Half of Purposeful Baseline Sandbaggers Undetected by ImPACT's Embedded Invalidity Indicators.

OBJECTIVE: The main objectives of this study were to determine how accurately the embedded invalidity indicators (EIIs) identify purposeful underperformers on the baseline Immediate Post-concussion Assessment and Cognitive Test (ImPACT); and to assess the effectiveness of each individual EII. METHODS: A randomized controlled trial was conducted in which all participants completed a baseline ImPACT assessment. Participants were randomized into a control or purposeful underperformance (sandbagging) group. The primary outcomes measured were the number of participants identified as invalid (via any EII), as well as the ability of each individual EII to detect purposeful sandbagging. Additionally, participants mean raw composite scores and percentiles were evaluated. RESULTS: Seventy-seven participants completed the study (control n = 37, sandbag n = 40.) None of the participants in the control group, and 50% of the purposeful sandbaggers were identified as invalid via the current EIIs. Of the five EIIs, three were unable to identify more than 15% of purposeful sandbaggers. The best performing EIIs were Word Memory and Three Letters, identifying 40% and 35% of purposeful sandbaggers, respectively. Sixty- five percent of the purposeful sandbaggers had at least one composite score ≤1st percentile. Using a composite score ≤1st percentile as potential marker of invalidity would have accurately identified more purposeful sandbaggers than all existing EIIs combined. CONCLUSION: Half of purposeful sandbaggers were not identified by ImPACT's current EIIs. Multiple EIIs were only able to identify <15% of purposeful underperformers, suggesting that reevaluation and/or recalibration of EII cutoffs may be appropriate.

Reliable Digit Span: Does it Adequately Measure Suboptimal Effort in an Adult Epilepsy Population?

OBJECTIVE: Assessment of performance validity is a necessary component of any neuropsychological evaluation. Prior research has shown that cutoff scores of ≤6 or ≤7 on Reliable Digit Span (RDS) can detect suboptimal effort across numerous adult clinical populations; however, these scores have not been validated for that purpose in an adult epilepsy population. This investigation aims to determine whether these previously established RDS cutoff scores could detect suboptimal effort in adults with epilepsy. METHOD: Sixty-three clinically referred adults with a diagnosis of epilepsy or suspected seizures were administered the Digit Span subtest of the Wechsler Adult Intelligence Scale (WAIS-III or WAIS-IV). Most participants (98%) passed Trial 2 of the Test of Memory Malingering (TOMM), achieving a score of ≥45. RESULTS: Previously established cutoff scores of ≤6 and ≤7 on RDS yielded a specificity rate of 85% and 77% respectively. Findings also revealed that RDS scores were positively related to attention and intellectual functioning. Given the less than ideal specificity rate associated with each of these cutoff scores, together with their strong association to cognitive factors, secondary analyses were conducted to identify more optimal cutoff scores. Preliminary results suggest that an RDS cutoff score of ≤4 may be more appropriate in a clinically referred adult epilepsy population with a low average IQ or lower. CONCLUSIONS: Preliminary findings indicate that cutoff scores of ≤6 and ≤7 on RDS are not appropriate in adults with epilepsy, especially in individuals with low average IQ or below.

University students with attention deficit hyperactivity disorder (ADHD): a literature review.

OBJECTIVES: To review existing literature about university students with Attention Deficit Hyperactivity Disorder (ADHD). METHODS: A framework for scoping studies and content analysis were used to source and review selected publications from PubMed, ScienceDirect, Google Scholar and relevant bibliographies. RESULTS: Seventy-four publications were reviewed and key findings were categorised under six core themes that represent the issues germane to university students with ADHD. These themes are: academic, social and psychological functioning, giftedness, new media technologies, treatment, substance misuse and the non-medical use of prescription stimulants, and malingering. CONCLUSION: In Ireland and the United Kingdom (UK) young people with ADHD are unlikely to enrol into further education, and of those who do go to university, few will graduate at the same time as their non-ADHD peers. ADHD is associated with poor educational outcomes and it may be a hidden disability within institutions of higher education (e.g. universities). Surprisingly, in this topic area, there is a paucity of research in Ireland and the UK. Most studies originate from North America were research activity in the field has been ongoing since the 1990s. These studies however, tend to use relatively small samples of college (university) students recruited at a single institution. It is difficult to generalise the findings of these studies to student populations in North America, let alone in Ireland and the UK. At the very least, these North American studies provide insights into key areas of concern. This topic area straddles education and psychiatry. This means an inter-disciplinary approach is required to examine, better understand and address the impact of ADHD on the educational outcomes of university students. The philosophies of difference, equity and self-realisation can offer a conceptual framework for conducting further research and/or developing services to deliver more personalised learning support for university students with ADHD.

