Disability Exams Research

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.

Disability Exams Research 
Table of Contents

Dissociative Symptoms Associated with Greater Suicide Risk, Poor Functioning, & Co-Morbid Psychopathology


Herzog, Sarah, Brienna M. Fogle, Ilan Harpaz-Rotem, Jack Tsai, and Robert H. Pietrzak. “Dissociative Symptoms in a Nationally Representative Sample of Trauma-Exposed U.S. Military Veterans: Prevalence, Comorbidities, and Suicidality.” Journal of Affective Disorders 272 (July 2020): 138–45. https://doi.org/10.1016/j.jad.2020.03.177


1 in 5 veterans in a broad national sample endorsed mild-to-severe dissociative symptoms.

• Vets with dissociative symptoms had greater psychiatric comorbidity and poorer functioning.

• Dissociative symptoms predicted suicide risk above other comorbidities and trauma history.

• Dissociative symptoms in veterans may be a transdiagnostic risk factor independent of PTSD.


Background: Dissociative symptoms have been documented in diverse clinical and non-clinical populations, and are associated with poor mental health outcomes. Yet, research on dissociative symptoms is frequently limited to PTSD samples, and therefore little is known about the prevalence, clinical correlates, and risk factors related to dissociative symptoms in broader, representative trauma-exposed populations.

Methods: The current study assessed dissociative symptoms in a contemporary, nationally representative sample of trauma-exposed U.S. veterans irrespective of PTSD diagnostic status.

We then compared sociodemographic, military, and psychiatric characteristics, trauma histories, level of functioning, and quality of life in veterans with dissociative symptoms to those without dissociative symptoms; and determined the incremental association between dissociative symptoms, and suicidality, functioning, and quality of life, independent of comorbidities.

Results: A total 20.8% of U.S. veterans reported experiencing mild-to-severe dissociative symptoms.

Compared to veterans without dissociative symptoms, veterans with dissociative symptoms were younger, and more likely to be non-white, unmarried/partnered and unemployed, had lower education and income, and were more likely to have been combat-exposed and use the VA are their primary source of healthcare. They also had elevated rates of psychiatric comorbidities, lower functioning and quality of life, and a 5-fold greater likelihood of current suicidal ideation and 4-fold greater likelihood of lifetime suicide attempt history.

Limitations: Cross-sectional data limit inference of the directionality of findings, and results may not generalize to non-veteran populations.

Conclusions: Dissociative symptoms are prevalent in U.S. veterans and may be an important transdiagnostic marker of heightened risk for suicidality and psychiatric comorbidities.

These results underscore the importance of assessing, monitoring, and treating dissociative symptoms in this population.

[emphasis added; line breaks added to ease online reading]

Implications for C&P Examiners

  • Enhance your understanding of dissociative symptomatology.

  • Use the CAPS-5 or another well-validated structured diagnostic interview because structured or semi-structured interviews leads to more reliable and valid diagnosis and to a richer understanding of the veteran. 

  • In addition, the CAPS-5 has two questions about dissociative symptoms. 
    » These questions constituted one of the measures in this research.

  • Consider administering a dissociative symptoms self-report inventory such as the Multiscale Dissociation Inventory or Dissociative Experiences Scale.

  • If a veteran has dissociative symptoms, conduct a thorough suicide risk assessment.

  • Have protocols in place to effectively refer suicidal veterans to a psychiatric inpatient facility, including options to have the veteran safely transported.

  • Establish connections with local Veterans Health Administration (VHA) facilities—medical centers or outpatient clinics—so that you understand how to best facilitate referrals of potentially suicidal veterans. (This research article noted that the veterans with the more serious psychopathology and higher suicide risk were more likely to already be established patients at a VHA facility.)

  • Assuming that you have screened and assessed for significant exaggeration/feigning, and that such dissimulation is not a concern, expect greater functional impairment with veterans exhibiting dissociative symptomatology. 

  • Keep in mind that standard interpretations of validity scales and symptom validity tests might need to be modified with veterans exhibiting dissociative symptomatology. For example, standard interpretation of F-scale elevations on the MMPI-2 and MMPI-2-RF must be modified, i.e., higher cutoff scores should be used. 

