Disability Exams Research

June 22, 2024 – Disability exams research published in peer-reviewed academic journals, books, and related publications, with an emphasis on disability among United States military veterans.

On this page:

PTSDexams.net is an educational site with no advertising and no affiliate links. Dr. Worthen conducts Independent Psychological Exams (IPE) with veterans, but that information is on his professional practice website.

Concerns About the Morel Emotional Numbing Test (MENT)

Worthen & Moering (2011)

In our Practical Guide article, Dr. Robert Moering and I recommended that C&P examiners “consider using the MENT in Initial PTSD exams, along with the other measures mentioned earlier, e.g., the MMPI-2.”[1]

At the same time, we cautioned that “it is not yet known how many combat veterans with genuine PTSD intentionally perform poorly on the test because they naively believe that they are ‘supposed to’ fail the test because they have PTSD.”

We based this concern on our clinical impression: “Our anecdotal experience is that some veterans produce a MENT score above the recommended cutoff when all other evidence indicates they have genuine PTSD.”

Recent Research Supports Our Concern About Morel Emotional Numbing Test Interpretation

Williamson et al. (2024) found that psychological factors other than dissimulation, such as diagnosis threat, exert an influence on some veterans, resulting in higher MENT error scores for veterans with genuine PTSD.[2],[3]

The authors describe the MENT administration instructions as “deceptive” and question the ethics of these instructions. I do not believe the MENT violates APA ethical principles because, in part, other scholars argue that “such deception is necessary … and psychologists satisfy ethical responsibilities in the informed consent process through the explanation in general terms that validity measures will be used.”[3a]

But I agree that the MENT instructions are akin to a “leading question” for some veterans and likely lead to higher MENT scores for a nontrivial number of veterans with genuine PTSD.

The Williamson et al. (2024) study found that Veterans who received generic test instructions (no mention of PTSD) produced a median score of two errors, whereas the standard instructions, which indicate that the MENT is a PTSD test, resulted in a median score of three errors.

In addition, with the standard instructions 37% of the subjects “failed” the MENT, i.e., they produced 8 or 9 errors, compared to an 8% failure rate in the generic instructions condition.

Note that these research subjects received clinical neuropsychological evaluations, i.e., these were not forensic evaluations. Three veterans were service connected for PTSD, but the evaluations were not C&P exams; the veterans were referred for clinical reasons.

I do not believe this study invalidates the MENT as a legitimate PVT for use in forensic psychological evaluations, including C&P exams. Instead, it reinforces a foundational principle of forensic psychological assessment, i.e., that we should always consider the possibility that elevated scores represent something other than significant exaggeration or feigning. 

In addition, I do not know how one could develop a PVT for PTSD without introducing the measure as a PTSD test. To do otherwise would defeat the purpose of identifying dissimulation for a specific disorder. 

In my estimation, ethical use of the MENT requires:

  1. Including a statement in one's informed consent document truthfulness and accuracy will be assessed in a variety of ways, and that examinees should respond honestly to all questions during interviews and on questionnaires or psychological tests.

  2. Assiduously exploring alternative explanations for MENT scores above the standard cut score.

  3. Develop an interpretation rubric of your own, similar to the tables below, based on your understanding of the extant empirical literature and its application to MENT score interpretation.

 

 

Citation

Emily S Williamson et al., The Importance of the Morel Emotional Numbing Test Instructions: A Diagnosis Threat Induction Study, 39 Aʀᴄʜ. Cʟɪɴ. Nᴇᴜʀᴏᴘsʏᴄʜᴏʟ. 35 (2024).

Abstract

Objective

Marketed as a validity test that detects feigning of posttraumatic stress disorder (PTSD), the Morel Emotional Numbing Test for PTSD (MENT) instructs examinees that PTSD may negatively affect performance on the measure. This study explored the potential that MENT performance depends on inclusion of “PTSD” in its instructions and the nature of the MENT as a performance validity versus a symptom validity test (PVT/SVT).

