Compassion Versus Accuracy: Lenient Scoring of the Spatial Orientation Items on the Mini-mental State Exam Lowers Sensitivity.

The Mini-mental State Examination (MMSE) is a commonly used screening tool for cognitive impairment. Lenient scoring of spatial orientation errors (SOEs) on the MMSE is common and negatively affects its diagnostic utility. We examined the effect of lenient SOE scoring on MMSE classification accuracy in a consecutive case series of 103 older adults (age 60 or above) clinically referred for neuropsychological evaluation. Lenient scoring of SOEs on the MMSE occurred in 53 (51.4%) patients and lowered the sensitivity by 7% to 18%, with variable gains in specificity (0% to 11%) to psychometrically operationalized cognitive impairment. Results are consistent with previous reports that lenient scoring is widespread and attenuates the sensitivity of the MMSE. Given the higher clinical priority of correctly detecting early cognitive decline over specificity, a warning against lenient scoring of SOEs (on the MMSE and other screening tools) during medical education and in clinical practice is warranted.

Geographic variability in limited English proficiency: A cross-cultural study of cognitive profiles.

OBJECTIVE: This study was designed to evaluate the effect of limited English proficiency (LEP) on neurocognitive profiles. METHOD: Romanian (LEP-RO; n = 59) and Arabic (LEP-AR; n = 30) native speakers were compared to Canadian native speakers of English (NSE; n = 24) on a strategically selected battery of neuropsychological tests. RESULTS: As predicted, participants with LEP demonstrated significantly lower performance on tests with high verbal mediation relative to US norms and the NSE sample (large effects). In contrast, several tests with low verbal mediation were robust to LEP. However, clinically relevant deviations from this general pattern were observed. The level of English proficiency varied significantly within the LEP-RO and was associated with a predictable performance pattern on tests with high verbal mediation. CONCLUSIONS: The heterogeneity in cognitive profiles among individuals with LEP challenges the notion that LEP status is a unitary construct. The level of verbal mediation is an imperfect predictor of the performance of LEP examinees during neuropsychological testing. Several commonly used measures were identified that are robust to the deleterious effects of LEP. Administering tests in the examinee's native language may not be the optimal solution to contain the confounding effect of LEP in cognitive evaluations.

From "below chance" to "a single error is one too many": Evaluating various thresholds for invalid performance on two forced choice recognition tests.

This study was designed to empirically evaluate the classification accuracy of various definitions of invalid performance in two forced-choice recognition performance validity tests (PVTs; FCRCVLT-II and Test of Memory Malingering [TOMM-2]). The proportion of at and below chance level responding defined by the binomial theory and making any errors was computed across two mixed clinical samples from the United States and Canada (N = 470) and two sets of criterion PVTs. There was virtually no overlap between the binomial and empirical distributions. Over 95% of patients who passed all PVTs obtained a perfect score. At chance level responding was limited to patients who failed ≥2 PVTs (91% of them failed 3 PVTs). No one scored below chance level on FCRCVLT-II or TOMM-2. All 40 patients with dementia scored above chance. Although at or below chance level performance provides very strong evidence of non-credible responding, scores above chance level have no negative predictive value. Even at chance level scores on PVTs provide compelling evidence for non-credible presentation. A single error on the FCRCVLT-II or TOMM-2 is highly specific (0.95) to psychometrically defined invalid performance. Defining non-credible responding as below chance level scores is an unnecessarily restrictive threshold that gives most examinees with invalid profiles a Pass.

Take Their Word for It: The Inventory of Problems Provides Valuable Information on Both Symptom and Performance Validity.

This study was designed to compare the validity of the Inventory of Problems (IOP-29) and its newly developed memory module (IOP-M) in 150 patients clinically referred for neuropsychological assessment. Criterion groups were psychometrically derived based on established performance and symptom validity tests (PVTs and SVTs). The criterion-related validity of the IOP-29 was compared to that of the Negative Impression Management scale of the Personality Assessment Inventory (NIMPAI) and the criterion-related validity of the IOP-M was compared to that of Trial-1 on the Test of Memory Malingering (TOMM-1). The IOP-29 correlated significantly more strongly (z = 2.50, p = .01) with criterion PVTs than the NIMPAI (rIOP-29 = .34; rNIM-PAI = .06), generating similar overall correct classification values (OCCIOP-29: 79-81%; OCCNIM-PAI: 71-79%). Similarly, the IOP-M correlated significantly more strongly (z = 2.26, p = .02) with criterion PVTs than the TOMM-1 (rIOP-M = .79; rTOMM-1 = .59), generating similar overall correct classification values (OCCIOP-M: 89-91%; OCCTOMM-1: 84-86%). Findings converge with the cumulative evidence that the IOP-29 and IOP-M are valuable additions to comprehensive neuropsychological batteries. Results also confirm that symptom and performance validity are distinct clinical constructs, and domain specificity should be considered while calibrating instruments.