Recurrent Ethylene Glycol Poisoning with Elevated Lactate Levels to Obtain Opioid Medications.

BACKGROUND: Malingering is when a patient feigns illness for secondary gain. While most patients with malingering manufacture or exaggerate symptoms, some patients may induce illness. Previous reports of malingering patients inducing illness include sepsis, kidney pain, migraine, and chest pain. However, acute poisoning as a manifestation of malingering appears to be rare. CASE REPORT: We describe the case of a 39-year-old man who presented to the emergency department complaining of diffuse body pain. The patient reported multiple admission at outside hospitals for "lactate" and said, "it feels like it is happening again because of how my body feels." Laboratory findings were concerning for serum lactate of >20.0 mmol/L and ethylene glycol (EG) level of 19 mg/dL. A chart review found that the man had been admitted for elevated serum lactate 8 times to area hospitals in several years, often in the setting of EG poisoning. During these episodes he required intravenous fluids and frequent intravenous pain medications. When confronted about concern regarding the recurrent fallacious lactate levels in the setting of factitious EG ingestion, the patient often became combative and left against medical advice. The primary metabolite of EG, glycolic acid, can interfere with lactate assays, causing a false elevation. Our patient apparently recognized this and took advantage of it to be admitted and receive intravenous opioids. This is the only case known to us of malingering via EG ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware that metabolites of EG may interfere with serum lactate assay. In addition, they should be aware of possible malingering-related poisoning and plausible association with requests for intravenous opioid pain medications. This represents a risk to the patient and others if undiagnosed.

A pilot study on the Chinese Minnesota Multiphasic Personality Inventory-2 in detecting feigned mental disorders: Simulators classified by using the Structured Interview of Reported Symptoms.

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is often used in forensic psychological/psychiatric assessment. This was a pilot study on the utility of the Chinese MMPI-2 in detecting feigned mental disorders. The sample consisted of 194 university students who were either simulators (informed or uninformed) or controls. All the participants were administered the Chinese MMPI-2 and the Structured Interview of Reported Symptoms-2 (SIRS-2). The results of the SIRS-2 were utilized to classify the participants into the feigning or control groups. The effectiveness of eight detection indices was investigated by using item analysis, multivariate analysis of covariance (MANCOVA), and receiver operating characteristic (ROC) analysis. Results indicated that informed-simulating participants with prior knowledge of mental disorders did not perform better in avoiding feigning detection than uninformed-simulating participants. In addition, the eight detection indices of the Chinese MMPI-2 were effective in discriminating participants in the feigning and control groups, and the best cut-off scores of three of the indices were higher than those obtained from the studies using the English MMPI-2. Thus, in this sample of university students, the utility of the Chinese MMPI-2 in detecting feigned mental disorders was tentatively supported, and the Chinese Infrequency Scale (ICH), a scale developed specifically for the Chinese MMPI-2, was also supported as a valid scale for validity checking.

Neural correlates of malingering in mild traumatic brain injury: A positron emission tomography study.

The detection of malingering in cognitive performance is a challenge in clinical and legal environments. Neuroimaging may provide an objective method to determine the source of failure on tests of symptom validity. Participants comprised 45 combat veterans, 31 with mild traumatic brain injury (mTBI), not seeking medical or legal compensation, who completed the Tombaugh Test of Memory Malingering (TOMM) and a positron emission tomography (PET) scan. Based on TOMM performance (i.e., less than 45 of 50 total correct, suggesting suboptimal effort or malingering), subjects were separated into poor TOMM score (PT; n=10) and good TOMM score (GT; n=35) groups. Voxel-based multiple regression analysis with Group (GT/PT) predicting uptake of fluorodeoxyglucose revealed decreased brain metabolism in the ventromedial prefrontal cortex of poor performers. The current findings may suggest that poor TOMM performance in those with combat trauma and mTBI may be related to ventromedial prefrontal cortical dysfunction. These findings have important implications for the disentanglement of feigned versus actual memory impairment, where the latter may be secondary to neural mechanisms not consistent with forgetting or deception.