Method

358 participants completed the MENT as a part of a clinical neuropsychological evaluation. Participants were either administered the MENT with the standard instructions (SIs) that referenced “PTSD” or revised instructions (RIs) that did not. Others were administered instructions that referenced “ADHD” rather than PTSD (AI). Comparisons were conducted on those who presented with concerns for potential traumatic-stress related symptoms (SI vs. RI-1) or attention deficit (AI vs. RI-2).

Results

Participants in either the SI or AI condition produced more MENT errors than those in their respective RI conditions. The relationship between MENT errors and other S/PVTs was significantly stronger in the SI: RI-1 comparison, such that errors correlated with self-reported trauma-related symptoms in the SI but not RI-1 condition. MENT failure also predicted PVT failure at nearly four times the rate of SVT failure.

Conclusions

Findings suggest that the MENT relies on overt reference to PTSD in its instructions, which is linked to the growing body of literature on “diagnosis threat” effects. The MENT may be considered a measure of suggestibility. Ethical considerations are discussed, as are the construct(s) measured by PVTs versus SVTs.

MENT Score Interpretation

Dr. Moering and I recommended a conservative MENT cut score of 18 (instead of 8 or 9).[3b]

Morel (2013) argued against this proposal based on a sophisticated mathematical analysis and classification accuracy statistics. He concluded that “there is theoretical justification and strong empirical evidence to continue the prevailing practice of using the standardized cutoff score on the MENT.”[4]

I found Morel’s arguments to be persuasive, but I nonetheless still worry that some veterans consciously or subconsciously underperform on the MENT, even though they actually have PTSD.

I modified my interpretation rubric based on Ken Morel's 2013 article, as reflected in the tables below, i.e., instead of a hard cut score of 18, I consider scores (for under age 60) of 8–12 as suggesting feigning, and 13–18 as likely feigning.

The standard cut scores, as indicated in the MENT manual are ≥ 8 for subjects under age 60 and ≥ 9 for older subjects.

My personal MENT interpretation tables[5] are below, but please keep in mind that other psychologists disagree with my conservative interpretation approach.

Younger Veterans (≤ 59) without neurocognitive disorder

MENT Score
(number of errors)

Interpretation

0–7

No evidence of feigning

8–12

Suggests feigning

13–18

Feigning likely

19–36

Feigning

37–60

Malingering[6]

 

Older Veterans (≥ 60), or any Veteran with neurocognitive cognitive disorder[7]

MENT Score
(number of errors)

Interpretation

0–8

No evidence of feigning

9–12

Possible feigning

13–15

Suggests feigning

15–19

Feigning likely

20–36

Feigning

37–60

Malingering

 

Footnotes

[1] Mark D. Worthen & Robert G. Moering, A Practical Guide to Conducting VA Compensation and Pension Exams for PTSD and Other Mental Disorders, 4 Psʏᴄʜ. Iɴᴊ. & L. 187, 207–208 (2011), https://perma.cc/C9QK-MR23.

[2] Diagnosis threat is analogous to concepts such as confirmation bias, expectation effects, self-fulfilling prophecy, and nocebo effects. Most research on the phenomenon comes from neuropsychology. Briefly, prior to administering neuropsychological tests, if the psychologist mentions that the subject might have difficulty with cognitive tasks due to a history of head injury, those subjects exhibit more deficits on testing compared to similar individuals receiving the same evaluation for whom the psychologist omitted the statement about potential cognitive difficulties.

[3] Julie A. Suhr & John Gunstad, “Diagnosis Threat”: The Effect of Negative Expectations on Cognitive Performance in Head Injury, 24 J. Cʟɪɴ. Exᴘ. Nᴇᴜʀᴏᴘsʏᴄʜᴏʟ. 448 (2002) (article that first introduced the concept).

