ORIGINAL ARTICLE

Psychotic-like Experiences, Symptom Expression, and Cognitive Performance in Combat Veterans With Posttraumatic Stress Disorder Steven E. Lindley, MD, PhD,*Þ Eve B. Carlson, PhD,*þ and Kimberly R. Hill, PhDÞ Abstract: Apparent psychotic symptoms are often associated with posttraumatic stress disorder (PTSD), but these symptoms are poorly understood. In a sample of 30 male Vietnam combat veterans with severe and chronic PTSD, we conducted detailed assessments of psychotic symptom endorsement, insight, symptom severity, neurocognitive function, and feigning. Two thirds of the subjects endorsed a psychotic item but did not believe that the experiences were real. Those endorsing psychotic items were higher in PTSD severity, general psychopathology, and dissociation but not depression, functional health, cognitive function, or feigned effort. Severity of psychotic symptoms correlated with dissociation, combat exposure, and attention but not PTSD, depression, or functional health. Those endorsing psychotic items scored higher on a screen but not on a detailed structured interview for malingering. Endorsement of psychotic experiences by combat veterans with PTSD do not seem to reflect psychotic symptoms or outright malingering. Key Words: Psychotic symptoms, hallucinations, posttraumatic stress disorder, veterans, malingering, dissociation (J Nerv Ment Dis 2014;202: 91Y96)

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sychotic-like symptoms have been reported to occur with high frequency in patients with severe and chronic posttraumatic stress disorder (PTSD; Braakman et al., 2009; Lindley et al., 2000). Specifically, studies of combat veterans with PTSD who had been screened for other primary psychotic conditions have found 30% to 40% reporting auditory hallucinations, visual hallucinations, or delusions (David et al., 1999; Hamner, 1997). This is more than double the highest rates reported for psychotic symptoms in patients with depression (Schatzberg et al., 2000). The presence of hallucinations in PTSD has been observed for years (Faustman and White, 1989; Mueser et al., 1990; Van Putten and Emory, 1973), and these are often the focus of pharmacological treatment (Ahearn et al., 2003; Donnelly, 2003; Hamner et al., 2003), but few studies have investigated the phenomenology of these experiences. The recent finding of a lack of efficacy but increased adverse effects of the atypical antipsychotic risperidone in military combat veterans with PTSD who are resistant to antidepressant treatment (Krystal et al., 2011) raises the importance of understanding psychoticlike symptoms in PTSD. Most research on psychotic symptoms in patients with PTSD has focused on differentiating the symptoms from re-experiencing symptoms such as intrusive images of a traumatic event (Ivezic et al., 2000). Experiences of acting or feeling as if the traumatic event is recurring are one of the possible diagnostic criteria for re-experiencing symptoms, one of three clusters of symptom criteria that are for PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth

*VA Palo Alto Health Care System, Palo Alto, CA; †Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA; and ‡VA National Center for Posttraumatic Stress Disorder, Menlo Park, CA. Send reprint requests to Steven E. Lindley, MD, PhD, MC 116A/MHC/MPD, VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA 94025. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0091 DOI: 10.1097/NMD.0000000000000077

