom exaggeration were related at the bivariate level. We found a significant inverse correlation between effort failure and symptom exaggeration (r = −0.388, P = 0.006), suggesting that less effort is associated with greater symptom exaggeration. Relatedly, one-way analysis of variance (ANOVA) revealed a significant difference between Veterans who passed and failed effort testing and symptom exaggeration (F (1, 48) = 8.4, P = 0.006), with those failing effort testing having higher symptom exaggeration. We also found no differences in the number of Veterans who failed effort testing (Χ2 (2, n = 60) = 0.401, P = 0.818)) or whose scores were indicative of symptom exaggeration (F (1, 48) = 0.8, P = 0.779) between Veterans who self-selected into CPT group or TAU.
Effort Testing and T1 Outcome Variables
Next, we conducted one-way ANOVAs to examine the differences between Veterans who passed and failed effort testing on T1 outcome measures (see Table II). Veterans who failed effort testing had significantly higher T1 scores on the CAPS-IV, but not PCL-M, compared to Veterans who passed effort testing. They also displayed higher scores on depression and lower scores on resiliency,
TABLE II.
Effort Failure and Pre-treatment (T1) Outcome Measures
| Outcome Measure | Effort Failure? | N | M (SD) | F | P |
|---|---|---|---|---|---|
| M-FAST | Yes | 13 | 6.77 (5.0) | 8.4 | 0.006* |
| No | 37 | 3.27 (3.2) | |||
| Total | 51 | 4.18 (4.0) | |||
| CAPS-IV | Yes | 14 | 84.1 (17.5) | 6.071 | 0.017* |
| No | 47 | 66.8 (24.2) | |||
| Total | 61 | 70.8 (23.9) | |||
| PCL-M | Yes | 14 | 65.5 (10.5) | 2.512 | 0.118 |
| No | 47 | 60.1 (11.5) | |||
| Total | 61 | 61.3 (11.4) | |||
| BDI-II | Yes | 14 | 36 (11.6) | 7.971 | 0.006** |
| No | 47 | 26.7 (10.4) | |||
| Total | 61 | 28.8 (11.5) | |||
| CD-RISC | Yes | 14 | 52.6 (13.5) | 5.6 | 0.021* |
| No | 42 | 62.6 (13.8) | |||
| Total | 56 | 60.1 (14.3) |
* P ≤ 0.05.
** P ≤ 0.01.
Effort Testing and T2 Outcome Variables
Effort failure was not associated with higher levels of PTSD or depressive symptoms after completion of the CPT group or the TAU period (see Table III). There were no significant differences between Veterans who failed or passed effort testing on T2 PTSD or BDI-II scores. There was a significant difference between Veterans who failed and passed effort testing and T2 resilience scores, with Veterans with pre-treatment effort failure reporting lower levels of resiliency.
TABLE III.
Effort Failure and Post-Treatment (T2) Outcome Measures
| Outcome | Measure | Effort Failure? | N | M (SD) | F | P |
|---|---|---|---|---|---|---|
| CAPS-IV | T2 | Yes | 10 | 78.7 (18.0) | 2.548 | 0.117 |
| No | 37 | 64.4 (26.7) | ||||
| Total | 47 | 67.4 (25.6) | ||||
| PCL-M | T2 | Yes | 13 | 62 (11.9) | 2.069 | 0.157 |
| No | 39 | 55.1 (15.7) | ||||
| Total | 52 | 56.9 (15.0) | ||||
| BDI-II | T2 | Yes | 10 | 31.7 (9.1) | 3.482 | 0.069 |
| No | 37 | 23.6 (12.9) | ||||
| Total | 47 | 25.3 (12.6) | ||||
| CD-RISC | T2 | Yes | 9 | 52.6 (13.5) | 5.3 | 0.026* |
| No | 34 | 64.8 (14.3) | ||||
| Total | 43 | 62.2 (14.9) |
* P ≤ 0.05.
Note: Variables contain missing values because of Veterans who dropped out of treatment and patient refusal to complete the measures.
Effort Testing and TC
We performed a goodness-of-fit chi-square test to determine whether Veterans who failed effort testing were as likely to attain a statistically significant change in PTSD symptoms over the course of their treatment as Veterans who passed effort testing. Our results revealed no significant difference between these groups (CAPS-IV, Χ2 (2, n = 46) = 0.465, P = 0.352); PCL-M, Χ2 (2, n = 52) = 1.000, P = 0.585), suggesting a comparable treatment benefit, regardless of effort. We performed a goodness-of-fit chi-square test to determine if the rate of TC differed based on pre-treatment assessment effort. Our results revealed no significant differences in TC between those who failed and passed effort testing (Χ2 (2, n = 60) = 0.048, P = 0.976), with virtually the same percentage of Veterans completing (n = 4, 22%) and dropping out (n = 5, 22.7%) of treatment among those with failed effort testing.
Symptom Exaggeration and T1 Outcome Variables
There was no significant relationship between T1 M-FAST scores and pre-treatment PTSD symptoms (CAPS-IV (r = 0.183, P = 0.202); PCL-M (r = 0.104, P = 0.473). However, M-FAST was significantly correlated with higher T1 BDI-II (r = 0.416, P = 0.005) and lower T1 CD-RISC (r = −0.356, P = 0.014).
