An Inventory of Problems-29 Sensitivity Study Investigating Feigning of Four Different Symptom Presentations Via Malingering Experimental Paradigm.

The Inventory of Problems-29 (IOP-29) is a newly developed, self-administered test designed to assist practitioners evaluating the credibility of various symptom presentations. In a recent simulation study comparing real patients against experimental feigners, its classification accuracy compared favorably with that of the Structured Inventory of Malingered Symptomatology and generalized better to different types of symptom reports (i.e., mood- or trauma-related vs. psychosis-related). Extending on these findings, this sensitivity study tested whether the IOP-29 would be similarly accurate in detecting feigning of conditions related to depression, mild traumatic brain injury, posttraumatic stress disorder (PTSD), and schizophrenia. Additionally, it also evaluated the susceptibility of the IOP-29 to uncooperative or random-like responding. Examination of 1,200 IOP-29 records from 400 nonclinical Italian volunteers who took the Italian version of the IOP-29 3 times, in 3 different conditions (i.e., standard instructions, feigned disorder, and random-like responding), confirmed that the IOP-29 might be similarly valid across a wide variety of mental health and cognitive complaints. Indeed, using the standard a priori cutoff of the IOP-29 (i.e., ≥ .50), sensitivity estimates ranged from .86 (for feigned PTSD) to .95 (for feigned depression) and did not significantly differ from one symptom presentation to another. These findings were obtained despite the fact that participants were coached to respond in a believable manner. Interestingly, the random-like responding generated extremely variable IOP-29 scores.

Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI.

OBJECTIVE: Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance. METHOD: Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass). RESULTS: Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition. CONCLUSION: Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.

Evaluation of a visual acuity test using closed Landolt-Cs to determine malingering.

PURPOSE: To evaluate a visual acuity test (VAT) with unexpected optotypes to detect malingering. METHODS: We tested two groups. Group 1 consisted of 20 individuals with normal best corrected visual acuity (BCVA). Group 2 included participants with ocular diseases and reduced BCVA. All subjects underwent a VAT proposed by Gräf and Roesen to assess suspected malingering. This test used 36 charts with one Landolt-C per page. The first 20 optotypes were Landolt-Cs, while at positions 21, 26, 30, and 34 closed rings were presented. The testing distance was adapted to 50% of the test person's visual acuity. The test person was requested to name the gap direction of the Landolt-C within 3 s. The complete testing conversation was recorded digitally to determine response latency for each optotype from the audio tracks. RESULTS: The average response time was 0.46 s in group 1 and 0.45 s in group 2 for the first 20 Landolt-Cs. In both groups the response time was significantly extended (p < 0.05) for the first closed ring compared to the mean of the first 20 Landolt-Cs, (group 1: 2.9 s; group 2: 2.3 s). The following three closed rings had also longer response times. However, these differences were not significant. CONCLUSIONS: Our results suggest that the proposed test may be helpful to evaluate ocular malingering. The testing procedure appeared to be feasible and showed good repeatability. The fast training effect may be a limitation for malingering detection.

Longitudinal changes in brain morphology from 4 weeks to 12 months after mild traumatic brain injury: Associations with cognitive functions and clinical variables.

OBJECTIVE: To investigate longitudinal changes in cortical and subcortical volumes in patients with mild traumatic brain injury (MTBI) and to evaluate whether such changes were associated with self-reported post-concussive symptoms, global functional outcomes and neuropsychological functioning. METHODS: This was a prospecitve, longitudinal cohort study of patients with complicated (i.e presence of intracranial abnormalities on the day of injury CT) and uncomplicated MTBI (i.e, absence of intracranial abnormalities). Magnetic resonance imaging (MRI) was performed at approximately 4 weeks and 12 months. We utilized a 3T MRI system, cortical reconstruction and volumetric segmentation by FreeSurfer software. We included 33 patients with uncomplicated and 29 with complicated MTBI, who were aged 16-65 years. RESULTS: 12 months after MTBI, significant within-group volume reductions were detected in the left accumbens area and right caudate nucleus for both patients groups, but no significant differences between the groups were revealed. No associations between volumetric variables and post-concussive symptoms or global functioning were found. The left temporal thickness was significantly associated with executive functioning. CONCLUSION: Structural subcortical alterations occur after complicated and uncomplicated MTBIs but these findings were not associated with symptoms burden or functional outcomes. Nonetheless, worse executive functioning was found in patients with shrinkage of the left temporal lobe.