[3a] Shane S. Bush, Robert L. Heilbronner & Ronald M. Ruff, Psychological Assessment of Symptom and Performance Validity, Response Bias, and Malingering: Official Position of the Association for Scientific Advancement in Psychological Injury and Law, 7 Psʏᴄʜ. Iɴᴊ. & L. 197, 201 (2014).

[3b] Worthen & Moering (2011), supra note 1, at 208.

[4] Kenneth R. Morel, Cutoff Scores for the Morel Emotional Numbing Test for PTSD: Considerations for Use in VA Mental Health Examinations, 6 Psʏᴄʜ. Iɴᴊ. & L. 138, 141 (2013).

[5] These tables are based on my reading of the research literature, but they should be considered a rule of thumb, not a definitive guide.

[6] You have to concentrate intensely to intentionally choose the wrong option on this easy-to-answer PVT; there is only a 4.6% chance that a score of 37 or higher would occur by chance, e.g., flipping a coin. And, as Morel points out in the MENT Manual, the choices with the MENT are not by chance, so the actual odds of such a high error score (37) are exceptionally small. (Morel provides a mathematical explanation that is over my head, but his odds ratio has a trillion in the denominator.)

[7] See Thomas Merten, Comparative Data for the Morel Emotional Numbing Test: High False-Positive Rate in Older Bona-Fide Neurological Patients, 16 Psʏᴄʜ. Iɴᴊ. & L. 49, 54 (2023) (reporting a false positive rate of 34% for neurological patients over age 70).

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Trauma Exposure and Transdiagnostic Distress

Journal of Traumatic Stress

CITATION
Crowe, M. L., Hawn, S. E., Wolf, E. J., Keane, T. M., & Marx, B. P. (2024). Trauma exposure and transdiagnostic distress: Examining shared and posttraumatic stress disorder–specific associations. Journal of Traumatic Stress. Advance online publication. https://doi.org/10.1002/jts.23009

ABSTRACT
We examined transdiagnostic and posttraumatic stress disorder (PTSD)–specific associations with multiple forms of trauma exposure within a nationwide U.S. sample ( N = 1,649, 50.0% female) of military veterans overselected for PTSD.

A higher‐order Distress factor was estimated using PTSD, major depressive disorder (MDD), and generalized anxiety disorder (GAD) symptoms as indicators.

A structural equation model spanning three assessment points over an average of 3.85 years was constructed to examine the unique roles of higher‐order Distress and PTSD‐specific variance in accounting for the associations between trauma exposure, measured using the Life Events Checklist (LEC) and Deployment Risk and Resiliency Inventory Combat subscale (DRRI‐C), and psychosocial impairment.

The results suggest the association between trauma exposure and PTSD symptoms was primarily mediated by higher‐order distress (70.7% of LEC effect, 63.2% of DRRI‐C effect), but PTSD severity retained a significant association with trauma exposure independent of distress, LEC: β = .10, 95% CI [.06, .13]; DRRI‐C: β = .11, 95% CI [.07, .14].

Both higher‐order distress, β = .31, and PTSD‐specific variance, β = .36, were necessary to account for the association between trauma exposure and future impairment. Findings suggest that trauma exposure may contribute to comorbidity across a range of internalizing symptoms as well as to PTSD‐specific presentations.

Why is this Research Important for C&P Examiners?

The authors of this article stated: "PTSD is a necessary but not sufficient construct in that it captures reactions distinct from higher-order distress but does not represent the full range of trauma-related psychopathology."

Based on this research (Crowe, Hawn, Wolf, Keane, & Marx, 2024), we could (accurately) say that trauma independently causes PTSD, and that trauma directly causes depression. This is direct causation between an event and a mental disorder.

Event ⇢ Mental Disorder

Thus, a C&P psychologist could legitimately opine:

"It is more likely than not that traumatic experiences the veteran endured caused her major depressive disorder."

However, I suggest that you do not write your opinion like that.

