The Minnesota Multiphasic Personality Inventory-2-RF in Treatment-Seeking Veterans with History of Mild Traumatic Brain Injury

S M Jurick; L D Crocker; A V Keller; S N Hoffman; J Bomyea; M W Jacobson; A J Jak

doi:10.1093/arclin/acy048

The Minnesota Multiphasic Personality Inventory-2-RF in Treatment-Seeking Veterans with History of Mild Traumatic Brain Injury

Jurick, S M; Crocker, L D; Keller, A V; Hoffman, S N; Bomyea, J; Jacobson, M W; Jak, A J 2019-05-01 00:00:00 Objective: This study examined the Minnesota Multiphasic Personality Inventory—Second Edition-Restructured Form (MMPI-2-RF) to better understand symptom presentation in a sample of treatment-seeking Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with self-reported history of mild traumatic brain injury (mTBI). Method: Participants underwent a comprehensive clinical neuropsychological battery including performance and symptom validity mea- sures and self-report measures of depressive, posttraumatic, and post-concussive symptomatology. Those with possible symptom exaggera- tion (SE+) on the MMPI-2-RF were compared with those without (SE−) with regard to injury, psychiatric, validity, and cognitive variables. Results: Between 50% and 87% of participants demonstrated possible symptom exaggeration on one or more MMPI-2-RF validity scales, and a large majority were elevated on content scales related to cognitive, somatic, and emotional complaints. The SE+ group reported higher depressive, posttraumatic, and post-concussive symptomatology, had higher scores on symptom validity measures, and performed more poorly on neuropsychological measures compared with the SE− group. There were no group differences with regard to injury variables or performance validity measures. Participants were more likely to exhibit possible symptom exaggeration on cognitive/somatic compared with traditional psychopathological validity scales. Conclusions: A sizable portion of treatment-seeking OEF/OIF Veterans demonstrated possible symptom exaggeration on MMPI-2-RF validity scales, which was associated with elevated scores on self-report measures and poorer cognitive performance, but not higher rates of performance validity failure, suggesting symptom and performance validity are distinct concepts. These ﬁndings have implications for the interpretation of clinical data in the context of possible symptom exaggeration and treatment in Veterans with persistent post-concussive symptoms. Keywords: Symptom validity testing; Head injury; Traumatic brain injury; Assessment; Posttraumatic stress disorder; Depression Introduction Evaluation of response bias is a necessary component of neuropsychological assessment (Bush et al., 2005; Heilbronner et al., 2009) and is routinely practiced by providers across multiple settings (Martin, Schroeder, & Odland, 2015; Schroeder, Martin, & Odland, 2016). Symptom validity testing (SVT; assessment of self-report measure validity) and performance valid- ity testing (PVT; assessment of neuropsychological test performance validity) are related (Martin, Schroeder, Heinrichs, & Baade, 2015), but not entirely overlapping concepts that are both important to consider during neuropsychological evaluations (Larrabee, 2012; Van Dyke, Millis, Axelrod, & Hanks, 2013; Jurick et al., 2016). Base-rate estimates of PVT and SVT failure are higher in routine clinical examinations at the Veterans Administration (VA) than in other medical or clinical settings, Published by Oxford University Press 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. doi:10.1093/arclin/acy048 Advance Access publication on 30 May 2018 Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 367 particularly for those referred for evaluation of symptoms related to posttraumatic stress disorder (PTSD) and history of mild traumatic brain injury (mTBI; Whitney, Davis, Shepard, & Herman, 2008; Axelrod & Schutte, 2010; Jurick et al., 2016; Young, Roper, & Arentsen, 2016). Despite these high rates of PVT and SVT failure, as well as the large number of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans returning with history of mTBI and comorbid mental health conditions (Hoge et al., 2008; Terrio et al., 2009), response bias (particularly SVT failure) within treatment-seeking OEF/OIF Veterans remains relatively understudied (Nelson et al., 2011; Young, Kearns, & Roper, 2011; Young, Roper, & Arentsen, 2016). Understanding the factors related to response bias in this population can be clinically informative as it is associated with many negative outcomes, including artiﬁcially elevated scores on psychological assessment measures (Larrabee, 2003), artiﬁcially reduced cognitive test scores (Grills & Armistead-Jehle, 2016), increased disability claims (Armistead-Jehle, 2010), poor treatment adherence (Anestis, Finn, Gottfried, Arbisi, & Joiner, 2015), poorer adaptive functioning within the community (Lippa et al., 2014), and increased ﬁnancial burden on the VA healthcare system (Denning, 2012; Horner, VanKirk, Dismuke, Turner, & Muzzy, 2014). A growing body of research has demonstrated stronger relationships between PVT failure and cognitive test scores, psy- chological distress, and disability/litigation status compared to demographic or TBI injury variables in civilians (Green, Rohling, Lees-Haley, & Allen, 2001; Nelson et al., 2011; West, Curtis, Greve, & Bianchini, 2011; Webb, Batchelor, Meares, Taylor, & Marsh, 2012; Grills & Armistead-Jehle, 2016) and in OEF/OIF active duty service members with history of mTBI (Lange, Pancholi, Bhagwat, Anderson-Barnes, & French, 2012; Lippa et al., 2014; Armistead-Jehle, Cooper, & Vanderploeg, 2015). PVT failure rates within treatment-seeking OEF/OIF Veterans with a history of mTBI have varied considerably, rang- ing from 23% to 68%, depending on the type and the number of measures used to indicate PVT failure (Armistead-Jehle, 2010; Russo, 2012; Spencer et al., 2013; Lippa et al., 2014; Proto et al., 2014; Heyanka et al., 2015; Jak et al., 2015). Although some studies have shown positive associations between PVTs and SVTs (Thomas & Youngjohn, 2009; Peck et al., 2013), others have demonstrated that they are distinct factors which should be measured separately (Armistead-Jehle, 2010; Van Dyke et al., 2013). A recently published survey of VA providers indicated that the Minnesota Multiphasic Personality Inventory—Second Edition (MMPI-2) and the restructured form (MMPI-2-RF) were by far the most commonly used SVTs (Young, Roper, & Arentsen, 2016); however, the rate and factors that inﬂuence MMPI-2-RF failure in Veterans, and SVT failure more generally, have not been fully characterized (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; Ben-Porath & Tellegen, 2008). The MMPI-2 was restructured relatively recently to reduce overlap between scales, which created a signiﬁcantly shorter MMPI-2-RF (Ben-Porath & Tellegen, 2008; Locke et al., 2010). A recent meta-analysis of the MMPI-2-RF validity scales suggested that their effectiveness in detecting invalid responding has not been assessed in areas of clinical practice that see frequent referrals such as Veterans with TBI history, possibly due to the MMPI-2-RF’s relative youth as a measure (Ingram & Ternes, 2016). Civilian studies of the MMPI-2/MMPI-2-RF scales have demonstrated a “paradoxical effect” in which those with history of mild TBI have higher elevations on scales thought to measure psychogenic components of physical and somatic complaints such as the Hypochondriasis (Hs), Hysteria (Hy), and RC1 (Somatic Complaints) scales compared with those with moderate-to-severe TBI (Youngjohn, Davis, & Wolf, 1997; Thomas & Youngjohn, 2009). With respect to objec- tive neurocognitive functioning in civilians, Martin, Schroeder, Heinrichs, et al. (2015) found no associations between MMPI- 2-RF validity scales and objective neurocognitive dysfunction in various domains once controlling for PVT performance. Within military samples, one study of National Guard Soldiers who had recently returned from Iraq detected no MMPI-2- RF validity scale elevations in those with history of mTBI only (i.e., no comorbid psychiatric conditions) compared with those with PTSD, comorbid PTSD and history of mTBI, and a healthy comparison group without PTSD or history of mTBI, whereas the comorbid group did have signiﬁcant elevations on the Fs scale (Infrequent Somatic Responses) compared with the other groups (Arbisi, Polusny, Erbes, Thuras, & Reddy, 2011). The majority of studies that have utilized the MMPI-2-RF in OEF/OIF military populations have employed mixed neurological or non-treatment-seeking research samples, active duty military service members rather than Veterans, and/or have focused primarily on feigned PTSD responding (Gass & Odland, 2012; Jones, Ingram, & Ben-Porath, 2012; Goodwin, Sellbom, & Arbisi, 2013; Mason et al., 2013). Although studies have demonstrated that the MMPI-2-RF F-r, Fp-r, Fs, FBS-r, and RBS scales can adequately detect feigned PTSD responding (Goodwin, Sellbom, & Arbisi, 2013; Mason et al., 2013), one study demonstrated that FBS-r has poor construct validity and substantial measurement error in a diagnostically diverse group of Veterans (Gass & Odland, 2012). Due to various factors speciﬁc to the VA that may cause greater reporting or experience of post-concussive symptoms over time (e.g., high rates of comorbidities, TBI screening, expectations of recovery, the VA’s dual role in patient care and disabil- ity determination), ﬁndings from active duty service members may not generalize to Veteran samples (Belanger, Uomoto, Vanderploeg, 2009; Russo, 2012; Roth & Spencer, 2013; Lippa et al., 2014; Jak et al., 2015). It appears that only one study to date has evaluated the MMPI-2-RF in a homogenous sample of OEF/OIF Veterans with history of mTBI and included a group of treatment-seekers within a VA setting (Nelson et al., 2011). Nelson and colleagues found no differences between the Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 368 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 “forensic group” (those seeking disability services) and the “clinical group” (those seeking clinical services), but did detect differences on the MMPI-2-RF validity scales between those groups and a group recruited for research purposes only. The forensic and clinical groups demonstrated potential symptom exaggeration on the Symptom Validity scale (FBS-r), Response Bias Scale (RBS), and Infrequent Responses scale (F-r), with prevalence of elevation ranging from 19% to 54% (Nelson et al., 2011). Factors such as whether the Veterans were actively seeking disability claims and presence of psychiatric comor- bidities, but not demographic or injury variables (e.g., presence of loss of consciousness or history of multiple mTBIs), inﬂu- enced the number of clinically signiﬁcant validity scale elevations. However, Nelson and colleagues did not evaluate relationships between the MMPI-2-RF and PVTs, other SVT measures, or neuropsychological measures of cognition. Thus, the present study sought to determine the rate of symptom exaggeration on the MMPI-2-RF scales and examine dif- ferences in injury, disability rating, psychiatric, PVT, SVT, and cognitive variables between those with and without possible symptom exaggeration in a sample of OEF/OIF Veterans with self-reported history of mTBI seeking treatment for post- concussive complaints. Based on previous research, we hypothesized that approximately half of the Veterans would be ele- vated on one or more MMPI-2-RF validity scale, as well as the content scales related to somatic and cognitive complaints. Second, we hypothesized that those with possible symptom exaggeration on the MMPI-2-RF (SE+) would have higher ser- vice connection percentage (VA disability rating), higher psychiatric symptomatology, worse performance on other SVTs, and worse performance on PVTs than those without possible symptom exaggeration (SE−). With regard to cognition, we pre- dicted that the SE+ group would have poorer performance on objective measures of cognition across all domains (processing speed, attention, memory, and executive functioning) compared with the SE− group, but that these relationships would not remain signiﬁcant once controlling for PVT performance. As an exploratory aim, we also wanted to determine whether there were differences between those with possible symptom exaggeration on the scales related to cognitive and somatic over- reporting (Fs, RBS, FBS-r) compared with those with possible symptom exaggeration on the traditional F-family of scales (F-r, Fp-r), which indicate general psychiatric symptom exaggeration; the cognitive and somatic over-reporting scales have been shown to be more sensitive to cognitive and somatic symptom exaggeration in OEF/OIF military service members or Veterans with mixed neurological disorders, including TBI, likely due to the differential item content of the validity scales (Whitney et al., 2008; Jones, Ingram, & Ben-Porath, 2012). Method Participants The present study consisted of OEF/OIF Veterans with self-reported history of mTBI who were consecutively referred to a VA TBI/Cognitive Rehabilitation Clinic for evaluation and treatment of subjective cognitive complaints. Mild TBI was deﬁned by self-reported loss of consciousness (LOC) less than or equal to 30 min or alteration of consciousness (AOC) and/ or posttraumatic amnesia (PTA) less than or equal to 24 hr (Management of Concussion/mTBI Working Group, 2016). All mild TBI events occurred greater than 3 months prior to examination; no participants were in the acute recovery period fol- lowing injury. Exclusion criteria were self-reported history of moderate-to-severe TBI as deﬁned as LOC > 30 min and/or AOC or PTA > 24 hr, history of other neurological condition, and history of psychotic disorder (e.g., schizophrenia). In addi- tion, participants were excluded who had 15 or more omissions on the MMPI-2-RF, or an elevated score (T > 79) on either the Variable Response Inconsistency (VRIN-r) or the True Response Inconsistency (TRIN-r) scales as these variables have been shown to affect content-based invalid responding (Burchett et al., 2016). Procedure All participants underwent a comprehensive clinical assessment including acquisition of information regarding TBI and psychiatric history and administration of neuropsychological tests (e.g., attention, memory, processing speed, and executive functioning), emotional self-report measures, PVTs, and SVTs, including the MMPI-2-RF. Severity of TBI was determined based on self-reported information regarding injury history acquired by clinical neuropsychologists, physicians, or advanced doctoral trainees in a semi-structured clinical interview as medical record documentation at the time of the injury event was not available in most cases. When available, the results of the VA Comprehensive TBI Evaluation (CBTIE) veriﬁed the TBI severity. Experienced raters trained to retrieve and enter data conducted medical chart reviews to gather information regarding service connection percentage. Psychiatric diagnoses were also acquired from medical records based on clinical assessments from qualiﬁed providers. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 369 Measures Neuropsychological measures included the Digit Span, Symbol Search, and Coding subtests from the Wechsler Adult Intelligence Scale-IV (WAIS-IV; Wechsler, 2008), Verbal Fluency and Trail Making Test from the Delis–Kaplan Executive Function System (D-KEFS; Delis, Kaplan, & Kramer, 2001) the California Verbal Learning Test—Second Edition (CVLT-II; Delis, Kramer, Kaplan, & Ober, 1999) and the Wide Range Achievement Test-4 Reading subtest as a measure of premorbid intellectual functioning (WRAT-4; Wilkinson & Roberts, 2006). To reduce the number of cognitive measures, four composite scores were created in the domains of attention, processing speed, executive functioning, and memory. The attention compos- ite score included an average of the scaled scores from the visual scanning subtest of the D-KEFS Trail Making Test and the forward condition of WAIS-IV Digit Span. The processing speed composite score was composed of the average of the scaled scores from the Symbol Search and Coding subtests of the WAIS-IV and the D-KEFS Trail Making Test number and letter conditions (D-KEFS; Delis, Kaplan, & Kramer, 2001). The executive functioning composite score was an average of the scaled scores from D-KEFS Verbal Fluency number of correct switches, D-KEFS Trail Making Test number–letter switching condition, and the sequencing condition of the WAIS-IV Digit Span (McCabe, Roediger, McDaniel, Balota, & Hambrick, 2010). Finally, the memory composite was an average of the z-scores of the short delay free recall and long delay free recall. Psychiatric symptom severity measures included the 21-item Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), the 17-item PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993), and the 22-item Neurobehavioral Symptom Inventory (NSI; Cicerone & Kalmar, 1995), which rates difﬁculty with cognitive, emotional, somatic, and vestibular post-concussive symptoms. The 3-item Alcohol Use Disorders Identiﬁcation Test (AUDIT-C; Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998) and the 10-item Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) were also included to screen for alcohol use disorders and measure sleep quality, respec- tively. Participants completed the MMPI-2-RF, which was computer-scored with T-scores derived from the complete norma- tive sample (n = 2,276; non-gendered and non-K-corrected). PVTs included the Test of Memory Malingering (TOMM; Tombaugh & Tombaugh, 1996) and the CVLT-II forced-choice condition. Cut scores on TOMM Trials 2 and retention (<45) were based off the TOMM manual, whereas the cut score on CVLT-II forced choice (<15) was based on a published study aimed to maximize sensitivity and speciﬁcity (Root, Robbins, Chang, & Van Gorp, 2006). SVTs were the MMPI-2-RF valid- ity scales (cut scores described in the Results section), cut scores of >24 and >27 on the NSI Validity-10 (Dretsch et al., 2016; Vanderploeg et al., 2014), and a cut score of >8 on the Mild Brain Injury Atypical Symptoms Scale (mBIAS; Cooper, Nelson, Armistead-Jehle, & Bowles, 2011). Statistical analyses To address the ﬁrst aim of characterizing the MMPI-2-RF in a sample of treatment-seeking OEF/OIF Veterans with self-reported mTBI history, descriptive statistics were employed to describe the percentage of those scoring above clinically relevant T-scores on validity and content scales, as described in the manual (Ben-Porath & Tellegen, 2008). Second, group differences between those with possible symptom exaggeration (SE+) on one or more MMPI-2-RF validity scales (F-r, Fp-r, Fs, FBS-r, and RBS) and those without possible symptom exaggeration (SE−) were conducted using Chi-square tests and independent samples t-tests. Dependent variables included demographic, injury (e.g., LOC, PTA, and number of mTBIs), SVT, PVT, and cognitive variables. To address the issue of multiple comparisons in primary analyses, family-wise Bonferroni-corrected p-values were utilized (p < .008 for demographics, .007 for injury variables, .004 for mental health vari- ables, .005 for SVTs, .007 for PVTs, and .01 for cognitive measures). To determine whether PVT failure accounted for differ- ences in cognitive performance between the two groups, independent samples t-tests were repeated excluding those with poor PVT performance on one or more measures (see Measures section). Additionally, analyses of covariance (ANCOVA) were conducted to compare the two groups using the cognitive composite scores as the dependent variables and each PVT as a covariate. The ﬁnal aim was to evaluate whether possible symptom exaggeration on speciﬁc validity scales (i.e., those target- ing cognitive and somatic versus general psychiatric symptom exaggeration) have different relationships with the variables of interest. Chi-square tests and independent samples t-tests were conducted to determine whether those with possible symptom exaggeration on the validity scales targeting somatic and cognitive symptoms (Fs, FBS-r, and RBS) versus the traditional F-family scales (F-r and Fp-r) differed with regard to variables of interest (e.g., demographic, injury, SVT, PVT, and cognitive variables). The Bonferroni corrections described previously were not applied to these analyses as they were exploratory in nature. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 370 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 Results Demographic and sample characteristics Of the 59 consecutive clinic referrals, a total of 13 participants were excluded (ﬁve reported an event consistent with a moderate-to-severe TBI, seven had elevated scores on VRIN-r and/or TRIN-r T > 79, one had a diagnosis of schizophrenia). The remaining sample (N = 46) was predominantly male (89%) with an average of 13.7 years of education. Over half of the sample had self-reported history of LOC (60.5%), nearly half had a self-reported history of three or more mTBIs (45.7%), and 56.5% had a self-reported history of blast exposure. The large majority had a PTSD diagnosis listed in their VA medical chart (82.6%), and over half had a depression diagnosis (56.1%). The range of the NSI Validity-10 scores was 34 (ranged from 4 to 38) and the range of the mBIAS scores was 15 (ranged from 0 to 15). See Table 1 for full sample characteristics). MMPI-2-RF Validity and Content Scale Elevations The large majority of participants (87%) scored within the “possible over-reporting” range utilized in previous studies (Lange, Brickell, & French, 2015) on one or more validity scales (n = 17, T > 89 on F-r; n = 13, T > 79 on Fp-r; n = 31, T > 79 on Fs; n = 26, T > 79 on FBS-r; n = 36, T > 79 on RBS). Because the MMPI-2-RF validity scales have been shown to be elevated in those with genuine physical problems and major depressive disorder (see Sharf et al., 2017 for full review), the next highest cut score in the MMPI-2-RF manual was used for all analyses given the high rate of psychiatric comorbidities and self-reported blast exposure in the present sample. When using a more stringent cut score for invalidity in the MMPI-2- RF manual, 50% of participants scored within the “possible over-reporting/invalid” range on one or more validity scales (n = 15, T > 99 on F-r; n = 2, T > 99 on Fp-r; n = 19, T > 99 on Fs; n = 5, T > 99 on FBS-r; n = 13, T > 99 on RBS). Although there have been concerns raised regarding false positive rates when using a cut score of 100 T on the F-r scale in a low base-rate sample (Sellbom, Toomey, Wygant, Kucharski, & Duncan, 2010), every Veteran who had an elevated score on this scale was elevated on one or more other validity scales. With regard to content scale elevations, over half of the sample was elevated (T ≥ 65) on the cognitive complaints scale (COG; 84.8%), somatic complaints (RC1; 82.6%), neurological com- plaints (NUC; 80.4%), anxiety (AXY; 78.3%), head pain complaints (HPC; 76.1%), malaise (MLS; 69.6%), stress/worry (STW; 65.2%), gastrointestinal complaints (CIG; 58.7%), social avoidance (SAV; 58.7%), anger proneness (ANP; 56.5%), emotional/internalizing dysfunction (EID; 56.5%), and low positive emotions (RC2; 56.5%, for full list see Table 2). Group differences in demographic, injury, psychiatric, PVT, and cognitive variables All variables were assessed for normality and outliers. For those variables that were not normally distributed (number of mTBIs, duration of LOC, and PTA), or had outliers (number of mTBIs), analyses were replicated with non-parametric tests and log transformed variables, and without outliers. No demographic or injury variables signiﬁcantly differed between the SE+ and SE− groups (all p’s > .008; see Table 1). With regard to psychiatric symptom variables, there were no group differences with regard to the percentage of psychiatric diagnoses (PTSD, depression, or substance abuse) in each group, however, the SE+ group reported a greater number of PTSD symptoms t(38) = 3.34, p = .002, depressive symptoms t(42) = 4.18, p < .001, and post-concussive symptoms t(44) = 4.28, p < .001 than the SE− group. Within the NSI, emotional t(44) = 3.61, p = .001, cognitive t(44) = 4.01, p < .001, and somatic t(44) = 4.38, p < .001, but not vestibular t(44) = 2.28, p = .027, post-concussive symptoms were signiﬁcantly ele- vated in the SE+ group compared to the SE− group. No group differences existed with regard to self-reported alcohol use or sleep quality (p’s > .004). With regard to SVTs, the SE+ group had higher (worse) scores on the NSI Validity-10 t(44) = 3.95, p < .001, all MMPI-2-RF validity scales except Fp-r (all t’s > 4.9, all p’s < .001), and exhibited higher rates of scoring above cutoff on the mBIAS (χ = 8.69, p = .003). Although the SE+ group exhibited higher rates of scoring above cutoff on 2 2 the Validity-10 at the 24 (χ = 6.77, p = .022) and 27 (χ = 6.90, p = .022) cut scores compared with the SE− group, this ﬁnding did not survive Bonferroni-correction. No SE group differences emerged on PVTs including TOMM trial 2, retention trial, or CVLT-II forced choice (all p’s > .05). There were also no differences in the percentage of participants who failed PVTs, or the number of failed PVTs (all p’s > .05). With regard to cognition, the SE+ group performed worse in the domains of attention t(43) = −2.68, p = .010, and executive functioning t(44) = −3.11, p = .003, but not processing speed t(44) = −2.45, p = .018 or memory t(42) = −.43, p = .671 com- pared with the SE− group. To determine whether these differences remained signiﬁcant when controlling for PVT performance, the independent samples t-tests were successfully replicated after excluding those with poor performance validity on one or Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 371 Table 1. Descriptive and group differences on demographic, injury, cognitive, and psychiatric measures Total sample SE+ SE− Χ ortp Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Demographics Age 33.91 (7.77) 46 35.74 (8.11) 23 32.09 (7.14) 23 1.62 .112 % Male 89.1 46 91.3 23 87.0 23 .22 .636 Education 13.74 (1.53) 46 13.52 (1.44) 23 13.96 (1.61) 23 −.97 .340 % Hispanic 19.6 46 17.4 23 21.7 23 .14 .710 % Caucasian 64.4 45 59.0 22 69.6 23 .54 .463 VA Service Connection % 62.4 (33.4) 46 72.2 (33.16) 23 52.61 (31.46) 23 2.06 .046 Injury variables % with LOC history 60.5 43 50.0 22 71.4 21 2.06 .151 % with PTA history 44.2 43 47.6 21 40.9 22 .20 .658 LOC duration 3.69 (8.81) 28 4.64 (10.82) 14 2.75 (6.49) 14 .56 .580 PTA duration 110.78 (391.31) 26 120.00 (415.69) 12 102.86 (284.86) 14 .11 .914 # of mTBIs 2.41 (1.44) 37 2.29 (1.05) 17 2.50 (1.73) 20 −.43 .671 % with three or more mTBIs 45.7 46 47.8 23 43.5 23 .09 .500 % with blast history 40.0 46 43.4 23 36.4 22 .24 .428 Mental health variables PCL-S 64.15 (12.85) 40 70.20 (12.43) 20 58.10 (10.37) 20 3.34 .002* BDI-II 27.32 (11.02) 44 33.23 (10.15) 22 21.41 (8.52) 22 4.18 <.001* AUDIT-C 2.89 (3.16) 46 3.43 (3.49) 23 2.35 (2.77) 23 1.17 .248 PSQI 14.02 (4.19) 44 15.19 (3.60) 21 12.96 (4.48) 23 1.81 .077 NSI 48.37 (16.09) 46 57.00 (13.22) 23 39.74 (14.13) 23 4.28 <.001* Vestibular Cluster 4.20 (2.77) 46 5.09 (2.79) 23 3.30 (2.49) 23 2.28 .027 Somatic Cluster 12.96 (5.66) 46 16.04 (4.98) 23 9.87 (4.57) 23 4.38 <.001* Cognitive Cluster 10.98 (3.19) 46 12.61 (2.43) 23 9.35 (3.05) 23 4.01 <.001* Emotional Cluster 16.07 (5.11) 46 18.48 (4.19) 23 13.65 (4.87) 23 3.61 .001* % with PTSD 82.6 46 82.6 23 82.6 23 .00 1.00 % with depression 56.1 43 66.7 21 45.5 22 1.96 .161 % with substance abuse 13.0 46 13.0 23 13.0 23 .00 1.00 Symptom validity measures NSI Validity-10 17.17 (7.90) 46 21.17 (7.53) 23 13.17 (6.13) 23 3.95 <.001* % Validity-10 Fail ≥24 19.6 46 34.8 23 4.3 23 6.77 .022 % Validity-10 Fail ≥27 13.0 46 26.1 23 0.0 23 6.90 .022 mBIAS 6.87 (2.81) 46 7.78 (2.83) 23 5.96 (2.53) 23 2.31 .026 % mBIAS Fail ≥8 28.3 46 47.8 23 8.7 23 8.69 .003* F-r 85.65 (22.40) 46 101.96 (16.71) 23 69.35 (13.82) 23 7.21 <.001* Fp-r 70.78 (17.61) 46 77.04 (18.53) 23 64.52 (14.46) 23 2.56 .014 Fs 85.83 (21.29) 46 103.22 (10.66) 23 68.43 (13.46) 23 9.72 <.001* FBS 77.85 (16.46) 46 87.57 (12.08) 23 68.13 (14.51) 23 4.94 <.001* RBS 88.41 (18.62) 46 100.26 (12.56) 23 76.57 (16.05) 23 5.58 <.001* Performance validity measures TOMM Trial 2 46.02 (6.83) 46 45.57 (7.04) 23 46.48 (6.74) 23 −.45 .655 TOMM Retention Trial 45.11 (6.58) 45 44.32 (6.67) 22 45.87 (6.55) 23 −.79 .435 % Trial two or Retention <45 33.3 45 36.4 22 30.4 23 .18 .673 CVLT-II Forced Choice 14.91 (1.79) 46 14.83 (1.92) 23 15.00 (1.68) 23 −.33 .745 % CVLT <15 23.9 46 26.1 23 21.7 23 .12 .730 % Fail PVT 37.0 46 39.1 23 34.8 23 .09 .760 # of Failed PVT Measures .80 (1.12) 46 .91 (1.24) 23 .70 (1.11) 23 .63 .533 Cognitive measures WRAT-4 reading ss 96.07 (9.12) 46 94.39 (8.84) 23 97.74 (9.27) 23 −1.25 .217 Memory composite −.76 (.96) 44 −.69 (.77) 21 −.82 (1.12) 23 −.43 .671 PS composite 9.31 (2.58) 46 8.42 (2.51) 23 10.20 (2.40) 23 −2.45 .018 Attention composite 8.62 (3.01) 45 7.52 (3.07) 23 9.77 (2.52) 22 −2.68 .010* EF composite 9.28 (1.94) 46 8.46 (1.52) 23 10.09 (1.99) 23 −3.11 .003* p is signiﬁcant at family-wise Bonferroni-corrected p-value; χ or t indicates Chi-square or t-test values. SE+= those with possible symptom exaggeration; SE− = those without possible symptom exaggeration; SD = standard deviation; % = percent; # = number; VA = Veterans Affairs; LOC = loss of consciousness; PTA = posttraumatic amnesia; mTBI = mild traumatic brain injury; PCL-S = Posttraumatic Stress Disorder Checklist—Speciﬁc Trauma; BDI-II = Beck Depression Inventory—Second Edition; AUDIT-C = Alcohol Use Disorders Identiﬁcation Test— Consumption; PSQI = Pittsburgh Sleep Quality Index; NSI = Neurobehavioral Symptom Inventory; PTSD = posttraumatic stress disorder; mBIAS = Mild Brain Injury Atypical Symptoms Scale; F-r = Infrequent Responses; Fp-r = Infrequent Psychopathology Responses; Fs = Infrequent Somatic Responses; FBS = Symptom Validity; RBS = Response Bias Scale; TOMM = Test of Memory Malingering; CVLT-II = California Verbal Learning Test—Second Edition; PVTs = performance validity tests; WRAT-4 = Wide Range Achievement Test—Fourth Edition; ss = standard score; PS = processing speed; EF = executive function. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 372 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 Table 2. Frequency of elevation, mean, and standard deviation of MMPI-2-RF content scales Total sample (n = 46) Content Scales % Frequency Mean T-score SD Cognitive Complaints 84.78 77.89 12.31 Somatic Complaints 82.61 77.48 14.65 Neurological Complaints 80.43 74.76 12.63 Anxiety 78.26 76.70 17.77 Head Pain Complaints 76.09 72.83 12.47 Malaise 69.57 72.17 12.51 Stress/Worry 65.22 64.74 11.46 Negative Emotionality/Neuroticism-Revised 60.87 66.70 14.19 Disafﬁliativeness 58.70 66.70 15.74 Gastrointestinal Complaints 58.70 70.61 17.46 Social Avoidance 58.70 65.24 13.62 Anger Proneness 56.52 64.78 12.40 Emotional/Internalizing Dysfunction 56.52 66.11 14.30 Low Positive Emotions 56.52 67.37 16.57 Demoralization 54.35 66.70 13.18 Aberrant Experiences 54.35 65.67 14.10 Introversion/Low Positive Emotionality-Revised 54.35 66.72 16.73 Dysfunctional Negative Emotions 52.17 65.78 14.62 Self-Doubt 50.00 60.61 13.88 Cynicism 45.65 61.67 11.11 Ideas of Persecution 45.65 63.04 14.85 Psychoticism-Revised 41.30 63.11 14.19 Thought Dysfunction 41.30 63.00 14.78 Inefﬁcacy 34.78 61.70 11.13 Aggression 32.61 58.46 10.69 Helplessness/Hopelessness 32.61 58.67 15.92 Suicidal/Death Ideation 30.43 55.07 17.09 Mechanical-Physical Interests 28.26 56.83 9.50 Aggressiveness-Revised 28.26 57.02 12.56 Behavioral/Externalizing Dysfunction 23.91 54.96 9.14 Behavior-Restricting Fears 23.91 60.46 14.45 Family Problems 19.57 55.26 10.82 Juvenile Conduct Problems 19.57 55.93 12.19 Antisocial Behavior 19.57 56.11 10.57 Activation 15.22 50.26 12.19 Hypomanic Activation 13.04 53.74 9.15 Substance Abuse 13.04 52.20 11.28 Disconstraint-Revised 10.87 54.00 9.08 Shyness 10.87 51.33 8.41 Interpersonal Passivity 6.52 46.50 9.63 Esthetic-Literary Interests 4.35 40.22 7.88 Multiple Speciﬁc Fears 4.35 46.43 8.75 % Frequency is the percentage of the entire sample with T-score of 65 or higher on the content scale. SD = standard deviation. more PVT measures. Further, one-way ANCOVAs were performed using each signiﬁcant cognitive composite score (attention, executive function) as the dependent variable, SE+/SE− group as the independent variable, and each PVT (TOMM Trial 2, retention trial, CVLT-II forced choice) as covariates. All group differences remained signiﬁcant even after controlling for PVT performance. Please see Supplementary Table for individual subtest data. There was signiﬁcant overlap between those with possible symptom exaggeration on the F-family scales (F-r and Fp-r) and the scales speciﬁcally targeting cognitive and somatic symptoms (Fs, FBS-r, and RBS), such that everyone who had possible symptom exaggeration on the F-r and Fp-r scales also had symptom exaggeration on the Fs, FBS-r, and/or RBS scales. However, analyses were still conducted separately for both types of symptom exaggeration (see Table 3). Those with possible symptom exaggeration on F-r and/or Fp-r were less likely to have a self-reported history of LOC (χ = 4.04, p = .045) than those without possible symptom exaggeration on those scales, but the groups did not differ on any other demographic or injury variables (all p’s > .05). Those with possible symptom exaggeration on F-r and/or Fp-r were more likely to fail the Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 373 Table 3. Descriptive and group differences on demographic, injury, cognitive, and psychiatric measures for those with possible symptom exaggeration on the MMPI-2-RF F-Family scales (F-r and Fp-r) or the somatic/cognitive scales (Fs, FBS-r, and RBS) Invalid Fr/Fp-r Valid Fr/Fp-r χ ortp Invalid Fs/FBS-r/RBS Valid Fs/FBS-r/RBS χ ortp Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Demographics Age 35.93 (8.43) 15 32.94 (7.38) 31 1.23 .224 35.74 (8.11) 23 32.09 (7.14) 23 1.62 .112 % Male 100.0 15 83.9 31 −2.71 .099 91.3 23 87.0 23 .22 .636 Education 13.33 (1.35) 15 13.94 (1.59) 31 −1.26 .213 13.52 (1.44) 23 13.96 (1.61) 23 −.97 .340 % Hispanic 26.7 15 16.1 31 −.71 .398 17.4 23 21.7 23 .14 .710 % Caucasian 57.1 14 67.7 31 −.47 .492 59.1 22 69.6 23 .54 .463 VA SC % 72.0 (34.) 15 57.74 (32.63) 31 1.37 .178 72.17 (33.16) 23 52.61 (31.37) 23 2.06 .046* Injury variables % with LOC 40.0 15 71.4 28 4.04 .045* 50.0 22 71.4 21 2.06 .151 % with PTA 50.0 14 41.4 29 .29 .594 47.6 21 40.9 22 .20 .658 LOC duration 5.45 (12.14) 11 2.56 (5.96) 17 .85 .406 4.64 (10.82) 14 2.75 (6.49) 14 .56 .580 PTA duration 180.00 (509.12) 8 80.00 (339.41) 18 .59 .558 120.00(415.69) 12 102.86 (384.86) 14 .11 .914 # of mTBIs 2.00 (0.63) 11 2.58 (1.65) 26 −1.12 .272 2.29 (1.05) 17 2.50 (1.73) 20 −.43 .671 % three or more mTBIs 40.0 15 48.4 31 .29 .592 47.8 23 43.5 23 .09 .500 % with blast history 33.3 15 43.3 31 .42 .376 43.4 23 36.4 22 .24 .428 Mental health variables PCL-S 72.08 (12.37) 13 60.33 (11.43) 27 2.97 .005* 70.20 (12.43) 20 58.10 (10.37) 20 3.34 .002* BDI-II 35.79 (8.04) 14 23.37 (10.02) 30 4.06 .000* 33.23 (10.15) 22 21.41 (8.52) 22 4.18 <.001* AUDIT-C 3.20 (3.39) 15 2.74 (3.10) 31 .46 .650 3.43 (3.49) 23 2.35 (2.77) 23 1.17 .248 PSQI 72.08 (12.37) 13 60.33 (11.43) 27 2.02 .050 15.19 (3.60) 21 12.96 (4.48) 23 1.81 .077 NSI 57.60 (12.65) 15 43.90 (15.84) 31 2.92 .005* 57.00 (13.22) 23 39.74 (14.13) 23 4.28 .000* Vestibular Cluster 4.87 (3.11) 15 3.87 (2.58) 31 1.15 .258 5.09 (2.79) 23 3.30 (2.49) 23 2.28 .027* Somatic Cluster 15.87 (5.13) 15 11.55 (5.43) 31 2.57 .014* 16.04 (4.98) 23 9.87 (4.57) 23 4.38 .000* Cognitive Cluster 12.47 (2.00) 15 10.26 (3.43) 31 2.31 .026* 12.61 (2.43) 23 9.35 (3.05) 23 4.01 .000* Emotional Cluster 19.67 (3.60) 15 14.32 (4.85) 31 3.79 .000* 18.45 (4.19) 23 13.65 (4.87) 23 3.61 .001* % with PTSD 86.7 15 80.6 31 .26 .613 82.6 23 82.6 23 .00 1.00 % with depression 73.3 15 46.4 28 2.87 .090 66.7 21 45.5 22 .37 .162 % with SA 13.3 15 12.9 31 .00 .968 13.0 23 13.0 23 .00 1.00 Symptom validity measures NSI V-10 20.33 (7.91) 15 15.65 (7.56) 31 1.94 .058 21.17 (7.53) 23 13.17 (6.13) 23 3.95 .000* % V-10 Fail ≥ 24 20.0 15 19.4 31 .00 .959 34.8 23 4.3 23 6.77 .009* % V-10 Fail ≥ 27 20.0 15 9.7 31 .95 .330 26.1 23 0.0 23 6.90 .009* mBIAS 7.93 (3.11) 15 6.35 (2.55) 31 1.83 .074 7.78 (2.83) 23 5.96 (2.53) 23 2.31 .026* % mBIAS Fail ≥8 53.3 15 16.1 31 6.90 .009* 47.8 23 8.7 23 8.69 .003* F-r 112.20 (7.02) 15 72.81 (14.37) 31 10.01 .000* 101.96 (16.71) 23 69.35 (13.82) 23 7.21 .000* Fp-r 81.20 (18.58) 15 65.74 (14.96) 31 3.03 .004* 77.04 (18.53) 23 64.52 (14.46) 23 2.56 .014* Fs 104.40 (12.94) 15 76.84 (18.60) 31 5.15 .000* 103.22 (10.66) 23 68.43 (13.46) 23 9.72 .000* FBS-r 91.53 (12.79) 15 71.23 (13.82) 31 4.78 .000* 87.57 (12.08) 23 68.13 (14.51) 23 4.94 .000* RBS 105.00 (11.58) 15 80.39 (15.91) 31 5.33 .000* 100.26 (12.56) 23 76.57 (16.05) 23 5.58 .000* (continued on next page) Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 374 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 Table 3. (continued) Invalid Fr/Fp-r Valid Fr/Fp-r χ ortp Invalid Fs/FBS-r/RBS Valid Fs/FBS-r/RBS χ ortp Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Performance validity measures TOMM Trial 2 46.87 (4.53) 15 45.61 (7.74) 31 .58 .565 45.57 (7.04) 23 46.48 (6.74) 23 −.45 .655 TOMM Retention 44.36 (5.73) 14 45.45 (6.99) 31 −.51 .611 44.32 (6.67) 23 45.87 (6.55) 23 −.79 .435 % TOMM < 45 35.7 14 32.3 31 .05 .820 36.4 22 30.4 23 .18 .673 CVLT-II FC 14.67 (2.02) 15 15.03 (1.68) 31 −.65 .521 14.83 (1.92) 23 15.00 (1.68) 23 −.33 .745 % CVLT-II FC < 15 26.7 15 22.6 31 .09 .761 26.1 23 21.7 23 .12 .730 % Fail Effort 40.0 15 35.5 31 .09 .766 39.1 23 34.8 23 .09 .760 # Failed PVTs .87 (1.19) 15 .81 (1.20) 31 .16 .873 .91 (1.24) 23 .70 (1.11) 23 .63 .533 Cognitive measures WRAT-4 reading ss 94.67 (8.18) 15 96.74 (9.59) 31 −.72 .475 94.39 (8.84) 23 97.74 (9.27) 23 −1.25 .217 Memory composite −.96 (.82) 13 −.67 (1.01) 31 −.92 .361 -.69 (.77) 21 -.82 (1.12) 23 −.43 .671 PS composite 8.55 (1.93) 15 9.67 (2.80) 31 −1.40 .168 8.42 (2.51) 23 10.20 (2.40) 23 −2.45 .018* Attention composite 7.80 (2.72) 15 9.03 (3.10) 30 −1.31 .198 7.52 (3.07) 23 9.77 (2.52) 22 −2.68 .010* EF composite 8.33 (1.58) 15 9.73 (1.94) 31 −2.42 .020* 8.46 (1.52) 23 10.09 (1.99) 23 −3.11 .003* p < .05; χ or t indicates Chi-square or t-test values of group differences. SD = standard deviation; % = percent; # = number; VA SC = Veterans Affairs Service Connection; LOC = loss of consciousness; PTA = posttraumatic amnesia; mTBI = mild traumatic brain injury; PCL-S = Posttraumatic Stress Disorder Checklist—Speciﬁc Trauma; BDI-II = Beck Depression Inventory—Second Edition; AUDIT-C = Alcohol Use Disorders Identiﬁcation Test- Consumption; PSQI = Pittsburgh Sleep Quality Index; NSI = Neurobehavioral Symptom Inventory; PTSD = posttraumatic stress disorder; SA = substance abuse; V-10 = Validity-10; mBIAS = Mild Brain Injury Atypical Symptoms Scale; F-r = Infrequent Responses; Fp-r = Infrequent Psychopathology Responses; Fs = Infrequent Somatic Responses; FBS-r = Symptom Validity; RBS = Response Bias Scale; TOMM = Test of Memory Malingering; CVLT-II = California Verbal Learning Test—Second Edition; FC = forced choice; PVTs = performance validity tests; WRAT-4 = Wide Range Achievement Test—Fourth Edition; ss = standard score; PS = processing speed; EF = executive function. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 375 mBIAS (χ = 6.90, p = .009) had higher scores on all MMPI-2-RF validity scales (all t’s > 3.0, all p’s < .005), reported high- er depressive, t(42) = 4.06, p < .001, posttraumatic, t(38) = 2.97, p = .005, and post-concussive, t(44) = 2.92, p = .005, symptoms across all NSI symptom clusters except for vestibular, as well as exhibited poorer executive function performance, t(44) = −2.42, p = .020, compared with those without possible symptom exaggeration on those scales. No signiﬁcant group differences between percentage of psychiatric diagnoses, other SVTs, PVTs, or other cognitive measures were detected (all p’s > .05). When comparing those with and without possible symptom exaggeration on scales speciﬁcally targeting cognitive and somatic over-reporting (Fs/FBS-r/RBS), those with possible symptom exaggeration had higher service connection percentage t(44) = 2.06, p = .046, but this ﬁnding did not survive Bonferroni-correction. There were no other group differences with regard to demographic or injury variable differences (all p’s > .05). Those with possible symptom exaggeration on the Fs, FBR-r, and/or RBS scales also had higher self-reported depressive t(42) = 4.18, p < .001, posttraumatic t(38) = 3.34, p = .002, and post-concussive t(42) = 4.28, p < .001 symptoms across all four NSI symptom clusters, higher scores on all MMPI-2-RF validity scales (all t’s > 2.5, all p’s < .015), the mBIAS t(44) = 2.31, p = .026 and Validity-10 t(44) = 3.95, 2 2 p < .001, and were more likely to fail the Validity-10 (cut score 24, χ = 6.77, p = .009; cut score 27, χ = 6.90, p = .009), and mBIAS (χ = 8.69, p = .003) compared with those without possible symptom exaggeration on those scales. Those with possible symptom exaggeration on Fs, FBS-r, and/or RBS scales also had poorer performance on measures of attention t(43) = −2.68, p = .010, executive functioning t(44) = −3.11, p = .003, and processing speed t(44) = −2.45, p = .018 than those without. No signiﬁcant group differences between percentage of psychiatric diagnoses, PVTs, or memory performance were detected (all p’s > .05). As with the previous analyses, the group differences with regard to cognition remained signiﬁcant when those failing one or more PVTs were excluded. To determine whether these relationships remained signiﬁcant when controlling for PVT per- formance, the independent samples t-tests were successfully replicated after excluding those with poor performance validity on one or more PVT measures (all t’s > 2.2, all p’s < .04) and controlling for each PVT using ANCOVAs (all F’s > 5.7, all p’s < .03). Conclusions As hypothesized, a substantial portion of consecutively referred, treatment-seeking OEF/OIF Veterans with self-reported history of mTBI had possible symptom exaggeration on one or more MMPI-2-RF validity scales, as well as elevated scores