Accuracy of MMPI-2-RF validity scales for identifying feigned PTSD symptoms, random responding, and genuine PTSD.

The Minnesota Multiphasic Personality Inventory-2-RF (MMPI-2-RF) validity scales were evaluated to determine accuracy when differentiating honest responding, random responding, genuine posttraumatic stress disorder (PTSD), and feigned PTSD. Undergraduate students (n = 109), screened for PTSD, were randomly assigned to 1 of 4 instructional groups: honest, feign PTSD, half random, and full random. Archival data provided clinical MMPI-2-RF profiles consisting of 31 veterans diagnosed with PTSD. Veterans were diagnosed with PTSD using a structured interview and had passed a structured interview for malingering. Validity scales working as a group had correct classification rates of honest (96.6%), full random (88.9%), genuine PTSD (80.7%), fake PTSD (73.1%), and half random (44.4%). Results were fairly supportive of the scales' ability to discriminate feigning and full random responding from honest responding of normal students as well as veterans with PTSD. However, the RF validity scales do not appear to be as effective in detecting partially random responding.

Psychological testing and the assessment of malingering.

This article discusses the prevalence of feigning in both criminal and civil settings and various psychological assessments useful in detecting feigning. The focus of this information is on the various psychological assessments available to assist clinicians in making a determination of whether or not an individual is feigning and concludes with the recommendations that multiple assessments are necessary to improve the sensitivity of detection methods.

Brief report: the temporal stability of the Repeatable Battery for the Assessment of Neuropsychological Status Effort Index in geriatric samples.

The Effort Index (EI) of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was developed to identify inadequate effort. Although researchers have examined its validity, the reliability of the EI has not been evaluated. The current study examined the temporal stability of the EI across 1 year in two independent samples of older adults. One sample consisted of 445 cognitively intact older adults (mean age = 72.89; 59% having 12-15 years of education) and the second sample consisted of 51 individuals diagnosed with amnestic Mild Cognitive Impairment (mean age = 82.41; 41% having 12-15 years of education). For both samples, the EI was found to have low stability (Spearman's ρ = .32-.36). When participants were divided into those whose EI stayed stable or improved versus those whose EI worsened (i.e., declining effort) on retesting, it was observed that individuals with lower baseline RBANS Total scores tended to worsen on the EI across time. Overall, the findings suggest low temporal stability of the EI in two geriatric samples. In particular, individuals with poorer cognition at baseline could present with poorer effort across time. These findings also suggest the need to further examine the temporal stability of other effort measures.

A case of malingering by proxy in a Social Security disability psychological consultative examination.

The term "malingered neurocognitive dysfunction by proxy" was discussed by Slick, Sherman, and Iverson (1999) as part of the differential for defining malingering when a patient is responding to directions or pressure from others. In Chafetz (2008), rates of symptom validity failure in children whose parents are seeking Social Security Disability (SSD) on their behalf were presented and showed 20% to 26% symptom validity test failure rates at chance or below-chance levels. The objective of the current case study was to determine whether the requirements of malingering were met in a 9-year-old whose parent was seeking SSD on his behalf. A retrospective approach was employed using an archived case from one of the author's records. This case shows a practical application of a symptom validity scale for low-functioning individuals (Chafetz, Abrahams, & Kohlmaier, 2007), which was designed initially for use with adult and child SSD claimants. The egregious nature of symptom validity failure, coupled with SSD seeking for the whole family, along with conduct disorder symptoms provided a strong suggestion of malingering by proxy. The present results are discussed with respect to low-functioning claimants.

Retrograde amnesia and malingering.

PURPOSE OF REVIEW: Malingered anterograde amnesia is a phenomenon that has been exhaustively studied, whereas research on retrograde amnesia has tended to focus upon functional and organic accounts of impairment. The present review explores studies relevant to extending the malingering paradigm to retrograde amnesia. RECENT FINDINGS: In the period reviewed, very little work has directly addressed the area of malingered retrograde amnesia. Researchers have tended to explain apparent 'anomalies' in memory performance or individual presentation, as manifestations of unconscious or psychological distress-mediated behaviour. In contrast, research with offenders claiming amnesia for their crimes has emphasized that malingered retrograde amnesia can be identified with relevant assessment methods. Brain imaging work too has begun to clearly describe the associated neural processes that underlie deception. It appears that the necessary coalescence of insights from clinical neuropsychology, brain imaging and neurology has reached a critical moment. SUMMARY: Current and previous studies are reviewed that addresses the assessment of malingered retrograde amnesia and evidences that a critical moment has been reached.

