James B. Hoelzle

Evaluation Context Impacts Neuropsychological Performance of OEF/OIF Veterans with Reported Combat-Related Concussion

Although soldiers of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) encounter combat-related concussion at an unprecedented rate, relatively few studies have examined how evaluation context, insufficient effort, and concussion history impact neuropsychological performances in the years following injury. The current study explores these issues in a sample of 119 U.S. veterans (OEF/OIF forensic concussion, n = 24; non-OEF/OIF forensic concussion, n = 20; OEF/OIF research concussion, n = 38; OEF/OIF research without concussion, n = 37). The OEF/OIF forensic concussion group exhibited significantly higher rates of insufficient effort relative to the OEF/OIF research concussion group, but a comparable rate of insufficient effort relative to the non-OEF/OIF forensic concussion group. After controlling for effort, the research concussion and the research non-concussion groups demonstrated comparable neuropsychological performance. Results highlight the importance of effort assessment among OEF/OIF and other veterans with concussion history, particularly in forensic contexts.

Updated meta-analysis of the MMPI-2 symptom validity scale (FBS): verified utility in forensic practice

Clinical research interest in the symptom reporting validity scale currently known as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Symptom Validity Scale (FBS) has continued to be strong, with multiple new publications annually in peer-reviewed journals that publish psychological and neuropsychological assessment research. Related to this growth in relevant literature, the present study was conducted to update the Nelson, Sweet, and Demakis (2006b) FBS meta-analysis. A total of 83 FBS studies (43 new studies) were identified, and 32 (38.5%) met inclusion criteria. Analyses were conducted on a pooled sample of 2218 over-reporting and 3123 comparison participants. Large omnibus effect sizes were observed for FBS, Obvious-Subtle (O-S), and the Dissimulation Scale-Revised (Dsr2) scales. Moderate effect sizes were observed for the following scales: Back Infrequency (Fb), Goughs F-K, Infrequency (F), Infrequency Psychopathology (Fp), and Dissimulation (Ds2). Moderator analyses illustrate that relative to the F-family scales, FBS exhibited larger effect sizes when (1) effort is known to be insufficient and (2) evaluation is conducted in the context of traumatic brain injury. Overall, current results summarize an extensive literature that continues to support use of FBS in forensic neuropsychology practice.

Neuropsychological outcomes of U.S. Veterans with report of remote blast-related concussion and current psychopathology

This study explored whether remote blast-related MTBI and/or current Axis I psychopathology contribute to neuropsychological outcomes among OEF/OIF veterans with varied combat histories. OEF/OIF veterans underwent structured interviews to evaluate history of blast-related MTBI and psychopathology and were assigned to MTBI (n = 18), Axis I (n = 24), Co-morbid MTBI/Axis I (n = 34), or post-deployment control (n = 28) groups. A main effect for Axis I diagnosis on overall neuropsychological performance was identified (F(3,100) = 4.81; p = .004), with large effect sizes noted for the Axis I only (d = .98) and Co-morbid MTBI/Axis I (d = .95) groups relative to the control group. The latter groups demonstrated primary limitations on measures of learning/memory and processing speed. The MTBI only group demonstrated performances that were not significantly different from the remaining three groups. These findings suggest that a remote history of blast-related MTBI does not contribute to objective cognitive impairment in the late stage of injury. Impairments, when present, are subtle and most likely attributable to PTSD and other psychological conditions. Implications for clinical neuropsychologists and future research are discussed. (JINS, 2012, 18, 1-11).

The Invariant Component Structure of the Personality Assessment Inventory (PAI) Full Scales

We investigated methodological and sample-based characteristics that might contribute to discrepancies in the structure of the 22-scale Personality Assessment Inventory (PAI; Morey, 1991, 2007). In Study 1, we used parallel analysis, Velicers minimum average partial procedure, and random variables to determine the appropriate number of principal components to retain in a clinical sample (N = 227). We retained 3 oblique dimensions that broadly emphasized (a) general distress, (b) elevated mood and dominance, and (c) substance abuse and psychopathy. In Study 2, we applied the same uniform criteria and procedures to 5 previously published samples and conducted orthogonal vector matrix comparisons to determine how congruent 3- and 4-dimensional structures were across samples. Results suggested the PAI has 3 dimensions that are highly congruent across samples. Using Moreys normative sample, we provide the formulas needed to compute T scores for each component so they can be used in clinical work with patients. We discuss clinical implications and directions for future PAI research.