on content scales related to cognitive and somatic symptoms. Although the SE+ group did not differ from the SE− group with regard to demographic or injury variables or percentage of those with psychiatric diagnoses, the SE+ group did report higher depressive, posttraumatic, and post-concussive symptoms compared with the SE− group. As anticipated, the SE+ group had higher scores on other SVTs, providing convergent validity for the MMPI-2-RF validity scales within this popula- tion. Contrary to our hypothesis, the SE+ group did not have worse performance on PVT measures and were no more likely to score below a cut score on those measures than the SE− group. Additionally, cognitive performance was poorer in the SE+ group compared with the SE− group, even when excluding those with poor performance validity or controlling for mea- sures of performance validity. Those with possible symptom exaggeration on the traditional F-family MMPI-2-RF validity scales (F-r and Fp-r) were less likely to have a self-reported history of LOC, had higher self-reported psychiatric symptoms, poorer executive functioning, and were more likely to score above a cut score on only one SVT measure (mBIAS) than those without possible symptom exaggeration on those scales. Finally, those with possible symptom exaggeration on the somatic and cognitive MMPI-2-RF validity scales (Fs, FBS, and RBS) had higher service connection percentage, higher self-reported psychiatric symptoms, higher scores on other SVT measures, and lower scores in three cognitive domains than those without possible symptom exaggeration on those scales. The ﬁnding that the majority (50–87% depending on the cut score used) of the present sample performed within the possi- ble symptom exaggeration range on one or more MMPI-2-RF validity scales is consistent with a previous study reporting sim- ilar rates of possible symptom over-reporting in this population (Nelson et al., 2011), but not with previous research in military service members (Lange et al., 2015 found that 38% of military service members exhibited possible symptom exaggeration on one or more MMPI-2-RF validity scale using the more stringent cut scores from the manual). It has been hypothesized that the VA’s dual role in healthcare and disability disbursement may contribute to high SVT and PVT failure rates within Veteran populations (Young, Roper, & Arentsen, 2016). More speciﬁcally, Veterans may not distinguish between the Veterans Beneﬁts Administration (VBA), which oversees disability determination, and the Veterans Healthcare Administration (VHA), which primarily provides healthcare services but also conducts compensation and pension evaluations for the VBA. Various other factors including the fact that the VBA periodically reviews service connection, concerns about Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 376 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 inclusion in programs for TBI and PTSD that provide supplemental income, and misattribution of psychiatric symptoms to a TBI may also contribute to high rates of SVT failure in this population. The present study did not have a direct measure of whether participants had an external incentive to exaggerate self-report of emotional, cognitive, or physical symptoms; however, Veterans frequently initiate compensation and pension evaluations coincident with their clinical care and thus it is extremely difﬁcult to obtain an accurate proxy for incentive to exaggerate (Armistead-Jehle, 2010). Participants in the SE+ group had higher service connection percentage than those in the SE− group, but this ﬁnding did not survive Bonferroni-correction. Previous research that has found comparable rates of symptom exaggeration in forensic compared with treatment-seeking groups of OEF/OIF Veterans with self-reported history of mTBI and higher scores on MMPI-2-RF validity scales in those with active disability claims than those without (Nelson et al., 2011). Given that the present study did not include data to directly address this question, future research should explore rela- tionships between symptom validity scales and incentive to exaggerate. It is also possible that the SE+ group had higher rates of bona ﬁde PTSD, depression, and post-concussive symptoms than the SE− group, therefore, leading to higher genuine reporting of emotional, cognitive, and somatic symptoms compared with the SE− group. Although the SE+ group had higher self-reported psychological distress and post-concussive symptoms, there were no group differences in self-reported alcohol use or sleep problems, indicating that there was no greater endorsement of problems across all self-report measures. Interestingly, the SE+ group had poorer attention and executive functioning perfor- mance even when accounting for PVT performance. More severe depression and PTSD symptoms have been associated with poorer performance on neuropsychological measures (Qureshi et al., 2011; Spencer et al., 2013). However, the groups did not differ with regard to rates of psychiatric diagnoses or injury severity variables, and scores on the BDI-II, PCL, and NSI were clinically elevated in both groups supporting the hypothesis that this ﬁnding could be due to symptom exaggeration rather than greater psychopathology. Alternatively, elevations on SVTs may reﬂect unconscious magniﬁcation of genuine symptoms or a co-occurrence of exter- nal incentives and somatoform symptoms rather than pure intentional exaggeration for secondary gain (Nelson et al., 2011). This idea is further supported by the rates of elevation on the MMPI-2-RF content scales related to cognitive and somatic complaints. Previous research has shown that symptoms of posttraumatic stress in OEF/OIF Veterans were associated with negative perceptions regarding the consequences of their TBI or non-TBI (i.e., orthopedic) injury, negative emotional re- sponses to their injury, and poorer understanding of their injury (the latter of which was exacerbated in those with a history of mTBI relative to those with non-TBI injuries; Bahraini et al., 2017). Thus, for OEF/OIF Veterans with self-reported history of mTBI, signiﬁcant PTSD symptoms may inﬂuence their perception of their TBI, therefore, increasing endorsement of cognitive and somatic symptoms. Although there were no group differences with regard to PVT performance in the present study (fur- ther supporting that PVT and SVT performance are distinct constructs and should be tested separately; Armistead-Jehle, 2010; Van Dyke et al., 2013), the poorer cognitive scores in the SE+ group compared with the SE− group could reﬂect a more subtle decline in cognitive performance, possibly as a result of somatization. Participants in the SE+ group may have ex- pected to do worse on cognitive testing, which can negatively affect cognitive outcomes in mTBI (Silver, 2015). Our ﬁndings are in contrast to Martin, Schroeder, Heinrichs, et al. (2015) who failed to ﬁnd a relationship between MMPI validity scales and objective neuropsychological performance after accounting for PVT. Martin, Schroeder, Heinrichs, et al. (2015) examined a civilian outpatient sample, whereas the present study was looking speciﬁcally at Veterans. Additionally, the present sample had a much higher rate of psychiatric comorbidity, particularly PTSD, than did the Martin, Schroeder, Heinrichs, et al. (2015) sam- ple. These differences are likely contributing to the disparate ﬁndings and highlight the importance of exploring this relationship across different samples. However, PTSD alone also does not seem to be solely driving the elevated scores on SVT indicators. Mason and colleagues (2013) reported MMPI-RF validity scale mean scores for Veterans diagnosed with PTSD, scores that are 1.0–1.5 SD lower than those reported in the present sample (Mason et al., 2013). Although frank neurological effects of mTBI are also unlikely to be notably contributing to the elevated rates of symptom reporting in this population, the chronic multisymp- tom and functional presentation in those seeking treatment in the chronic phase following mTBI is likely to manifest differently than PTSD alone (Hoge, Goldberg, & Castro, 2009; Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009). The higher SVT elevations re- ported in the present study appear to be capturing this comorbid and functional presentation. Interestingly, previous studies examining objective cognitive performance in association with performance validity tests have identiﬁed poorer memory scores in those who failed versus passed PVTs (Armistead-Jehle & Buican, 2012; Grills & Armistead-Jehle, 2016), whereas the present study revealed worse performance on tests of attention and executive functioning in those who failed vs. passed symptom validity tests. Finally, those with possible symptom exaggeration on the cognitive and somatic MMPI-2-RF validity scales appeared to be driving the majority of signiﬁcant ﬁndings between the SE+ and SE− groups, further supporting the use of these scales in this population. Although the present study has many strengths including the characterization of symptom reporting and associated factors in a consecutively referred, treatment-seeking group of OEF/OIF Veterans with self-reported history of mTBI, there are Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 377 several limitations which should be noted. First, the study is cross-sectional in nature and thus any inferences regarding the predictive utility of any measures are limited. Additionally, as with many studies of Veterans with history of mTBI, the infor- mation collected regarding injury history was self-reported because medical records documentation from the time of the injury was not available in most cases. Although we have noted the ﬁndings that did not survive Bonferroni-correction, the present study included a large number of analyses and thus may reﬂect an elevated Type I error rate. Although the neuro- psychological measures used in the present study are well validated and widely used, some subtests had lower psychometric strength that may have contributed some error into the results. Bodily injury data were not systematically available for this sample, though may contribute to validity performances and should be explored in future work. Although it is valuable to report on the presentation of “real world” samples of treatment-seeking Veterans, the relationship between service connection and SVT in this clinical sample is complicated and difﬁcult to fully deconstruct. Our reported service connection percentages represent only one snapshot in time; these ratings can and do change over time and over-reporting of symptoms may result in higher ratings. Future work should explore greater detail the relationship between SVT and service connection ratings, includ- ing relationship of SVT to change in service connection over time as well as to speciﬁc ratings for medical vs. mental health conditions. Additionally, the psychiatric diagnoses were acquired from medical records and not from standardized clinical in- terviews at the time of the assessment. Thus, future studies should attempt to replicate these ﬁndings using validated clinical interviews to diagnose psychiatric disorders within this population. Finally, the sample size of the present study was relatively small, and, therefore, may have been insufﬁciently powered to detect effects; future research would beneﬁt from expanding on the present study in large samples. Despite these limitations, the present study provides valuable information regarding OEF/OIF Veterans with self-reported history of mTBI that present for the treatment at the VA. The results demonstrate the importance of utilizing both SVTs and PVTs in the evaluation of Veterans with persistent post-concussive symptoms. When evaluating psychiatric self-report assess- ments in this population, our data suggest it is imperative to consider Veteran’s performance on the MMPI-2-RF validity scales (or other SVT) as results on these measures are associated with elevated self-report of depression, posttraumatic, and post-concussive symptoms. A large portion of the participants performed within the possible symptom exaggeration range on one or more MMPI-2-RF validity scales and over 80% were within the clinically signiﬁcant elevation range on the MMPI-2- RF cognitive and somatic content scales. These ﬁndings highlight the need to treat cognitive and somatic symptom complaints and/or target somatization in the context of evidence-based treatments for common co-occurring mental health conditions such as PTSD and depression. Future studies should evaluate the effectiveness of such treatments in addressing both self- reported cognitive and somatic symptom complaints as well as any objective cognitive difﬁculties that may be present. Conﬂict of interest None declared. Acknowledgements The authors have no conﬂicts of interest to report, and none have any ﬁnancial interest with the subject matter discussed in the manuscript. The views expressed herein are those of the authors and do not necessarily reﬂect the views or the ofﬁcial pol- icy of the Department of Veterans Affairs or U.S. Government. Authors were supported in part by Department of Defense award W81XWH-11-1-0641. Laura Crocker was supported by the VA Ofﬁce of Academic Afﬁliations Interprofessional Polytrauma and Traumatic Brain Injury Rehabilitation Fellowship. Supplementary Material Supplementary material is available at Archives of Clinical Neuropsychology online. References Anestis, J. C., Finn, J. A., Gottfried, E., Arbisi, P. A., & Joiner, T. E. (2015). Reading the road signs: The utility of the MMPI-2 Restructured Form Validity Scales in prediction of premature termination. Assessment, 22, 279–288. Arbisi, P. A., Polusny, M. A., Erbes, C. R., Thuras, P., & Reddy, M. K. (2011). 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Psychological Assessment, 9, 177. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Clinical Neuropsychology Oxford University Press http://www.deepdyve.com/lp/oxford-university-press/the-minnesota-multiphasic-personality-inventory-2-rf-in-treatment-uUXuRsMNkT