BNT-15: Revised Performance Validity Cutoffs and Proposed Clinical Classification Ranges.

BACKGROUND: Abbreviated neurocognitive tests offer a practical alternative to full-length versions but often lack clear interpretive guidelines, thereby limiting their clinical utility. OBJECTIVE: To replicate validity cutoffs for the Boston Naming Test-Short Form (BNT-15) and to introduce a clinical classification system for the BNT-15 as a measure of object-naming skills. METHOD: We collected data from 43 university students and 46 clinical patients. Classification accuracy was computed against psychometrically defined criterion groups. Clinical classification ranges were developed using a z -score transformation. RESULTS: Previously suggested validity cutoffs (≤11 and ≤12) produced comparable classification accuracy among the university students. However, a more conservative cutoff (≤10) was needed with the clinical patients to contain the false-positive rate (0.20-0.38 sensitivity at 0.92-0.96 specificity). As a measure of cognitive ability, a perfect BNT-15 score suggests above average performance; ≤11 suggests clinically significant deficits. Demographically adjusted prorated BNT-15 T-scores correlated strongly (0.86) with the newly developed z -scores. CONCLUSION: Given its brevity (<5 minutes), ease of administration and scoring, the BNT-15 can function as a useful and cost-effective screening measure for both object-naming/English proficiency and performance validity. The proposed clinical classification ranges provide useful guidelines for practitioners.

Delirium as a Presenting Symptom of COVID-19.

BACKGROUND: Delirium is a common neurologic manifestation of coronavirus disease 2019 (COVID-19) in older adults who present to the emergency department (ED). OBJECTIVE: To investigate clinical characteristics associated with delirium as a presenting symptom of COVID-19 in older adults and develop a logistic regression to predict the likelihood of delirium. METHOD: We compared clinical characteristics in an age- and gender-matched sample of 68 delirious individuals with 68 nondelirious individuals (Mage = 78) who presented to the ED with COVID-19. RESULTS: The delirious group was more likely to have neurologic, psychiatric, and cardiovascular comorbidities; a prior history of delirium; and deliriogenic medications in their medication list. They were less likely to present with respiratory symptoms and more likely to present with sepsis, hypoxia, higher heart rate, and higher sodium. The delirious group had higher mortality (51%) than the nondelirious group (32%). Delirium developed within an average of 2 days of initial COVID-19 symptom onset, with symptom onset to ED within an average of 4 days and symptom onset to death within an average of 11 days. Logistic regression based on five delirium predictors correctly predicted 80% of those with delirium (75% sensitivity at 86% specificity). CONCLUSION: Our results are largely consistent with prior studies and suggest that delirium is a common, early occurring, and lethal manifestation of COVID-19 in older adults presenting to the ED, in most cases causing acute on chronic neurocognitive dysfunction strongly influenced by inflammatory and hypoxic-ischemic mechanisms.

Altered mental status in 71 deaths due to COVID-19.

OBJECTIVE: The purpose of this study was to investigate the occurrence of neurologic symptoms with a focus on altered mental status in a sample of deaths due to COVID-19. METHODS: We reviewed neurologic symptoms in 71 deaths due to COVID-19 at the first US hospital with reported cases, of which 66 (93%) had medical comorbidities, 47 (66%) came from assisted living facilities or nursing homes and 35 (49%) had baseline dementia. RESULTS: Sixty-one patients (86%) demonstrated neurologic symptoms at hospital admission. Altered mental status was seen in 47 patients (66%) and represented the most common neurologic symptom. Seven patients (10%) were comatose at hospital admission and 5 (7%) presented with altered mental status without respiratory symptoms. Three patients had seizures and two had strokes. Hypertension (61%), cardiovascular disease (59%), and dementia (49%) were the most common comorbidities associated with death due to COVID-19 in our sample. CONCLUSIONS: Neurologic symptoms, particularly altered mental status, are very common in COVID-19 patients with high risk of mortality. In a small subset of patients, altered mental status is the defining feature of disease presentation. A mental status examination should be incorporated in the medical assessment of COVID-19.

