An International Perspective on Feigned Mental Disabilities: Conceptual Issues and Continuing Controversies.

In forensic contexts, an increased prevalence of feigned symptom presentations should be expected, although it will probably vary by the context and specific forensic issue. Forensic experts should examine this possibility proactively while maintaining a balanced perspective that actively considers clinical data for both feigning and genuine responding. Psychological measures and standardized methods developed for feigning and other response styles can facilitate these often complex determinations. The current article provides an international perspective on the issue of feigned mental disabilities. In particular, important conceptual issues are discussed, such as the categorical versus dimensional approaches to feigning, and the advisability of well-defined rather than single-point cut scores for accuracy in clinical decision-making. Salient problems of differential diagnosis include a spectrum from malingering and factitious disorders to somatoform and conversion disorders. In rendering these important diagnostic distinctions, the questions of motivations and intentions remain key. However, the establishment of motivation cannot be facilely assumed from the context. Instead, forensic psychologists and psychiatrists bear the professional burden of carefully evaluating motivation and recognizing the clinical reality that sometimes the motivation in especially challenging cases may not be fully determined. Copyright © 2017 John Wiley & Sons, Ltd.

[The picture of malingered symptom presentation in public opinion]. / Das Bild vorgetäuschter Gesundheitsstörungen in der öffentlichen Meinung.

The views held by health experts on certain topics may differ drastically from what appears to be obvious from observations in daily living or public opinion. This is true for a number of myths which continue to haunt the literature with respect to feigned health problems. Such myths tend to ignore or to distort the results of modern research. We performed two pilot studies: first a content analysis of 67 German- and English-language articles from newspapers, magazines or internet journals, and second, a survey on the experience of, and beliefs related to, exaggeration and symptom invention in health care and forensic assessment. A non-representative sample of 15 adults from the general population was interviewed. Most of them reported their own experiences or incidents in their social networks involving feigned health problems. Base rate estimates of malingering in five prototypical contexts ranged between 46 and 67 percent of cases. While the participants showed a preference for an adaptational explanatory model of malingering (selected for about 53% of cases of malingering), journalistic sources often employed pejorative language and combat rhetoric, aiming to arouse indignation or outrage in the readership. The majority of articles were classified to adhere to a criminological explanatory model. While the pilot character of the studies limits their generalisability, the results may be suited to question the validity of some long-held expert beliefs.

Psychometric validation of the Italian Self-Report Symptoms inventory (SRSI): Factor structure, construct validity, and diagnostic accuracy.

The Self-Report Symptom Inventory (SRSI) is a novel tool designed to detect symptom overreporting and other forms of noncredible responding. Unlike existing scales, the SRSI includes genuine and pseudosymptoms scales covering cognitive, affective, motor, pain, and post-traumatic stress disorder domains. The present study aims to investigate the psychometric properties of the Italian Version of the SRSI (SRSI-It), in particular, its factor structure, reliability, convergent and discriminant validity, and diagnostic accuracy. Data from 1180 healthy participants showed a hierarchical structure with higher-order constructs for genuine symptoms and pseudosymptoms, each comprising five subscales. The SRSI-It showed a strong convergent validity with the Structured Inventory of Malingered Symptomatology and discriminant validity through low correlations with the Psychopathic Personality Inventory-Revised. Receiver operating characteristic analysis determined cut scores of 6 (95% specificity) and 9 (98% specificity) for pseudosymptoms, with a Ratio Index score of 0.289 (82% specificity). In summary, the SRSI-It appears to be a promising tool for identifying symptom exaggeration in clinical and forensic contexts, ultimately enhancing the quality and reliability of evaluations in these contexts.

Prevalence Estimates of Symptom Feigning and Malingering in Spain.

Symptom feigning and malingering should be evaluated in forensic contexts due to their important socio-economic consequences. Despite this, to date, there is little research in Spain that evaluates its prevalence. The aim of this study was to investigate this issue using the perception of the general population, students, and professionals of medicine and forensic psychology. Three adapted questionnaires were applied to a total of 1003 participants (61.5% women) from 5 different groups. Approximately two-thirds of participants reported knowing someone who feigned symptoms, and one-third disclosed feigning symptoms themselves in the past. Headache/migraine, neck pain, and anxious-depressive symptoms were the most commonly chosen. Experts in psychology and forensic medicine estimated a prevalence of 20 to 40% of non-credible symptom presentations in their work settings and reported not having sufficient means to assess the distorted presentation of symptoms with certainty. Professionals and laypersons alike acknowledge that non-credible symptom presentations (like feigning or malingering) are relevant in Spain and occur at a non-trivial rate, which compares with estimates in other parts of the world.