The Mild Brain Injury Atypical Symptoms (mBIAS) scale in a mixed clinical sample.

INTRODUCTION: The Mild Brain Injury Atypical Symptoms (mBIAS) scale was developed as a symptom validity test (SVT) for use with patients following mild traumatic brain injury. This study was the first to examine the clinical utility of the mBIAS in a mixed clinical sample presenting to a Department of Veterans Affairs (VA) neuropsychology clinic. METHOD: Participants were 117 patients with mixed etiologies (85.5% male; age: M = 39.2 years, SD = 11.6) from a VA neuropsychology clinic. Participants were divided into pass/fail groups using two different SVT criteria, based on select validity scales from the Minnesota Multiphasic Personality Inventory-2 (MMPI-2): first, Infrequency Scale (F) scores: (a) MMPI-F-Fail (n = 21) and (b) MMPI-F-Pass (n = 96); and, second, Symptom Validity Scale (FBS) scores: (a) MMPI-FBS-Fail (n = 36) and (b) MMPI-FBS-Pass (n = 81). RESULTS: The mBIAS demonstrated good internal consistency, and each item contributed meaningfully to the total score. At a symptom exaggeration base rate of 35%, an mBIAS cutoff of ≥11 was optimal for screening symptom exaggeration when groups were classified using both F and FBS scales. This cutoff score resulted in very high specificity (.89 to .94); moderate-high positive predictive power (.71 to .75) and negative predictive power (.72 to .79); and low-moderate sensitivity (.31 to .57). At all base rates of probable somatic exaggeration, a cutoff of ≥16 resulted in perfect specificity and positive predictive power, but very low sensitivity. CONCLUSIONS: The mBIAS has potential for use in samples outside of mild traumatic brain injury. In settings where the symptom exaggeration base rate is 35%, a cutoff of ≥11 may be used as a "red flag" for further evaluation, but should not be relied on for clinical decision making. At all base rates of probable somatic exaggeration, psychologists with patients who score ≥16 can be confident that those patients were exaggerating. Importantly, however, this cutoff may fail to identify a large proportion of patients who are exaggerating.

Empirically derived algorithm for performance validity assessment embedded in a widely used neuropsychological battery: Validation among TBI patients in litigation.

INTRODUCTION: Validity of neuropsychological assessment depends, inter alia, on the cooperation of the examinee, requiring separate assessment. Stand-alone tests devised for detecting negative response bias (NRB) are exposed to potential threats to their validity. In this study, an algorithm was developed for assessing NRB within a standardized, computerized neuropsychological battery (NeuroTrax), making it difficult to detect and circumvent. METHOD: Data were collected from the archived medical records of 75 outpatients with mild to moderate head injury, all in litigation. Participants were classified as low or high likelihood for NRB, using a known test for effort assessment (Test of Memory Malingering). RESULTS: Variables judged to be prone for exaggeration and showing large differences between the groups were entered into a logistic regression analysis. The resulting formula exhibited high specificity (98.0%) and sensitivity (87.5%), classifying correctly 94% of the cases. CONCLUSION: It is suggested that the algorithm developed empirically using scores on the NeuroTrax computerized battery can be a useful tool for assessing effort. This algorithm should resist threats to its validity and can be automatically computed while assessing a range of cognitive skills.

Clinical utility of the Neurobehavioral Symptom Inventory validity scales to screen for symptom exaggeration following traumatic brain injury.