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Publisher: Oxford University Press
Copyright: Copyright © 2022 Oxford University Press
ISSN: 0887-6177
eISSN: 1873-5843
DOI: 10.1093/arclin/acy048
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Abstract

Objective: This study examined the Minnesota Multiphasic Personality Inventory—Second Edition-Restructured Form (MMPI-2-RF) to better understand symptom presentation in a sample of treatment-seeking Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with self-reported history of mild traumatic brain injury (mTBI). Method: Participants underwent a comprehensive clinical neuropsychological battery including performance and symptom validity mea- sures and self-report measures of depressive, posttraumatic, and post-concussive symptomatology. Those with possible symptom exaggera- tion (SE+) on the MMPI-2-RF were compared with those without (SE−) with regard to injury, psychiatric, validity, and cognitive variables. Results: Between 50% and 87% of participants demonstrated possible symptom exaggeration on one or more MMPI-2-RF validity scales, and a large majority were elevated on content scales related to cognitive, somatic, and emotional complaints. The SE+ group reported higher depressive, posttraumatic, and post-concussive symptomatology, had higher scores on symptom validity measures, and performed more poorly on neuropsychological measures compared with the SE− group. There were no group differences with regard to injury variables or performance validity measures. Participants were more likely to exhibit possible symptom exaggeration on cognitive/somatic compared with traditional psychopathological validity scales. Conclusions: A sizable portion of treatment-seeking OEF/OIF Veterans demonstrated possible symptom exaggeration on MMPI-2-RF validity scales, which was associated with elevated scores on self-report measures and poorer cognitive performance, but not higher rates of performance validity failure, suggesting symptom and performance validity are distinct concepts. These ﬁndings have implications for the interpretation of clinical data in the context of possible symptom exaggeration and treatment in Veterans with persistent post-concussive symptoms. Keywords: Symptom validity testing; Head injury; Traumatic brain injury; Assessment; Posttraumatic stress disorder; Depression Introduction Evaluation of response bias is a necessary component of neuropsychological assessment (Bush et al., 2005; Heilbronner et al., 2009) and is routinely practiced by providers across multiple settings (Martin, Schroeder, & Odland, 2015; Schroeder, Martin, & Odland, 2016). Symptom validity testing (SVT; assessment of self-report measure validity) and performance valid- ity testing (PVT; assessment of neuropsychological test performance validity) are related (Martin, Schroeder, Heinrichs, & Baade, 2015), but not entirely overlapping concepts that are both important to consider during neuropsychological evaluations (Larrabee, 2012; Van Dyke, Millis, Axelrod, & Hanks, 2013; Jurick et al., 2016). Base-rate estimates of PVT and SVT failure are higher in routine clinical examinations at the Veterans Administration (VA) than in other medical or clinical settings, Published by Oxford University Press 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. doi:10.1093/arclin/acy048 Advance Access publication on 30 May 2018 Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 367 particularly for those referred for evaluation of symptoms related to posttraumatic stress disorder (PTSD) and history of mild traumatic brain injury (mTBI; Whitney, Davis, Shepard, & Herman, 2008; Axelrod & Schutte, 2010; Jurick et al., 2016; Young, Roper, & Arentsen, 2016). Despite these high rates of PVT and SVT failure, as well as the large number of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans returning with history of mTBI and comorbid mental health conditions (Hoge et al., 2008; Terrio et al., 2009), response bias (particularly SVT failure) within treatment-seeking OEF/OIF Veterans remains relatively understudied (Nelson et al., 2011; Young, Kearns, & Roper, 2011; Young, Roper, & Arentsen, 2016). Understanding the factors related to response bias in this population can be clinically informative as it is associated with many negative outcomes, including artiﬁcially elevated scores on psychological assessment measures (Larrabee, 2003), artiﬁcially reduced cognitive test scores (Grills & Armistead-Jehle, 2016), increased disability claims (Armistead-Jehle, 2010), poor treatment adherence (Anestis, Finn, Gottfried, Arbisi, & Joiner, 2015), poorer adaptive functioning within the community (Lippa et al., 2014), and increased ﬁnancial burden on the VA healthcare system (Denning, 2012; Horner, VanKirk, Dismuke, Turner, & Muzzy, 2014). A growing body of research has demonstrated stronger relationships between PVT failure and cognitive test scores, psy- chological distress, and disability/litigation status compared to demographic or TBI injury variables in civilians (Green, Rohling, Lees-Haley, & Allen, 2001; Nelson et al., 2011; West, Curtis, Greve, & Bianchini, 2011; Webb, Batchelor, Meares, Taylor, & Marsh, 2012; Grills & Armistead-Jehle, 2016) and in OEF/OIF active duty service members with history of mTBI (Lange, Pancholi, Bhagwat, Anderson-Barnes, & French, 2012; Lippa et al., 2014; Armistead-Jehle, Cooper, & Vanderploeg, 2015). PVT failure rates within treatment-seeking OEF/OIF Veterans with a history of mTBI have varied considerably, rang- ing from 23% to 68%, depending on the type and the number of measures used to indicate PVT failure (Armistead-Jehle, 2010; Russo, 2012; Spencer et al., 2013; Lippa et al., 2014; Proto et al., 2014; Heyanka et al., 2015; Jak et al., 2015). Although some studies have shown positive associations between PVTs and SVTs (Thomas & Youngjohn, 2009; Peck et al., 2013), others have demonstrated that they are distinct factors which should be measured separately (Armistead-Jehle, 2010; Van Dyke et al., 2013). A recently published survey of VA providers indicated that the Minnesota Multiphasic Personality Inventory—Second Edition (MMPI-2) and the restructured form (MMPI-2-RF) were by far the most commonly used SVTs (Young, Roper, & Arentsen, 2016); however, the rate and factors that inﬂuence MMPI-2-RF failure in Veterans, and SVT failure more generally, have not been fully characterized (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; Ben-Porath & Tellegen, 2008). The MMPI-2 was restructured relatively recently to reduce overlap between scales, which created a signiﬁcantly shorter MMPI-2-RF (Ben-Porath & Tellegen, 2008; Locke et al., 2010). A recent meta-analysis of the MMPI-2-RF validity scales suggested that their effectiveness in detecting invalid responding has not been assessed in areas of clinical practice that see frequent referrals such as Veterans with TBI history, possibly due to the MMPI-2-RF’s relative youth as a measure (Ingram & Ternes, 2016). Civilian studies of the MMPI-2/MMPI-2-RF scales have demonstrated a “paradoxical effect” in which those with history of mild TBI have higher elevations on scales thought to measure psychogenic components of physical and somatic complaints such as the Hypochondriasis (Hs), Hysteria (Hy), and RC1 (Somatic Complaints) scales compared with those with moderate-to-severe TBI (Youngjohn, Davis, & Wolf, 1997; Thomas & Youngjohn, 2009). With respect to objec- tive neurocognitive functioning in civilians, Martin, Schroeder, Heinrichs, et al. (2015) found no associations between MMPI- 2-RF validity scales and objective neurocognitive dysfunction in various domains once controlling for PVT performance. Within military samples, one study of National Guard Soldiers who had recently returned from Iraq detected no MMPI-2- RF validity scale elevations in those with history of mTBI only (i.e., no comorbid psychiatric conditions) compared with those with PTSD, comorbid PTSD and history of mTBI, and a healthy comparison group without PTSD or history of mTBI, whereas the comorbid group did have signiﬁcant elevations on the Fs scale (Infrequent Somatic Responses) compared with the other groups (Arbisi, Polusny, Erbes, Thuras, & Reddy, 2011). The majority of studies that have utilized the MMPI-2-RF in OEF/OIF military populations have employed mixed neurological or non-treatment-seeking research samples, active duty military service members rather than Veterans, and/or have focused primarily on feigned PTSD responding (Gass & Odland, 2012; Jones, Ingram, & Ben-Porath, 2012; Goodwin, Sellbom, & Arbisi, 2013; Mason et al., 2013). Although studies have demonstrated that the MMPI-2-RF F-r, Fp-r, Fs, FBS-r, and RBS scales can adequately detect feigned PTSD responding (Goodwin, Sellbom, & Arbisi, 2013; Mason et al., 2013), one study demonstrated that FBS-r has poor construct validity and substantial measurement error in a diagnostically diverse group of Veterans (Gass & Odland, 2012). Due to various factors speciﬁc to the VA that may cause greater reporting or experience of post-concussive symptoms over time (e.g., high rates of comorbidities, TBI screening, expectations of recovery, the VA’s dual role in patient care and disabil- ity determination), ﬁndings from active duty service members may not generalize to Veteran samples (Belanger, Uomoto, Vanderploeg, 2009; Russo, 2012; Roth & Spencer, 2013; Lippa et al., 2014; Jak et al., 2015). It appears that only one study to date has evaluated the MMPI-2-RF in a homogenous sample of OEF/OIF Veterans with history of mTBI and included a group of treatment-seekers within a VA setting (Nelson et al., 2011). Nelson and colleagues found no differences between the Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 368 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 “forensic group” (those seeking disability services) and the “clinical group” (those seeking clinical services), but did detect differences on the MMPI-2-RF validity scales between those groups and a group recruited for research purposes only. The forensic and clinical groups demonstrated potential symptom exaggeration on the Symptom Validity scale (FBS-r), Response Bias Scale (RBS), and Infrequent Responses scale (F-r), with prevalence of elevation ranging from 19% to 54% (Nelson et al., 2011). Factors such as whether the Veterans were actively seeking disability claims and presence of psychiatric comor- bidities, but not demographic or injury variables (e.g., presence of loss of consciousness or history of multiple mTBIs), inﬂu- enced the number of clinically signiﬁcant validity scale elevations. However, Nelson and colleagues did not evaluate relationships between the MMPI-2-RF and PVTs, other SVT measures, or neuropsychological measures of cognition. Thus, the present study sought to determine the rate of symptom exaggeration on the MMPI-2-RF scales and examine dif- ferences in injury, disability rating, psychiatric, PVT, SVT, and cognitive variables between those with and without possible symptom exaggeration in a sample of OEF/OIF Veterans with self-reported history of mTBI seeking treatment for post- concussive complaints. Based on previous research, we hypothesized that approximately half of the Veterans would be ele- vated on one or more MMPI-2-RF validity scale, as well as the content scales related to somatic and cognitive complaints. Second, we hypothesized that those with possible symptom exaggeration on the MMPI-2-RF (SE+) would have higher ser- vice connection percentage (VA disability rating), higher psychiatric symptomatology, worse performance on other SVTs, and worse performance on PVTs than those without possible symptom exaggeration (SE−). With regard to cognition, we pre- dicted that the SE+ group would have poorer performance on objective measures of cognition across all domains (processing speed, attention, memory, and executive functioning) compared with the SE− group, but that these relationships would not remain signiﬁcant once controlling for PVT performance. As an exploratory aim, we also wanted to determine whether there were differences between those with possible symptom exaggeration on the scales related to cognitive and somatic over- reporting (Fs, RBS, FBS-r) compared with those with possible symptom exaggeration on the traditional F-family of scales (F-r, Fp-r), which indicate general psychiatric symptom exaggeration; the cognitive and somatic over-reporting scales have been shown to be more sensitive to cognitive and somatic symptom exaggeration in OEF/OIF military service members or Veterans with mixed neurological disorders, including TBI, likely due to the differential item content of the validity scales (Whitney et al., 2008; Jones, Ingram, & Ben-Porath, 2012). Method Participants The present study consisted of OEF/OIF Veterans with self-reported history of mTBI who were consecutively referred to a VA TBI/Cognitive Rehabilitation Clinic for evaluation and treatment of subjective cognitive complaints. Mild TBI was deﬁned by self-reported loss of consciousness (LOC) less than or equal to 30 min or alteration of consciousness (AOC) and/ or posttraumatic amnesia (PTA) less than or equal to 24 hr (Management of Concussion/mTBI Working Group, 2016). All mild TBI events occurred greater than 3 months prior to examination; no participants were in the acute recovery period fol- lowing injury. Exclusion criteria were self-reported history of moderate-to-severe TBI as deﬁned as LOC > 30 min and/or AOC or PTA > 24 hr, history of other neurological condition, and history of psychotic disorder (e.g., schizophrenia). In addi- tion, participants were excluded who had 15 or more omissions on the MMPI-2-RF, or an elevated score (T > 79) on either the Variable Response Inconsistency (VRIN-r) or the True Response Inconsistency (TRIN-r) scales as these variables have been shown to affect content-based invalid responding (Burchett et al., 2016). Procedure All participants underwent a comprehensive clinical assessment including acquisition of information regarding TBI and psychiatric history and administration of neuropsychological tests (e.g., attention, memory, processing speed, and executive functioning), emotional self-report measures, PVTs, and SVTs, including the MMPI-2-RF. Severity of TBI was determined based on self-reported information regarding injury history acquired by clinical neuropsychologists, physicians, or advanced doctoral trainees in a semi-structured clinical interview as medical record documentation at the time of the injury event was not available in most cases. When available, the results of the VA Comprehensive TBI Evaluation (CBTIE) veriﬁed the TBI severity. Experienced raters trained to retrieve and enter data conducted medical chart reviews to gather information regarding service connection percentage. Psychiatric diagnoses were also acquired from medical records based on clinical assessments from qualiﬁed providers. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 369 Measures Neuropsychological measures included the Digit Span, Symbol Search, and Coding subtests from the Wechsler Adult Intelligence Scale-IV (WAIS-IV; Wechsler, 2008), Verbal Fluency and Trail Making Test from the Delis–Kaplan Executive Function System (D-KEFS; Delis, Kaplan, & Kramer, 2001) the California Verbal Learning Test—Second Edition (CVLT-II; Delis, Kramer, Kaplan, & Ober, 1999) and the Wide Range Achievement Test-4 Reading subtest as a measure of premorbid intellectual functioning (WRAT-4; Wilkinson & Roberts, 2006). To reduce the number of cognitive measures, four composite scores were created in the domains of attention, processing speed, executive functioning, and memory. The attention compos- ite score included an average of the scaled scores from the visual scanning subtest of the D-KEFS Trail Making Test and the forward condition of WAIS-IV Digit Span. The processing speed composite score was composed of the average of the scaled scores from the Symbol Search and Coding subtests of the WAIS-IV and the D-KEFS Trail Making Test number and letter conditions (D-KEFS; Delis, Kaplan, & Kramer, 2001). The executive functioning composite score was an average of the scaled scores from D-KEFS Verbal Fluency number of correct switches, D-KEFS Trail Making Test number–letter switching condition, and the sequencing condition of the WAIS-IV Digit Span (McCabe, Roediger, McDaniel, Balota, & Hambrick, 2010). Finally, the memory composite was an average of the z-scores of the short delay free recall and long delay free recall. Psychiatric symptom severity measures included the 21-item Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), the 17-item PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993), and the 22-item Neurobehavioral Symptom Inventory (NSI; Cicerone & Kalmar, 1995), which rates difﬁculty with cognitive, emotional, somatic, and vestibular post-concussive symptoms. The 3-item Alcohol Use Disorders Identiﬁcation Test (AUDIT-C; Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998) and the 10-item Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) were also included to screen for alcohol use disorders and measure sleep quality, respec- tively. Participants completed the MMPI-2-RF, which was computer-scored with T-scores derived from the complete norma- tive sample (n = 2,276; non-gendered and non-K-corrected). PVTs included the Test of Memory Malingering (TOMM; Tombaugh & Tombaugh, 1996) and the CVLT-II forced-choice condition. Cut scores on TOMM Trials 2 and retention (<45) were based off the TOMM manual, whereas the cut score on CVLT-II forced choice (<15) was based on a published study aimed to maximize sensitivity and speciﬁcity (Root, Robbins, Chang, & Van Gorp, 2006). SVTs were the MMPI-2-RF valid- ity scales (cut scores described in the Results section), cut scores of >24 and >27 on the NSI Validity-10 (Dretsch et al., 2016; Vanderploeg et al., 2014), and a cut score of >8 on the Mild Brain Injury Atypical Symptoms Scale (mBIAS; Cooper, Nelson, Armistead-Jehle, & Bowles, 2011). Statistical analyses To address the ﬁrst aim of characterizing the MMPI-2-RF in a sample of treatment-seeking OEF/OIF Veterans with self-reported mTBI history, descriptive statistics were employed to describe the percentage of those scoring above clinically relevant T-scores on validity and content scales, as described in the manual (Ben-Porath & Tellegen, 2008). Second, group differences between those with possible symptom exaggeration (SE+) on one or more MMPI-2-RF validity scales (F-r, Fp-r, Fs, FBS-r, and RBS) and those without possible symptom exaggeration (SE−) were conducted using Chi-square tests and independent samples t-tests. Dependent variables included demographic, injury (e.g., LOC, PTA, and number of mTBIs), SVT, PVT, and cognitive variables. To address the issue of multiple comparisons in primary analyses, family-wise Bonferroni-corrected p-values were utilized (p < .008 for demographics, .007 for injury variables, .004 for mental health vari- ables, .005 for SVTs, .007 for PVTs, and .01 for cognitive measures). To determine whether PVT failure accounted for differ- ences in cognitive performance between the two groups, independent samples t-tests were repeated excluding those with poor PVT performance on one or more measures (see Measures section). Additionally, analyses of covariance (ANCOVA) were conducted to compare the two groups using the cognitive composite scores as the dependent variables and each PVT as a covariate. The ﬁnal aim was to evaluate whether possible symptom exaggeration on speciﬁc validity scales (i.e., those target- ing cognitive and somatic versus general psychiatric symptom exaggeration) have different relationships with the variables of interest. Chi-square tests and independent samples t-tests were conducted to determine whether those with possible symptom exaggeration on the validity scales targeting somatic and cognitive symptoms (Fs, FBS-r, and RBS) versus the traditional F-family scales (F-r and Fp-r) differed with regard to variables of interest (e.g., demographic, injury, SVT, PVT, and cognitive variables). The Bonferroni corrections described previously were not applied to these analyses as they were exploratory in nature. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 370 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 Results Demographic and sample characteristics Of the 59 consecutive clinic referrals, a total of 13 participants were excluded (ﬁve reported an event consistent with a moderate-to-severe TBI, seven had elevated scores on VRIN-r and/or TRIN-r T > 79, one had a diagnosis of schizophrenia). The remaining sample (N = 46) was predominantly male (89%) with an average of 13.7 years of education. Over half of the sample had self-reported history of LOC (60.5%), nearly half had a self-reported history of three or more mTBIs (45.7%), and 56.5% had a self-reported history of blast exposure. The large majority had a PTSD diagnosis listed in their VA medical chart (82.6%), and over half had a depression diagnosis (56.1%). The range of the NSI Validity-10 scores was 34 (ranged from 4 to 38) and the range of the mBIAS scores was 15 (ranged from 0 to 15). See Table 1 for full sample characteristics). MMPI-2-RF Validity and Content Scale Elevations The large majority of participants (87%) scored within the “possible over-reporting” range utilized in previous studies (Lange, Brickell, & French, 2015) on one or more validity scales (n = 17, T > 89 on F-r; n = 13, T > 79 on Fp-r; n = 31, T > 79 on Fs; n = 26, T > 79 on FBS-r; n = 36, T > 79 on RBS). Because the MMPI-2-RF validity scales have been shown to be elevated in those with genuine physical problems and major depressive disorder (see Sharf et al., 2017 for full review), the next highest cut score in the MMPI-2-RF manual was used for all analyses given the high rate of psychiatric comorbidities and self-reported blast exposure in the present sample. When using a more stringent cut score for invalidity in the MMPI-2- RF manual, 50% of participants scored within the “possible over-reporting/invalid” range on one or more validity scales (n = 15, T > 99 on F-r; n = 2, T > 99 on Fp-r; n = 19, T > 99 on Fs; n = 5, T > 99 on FBS-r; n = 13, T > 99 on RBS). Although there have been concerns raised regarding false positive rates when using a cut score of 100 T on the F-r scale in a low base-rate sample (Sellbom, Toomey, Wygant, Kucharski, & Duncan, 2010), every Veteran who had an elevated score on this scale was elevated on one or more other validity scales. With regard to content scale elevations, over half of the sample was elevated (T ≥ 65) on the cognitive complaints scale (COG; 84.8%), somatic complaints (RC1; 82.6%), neurological com- plaints (NUC; 80.4%), anxiety (AXY; 78.3%), head pain complaints (HPC; 76.1%), malaise (MLS; 69.6%), stress/worry (STW; 65.2%), gastrointestinal complaints (CIG; 58.7%), social avoidance (SAV; 58.7%), anger proneness (ANP; 56.5%), emotional/internalizing dysfunction (EID; 56.5%), and low positive emotions (RC2; 56.5%, for full list see Table 2). Group differences in demographic, injury, psychiatric, PVT, and cognitive variables All variables were assessed for normality and outliers. For those variables that were not normally distributed (number of mTBIs, duration of LOC, and PTA), or had outliers (number of mTBIs), analyses were replicated with non-parametric tests and log transformed variables, and without outliers. No demographic or injury variables signiﬁcantly differed between the SE+ and SE− groups (all p’s > .008; see Table 1). With regard to psychiatric symptom variables, there were no group differences with regard to the percentage of psychiatric diagnoses (PTSD, depression, or substance abuse) in each group, however, the SE+ group reported a greater number of PTSD symptoms t(38) = 3.34, p = .002, depressive symptoms t(42) = 4.18, p < .001, and post-concussive symptoms t(44) = 4.28, p < .001 than the SE− group. Within the NSI, emotional t(44) = 3.61, p = .001, cognitive t(44) = 4.01, p < .001, and somatic t(44) = 4.38, p < .001, but not vestibular t(44) = 2.28, p = .027, post-concussive symptoms were signiﬁcantly ele- vated in the SE+ group compared to the SE− group. No group differences existed with regard to self-reported alcohol use or sleep quality (p’s > .004). With regard to SVTs, the SE+ group had higher (worse) scores on the NSI Validity-10 t(44) = 3.95, p < .001, all MMPI-2-RF validity scales except Fp-r (all t’s > 4.9, all p’s < .001), and exhibited higher rates of scoring above cutoff on the mBIAS (χ = 8.69, p = .003). Although the SE+ group exhibited higher rates of scoring above cutoff on 2 2 the Validity-10 at the 24 (χ = 6.77, p = .022) and 27 (χ = 6.90, p = .022) cut scores compared with the SE− group, this ﬁnding did not survive Bonferroni-correction. No SE group differences emerged on PVTs including TOMM trial 2, retention trial, or CVLT-II forced choice (all p’s > .05). There were also no differences in the percentage of participants who failed PVTs, or the number of failed PVTs (all p’s > .05). With regard to cognition, the SE+ group performed worse in the domains of attention t(43) = −2.68, p = .010, and executive functioning t(44) = −3.11, p = .003, but not processing speed t(44) = −2.45, p = .018 or memory t(42) = −.43, p = .671 com- pared with the SE− group. To determine whether these differences remained signiﬁcant when controlling for PVT performance, the independent samples t-tests were successfully replicated after excluding those with poor performance validity on one or Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 371 Table 1. Descriptive and group differences on demographic, injury, cognitive, and psychiatric measures Total sample SE+ SE− Χ ortp Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Demographics Age 33.91 (7.77) 46 35.74 (8.11) 23 32.09 (7.14) 23 1.62 .112 % Male 89.1 46 91.3 23 87.0 23 .22 .636 Education 13.74 (1.53) 46 13.52 (1.44) 23 13.96 (1.61) 23 −.97 .340 % Hispanic 19.6 46 17.4 23 21.7 23 .14 .710 % Caucasian 64.4 45 59.0 22 69.6 23 .54 .463 VA Service Connection % 62.4 (33.4) 46 72.2 (33.16) 23 52.61 (31.46) 23 2.06 .046 Injury variables % with LOC history 60.5 43 50.0 22 71.4 21 2.06 .151 % with PTA history 44.2 43 47.6 21 40.9 22 .20 .658 LOC duration 3.69 (8.81) 28 4.64 (10.82) 14 2.75 (6.49) 14 .56 .580 PTA duration 110.78 (391.31) 26 120.00 (415.69) 12 102.86 (284.86) 14 .11 .914 # of mTBIs 2.41 (1.44) 37 2.29 (1.05) 17 2.50 (1.73) 20 −.43 .671 % with three or more mTBIs 45.7 46 47.8 23 43.5 23 .09 .500 % with blast history 40.0 46 43.4 23 36.4 22 .24 .428 Mental health variables PCL-S 64.15 (12.85) 40 70.20 (12.43) 20 58.10 (10.37) 20 3.34 .002* BDI-II 27.32 (11.02) 44 33.23 (10.15) 22 21.41 (8.52) 22 4.18 <.001* AUDIT-C 2.89 (3.16) 46 3.43 (3.49) 23 2.35 (2.77) 23 1.17 .248 PSQI 14.02 (4.19) 44 15.19 (3.60) 21 12.96 (4.48) 23 1.81 .077 NSI 48.37 (16.09) 46 57.00 (13.22) 23 39.74 (14.13) 23 4.28 <.001* Vestibular Cluster 4.20 (2.77) 46 5.09 (2.79) 23 3.30 (2.49) 23 2.28 .027 Somatic Cluster 12.96 (5.66) 46 16.04 (4.98) 23 9.87 (4.57) 23 4.38 <.001* Cognitive Cluster 10.98 (3.19) 46 12.61 (2.43) 23 9.35 (3.05) 23 4.01 <.001* Emotional Cluster 16.07 (5.11) 46 18.48 (4.19) 23 13.65 (4.87) 23 3.61 .001* % with PTSD 82.6 46 82.6 23 82.6 23 .00 1.00 % with depression 56.1 43 66.7 21 45.5 22 1.96 .161 % with substance abuse 13.0 46 13.0 23 13.0 23 .00 1.00 Symptom validity measures NSI Validity-10 17.17 (7.90) 46 21.17 (7.53) 23 13.17 (6.13) 23 3.95 <.001* % Validity-10 Fail ≥24 19.6 46 34.8 23 4.3 23 6.77 .022 % Validity-10 Fail ≥27 13.0 46 26.1 23 0.0 23 6.90 .022 mBIAS 6.87 (2.81) 46 7.78 (2.83) 23 5.96 (2.53) 23 2.31 .026 % mBIAS Fail ≥8 28.3 46 47.8 23 8.7 23 8.69 .003* F-r 85.65 (22.40) 46 101.96 (16.71) 23 69.35 (13.82) 23 7.21 <.001* Fp-r 70.78 (17.61) 46 77.04 (18.53) 23 64.52 (14.46) 23 2.56 .014 Fs 85.83 (21.29) 46 103.22 (10.66) 23 68.43 (13.46) 23 9.72 <.001* FBS 77.85 (16.46) 46 87.57 (12.08) 23 68.13 (14.51) 23 4.94 <.001* RBS 88.41 (18.62) 46 100.26 (12.56) 23 76.57 (16.05) 23 5.58 <.001* Performance validity measures TOMM Trial 2 46.02 (6.83) 46 45.57 (7.04) 23 46.48 (6.74) 23 −.45 .655 TOMM Retention Trial 45.11 (6.58) 45 44.32 (6.67) 22 45.87 (6.55) 23 −.79 .435 % Trial two or Retention <45 33.3 45 36.4 22 30.4 23 .18 .673 CVLT-II Forced Choice 14.91 (1.79) 46 14.83 (1.92) 23 15.00 (1.68) 23 −.33 .745 % CVLT <15 23.9 46 26.1 23 21.7 23 .12 .730 % Fail PVT 37.0 46 39.1 23 34.8 23 .09 .760 # of Failed PVT Measures .80 (1.12) 46 .91 (1.24) 23 .70 (1.11) 23 .63 .533 Cognitive measures WRAT-4 reading ss 96.07 (9.12) 46 94.39 (8.84) 23 97.74 (9.27) 23 −1.25 .217 Memory composite −.76 (.96) 44 −.69 (.77) 21 −.82 (1.12) 23 −.43 .671 PS composite 9.31 (2.58) 46 8.42 (2.51) 23 10.20 (2.40) 23 −2.45 .018 Attention composite 8.62 (3.01) 45 7.52 (3.07) 23 9.77 (2.52) 22 −2.68 .010* EF composite 9.28 (1.94) 46 8.46 (1.52) 23 10.09 (1.99) 23 −3.11 .003* p is signiﬁcant at family-wise Bonferroni-corrected p-value; χ or t indicates Chi-square or t-test values. SE+= those with possible symptom exaggeration; SE− = those without possible symptom exaggeration; SD = standard deviation; % = percent; # = number; VA = Veterans Affairs; LOC = loss of consciousness; PTA = posttraumatic amnesia; mTBI = mild traumatic brain injury; PCL-S = Posttraumatic Stress Disorder Checklist—Speciﬁc Trauma; BDI-II = Beck Depression Inventory—Second Edition; AUDIT-C = Alcohol Use Disorders Identiﬁcation Test— Consumption; PSQI = Pittsburgh Sleep Quality Index; NSI = Neurobehavioral Symptom Inventory; PTSD = posttraumatic stress disorder; mBIAS = Mild Brain Injury Atypical Symptoms Scale; F-r = Infrequent Responses; Fp-r = Infrequent Psychopathology Responses; Fs = Infrequent Somatic Responses; FBS = Symptom Validity; RBS = Response Bias Scale; TOMM = Test of Memory Malingering; CVLT-II = California Verbal Learning Test—Second Edition; PVTs = performance validity tests; WRAT-4 = Wide Range Achievement Test—Fourth Edition; ss = standard score; PS = processing speed; EF = executive function. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 372 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 Table 2. Frequency of elevation, mean, and standard deviation of MMPI-2-RF content scales Total sample (n = 46) Content Scales % Frequency Mean T-score SD Cognitive Complaints 84.78 77.89 12.31 Somatic Complaints 82.61 77.48 14.65 Neurological Complaints 80.43 74.76 12.63 Anxiety 78.26 76.70 17.77 Head Pain Complaints 76.09 72.83 12.47 Malaise 69.57 72.17 12.51 Stress/Worry 65.22 64.74 11.46 Negative Emotionality/Neuroticism-Revised 60.87 66.70 14.19 Disafﬁliativeness 58.70 66.70 15.74 Gastrointestinal Complaints 58.70 70.61 17.46 Social Avoidance 58.70 65.24 13.62 Anger Proneness 56.52 64.78 12.40 Emotional/Internalizing Dysfunction 56.52 66.11 14.30 Low Positive Emotions 56.52 67.37 16.57 Demoralization 54.35 66.70 13.18 Aberrant Experiences 54.35 65.67 14.10 Introversion/Low Positive Emotionality-Revised 54.35 66.72 16.73 Dysfunctional Negative Emotions 52.17 65.78 14.62 Self-Doubt 50.00 60.61 13.88 Cynicism 45.65 61.67 11.11 Ideas of Persecution 45.65 63.04 14.85 Psychoticism-Revised 41.30 63.11 14.19 Thought Dysfunction 41.30 63.00 14.78 Inefﬁcacy 34.78 61.70 11.13 Aggression 32.61 58.46 10.69 Helplessness/Hopelessness 32.61 58.67 15.92 Suicidal/Death Ideation 30.43 55.07 17.09 Mechanical-Physical Interests 28.26 56.83 9.50 Aggressiveness-Revised 28.26 57.02 12.56 Behavioral/Externalizing Dysfunction 23.91 54.96 9.14 Behavior-Restricting Fears 23.91 60.46 14.45 Family Problems 19.57 55.26 10.82 Juvenile Conduct Problems 19.57 55.93 12.19 Antisocial Behavior 19.57 56.11 10.57 Activation 15.22 50.26 12.19 Hypomanic Activation 13.04 53.74 9.15 Substance Abuse 13.04 52.20 11.28 Disconstraint-Revised 10.87 54.00 9.08 Shyness 10.87 51.33 8.41 Interpersonal Passivity 6.52 46.50 9.63 Esthetic-Literary Interests 4.35 40.22 7.88 Multiple Speciﬁc Fears 4.35 46.43 8.75 % Frequency is the percentage of the entire sample with T-score of 65 or higher on the content scale. SD = standard deviation. more PVT measures. Further, one-way ANCOVAs were performed using each signiﬁcant cognitive composite score (attention, executive function) as the dependent variable, SE+/SE− group as the independent variable, and each PVT (TOMM Trial 2, retention trial, CVLT-II forced choice) as covariates. All group differences remained signiﬁcant even after controlling for PVT performance. Please see Supplementary Table for individual subtest data. There was signiﬁcant overlap between those with possible symptom exaggeration on the F-family scales (F-r and Fp-r) and the scales speciﬁcally targeting cognitive and somatic symptoms (Fs, FBS-r, and RBS), such that everyone who had possible symptom exaggeration on the F-r and Fp-r scales also had symptom exaggeration on the Fs, FBS-r, and/or RBS scales. However, analyses were still conducted separately for both types of symptom exaggeration (see Table 3). Those with possible symptom exaggeration on F-r and/or Fp-r were less likely to have a self-reported history of LOC (χ = 4.04, p = .045) than those without possible symptom exaggeration on those scales, but the groups did not differ on any other demographic or injury variables (all p’s > .05). Those with possible symptom exaggeration on F-r and/or Fp-r were more likely to fail the Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 373 Table 3. Descriptive and group differences on demographic, injury, cognitive, and psychiatric measures for those with possible symptom exaggeration on the MMPI-2-RF F-Family scales (F-r and Fp-r) or the somatic/cognitive scales (Fs, FBS-r, and RBS) Invalid Fr/Fp-r Valid Fr/Fp-r χ ortp Invalid Fs/FBS-r/RBS Valid Fs/FBS-r/RBS χ ortp Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Demographics Age 35.93 (8.43) 15 32.94 (7.38) 31 1.23 .224 35.74 (8.11) 23 32.09 (7.14) 23 1.62 .112 % Male 100.0 15 83.9 31 −2.71 .099 91.3 23 87.0 23 .22 .636 Education 13.33 (1.35) 15 13.94 (1.59) 31 −1.26 .213 13.52 (1.44) 23 13.96 (1.61) 23 −.97 .340 % Hispanic 26.7 15 16.1 31 −.71 .398 17.4 23 21.7 23 .14 .710 % Caucasian 57.1 14 67.7 31 −.47 .492 59.1 22 69.6 23 .54 .463 VA SC % 72.0 (34.) 15 57.74 (32.63) 31 1.37 .178 72.17 (33.16) 23 52.61 (31.37) 23 2.06 .046* Injury variables % with LOC 40.0 15 71.4 28 4.04 .045* 50.0 22 71.4 21 2.06 .151 % with PTA 50.0 14 41.4 29 .29 .594 47.6 21 40.9 22 .20 .658 LOC duration 5.45 (12.14) 11 2.56 (5.96) 17 .85 .406 4.64 (10.82) 14 2.75 (6.49) 14 .56 .580 PTA duration 180.00 (509.12) 8 80.00 (339.41) 18 .59 .558 120.00(415.69) 12 102.86 (384.86) 14 .11 .914 # of mTBIs 2.00 (0.63) 11 2.58 (1.65) 26 −1.12 .272 2.29 (1.05) 17 2.50 (1.73) 20 −.43 .671 % three or more mTBIs 40.0 15 48.4 31 .29 .592 47.8 23 43.5 23 .09 .500 % with blast history 33.3 15 43.3 31 .42 .376 43.4 23 36.4 22 .24 .428 Mental health variables PCL-S 72.08 (12.37) 13 60.33 (11.43) 27 2.97 .005* 70.20 (12.43) 20 58.10 (10.37) 20 3.34 .002* BDI-II 35.79 (8.04) 14 23.37 (10.02) 30 4.06 .000* 33.23 (10.15) 22 21.41 (8.52) 22 4.18 <.001* AUDIT-C 3.20 (3.39) 15 2.74 (3.10) 31 .46 .650 3.43 (3.49) 23 2.35 (2.77) 23 1.17 .248 PSQI 72.08 (12.37) 13 60.33 (11.43) 27 2.02 .050 15.19 (3.60) 21 12.96 (4.48) 23 1.81 .077 NSI 57.60 (12.65) 15 43.90 (15.84) 31 2.92 .005* 57.00 (13.22) 23 39.74 (14.13) 23 4.28 .000* Vestibular Cluster 4.87 (3.11) 15 3.87 (2.58) 31 1.15 .258 5.09 (2.79) 23 3.30 (2.49) 23 2.28 .027* Somatic Cluster 15.87 (5.13) 15 11.55 (5.43) 31 2.57 .014* 16.04 (4.98) 23 9.87 (4.57) 23 4.38 .000* Cognitive Cluster 12.47 (2.00) 15 10.26 (3.43) 31 2.31 .026* 12.61 (2.43) 23 9.35 (3.05) 23 4.01 .000* Emotional Cluster 19.67 (3.60) 15 14.32 (4.85) 31 3.79 .000* 18.45 (4.19) 23 13.65 (4.87) 23 3.61 .001* % with PTSD 86.7 15 80.6 31 .26 .613 82.6 23 82.6 23 .00 1.00 % with depression 73.3 15 46.4 28 2.87 .090 66.7 21 45.5 22 .37 .162 % with SA 13.3 15 12.9 31 .00 .968 13.0 23 13.0 23 .00 1.00 Symptom validity measures NSI V-10 20.33 (7.91) 15 15.65 (7.56) 31 1.94 .058 21.17 (7.53) 23 13.17 (6.13) 23 3.95 .000* % V-10 Fail ≥ 24 20.0 15 19.4 31 .00 .959 34.8 23 4.3 23 6.77 .009* % V-10 Fail ≥ 27 20.0 15 9.7 31 .95 .330 26.1 23 0.0 23 6.90 .009* mBIAS 7.93 (3.11) 15 6.35 (2.55) 31 1.83 .074 7.78 (2.83) 23 5.96 (2.53) 23 2.31 .026* % mBIAS Fail ≥8 53.3 15 16.1 31 6.90 .009* 47.8 23 8.7 23 8.69 .003* F-r 112.20 (7.02) 15 72.81 (14.37) 31 10.01 .000* 101.96 (16.71) 23 69.35 (13.82) 23 7.21 .000* Fp-r 81.20 (18.58) 15 65.74 (14.96) 31 3.03 .004* 77.04 (18.53) 23 64.52 (14.46) 23 2.56 .014* Fs 104.40 (12.94) 15 76.84 (18.60) 31 5.15 .000* 103.22 (10.66) 23 68.43 (13.46) 23 9.72 .000* FBS-r 91.53 (12.79) 15 71.23 (13.82) 31 4.78 .000* 87.57 (12.08) 23 68.13 (14.51) 23 4.94 .000* RBS 105.00 (11.58) 15 80.39 (15.91) 31 5.33 .000* 100.26 (12.56) 23 76.57 (16.05) 23 5.58 .000* (continued on next page) Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 374 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 Table 3. (continued) Invalid Fr/Fp-r Valid Fr/Fp-r χ ortp Invalid Fs/FBS-r/RBS Valid Fs/FBS-r/RBS χ ortp Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Mean (SD) or % n Performance validity measures TOMM Trial 2 46.87 (4.53) 15 45.61 (7.74) 31 .58 .565 45.57 (7.04) 23 46.48 (6.74) 23 −.45 .655 TOMM Retention 44.36 (5.73) 14 45.45 (6.99) 31 −.51 .611 44.32 (6.67) 23 45.87 (6.55) 23 −.79 .435 % TOMM < 45 35.7 14 32.3 31 .05 .820 36.4 22 30.4 23 .18 .673 CVLT-II FC 14.67 (2.02) 15 15.03 (1.68) 31 −.65 .521 14.83 (1.92) 23 15.00 (1.68) 23 −.33 .745 % CVLT-II FC < 15 26.7 15 22.6 31 .09 .761 26.1 23 21.7 23 .12 .730 % Fail Effort 40.0 15 35.5 31 .09 .766 39.1 23 34.8 23 .09 .760 # Failed PVTs .87 (1.19) 15 .81 (1.20) 31 .16 .873 .91 (1.24) 23 .70 (1.11) 23 .63 .533 Cognitive measures WRAT-4 reading ss 94.67 (8.18) 15 96.74 (9.59) 31 −.72 .475 94.39 (8.84) 23 97.74 (9.27) 23 −1.25 .217 Memory composite −.96 (.82) 13 −.67 (1.01) 31 −.92 .361 -.69 (.77) 21 -.82 (1.12) 23 −.43 .671 PS composite 8.55 (1.93) 15 9.67 (2.80) 31 −1.40 .168 8.42 (2.51) 23 10.20 (2.40) 23 −2.45 .018* Attention composite 7.80 (2.72) 15 9.03 (3.10) 30 −1.31 .198 7.52 (3.07) 23 9.77 (2.52) 22 −2.68 .010* EF composite 8.33 (1.58) 15 9.73 (1.94) 31 −2.42 .020* 8.46 (1.52) 23 10.09 (1.99) 23 −3.11 .003* p < .05; χ or t indicates Chi-square or t-test values of group differences. SD = standard deviation; % = percent; # = number; VA SC = Veterans Affairs Service Connection; LOC = loss of consciousness; PTA = posttraumatic amnesia; mTBI = mild traumatic brain injury; PCL-S = Posttraumatic Stress Disorder Checklist—Speciﬁc Trauma; BDI-II = Beck Depression Inventory—Second Edition; AUDIT-C = Alcohol Use Disorders Identiﬁcation Test- Consumption; PSQI = Pittsburgh Sleep Quality Index; NSI = Neurobehavioral Symptom Inventory; PTSD = posttraumatic stress disorder; SA = substance abuse; V-10 = Validity-10; mBIAS = Mild Brain Injury Atypical Symptoms Scale; F-r = Infrequent Responses; Fp-r = Infrequent Psychopathology Responses; Fs = Infrequent Somatic Responses; FBS-r = Symptom Validity; RBS = Response Bias Scale; TOMM = Test of Memory Malingering; CVLT-II = California Verbal Learning Test—Second Edition; FC = forced choice; PVTs = performance validity tests; WRAT-4 = Wide Range Achievement Test—Fourth Edition; ss = standard score; PS = processing speed; EF = executive function. Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 375 mBIAS (χ = 6.90, p = .009) had higher scores on all MMPI-2-RF validity scales (all t’s > 3.0, all p’s < .005), reported high- er depressive, t(42) = 4.06, p < .001, posttraumatic, t(38) = 2.97, p = .005, and post-concussive, t(44) = 2.92, p = .005, symptoms across all NSI symptom clusters except for vestibular, as well as exhibited poorer executive function performance, t(44) = −2.42, p = .020, compared with those without possible symptom exaggeration on those scales. No signiﬁcant group differences between percentage of psychiatric diagnoses, other SVTs, PVTs, or other cognitive measures were detected (all p’s > .05). When comparing those with and without possible symptom exaggeration on scales speciﬁcally targeting cognitive and somatic over-reporting (Fs/FBS-r/RBS), those with possible symptom exaggeration had higher service connection percentage t(44) = 2.06, p = .046, but this ﬁnding did not survive Bonferroni-correction. There were no other group differences with regard to demographic or injury variable differences (all p’s > .05). Those with possible symptom exaggeration on the Fs, FBR-r, and/or RBS scales also had higher self-reported depressive t(42) = 4.18, p < .001, posttraumatic t(38) = 3.34, p = .002, and post-concussive t(42) = 4.28, p < .001 symptoms across all four NSI symptom clusters, higher scores on all MMPI-2-RF validity scales (all t’s > 2.5, all p’s < .015), the mBIAS t(44) = 2.31, p = .026 and Validity-10 t(44) = 3.95, 2 2 p < .001, and were more likely to fail the Validity-10 (cut score 24, χ = 6.77, p = .009; cut score 27, χ = 6.90, p = .009), and mBIAS (χ = 8.69, p = .003) compared with those without possible symptom exaggeration on those scales. Those with possible symptom exaggeration on Fs, FBS-r, and/or RBS scales also had poorer performance on measures of attention t(43) = −2.68, p = .010, executive functioning t(44) = −3.11, p = .003, and processing speed t(44) = −2.45, p = .018 than those without. No signiﬁcant group differences between percentage of psychiatric diagnoses, PVTs, or memory performance were detected (all p’s > .05). As with the previous analyses, the group differences with regard to cognition remained signiﬁcant when those failing one or more PVTs were excluded. To determine whether these relationships remained signiﬁcant when controlling for PVT per- formance, the independent samples t-tests were successfully replicated after excluding those with poor performance validity on one or more PVT measures (all t’s > 2.2, all p’s < .04) and controlling for each PVT using ANCOVAs (all F’s > 5.7, all p’s < .03). Conclusions As hypothesized, a substantial portion of consecutively referred, treatment-seeking OEF/OIF Veterans with self-reported history of mTBI had possible symptom exaggeration on one or more MMPI-2-RF validity scales, as well as elevated scores on content scales related to cognitive and somatic symptoms. Although the SE+ group did not differ from the SE− group with regard to demographic or injury variables or percentage of those with psychiatric diagnoses, the SE+ group did report higher depressive, posttraumatic, and post-concussive symptoms compared with the SE− group. As anticipated, the SE+ group had higher scores on other SVTs, providing convergent validity for the MMPI-2-RF validity scales within this popula- tion. Contrary to our hypothesis, the SE+ group did not have worse performance on PVT measures and were no more likely to score below a cut score on those measures than the SE− group. Additionally, cognitive performance was poorer in the SE+ group compared with the SE− group, even when excluding those with poor performance validity or controlling for mea- sures of performance validity. Those with possible symptom exaggeration on the traditional F-family MMPI-2-RF validity scales (F-r and Fp-r) were less likely to have a self-reported history of LOC, had higher self-reported psychiatric symptoms, poorer executive functioning, and were more likely to score above a cut score on only one SVT measure (mBIAS) than those without possible symptom exaggeration on those scales. Finally, those with possible symptom exaggeration on the somatic and cognitive MMPI-2-RF validity scales (Fs, FBS, and RBS) had higher service connection percentage, higher self-reported psychiatric symptoms, higher scores on other SVT measures, and lower scores in three cognitive domains than those without possible symptom exaggeration on those scales. The ﬁnding that the majority (50–87% depending on the cut score used) of the present sample performed within the possi- ble symptom exaggeration range on one or more MMPI-2-RF validity scales is consistent with a previous study reporting sim- ilar rates of possible symptom over-reporting in this population (Nelson et al., 2011), but not with previous research in military service members (Lange et al., 2015 found that 38% of military service members exhibited possible symptom exaggeration on one or more MMPI-2-RF validity scale using the more stringent cut scores from the manual). It has been hypothesized that the VA’s dual role in healthcare and disability disbursement may contribute to high SVT and PVT failure rates within Veteran populations (Young, Roper, & Arentsen, 2016). More speciﬁcally, Veterans may not distinguish between the Veterans Beneﬁts Administration (VBA), which oversees disability determination, and the Veterans Healthcare Administration (VHA), which primarily provides healthcare services but also conducts compensation and pension evaluations for the VBA. Various other factors including the fact that the VBA periodically reviews service connection, concerns about Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 376 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 inclusion in programs for TBI and PTSD that provide supplemental income, and misattribution of psychiatric symptoms to a TBI may also contribute to high rates of SVT failure in this population. The present study did not have a direct measure of whether participants had an external incentive to exaggerate self-report of emotional, cognitive, or physical symptoms; however, Veterans frequently initiate compensation and pension evaluations coincident with their clinical care and thus it is extremely difﬁcult to obtain an accurate proxy for incentive to exaggerate (Armistead-Jehle, 2010). Participants in the SE+ group had higher service connection percentage than those in the SE− group, but this ﬁnding did not survive Bonferroni-correction. Previous research that has found comparable rates of symptom exaggeration in forensic compared with treatment-seeking groups of OEF/OIF Veterans with self-reported history of mTBI and higher scores on MMPI-2-RF validity scales in those with active disability claims than those without (Nelson et al., 2011). Given that the present study did not include data to directly address this question, future research should explore rela- tionships between symptom validity scales and incentive to exaggerate. It is also possible that the SE+ group had higher rates of bona ﬁde PTSD, depression, and post-concussive symptoms than the SE− group, therefore, leading to higher genuine reporting of emotional, cognitive, and somatic symptoms compared with the SE− group. Although the SE+ group had higher self-reported psychological distress and post-concussive symptoms, there were no group differences in self-reported alcohol use or sleep problems, indicating that there was no greater endorsement of problems across all self-report measures. Interestingly, the SE+ group had poorer attention and executive functioning perfor- mance even when accounting for PVT performance. More severe depression and PTSD symptoms have been associated with poorer performance on neuropsychological measures (Qureshi et al., 2011; Spencer et al., 2013). However, the groups did not differ with regard to rates of psychiatric diagnoses or injury severity variables, and scores on the BDI-II, PCL, and NSI were clinically elevated in both groups supporting the hypothesis that this ﬁnding could be due to symptom exaggeration rather than greater psychopathology. Alternatively, elevations on SVTs may reﬂect unconscious magniﬁcation of genuine symptoms or a co-occurrence of exter- nal incentives and somatoform symptoms rather than pure intentional exaggeration for secondary gain (Nelson et al., 2011). This idea is further supported by the rates of elevation on the MMPI-2-RF content scales related to cognitive and somatic complaints. Previous research has shown that symptoms of posttraumatic stress in OEF/OIF Veterans were associated with negative perceptions regarding the consequences of their TBI or non-TBI (i.e., orthopedic) injury, negative emotional re- sponses to their injury, and poorer understanding of their injury (the latter of which was exacerbated in those with a history of mTBI relative to those with non-TBI injuries; Bahraini et al., 2017). Thus, for OEF/OIF Veterans with self-reported history of mTBI, signiﬁcant PTSD symptoms may inﬂuence their perception of their TBI, therefore, increasing endorsement of cognitive and somatic symptoms. Although there were no group differences with regard to PVT performance in the present study (fur- ther supporting that PVT and SVT performance are distinct constructs and should be tested separately; Armistead-Jehle, 2010; Van Dyke et al., 2013), the poorer cognitive scores in the SE+ group compared with the SE− group could reﬂect a more subtle decline in cognitive performance, possibly as a result of somatization. Participants in the SE+ group may have ex- pected to do worse on cognitive testing, which can negatively affect cognitive outcomes in mTBI (Silver, 2015). Our ﬁndings are in contrast to Martin, Schroeder, Heinrichs, et al. (2015) who failed to ﬁnd a relationship between MMPI validity scales and objective neuropsychological performance after accounting for PVT. Martin, Schroeder, Heinrichs, et al. (2015) examined a civilian outpatient sample, whereas the present study was looking speciﬁcally at Veterans. Additionally, the present sample had a much higher rate of psychiatric comorbidity, particularly PTSD, than did the Martin, Schroeder, Heinrichs, et al. (2015) sam- ple. These differences are likely contributing to the disparate ﬁndings and highlight the importance of exploring this relationship across different samples. However, PTSD alone also does not seem to be solely driving the elevated scores on SVT indicators. Mason and colleagues (2013) reported MMPI-RF validity scale mean scores for Veterans diagnosed with PTSD, scores that are 1.0–1.5 SD lower than those reported in the present sample (Mason et al., 2013). Although frank neurological effects of mTBI are also unlikely to be notably contributing to the elevated rates of symptom reporting in this population, the chronic multisymp- tom and functional presentation in those seeking treatment in the chronic phase following mTBI is likely to manifest differently than PTSD alone (Hoge, Goldberg, & Castro, 2009; Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009). The higher SVT elevations re- ported in the present study appear to be capturing this comorbid and functional presentation. Interestingly, previous studies examining objective cognitive performance in association with performance validity tests have identiﬁed poorer memory scores in those who failed versus passed PVTs (Armistead-Jehle & Buican, 2012; Grills & Armistead-Jehle, 2016), whereas the present study revealed worse performance on tests of attention and executive functioning in those who failed vs. passed symptom validity tests. Finally, those with possible symptom exaggeration on the cognitive and somatic MMPI-2-RF validity scales appeared to be driving the majority of signiﬁcant ﬁndings between the SE+ and SE− groups, further supporting the use of these scales in this population. Although the present study has many strengths including the characterization of symptom reporting and associated factors in a consecutively referred, treatment-seeking group of OEF/OIF Veterans with self-reported history of mTBI, there are Downloaded from https://academic.oup.com/acn/article/34/3/366/5025416 by DeepDyve user on 18 July 2022 S.M. Jurick et al. / Archives of Clinical Neuropsychology 34 (2019); 366–380 377 several limitations which should be noted. First, the study is cross-sectional in nature and thus any inferences regarding the predictive utility of any measures are limited. Additionally, as with many studies of Veterans with history of mTBI, the infor- mation collected regarding injury history was self-reported because medical records documentation from the time of the injury was not available in most cases. Although we have noted the ﬁndings that did not survive Bonferroni-correction, the present study included a large number of analyses and thus may reﬂect an elevated Type I error rate. Although the neuro- psychological measures used in the present study are well validated and widely used, some subtests had lower psychometric strength that may have contributed some error into the results. Bodily injury data were not systematically available for this sample, though may contribute to validity performances and should be explored in future work. Although it is valuable to report on the presentation of “real world” samples of treatment-seeking Veterans, the relationship between service connection and SVT in this clinical sample is complicated and difﬁcult to fully deconstruct. Our reported service connection percentages represent only one snapshot in time; these ratings can and do change over time and over-reporting of symptoms may result in higher ratings. Future work should explore greater detail the relationship between SVT and service connection ratings, includ- ing relationship of SVT to change in service connection over time as well as to speciﬁc ratings for medical vs. mental health conditions. Additionally, the psychiatric diagnoses were acquired from medical records and not from standardized clinical in- terviews at the time of the assessment. Thus, future studies should attempt to replicate these ﬁndings using validated clinical interviews to diagnose psychiatric disorders within this population. Finally, the sample size of the present study was relatively small, and, therefore, may have been insufﬁciently powered to detect effects; future research would beneﬁt from expanding on the present study in large samples. Despite these limitations, the present study provides valuable information regarding OEF/OIF Veterans with self-reported history of mTBI that present for the treatment at the VA. The results demonstrate the importance of utilizing both SVTs and PVTs in the evaluation of Veterans with persistent post-concussive symptoms. When evaluating psychiatric self-report assess- ments in this population, our data suggest it is imperative to consider Veteran’s performance on the MMPI-2-RF validity scales (or other SVT) as results on these measures are associated with elevated self-report of depression, posttraumatic, and post-concussive symptoms. A large portion of the participants performed within the possible symptom exaggeration range on one or more MMPI-2-RF validity scales and over 80% were within the clinically signiﬁcant elevation range on the MMPI-2- RF cognitive and somatic content scales. These ﬁndings highlight the need to treat cognitive and somatic symptom complaints and/or target somatization in the context of evidence-based treatments for common co-occurring mental health conditions such as PTSD and depression. Future studies should evaluate the effectiveness of such treatments in addressing both self- reported cognitive and somatic symptom complaints as well as any objective cognitive difﬁculties that may be present. Conﬂict of interest None declared. Acknowledgements The authors have no conﬂicts of interest to report, and none have any ﬁnancial interest with the subject matter discussed in the manuscript. The views expressed herein are those of the authors and do not necessarily reﬂect the views or the ofﬁcial pol- icy of the Department of Veterans Affairs or U.S. Government. Authors were supported in part by Department of Defense award W81XWH-11-1-0641. Laura Crocker was supported by the VA Ofﬁce of Academic Afﬁliations Interprofessional Polytrauma and Traumatic Brain Injury Rehabilitation Fellowship. Supplementary Material Supplementary material is available at Archives of Clinical Neuropsychology online. References Anestis, J. C., Finn, J. A., Gottfried, E., Arbisi, P. A., & Joiner, T. E. (2015). Reading the road signs: The utility of the MMPI-2 Restructured Form Validity Scales in prediction of premature termination. Assessment, 22, 279–288. Arbisi, P. A., Polusny, M. A., Erbes, C. R., Thuras, P., & Reddy, M. K. (2011). 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Journal

