Importance of validity testing in psychiatric assessment: evidence from a sample of multimorbid post-9/11 veterans.

OBJECTIVE: Performance validity (PVTs) and symptom validity tests (SVTs) are necessary components of neuropsychological testing to identify suboptimal performances and response bias that may impact diagnosis and treatment. The current study examined the clinical and functional characteristics of veterans who failed PVTs and the relationship between PVT and SVT failures. METHOD: Five hundred and sixteen post-9/11 veterans participated in clinical interviews, neuropsychological testing, and several validity measures. RESULTS: Veterans who failed 2+ PVTs performed significantly worse than veterans who failed one PVT in verbal memory (Cohen's d = .60-.69), processing speed (Cohen's d = .68), working memory (Cohen's d = .98), and visual memory (Cohen's d = .88-1.10). Individuals with 2+ PVT failures had greater posttraumatic stress (PTS; ß = 0.16; p = .0002), and worse self-reported depression (ß = 0.17; p = .0001), anxiety (ß = 0.15; p = .0007), sleep (ß = 0.10; p = .0233), and functional outcomes (ß = 0.15; p = .0009) compared to veterans who passed PVTs. 7.8% veterans failed the SVT (Validity-10; ≥19 cutoff); Multiple PVT failures were significantly associated with Validity-10 failure at the ≥19 and ≥23 cutoffs (p's < .0012). The Validity-10 had moderate correspondence in predicting 2+ PVTs failures (AUC = 0.83; 95% CI = 0.76, 0.91). CONCLUSION: PVT failures are associated with psychiatric factors, but not traumatic brain injury (TBI). PVT failures predict SVT failure and vice versa. Standard care should include SVTs and PVTs in all clinical assessments, not just neuropsychological assessments, particularly in clinically complex populations.

An overview of malingering and deception in neuropsychiatric cases.

Forensic practitioners must shoulder special responsibilities when evaluating over-stated pathology (e.g., malingering) as well as simulated adjustment. Such determinations may modify or even override other clinical findings. As a result, practitioners must be alert to their own misassumptions that may unintentionally bias their conclusions about response styles. Detection strategies for malingering-based on unlikely or markedly amplified presentations-are highlighted in this article. Given page constraints, assessment methods for feigning are succinctly presented with their applications to administrative, civil, and criminal referrals.

Forensic neuropsychological assessment.

With its firm establishment as a neuropsychology subspecialty, forensic neuropsychological assessment is integral to many criminal and civil forensic evaluations. In addition to evaluating cognitive deficits, forensic neuropsychologists can provide reliable information regarding symptom magnification, malingering, and other neurocognitive and psychological issues that may impact the outcome of a particular legal case. This article is an overview and introduction to neuropsychological assessment in the forensic mental health context. Major issues impacting the current practice of forensic neuropsychology are summarized, and several examples from case law are highlighted.

Forensic assessment of somatoform and functional neurological disorders.

Functional neurological disorders (FND) and somatization are common in clinical practice and medicolegal settings. These conditions are frequently disabling and, if arising following an accident, may lead to claims for legal compensation or occupational disability (such as social security disability insurance). However, distinguishing FND and somatization from symptoms that are intentionally produced (i.e., malingered or factitious) may pose a major forensic psychiatric challenge. In this article, we describe how somatoform disorders and FND lie along a spectrum of abnormal illness-related behaviors, including factitious disorder, compensation neurosis, and malingering. We provide a systematic approach to the forensic assessment of FND and conclude by describing common litigation scenarios in which FND may be at issue. Forensic testimony may play an important role in the resolution of such cases.

MMPI-2-RF Profiles of Treatment-Seeking Veterans in a VA Pain Clinic and Associations with Markers of Physical Performance.

Chronic pain is a debilitating condition for many military Veterans and is associated with posttraumatic stress disorder (PTSD). This study examined the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in 144 Veterans (88.2% male, mean age = 57.95 years) recruited from a VA outpatient pain clinic and associations with self-reported pain severity, pain-related interference in daily activities, prescription opioid use, and objective metrics of physical performance on tasks impacted by pain (walking, stair climbing, grip strength, indexed by a single latent variable). Among the cohort with valid responses on the MMPI-2-RF (n = 117) and probable PTSD, mean Somatic Complaints (RC1) and Ideas of Persecution (RC6) scores were clinically elevated. All MMPI-2-RF scales were more strongly correlated with self-reported pain interference than severity. Regressions revealed associations between self-rated pain interference (but not pain or PTSD severity) and physical performance scores (ß = .36, p = .001). MMPI-2-RF overreporting Validity and Higher-Order scales contributed incremental variance in predicting physical performance, including Infrequent Psychopathology Responses (ß = .33, p = .002). PTSD severity was associated with prescription opioid use when accounting for the effects of over-reported somatic and cognitive symptoms (odds ratio 1.05, p ≤ .025). Results highlight the role of symptom overreporting and perceptions of functional impairment to observable behaviors among individuals with chronic pain.