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Edition (American Psychiatric Association, 1994). The phenomenology of flashbacks is the subject of controversy (Frankel, 1994; Jones et al., 2003) and generally not well described. In addition, the distinction between re-experiencing and hallucinations is often not clear. Many of the reports of psychotic symptoms in PTSD have included nonYtraumaspecific material that seems distinct from re-experiencing symptoms (Butler et al., 1996; David et al., 1999; Hamner, 1997). The presence of psychotic symptoms in PTSD has been associated with significant differences in other symptoms including higher levels of general psychopathology, paranoia, violent thoughts, feelings, and behaviors as well as greater degrees of depression, anxiety, and anhedonia (Butler et al., 1996; David et al., 1999; Sautter et al., 1999). In addition, PTSD with psychotic symptoms has been linked to biochemical differences in catecholamine metabolites (Hamner and Gold, 1998), corticotropin-releasing factor (Sautter et al., 2003), and abnormalities in smooth-eye pursuit (Cerbone et al., 2003). These findings suggest that psychotic symptoms may be associated with important psychopathological and/or physiological phenomena in patients with PTSD. This would be consistent with the findings of such associations in patients with other disorders. In patients with major depression, psychotic symptoms are associated with greater morbidity and residual impairment (Schatzberg and Rothschild, 1992), neurocognitive deficits (Schatzberg et al., 2000), and greater hypercortisolemia (Nelson and Davis, 1997). Another possible explanation for reports of apparent psychotic symptoms in veterans is exaggeration or feigning (Freeman et al., 2008; Frueh et al., 2000). Although some veterans feign symptoms for financial gain, the prevalence of this behavior is quite controversial, with some concluding that complete fabrication of disorder is uncommon (Institute of Medicine, 2007; Jackson et al., 2011) and others concluding that there is reason to be concerned about malingering in veterans who apply for disability because of PTSD (McNally and Freuh, 2011). In the current study, we investigated possible explanations for reports of psychotic symptoms in a sample of combat veterans with severe and chronic PTSD. We assessed psychotic symptoms, insight into those symptoms, symptoms of PTSD, dissociation, depression, physical health, mental health, malingering, overreporting of symptoms, feigning of effort on cognitive tasks, and neurocognitive function. We compared patients who reported psychotic symptoms and those who did not on these variables and examined the relationships in the entire sample between psychotic symptoms and the variables studied. We also examined relationships between positive and negative symptoms and cognitive function in the whole sample because other researchers have reported associations of positive and negative symptoms with neurocognitive deficits in studies of patients with psychotic depression or schizophrenia (Addington et al., 1991; Che et al., 2012; O’Leary et al., 2000).

METHODS Subjects and Procedures This research was reviewed and approved by a human subjects protection panel. The participants were Vietnam veterans who were

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patients in a 60-day residential milieu treatment program for veterans with severe and chronic combat-related PTSD. Exclusion criteria, as determined by a complete history and physical examination with standard laboratory evaluations, included a primary diagnosis involving psychosis (e.g., schizophrenia, schizoaffective, bipolar disorder), any alcohol or other substance abuse in the past month, or a physical disorder that significantly contributed to cognitive dysfunction (e.g., traumatic brain injury; Parkinson’s disease; severe alcohol or substance abuse; or a cardiovascular, hepatic, endocrine, or other systemic disease affecting brain function). Thirty-six patients were approached and invited to participate in a study of the relationship between symptoms of PTSD and cognitive function that would examine the relationship among traumatic experiences, patients’ beliefs and cognitive functions, and abilities such as problem solving and memory. Written informed consent was obtained from all participants. All patients were male veterans of the Vietnam War, 67% were receiving some level of disability compensation for PTSD, and the mean age was 53 years. Self-reported race/ethnicity was 60% white, 27% African-American, and 13% Hispanic.

