This page highlights new disability exams research published in peer-reviewed academic journals, books, and related publications.1,2
Also see the PTSD Clinical Research page on this website, as some of the insights garnered from treatment studies can help inform evidence-based assessment of veterans seeking service-connected disability benefits.
Russell, Duncan N., and Leslie C. Morey. Use of Validity Indicators on the Personality Assessment Inventory to Detect Feigning of Post-Traumatic Stress Disorder. Psychological Injury and Law 12, no. 3–4 (2019). https://doi.org/10.1007/s12207-019-09349-7
The Multiscale Feigning Inventory (MFI) was the best (most effective) PAI validity scale for detecting feigned PTSD.
The MFI had the largest effect size; best combination of sensitivity and specificity; and it demonstrated incremental validity over the NIM (Negative Impression Management) scale.
This study examined the ability of several Personality Assessment Inventory (PAI) validity indicators to detect feigning of posttraumatic stress disorder (PTSD).
Participants included 491 individuals recruited through Amazon Mechanical Turk (MTURK): 44 participants were asked to feign PTSD, 25 participants carried a diagnosis of PTSD and demonstrated at least moderate levels of current symptoms, and 422 served as control subjects.
Results indicated that all of the PAI negative distortion validity indicators significantly distinguished the true PTSD from the feigned PTSD group.
The indicators with the largest effect sizes were the Hong Malingering Function and the Multiscale Feigning Index, both of which demonstrated moderate sensitivity to feigned PTSD with specificity above 90%.
Brown, Tiffany A., and Martin Sellbom. The Utility of the MMPI–2–RF Validity Scales in Detecting Underreporting. epub ahead of print, Journal of Personality Assessment (11 Jan 2019). https://doi.org/10.1080/00223891.2018.1539003
This study examined the [underreporting] validity [scales] of the Minnesota Multiphasic Personality Inventory–2–Restructured Form (MMPI–2–RF):
The study aimed to increment the previous literature in this field using a New Zealand population. We used a combined sample of 784 university students, with 173 participants completing the MMPI–2–RF with instruction to underreport in the context of applying for a job, and 611 completing the test under standard instructions.
Results indicated that individuals who completed the MMPI–2–RF with underreporting instructions exhibited significantly lower scores on the majority of the MMPI–2–RF substantive scales, and significantly higher scores on the L-r and K-r validity scales.
Additionally, L-r and K-r added incremental predictive utility over one another when differentiating the standard instruction and underreporting groups.
Classification accuracy analyses provided additional evidence for the utility of the L-r and K-r scales by supporting their respective cut scores listed in the MMPI–2–RF manual.
The findings of this study provide further evidence for the utility of the L-r and K-r scales in detecting underreporting extension to both a preemployment evaluation context and a novel population.
It is not uncommon for veterans to under-report psychological problems and symptoms during Department of Veterans Affairs (VA) disability exams for PTSD and other mental disorders.
This is another reason why VA psychologist-examiners should administer a multiscale inventory like the MMPI-2-RF during VA claim exams.
With encouragement, many veterans who underreport problems will discuss the actual severity of their symptoms and associated functional impairment.
But if you don't know that a veteran is underreporting, you are more likely to accept their self-reported problems at face value.
A veteran's increased openness leads to a more accurate disability rating and improved receptiveness to mental health counseling or psychiatric care.
Martin Sellbom PhD
Department of Psychology
University of Otago
Dunedin, New Zealand
Murdoch, Maureen, Shannon Kehle-Forbes, Michele Spoont, Nina A Sayer, Siamak Noorbaloochi, and Paul Arbisi. Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study. Military Medicine 184, no. 11-12 (Nov-Dec 2019): 715–722. https://doi.org/10.1093/milmed/usz052
Maureen Murdoch MD MPH
Center for Care Delivery and Outcomes Research
Minneapolis VA Health Care System
One Veterans Drive (152)
Minneapolis MN 55417
Mandatory, age-based re-evaluations for post-traumatic stress disorder (PTSD) service connection contribute substantially to the Veterans Benefits Administration’s work load, accounting for almost 43% of the 168,013 assessments for PTSD disability done in Fiscal Year 2017 alone. The impact of these re-evaluations on Veterans’ disability benefits has not been described.
Materials and Methods
The study is an 18-year, ecological, ambispective cohort of 620 men and 970 women receiving Department of Veterans Affairs PTSD disability benefits.
