Prevalence of malingering in patients with chronic pain referred for psychologic evaluation in a medico-legal context.

OBJECTIVE: To provide an empirical estimate of the prevalence of malingered disability in patients with chronic pain who have financial incentive to appear disabled. DESIGN: Retrospective review of cases. SETTING: A private neuropsychologic clinic in a southeastern metropolitan area. PARTICIPANTS: Consecutive patients (N=508) referred for psychologic evaluation related to chronic pain over a 10-year period (1995-2005). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence of malingering was examined using 2 published clinical diagnostic systems (Malingered Pain-Related Disability and Malingered Neurocognitive Dysfunction) as well as statistical estimates based on well validated indicators of malingering. RESULTS: The prevalence of malingering in patients with chronic pain with financial incentive is between 20% and 50% depending on the diagnostic system used and the statistical model's underlying assumptions. Some factors associated with the medico-legal context such as the jurisdiction of a workers' compensation claim or attorney representation were associated with slightly higher malingering rates. CONCLUSIONS: Malingering is present in a sizable minority of patients with pain seen for potentially compensable injuries. However, not all excess pain-related disability is a result of malingering. It is important not to diagnose malingering reflexively on the basis of limited or unreliable findings. A diagnosis of malingering should be explicitly based on a formal diagnostic system.

Detecting malingered pain-related disability with the pain catastrophizing scale: a criterion groups validation study.

Objective: Intentional exaggeration of symptoms is a potential problem in contexts where there are financial incentives to appear disabled. Therefore, calibration of tools to accurately evaluate malingering in these contexts is important. The present study used a criterion groups validation design to determine the ability of the Pain Catastrophizing Scale (PCS) to detect Malingered Pain-Related Disability (MPRD). Method: Individuals meeting inclusionary/exclusionary criteria were selected for this study (n = 219) from a larger dataset of chronic pain patients referred for a psychological evaluation. Patients were classified into malingering groups using the Bianchini, Greve, and Glynn classification system for MPRD. PCS T scores were compared in patients who met MPRD criteria and those who showed no indication of malingering on multiple validity tests. Results: No group differences were observed regarding medicolegal and injury characteristics. Group analyses showed that the Not MPRD group had a significantly lower PCS score (Estimated Marginal Mean [EMM] = 62.3) than all other groups. The Probable and Definite MPRD groups (which together comprise the MPRD group) had the highest PCS T scores (EMM = 77.2 and EMM = 83.8, respectively). A PCS T score of 81 was associated with a 7% false-positive (FP) error rate, sensitivity of 47%, likelihood ratio (LR) of 6.7, and a positive predictive value (PPV) of .74 at base rates around 30%. Conclusions: PCS T scores greater than 81 should raise concerns about the validity of the PCS report and provide additional information that can be helpful in identifying intentional symptom exaggeration in patients with chronic pain.

Integrative Care Models in Neuropsychology: A National Academy of Neuropsychology Education Paper.

Although collaborative, and more specifically, integrated models of care have existed for years, the 2010 Patient Protection and Affordable Care Act expanded their use, and Medicare has adopted a value-based payment system that further emphasizes service provision within the collaborative health care setting. Neuropsychology as a field is well-situated to work within the integrated health care setting, which presents both opportunities and challenges for clinical neuropsychologists. This education paper details how different neuropsychology clinical practice settings fit into an integrated care framework; discusses challenges to service delivery and fiscal viability in such settings and other health care related settings; and examines future directions for the role of neuropsychology within a dynamic health care system.

The relationship between the modified somatic perception questionnaire and dynamic platform posturography.