Measures Psychotic symptom intensity was measured with the Positive and Negative Symptoms Scale for Schizophrenia (PANSS; including the positive, negative, and general psychopathology scale; Kay et al., 1987). Insight about delusions and hallucinations was assessed with the Brown Assessment of Beliefs Scale, a measure designed to assess delusions across a wide range of psychiatric disorders (Eisen et al., 1998). PTSD symptom severity was measured with the PTSD Symptom ChecklistYCivilian (PCL-C; Weathers et al., 1993); and depressive symptoms, with the Beck Depression Inventory (BDI; Beck and Steer, 1987). The Dissociative Symptoms Scale (DSS) was used to assess disruptive dissociative symptoms including derealization, depersonalization, gaps in awareness and memory, and dissociative re-experiencing. The DSS has shown very strong internal validity and correlations with other measures of dissociation and PTSD in clinical and community samples (manuscript in review). As an indicator of overall distress, self-reported mental and physical health symptoms were assessed with the 12-item Short-Form Health SurveyYversion 2 (SF-12; Ware et al., 1996). The Combat Exposure Scale (Keane et al., 1989) was used to assess combat exposure. Cognitive function was assessed with specialized measures for overall IQ, attention, working memory, executive function, and auditory memory. Full-scale IQ was assessed with the Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler, 2002). Attention was assessed with part A of the Trail-Making subtest of the Halstead-Reitan Neuropsychological Test Battery (Reitan, 2004) and the Conner’s Continuous Performance Task (CPT; Connors, 1995). Working memory was assessed with the Working Memory Index of the Wechsler Memory ScaleYIII (WMS-III; Wechsler, 1997) and the digit span. Executive function was assessed with the Stroop color-word test (Golden, 1994), part B of the Trail-Making subtest of the Halstead-Reitan Neuropsychological Test Battery (Reitan, 2004), and the perseveration task from the computerized version of the Wisconsin Card Sorting Test (WCST; Loong, 1989). Auditory memory was assessed with the immediate recall, delayed recall, and recognition indices of the WMS-III (Wechsler, 1997). Symptom exaggeration was assessed with the Miller Forensic Assessment of Symptoms Test (MFAST; Miller, 2005) and the Structured Interview of Reported Symptoms (SIRS; Rogers et al., 1992), which have both been used to study patients with PTSD (Freeman et al., 2008; Rogers et al., 2009). The MFAST is a 25-item screening tool for symptom exaggeration. The SIRS is a 172-item structured interview measure with eight primary symptom scales, which has been used in a wide variety of clinical populations. Feigning of impaired cognitive performance was assessed by the Rey’s Dot 92

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Counting Test and the Rey’s 15-item Memory Test (Boone et al., 2002). These measures are particularly sensitive to feigning because respondents typically have no way to know what type of performance is typical for someone with cognitive impairments. Although one would guess that someone with mild or moderate cognitive impairments would make errors, in fact, only those with gross cognitive impairments make errors.

RESULTS Symptom Frequencies and Characteristics Of the 30 subjects assessed, 67% (20/30) responded positively during the PANSS structured interview when asked whether they had ever heard voices or had false beliefs that were not associated with acute alcohol or other substance abuse. All 20 subjects with reports of hearing voices or having false beliefs stated that the experiences developed after they had PTSD. The PANSS auditory hallucinations item was endorsed in 100%; the visual hallucination item, in 65%; the olfactory hallucination item, in 25%; and the delusion items, in 30% of the 20 subjects. Of those endorsing the hallucination item, 60% had these experiences at least a few times per week, and 55% described experiences that contained combat-related material (e.g., ‘‘I see and smell dead bodies’’ and ‘‘I hear screaming in Vietnamese’’). Most of those experiences (55%) were re-experiencing of traumatic events (i.e., part of specific episodes of acting or feeling as if the traumatic events were reoccurring). The remaining 45% of the subjects described noncombat experiences (e.g., ‘‘I clearly see a person sitting in front of me’’ and ‘‘a group of voices comment on my actions’’). Responses of all 20 subjects in the group reporting psychotic-like experiences on the Brown Assessment of Beliefs Scale indicated complete certainty that the experiences or beliefs were unrealistic or absurd. None of the subjects demonstrated evidence of a formal thought disorder or bizarre behavior. Of the subjects endorsing voices or delusions, 25% were taking an antipsychotic, but 40% of the subjects without such a history were also on an antipsychotic (for treatment-refractory insomnia, reexperiencing symptoms other than hallucinations/delusions, etc.). There was no significant difference in those receiving disability compensation between the two groups (W2 = 0.78, not significant). Hallucinations and/or delusions were reported in 67% (12/18) of the whites, 63% (5/8) of the African-Americans, and 75% (3/4) of the Hispanics. Twenty-nine of 30 patients had some history of alcohol (77%), stimulant (53%), opiate (33%), or marijuana (40%) abuse or dependence. There was no significant relationship between histories of any type of abuse or dependence and endorsement of hallucinations or delusions (data not shown).