Comparison of Wechsler Memory Scale–Fourth Edition (WMS–IV) and Third Edition (WMS–III) dimensional structures: Improved ability to evaluate auditory and visual constructs

Dimensional structures underlying the Wechsler Memory Scale–Fourth Edition (WMS–IV) and Wechsler Memory Scale–Third Edition (WMS–III) were compared to determine whether the revised measure has a more coherent and clinically relevant factor structure. Principal component analyses were conducted in normative samples reported in the respective technical manuals. Empirically supported procedures guided retention of dimensions. An invariant two-dimensional WMS–IV structure reflecting constructs of auditory learning/memory and visual attention/memory (C1 = .97; C2 = .96) is more theoretically coherent than the replicable, heterogeneous WMS–III dimension (C1 = .97). This research suggests that the WMS–IV may have greater utility in identifying lateralized memory dysfunction.

Repeatable Battery for the Assessment of Neuropsychological Status Effort Index Performance in a Medically Ill Geriatric Sample

Using a sample of 44 clinically referred, non-litigating, older adults, we evaluated the Repeatable Battery for the Assessment of Neuropsychological Status Effort Index [RBANS EI; Silverberg, N. D., Wertheimer, J. C., & Fichtenberg, N. L. (2007). An effort index for the Repeatable Battery for the Assessment of Neurospcyhological Status (RBANS). The Clinical Neuropsychologist, 21, 841-854]. With the current RBANS EI cut-score guidelines, 31% of our sample was classified as putting forth suspect effort. With this, cognitive ability was significantly correlated with suspect effort scores. Thus, it appears that the current guidelines may not be useful in a cognitively impaired medically ill geriatric sample. Hence, further research on RBANS EI validation is warranted.

Neuropsychological evaluation of blast-related concussion: Illustrating the challenges and complexities through OEF/OIF case studies

Background/objective: Soldiers of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) sustain blast-related mild traumatic brain injury (concussion) with alarming regularity. This study discusses factors in addition to concussion, such as co-morbid psychological difficulty (e.g. post-traumatic stress) and symptom validity concerns that may complicate neuropsychological evaluation in the late stage of concussive injury. Case report: The study presents the complexities that accompany neuropsychological evaluation of blast concussion through discussion of three case reports of OEF/OIF personnel. Discussion: The authors emphasize uniform assessment of blast concussion, the importance of determining concussion severity according to acute-injury characteristics and elaborate upon non-concussion-related factors that may impact course of cognitive limitation. The authors conclude with a discussion of the need for future research examining the impact of blast concussion (particularly recurrent concussion) and neuropsychological performance.

The Factor Structure of the MMPI-2 Restructured Clinical (RC) Scales

We investigated the MMPI–2 Restructured Clinical (RC) scales (Tellegen et al., 2003) to determine if they had a more differentiated factor structure than the MMPI–2 Clinical scales. When factored alone, the RC scales had a 5-dimensional structure; the Clinical scales had 3 dimensions. When factored in combination with the Content scales, both sets of scales produced 5 dimensions. However, the RC and Content factors generally provided more efficient and logical markers of psychopathology than the Clinical and Content factors. We discuss interpretive considerations.

Self-Report of Psychological Function Among OEF/OIF Personnel Who Also Report Combat-Related Concussion

MMPI-2 RF profiles of 128 U.S. soldiers and veterans with history of concussion were examined. Participants evaluated in forensic (n = 42) and clinical (n = 43) settings showed significantly higher validity and clinical elevations relative to a research group (n = 43). In the full sample, a multivariate GLM identified main effects for disability claim status and Axis I diagnosis across numerous MMPI-2 RF scales. Participants with co-morbid PTSD and concussion showed significant Restructured Clinical and Specific Problem scale elevations relative to those without Axis I diagnosis. Participants with PTSD and active disability claims were especially prone to elevate on FBS/FBS-r and RBS. Implications for neuropsychologists who routinely administer the MMPI-2/RF in the context of combat-related concussion are discussed.

Day of Injury Cognitive Performance on the Military Acute Concussion Evaluation (MACE) by U.S. Military Service Members in OEF/OIF

OBJECTIVES The study investigated the clinical validity of the cognitive screening component of the Military Acute Concussion Evaluation (MACE) for the evaluation of acute mild traumatic brain injury (mTBI) in a military operational setting. METHODS This was a retrospective data study involving analysis of MACE data on Operation Enduring Freedom/Operation Iraqi Freedom deployed service members with mTBI. In total, 179 cases were included in analyses based on ICD-9 diagnostic codes and characteristics of mTBI, and availability of MACE data on day of injury. MACE data from the mTBI group was compared to a military sample without mTBI administered the MACE as part of a normative data project. RESULTS On day of injury, the mTBI group performed worse than controls on the MACE cognitive test (d = 0.90), with significant impairments in all cognitive domains assessed. MACE cognitive score was strongly associated with established indicators of acute injury severity. Lower MACE cognitive performance on day of injury was predictive of lengthier postinjury recovery time and time until return to duty after mTBI. CONCLUSIONS Findings from the current study support the use of the MACE as a valid screening tool to assess for cognitive dysfunction in military service members during the acute phase after mTBI.