The English-language version of the Self-Report Symptom Inventory: a pilot analogue study with feigned head injury sequelae.

Questionnaire-based symptom validity tests (SVTs) are an indispensable diagnostic tool for evaluating the credibility of patients' claimed symptomatology, both in forensic and in clinical assessment contexts. In 2019, the comprehensive professional manual of a new SVT, the Self-Report Symptom Inventory (SRSI), was published in German. Its English-language version was first tested in the UK. This experimental analogue study investigated 20 adults simulating minor head injury symptoms and 21 honestly responding participants. The effect sizes of differences between the two groups were large, with the simulating group endorsing a higher number of pseudosymptoms, both on the SRSI and the Structured Inventory of Malingered Symptomatology, and scoring lower on the Reliable Digit Span than the control group. The results are similar to those obtained in previous research of different SRSI language versions, supporting the effort to validate the English-language SRSI version.

Cry for help as a root cause of poor symptom validity: A critical note.

When patients fail symptom validity tests (SVTs) and/or performance validity tests (PVTs), their self-reported symptoms and test profiles are unreliable and cannot be taken for granted. There are many well-established causes of poor symptom validity and malingering is only of them. Some authors have proposed that a cry for help may underlie poor symptom validity. In this commentary, we argue that cry for help is a (1) metaphorical concept that is (2) difficult to operationalize and, at present, (3) impossible to falsify. We conclude that clinicians or forensic experts should not invoke cry for help as an explanation for poor symptom validity. To encourage conceptual clarity, we propose a tentative framework for explaining poor symptom validity.

The Impact of Different Forms of Coaching on the Structured Inventory of Malingered Symtomatology (SIMS).

BACKGROUND: Psychometric symptom validity instruments (SVTs) can be vulnerable to coaching, which can negatively affect their performance. Our aim was to assess the impact that different types of coaching may have on the sensitivity of the Structured Inventory of Malingered Symptomatology (SIMS). METHODS: A simulation design was used with 232 non-clinical adults divided into five experimental simulation conditions and 58 patients with anxious-depressive symptomatology derived from a traffic accident. All simulators received a basic scenario and, in addition, the second group was instructed on the symptomatology, the third was warned about the risk of exaggerating the presentation, the fourth received a combination of the two previous groups and the fifth received specific training on SVTs. RESULTS: The discriminative ability of the SIMS was higher in the basic and symptom information groups, and it decreased significantly in the specific training group on SVTs. CONCLUSIONS: SIMS seems not to be severely impacted by a variety of symptom coaching styles, although test coaching diminished its performance.

Symptom and Performance Validity Assessment in European Countries: an Update.

In 2013, a special issue of the Spanish journal Clínica y Salud published a review on symptom and performance validity assessment in European countries (Merten et al. in Clínica y Salud, 24(3), 129-138, 2013). At that time, developments were judged to be in their infancy in many countries, with major publication activities stemming from only four countries: Spain, The Netherlands, Great Britain, and Germany. As an introduction to a special issue of Psychological Injury and Law, this is an updated report of developments during the last 10 years. In that period of time, research activities have reached a level where it is difficult to follow all developments; some validity measures were newly developed, others were adapted for European languages, and validity assessment has found a much stronger place in real-world evaluation contexts. Next to an update from the four nations mentioned above, reports are now given from Austria, Italy, and Switzerland, too.

Symptom and performance validation in patients with subjective cognitive decline and mild cognitive impairment.

Nonauthentic symptom claims (overreporting) and invalid test results (underperformance) can regularly be expected in a forensic context, but may also occur in clinical referrals. While the applicability of symptom and performance validity tests in samples of dementia patients is well studied, the same is not true for patients with subjective cognitive decline (SCD) and mild cognitive impairment (MCI). A sample of 54 memory-clinic outpatients with evidence of SCD or MCI was studied. We evaluated the rate of positive results in three validity measures. A total of 7.4% of the patients showed probable negative response bias in the Word Memory Test. The rate of positive results on the Structured Inventory of Malingered Symptomatology was 14.8% while only one participant (1.9%) scored positive on the Self-Report Symptom Inventory using the standard cutoff. The two questionnaires were moderately correlated at .67. In a combined analysis of all results, five of the patients (9.3%) were judged to show evidence of probable negative response bias (or probably feigned neurocognitive impairment). In the current study, a relatively small but nontrivial rate of probable response distortions was found in a memory-clinic sample. However, it remains a methodological challenge for this kind of research to reliably distinguish between false-positive and correct-positive classifications in clinical patient groups.