Veterans were representatively sampled within gender; all were eligible for PTSD disability re-evaluations at least once because of age.
Outcomes included the percentage whose PTSD service connection was discontinued, reduced, re-instated, or restored. We also examined total disability ratings among those with discontinued or reduced PTSD service connection.
Subgroup analyses examined potential predictors of discontinued PTSD service connection, including service era, race/ethnicity, trauma exposure type, and chart diagnoses of PTSD or serious mental illness.
Our institution’s Internal Review Board reviewed and approved the study.
Over the 18 years, 32 (5.2%) men and 180 (18.6%) women had their PTSD service connection discontinued; among them, the reinstatement rate was 50% for men and 34.3% for women.
Six men (1%) and 23 (2.4%) women had their PTSD disability ratings reduced; ratings were restored for 50.0% of men and 57.1% of women.
Overall, Veterans who lost their PTSD service connection tended to maintain or increase their total disability rating.
Predictors of discontinued PTSD service connection for men were service after the Vietnam Conflict and not having a Veterans Health Administration chart diagnosis of PTSD; for women, predictors were African American or black race, Hispanic ethnicity, no combat or military sexual assault history, no chart diagnosis of PTSD, and persistent serious mental illness.
However, compared to other women who lost their PTSD service connection, African American and Hispanic women, women with no combat or military sexual assault history, and women with persistent serious illness had higher mean total disability ratings.
For both men and women who lost their PTSD service connection, those without a PTSD chart diagnosis had lower mean total disability ratings than did their counterparts.
Particularly for men, discontinuing or reducing PTSD service connection in this cohort was rare and often reversed.
Regardless of gender, most Veterans with discontinued PTSD service connection did not experience reductions in their overall, total disability rating.
Cost-benefit analyses could help determine if mandated, age-based re-evaluations of PTSD service connection are cost-effective.
Two important points from this disability exams research:
(1) Mandatory review exams for PTSD rarely result in reduced service-connected disability benefits.
(2) If the Veterans Benefits Administration (VBA) does reduce or remove a veteran's service-connected disability compensation for PTSD, he or she has at least an even chance of a restoration of some or all of those benefits upon appeal.
Petri, Jessica M., Frank W. Weathers, Tracy K. Witte, and Madison W. Silverstein. The Detailed Assessment of Posttraumatic Stress–Second Edition (DAPS-2): Initial Psychometric Evaluation in an MTurk-Recruited, Trauma-Exposed Community Sample. Assessment, epub ahead of print (4 Oct 2019): e1–e2. https://doi.org/1073191119880963
Jessica M. Petri
Department of Psychology
Auburn University, 226 Thach Hall
Auburn AL 36849
The Detailed Assessment of Posttraumatic Stress is a comprehensive questionnaire that assesses posttraumatic stress disorder (PTSD) diagnostic criteria as well as peritraumatic responses and associated problems such as dissociation, suicidality, and substance abuse.
DAPS scores have demonstrated excellent reliability, validity, and clinical utility, performing as well or better than leading PTSD questionnaires.
The present study was an initial psychometric evaluation of the unreleased DAPS (DAPS-2), revised for Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM-5), in an MTurk-recruited mixed trauma sample (N = 367). DAPS-2 PTSD scale and associated features scales demonstrated high internal consistency and strong convergent and discriminant validity.
In confirmatory factor analyses, the DSM-5 four-factor model of PTSD provided adequate fit, but the leading seven-factor model provided superior fit.
These results indicate the DAPS-2 is a psychometrically sound measure of DSM-5 PTSD symptoms.
* The DAPS is an excellent PTSD assessment measure that does not receive the attention it deserves, both for clinical and forensic evaluations and in disability exams research.
* The DAPS-2 continues the tradition of strong reliability & validity, plus superb clinical utility.
* As noted in the article, the DAPS-2 has not yet been published.
Bovin, Michelle J., Eric C. Meyer, Nathan A. Kimbrel, Sarah E. Kleiman, Jonathan D. Green, Sandra B. Morissette, Brian P. Marx. Using the World Health Organization Disability Assessment Schedule 2.0 to Assess Disability in Veterans with Posttraumatic Stress Disorder. PLoS ONE 14, no. 8 (2019): e0220806. https://doi.org/10.1371/journal.pone.0220806 (open access)
Research - Disability Exams
WHODAS 2.0 demonstrated criterion validity with interviewer assessment of functional impairment (as part of CAPS-IV or CAPS-5 structured diagnostic interviews).
