Cross validation of the Personality Assessment Inventory (PAI) Cognitive Bias Scale of Scales (CB-SOS) over-reporting indicators in a military sample.

Following the development of the Cognitive Bias Scale (CBS), three other cognitive over-reporting indicators were created. This study cross-validates these new Cognitive Bias Scale of Scales (CB-SOS) measurements in a military sample and contrasts their performance to the CBS. We analyzed data from 288 active-duty soldiers who underwent neuropsychological evaluation. Groups were established based on performance validity testing (PVT) failure. Medium effects (d = .71 to .74) were observed between those passing and failing PVTs. The CB-SOS scales have high specificity (≥.90) but low sensitivity across the suggested cut scores. While all CB-SOS were able to achieve .90, lower scores were typically needed. CBS demonstrated incremental validity beyond CB-SOS-1 and CB-SOS-3; only CB-SOS-2 was incremental beyond CBS. In a military sample, the CB-SOS scales have more limited sensitivity than in its original validation, indicating an area of limited utility despite easier calculation. The CBS performs comparably, if not better, than CB-SOS scales. CB-SOS-2's differences in performance in this study and its initial validation suggest that its psychometric properties may be sample dependent. Given their ease of calculation and relatively high specificity, our study supports the interpretation of elevated CB-SOS scores indicating those who are likely to fail concurrent PVTs.

Relationship of Personality Assessment Inventory (PAI) over-reporting scales to performance validity testing in a military neuropsychological sample.

This study evaluated the Personality Assessment Inventory's (PAI) symptom validity-based over-reporting scales with concurrently administered performance validity testing in a sample of active-duty military personnel seen within a neuropsychology clinic. We utilize two measures of performance validity to identify problematic performance validity (pass all/fail any) in 468 participants. Scale means, sensitivity, specificity, predictive value, and risk ratios were contrasted across symptom validity-based over-reporting scales. Results indicate that the Negative Impression Management (NIM), Malingering Index (MAL), and Multiscale Feigning Index (MFI) scales are the best at classifying failed performance validity testing with medium to large effects (d = .61-.73). In general, these scales demonstrated high specificity and low sensitivity. Roger's Discriminant Function (RDF) had negligible group differences and poor classification. The Feigned Adult ADHD index (FAA) performed inconsistently. This study provides support for the use of several PAI over-reporting scales at detecting probable patterns of performance-based invalid responses within a military sample. Military clinicians using NIM, MAL, or MFI are confident that those who elevate these scales at recommended cut scores are likely to fail concurrent performance validity testing. Use of the Feigned Adult FAA and RDF scales is discouraged due to their poor or mixed performance.

Self-efficacy predicts response to cognitive rehabilitation in military service members with post-concussive symptoms.

This study examined whether self-efficacy differentiated treatment responders from non-responders in a trial of cognitive rehabilitation (CR) for postconcussive symptoms. 126 service members with mild TBI seen on average 9.5 months since injury completed one of four cognitive rehabilitation treatments for 6 weeks. The four treatment arms were: (1) Psychoeducation control, (2) Self-administered computerized CR, (3) Interdisciplinary CR, and (4) Interdisciplinary CR integrated with CBT. Outcome was assessed across time (baseline, and 6, 12, and 18 weeks post-treatment) for three domains: psychological (Symptom Checklist-90-Revised; SCL-90-R), cognitive (Paced Auditory Serial Addition Test; PASAT), and functional/behavioural (Key Behaviors Change Inventory; KBCI). Mixed model ANOVAs tested for self-efficacy differences across time in treatment responders versus non-responders, as defined by reliable change indices. A significant interaction was found on the SCL-90 such that responders had increasing self-efficacy with respect to psychological symptoms across four time points, whereas non-responders' self-efficacy did not change. Perceived self-efficacy at the beginning of treatment was associated with treatment engagement within the psychological domain for responders only, suggesting a mediating role in treatment outcome. Overall, results suggest that increasing patients' level of self-efficacy may be important for successful treatment of psychological distress in those with remote concussion.

Neuropsychological Performance and Subjective Symptom Reporting in Military Service Members With a History of Multiple Concussions: Comparison With a Single Concussion, Posttraumatic Stress Disorder, and Orthopedic Trauma.