The purpose of this study was to examine the clinical utility of three recently developed validity scales (Validity-10, NIM5, and LOW6) designed to screen for symptom exaggeration using the Neurobehavioral Symptom Inventory (NSI). Participants were 272 U.S. military service members who sustained a mild, moderate, severe, or penetrating traumatic brain injury (TBI) and who were evaluated by the neuropsychology service at Walter Reed Army Medical Center within 199 weeks post injury. Participants were divided into two groups based on the Negative Impression Management scale of the Personality Assessment Inventory: (a) those who failed symptom validity testing (SVT-fail; n = 27) and (b) those who passed symptom validity testing (SVT-pass; n = 245). Participants in the SVT-fail group had significantly higher scores (p<.001) on the Validity-10, NIM5, LOW6, NSI total, and Personality Assessment Inventory (PAI) clinical scales (range: d = 0.76 to 2.34). Similarly high sensitivity, specificity, positive predictive power (PPP), and negative predictive (NPP) values were found when using all three validity scales to differentiate SVT-fail versus SVT-pass groups. However, the Validity-10 scale consistently had the highest overall values. The optimal cutoff score for the Validity-10 scale to identify possible symptom exaggeration was ≥19 (sensitivity = .59, specificity = .89, PPP = .74, NPP = .80). For the majority of people, these findings provide support for the use of the Validity-10 scale as a screening tool for possible symptom exaggeration. When scores on the Validity-10 exceed the cutoff score, it is recommended that (a) researchers and clinicians do not interpret responses on the NSI, and (b) clinicians follow up with a more detailed evaluation, using well-validated symptom validity measures (e.g., Minnesota Multiphasic Personality Inventory-2 Restructured Form, MMPI-2-RF, validity scales), to seek confirmatory evidence to support an hypothesis of symptom exaggeration.

False-positive rates associated with the use of multiple performance and symptom validity tests.

Performance validity test (PVT) error rates using Monte Carlo simulation reported by Berthelson and colleagues (in False positive diagnosis of malingering due to the use of multiple effort tests. Brain Injury, 27, 909-916, 2013) were compared with PVT and symptom validity test (SVT) failure rates in two nonmalingering clinical samples. At a per-test false-positive rate of 10%, Monte Carlo simulation overestimated error rates for: (i) failure of ≥2 out of 5 PVTs/SVT for Larrabee (in Detection of malingering using atypical performance patterns on standard neuropsychological tests. The Clinical Neuropsychologist, 17, 410-425, 2003) and ACS (Pearson, Advanced clinical solutions for use with WAIS-IV and WMS-IV. San Antonio: Pearson Education, 2009) and (ii) failure of ≥2 out of 7 PVTs/SVT for Larrabee (Detection of malingering using atypical performance patterns on standard neuropsychological tests. The Clinical Neuropsychologist, 17, 410-425, 2003; Malingering scales for the Continuous Recognition Memory Test and Continuous Visual Memory Test. The Clinical Neuropsychologist, 23, 167-180, 2009 combined). Monte Carlo overestimation is likely because PVT performances are atypical in pattern or degree for what occurs in actual neurologic, psychiatric, or developmental disorders. Consequently, PVT scores form skewed distributions with performance at ceiling and restricted range, rather than forming a standard normal distribution with mean of 0 and standard deviation of 1.0. These results support the practice of using ≥2 PVT/SVT failures as representing probable invalid clinical presentation.

Pitfalls in clinical assessment of neurotoxic diseases: negative effects of repeated diagnostic evaluation, illustrated by a clinical case.

Exposure to different toxic substances can have acute and chronic neurological and neuropsychiatric health effects on humans. Patients often report impaired concentration and memory, irritability, fatigue, instability of affect and difficulties in impulse control. The diagnostic process for neurotoxic diseases is complex and relies heavily on the exclusion of differential diagnosis and substantiating the cognitive complaints by neuropsychological assessment. Diagnostic evaluations have the purpose to help the patient by finding an explanation for the symptoms to guide treatment strategy or prevent further deterioration. But what if the diagnostic process in itself leads to problems that can be quite persistent and difficult to manage? The iatrogenic, or sick-making, side effects of the diagnostic process are the main focus of this case study.