OBJECTIVE: To analyze if patients whose vestibular symptoms are associated with nonorganic sway patterns show more evidence of somatization and/or malingering than patients whose vestibular symptoms are associated with normal or physiologically abnormal sway patterns observed in people with documented vestibular pathologic findings. PATIENTS: One hundred fifteen patients with complaints of vestibular dysfunction and hearing impairment. INTERVENTIONS: Computerized dynamic posturography (CDP) and completion of the Modified Somatic Perception Questionnaire (MSPQ)--a validated test for the detection of malingering. MAIN OUTCOME MEASURES: Computerized dynamic posturography results classified into 4 categories (normal, physiologic abnormal, borderline-aphysiologic, and aphysiologic) were correlated with the results of the MSPQ. RESULTS: A significant CDP group effect on the MSPQ, with the aphysiologic patients scoring significantly higher than the other groups. Moreover, a significantly higher proportion of aphysiologic patients scored more than the MSPQ cutoffs for malingering. CONCLUSION: Results indicate that patients who have aphysiologic CDP sway patterns are more likely to have higher MSPQ scores. Both aphysiologic CDP results and high MSPQ scores have been associated with intentional exaggeration. These results indicate that patients with both aphysiologic CDP findings and high MSPQ scores are more likely to be intentionally exaggerating their balance-related complaints and deficits.

Observed versus estimated IQ as an index of malingering in traumatic brain injury: classification accuracy in known groups.

This study examined the classification accuracy of observed WAIS-III VIQ, PIQ, and FSIQ minus Barona-estimate differential scores in the detection of Malingered Neurocognitive Dysfunction (MND) in Traumatic Brain Injury (TBI) using a known-groups design. Two hundred eleven TBI patients were assigned to one of three groups: Not-MND (n = 87), Indeterminate (n = 68), and MND (n = 56). A General Clinical Sample of 93 no-incentive patients (e.g., CVA, memory disorder) was also included to better study specificity. The VIQ differential accurately differentiated MND from Not-MND TBI patients regardless of injury severity. The PIQ differential was only accurate in mild TBI and did not add incremental validity to the VIQ differential. This study indicates that VIQ declines of greater than 24 points are rare except in very severe TBI. Particularly in mild TBI, such differentials likely indicate intentional suppression of WAIS-III performance consistent with MND. Clinical application is discussed.

Classification accuracy of MMPI-2 validity scales in the detection of pain-related malingering: a known-groups study.

The purpose of this study was to determine the accuracy of Minnesota Multiphasic Personality Inventory 2nd edition (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) validity indicators in the detection of malingering in clinical patients with chronic pain using a hybrid clinical-known groups/simulator design. The sample consisted of patients without financial incentive (n = 23), nonmalingering patients with financial incentive (n = 34), patients definitively determined to be malingering based on published criteria ( n = 32), and college students asked to simulate pain-related disability (n = 26). The MMPI-2 validity scales differentiated malingerers from nonmalingerers with a high degree of accuracy. Hypochondriasis and Hysteria were also effective. For all variables except Scale L, more extreme scores were associated with higher specificity. This study demonstrates that the MMPI-2 is capable of differentiating intentional exaggeration from the effects on symptom report of chronic pain, genuine psychological disturbance, and concurrent stress associated with pursuing a claim in a medico-legal context.

Deciding to adopt revised and new psychological and neuropsychological tests: an inter-organizational position paper.

OBJECTIVE: Neuropsychological tests undergo periodic revision intended to improve psychometric properties, normative data, relevance of stimuli, and ease of administration. In addition, new tests are developed to evaluate psychological and neuropsychological constructs, often purporting to improve evaluation effectiveness. However, there is limited professional guidance to neuropsychologists concerning the decision to adopt a revised version of a test and/or replace an older test with a new test purporting to measure the same or overlapping constructs. This paper describes ethical and professional issues related to the selection and use of older versus newer psychological and neuropsychological tests, with the goal of promoting appropriate test selection and evidence-based decision making. METHOD: Ethical and professional issues were reviewed and considered. CONCLUSIONS: The availability of a newer version of a test does not necessarily render obsolete prior versions of the test for purposes that are empirically supported, nor should continued empirically supported use of a prior version of a test be considered unethical practice. Until a revised or new test has published evidence of improved ability to help clinicians to make diagnostic determinations, facilitate treatment, and/or assess change over time, the choice to delay adoption of revised or new tests may be viewed as reasonable and appropriate. Recommendations are offered to facilitate decisions about the adoption of revised and new tests. Ultimately, it is the responsibility of individual neuropsychologists to determine which tests best meet their patients' needs, and to be able to support their decisions with empirical evidence and sound clinical judgment.