Performance validity tests in nonlitigant patients with functional motor disorder.

BACKGROUND AND PURPOSE: Performance validity tests (PVTs) are used in neuropsychological assessments to detect patterns of performance suggesting that the broader evaluation may be an invalid reflection of an individual's abilities. Data on functional motor disorder (FMD) are currently poor and conflicting. We aimed to examine the rate of failure on three different PVTs of nonlitigant, non-compensation-seeking FMD patients, and we compared their performance to that of healthy controls and controls asked to simulate malingering (healthy simulators). METHODS: We enrolled 29 nonlitigant, non-compensation-seeking patients with a clinical diagnosis of FMD, 29 healthy controls, and 29 healthy simulators. Three PVTs, the Coin in the Hand Test (CIH), the Rey 15-Item Test (REY), and the Finger Tapping Test (FTT), were employed. RESULTS: Functional motor disorder patients showed low rates of failure on the CIH and REY (7% and 10%, respectively) and slightly higher rates on the FTT (15%, n = 26), which implies a motor task. Their performance was statistically comparable to that of healthy controls but statistically different from that of healthy simulators (p < 0.001). Ninety-three percent of FMD patients, 7% of healthy simulators, and 100% of healthy controls passed at least two of the three tests. CONCLUSIONS: Performance validity test performance of nonlitigant, non-compensation-seeking patients with FMD ranged from 7% to 15%. Patients' performance was comparable to that of controls and significantly differed from that of simulators. This simple battery of three PVTs could be of practical utility and routinely used in clinical practice.

Low rate of performance validity failures among individuals with bipolar disorder.

OBJECTIVE: Assessing performance validity is imperative in both clinical and research contexts as data interpretation presupposes adequate participation from examinees. Performance validity tests (PVTs) are utilized to identify instances in which results cannot be interpreted at face value. This study explored the hit rates for two frequently used PVTs in a research sample of individuals with and without histories of bipolar disorder (BD). METHOD: As part of an ongoing longitudinal study of individuals with BD, we examined the performance of 736 individuals with BD and 255 individuals with no history of mental health disorder on the Test of Memory Malingering (TOMM) and the California Verbal Learning Test forced choice trial (CVLT-FC) at three time points. RESULTS: Undiagnosed individuals demonstrated 100% pass rate on PVTs and individuals with BD passed over 98% of the time. A mixed effects model adjusting for relevant demographic variables revealed no significant difference in TOMM scores between the groups, a = .07, SE = .07, p = .31. On the CVLT-FC, no clinically significant differences were observed (ps < .001). CONCLUSIONS: Perfect PVT scores were obtained by the majority of individuals, with no differences in failure rates between groups. The tests have approximately >98% specificity in BD and 100% specificity among non-diagnosed individuals. Further, nearly 90% of individuals with BD obtained perfect scores on both measures, a trend observed at each time point.

Development and application of novel performance validity metrics for computerized neurocognitive batteries.

OBJECTIVES: Data from neurocognitive assessments may not be accurate in the context of factors impacting validity, such as disengagement, unmotivated responding, or intentional underperformance. Performance validity tests (PVTs) were developed to address these phenomena and assess underperformance on neurocognitive tests. However, PVTs can be burdensome, rely on cutoff scores that reduce information, do not examine potential variations in task engagement across a battery, and are typically not well-suited to acquisition of large cognitive datasets. Here we describe the development of novel performance validity measures that could address some of these limitations by leveraging psychometric concepts using data embedded within the Penn Computerized Neurocognitive Battery (PennCNB). METHODS: We first developed these validity measures using simulations of invalid response patterns with parameters drawn from real data. Next, we examined their application in two large, independent samples: 1) children and adolescents from the Philadelphia Neurodevelopmental Cohort (n = 9498); and 2) adult servicemembers from the Marine Resiliency Study-II (n = 1444). RESULTS: Our performance validity metrics detected patterns of invalid responding in simulated data, even at subtle levels. Furthermore, a combination of these metrics significantly predicted previously established validity rules for these tests in both developmental and adult datasets. Moreover, most clinical diagnostic groups did not show reduced validity estimates. CONCLUSIONS: These results provide proof-of-concept evidence for multivariate, data-driven performance validity metrics. These metrics offer a novel method for determining the performance validity for individual neurocognitive tests that is scalable, applicable across different tests, less burdensome, and dimensional. However, more research is needed into their application.