Base rates of negative response bias and malingered neurocognitive dysfunction among criminal defendants referred for neuropsychological evaluation.

Several studies reveal the prevalence of negative response bias (NRB) in civil forensic settings, but little NRB base rate information is available for criminal forensic neuropsychological settings. We reviewed the published literature on neuropsychological NRB in the civil setting. We then present data from 105 criminal defendants serially referred for neuropsychological assessment to determine the prevalence of NRB. The rate of NRB using one positive indicator was 89.5%. The rate was 70.5% when using two or more positive indicators and 53.3% for three or more indicators. Based on the Slick, Sherman, and Iverson (1999) classification for malingered neurocognitive dysfunction (MND), 19% were Valid, 26.7% were Possible MND, 32.4% were Probable MND, and 21.9% were Definite MND. The combined rate of probable and definite MND was 54.3%. Results suggest rates of neuropsychological NRB and malingering in criminal forensic settings are higher than in civil forensic settings.

Derived trail making test cutoffs and malingering among substance abusers.

The Trail Making test (TMT) is often used to screen for cognitive impairment in substance abusers. A possible limitation of the TMT in clinical settings is that substance abusers may malinger and give poor effort. Data from the Drug Abuse Treatment Outcome Study (DATOS) were analyzed to develop derived TMT cutoffs. Data were analyzed to determine number of substance abusers that fell beyond the upper end of the distribution of selected derived TMT scores at the 10, 5, and 1 percentiles. These percentiles were set for alcoholics (n = 1000), cocaine abusers (n = 4306), and heroin abusers (n = 1548) for TMT selected derived scores. Inspection of the selected TMT derived scores yielded an impression that the percentile values for the 3 sub-samples of primary drugs of abuse, alcohol, cocaine, and heroin, are actually very similar at each of the 3 percentile levels. This would suggest that these estimates are actually quite stable and reinforces the notion that they may be creditable estimates. The proper use of the derived TMT cutoff scores is to alert clinicians to the increasingly higher probability of poor effort when a substance abuser in one of the three groups scores beyond the one percent cutoff for the primary drug of abuse sample. Clearly, the use of these cutoffs needs further empirical validation before they would be considered as a single source to suggest malingering. Great caution is suggested in using these cutoff scores for clinical purposes with substance abusing patients in their current state of validation. In short, further research is warranted.

Is there a relationship between nonorganic physical findings (Waddell signs) and secondary gain/malingering?

This is a structured evidence based review of all available studies addressing the concept of nonorganic findings (Waddell signs) and their potential relationship to secondary gain and malingering. The objective of this review is to determine what evidence, if any, exists for a relationship between Waddell signs and secondary gain and malingering. Waddell signs are a group of 8 physical findings divided into 5 categories, the presence of which has been alleged at times to indicate the presence of secondary gain and malingering. A computer and manual literature search produced 16 studies relating to Waddell signs and secondary gain or malingering. These references were reviewed in detail, sorted, and placed into tabular form according to topic areas, which historically have been linked with the alleged possibility of secondary gain and malingering: 1) Waddell sign correlation with worker compensation and medicolegal status; 2) Waddell sign improvement with treatment; 3) Waddell sign correlation with Minnesota Multiphasic Personality Inventory validity scores; and 4) Waddell sign correlation with physician dishonesty perception. Each report in each topic area was categorized for scientific quality according to guidelines developed by the Agency for Health Care Policy and Research. The strength and consistency of this evidence in each subject area was then also categorized according to Agency for Health Care Policy and Research guidelines. Conclusions of this review were based on these results. There was inconsistent evidence that Waddell signs were not associated with worker's compensation and medicolegal status; there was consistent evidence that Waddell signs improved with treatment; there was consistent evidence that Waddell signs were not associated with invalid paper-pencil test; and there was inconsistent evidence that Waddell signs were not associated with physician perception of effort exaggeration. Overall, 75% of these reports reported no association between Waddell signs and the 4 possible methods of identifying patients with secondary gain and/or malingering. Based on the above results, it was concluded that there was little evidence for the claims of an association between Waddell signs and secondary gain and malingering. The preponderance of the evidence points to the opposite: no association.