When it comes to causality, C&P psychologists should consider the legal landscape. Specifically: "What type of causality is legally important?" 

Direct (independent) causation is obviously important when conducting an initial PTSD exam since the primary objective is to determine if service-related1 trauma directly caused post-traumatic stress disorder. 

But when you conduct an initial PTSD exam with a veteran and discover that he or she has PTSD and another mental disorder, you should think about causation differently.

You should think about the causal relationship between two mental disorders, where one mental disorder causes (or aggravates) a second mental disorder.2

Mental Disorder A ⇢ Mental Disorder B

If a C&P examiner opines that the veteran's service-related trauma caused major depressive disorder, such an opinion would complicate claim adjudication.

This is true because VBA adjudicates original (initial) claims for other mental disorders under a different standard of proof3 than initial PTSD claims.4

In addition, like all psychological evaluations, psychologists should answer the referral question. For Initial PTSD C&P exams the implied referral question is:

"If the veteran has another mental disorder (in addition to PTSD), is that mental disorder proximately due to or the result of PTSD?"

I say implied because the actual questions asked on the Initial PTSD DBQ are:

3a. Does the Veteran Have More Than One Mental Disorder Diagnosed?
YES  NO (If “yes,” Complete Item 3b)
3b. Is it Possible to Differentiate What Symptom(s) is/are Attributable to Each Diagnosis?
(If "Yes," list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses)

The question about "clinical association" essentially asks:

"Is the other mental disorder proximately due to or the result of the PTSD?"

See 38 C.F.R. § 3.310 for the phrase "proximately due to or the result of."5

Finally, if you determine, during an Initial PTSD C&P exam, that a veteran has PTSD and another mental disorder, in most cases you should provide an opinion like this:

"It is more likely than not that the veteran's Major Depressive Disorder is proximately due to or the result of her Posttraumatic Stress Disorder."

Footnotes

1. I use the term service-related instead of service-connected because at the C&P exam stage, examiners proffer an expert witness opinion about the relationship between military service and a veteran's mental disorder(s), but the adjudicator—the Veterans Benefits Administration—makes the legal determination of service connection.

2. Two mental disorders can also exhibit bidirectional causality. Bidirectional causality means that two variables or factors influence each other mutually. It is not just that one variable (A) causes a change in another variable (B), but also that variable B, in turn, changes variable A: 

Mental Disorder A 🡘 Mental Disorder B.

3. Posttraumatic stress disorder, 38 C.F.R. § 3.304(f)(3).

4. Principles relating to service connection, 38 C.F.R. § 3.303 (Jan. 11, 2024), and, for combat-related disorders, § 3.304(d).

5. Disabilities that are proximately due to, or aggravated by, service-connected disease or injury, 38 C.F.R. § 3.310 (Jan. 11, 2024).


CITATION
Webermann, A. R., Gianoli, M. O., Rosen, M. I., Portnoy, G. A., Runels, T., & Black, A. C. (2024). Military sexual trauma-related posttraumatic stress disorder service-connection: Characteristics of claimants and award denial across gender, race, and compared to combat trauma. PLOS ONE, 19(1), e0280708. https://doi.org/10.1371/journal.pone.0280708

ABSTRACT
The current study characterizes a cohort of veteran claims filed with the Veterans Benefits Administration for posttraumatic stress disorder secondary to experiencing military sexual trauma, compares posttraumatic stress disorder service-connection award denial for military sexual trauma-related claims versus combat-related claims, and examines military sexual trauma-related award denial across gender and race.

We conducted analyses on a retrospective national cohort of veteran claims submitted and rated between October 2017-May 2022, including 102,409 combat-related claims and 31,803 military sexual trauma-related claims.

Descriptive statistics were calculated, logistic regressions assessed denial of service-connection across stressor type and demographics, and odds ratios were calculated as effect sizes.