What are the predictors of TOMM failure in clinical TBI populations? A retrospective analysis.

OBJECTIVES: To determine base rates of invalid performance on the Test of Memory Malingering (TOMM) in patients with traumatic brain injury (TBI) undertaking rehabilitation who were referred for clinical assessment, and the factors contributing to TOMM failure. METHODS: Retrospective file review of consecutive TBI referrals for neuropsychological assessment over seven years. TOMM failure was conventionally defined as performance <45/50 on Trial 2 or Retention Trial. Demographic, injury, financial compensation, occupational, and medical variables were collected. RESULTS: Four hundred and ninety one TBI cases (Median age = 40 years [IQR = 26-52], 79% male, 82% severe TBI) were identified. Overall, 48 cases (9.78%) failed the TOMM. Logistic regression analyses revealed that use of an interpreter during the assessment (adjusted odds ratio [aOR] = 8.25, 95%CI = 3.96-17.18), outpatient setting (aOR = 4.80, 95%CI = 1.87-12.31) and post-injury psychological distress (aOR = 2.77, 95%CI = 1.35-5.70) were significant multivariate predictors of TOMM failure. The TOMM failure rate for interpreter cases was 49% (21/43) in the outpatient setting vs. 7% (2/30) in the inpatient setting. By comparison, 9% (21/230) of non-interpreter outpatient cases failed the TOMM vs. 2% (4/188) of inpatient cases. CONCLUSIONS: TOMM failure very rarely occurs in clinical assessment of TBI patients in the inpatient rehabilitation setting. It is more common in the outpatient setting, particularly in non-English-speaking people requiring an interpreter. The findings reinforce the importance of routinely administering stand-alone performance validity tests in assessments of clinical TBI populations, particularly in outpatient settings, to ensure that neuropsychological test results can be interpreted with a high degree of confidence.

Assessing malingering and personality styles in dissociative identity disorder: a case study.

Dissociative Identity Disorder (DID), formerly Multiple Personality Disorder, involves two or more distinct identities controlling behaviour, stemming from trauma-related dissociation. Understanding DID's cognitive, neural, and psychometric aspects remains a challenge, especially in distinguishing genuine cases from malingering. We present a case of a DID patient with nine identities, evaluated to rule out malingering. Using the Millon Index of Personality Styles, we assessed the primary and two alternate identities, revealing marked differences. High consistency scores support validity. We suggest employing personality inventories beyond symptomatology to characterise dissociative identities' consistency and adaptation styles, aiding in malingering assessments in future studies.

Analysis of malingered psychological symptoms in a clinical sample for early detection in initial interviews.

Malingering consists of the production of false physical or psychological symptoms motivated by external incentives that are normally reproduced in pathologies that are not related to organic origin or there are no laboratory tests for their diagnosis, as is the case of mixed anxiety-depressive disorder and fibromyalgia syndrome. The objective of this research consisted of comparing the profile of simulative patients with fibromyalgia and mixed anxiety-depressive disorder to obtain a profile and facilitate its detection in initial interviews. The research was carried out with 78 patients (42 patients with fibromyalgia and 36 patients with mixed anxiety-depressive disorder) who were administered the professional's structured clinical judgment, the Beck Depression Inventory, the State-Trait Anxiety Questionnaire, and the Structured Symptom Simulation Inventory. The main obtained results show that the simulation classification proposed by the questionnaire is in the range of 66.67-80% with regard to coinciding with the judgment of experts, and people with suspicion of simulation of both groups of patients present similar characteristics. The simulators thus present incongruous responses in relation to the questionnaires, and high levels of trait anxiety, state, and depression predict the simulation of symptoms.

Ruling out feigned crime-related amnesia? A response to Acklin (2022).