Predictors of survival in older adults hospitalized with COVID-19.

OBJECTIVE: This study was designed to investigate clinical characteristics associated with mortality and predictors of survival in older adults hospitalized with COVID-19 with a focus on neurological comorbidities and presenting neurological manifestations. METHODS: We compared clinical characteristics in an age- and gender-matched sample of 75 deceased and 75 recovered patients (MAge = 78) hospitalized with COVID-19 and developed a logistic regression to predict likelihood of survival. RESULTS: Deceased patients were more like to have dementia, altered mental status (AMS), acute respiratory distress syndrome (ARDS), sepsis, mechanical ventilation, and balance difficulties; higher heart rate, respiratory rate, blood urea nitrogen, creatinine, and absolute neutrophils; lower oxygen saturation and absolute lymphocytes; and shorter length of hospitalization. Logistic regression based on three mortality predictors (ARDS, AMS, and length of hospitalization) correctly predicted 87% of the outcome (89% sensitivity at 85% specificity). CONCLUSIONS: Dementia and AMS were strong predictors of death in older adults hospitalized with COVID-19. Our findings add to the rapidly growing neurology of COVID-19 literature and underscore the importance of early recognition and the incorporation of a mental status examination into the medical assessment of COVID-19.

Introducing the ImPACT-5: An Empirically Derived Multivariate Validity Composite.

OBJECTIVE: To create novel Immediate Post-Concussion and Cognitive Testing (ImPACT)-based embedded validity indicators (EVIs) and to compare the classification accuracy to 4 existing EVIImPACT. METHOD: The ImPACT was administered to 82 male varsity football players during preseason baseline cognitive testing. The classification accuracy of existing EVIImPACT was compared with a newly developed index (ImPACT-5A and B). The ImPACT-5A represents the number of cutoffs failed on the 5 ImPACT composite scores at a liberal cutoff (0.85 specificity); ImPACT-5B is the sum of failures on conservative cutoffs (≥0.90 specificity). RESULTS: ImPACT-5A ≥1 was sensitive (0.81), but not specific (0.49) to invalid performance, consistent with EVIImPACT developed by independent researchers (0.68 sensitivity at 0.73-0.75 specificity). Conversely, ImPACT-5B ≥3 was highly specific (0.98), but insensitive (0.22), similar to Default EVIImPACT (0.04 sensitivity at 1.00 specificity). ImPACT-5A ≥3 or ImPACT-5B ≥2 met forensic standards of specificity (0.91-0.93) at 0.33 to 0.37 sensitivity. Also, the ImPACT-5s had the strongest linear relationship with clinically meaningful levels of invalid performance of existing EVIImPACT. CONCLUSIONS: The ImPACT-5s were superior to the standard EVIImPACT and comparable to existing aftermarket EVIImPACT, with the flexibility to optimize the detection model for either sensitivity or specificity. The wide range of ImPACT-5 cutoffs allows for a more nuanced clinical interpretation.

Performance Validity in Collegiate Football Athletes at Baseline Neurocognitive Testing.

OBJECTIVE: To assess the prevalence of invalid performance on baseline neurocognitive testing using embedded measures within computerized tests and individually administered neuropsychological measures, and to examine the influence of incentive status and performance validity on neuropsychological test scores. SETTING: Sport-related concussion management program at a regionally accredited university. PARTICIPANTS: A total of 83 collegiate football athletes completing their preseason baseline assessment within the University's concussion management program and a control group of 140 nonathlete students. DESIGN: Cross-sectional design based on differential incentive status: motivated to do poorly to return to play more quickly after sustaining a concussion (athletes) versus motivated to do well due to incentivizing performance (students). MAIN MEASURES: Immediate Post-Concussion and Cognitive Testing (ImPACT), performance validity tests, and measures of cognitive ability. RESULTS: Half of the athletes failed at least 1 embedded validity indicator within ImPACT (51.8%), and the traditional neuropsychological tests (49.4%), with large effects for performance validity on cognitive test scores (d: 0.62-1.35), incentive status (athletes vs students; d: 0.36-1.15), and the combination of both factors (d: 1.07-2.20) on measures of attention and processing speed. CONCLUSION: Invalid performance on baseline assessment is common (50%), consistent across instruments (ImPACT or neuropsychological tests) and settings (one-on-one or group administration), increases as a function of incentive status (risk ratios: 1.3-4.0) and results in gross underestimates of the athletes' true ability level, complicating the clinical interpretation of the postinjury evaluation and potentially leading to premature return to play.

