Does Validity Measure Response Affect CPT Group Outcomes in Veterans with PTSD?
Authors: Williams M Wright , Graham David , Sciarrino Nicole A , Estey Matt , McCurry Katherine L , Chiu Pearl , King-Casas Brooks 
Published: November 2019

Abstract

Introduction
There is a dearth of research on the impact of pre-treatment assessment effort and symptom exaggeration on the treatment outcomes of Veterans engaging in trauma-focused therapy, handicapping therapists providing these treatments. Research suggests a multi-method approach for assessing symptom exaggeration in Veterans with posttraumatic stress disorder (PTSD), which includes effort and symptom validity tests, is preferable. Symptom exaggeration has also been considered a “cry for help,” associated with increased PTSD and depressive symptoms. Recently, research has identified resilience as a moderator of PTSD and depressive symptom severity and an important predictor of treatment response among individuals with PTSD. Thus, it is important to examine the intersection of symptom exaggeration, resilience, and treatment outcome to determine whether assessment effort and symptom exaggeration compromise treatment response.

Materials and Methods
We recruited Veterans, aged 18–50 who served during the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) era, from mental health clinics and fliers posted in a large Veterans Affairs Medical Center. Veterans met inclusion criteria if they were diagnosed with PTSD via a clinician-administered assessment. Sixty-one Veterans consented to participate and self-selected into a cognitive processing therapy (CPT) group or treatment-as-usual. We offered self-selection because low recruitment rates delayed treatment start dates and were consistent with a Veteran-centered care philosophy. Veterans were assessed before and after treatment to determine the impact of assessment effort and symptom exaggeration scores on measures of PTSD and depressive symptoms and resilience. This study examined whether assessment effort failure and symptom exaggeration were associated with compromised psychotherapy outcomes in Veterans with PTSD undergoing CPT group. We hypothesized that a pattern of responding consistent with both effort and symptom exaggeration would result in higher (ie, more severe) pre- and post-treatment scores on PTSD and depressive symptom outcome measures and lower resiliency when compared to Veterans providing good effort and genuine responding. Hypotheses were evaluated using bivariate correlation analyses, analysis of variance, and chi-square analyses.

Results
Pre-treatment scores on measures of PTSD and depressive symptoms were higher among Veterans whose pattern of responding was consistent with poor assessment effort and symptom exaggeration; these Veterans also scored lower on a measure of resiliency. At post-treatment, there were no differences between Veterans displaying good and failed effort testing on measures of PTSD and depressive symptoms or in whether they completed treatment. Post-treatment resiliency scores remained significantly lower in those with failed effort testing.

Conclusion
These results suggest that Veterans with PTSD whose validity testing scores are indicative of poor effort and symptom exaggeration may be less resilient but may still complete a CPT group treatment and benefit from treatment at a rate comparable to Veterans who evidence good assessment effort and genuine symptom reporting pre-treatment. These findings also challenge the assumption that pre-treatment assessment effort failure and symptom exaggeration accurately predict poor effort in trauma-focused psychotherapy.