In a recent paper, Acklin discussed a case of possible amnesia for a murder in terms of neurobiology, psychoanalysis, and personality assessment. Acklin accepted the defendant's claim of amnesia for the crime as genuine. The considerable literature that takes a skeptical view of crime-related amnesia was not cited, and the possibility of feigning or malingering was "ruled out" with a single sentence that does not withstand scrutiny. A review of the literature on feigned amnesia suggests that it may not be possible to rule out malingering even if the best available tools are used: There has been minimal investigation of most validity tests and estimates of base rates of feigned amnesia for a crime vary widely and make estimates of Negative Predictor Power highly unreliable. Although one cannot know from the information presented if Acklin's defendant legitimately experienced amnesia, feigning could not be ruled out using an interview and the test data cited by Acklin. I call for a moratorium on publication of further articles on crime specific amnesia that do not conscientiously examine other potential explanations and do not use current best practices for assessing negative response bias.

Do we know the mind of others? Suspicion of malingering in emergency psychiatry.

INTRODUCTION: Malingering can be divided into simulation and exaggeration of symptoms. Malingering has traditionally been considered rare in general psychiatry. In contrast to earlier estimates, more recent studies report that doctors suspect malingering frequently in psychiatric emergency departments. The aim of this study is to survey how often doctors in psychiatric emergency units in a public, free-of-charge, mental health service suspect that patients are malingering, and which diagnoses, symptom complaints and suspected reasons for malingering doctors ascribe to their patients. METHODS: Questionnaires were distributed in three psychiatric emergency departments in Denmark. Suspected simulation and exaggeration were rated with a 5-point scale. Doctors were encouraged to write down the symptoms and perceived causes for suspected malingering. RESULTS: 362 questionnaires were filled in. 25% of all patients were suspected of simulating to some degree. 8% of patients were highly suspected or definitely believed to be simulating. Patients complaining of suicidal ideation were most frequently suspected of malingering. 'Attention seeking' was the most common suspected reason for malingering. Patients with diagnoses of substance use and personality disorder were the most suspected of malingering. CONCLUSION: This is the first study to investigate doctors' suspicions of psychiatric malingering in a European setting. Patients with established personality and substance use disorder are at higher risk of being suspected of malingering, which potentially affects the course of treatment significantly. The rise in suspected malingering is conspicuous and requires further investigation. Doctors are encouraged to act conservatively upon suspicion of malingering in emergency psychiatry.

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.

Structured Interview of Reported Symptoms-2nd Edition (SIRS-2): Use and Admissibility in Forensic Mental Health Assessment.

Assessment of symptom feigning is paramount in forensic psychological and psychiatric assessment. The Structured Interview of Reported Symptoms, 2nd Edition (SIRS-2; Rogers et al., 2010) is a revised edition to the original SIRS (Rogers et al., Structured Interview of Reported Symptoms (SIRS) and professional manual. Psychological Assessment Resources, Inc, 1992) and was developed to assess feigned psychiatric symptoms. The current paper reviews use of the SIRS-2 in forensic assessment, specifically addressing topics such as translations of the instrument, its use in assessing psychiatric and cognitive feigning, and its use in special populations. Empirical foundation and psychometric properties of the SIRS-2 is also covered. The SIRS-2 was revised in part to reduce false positive classifications of feigning. Research suggests that this goal was largely accomplished, albeit at the expense of reduced sensitivity. The paper also provides a review of federal and state appellate cases that mention the SIRS-2. Notably, most cases that cite the SIRS-2 do not actually center on the SIRS-2, and the test's admissibility has never been outrightly challenged. The paper concludes with a discussion of expert testimony concerning the SIRS-2.

[Validity of the "Structured Inventory of Malingered Symptomatology" [SIMS] in the Assessment of Healthy Individuals and Patients with Psychiatric Disorders Outside the Forensic Context]. / Validität des "Strukturierten Fragebogens Simulierter Symptome" [SIMS] bei gesunden Probanden und Patienten mit psychiatrischen Erkrankungen außerhalb eines forensischen Kontexts.

OBJECTIVE: Assessment of the rate of false-positive results of the Structured Inventory of Malingered Symptomatology (SIMS) in healthy controls and authentic patients outside the forensic or rehabilitative context. METHODS: Beyond the SIMS scores, further variables (PANSS, Hamilton scale, MMSE) were obtained. SIMS scores of healthy individuals were compared with the SIMS scores of the different groups of patients. Additionally, correlations between the SIMS scores and other variables were investigated. RESULTS: Patients with psychotic disorders (n=30) or depressive episodes (n=32) more frequently achieved SIMS scores >16 as compared to healthy controls. In comparison, patients with amnestic disorders (n=15) had inconspicuous SIMS scores. Depressed patients with positive SIMS results were significantly more likely to be diagnosed with another psychiatric disorder and the scores of these patients on the Hamilton scale were correlated with positive results on 2 subscales of the SIMS (NI, AF). CONCLUSION: If this instrument is to applied in clinical practice in the future, further validation of the SIMS is necessary. The specificity of the SIMS seems to be context-related.