Differentiating epilepsy from psychogenic nonepileptic seizures using neuropsychological test data.

OBJECTIVE: Differentiating epileptic seizures (ES) from psychogenic nonepileptic seizures (PNES) represents a challenging differential diagnosis with important treatment implications. This study was designed to explore the utility of neuropsychological test scores in differentiating ES from PNES. METHOD: Psychometric data from 72 patients with ES and 33 patients with PNES were compared on various tests of cognitive ability and performance validity. Individual measures that best discriminated the diagnoses were then entered as predictors in a logistic regression equation with group membership (ES vs. PNES) as the criterion. RESULTS: On most tests of cognitive ability, the PNES sample outperformed the ES sample (medium-large effect) and was less likely to fail the Reliable Digit Span. However, patients with PNES failed two embedded validity indicators at significantly higher rates (risk ratios (RR): 2.45-4.16). There were no group differences on the Test of Memory Malingering (TOMM). A logistic regression equation based on seven neuropsychological tests correctly classified 85.1% of patients. The cutoff with perfect specificity was associated with 0.47 sensitivity. CONCLUSIONS: Consistent with previous research, the utility of psychometric methods of differential diagnosis is limited by the complex neurocognitive profiles associated with ES and PNES. Although individual measures might help differentiate ES from PNES, multivariate assessment models have superior discriminant power. The strongest psychometric evidence for PNES appears to be a consistent lack of impairment on tests sensitive to diffuse neurocognitive deficits such as processing speed, working memory, and verbal fluency. While video-electroencephalogram (EEG) monitoring is the gold standard of differential diagnosis, psychometric testing has the potential to enhance clinical decision-making, particularly in complex or unclear cases such as patients with nondiagnostic video-EEGs. Adopting a standardized, fixed neuropsychological battery at epilepsy centers would advance research on the differential diagnostic power of psychometric testing.

A single error is one too many: Examining alternative cutoffs on Trial 2 of the TOMM.

OBJECTIVE: This study investigated the potential of alternative, more liberal cutoffs on Trial 2 of the Test of Memory Malingering (TOMM) to improve classification accuracy relative to the standard cutoffs (≤44). METHOD: The sample consisted of 152 patients (49.3% male) with psychiatric conditions (PSY) and traumatic brain injury (TBI) referred for neuropsychological assessment in a medico-legal setting (MAge = 44.4, MEducation = 11.9 years). Classification accuracy for various TOMM Trial 2 cutoffs was computed against three criterion measures. RESULTS: Patients with TBI failed TOMM Trial 2 cutoffs at higher rates than patients with PSY. Trial 2 ≤49 achieved acceptable combinations of sensitivity (0.38-0.67) and specificity (0.89-0.96) in all but one comparison group. Trial 2 ≤48 improved specificity (0.94-0.98) with minimal loss in sensitivity. The standard cutoff (≤44) disproportionally traded sensitivity (0.15-0.50) for specificity (0.96-1.00). CONCLUSIONS: One error on TOMM Trial 2 constitutes sufficient evidence to question the credibility of a response set. However, the confidence in classifying a score as invalid continues to increase with each additional error. Even at the most liberal conceivable cutoff (≤49), the TOMM detected only about half of the patients who failed other criterion measures. Therefore, it should never be used in isolation to determine performance validity.

CVLT-II Forced Choice Recognition Trial as an Embedded Validity Indicator: A Systematic Review of the Evidence.

OBJECTIVES: The Forced Choice Recognition (FCR) trial of the California Verbal Learning Test, 2nd edition, was designed as an embedded performance validity test (PVT). To our knowledge, this is the first systematic review of classification accuracy against reference PVTs. METHODS: Results from peer-reviewed studies with FCR data published since 2002 encompassing a variety of clinical, research, and forensic samples were summarized, including 37 studies with FCR failure rates (N=7575) and 17 with concordance rates with established PVTs (N=4432). RESULTS: All healthy controls scored >14 on FCR. On average, 16.9% of the entire sample scored ≤14, while 25.9% failed reference PVTs. Presence or absence of external incentives to appear impaired (as identified by researchers) resulted in different failure rates (13.6% vs. 3.5%), as did failing or passing reference PVTs (49.0% vs. 6.4%). FCR ≤14 produced an overall classification accuracy of 72%, demonstrating higher specificity (.93) than sensitivity (.50) to invalid performance. Failure rates increased with the severity of cognitive impairment. CONCLUSIONS: In the absence of serious neurocognitive disorder, FCR ≤14 is highly specific, but only moderately sensitive to invalid responding. Passing FCR does not rule out a non-credible presentation, but failing FCR rules it in with high accuracy. The heterogeneity in sample characteristics and reference PVTs, as well as the quality of the criterion measure across studies, is a major limitation of this review and the basic methodology of PVT research in general. (JINS, 2016, 22, 851-858).