Cause-Specific Mortality Risks Among Veterans 25 Years After 1990–1991 Gulf War


Bullman, Tim, Aaron Schneiderman, and Erin Dursa. “Cause-Specific Mortality Risks Among U.S. Veterans: 25 Years After Their Service in the 1990-1991 Gulf War.” Annals of Epidemiology, epub before print (11 February 2021). https://doi.org/10.1016/j.annepidem.2021.01.005


Purpose: There is concern about adverse health effects related to military service in the 1990-1991 Gulf War. This study assessed cause-specific mortality risks among Veterans who served in the war.

Methods: The mortality of 621,244 veterans deployed to the Gulf War was compared to that of 745,704 Veterans who served during the war but were not deployed to the Gulf Theater. Cause-specific mortality of both deployed and non-deployed was also compared to that of the US general population.

Results: There was no increased risk of disease-specific mortality among deployed Veterans compared to non-deployed.

Deployed Veterans did have an increased risk of motor vehicle deaths compared to non-deployed Veterans, (hazard ratio, 1.12;, 95% confidence interval, 1.04-1.21).

Cause-specific mortality of both deployed and non-deployed Veterans was less than that of the US population.

When stratified by gender, only female Veterans, both deployed and non-deployed, had increased risks of suicide compared to the female US population (standardized mortality ratio, 1.40; 95% confidence interval, 1.13-1.71 and standardized mortality ratio, 1.22; 95% confidence interval, 1.05-1.40, respectively).

Conclusion: There was no increased risk of disease mortality among Veterans of the 1990-1991 Gulf War.

Both deployed and non-deployed female Veterans had increased risks of suicide compared to US female population.

Female and Black Veterans are Less Likely to Receive PTSD Disability Compensation


Redd, Andrew M., et al. “Exploring Disparities in Awarding VA Service-Connected Disability for Post-Traumatic Stress Disorder for Active Duty Military Service Members from Recent Conflicts in Iraq and Afghanistan.” In "Proceedings of the 2018 Military Health System Research Symposium," edited by Patricia A. Reilly and Teresa L. Hendrickson. Supplement, Military Medicine 185, no. S1  (January-February 2020): 296–302.


Introduction: We explore disparities in awarding post-traumatic stress disorder (PTSD) service-connected disability benefits (SCDB) to veterans based on gender, race/ethnicity, and misconduct separation.

Methods: Department of Defense data on service members who separated from October 1, 2001 to May 2017 were linked to Veterans Administration (VA) administrative data.

Using adjusted logistic regression models, we determined the odds of receiving a PTSD SCDB conditional on a VA diagnosis of PTSD. [If a veteran was diagnosed by a VHA clinician with PTSD, what are the odds that he or she would receive service-connected disability benefits for PTSD?]

Results: A total of 1,558,449 (79% of separating service members) had at least one encounter in VA during the study period (12% female, 4.5% misconduct separations).

Females (OR [odds ratio] 0.72) and Blacks (OR 0.93) were less likely to receive a PTSD award and were nearly equally likely to receive a PTSD diagnosis [from VHA, not the C&P exam] (OR 0.97, 1.01). [Thus, if a VHA clinician diagnosed a female veteran with PTSD, the odds that the female vet would receive service-connected disability compensation for PTSD was 0.72]

Other racial/ethnic minorities were more likely to receive an award and diagnosis, as were those with misconduct separations (award OR 1.3, diagnosis 2.17).

Conclusions: Despite being diagnosed with PTSD at similar rates to their referent categories, females and Black veterans are less likely to receive PTSD disability awards.

Other racial/ethnic minorities and those with misconduct separations were more likely to receive PTSD diagnoses and awards. Further study is merited to explore variation in awarding SCDB.

[emphasis & line breaks added to ease online reading]

Large Outpatient Psychological Dataset of Marines and Navy Personnel


Puente, Antonio E., Angela Sekely, Cuixian Chen, Yishi Wang, and Alan Steed. “Development of a Large Outpatient Psychological Dataset of Marines and Navy Personnel.” Archives of Scientific Psychology 8, no. 1 (July 2020): 15–33. https://doi.org/10.1037/arc0000074

Key Points

  1. This large dataset draws on extensive demographic, historical, structured interview, and psychometric information, obtained during comprehensive neuropsychological evaluations of service members referred after reporting cognitive problems.

  2. Evaluators administered several performance validity tests (PVTs) and symptom validity tests (SVTs).

  3. This initial article is descriptive in nature, although it does provide results of the Test of Memory Malingering (TOMM).