OBJECTIVE: To examine differences in objective neurocognitive performance and subjective cognitive symptoms in individuals with a history of a single concussion, multiple concussions, orthopedic injuries, and posttraumatic stress disorder (PTSD). METHOD: Participants included 116 military service members who sustained a mild traumatic brain injury (mTBI) during combat deployment. Subjects were subdivided into groups based on concussion frequency: a single concussion (n = 42), 2 concussions (n = 21), and 3 or more concussions (n = 53). Eighty-one subjects sustained an orthopedic injury (n = 60) during deployment or were diagnosed with PTSD (n = 21), but had no history of mTBI. Subjects completed a battery of neuropsychological tests and self-report measures of postconcussive symptoms, PTSD symptoms, and psychopathology. RESULTS: No differences were found among the concussion groups on a composite neuropsychological measure. The PTSD group had the highest number of symptom complaints, with the 2-concussion and 3-plus-concussion groups being most similar to the PTSD group. The concussion groups showed a nonsignificant pattern of increasing distress with increasing number of concussions. CONCLUSIONS: The current findings are consistent with meta-analytic results showing no differential effect on neuropsychological functioning due to multiple concussions. Results also support the burden of adversity hypothesis suggesting increasing symptom levels with increasing psychological or physically traumatic exposures.

Neuropsychological Evaluation in Traumatic Brain Injury.

Neuropsychological evaluations can be helpful in the aftermath of traumatic brain injury. Cognitive functioning is assessed using standardized assessment tools and by comparing an individual's scores on testing to normative data. These evaluations examine objective cognitive functioning as well as other factors that have been shown to influence performance on cognitive tests (eg, psychiatric conditions, sleep) in an attempt to answer a specific question from referring providers. Referral questions may focus on the extent of impairment, the trajectory of recovery, or ability to return to work, sport, or the other previous activity.

Cross validation of the response bias scale and the response bias scale-19 in active-duty personnel: use on the MMPI-2-RF and MMPI-3.

The Response Bias Scale (RBS) is the central measure of cognitive over-reporting in the MMPI-family of instruments. Relative to other clinical populations, the research evaluating the detection of over-reporting is more limited in Veteran and Active-Duty personnel, which has produced some psychometric variability across studies. Some have suggested that the original scale construction methods resulted in items which negatively impact classification accuracy and in response crafted an abbreviated version of the RBS (RBS-19; Ratcliffe et al., 2022; Spencer et al., 2022). In addition, the most recent edition of the MMPI is based on new normative data, which impacts the ability to use existing literature to determine effective cut-scores for the RBS (despite all items having been retained across MMPI versions). To date, no published research exists for the MMPI-3 RBS. The current study examined the utility of the RBS and the RBS-19 in a sample of Active-Duty personnel (n = 186) referred for neuropsychological evaluation. Using performance validity tests as the study criterion, we found that the RBS-19 was generally equitably to RBS in classification. Correlations with other MMPI-2-RF over- and under-reporting symptom validity tests were slightly stronger for RBS-19. Implications and directions for research and practice with RBS/RBS-19 are discussed, along with implications for neuropsychological assessment and response validity theory.

Development and initial validation of the Scale of Scales (SOS) overreporting scores for the MMPI family of instruments.

Overreporting is a common problem that complicates psychological evaluations. A challenge facing the effective detection of overreporting is that many of the identified strategies (e.g., symptom severity approaches; see Rogers & Bender, 2020) are not incorporated into broadband measures of personality and psychopathology (e.g., Minnesota Multiphasic Personality Inventory family of instruments). While recent efforts have worked to incorporate some of these newer strategies, no such work has been conducted on the MMPI-3. For instance, recent symptom severity approaches have been used to identify patterns of multivariate base rate "skyline" elevations on the BASC, and similar strategies have been adopted into the PAI to measure psychopathology (Multi-Feigning Index; Gaines et al., 2013) and cognitive symptoms (Cognitive Bias Scale of Scales; Boress et al., 2022b). This study used data from a simulation study (n = 318) and an Active-Duty (AD) clinical sample (n = 290) to develop and cross-validate such a scale on the MMPI-2-RF and MMPI-3. Results suggest that the MMPI SOS (Scale of Scales) scores perform equitably to existing measures of overreporting on the MMPI-2-RF and MMPI-3 and incrementally predict a PVT-classified "known-group" of Active Duty service members. Effects were generally large in magnitude. Classification accuracy achieved desired specificity (.90) and approximated expected sensitivity (.30). Implications of these findings are discussed, which emphasize how alternative overreporting detection strategies may be useful to consider for the MMPI. These alternative strategies have room for expansion and refinement.