Prevalence of overreporting on symptom validity tests in a large sample of psychosomatic rehabilitation inpatients.

Objective: Noncredible symptom claims, regularly expected in forensic contexts, may also occur in clinical and rehabilitation referral contexts. Hidden motives and secondary gain expectations may play a significant role in clinical patients. We studied the prevalence of noncredible symptom report in patients treated for minor mental disorders in an inpatient setting.Method: Five hundred and thirty seven clinical inpatients of a psychosomatic rehabilitation center were studied (mean age: 50.2 years; native speakers of German). They were referred for treatment of depression, anxiety, somatoform disorder, adjustment disorder, and neurasthenia. Results of two symptom validity tests (Structured Inventory of Malingered Symptomatology, SIMS; Self-Report Symptom Inventory, SRSI) and the Beck Depression Inventory-II (BDI-II) were analyzed.Results: At screening level, 34.5% and 29.8% of the patients were found to presumably overreport symptoms on the SIMS and SRSI, respectively. At the standard cut score of the SRSI (maximum false positive rate: 5%), the proportion of diagnosed overreporting was 18.8%. SIMS and SRSI pseudosymptom endorsement correlated at .73. Highly elevated depressive symptom claims with BDI-II scores above 40, found in 9.3% of the patients, were associated with elevated pseudosymptom endorsement. Moreover, extended times of sick leave and higher expectations of disability pension were associated with elevated pseudosymptom endorsement.Conclusions: The prevalence of symptom overreporting in some clinical patient groups is a serious, yet underinvestigated problem. The current estimates yielded a high prevalence of distorted, noncredible symptom claims in psychosomatic rehabilitation patients. The challenges arising to health professionals working in such settings are immense and need more consideration.

Feigning memory impairment in a forced-choice task: Evidence from event-related potentials.

Strategies of malingering detection have brought about a wealth of neuropsychological studies in the last decades. However, the investigation of physiological measures to reliably differentiate between authentic and manipulated symptom presentations is still in its infancy. The present study examined event-related potentials (ERP) to identify feigned memory impairment. We tested instructed malingerers (n = 25) and control participants (n = 22) with a recognition task similar to the Test of Memory Malingering. No differences between groups were found for P1 (70-110 ms) but for N1 (120-170 ms) and P300 components, with lower amplitudes for instructed malingerers. Behavioral data showed a typical pattern of unrealistically high errors in a forced-choice recognition task and less overall recalled stimuli in instructed malingerers. We also found study-phase repetition and old/new effects in the P300, but no interactions with groups (control vs. malingering). Post-hoc analyses revealed that the P300 effect is greater when participants reported an attention-based faking strategy, as opposed to response-based malingerers and controls. The employment of physiological measures can yield additional information on the validity of test data without the need to perform additional tests.

Detection of suboptimal effort with the Rey Complex Figure Test and Recognition Trial.

The Rey Complex Figure Test is a neuropsychological instrument that can be employed in different cultural backgrounds. Meyers and Meyers (1995) proposed an extended test version including a Recognition Trial (RT), which permits an examination of test motivation through analyses of test profiles and rare recognition mistakes. In the present study, data from a full-effort group (clinical patients) and an insufficient-effort group (forensic patients) was analyzed. For both samples, a double gold standard was set for group membership. It was found that, on the average, both groups obtained similar results on the Immediate and Delayed Recall Trials, but they differed significantly on the Copy Trial and the RT. Only in the full-effort group did the total number of rare mistakes fit a random distribution (binomial distribution, approximating a Poisson distribution). In contrast, the error distribution of the insufficient-effort group did not fit such a model. Applying the Meyers and Meyers criteria for questionable effort based on rare mistakes and the analysis of memory error patterns (MEPs) yielded a specificity of .78 and a sensitivity of .50, whereas a classification using MEPs only yielded a specificity of .85 and a sensitivity of .48. A formula developed by Lu, Boone, Cozolino, and Mitchell (2003) yielded a specificity of .95 and a sensitivity of .52. Built-in RCFT validity indicators may need to be improved in order to elevate classification accuracy.

Performance validity measures in clinical patients with aphasia.