Symptom Severity We compared symptom levels in the group reporting past psychotic-like experiences with those in the group reporting none. Positive psychotic symptom scores on the PANSS were significantly higher in the group with psychotic symptoms (M = 14.1, SD = 3.7) than in the group without (M = 9.9, SD = 2.6) t[28] = 3.2, p G 0.005). General psychopathology scores were also significantly higher in the group with psychotic symptoms (M = 33.9, SD = 9.4) vs. (M = 26.6, SD = 7.6); t[28] = 2.1, p G 0.05) along with PTSD symptoms on the PCL-C (M = 67.7, SD = 8.8) vs. (M = 59.5, SD = 12.8); t [28] = 2.1, p G 0.05). Dissociation scores were also significantly higher in the psychotic symptoms group (M = 31.9, SD = 4.9) vs. M = 9.9, SD = 3.5); t [26] = 2.9, p G 0.01; data missing for one subject in each group). There were no significant group differences for depression, physical or mental health symptoms, or negative psychotic symptom scores. Table 1 shows correlations between measures of symptoms and combat exposure and scores for positive and negative psychotic symptoms on the PANSS for all 30 subjects. In addition, PTSD * 2014 Lippincott Williams & Wilkins

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TABLE 1. Correlation Between PANSS Scores and Other Rating Scales PCL BDI DSS CES SF-12 physical health SF-12 mental health

PANSS-P

PANSS-N

PANSS-G

0.23 0.03 0.58* 0.39* 0.15 j0.23

0.26 0.18 0.43* 0.08 j0.09 j0.39*

0.41* 0.39* 0.60* 0.17 j0.27 j0.33

Higher scores indicate higher symptom level on all assessments. *p G 0.05. CES indicates Combat Exposure Scale; PANSS-G, general psychopathology scale of the PANSS; PANSS-N, negative symptom scale of the PANSS; PANSS-P, positive symptom scale of the PANSS.

symptom severity was positively correlated with general psychopathology (r = 0.44, p G 0.05), dissociation (r = 0.55, p G 0.005), and depression (r = 0.69, p G 0.001) and negatively correlated with SF-12 physical health scores (r = j0.48, p G 0.01).

Cognitive Performance Data were examined for outliers and Trails A, Trails B, and WCST perseveration; each had one outlier of more than 3 SDs higher than the mean. To avoid undue influence of outliers on correlations, these values were transformed by the Winsorization method, in which the data point is replaced by the value for the 95th percentile for that variable. There were no significant between-group differences in cognitive assessment scores. Table 2 shows relationships between positive, negative, and general psychotic symptoms severity and a range of cognitive variables. Positive psychotic symptoms severity was positively correlated TABLE 2. Correlation Between PANSS Scores and Cognitive Performance Full-scale IQa WASI Attentionb Trails A CPT commission CPT omission Working memorya WMS-III Working Memory Index Digit span Executive function Stroop (color-word)a Trails Bb WCST perseverationb Auditory memorya Immediate recall Delayed recall Recognition

PANSS-P

PANSS-N

PANSS-G

j0.49*

j0.43*

j0.27

0.42** 0.43* 0.43* j0.26

0.29 0.26 0.48** j0.31

0.26 0.22 0.29 j0.29

j0.34

j0.60**

j0.41*

0.03 0.21 j0.13

j0.15 0.48** j0.15

0.09 0.24 j0.38

j0.17 j0.20 j0.13

j0.26 j0.17 j0.06

j0.07 j0.02 0.07

n = 28. a Higher scores indicate better cognitive performance. b Higher scores indicate worse cognitive performance. *p G 0.05. **p G 0.01. PANSS-G indicates general psychopathology scale of the PANSS; PANSS-N, negative symptom scale of the PANSS; PANSS-P, positive symptom scale of the PANSS;

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Psychotic-like Experiences in PTSD

with poor performance on tests of attention (Trails A, CPT-commission, and CPT-omission) and negatively correlated with full-scale IQ but not significantly correlated with episodic (WMS-R) or working memory or executive function (Stroop and WCST). The general psychopathology scale was negatively correlated with digit span, whereas the negative symptom scale of the PANSS was positively correlated with poor performance on tests of attention (CPT-omission) and executive function (Trails B), working memory (digit span), and fullscale IQ but not other measures of executive function (Stroop and WCST perseveration).