Base Rates of Performance and Symptom Validity Test Failures in Active Duty and Veteran Samples Referred for Attention-Deficit/Hyperactivity Disorder Evaluation.

OBJECTIVE: The objective of this study was to determine base rates of response bias in veterans and service members (SM) referred specifically for attention-deficit/hyperactivity disorder (ADHD) evaluation. METHOD: Observational study of various performance validity tests (PVTs) and symptom validity tests (SVTs) in a sample of SMs (n = 94) and veterans (n = 504) referred for clinical evaluation of ADHD. RESULTS: SVT and PVT failure rates were similar between the samples, but they were lower than previous Veterans Affairs (VA) and SM studies that were not exclusive to ADHD evaluations. Invalid reporting across all SVT scales on the Minnesota Multiphasic Personality Inventory and Personality Assessment Inventory was relatively uncommon, with rates of invalid scores falling at less than 7%. In both samples, free-standing PVTs were failed at about 22%. CONCLUSIONS: Although the base rates of PVT and SVT failures in ADHD-specific evaluations were lower than previously published data on non-ADHD-specific evaluations in veterans and SMs, the current study continues to support the inclusion of these measures.

Comparison of the Memory Complaints Inventory and the PAI Cognitive Bias Scale in a Military Sample.

OBJECTIVE: The Memory Complaints Inventory (MCI) is a stand-alone memory-based symptom validity test (SVT). The measure is promising and has been used with relative frequency, but requires additional research (Armistead-Jehle & Shura, 2022). The current study sought to expand the empirical base of the MCI by comparing it to the Cognitive Bias Scale, a new symptom validity measure assessing cognitive over reporting on the Personality Assessment Inventory (PAI). METHOD: Retrospective review of 273 military service members seen for neuropsychological evaluation and administered both the PAI and MCI. RESULTS: Area under the curve values for the MCI overall mean score and MCI implausible scales for a PAI Cognitive Bias Scale (CBS) cut score of >14 were large in effect (0.77 and 0.78, respectively). The effect size between those that passed and failed the CBS on the mean of MCI scales was also large (d = 1.13). Classification statistics indicated that a cut score of 52% on the mean MCI scales and 29% on the mean MCI implausible subscales indicated specificities of 0.94 and 0.93 and sensitivities of 0.30 and 0.29, respectively. CONCLUSIONS: These data support the MCI as a cognitive SVT relative to the PAI CBS. We offer guidance on how to integrate these SVT measures in military samples.

Evaluating Personality Assessment Inventory Response Patterns in Active-Duty Personnel With Head Injury Using a Latent Class Approach.

OBJECTIVE: Previous research has found that among those with brain injury, individuals have a variety of different potential symptom sets, which will be seen on the Personality Assessment Inventory (PAI). The number of different groups and what they measure have varied depending on the study. METHOD: In active-duty personnel with a remote history of mild traumatic brain injury (n = 384) who were evaluated at a neuropsychology clinic, we used a retrospective database to examine if there are different groups of individuals who have distinct sets of symptoms as measured on the PAI. We examined the potential of distinct groups of respondents by conducting a latent class analysis of the clinical scales. Post hoc testing of group structures was conducted on concurrently administered cognitive testing, performance validity tests, and the PAI subscales. RESULTS: Findings indicate a pattern of broad symptom severity as the most probable reason for multiple groups of respondents, suggesting that there are no distinct symptom sets observed within this population. Pathology levels were the most elevated on internalizing and thought disorder scales across the various class solutions. CONCLUSION: Findings indicate that among active-duty service members with remote brain injury, there are no distinct groups of respondents with different sets of symptom types as has been found in prior work with other neuropsychology samples. We conclude that the groups found are likely a function of general psychopathology present in the population/sample rather than bona fide differences.

The role of posttraumatic stress symptoms on memory complaints and performance in active-duty service members.

