Performance Validity Test Failure in the Clinical Population: A Systematic Review and Meta-Analysis of Prevalence Rates.

Performance validity tests (PVTs) are used to measure the validity of the obtained neuropsychological test data. However, when an individual fails a PVT, the likelihood that failure truly reflects invalid performance (i.e., the positive predictive value) depends on the base rate in the context in which the assessment takes place. Therefore, accurate base rate information is needed to guide interpretation of PVT performance. This systematic review and meta-analysis examined the base rate of PVT failure in the clinical population (PROSPERO number: CRD42020164128). PubMed/MEDLINE, Web of Science, and PsychINFO were searched to identify articles published up to November 5, 2021. Main eligibility criteria were a clinical evaluation context and utilization of stand-alone and well-validated PVTs. Of the 457 articles scrutinized for eligibility, 47 were selected for systematic review and meta-analyses. Pooled base rate of PVT failure for all included studies was 16%, 95% CI [14, 19]. High heterogeneity existed among these studies (Cochran's Q = 697.97, p < .001; I2 = 91%; τ2 = 0.08). Subgroup analysis indicated that pooled PVT failure rates varied across clinical context, presence of external incentives, clinical diagnosis, and utilized PVT. Our findings can be used for calculating clinically applied statistics (i.e., positive and negative predictive values, and likelihood ratios) to increase the diagnostic accuracy of performance validity determination in clinical evaluation. Future research is necessary with more detailed recruitment procedures and sample descriptions to further improve the accuracy of the base rate of PVT failure in clinical practice.

Performance Validity and Outcome of Cognitive Behavior Therapy in Patients with Chronic Fatigue Syndrome.

OBJECTIVE: There is limited research examining the impact of the validity of cognitive test performance on treatment outcome. All known studies to date have operationalized performance validity dichotomously, leading to the loss of predictive information. Using the range of scores on a performance validity test (PVT), we hypothesized that lower performance at baseline was related to a worse treatment outcome following cognitive behavioral therapy (CBT) in patients with Chronic Fatigue Syndrome (CFS) and to lower adherence to treatment. METHOD: Archival data of 1081 outpatients treated with CBT for CFS were used in this study. At baseline, all patients were assessed with a PVT, the Amsterdam Short-Term Memory test (ASTM). Questionnaires assessing fatigue, physical disabilities, psychological distress, and level of functional impairment were administered before and after CBT. RESULTS: Our main hypothesis was not confirmed: the total ASTM score was not significantly associated with outcomes at follow-up. However, patients with a missing follow-up assessment had a lower ASTM performance at baseline, reported higher levels of physical limitations, and completed fewer therapy sessions. CONCLUSIONS: CFS patients who scored low on the ASTM during baseline assessment are more likely to complete fewer therapy sessions and not to complete follow-up assessment, indicative of limited adherence to treatment. However, if these patients were retained in the intervention, their response to CBT for CFS was comparable with subjects who score high on the ASTM. This finding calls for more research to better understand the impact of performance validity on engagement with treatment and outcomes.

Effort and liberal acceptance bias in patients with schizophrenia.

Introduction: A liberal acceptance bias is implicated in the formation and maintenance of delusions in schizophrenia. The present study tested the hypothesis that patients with schizophrenia are more quickly satisfied with their task performance than controls despite poor objective performance. Methods: Fifty patients with schizophrenia and 50 healthy controls performed the newly developed copy figure task in which participants copy a complex geometrical figure up to eight times until they are satisfied with the result. Objective performance was scored blind to group status. Subjective performance was rated on a 10-point scale. Carefulness of the drawing using anchor points served as a proxy for effort. Results: Patients made as many attempts as controls to copy the figure despite their worse subjective and objective performance. The number of attempts was negatively correlated with (persecutory) delusions and the PANSS total score. Neither effort nor possible frustration due to a plateau in performance was a reason for task termination. Conclusions: This exploratory study is in line with predictions based on the liberal acceptance model. For future studies, we recommend further cross-validating this paradigm and testing whether patients' retrospective assessment of their performance is exaggerated relative to controls. We also suggest that researchers pursue this line of research with personally meaningful material where a decreased threshold of acceptance may more easily translate into the subsequent fixation of ideas.

Providing a brief corrective statement does not improve test performance in patients invalidating testing: A multisite, single-blind randomized controlled trial.