The classification accuracy of Warrington's recognition memory test (words) as a performance validity Test in a neurorehabilitation setting.

This study was designed to evaluate the classification accuracy of the Warrington's Recognition Memory Test (RMT) in 167 patients (97 or 58.1% men; MAge = 40.4; MEducation= 13.8) medically referred for neuropsychological evaluation against five psychometrically defined criterion groups. At the optimal cutoff (≤42), the RMT produced an acceptable combination of sensitivity (.36-.60) and specificity (.85-.95), correctly classifying 68.4-83.3% of the sample. Making the cutoff more conservative (≤41) improved specificity (.88-.95) at the expense of sensitivity (.30-.60). Lowering the cutoff to ≤40 achieved uniformly high specificity (.91-.95) but diminished sensitivity (.27-.48). RMT scores were unrelated to lateral dominance, education, or gender. The RMT was sensitive to a three-way classification of performance validity (Pass/Borderline/Fail), further demonstrating its discriminant power. Despite a notable decline in research studies focused on its classification accuracy within the last decade, the RMT remains an effective free-standing PVT that is robust to demographic variables. Relatively low sensitivity is its main liability. Further research is needed on its cross-cultural validity (sensitivity to limited English proficiency).

Replicating the classification accuracy of the Verbal Paired Associates and Visual Reproduction recognition trials as embedded performance validity tests.

OBJECTIVE: This study was designed to replicate previous research on the clinical utility of the Verbal Paired Associates (VPA) and Visual Reproduction (VR) subtests of the WMS-IV as embedded performance validity tests (PVTs) and perform a critical item (CR) analysis within the VPA recognition trial. METHOD: Archival data were collected from a mixed clinical sample of 119 adults (MAge = 42.5, MEducation = 13.9). Classification accuracy was computed against psychometrically defined criterion groups based on the outcome of various free-standing and embedded PVTs. RESULTS: Age-corrected scaled scores ≤ 6 were specific (.89-.98) but had variable sensitivity (.36-.64). A VPA recognition cutoff of ≤ 34 produced a good combination of sensitivity (.46-.56) and specificity (.92-.93), as did a VR recognition cutoff of ≤ 4 (.48-.53 sensitivity at .86-.94 specificity). Critical item analysis expanded the VPA's sensitivity by 3.5%-7.0% and specificity by 5%-8%. Negative learning curves (declining output on subsequent encoding trials) were rare but highly specific (.99-1.00) to noncredible responding. CONCLUSIONS: Results largely support previous reports on the clinical utility of the VPA and VR as embedded PVTs. Sample-specific fluctuations in their classification accuracy warrant further research into the generalizability of the findings. Critical item analysis offers a cost-effective method for increasing confidence in the interpretation of the VPA recognition trial as a PVT. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Multivariate Models of Performance Validity: The Erdodi Index Captures the Dual Nature of Non-Credible Responding (Continuous and Categorical).

This study was designed to examine the classification accuracy of the Erdodi Index (EI-5), a novel method for aggregating validity indicators that takes into account both the number and extent of performance validity test (PVT) failures. Archival data were collected from a mixed clinical/forensic sample of 452 adults referred for neuropsychological assessment. The classification accuracy of the EI-5 was evaluated against established free-standing PVTs. The EI-5 achieved a good combination of sensitivity (.65) and specificity (.97), correctly classifying 92% of the sample. Its classification accuracy was comparable with that of another free-standing PVT. An indeterminate range between Pass and Fail emerged as a legitimate third outcome of performance validity assessment, indicating that the underlying construct is an inherently continuous variable. Results support the use of the EI model as a practical and psychometrically sound method of aggregating multiple embedded PVTs into a single-number summary of performance validity. Combining free-standing PVTs with the EI-5 resulted in a better separation between credible and non-credible profiles, demonstrating incremental validity. Findings are consistent with recent endorsements of a three-way outcome for PVTs (Pass, Borderline, and Fail).

Limited English proficiency inhibits auditory verbal learning in cognitively healthy young adults - exploring culturally responsive diagnostic and educational safeguards.