  4. There are of course limitations to the study, nonetheless the comprehensive nature of the evaluations and access to indices of premorbid functioning standout, along with the sheer number of "datapoints" (over one million).


The recent wars have brought new challenges for military service members, particularly as it relates to posttraumatic stress disorder (PTSD) and blast injuries.

Though research has been conducted on the psychological effects of these injuries, the 2 most common disorders have yet to be studied together with large sample sizes. This article describes the gathering and analysis of demographic, premorbid and subsequent neuropsychological and psychological data.

The sample includes 893 active duty military personnel and has approximately 1 million data points.

We believe that this is the largest dataset of its kind and will serve as a foundation for research by both the group involved in gathering and cleaning this dataset, as well as other researchers and clinicians that request access to the data.

Scientific Abstract

The use of improvised explosive devices, rocket-propelled grenades, and landmines in recent wars has raised awareness into the effects of mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD).

In this study, 893 active duty military personnel were administered a comprehensive evaluation that included extensive premorbid functioning e.g., Armed Services Vocational Aptitude Battery (ASVAB), structured interview, as well as psychological and neuropsychological testing postdeployment.

In this first publication on this dataset, we first present the approach taken to obtain, record, clean, and analyze the data.

Over 1 million data points are presented in a descriptive fashion to provide an initial overview of the information obtained by grouping individuals into four groups:

(a) blast only;

(b) PTSD only;

(c) comorbid blast and PTSD; and

(d) neither blast nor PTSD.

Findings using this dataset have the potential to meaningfully add to the understanding of deployment-related mTBI and PTSD.

The robustness of a demographically and psychometrically extensive dataset is discussed, as well as the inclusion of blast and PTSD groups and the value of premorbid data.

Quote re: Future Studies

... the data in Phase 1 (i.e., all profiles) were comparable with the data in phase three (i.e., valid profiles only).

This is particularly surprising as suboptimal levels of effort are predictive of decrements in neuropsychological testing.

Though future studies must be conducted to address this disparity, it could be that individuals are malingering or overreporting in one specific domain that was not identified in this preliminary analysis. Sweet (1999) explains that clinicians and researchers tend to view malingering as a dichotomous diagnostic conclusion, whereas feigning or overreporting in one domain does not imply feigning or overreporting overall.

This concept of selective presentation has been supported in the literature.

In addition, future studies using this dataset can explore this result further by assessing suboptimal effort using a multimethod assessment approach (i.e., TOMM, MMPI-2-RF validity scales, TSI validity scales).

The literature suggests that multiple assessments are needed to accurately assess effort, as the use of one effort measure alone has poor predictive validity.

A multimethod approach to assessment will determine which specific area is being feigned or exaggerated with greater predictive accuracy, thus explaining the results in Phase 3.

Addressing these results is of importance as effort may be creating a source of variance in the literature, causing disparities in research conclusions.α

Summary (Quote from Article)

In conclusion, this ongoing study contains many advantages that will enhance the understanding of postdeployment related disorders, addressing both emotional and cognitive impairment.

No inferential statistical analyses were conducted in this article, as its purpose was to describe the dataset and the methods used to gather and clean it.

With the surge of military personnel returned from OEF and OIF and the lingering effects of both PTSD and blast injuries, there is a critical and timely need to understand the emotional and neuropsychological effects of these injuries.

Future research using this dataset will build on the current understanding of the emotional and neurocognitive changes presented with combat-related PTSD and/or mTBI.

Ultimately, this research will inform servicemembers, policymakers, and clinicians about the possible emotional and neuropsychological effects of the current wars, leading to improved care.ß 


α. Puente et al., “Development of a Large Outpatient Psychological Dataset of Marines and Navy Personnel,” Archives of Scientific Psychology 8, no. 1 (July 2020): 29. 

ß. Puente et al., 31.

M-FAST Not Valid for PTSD Assessment

The article titled, "M-FAST Not Valid for PTSD Assessment" has moved to its own page

 → M-FAST Not Valid for PTSD Assessment

Types of Malingering in PTSD


Fox, Katherine A., and John P. Vincent. "Types of Malingering in PTSD: Evidence from a Psychological Injury Paradigm." Psychological Injury and Law 13, no. 1 (March 2020): 90–104. doi:10.1007/s12207-019-09367-5

Key Points

* C&P examiners (psychologists and psychiatrists) should administer at least one, and ideally two symptom validity test (SVT) screeners and one or two performance validity test (PVT) screeners, whether or not the veteran reports serious medical problems or cognitive impairment.