In addition, veterans diagnosed with PTSD had significantly higher WHODAS 2.0 scores (greater functional impairment) than veterans not diagnosed with PTSD.
From the article, here are WHODAS 2.0 gender and age cutoff scores for categorizing veterans as exhibiting significant PTSD-related functional impairment. The cut scores below balance sensitivity and specificity.
|Group||Most efficient cut score|
|Men age 18–34||32|
|Men age 35–59||31|
|Men age 60+||32|
|Women age 18–34||28|
|Women age 35–59||34|
Important notes about the WHODAS 2.0 cut score table immediately above, which I derived from the disability exams research under discussion here.
* As with any measurement instrument, there is always a standard error of measurement (SEM). Consequently, one should not use cut scores in a rigid manner, since a score of 32, for example, actually represents a range of scores. (I could not determine the range based on the statistics provided in the article.)
* In a previous study with veterans undergoing an Initial C&P exam for PTSD (compensation-seeking veterans), the most efficient WHODAS 2.0 cutoff score was 40.α
* The WHODAS 2.0 score should constitute one piece of information regarding functional impairment in the context of a multimethod, evidence-based psychological evaluation.
* If you conduct compensation and pension examinations (C&P exams) with veterans seeking service-connected disability benefits for PTSD, you should read the article to determine what you believe to be the most appropriate cutoff scores to use for a disability exam.
I personally believe the most efficient cut score is the most appropriate to use for disability exams, but one could argue for higher sensitivity or higher specificity.
* The sample size was too small to calculate utility statistics for older women (age 60+).
The introduction of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was accompanied by the elimination of the Global Assessment of Functioning (GAF) scale, which was previously used to assess functioning.
Although the World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0) was offered as a measure for further study, widespread adoption of the WHODAS 2.0 has yet to occur.
The lack of a standardized instrument for assessing posttraumatic stress disorder (PTSD)-related disability has important implications for disability compensation. Accordingly, this study was designed to determine and codify the utility of the WHODAS 2.0 for assessing PTSD-related disability.
Veterans from several VA medical centers (N = 1109) were included. We examined PTSD using several definitions and modalities and considered results by gender and age.
Across definitions and modalities, veterans with PTSD reported significantly greater WHODAS 2.0 total (large effects; all ts > 6.00; all ps < .01; all Cohen’s ds > 1.03) and subscale (medium-to-large effects; all ts > 2.29; all ps < .05; all Cohen’s ds > .39) scores than those without PTSD.
WHODAS 2.0 scores did not vary by gender; however, younger veterans reported less disability than older veterans (small effects; all Fs > 4.30; all ps < .05; all η2s < .05).
We identified 32 as the optimally efficient cutoff score for discriminating veterans with and without PTSD-related disability, although this varied somewhat by age and gender.
Findings support the utility of the WHODAS 2.0 in assessing PTSD-related disability.
* "Our findings will therefore allow disability examiners to use the WHODAS 2.0 in concert with a measure of PTSD symptom severity ... to establish whether individuals have clinically significant PTSD-related disability in addition to PTSD symptom levels consistent with the PTSD diagnosis." (p. 12 of PDF; 6th paragraph of Discussion section).
* "For younger women, cutoff scores of 28–34 demonstrated the same psychometric properties, and for mid-aged women, 34 was the optimally efficient cutoff score." (p. 12)
This is important disability exams research that is directly applicable to VA C&P exams for PTSD and other mental disorders.
Note that the authors of this article describe the PTSD Checklist for DSM-5 (PCL-5) as "a measure of PTSD symptom severity", which certainly is an accurate statement.
At the same time, one must remember that the PCL-5 is a screening instrument. Disability examiners should not determine a definitive diagnosis based on PCL-5 results alone.
The Department of Veteran's Affairs' National Center for PTSD website emphasizes this point:
The PCL-5 has a variety of purposes, including:
- Monitoring symptom change during and after treatment
- Screening individuals for PTSD
- Making a provisional PTSD diagnosis
The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis.
WHODAS 2.0 main page (World Health Organization website).