This study was designed to examine the effect of limited English proficiency (LEP) on the Hopkins Verbal Learning Test-Revised (HVLT-R). The HVLT-R was administered to 28 undergraduate student volunteers. Half were native speakers of English (NSE), half had LEP. The LEP sample performed significantly below NSE on individual acquisition trials and delayed free recall (large effects). In addition, participants with LEP scored 1.5-2 SDs below the normative mean. There was no difference in performance during recognition testing. LEP status was associated with a clinically significant deficit on the HVLT-R in a sample of cognitively healthy university students. Results suggest that low scores on auditory verbal learning tests in individuals with LEP should not be automatically interpreted as evidence of memory impairment or learning disability. LEP should be considered as grounds for academic accommodations. The generalizability of the findings is constrained by the small sample size.

Settling the Score: Can CPT-3 Embedded Validity Indicators Distinguish Between Credible and Non-Credible Responders Referred for ADHD and/or SLD?

OBJECTIVE: The purpose of the present study was to further investigate the clinical utility of individual and composite indicators within the CPT-3 as embedded validity indicators (EVIs) given the discrepant findings of previous investigations. METHODS: A total of 201 adults undergoing psychoeducational evaluation for ADHD and/or Specific Learning Disorder (SLD) were divided into credible (n = 159) and non-credible (n = 42) groups based on five criterion measures. RESULTS: Receiver operating characteristic curves (ROC) revealed that 5/9 individual indicators and 2/4 composite indicators met minimally acceptable classification accuracy of ≥0.70 (AUC = 0.43-0.78). Individual (0.16-0.45) and composite indicators (0.23-0.35) demonstrated low sensitivity when using cutoffs that maintained specificity ≥90%. CONCLUSION: Given the lack of stability across studies, further research is needed before recommending any specific cutoff be used in clinical practice with individuals seeking psychoeducational assessment.

Multivariate models provide an effective psychometric solution to the variability in classification accuracy of D-KEFS Stroop performance validity cutoffs.

ObjectiveThe study was designed to expand on the results of previous investigations on the D-KEFS Stroop as a performance validity test (PVT), which produced diverging conclusions. Method The classification accuracy of previously proposed validity cutoffs on the D-KEFS Stroop was computed against four different criterion PVTs in two independent samples: patients with uncomplicated mild TBI (n = 68) and disability benefit applicants (n = 49). Results Age-corrected scaled scores (ACSSs) ≤6 on individual subtests often fell short of specificity standards. Making the cutoffs more conservative improved specificity, but at a significant cost to sensitivity. In contrast, multivariate models (≥3 failures at ACSS ≤6 or ≥2 failures at ACSS ≤5 on the four subtests) produced good combinations of sensitivity (.39-.79) and specificity (.85-1.00), correctly classifying 74.6-90.6% of the sample. A novel validity scale, the D-KEFS Stroop Index correctly classified between 78.7% and 93.3% of the sample. Conclusions A multivariate approach to performance validity assessment provides a methodological safeguard against sample- and instrument-specific fluctuations in classification accuracy, strikes a reasonable balance between sensitivity and specificity, and mitigates the invalid before impaired paradox.

Logical memory, visual reproduction, and verbal paired associates are effective embedded validity indicators in patients with traumatic brain injury.

OBJECTIVE: This study was design to evaluate the potential of the recognition trials for the Logical Memory (LM), Visual Reproduction (VR), and Verbal Paired Associates (VPA) subtests of the Wechsler Memory Scales-Fourth Edition (WMS-IV) to serve as embedded performance validity tests (PVTs). METHOD: The classification accuracy of the three WMS-IV subtests was computed against three different criterion PVTs in a sample of 103 adults with traumatic brain injury (TBI). RESULTS: The optimal cutoffs (LM ≤ 20, VR ≤ 3, VPA ≤ 36) produced good combinations of sensitivity (.33-.87) and specificity (.92-.98). An age-corrected scaled score of ≤5 on either of the free recall trials on the VPA was specific (.91-.92) and relatively sensitive (.48-.57) to psychometrically defined invalid performance. A VR I ≤ 5 or VR II ≤ 4 had comparable specificity, but lower sensitivity (.25-.42). There was no difference in failure rate as a function of TBI severity. CONCLUSIONS: In addition to LM, VR, and VPA can also function as embedded PVTs. Failing validity cutoffs on these subtests signals an increased risk of non-credible presentation and is robust to genuine neurocognitive impairment. However, they should not be used in isolation to determine the validity of an overall neurocognitive profile.