Dissimulation and Effort Table 3 shows comparisons between the two groups in feigning of symptoms and cognitive deficits. Forty-six percent of all subjects had a score in the feigning range (96) on the MFAST. Of the subscales on the MFAST (reported versus observed symptoms, extreme symptoms, rare combination of symptoms, unusual hallucinations, unusual symptom course, negative image, and suggestibility), those in the psychotic-like symptoms group more frequently endorsed the presence of rare combinations of symptoms (17/20 vs. 1/10; W2 = 12.1, p G 0.001) and unusual hallucinations (16/20 vs. 1/10; W2 = 9.6, p G 0.005). Examples of commonly endorsed items in the category of rare combination of symptoms include ‘‘The times you when you can’t go to sleep, do you often smell strange odors that are not really there?’’ ‘‘Sometimes I am convinced I have more than one personality. At those times, I feel dizzy or lightheaded’’ and ‘‘On many days I feel so bad that I can’t even remember my full name.’’ Examples of unusual hallucination items endorsed include ‘‘I experience hallucinations that continuously last for days’’; ‘‘whenever I see people who are not there, they are always in black and white’’; and ‘‘Sometimes I feel things crawling on me that are not there.’’ On the SIRS, one subject had primary scales in the ‘‘definite malingering’’ range and two had three or more scales in the ‘‘probable malingering’’ range (both in the psychotic-like symptoms group). Of the eight primary symptom scales (rare, combined, improbable, extreme, blatant, subtle, selective, and reported versus observed), there were no significant differences between the groups in the number of subjects with scores within the probable feigning range. There were no differences between the groups in the number of subjects in high ranges on the supplementary scales (direct appraisal of honesty, defensive symptoms, symptom onset, or overly specified symptoms). On the measures of cognitive deficit feigning (shown in Table 3), there was no significant difference between the groups in the number of subjects classified as feigning effort by either test. Scores in the feigning range were observed in 33% on one test and 6% on both tests.

DISCUSSION Although many previous reports have emphasized similarities between the psychotic-like symptoms reported in some patients with PTSD and psychotic symptoms in schizophrenia, affective psychoses, or other psychotic disorders (Braakman et al., 2009; Jones et al., TABLE 3. Comparison of Rates of Symptom and Performance Dissimulation in PTSD Patients Without (PTSD) and With (PTSD + PL) Psychotic-like Symptoms

MFAST malingering SIRS probable malingering SIRS rare symptoms Rey’s 15-item malingering Rey’s Dot Counting malingering

PTSD (n = 10)

PTSD + PL (n = 20)