WHODAS 2.0 Manual - Note that the scoring instructions on page 41 are no longer correct. Use the spreadsheet below. Or hand-score—it's a 5-point Likert scale (0–4).
WHODAS 2.0 Scoring Spreadsheet (.xlsx) - It's the Excel file format, but it should work with Google Sheets too.
α. Marx, Brian P., Erika J. Wolf, Michelle M. Cornette, Paula P. Schnurr, Marc I. Rosen, Matthew J. Friedman, Terence M. Keane, and Theodore Speroff. "Using the WHODAS 2.0 to Assess Functioning Among Veterans Seeking Compensation for Posttraumatic Stress Disorder." Psychiatric Services 66, no. 12 (2015): 1312-1317. http://www.ptsd.va.gov/professional/articles/article-pdf/id44442.pdf
Ingram, Paul B., Anthony M. Tarescavage, Yossef S. Ben-Porath, and Mary E. Oehlert. Patterns of MMPI-2-Restructured Form (MMPI-2-RF) Validity Scale Scores Observed Across Veteran Affairs Settings. Psychological Services, epub ahead of print, 28 Feb 2019. https://doi.org/10.1037/ser0000339
The purpose of this investigation is to provide descriptive information on veteran response styles for a variety of VA referral types using the Minnesota Multiphasic Personality Inventory (MMPI)-2-Restructured Form (MMPI-2-RF), which has well-supported protocol validity scales.
The sample included 17,640 veterans who were administered the MMPI-2-RF between when it was introduced to the VA system in 2013 until May 31, 2015 at any VA in the United States.
This study examines frequencies of protocol invalidity based on the MMPI-2-RF’s validity scales and provides comprehensive descriptive findings on validity scale scores within the VA.
Three distinct trends can be seen.
First, a majority of the sample did not elevate any of the validity scales beyond their recommended interpretive cut-scores, indicating that scores on the substantive scales would be deemed valid and interpretable in those cases.
Second, elevation rates are higher for the overreporting scales in comparison to the underreporting and non-content-based invalid responding scales.
Lastly, a majority of those with an elevation on one overreporting validity indicator also had an elevation on at least one other overreporting scale.
Implications for practice and the utility of the MMPI-2-RF within the VA are discussed.
* The authors clearly understand the influence of the compensation claim process on self-reported psychiatric symptoms. For example:
... even in ... non-compensation evaluations, where an incentive to engage in non-credible responding may not be apparent, veterans are likely to be aware the results will be integrated into their medical record and may be considered during a subsequent compensation and pension evaluation (for a comprehensive review of the compensation and pension process see Worthen & Moering, 2011)." "Higher elevation rates on MMPI-2-RF over-reporting scales may reflect the potential for secondary gain because the service-related disability compensation assessment process is intermingled with assessments conducted for treatment provision at the VA (e.g., Ray, 2017)."
* The authors were not able to compare MMPI-2-RF scores conducted as part of a C&P exam for PTSD or other mental disorders because few of the test results were coded specifically for a C&P Clinic.
I suspect that some of the "stop codes" associated with the MMPI-2-RF administrations, e.g., "Internal Medicine", "MH Clinic", "Individual Psychology", and "MH Consultation" reflect testing conducted during a C&P exam. I base this educated guess on the fact that administratively, C&P Clinics fall under a variety of Services, e.g., Primary Care Services and Mental Health Services.
Waldron-Perrine, Brigid, Nicolette M. Gabel, Katharine Seagly, A. Zarina Kraal, Percival Pangilinan, Robert J. Spencer, and Linas Bieliauskas. Montreal Cognitive Assessment as a Screening Tool: Influence of Performance and Symptom Validity. Neurology: Clinical Practice, published ahead of print, 5 Mar 2019. https://doi.org/10.1212/CPJ.0000000000000604
Background: We evaluated Montreal Cognitive Assessment (MoCA) performance in a veteran traumatic brain injury (TBI) population, considering performance validity test (PVT) and symptom validity test (SVT) data, and explored associations of MoCA performance with neuropsychological test performance and self-reported distress.
Methods: Of 198 consecutively referred veterans to a Veterans Administration TBI/Polytrauma Clinic, 117 were included in the final sample. The MoCA was administered as part of the evaluation. Commonly used measures of neuropsychological functioning and performance and symptom validity were also administered to aid in diagnosis.