Clusters of financially incentivized chronic pain patients using the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF).

The Minnesota Multiphasic Personality Inventory (MMPI)-2 Restructured Form (MMPI-2-RF) has been shown to have clinical utility in the assessment of individuals with chronic pain (e.g., predicting surgical outcomes). The purpose of this study was to explore the ability of the MMPI-2-RF Validity Scales in profiling patients with chronic pain who had external financial incentive (e.g., workers' compensation claims) and determine the associations between Validity Scale response patterns and important outcomes. Cluster analysis identified 2 similarly sized clusters of patients with very different MMPI-2-RF profiles. Cluster 1 was characterized by valid responding and showed mean elevations on the somatic and low positive emotion Restructured Clinical scales. Cluster 2 was characterized by patients overreporting on the MMPI-2-RF Validity Scales, who also demonstrated elevations on 7 of the 9 RC scales. Cluster membership was differentially associated with clinical variables: patients in Cluster 2 had greater self-reported pain and disability, were less likely to have spine-related findings on imaging and were more likely to be classified as probable or definite malingerers. These results support the utility of the MMPI-2-RF Validity scales in distinguishing between credible and noncredible responses from patients with chronic pain seen within a medico-legal context. (PsycINFO Database Record

Classification accuracy of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)-Restructured form validity scales in detecting malingered pain-related disability.

The symptom reports of individuals with chronic pain are multidimensional (e.g., emotional, cognitive, and somatic) and significantly contribute to increased morbidity and lost work productivity. When pain occurs in the context of a legally compensable event, reliable assessment of a patient's multifactorial symptom experience during psychological or neuropsychological evaluations is a necessity. The Validity Scales of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) have been shown useful in identifying symptom overreporting and feigning within chronic pain samples and a number of studies have emerged supporting the use of the MMPI-2-Restructured Form (MMPI-2-RF) in the detection of simulated or feigned impairment in a variety of populations. To date, only 1 other study exists examining the ability of the MMPI-2-RF to detect exaggerated complaints using a strict operationalization of malingering exclusive to chronic pain samples. The purpose of this study was to examine the classification accuracy of MMPI-2-RF Validity Scales in a group of patients with chronic pain using a criterion-groups design. The final sample consisted of 501 clinical chronic pain patients assigned to groups based on the Bianchini, Greve, and Glynn (2005) criteria for Malingered Pain-Related Disability (MPRD). Results showed that all MMPI-2-RF Validity Scales differentiated malingerers from nonmalingerers with a high degree of accuracy. At cut-offs associated with ≥95% Specificity, Sensitivities ranged from 15% (Fs) to 60% (Response Bias Scale; RBS). This study demonstrates that the MMPI-2-RF Validity Scales are capable of differentiating intentional symptom exaggeration from genuine complaints in a sample of incentivized chronic pain patients. (PsycINFO Database Record

Malingering in toxic exposure: classification accuracy of reliable digit span and WAIS-III Digit Span scaled scores.

This study examined the sensitivity and false-positive error rate of reliable digit span (RDS) and the WAIS-III Digit Span (DS) scaled score in persons alleging toxic exposure and determined whether error rates differed from published rates in traumatic brain injury (TBI) and chronic pain (CP). Data were obtained from the files of 123 persons referred for neuropsychological evaluation related to alleged exposure to environmental and industrial substances. Malingering status was determined using the criteria of Slick, Sherman, and Iverson (1999). The sensitivity and specificity of RDS and DS in toxic exposure are consistent with those observed in TBI and CP. These findings support the use of these malingering indicators in cases of alleged toxic exposure and suggest that the classification accuracy data of indicators derived from studies of TBI patients may also be validly applied to cases of alleged toxic exposure.