* This research, along with previous studies, demonstrates that when individuals exaggerate or feign PTSD symptoms, they do so in a variety of ways, including exaggerating or feigning cognitive or physical symptoms, even if they have not suffered a physical injury such as a traumatic brain injury (TBI).


The extent to which persons may feign or malinger psychological symptoms is an important concern for civil litigation, specifically in the context of personal injury.

The consequences inherent in personal injury cases involving psychological distress require an understanding of how malingering presents in medico-legal contexts, and how it can be assessed using available measures.

Symptom validity tests (SVTs) and performance validity tests (PVTs) have been developed to assist in the detection of feigned psychological illness and neurocognitive impairment.

While demonstrated divergence between symptom-based and performance-based outcomes have been demonstrated in civil litigants with posttraumatic symptoms after the experience of a physical injury, limited research has evaluated how these measures operate in the context of psychological injury alone.

The present study evaluated the relationships among symptom-based and performance-based measures of malingering under a simulated personal injury paradigm in which psychological but not physical injury was sustained.

A total of 411 undergraduate participants completed four measures of malingered symptomatology, including both symptom validity and performance validity indicators. Participants were instructed to respond to measures as if they were experiencing common emotional, behavioral, and cognitive symptoms of PTSD following a motor vehicle accident.

Using a multi-trait multi-method matrix, weaker correlations were found between PVT and SVTs (ranging from .15 to .28), but moderate significant correlations were found across symptom validity measures (.51 to .65), thus demonstrating an expected dissociation between methods of malingering assessment.

Additional analyses support the stability of these findings, when accounting for past exposure to motor vehicle accidents, and replicated the need for a multiple failure approach.

Findings are consistent with expectations of convergent and discriminant validity and support the conceptualization of malingered PTSD as a non-unitary construct that is composed of multiple domains or “types,” as reflected by a lack of convergence between SVT and PVT methods.

In practice, evaluators of psychological injury are encouraged to utilize more than one measure of malingering, including both PVT and SVT approaches, when PTSD is alleged.

(Paragraph breaks, bold text, and emphasis added to facilitate online reading.)

What is the Best PAI Validity Scale for PTSD Exams?

Note: See also New PAI Plus on the C&P Exam News page.


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). doi:10.1007/s12207-019-09349-7

Key Points

The Multiscale Feigning Inventory (MFI)α 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.

  • Largest effect size (Cohen's d = 1.37)
  • Sensitivity = 59.1 / Specificity = 92.0 (at cutoff:  > 81.0)
  • Incremental validity (ηp2 = .285, < .01)

The Hong Malingering Function, developed by Korean researchers,ß also demonstrated incremental validity over the NIM scale, and showed moderate sensitivity to feigned PTSD with specificity over 90%.


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%.

Amazon Mechanical Turk logo


α. Gaines, Michelle V., Charles L. Giles, and Robert D. Morgan. “The Detection of Feigning Using Multiple PAI Scale Elevations: A New Index.” Assessment 20, no. 4 (2013): 437–447. https://doi.org/10.1177/1073191112458146 | Google Scholar

ß. Hong, S. H., and Y. H. Kim. "Detection of Random Response and Impression Management in the PAI: II. Detection Indices." Korean Journal of Clinical Psychology 20 (2001): 751–761.

MMPI-2-RF: Identifying UNDER-reporting


Brown, Tiffany A., and Martin Sellbom. The Utility of the MMPI–2–RF Validity Scales in Detecting Underreporting. Journal of Personality Assessment 102, no. 1 (2020): 66–74. 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):

  • Uncommon Virtues (L-r)

  • Adjustment Validity (K-r)

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.

Corresponding Author

Martin Sellbom PhD
Department of Psychology
University of Otago
Dunedin, New Zealand

University of Otago (logo)Image by Ulrich Lange, Dunedin, New Zealand

Losing Service Connection for
PTSD is Uncommon


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 StudyMilitary Medicine 184, no. 11-12 (Nov-Dec 2019): 715–722. https://doi.org/10.1093/milmed/usz052

Corresponding Author

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.