Objective: Performance below the actual abilities of the examinee can be measured using performance validity tests (PVTs). PVT failure negatively impacts the quality of the neuropsychological assessment. In our study, we addressed this issue by providing a brief corrective statement regarding invalidity to improve test-taking behavior. Methods: This study is a multisite single-blind randomized controlled trial in a consecutive sample of clinically referred adult patients (N = 196) in a general hospital setting. Patients who failed a PVT (n = 71) were randomly allocated to a corrective statement approach (CS; n = 39), in which a brief verbal corrective statement was given by the technician, or received no corrective statement upon indications of invalid performance (NO-CS; n = 32). Both groups (CS and NO-CS) were provided with the same subsequently repeated and newly administered tests. Results: There were no group (CS vs. NO-CS) differences on both the repeated and single-administered PVTs and standard cognitive tests. Furthermore, invalid performing participants benefited significantly less from the repeated test administration compared to the valid performing group. Conclusions: Our study found that a brief corrective within-session statement, to address PVT failure and improve test-taking behavior, did not improve consequent test performance. These results suggest limited value of a brief verbal corrective statement to influence performance below best of capabilities. It highlights the need for more research to identify more effective approaches that can enhance patients test-taking behavior. Ultimately, such efforts are critical in ensuring accurate diagnosis and effective treatment recommendations for patients.

Let's use those tests! Evaluations of crime-related amnesia claims.

Suspects awaiting trial often claim that they cannot remember important parts of their violent crimes. It is not unusual that forensic experts readily accept such claims and interpret them in terms of dissociative amnesia or, more specifically, a "red-out". This interpretation hinges on the assumption that heightened levels of stress implicated in violent crimes interfere with memory. We argue that the notion of red-out is a priori not plausible and that alternative interpretations-primarily malingering and substance-induced organic amnesia-should be considered and ruled out first before concluding that memory loss is dissociative in nature. We illustrate our point with four cases that superficially have the contours of red-out tragedies. We believe that, in such cases, neuropsychological tests and/or psychopharmacological information on dose-response relationships can assist forensic experts to exclude malingering or substance-induced amnesia. There is no reason for not using tests and tools from neuropsychology and psychopharmacology.

Veridical and false memory for scenic material in posttraumatic stress disorder.

The question whether memory aberrations in posttraumatic stress disorder (PTSD) also manifest as an increased production of false memories is important for both theoretical and practical reasons, but is yet unsolved. Therefore, for the present study we investigated veridical and false recognition in PTSD with a new scenic variant of the Deese-Roediger-McDermott (DRM) paradigm, which was administered to traumatized individuals with PTSD (n=32), traumatized individuals without PTSD (n=30), and non-traumatized controls (n=30). The PTSD group neither produced higher rates of false memories nor expressed more confidence in errors, but did show inferior memory sensitivity. Whereas depressive symptoms did not correlate with veridical nor false recognition, state dissociation was positively associated with false memories.

The classification of recovered memories: a cautionary note.

Traditionally, recovered memories of childhood sexual abuse (CSA) have been classified as those emerging spontaneously versus those surfacing during the course of suggestive therapy. There are indications that reinterpretation of memories might be a third route to recovered memories. Thus, recovered memories do not form a homogeneous category. Nevertheless, the conceptual distinctions between the various types of recovered memories remain difficult for researchers and clinicians. With this in mind, the current study explored whether recovered memories can be reliably classified. We found that classification is rather problematic in a subset of cases. To reduce potential bias, we urge for the development and subsequent use of a more reliable classification system and multiple expert raters in research on recovered memories.

Susceptibility to misleading information under social pressure in schizophrenia.

Research looking at specific memory aberrations in the schizophrenia has primarily focused on their phenomenology using standardized semantic laboratory tasks. However, no study has investigated to what extent such aberrations have consequences for everyday episodic memories using more realistic false memory paradigms. Using a false memory paradigm where participants are presented with misleading suggestive information (Gudjonsson Suggestibility Scale), we investigated the susceptibility of patients with schizophrenia (n = 21) and healthy controls (n = 18) to post hoc misleading information acceptance and compliance. Patients with schizophrenia exhibited an increased susceptibility to go along with misleading suggestive items. Furthermore, they showed an increased tendency to change answers under conditions of social pressure. Underscoring previous findings on memory aberrations in schizophrenia, patients with schizophrenia had reduced levels of correct recognition (ie, true memory) relative to healthy controls. The effects remained stable when controlling for specific mediating variables such as symptom severity and intelligence in patients with schizophrenia. These findings are a first indication that social pressure and misleading information may impair source memory for everyday episodic memories in schizophrenia, and such impairment has clear consequences for treatment issues and forensic practice.