OBJECTIVE: Memory complaints are the most common form of cognitive limitation reported by military service members, but prior research suggests that posttraumatic stress symptoms (PTSS) may account for the link between subjective cognitive complaints and objective cognitive performance. The mechanisms underlying this relationship are largely unknown, including whether the finding applies to memory complaints and performance, which clinical dimensions are involved, and how the association varies when memory complaints are non-credible. METHOD: Using a sample of 196 US military service members, the present study aims to address these gaps by modeling the relationship between objective memory performance and plausible/implausible subjective memory complaints, then evaluating how the association is influenced by PTSS and clinical traits commonly found within PTSS (e.g. depression, anxiety, and somatic concerns). RESULTS: Overall memory complaints were associated with immediate and delayed recall, but both associations were fully mediated by PTSS (95% CI -0.14, -0.01; 95% CI -0.14, -0.02, respectively). Implausible memory complaints, however, were inconsistently linked to memory performance, and no PTSS mediation was observed. Of the clinical traits, only depression moderated the impact of PTSS, specifically by influencing the link between PTSS and overall memory complaints (ß = -0.02, SE = 0.004, p < .001). CONCLUSIONS: These results corroborate the importance of assessment for PTSS and depression in service members who report subjective memory complaints and highlight how targeted intervention for these conditions may play a key role in the management of memory complaints.

Brain Injury: How Dietary Patterns Impact Long-Term Outcomes.

Purpose of Review: Individuals with a history of traumatic brain injury (TBI) are at a much greater risk for developing cardiovascular disease (CVD) compared to the general population. This review discusses dietary patterns as a means of addressing modifiable risk factors following TBI exposure. Evidence-based resources for practicing Physiatrists and Brain Injury Medicine specialists pertaining to nutrition education and counseling are also provided. Recent Findings: We examined Mediterranean, Dietary Approaches to Stop Hypertension, plant-based, ketogenic, and intermittent fasting dietary patterns through publications of clinical trials and systematic reviews. While many reviews had significant positive findings, some were limited by generalizability. Summary: While there is extensive literature on the immediate nutrition goals in the inpatient setting following an acute TBI exposure, there is limited literature discussing the nature of diet and nutrition in the post-acute setting. Fortunately, most individuals with TBI exposure survive their initial injury and continue into the recovery phase. The scientific literature supports increased morbidity and mortality with chronic TBI exposure compared to matched counterparts, most notably with CVD. A diet rich in fiber and nutrients but limited in added sugars, saturated fats, and excess calories would likely have the greatest cardiovascular and related neurologic protection. Future studies are needed to assess the specific impact of dietary interventions in the chronic phase of brain injury recovery.

Validation of the personality assessment inventory (PAI) cognitive bias (CBS) and cognitive bias scale of scales (CB-SOS) in a post-deployment veteran sample.

Objective: The present study evaluated the function of four cognitive, symptom validity scales on the Personality Assessment Inventory (PAI), the Cognitive Bias Scale (CBS) and the Cognitive Bias Scale of Scales (CB-SOS) 1, 2, and 3 in a sample of Veterans who volunteered for a study of neurocognitive functioning. Method: 371 Veterans (88.1% male, 66.1% White) completed a battery including the Miller Forensic Assessment of Symptoms Test (M-FAST), the Word Memory Test (WMT), and the PAI. Independent samples t-tests compared mean differences on cognitive bias scales between valid and invalid groups on the M-FAST and WMT. Area under the curve (AUC), sensitivity, specificity, and hit rate across various scale point-estimates were used to evaluate classification accuracy of the CBS and CB-SOS scales. Results: Group differences were significant with moderate effect sizes for all cognitive bias scales between the WMT-classified groups (d = .52-.55), and large effect sizes between the M-FAST-classified groups (d = 1.27-1.45). AUC effect sizes were moderate across the WMT-classified groups (.650-.676) and large across M-FAST-classified groups (.816-.854). When specificity was set to .90, sensitivity was higher for M-FAST and the CBS performed the best (sensitivity = .42). Conclusion: The CBS and CB-SOS scales seem to better detect symptom invalidity than performance invalidity in Veterans using cutoff scores similar to those found in prior studies with non-Veterans.

Grooved Pegboard adds incremental value over memory-apparent performance validity tests in predicting psychiatric symptom report.