Symptom Exaggeration and T2 Outcome Variables
There was no significant relationship between M-FAST scores and T2 PTSD symptoms (CAPS-IV (r = 0.062, P = 0.712); PCL-M (r = −0.063, P = 0.686)), T2 BDI-II (r = 0.206, P = 0.221), or T2 CD-RISC (r = −0.203, P = 0.243). ANOVAs revealed no significant difference between M-FAST scores and whether a Veteran achieved a statistically significant change in PTSD symptoms (CAPS-IV (F (1, 36) = 0.781, P = 0.383); PCL-M (F (1, 43) = 0.905, P = 0.347)) or whether Veterans completed the CPT group (F (1, 30) = 0.029, P = 0.865).
DISCUSSION
To our knowledge, this is one of the first studies to examine whether pre-treatment effort failure or symptom exaggeration impacts treatment outcomes in Veterans with PTSD. Although a pattern of responding indicative of effort failure was associated with a response style indicating greater symptom exaggeration, PTSD and depressive symptom severity, and less resiliency at T1, this pattern of responding did not significantly impact treatment outcome or TC. In other words, Veterans who failed effort testing experienced comparable improvements in PTSD and depressive symptoms after treatment to Veterans whose responding at pre-treatment suggested good assessment effort. Relatedly, symptom exaggeration in such Veterans may have represented a “cry for help,” rather than a desire to obtain secondary gain. Moreover, effort failure or symptom exaggeration could have been related to the presence of co-occurring disorders. Considered jointly, these findings suggest even among Veterans who may be less engaged or are exaggerating symptoms during the assessment process, they may still experience significant symptom reduction following treatment.
Previous research has suggested that compensation-seeking Veterans are more likely to significantly over-report symptoms across psychopathology when compared to non-compensation-seeking Veterans2 and that compensation-seeking Veterans are more likely to prematurely discontinue psychotherapy following achieving a full disability rating for PTSD.26 Since we did not evaluate the role of having or attaining service-connected disability in this study, we cannot determine whether Veterans whose pre-treatment pattern of responding to measures of effort and symptom validity were seeking compensation nor can we speak to whether Veterans’ use of mental health services declined following full disability rating for PTSD (ie, whether they prematurely discontinued treatment). However, results of the current study found no impact of effort failure or symptom exaggeration on TC as evidenced by Veterans having completed treatment at comparable rates, regardless of pre-treatment assessment scores. Future research should examine validity testing and treatment outcomes in compensation-seeking Veterans to further evaluate how the potential for a disability rating or higher disability rating may impact PTSD treatment outcomes.
Our results revealing lower levels of resiliency both pre- and post-treatment among Veterans who failed effort testing suggest that resiliency may be an important variable in understanding how Veterans fare on validity testing. For instance, lower levels of baseline resiliency may be related to deficient coping skills, having more severe psychopathology, more combat or other trauma exposure (eg, mTBI, childhood abuse), and additional comorbidities (eg, depression), all of which could have implications for interpreting Veterans’ assessment effort. Measuring pre-treatment assessment effort and resilience may alert therapists to potential challenges that they and their Veterans will face when initiating treatment and provide opportunities for interventions aimed at improving resilience (eg, coping skills training). Future research should examine the predictive nature of resiliency on assessment effort and various outcome measures to further explore this finding.
LIMITATIONS
The results of the current study have several methodological limitations. Given the exploratory nature, multiple analyses were conducted, which results in an increased alpha level. Veterans included in the analyses had missing data, and, as with any self-report measures, the accuracy of the data is dependent upon the Veterans’ attention to the items and pattern of responding. Consequently, results should be interpreted with caution. However, the exploratory nature of this study also highlights areas for future research in regard to the application of validity testing. For instance, researchers may wish to provide regular assessments of effort testing throughout treatment to further illuminate the relationship between effort and treatment outcomes. Next, although some Veterans in our sample joined the military prior to September 11, 2001, our Veteran sample is most closely identified as OEF/OIF/OND era Veterans, limiting the generalizability of findings to Veterans of other service eras. However, because of the high prevalence rate of PTSD among OEF/OIF/OND Veterans compared to other service eras,17,27 the findings from this study are relevant to Veterans seeking treatment in the VA and therapists working with this population.
Although our results revealed no differences on effort test failure or symptom exaggeration and treatment outcomes, it is important to consider that Veterans were able to self-select into an active treatment for PTSD or TAU. Selection of an active treatment could reflect higher motivation for symptom improvement. Lastly, the data for the current study were collected prior to the release of the DSM-5. Because of the revision of PTSD criteria, our findings may not be generalizable to all Veterans with a current PTSD diagnosis.
CONCLUSIONS
In summary, the results of the current study are encouraging and suggest that despite failed validity testing, Veterans can still achieve comparable and significant symptom reduction through CPT group. Additional research, including randomized-controlled trials, which include assessment of service-connected disability status, is needed to determine the impact of effort test failure and symptom exaggeration on treatment outcomes in Veterans with PTSD.
The views expressed are solely those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs. Portions of these data have previously been presented as a poster session at International Society for Traumatic Stress Studies, Philadelphia, Pennsylvania, November 2013.
Funding/COI
Williams, Grant B7760-P, from VA Rehabilitation Research and Development; King-Casas, Grant D2354R and D7030R, from VA Rehabilitation Research and Development; and Chiu, MH106756 and MH087692, from the National Institutes of Mental Health.
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