Underestimation of prior remembering and susceptibility to false memories: two sides of the same coin?

In two studies, we explored whether susceptibility to false memories and the underestimation of prior memories (i.e., forgot-it-all-along effect) tap overlapping memory phenomena. Study 1 investigated this issue by administering the Deese/Roediger-McDermott task (DRM) and the forgot-it-all-along (FIA) task to an undergraduate sample (N=110). It was furthermore explored how performances on these tasks correlate with clinically relevant traits such as fantasy proneness, dissociative experiences, and cognitive efficiency. Results show that FIA and DRM performances are relatively independent from each other, suggesting that these measures empirically apparently refer to separate dimensions. However, they do not seem to define different profiles in terms of dissociation, fantasy proneness, and cognitive efficiency. Study 2 replicated the finding of relative independence between false memory propensity (as measured with the DRM task) and the underestimation of prior memories (as measured with an autobiographical memory dating task) in people with a history of childhood sexual abuse (N=35).

Detecting coached feigning using the Test of Memory Malingering (TOMM) and the Structured Inventory of Malingered Symptomatology (SIMS).

Undergraduate students were administered the Test of Memory Malingering (TOMM) and the Structured Inventory of the Malingered Symptomatology (SIMS) and asked to respond honestly, or instructed to feign cognitive dysfunction due to head injury. Before both instruments were administered, symptom-coached feigners were provided with some information about brain injury, while feigners who received a mix of symptom-coaching and test-coaching were given the same information plus advice on how to defeat symptom validity tests. Results show that, although the accuracy of both instruments appears to be somewhat reduced by a mix of symptom coaching and test coaching, the TOMM and SIMS are relatively resistant to different kinds of coaching.

Metacognitive beliefs in obsessive-compulsive patients: a comparison with healthy and schizophrenia participants.

INTRODUCTION: Distorted metacognitive beliefs are increasingly considered in theoretical models of obsessive-compulsive disorder (OCD). However, so far no consensus has emerged regarding the specific metacognitive profile of OCD. METHODS: Participants with OCD (n=55), schizophrenia (n=39), and nonclinical controls (n=49) were assessed with the Metacognitions Questionnaire (MCQ-30). RESULTS: Except for positive beliefs about worry, both patient samples exceeded nonclinical controls on all MCQ subscales. The MCQ "need to control thoughts" and "negative beliefs about uncontrollability and danger" subscales showed strong correlations with obsessions, and scores in the former scale were elevated in hallucinators. In contrast to several prior studies, "cognitive confidence" was related neither to core OCD nor to schizophrenia symptomatology. CONCLUSIONS: Notwithstanding large pathogenetic differences between OCD and schizophrenia, findings suggest that obsessions and hallucinations may share a common metacognitive pathway. Need to control thoughts and dysfunctional beliefs about the malleability of worries may represent critical prerequisites for the two phenomena to emerge.

Feedback on underperformance in patients with Chronic Fatigue Syndrome: The impact on subsequent neuropsychological test performance.

Performance Validity Tests (PVTs) are used to measure the credibility of neuropsychological test results. Until now, however, a minimal amount is known about the effects of feedback upon noncredible results (i.e., underperformance) on subsequent neuropsychological test performance. The purpose of this study was to investigate the effects of feedback on underperformance in Chronic Fatigue Syndrome (CFS) patients. A subset of these patients received feedback on Amsterdam Short-Term Memory (ASTM) failure (i.e., feedback [FB] group). After matching, the final sample consisted of two comparable groups (i.e., FB and No FB; both n = 33). At baseline and follow-up assessment, the patients completed the ASTM and two measurements of information processing speed (Complex Reaction Time [CRT] and Symbol Digit Test [SDT]). Results indicated that the patients in the FB group improved significantly on the CRT, compared to the No FB group. Although not significant, a comparable trend-like effect was observed for the SDT. Independent of the feedback intervention there was a substantial improvement on ASTM performance at re-administration. A limited feedback intervention upon underperformance in CFS patients may result in improvement on information processing speed performance. This implies that such an intervention might be clinically relevant, since it maximizes the potential of examining the patients' actual level of cognitive abilities.

Subjective competence breeds overconfidence in errors in psychosis. A hubris account of paranoia.