The present study evaluated whether Grooved Pegboard (GPB), when used as a performance validity test (PVT), can incrementally predict psychiatric symptom report elevations beyond memory-apparent PVTs. Participants (N = 111) were military personnel and were predominantly White (84%), male (76%), with a mean age of 43 (SD = 12) and having on average 16 years of education (SD = 2). Individuals with disorders potentially compromising motor dexterity were excluded. Participants were administered GPB, three memory-apparent PVTs (Medical Symptom Validity Test, Non-Verbal Medical Symptom Validity Test, Reliable Digit Span), and a symptom validity test (Personality Assessment Inventory Negative Impression Management [NIM]). Results from the three memory-apparent PVTs were entered into a model for predicting NIM, where failure of two or more PVTs was categorized as evidence of non-credible responding. Hierarchical regression revealed that non-dominant hand GPB T-score incrementally predicted NIM beyond memory-apparent PVTs (F(2,108) = 16.30, p < .001; R2 change = .05, ß = -0.24, p < .01). In a second hierarchical regression, GPB performance was dichotomized into pass or fail, using T-score cutoffs (≤29 for either hand, ≤31 for both). Non-dominant hand GPB again predicted NIM beyond memory-apparent PVTs (F(2,108) = 18.75, p <.001; R2 change = .08, ß = -0.28, p < .001). Results indicated that noncredible/failing GPB performance adds incremental value over memory-apparent PVTs in predicting psychiatric symptom report.

Relationship between mechanism of injury and neurocognitive functioning in OEF/OIF service members with mild traumatic brain injuries.

Military personnel deployed to combat theaters in Iraq and Afghanistan are at risk of sustaining mild traumatic brain injuries (mTBI) from causes such as improvised explosive devices, motor vehicle accidents, and falls. Despite the high incidence of mTBI in deployed personnel, questions remain about the effects of blast-related vs. non-blast-related mTBI on acute and long-term sequelae. This investigation is a retrospective review of service members who presented for evaluation of suspected mTBI and underwent neurocognitive screening evaluation, mTBI diagnosis was made by semistructured clinical interview. Only individuals in whom mechanism of injury could be determined (blast vs. non-blast) were included. Sixty individuals were included in the final sample: 32 with blast mTBI and 28 with non-blast mTBI. There were no differences between the blast-related and non-blast-related mTBI groups on age, time since injury, combat stress symptoms, or headache. Analysis of variance showed no significant between-group differences on any of the neurocognitive performance domains. Although speculation remains that the effects of primary blast exposure are unique, the results of this study are consistent with prior research suggesting that blast-related mTBI does not differ from other mechanisms of injury with respect to cognitive sequelae in the postacute phase.

Validation of grooved pegboard cutoffs as an additional embedded measure of performance validity.

OBJECTIVE: Using embedded performance validity (PVT) comparisons, Erdodi et al. suggested that Grooved Pegboard (GPB) T-score cutoffs for either hand (≤ 29) or both hands (≤ 31) could be used as additional embedded PVTs. The current study evaluated the relationship between these proposed cutoff scores and established PVTs (Medical Symptom Validity Test [MSVT]; Non-Verbal Medical Symptom Validity Test [NV-MSVT], and Reliable Digit Span [RDS]). METHOD: Participants (N = 178) were predominately Caucasian (84%) males (79%) with a mean age and education of 41 (SD = 11.7) and 15.8 years (SD = 2.3), respectively. Participants were stratified as "passing" or "failing" the GPBviaErdodi's proposed criteria. "Failures" on the MSVT, NV-MSVT, and RDS were based on conventional recommendations. RESULTS: Moderate correlations between GPB classification and a condition of interest (COI; i.e. at least two failures on reference PVTs) were observed for dominant (χ2 (1, n = 178) = 34.72, ϕ = .44, p < .001), non-dominant (χ2 (1, n = 178) = 16.46, ϕ = .30, p = .001), and both hand conditions (χ2 (1, n = 178) = 32.48, ϕ = .43, p < .001). Sensitivity, specificity, and predictive power were generally higher than Erdodi et al.'s initial findings. CONCLUSION: These findingsprovide supportfor the clinical utility of the GPB as an additional embedded PVT. More specifically, dominant and both hand cutoffs were found to be more robust measures ofnon-genuine performance in those without motor deficits. While promising, sensitivity continues to be low; therefore, it is ill-advised to use the GPB as a sole measure of -performance validity.