W2

p

10% 0% 0% 20% 20%

65% 10% 35% 20% 15%

8.10 1.07 4.57 0.09 0.12

0.004 0.301 0.033 0.760 0.729

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2003), in the sample we studied, the reported symptoms differed in a number of important ways from those in psychotic illnesses. For example, the complete insight of the unrealistic nature of the hallucinations and delusions we found is different from that generally seen in psychotic disorders (Drake, 2008). We found that the severity of these symptoms, as measured by the PANSS, was less intense than reported in schizophrenia (Kay et al., 1987). The symptoms in these patients were chronic; brief; intermittent (majority occurring a few times a week); and, unlike those in schizophrenia, bipolar disorder, or psychotic depression (Mueser et al., 1990; Ohayon and Schatzberg, 2002), included a high frequency of visual hallucinations (65%). Interestingly, the rates of clinical antipsychotic use were actually lower in the patients reporting psychotic-like symptoms than in the other patients with PTSD (25% vs. 40%). We also found that significantly more of those with psychoticlike symptoms scored within the malingering range on a screening test of symptom dissimulation of serious mental illness (Miller, 2005). The group reporting psychotic-like symptoms also exhibited a higher rate of rare combinations of symptoms and unusual hallucinations. Because the MFAST is designed to identify symptoms not normally observed in patients with psychotic illnesses, this high positive screening rate on the MFAST further illustrates differences with those with psychotic disorders. However, only two of the subjects with psychoticlike symptoms endorsed items within the malingering range on the more stringent structured interview for malingering, indicating that most of the subjects were not deliberately feigning symptoms. Similarly, the group reporting psychotic-like symptoms did not score higher on two tests of feigned cognitive effort. Symptom dissimulation has been described as occurring on a spectrum from unconscious ‘‘biased self-perceptions’’ to ‘‘deliberate lying’’ (Ekman and O’Sullivan, 2006). Overall, some subjects in our sample with psychotic-like symptoms could be on the unconscious biased self-perception end of the spectrum rather than the deliberately lying end. In regard to the question of whether cognitive impairments exist in PTSD patients with psychotic-like symptoms that are similar to those observed in psychotic depression or schizophrenia, we failed to find any group differences in cognitive performance associated with the presence of psychotic symptoms. The results of correlations between positive and negative symptoms and indices of cognitive function for the entire sample showed that positive symptoms were negatively associated with overall IQ and attention but not with the other domains examined. PTSD severity may be mediating the association between positive symptoms and IQ (Vasterling et al., 2002), but this sample is not suitable for examining such a question because of its homogeneity and high PTSD severity. In addition, given that the presence of psychotic-like symptoms was also associated with symptom dissimulation, it is unclear how much the cognitive deficits observed may be related to effort. In regard to negative symptoms, we found associations with IQ and aspects of attention, executive function, and working memory in the overall sample. Similar associations with negative symptoms have been observed (Addington et al., 1991; Basso et al., 1998; O’Leary et al., 2000). This is consistent with the premise that negative symptoms are a variation on normal mental processes that are dimensional and occur in a variety of psychiatric disorders (Kaiser et al., 2011). Interestingly, we did not observe an association of psychoticlike symptoms with severity of PTSD or depression or patient’s self-assessment of impaired general physical or mental health, indicating neither an increase in global severity of distress nor a global overreporting of symptoms. We did find a significant association with dissociation, consistent with recent findings by others, who also found an association between hearing voices and dissociative experiences in samples of combat veterans and survivors of civilian trauma (Anketell et al., 2010; Brewin & Patel, 2010). The experiences were described in a manner consistent with ‘‘flashback episodes’’ 94