Key Points

Important points about the research article, Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study:

(1) For men, mandatory review exams for PTSD rarely result in reduced or discontinued service-connected disability benefits.

  • 2.6% of men had their PTSD service connection discontinued (after appeals).

  • 0.5% of men had their PTSD service connection rating reduced (after appeals).

(2a) For women, mandatory review exams for PTSD sometimes result in discontinued service-connected disability benefits.

  • 12.2% of women had their PTSD service connection discontinued (after appeals).

(2b) For women, mandatory review exams for PTSD rarely result in reduced service-connected disability benefits.

  • 1.0% of women had their PTSD service connection rating reduced (after appeals).

(2c) C&P examiners might harbor implicit biases against African-American and Hispanic women. [That is my conclusion, and does not necessarily reflect the authors' opinion. - Dr. Worthen

(3) If the Veterans Benefits Administration (VBA) does reduce or discontinue a veteran's service-connected disability compensation for PTSD, he or she has a decent chance of the decision being reversed upon appeal.

(4a) For both men and women, those without a VHA PTSD chart diagnosis were more likely to lose their service connection for PTSD, and they had lower mean total disability ratings than did their counterparts.

(4b) Implication for veterans: If you received PTSD treatment at a Vet Center or from a non-VA mental health clinician, make sure to obtain and include those records with your PTSD disability compensation claim.

IMPORTANT Info about Vet Center Records

Vet Center records must be requested directly from the Vet Center where you received counseling. 

⇒ You will not receive Vet Center records when you request your medical records from a VA medical center's Release of Information (ROI) Office.

⇒ Your Vet Center records are not on My HealtheVet.

⇒ The Veterans Benefits Administration (VBA) does not routinely seek out Vet Center records because most veterans have not been to a Vet Center. However, a lot of veterans with PTSD have sought counseling a Vet Center, and those Vet Center records could prove very helpful to your claim

Use the Vet Center locator to find contact information for any Vet Center(s) where you have received counseling. 

Call the Vet Center for advice on how to best obtain your records. For example, if you live close enough, it might be faster to simply visit the Vet Center. Otherwise, mail VA Form 10-5345a to the Vet Center to request your records.

Older Articles: Table of Contents

Detailed Assessment of Posttraumatic Stress–Second Edition (DAPS-2)


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 SampleAssessment, epub ahead of print (4 Oct 2019): e1–e2. https://doi.org/1073191119880963

Corresponding Author

Jessica M. Petri
Department of Psychology
Auburn University, 226 Thach Hall
Auburn AL 36849
email: petri[at]auburn[dot]edu


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.

* However, the DAPS is available from PAR, Inc. You can also review a sample report. (I do not have any affiliation with PAR, Inc., other than being a very satisfied customer for 25 years.)

Disability Assessment


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)

Quick Summary

WHODAS 2.0 Manual - Finnish versionWHODAS 2.0 Manual - Finnish version

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.

WHODAS 2.0 Cut-off Scores

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.

Key Points

* "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 Resources

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

MMPI-2-RF Validity Scale Scores Across VA Medical Centers & Clinics


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 SettingsPsychological 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.

Mild TBI Assessment: MoCA Validity


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 9, no. 2, (Apr 2019): 101–108. 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.

Forensic Perspective on
Disability Evaluations


Davis, Karen M. and Michael B. Lister. Conducting Disability Evaluations with a Forensic Perspective: the Application of Criminal Responsibility Evaluation GuidelinesPsychological 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.

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Moral Injury: an Integrative Review


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 ReviewJournal 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).

Disability Examinations Require Forensic Psychology Competence


Ohio Board of Psychology. Work Disability Examinations: Forensic Psychology Competence and Resources. Published online, 8 Jul 2018.

Disability Exams Research & Forensic Psychology Competence

See Disability Exams Require Forensic Psychology Competence for an in-depth review of this important psychology licensing board statement.

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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 many European languages the first three letters for the name of a month are the same or similar. See the chart below for examples.

Language "February"
Latin Februarius
Catalan Febrer
Corsican Febbraiu
Danish februar
French février
Frisian febrewaris
Galician Febreiro
German Februar
Icelandic Febrúar
Irish Feabhra
Italian febbraio
Norwegian februar
Portuguese fevereiro
Romanian februarie
Spanish febrero
Swedish februari

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