The MMPI-2/MMPI-2-RF Symptom Validity Scale (FBS/FBS-r) is not a measure of 'litigation response syndrome': commentary on Nichols and Gass (2015).

OBJECTIVES: To address (1) Whether there is empirical evidence for the contention of Nichols and Gass that the MMPI-2/MMPI-2-RF FBS/FBS-r Symptom Validity Scale is a measure of Litigation Response Syndrome (LRS), representing a credible set of responses and reactions of claimants to the experience of being in litigation, rather than a measure of non-credible symptom report, as the scale is typically used; and (2) to address their stated concerns about the validity of FBS/FBS-r meta-analytic results, and the risk of false positive elevations in persons with bona-fide medical conditions. METHOD: Review of published literature on the FBS/FBS-r, focusing in particular on associations between scores on this symptom validity test and scores on performance validity tests (PVTs), and FBS/FBS-r score elevations in patients with genuine neurologic, psychiatric and medical problems. RESULTS: (1) several investigations show significant associations between FBS/FBS-r scores and PVTs measuring non-credible performance; (2) litigants who pass PVTs do not produce significant elevations on FBS/FBS-r; (3) non-litigating medical patients (bariatric surgery candidates, persons with sleep disorders, and patients with severe traumatic brain injury) who have multiple physical, emotional and cognitive symptoms do not produce significant elevations on FBS/FBS-r. Two meta-analytic studies show large effect sizes for FBS/FBS-r of similar magnitude. CONCLUSIONS: FBS/FBS-r measures non-credible symptom report rather than legitimate experience of litigation stress. Importantly, the absence of significant FBS/FBS-r elevations in litigants who pass PVTs demonstrating credible performance, directly contradicts the contention of Nichols and Gass that the scale measures LRS. These data, meta-analytic publications, and recent test use surveys support the admissibility of FBS/FBS-r under both Daubert and the older Frye criteria.

The validity of the MMPI-2/MMPI-2-RF Symptom Validity Scale (FBS/FBS-r) is established: reply to Nichols (2017).

We reply to Nichols' (2017) critique of our commentary on the MMPI-2/MMPI-2-RF Symptom Validity Scale (FBS/FBS-r) as a measure of symptom exaggeration versus a measure of litigation response syndrome (LRS). Nichols claims that we misrepresented the thrust of the original paper he co-authored with Gass; namely, that they did not represent that the FBS/FBS-r were measures of LRS but rather, intended to convey that the FBS/RBS-r were indeterminate as to whether the scales measured LRS or measured symptom exaggeration. Our original commentary offered statistical support from published literature that (1) FBS/FBS-r were associated with performance validity test (PVT) failure, establishing the scales as measures of symptom exaggeration, and (2) persons in litigation who passed PVTs did not produce clinically significant elevations on the scales, contradicting that FBS/FBS-r were measures of LRS. In the present commentary, we draw a distinction between the psychometric data we present supporting the validity of FBS/FBS-r, and the conceptual, non-statistical arguments presented by Nichols, who does not refute our original empirically based conclusions.

Waddell non-organic signs: new evidence suggests somatic amplification among outpatient chronic pain patients.