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in 55% of the subjects (i.e., occurring as part of specific episodes in which the subjects were acting or feeling as if the traumatic events were reoccurring). As noted, the distinction between vivid flashbacks and other hallucinations is often not clear, and the phenomenology of flashbacks is generally not well described and the subject of some controversy (Frankel, 1994; Jones et al., 2003). In factor analyses of data on dissociative experiences from a variety of trauma-exposed and community samples, Carlson et al. (2013) found that items describing sensory misperceptions formed a coherent, distinct factor. In the current study, 45% of the subjects with psychotic-like symptoms described experiences that did not contain any obvious combat material. Possibly, some psychotic-like experiences were not directly related to trauma in content or were related to noncombat traumas that were not assessed. Anketell et al. (2010) have suggested that dissociation may be a mediating mechanism for hearing voices in those with PTSD. Reports of hallucinations and delusions are found quite frequently in the general, nonpsychiatric population (Pierre, 2010). The frequency varies depending on a variety of factors, including how questions are phrased and what population is surveyed. In the National Survey of Mental Health and Wellbeing of 10,641 Australians, 12% endorsed having psychotic experiences (Scott et al., 2006). The highest rates of psychotic-like experience were in subgroups that were younger, unemployed, of lower socioeconomic status, single or divorced, and nonYEnglish-speaking immigrants, and reports of exposure to a traumatic event were associated with a 2.68 relative risk for also endorsing delusional experiences. The greater number of traumatic events increased the rate of delusional experiences, as did a diagnosis of PTSD (Scott et al., 2007). Associations between trauma exposure and psychotic-like experiences have been seen in a number of other community surveys (Sareen et al., 2005; Shevlin et al., 2007). Possibly, the reasons for such experiences in combat veterans with PTSD are the same as for the general population. Some investigations into psychotic symptoms associated with PTSD have reported ethnic differences in the prevalence of reporting, with the highest response rates among African-American and Hispanic populations (David et al., 1999; Frueh et al., 2002; Hamner et al., 1999; Mueser and Butler, 1987). It is not known what factors may account for these ethnic differences, but ethnic and cultural influences are also noted in developing countries where a disproportionately high rate of acute and brief reactive psychosis is observed (Mezzich et al., 1999). As mentioned, reports of psychotic symptoms have also been associated with nonYnative-speaking populations in Australia (Scott et al., 2007). This may reflect the influence of cultural and sociological factors or biological differences or possibly the influence of both. There are a number of limitations to our study, including the relatively small sample size investigated and the moderately large number of statistical comparisons made. It is also uncertain how generalizable the findings are to other populations of patients with PTSD. Despite these limitations, we did observe a consistent pattern of responses in this population that, together, increases the understanding of the nature of the psychotic-like symptoms in PTSD.

CONCLUSIONS The psychotic-like symptoms reported by Vietnam combat veterans with PTSD exhibit numerous differences compared with those of patients with psychotic disorders. They may be best understood as related to dissociative experiences, an overexpression of symptoms, or a combination of both. They may be on the continuum with psychotic-like experiences seen in the general population. It is unclear how patients who report these symptoms may respond differently than those who do not to treatment interventions, including antipsychotics. Given the potentially serious long-term adverse effects of antipsychotics, our findings suggest that great care should be taken in assessing the nature of psychotic-like symptoms in PTSD before * 2014 Lippincott Williams & Wilkins

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Psychotic-like Experiences in PTSD

using antipsychotics to treat them. The high prevalence of these symptoms and their potential impact on treatment response warrant their further investigation.

Faustman WO, White PA (1989) Diagnostic and psychopharmacological treatment characteristics of 536 inpatients with posttraumatic stress disorder. J Nerv Ment Dis. 177:154Y159.

ACKNOWLEDGMENTS The authors thank Gilbert Villela, MD, for his assistance with the selection of the symptom dissimulation and effort measures for this research.

Freeman T, Powell M, Kimbrell T (2008) Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder. J Pers Soc Psychol. 158: 374Y380.

DISCLOSURES The authors declare no conflict of interest.

Frankel FH (1994) The concept of flashbacks in historical perspective. Int J Clin Exp Hypn. 42:321Y336.

Frueh BC, Gold PB, Dammeyer M, Pellegrin KL, Hamner MB, Johnson MR, Cahill SP, Arana GW (2000) Differentiation of depression and PTSD symptoms in combat veterans. Depress Anxiety. 11:175Y179. Frueh BC, Hamner MB, Bernat JA, Turner SM, Keane TM, Arana GW (2002) Racial differences in psychotic symptoms among combat veterans with PTSD. Depress Anxiety. 16:157Y161. Golden CJ (1994) The Stroop color and world test: A manual for clinical and experimental uses. Chicago: Stoelting Co.

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Psychotic-like experiences, symptom expression, and cognitive performance in combat veterans with posttraumatic stress disorder.

Apparent psychotic symptoms are often associated with posttraumatic stress disorder (PTSD), but these symptoms are poorly understood. In a sample of 3...
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