Archives of Clinical Neuropsychology – Oxford University Press

Published: May 1, 2019

Keywords: mmpi; psychiatry; veterans; symptom magnification; traumatic brain injury, mild; weight measurement scales; self-report; post-traumatic stress disorder; emotions; personality; depressive disorders; post-concussion syndrome; cognitive ability; demography

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Schroeder, R. W.; Martin, P. K.; Odland, A. P.
Utility of the MMPI-2-RF (Restructured Form) validity scales in detecting malingering in a criminal forensic setting: A known-groups design

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Screening for postdeployment conditions: Development and cross-validation of an embedded validity scale in the neurobehavioral symptom inventory

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Validation of the MMPI-2 Response Bias Scale and Henry–Heilbronner Index in a US veteran population

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The Minnesota Multiphasic Personality Inventory-2-RF in Treatment-Seeking Veterans with History of Mild Traumatic Brain Injury

The Minnesota Multiphasic Personality Inventory-2-RF in Treatment-Seeking Veterans with History of Mild Traumatic Brain Injury

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The Minnesota Multiphasic Personality Inventory-2-RF in Treatment-Seeking Veterans with History of Mild Traumatic Brain Injury

The Minnesota Multiphasic Personality Inventory-2-RF in Treatment-Seeking Veterans with History of Mild Traumatic Brain Injury

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