BACKGROUND CONTEXT: Waddell et al. identified a set of eight non-organic signs in 1980. There has been controversy about their meaning, particularly with respect to their use as validity indicators. PURPOSE: The current study examined the Waddell signs in relation to measures of somatic amplification or over-reporting in a sample of outpatient chronic pain patients. We examined the degree to which these signs were associated with measures of over-reporting. STUDY DESIGN/SETTING: This study examined scores on the Waddell signs in relation to over-reporting indicators in an outpatient chronic pain sample. PATIENT SAMPLE: We examined 230 chronic pain patients treated at a multidisciplinary pain clinic. The majority of these patients presented with primary back or spinal injuries. OUTCOME MEASURES: The outcome measures used in the study were Waddell signs, Modified Somatic Perception Questionnaire, Pain Disability Index, and the Minnesota Multiphasic Personality Inventory-2 Restructured Form. METHODS: We examined Waddell signs using multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA), receiver operating characteristic analysis, classification accuracy, and relative risk ratios. RESULTS: Multivariate analysis of variance and ANOVA showed a significant association between Waddell signs and somatic amplification. Classification analyses showed increased odds of somatic amplification at a Waddell score of 2 or 3. CONCLUSIONS: Our results found significant evidence of an association between Waddell signs and somatic over-reporting. Elevated scores on the Waddell signs (particularly scores higher than 2 and 3) were associated with increased odds of exhibiting somatic over-reporting.

Cognitive Screening Tests Versus Comprehensive Neuropsychological Test Batteries: A National Academy of Neuropsychology Education Paper†.

The American Medical Association Current Procedural Panel developed a new billing code making behavioral health screening a reimbursable healthcare service. The use of computerized testing as a means for cognitive screening and brief cognitive testing is increasing at a rapid rate. The purpose of this education paper is to provide information to clinicians, healthcare administrators, and policy developers about the purpose, strengths, and limitations of cognitive screening tests versus comprehensive neuropsychological evaluations. Screening tests are generally brief and narrow in scope, they can be administered during a routine clinical visit, and they can be helpful for identifying individuals in need of more comprehensive assessment. Some screening tests can also be helpful for monitoring treatment outcomes. Comprehensive neuropsychological assessments are multidimensional in nature and used for purposes such as identifying primary and secondary diagnoses, determining the nature  and severity of a person's cognitive difficulties, determining functional limitations, and planning treatment and rehabilitation. Cognitive screening tests are expected to play an increasingly important role in identifying individuals with cognitive impairment and in determining which individuals should be referred for further neuropsychological assessment. However, limitations of existing cognitive screening tests are present and cognitive screening tests should not be used as a replacement for comprehensive neuropsychological testing.

The prevalence of cognitive malingering in persons reporting exposure to occupational and environmental substances.

OBJECTIVE: Directly estimate the prevalence of cognitive malingering in persons claiming exposure to occupational and environmental substances. METHODS: Retrospective review of 128 neuropsychological cases with financial incentive. Estimates were based on two methods: (1) clinical identification using the Slick, Sherman and Iverson criteria for malingered neurocognitive dysfunction (MND), and (2) statistical modeling based on patient performance on several individual psychometric indicators of malingering. RESULTS: The prevalence based on the clinical method was 40%. The statistically based estimates ranged from 30% to more than 45% depending on model parameters. Different incentive parameters may influence prevalence. CONCLUSIONS: Cognitive malingering in toxic exposure is common and must be adequately addressed in the clinical neuropsychological assessment of toxic exposure and in research on its neurocognitive effects or findings will likely over-estimate the degree of cognitive impairment and related disability.

Should the Retention trial of the Test of Memory Malingering be optional?

The present study examined the false negative error rate associated with the optional use of the Retention trial the Test of Memory Malingering (TOMM). TOMM scores from 150 traumatic brain injury and 150 chronic pain patients were examined. Results indicated that early termination of the TOMM resulted in 3% of patients going undetected by the TOMM. The practical cost of this error was minimized by the inclusion of at least one other SVT. Clinical implications are discussed.

Classification accuracy of the Test of Memory Malingering in persons reporting exposure to environmental and industrial toxins: Results of a known-groups analysis.