BACKGROUND AND OBJECTIVES: Overconfidence in errors is a well-replicated cognitive bias in psychosis. However, prior studies have sometimes failed to find differences between patients and controls for more difficult tasks. We pursued the hypothesis that overconfidence in errors is exaggerated in participants with a liability to psychosis relative to controls only when they feel competent in the respective topic and/or deem the question easy. Whereas subjective competence likely enhances confidence in those with low psychosis liability as well, we still expected to find more 'residual' caution in the latter group. METHODS: We adopted a psychometric high-risk approach to circumvent the confounding influence of treatment. A total of 2321 individuals from the general population were administered a task modeled after the "Who wants to be a millionaire" quiz. Participants were requested to endorse one out of four response options, graded for confidence, and were asked to provide ratings regarding subjective competence for the knowledge domain as well as the subjective difficulty of each item. RESULTS: In line with our assumption, overconfidence in errors was increased overall in participants scoring high on the Paranoia Checklist core paranoia subscale (2 SD above the mean). This pattern of results was particularly prominent for items for which participants considered themselves competent and which they rated as easy. LIMITATIONS: Results need to be replicated in a clinical sample. DISCUSSION: In support of our hypothesis, subjective competence and task difficulty moderate overconfidence in errors in psychosis. Trainings that teach patients the fallibility of human cognition may help reduce delusional ideation.

Knowledge corruption for visual perception in individuals high on paranoia.

Studies revealed that patients with paranoid schizophrenia display overconfidence in errors for memory and social cognition tasks. The present investigation examined whether this pattern holds true for visual perception tasks. Nonclinical participants were recruited via an online panel. Individuals were asked to complete a questionnaire that included the Paranoia Checklist and were then presented with 24 blurry pictures; half contained a hidden object while the other half showed snowy (visual) noise. Participants were asked to state whether the visual items contained an object and how confident they were in their judgment. Data from 1966 individuals were included following a conservative selection process. Participants high on core paranoid symptoms showed a poor calibration of confidence for correct versus incorrect responses. In particular, participants high on paranoia displayed overconfidence in incorrect responses and demonstrated a 20% error rate for responses made with high confidence compared to a 12% error rate in participants with low paranoia scores. Interestingly, paranoia scores declined after performance of the task. For the first time, overconfidence in errors was demonstrated among individuals with high levels of paranoia using a visual perception task, tentatively suggesting it is a ubiquitous phenomenon. In view of the significant decline in paranoia across time, bias modification programs may incorporate items such as the one employed here to teach patients with clinical paranoia the fallibility of human cognition, which may foster subsequent symptom improvement.

Impact of emotionality on memory and meta-memory in schizophrenia using video sequences.

BACKGROUND AND OBJECTIVES: A vast amount of memory and meta-memory research in schizophrenia shows that these patients perform worse on memory accuracy and hold false information with strong conviction compared to healthy controls. So far, studies investigating these effects mainly used traditional static stimulus material like word lists or pictures. The question remains whether these memory and meta-memory effects are also present in (1) more near-life dynamic situations (i.e., using standardized videos) and (2) whether emotionality has an influence on memory and meta-memory deficits (i.e., response confidence) in schizophrenia compared to healthy controls. METHOD: Twenty-seven schizophrenia patients and 24 healthy controls were administered a newly developed emotional video paradigm with five videos differing in emotionality (positive, two negative, neutral, and delusional related). After each video, a recognition task required participants to make old-new discriminations along with confidence ratings, investigating memory accuracy and meta-memory deficits in more dynamic settings. RESULTS: For all but the positively valenced video, patients recognized fewer correct items compared to healthy controls, and did not differ with regard to the number of false memories for related items. In line with prior findings, schizophrenia patients showed more high-confident responses for misses and false memories for related items but displayed underconfidence for hits when compared to healthy controls, independent of emotionality. LIMITATIONS: Limited sample size and control group; combined valence and arousal indicator for emotionality; general psychopathology indicator. CONCLUSIONS: Emotionality differentially moderated memory accuracy, biases in schizophrenia patients compared to controls. Moreover, the meta-memory deficits identified in static paradigms also manifest in more dynamic settings near-life settings and seem to be independent of emotionality.

Assessment of subjective cognitive and emotional effects of antipsychotic drugs. Effect by defect?