INTRODUCTION: Performance validity testing has developed into an indispensible element of neuropsychological assessment, mostly applied in forensic determinations. Its aim is to distinguish genuine patient performance from invalid test profiles. Limits to the applicability of performance validity tests (PVTs) may arise when genuine cognitive symptoms are present. METHOD: We studied the robustness of four commonly used PVTs in a sample of 15 acute patients after cerebrovascular stroke, with first manifestations of aphasia. Severity of aphasia varied from very mild to severe. Subsequent neuroimaging revealed left-hemisphere infarction for all participants. RESULTS: The Test of Memory Malingering was the only measure found to be robust against effects of genuine language impairment (one positive on Trials 1 and 2, none on Trial 3), while unacceptable false-positive rates were found for the Fifteen-Item Test (60%) and two embedded measures, Reliable Spatial Span (40%) and Reliable Digit Span (73.3%). Four patients (26.7%) scored positive on at least three of the four PVTs. CONCLUSIONS: These data add to the ongoing discussion about the risk of false-positive classifications in genuine patient populations. Misdiagnosis with severe consequences for the patient in question may arise if results of PVTs are interpreted without concurrently considering the whole context of clinical evidence.

The Self-Report Symptom Inventory (SRSI) is sensitive to instructed feigning, but not to genuine psychopathology in male forensic inpatients: An initial study.

Objective: The Self-Report Symptom Inventory (SRSI) is a new symptom validity test that, unlike other symptom over-reporting measures, contains both genuine symptom and pseudosymptom scales. We tested whether its pseudosymptom scale is sensitive to genuine psychopathology and evaluated its discriminant validity in an instructed feigning experiment that relied on carefully selected forensic inpatients (n = 40). Method: We administered the SRSI twice: we instructed patients to respond honestly to the SRSI (T1) and then to exaggerate their symptoms in a convincing way (T2). Results: On T1, the pseudosymptom scale was insensitive to patients' actual psychopathology. Two patients (5%) had scores exceeding the liberal cut point (specificity = 0.95) and no patient scored above the more stringent cut point (specificity = 1.0). Also, the SRSI cut scores and ratio index discriminated well between honest (T1) and exaggerated (T2) responses (AUCs were 0.98 and 0.95, respectively). Conclusions: Given the relatively few false positives, our data suggest that the pseudosymptom scale of the SRSI is a useful measure of symptom over-reporting in forensic treatment settings.

Malingering and uncooperativeness in psychiatric and psychological assessment: prevalence and effects in a German sample of claimants.

Effort has repeatedly been shown to have a pervasive effect on performance in psychological tests. The current study evaluates to what degree performance on various psychological tests is affected by lack of effort as compared with brain injury. Psychological and medical data from a sample of 233 patients referred from Workers' Compensation Boards or from claimants in personal injury litigation were retrospectively analyzed. Each patient underwent a battery of psychological tests and a medical examination. Measures of effort were derived from the Word Memory Test (WMT) and the Medical Symptom Validity Test (MSVT). Insufficient effort was shown by 44.6% of the patients. The frequency of patients failing the effort tests was independent of age, sex, referral source, and leading complaint. Effort accounted for up to 35% of the variance of performance in the domains of cognitive speed, memory and intelligence. After controlling for effort, there was no significant effect that could be attributed to substantial brain injury. The findings confirm that there is a general and strong effect of effort on psychological test results, which dwarfs the impact of substantial brain injury. Effort testing should become a standard procedure in psychological testing.

The Modified Stroop Task Is Susceptible to Feigning: Stroop Performance and Symptom Over-endorsement in Feigned Test Anxiety.

Some researchers argue that the modified Stroop task (MST) can be employed to rule out feigning. According to these authors, modified Stroop interference effects are beyond conscious control and therefore indicative of genuine psychopathology. We examined this assumption using a within-subject design. In the first session, students (N = 22) responded honestly, while in the second session they were asked to read a vignette about test anxiety and then fake this condition. During both sessions, we administered an MST consisting of neutral, anxiety-related, and test anxiety-related words. Participants also completed the Self-Report Symptom Inventory (SRSI; Merten et al., 2016) that focuses on over-reporting of pseudosymptoms. Our feigning instructions were successful in that students succeeded in generating the typical MST effect by providing longer response latencies on anxiety related (r = 0.43) and test anxiety-related (r = 0.31) words, compared with neutral words. Furthermore, students endorsed significantly more pseudosymptoms on the SRSI (r = 0.62) in the feigning session than in the honest control condition. We conclude that the MST effect is not immune to feigning tendencies, while the SRSI provides promising results that require future research.