This study used a known-groups design to examine the classification accuracy of the Test of Memory Malingering in detecting cognitive malingering in patients claiming cognitive deficits due to exposure to environmental and industrial toxins. Thirty-three patients who met Slick et al. criteria for Malingered Neurocognitive Dysfunction were compared to 17 toxic exposure patients negative for evidence of malingering, 14 TBI patients and 22 memory disorder patients, both groups without incentive. The original cutoffs (<45) for Trial 2 and Retention demonstrated perfect specificity (0% false positive error rate) and impressive sensitivity (>50%). These findings indicate the TOMM can be used with confidence as an indicator of negative response bias in cases of cognitive deficits attributed to exposure to alleged neurotoxic substances.

Pain, malingering and the WAIS-III Working Memory Index.

BACKGROUND CONTEXT: Pain patients often report cognitive symptoms, and many will include them in their claims of disability. There is empirical evidence that patients with pain do experience problems on attention-demanding cognitive tasks, but the results are mixed and the potential impact of exaggeration in the context of pain-related litigation has not been addressed. PURPOSE: 1) Examine the impact of pain and malingering on attention; 2) determine if the Working Memory Index (WMI) of the Wechsler Adult Intelligence Scale-3 (WAIS-III) can reliably detect malingering. STUDY DESIGN/SETTING: Study 1: simulator design; Study 2: clinical known-groups design. PATIENT SAMPLE: Study 1 used healthy college students; Study 2 used chronic pain patients and neurological patients. OUTCOME MEASURES: The WMI and its constituent subtests. METHODS: Study 1: College students were administered the WMI under three conditions: standard administration, with cold-pressor induced pain, or with instructions to simulate impairment due to pain. Study 2: Known-groups design in which the WMI was examined in non-malingering and definite malingering chronic pain patients, non-malingering moderate-severe traumatic brain injury, and memory disorder patients seen for routine psychological evaluation. Malingering was operationalized using published criteria. RESULTS: There were no group differences in WMI or its subtests among non-malingering groups, but some individual clinical patients with pain did score at a level suggestive of attentional impairment. The lowest scores were found in the simulated malingering college students and definite malingering clinical pain groups, in which about half scored worse than 95% of the non-malingering clinical patients. CONCLUSIONS: This study demonstrated that even when controlling for exaggeration some pain patients do exhibit problems with attentional function. However, significant impairment in WMI performance (eg, index score

California verbal learning test indicators of Malingered Neurocognitive Dysfunction: sensitivity and specificity in traumatic brain injury.

The present study used well-defined traumatic brain injury (TBI) and mixed neurological (other than TBI) and psychiatric samples to examine the specificity and sensitivity to Malingered Neurocognitive Dysfunction (MND) of four individual California Verbal Learning Test (CVLT) variables and eight composite CVLT malingering indicators. Participants were 275 traumatic brain injury and 352 general clinical patients seen for neuropsychological evaluation. The TBI patients were assigned to one of five groups using the Slick, Sherman, and Iverson (1999) criteria: no incentive, incentive only, suspect, and malingering (both Probable MND and Definite MND). Within TBI, persons with the strongest evidence for malingering (Probable and Definite) had the most extreme scores. Good sensitivity (approximately 50%) in the context of excellent specificity (> 95%) was found in the TBI samples. Issues related to the appropriate clinical application of these data are discussed.

Psychological evaluation of the emotional effects of a community toxic exposure.

OBJECTIVE: We sought to assess the emotional effects of a major community toxic release while controlling the potential effects of response bias associated with litigation. METHODS: Participants included 152 exposed adult litigants and a matched unexposed comparison group (n = 76). Psychological assessment methods included: (1) Minnesota Multiphasic Personality Inventory-2; (2) Symptom Checklist-90-Revised; and (3) Impact of Event Scale-Revised. RESULTS: Ten to 40% of the exposed group demonstrated emotional distress (compared with a 5% comparison baseline) depending on indicator and cutoff score used. CONCLUSIONS: The psychological consequences of a community toxic exposure were present even when exaggeration was carefully controlled. Accounting for exaggeration in the assessment of subjective psychological complaints provides a more accurate view of the subjective emotional state of persons who have experienced toxic exposure thereby facilitating appropriate clinical management of their mental health needs.