A comparison of the self-report patterns of analog versus real-world malingerers of attention deficit hyperactivity disorder.

Much of what we know about malingering of attention deficit hyperactivity disorder (ADHD) has been learned from the performance of analog malingerers, typically first-year psychology students given credit for study participation. It is not clear, however, whether their performance is similar to that found in actual clinical settings. Indeed, past research suggests that analog malingerers may overexaggerate deficits relative to real-world malingerers, making them easier to identify in controlled studies. The purpose of the current study was, therefore, to compare the performance of analog malingers to post-secondary students strongly suspected of malingering ADHD on a self-report measure of ADHD symptoms. Their scores were, in turn, compared to those returned by students with genuine ADHD and clinical controls. Results demonstrated that, apart from analog subjects overexaggerating symptoms of hyperactivity, few differences exist between the scores returned by analog malingerers relative to clinical malingerers. While newly devised symptom validity measures show promise in identifying malingered ADHD, neither the analog nor the clinical malingers consistently failed these symptom validity scales. Furthermore, a good portion in both malingering groups failed to endorse high levels of ADHD symptoms in general. Clinical implications are discussed.

The detection of malingering in whiplash-related injuries: a targeted literature review of the available strategies.

OBJECTIVE: The present review is intended to provide an up-to-date overview of the strategies available to detect malingered symptoms following whiplash. Whiplash-associated disorders (WADs) represent the most common traffic injuries, having a major impact on economic and healthcare systems worldwide. Heterogeneous symptoms that may arise following whiplash injuries are difficult to objectify and are normally determined based on self-reported complaints. These elements, together with the litigation context, make fraudulent claims particularly likely. Crucially, at present, there is no clear evidence of the instruments available to detect malingered WADs. METHODS: We conducted a targeted literature review of the methodologies adopted to detect malingered WADs. Relevant studies were identified via Medline (PubMed) and Scopus databases published up to September 2020. RESULTS: Twenty-two methodologies are included in the review, grouped into biomechanical techniques, clinical tools applied to forensic settings, and cognitive-based lie detection techniques. Strengths and weaknesses of each methodology are presented, and future directions are discussed. CONCLUSIONS: Despite the variety of techniques that have been developed to identify malingering in forensic contexts, the present work highlights the current lack of rigorous methodologies for the assessment of WADs that take into account both the heterogeneous nature of the syndrome and the possibility of malingering. We conclude that it is pivotal to promote awareness about the presence of malingering in whiplash cases and highlight the need for novel, high-quality research in this field, with the potential to contribute to the development of standardised procedures for the evaluation of WADs and the detection of malingering.

A model to differentiate WAD patients and people with abnormal pain behaviour based on biomechanical and self-reported tests.

The prevalence of malingering among individuals presenting whiplash-related symptoms is significant and leads to a huge economic loss due to fraudulent injury claims. Various strategies have been proposed to detect malingering and symptoms exaggeration. However, most of them have been not consistently validated and tested to determine their accuracy in detecting feigned whiplash. This study merges two different approaches to detect whiplash malingering (the mechanical approach and the qualitative analysis of the symptomatology) to obtain a malingering detection model based on a wider range of indices, both biomechanical and self-reported. A sample of 46 malingerers and 59 genuine clinical patients was tested using a kinematic test and a self-report questionnaire asking about the presence of rare and impossible symptoms. The collected measures were used to train and validate a linear discriminant analysis (LDA) classification model. Results showed that malingerers were discriminated from genuine clinical patients based on a greater proportion of rare symptoms vs. possible self-reported symptoms and slower but more repeatable neck motions in the biomechanical test. The fivefold cross-validation of the LDA model yielded an area under the curve (AUC) of 0.84, with a sensitivity of 77.8% and a specificity of 84.7%.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering.

BACKGROUND: Malingering is a common and challenging clinical presentation in emergency departments (EDs). OBJECTIVE: This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service. METHODS: Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses. RESULTS: Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01). CONCLUSIONS: No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.