Sensitivity of the test of memory malingering and the Nonverbal Medical Symptom Validity Test: a replication study.

The current investigation sought to replicate and extend the findings of Green ( in press ), which demonstrated superior sensitivity of the Nonverbal Medical Symptom Validity Test (NV-MSVT) relative to the Test of Memory Malingering (TOMM) in the detection of suboptimal effort during neuropsychological assessment. Nearly twice as many examinees failed the NV-MSVT than the TOMM. Profile analyses of the NV-MSVT demonstrated patterns suggestive of inconsistent effort in those who failed the NV-MSVT but passed the TOMM. A classification analysis employing the Word Memory Test and Medical Symptom Validity Test as external criteria for poor effort showed that the NV-MSVT is substantially more sensitive to poor effort than the TOMM and maintains an acceptable false-positive rate. Overall, results closely matched those of the Green ( in press ) study and extend the evidence that the NV-MSVT possesses better sensitivity to poor effort than the TOMM.

Preliminary investigation of the Denver Attention Test (DAT) in a mixed clinical sample.

In this pilot study, the clinical utility of a new computerized performance validity test (PVT) called the Denver Attention Test (DAT) was evaluated in a known-groups experimental design. Subjects consisted of 130 adults with mixed neurological conditions evaluated in an outpatient setting. Using the Word Memory Test (WMT) to categorize subjects into valid and invalid groups, the DAT was found to have adequate discrimination. Classification statistics for the DAT demonstrated low to moderate sensitivity and excellent specificity relative to the WMT. ROC analyses demonstrated AUCs of at least .78 for select DAT subtests. Overall, data from this pilot study suggest that the DAT has potential to serve as a useful PVT. Future research directions are discussed.

Self-reported neurobehavioral symptoms in combat veterans: An examination of NSI with mBIAS symptom validity scales and potential effects of psychological distress.

This study evaluated symptom validity scales from the Neurobehavioral Symptom Inventory (NSI) and mild Brain Injury Atypical Symptom Scale (mBIAS) in a sample of 338 combat veterans. Classification statistics were computed using the Structured Inventory of Malingered Symptomatology (SIMS) as the validity criterion. Symptom distress was assessed with the Patient Health Questionnaire-9 and Posttraumatic Stress Disorder (PTSD) Checklist-5. At SIMS > 14, the NSI total score resulted in the highest area under the curve (AUC; .91), followed by Validity-10 (AUC = .88) and mBIAS (AUC = .67). At SIMS > 23, both NSI total and Validity-10 AUCs decreased to .88; in contrast, mBIAS AUC increased to .75. The NSI total score and Validity-10 were interpreted to reflect symptom magnification, whereas the mBIAS may reflect symptom fabrication. There was a subsample with elevated Patient Health Questionnaire-9 (PHQ-9) and PTSD Checklist-5 scores who were significantly distressed but not deemed invalid on the NSI; however, there appears to be an upper threshold on the NSI total score (>69) beyond which nobody produced an invalid score on the SIMS. A recommended approach is provided for using NSI-related validity measures. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Number of Concussions Does Not Affect Treatment Response to Cognitive Rehabilitation Interventions Following Mild TBI in Military Service Members.

OBJECTIVE: The study objective was to determine whether number of concussions would affect symptom improvement following cognitive rehabilitation (CR) interventions. METHOD: Service members (N = 126) with concussion history completed a 6-week randomized control trial of CR interventions. Participants were stratified based on self-reported lifetime concussion frequency. Outcome measures included the Paced Auditory Serial Addition Test (PASAT), the Global Severity Index (GSI) from the Symptom Checklist-90-Revised, and the Key Behaviors Change Inventory (KBCI). RESULTS: Mixed-model analyses of variance revealed a significant main effect for time on cognitive, psychological, and neurobehavioral functioning. A significant main effect for the number of concussions was observed for GSI and KBCI, but not PASAT. Interactions between the number of concussions and time were not significant for any of the outcome variables. CONCLUSIONS: Over the 6-week interval, improvements were found for all participants across all outcome measures. Number of concussions did not affect improvements over time.