The Impact of Different Forms of Coaching on the Structured Inventory of Malingered Symtomatology (SIMS)(AU) / El Impacto de Diferentes Formas de Coaching en el Inventario Estructurado de Simulación de Síntomas (SIMS)(AU)

Background: Psychometric symptom validity instruments (SVTs) can be vulnerable to coaching, which can negatively affect their performance. Our aim was to assess the impact that different types of coaching may have on the sensitivity of the Structured Inventory of Malingered Symptomatology (SIMS). Methods: A simulation design was used with 232 non-clinical adults divided into five experimental simulation conditions and 58 patients with anxious-depressive symptomatology derived from a traffic accident. All simulators received a basic scenario and, in addition, the second group was instructed on the symptomatology, the third was warned about the risk of exaggerating the presentation, the fourth received a combination of the two previous groups and the fifth received specific training on SVTs. Results: The discriminative ability of the SIMS was higher in the basic and symptom information groups, and it decreased significantly in the specific training group on SVTs. Conclusions: SIMS seems not to be severely impacted by a variety of symptom coaching styles, although test coaching diminished its performance.(AU)

Antecedentes: Los instrumentos psicométricos de validez de síntomas (SVTs) pueden ser vulnerables a la preparación, lo que puede afectar negativamente a su rendimiento. Nuestro objetivo evaluar el impacto que diferentes tipos de preparación pueden tener en la sensibilidad del Inventario Estructurado de Simulación de Síntomas (SIMS). Método: Se utilizó un diseño de simulación con 232 adultos no clínicos divididos en cinco condiciones de simulación y 58 pacientes con sintomatología ansioso-depresiva derivada de un accidente de circulación. Todos los simuladores recibieron un escenario básico y, además, el segundo grupo fue instruido sobre la sintomatología a presentar, el tercero fue advertido sobre el riesgo de exagerar su presentación, el cuarto recibió una combinación de los dos grupos anteriores y el quinto recibió un entrenamiento específico sobre SVTs. Resultados: La capacidad discriminativa del SIMS fue más elevada en el grupo de escenario básico e información de síntomas, disminuyendo significativamente en el grupo de entrenamiento sobre SVTs. Conclusiones: El SIMS parece no verse afectado severamente por las diferentes formas de coaching, no obstante, la preparación específica sobre el test disminuye su rendimiento.(AU)

Objective tests of symptom exaggeration in independent medical examinations.

OBJECTIVE: This study used the Medical Symptom Validity Test (MSVT) to examine exaggeration of memory impairment in disability claimants. METHODS: The MSVT was administered to patients with soft tissue injuries undergoing an independent medical examination (IME). Their results were compared with those from groups of volunteers who were either trying their best on the test or simulating memory impairment. RESULTS: Non-French-speaking volunteers, who were tested in French, showed near perfect performance on the effort subtests, but 42% of IME patients failed the effort tests in English. Their overall results were very similar to those of simulators. CONCLUSION: This study suggests that exaggeration of cognitive symptoms is widespread in disability-related evaluations. It would be unwise to accept self-reported memory complaints at face value. Criteria-normed symptom validity testing should be done to rule out symptom exaggeration.

Factor structure of the Hooper Visual Organization Test: a cross-cultural replication and extension.

To investigate construct validity of the Hooper Visual Organization Test (VOT), a principal-axis analysis was performed on the neuropsychological test results of 200 German-speaking neurological patients who received a comprehensive battery, encompassing tests of visuospatial functions, memory, attention, executive functions, naming ability, and vocabulary. A four-factor solution was obtained with substantial loadings of the VOT only on the first factor, interpreted as a global dimension of non-verbal cognitive functions. This factor loaded significantly on numerous measures of visuospatial processing and attention (with particularly high loadings on WAIS-R Block Design, Trails A and B, and Raven's Standard Progressive Matrices). The remaining three factors were interpreted as memory, verbal abilities (vocabulary), and a separate factor of naming abilities.

Analog validation of German-language symptom validity tests and the influence of coaching.

Although symptom validity testing is an integral part of the repertory of neuropsychologists in a number of countries, this is not yet true for Germany. The German adaptations of two effort tests, the Medical Symptom Validity Test (MSVT) by Green and the Amsterdam Short-Term Memory Test (ASTM) by Schmand et al., were investigated with a German-language sample. An analog study was performed with 18 healthy experimental malingerers and 18 controls with a mean age of 25.4 years. The scenario contained detailed information about mild post-traumatic cognitive impairment, as well as an explicit warning against symptom exaggeration. In addition to MSVT and ASTM, the Trail Making Test (TMT), the Complex Figure Test (CFT), and Digit Span were performed. Half of the sample were also given Rey's 15-Item-Test (FIT). Both groups were significantly different in all effort and performance measures, with the exception of the ratio TMT-B:TMT-A. With MSVT and ASTM, correct classification of group membership was between 97 and 100%. For the ratio TMT-B:TMT-A, there was a considerable overlap in the test scores for the two groups and the sensitivity of the FIT was too low. Although the ASTM and the MSVT were identified by a number of subjects as possible effort measures, both tests obtained very good results within this analog design.