Military sexual trauma-related claims were submitted primarily by White women Army veterans, and had higher odds of being denied than combat claims (27.6% vs 18.2%).

When controlling for age, race, and gender, men veterans had a 1.78 times higher odds of having military sexual trauma-related claims denied compared to women veterans (36.6% vs. 25.4%), and Black veterans had a 1.39 times higher odds of having military sexual trauma-related claims denied compared to White veterans (32.4% vs. 25.3%).

Three-fourths of military sexual trauma-related claims were awarded in this cohort. However, there were disparities in awarding of claims for men and Black veterans, which suggest the possibility of systemic barriers for veterans from underserved backgrounds and/or veterans who may underreport military sexual trauma.

Functional Disability in U.S. Military Veterans


CITATION
Meisler, A. W., Gianoli, M. O., Na, P. J., & Pietrzak, R. H. (2023). Functional disability in US military veterans: the importance of integrated whole health initiatives. Primary Care Companion For CNS Disorders, 25(4), 22m03461. https://doi.org/10.4088/PCC.22m03461

ABSTRACT
Objective: To examine the prevalence and sociodemographic, medical, and psychiatric correlates of disability in activities of daily living (ADLs) and instrumental ADLs (IADLs) in the US veteran population.

Methods: Data were analyzed from 4,069 US veterans who participated in the 2019–2020 National Health and Resilience in Veterans Study (NHRVS). Multivariable and relative importance analyses (RIAs) were conducted to identify independent and strongest correlates of ADL and IADL disability.

Results: A total of 5.2% (95% CI, 4.4%–6.2%) and 14.2% (95% CI, 12.8%–15.7%) of veterans reported ADL and IADL disability, respectively. Older age, male sex, Black race, lower income, and deployment-related injuries were associated with ADL and IADL disabilities, as were certain medical and cognitive conditions. Results of RIAs revealed that sleep disorders, diabetes, posttraumatic stress disorder (PTSD), older age, and cognitive disorders were most strongly associated with ADL disability, while chronic pain, PTSD, lower income, and sleep and cognitive disorders were most strongly associated with IADL disability.

Conclusions: Results of this study provide an up-to-date estimate of the prevalence and sociodemographic, military, and health correlates of functional disability in US veterans. Improved identification and integrated clinical management of these risk factors may help mitigate disability risk and promote the maintenance of functional capacity in this population.

Measures of Functional Ability - ADLs and IADLsMeasures of Functional Ability: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs are basic selfcare tasks whereas IADLs are more complex skills; together they represent what a person needs to be able to manage on their own in order to live independently or functional ability.

The image above and its caption are from a preprint of this article:

Petrich, L., Jin, J., Dehghan, M., & Jagersand, M. (2022, May). A quantitative analysis of activities of daily living: Insights into improving functional independence with assistive robotics. In 2022 International Conference on Robotics and Automation (ICRA) (pp. 6999-7006). IEEE.

License: CC BY-SA 4.0, which requires, among other conditions, that you give appropriate credit and provide a link to the license.

These concepts (ADLs & IADLs) are increasingly important in disability exams research.

C&P Exams for MST-related PSTD: Examiner Perspectives


CITATION
Webermann, A. R., Nester, M. S., Gianoli, M. O., Black, A. C., Rosen, M. I., Mattocks, K. M., & Portnoy, G. A. (2023). Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies. Women's Health Issues, 33(4), 428–434. https://doi.org/10.1016/j.whi.2023.02.002

ABSTRACT
Background
It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants.

Methods
Thirteen clinicians (“examiners”) who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods.

Results
Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing “markers” of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process.

Conclusions
Examiners’ responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.


Face Hardened by Trauma by UnrealA face hardened by trauma by Unreal.

License: CC BY-SA 4.0, which requires, among other conditions, that you give appropriate credit and provide a link to the license.

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Previous posts about disability exams research can be found at: Disability Exams Research Archives.

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