Antipsychotic medication represents the first-line treatment for schizophrenia. While it is undisputed that antipsychotics ameliorate positive symptoms, the exact cognitive and emotional pathways through which the effect is exerted has remained unclear. The present study investigated the subjective effects of antipsychotics across various domains of cognition and emotion in both patients with psychotic symptoms and patients with other psychiatric diagnoses. A total of 69 patients with a probable history of psychosis or psychotic symptoms and 26 patients with psychiatric diagnoses other than psychosis participated in a survey conducted over the Internet. Multiple control measures aimed to secure response validity. All patients were currently or had previously been treated with antipsychotic agents. A questionnaire comprising 49 items and measuring possible effects of antipsychotics on cognition and emotion was administered. For 30 out of 49 items a clear response pattern emerged, which was similar for patients with psychotic disorders and patients with other diagnoses. Factor analysis of these items revealed three main effects of antipsychotic medication related to doubt and self-doubt, cognitive and emotional numbing, and social withdrawal. Antipsychotic treatment appears to be connected to a number of negative subjective effects on cognition and emotion. Further studies are warranted to assess how these effects impact on the patients' subjective well-being and quality of life, as well as their association with antipsychotic efficacy on one hand, and adherence rates on the other. Induction of doubt and dampening of emotion may be one reason why antipsychotics work and at the same time offer an explanation why they are experienced as rather unpleasant and are eventually discontinued by many patients.

Survival processing in times of stress.

Recent studies have found that processing information according to an evolutionary relevant (i.e., survival) scenario improves its subsequent memorability, potentially as a result of fitness advantages gained in the ancestral past. So far, research has not revealed much about any proximate mechanisms that might underlie this so-called survival processing advantage in memory. Intriguingly, research has shown that the memorability of stressful situations is enhanced via the release of stress hormones acting on brain regions involved in memory. Since survival situations habitually involve some degree of stress, in the present study, we investigated whether stress serves as a proximate mechanism to promote survival processing. Participants rated words for their relevance to either a survival or a neutral (moving) scenario after they had been exposed to a psychosocial stressor or a no-stress control condition. Surprise retention tests immediately following the rating task revealed that survival processing and acute stress independently boosted memory performance. These results therefore suggest that stress does not serve as a proximate mechanism of the survival processing advantage in memory.

[When the suspect hears voices: feigned imperative hallucinations]. / Een verdachte die stemmen hoort: geveinsde bevelshallucinaties.

BACKGROUND: On occasion a suspect will feign psychotic symptoms such as hallucinations in order to trivialize their criminal responsibility. If doctors exercise only their clinical judgement, however, every now and then they will fail to identify a malingerer. CASE DESCRIPTION: A 38-year-old male was remanded in custody. He was accused of having murdered 2 family members. He claimed that he had committed the murders as a result of hearing imperative hallucinations. We conducted a structured interview and specially designed tests to examine the plausibility of this claim. All our instruments pointed to the man having feigned his imperative hallucinations. When confronted with this, he confirmed that he had simulated his hallucinations. CONCLUSION: Feigned hallucinations in a forensic setting can be detected using validated tests.

Heart rate variability in response to affective scenes in posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is characterized by psychophysiological abnormalities, such as an altered baseline heart rate and either hyper- or hyporeactivity to a wide range of stimuli, implying dysfunctional arousal regulation. Heart rate variability (HRV) has been established as an important marker of arousal regulatory ability. The aim of the present study was to examine HRV in PTSD under different affective conditions and to explore the role of potential moderating factors. To meet this purpose, videos of varying emotional valence were presented to trauma-exposed participants with PTSD (n=26), trauma-exposed participants without PTSD (n=26), as well as non-trauma-exposed controls (n=18) while HRV was recorded. The PTSD group showed lower HRV than non-trauma-exposed controls at baseline (corrected for age) and throughout different affective conditions implying decreased parasympathetic activity and an inflexible response regulation. There was a negative relationship between HRV and self-report of both depression and state dissociation.

Cognitive underperformance and symptom over-reporting in a mixed psychiatric sample.

The current study examined the prevalence of cognitive underperformance and symptom over-reporting in a mixed sample of psychiatric patients (N = 183). We employed the Amsterdam Short-Term Memory Test (ASTM) to measure cognitive underperformance and the Structured Inventory of Malingered Symptomatology (SIMS) to measure the tendency to over-report symptoms. We also administered neuropsychological tests (e.g., Concept Shifting Task; Rey's Verbal Learning Test) and the Symptom Checklist-90 (SCL-90) to the patients. A total of 34% of them failed the ASTM, the SIMS or both tests. ASTM and SIMS scores were significantly, albeit modestly, correlated with each other (r = -.22). As to the links between underperformance, over-reporting, neuropsychological tasks, and the SCL-90, the association between over-reporting on the SIMS and SCL-90 scores was the most robust one. The subsample that only failed on the ASTM performed significantly worse on a compound index of memory performance. Our findings indicate that underperformance and over-reporting are loosely coupled dimensions and that particularly over-reporting is intimately linked to heightened SCL-90 scores.