Results: Successively worse MoCA performances were associated with a greater number of PVT failures (ps < 0.05). Failure of both the SVT and at least 1 PVT yielded the lowest MoCA scores. Self-reported distress (both posttraumatic stress disorder symptoms and neurobehavioral cognitive symptoms) was also related to MoCA performance.
Conclusions: Performance on the MoCA is influenced by task engagement and symptom validity. Causal inferences about neurologic and neurocognitive impairment, particularly in the context of mild TBI, wherein the natural course of recovery is well known, should therefore be made cautiously when such inferences are based heavily on MoCA scores.
Neuropsychologists are well versed in the assessment of performance and symptom validity and thus may be well suited to explore the influences of abnormal performances on cognitive screening.
Davis, Karen M. and Michael B. Lister. Conducting Disability Evaluations with a Forensic Perspective: the Application of Criminal Responsibility Evaluation Guidelines. Psychological Injury and Law. Published ahead of print, 31 Jan 2019. https://doi.org/10.1007/s12207-019-09343-z
Although the goals of disability and criminal responsibility evaluations differ greatly, both evaluations require determining whether an individual evidences genuine impairment that aligns with a legal definition and the extent to which mental health symptoms impact the individual’s functioning.
Recommendations for how to conduct criminal responsibility evaluations often include a multi-step process for completing an objective evaluation that thoroughly addresses the clinical and legal issues at hand.
Forensic recommendations also emphasize the need to evaluate the extent to which reported symptoms are genuine and how to determine whether the clinical presentation aligns with the legal standard at issue.
This paper will illustrate how recommendations for conducting criminal responsibility evaluations can be applied to disability evaluations done to determine whether someone should receive accommodations under the Americans with Disabilities Act (1990) to ensure a thorough assessment that addresses relevant clinical issues and legal standards.
Griffin, Brandon J., Natalie Purcell, Kristine Burkman, Brett T. Litz, Craig J. Bryan, Martha Schmitz, Claudia Villierme, Jessica Walsh, and Shira Maguen. Moral Injury: an Integrative Review. Journal of Traumatic Stress. Published ahead of print, 28 Jan 2019. https://doi.org/10.1002/jts.22362
Individuals who are exposed to traumatic events that violate their moral values may experience severe distress and functional impairments known as “moral injuries.”
Over the last decade, moral injury has captured the attention of mental health care providers, spiritual and faith communities, media outlets, and the general public. Research about moral injury, especially among military personnel and veterans, has also proliferated.
For this article, we reviewed scientific research about moral injury. We identified 116 relevant epidemiological and clinical studies.
Epidemiological studies described a wide range of biological, psychological / behavioral, social, and religious / spiritual sequelae associated with exposure to potentially morally injurious events.
Although a dearth of empirical clinical literature exists, some authors debated how moral injury might and might not respond to evidence‐based treatments for posttraumatic stress disorder (PTSD) whereas others identified new treatment models to directly address moral repair.
Limitations of the literature included variable definitions of potentially morally injurious events, the absence of a consensus definition and gold‐standard measure of moral injury as an outcome, scant study of moral injury outside of military‐related contexts, and clinical investigations limited by small sample sizes and unclear mechanisms of therapeutic effect.
We conclude our review by summarizing lessons from the literature and offering recommendations for future research.
Although "moral injury" is not an official diagnosis, psychologists often discuss the concept when evaluating military veterans who have filed a PTSD disability claim with the Department of Veterans Affairs (VA).
Ohio Board of Psychology. Work Disability Examinations: Forensic Psychology Competence and Resources. Published online, 8 Jul 2018.
See Disability Exams Require Forensic Psychology Competence for an in-depth review of this important psychology licensing board statement.
1. Note that I often break up abstracts into paragraphs for ease of reading and bold some of the text for the same reason.
2. Although I am a psychologist, I am not a fan of APA Style. The citation format on this page is a slight modification of Chicago Manual of Style. I deviate from the style in how dates are written and how article titles are formatted. Instead of putting "titles" in quotes, I bold the title.
Regarding dates, I prefer the U.S. military's tradition of Date Month (3-letter abbrev.) Year, e.g., 22 Feb 2019, because this method is least likely to cause confusion.
Plus, in almost all Latin-influenced European languages, the first three letters for the name of a month are the same. See the chart below for examples.
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