Effort, exaggeration and malingering after concussion.

Although most individuals who suffer a mild traumatic brain injury have complete recovery, a number experience persistent symptoms that appear inconsistent with the severity of the injury. Symptoms may be ascribed to malingering, exaggeration or poor effort on cognitive testing. The purpose of this paper is to propose that previously unconsidered factors, informed by social psychology and behavioural economics, can appear as 'symptom magnification' or 'poor effort', which are incorrectly interpreted as the result of a conscious process. These are complex and multi-determined behaviours with a unique differential diagnosis which have important implications for research, evaluation and treatment.

Assessing sub-optimal performance with the Test of Memory Malingering in Spanish speaking patients with TBI.

PRIMARY OBJECTIVES: To examine the clinical utility of the Test of Memory Malingering (TOMM) with US Spanish speaking patients diagnosed with traumatic brain injury (TBI). RESEARCH DESIGN: The demographic characteristics and neuropsychological functioning of Spanish speaking patients with TBI with valid vs suboptimal performance were compared. METHODS AND PROCEDURES: Demographic and neuropsychological data were retrospectively collected from charts of patients who underwent neurocognitive evaluations for clinical, med-legal and workmen's compensation purposes. Slick et al. criteria for malingered neurocognitive dysfunction were employed for clinical determination of the validity of participants' neuropsychological profiles, resulting in 16 valid and four suboptimal performers. MAIN OUTCOMES AND RESULTS: Valid performers obtained significantly greater scores than suboptimal performers on all trials of the TOMM and generally demonstrated less impairment across neuropsychological domains. The traditional cut-off score for the TOMM misclassified 18.8% of participants not suspected of malingering and lower levels of education appeared to reduce performance on this measure within the valid group. CONCLUSIONS: The current findings generally support the use of the TOMM with US primarily Spanish speaking patients diagnosed with TBI. However, caution is recommended when utilizing this measure with individuals having minimal levels of education. Future research with a larger sample and a non-neurological age- and education-matched sample should investigate lower cut-off scores for use with such patients.

Cognitive underperformance and symptom over-reporting in a mixed psychiatric sample.

The current study examined the prevalence of cognitive underperformance and symptom over-reporting in a mixed sample of psychiatric patients (N = 183). We employed the Amsterdam Short-Term Memory Test (ASTM) to measure cognitive underperformance and the Structured Inventory of Malingered Symptomatology (SIMS) to measure the tendency to over-report symptoms. We also administered neuropsychological tests (e.g., Concept Shifting Task; Rey's Verbal Learning Test) and the Symptom Checklist-90 (SCL-90) to the patients. A total of 34% of them failed the ASTM, the SIMS or both tests. ASTM and SIMS scores were significantly, albeit modestly, correlated with each other (r = -.22). As to the links between underperformance, over-reporting, neuropsychological tasks, and the SCL-90, the association between over-reporting on the SIMS and SCL-90 scores was the most robust one. The subsample that only failed on the ASTM performed significantly worse on a compound index of memory performance. Our findings indicate that underperformance and over-reporting are loosely coupled dimensions and that particularly over-reporting is intimately linked to heightened SCL-90 scores.

Functional neuro-ophthalmology.

Patients with physical signs and symptoms for which no adequate organic cause can be found may receive any one of a large range of diagnostic labels, including functional illness, functional overlay, hysteria, hysterical overlay, conversion reaction, psychophysiological reaction, somatization reaction, hypochondriasis, invalid reaction, neurasthenia, psychogenic reaction, psychosomatic illness, malingering, and Münchausen syndrome. In this chapter, we describe both common and uncommon "functional" ocular symptoms and signs, including visual loss in one or both eyes, constricted visual fields and other field defects, various types of ocular motor dysfunction, including disorders of ocular motility and alignment, disorders of pupillary size and reactivity, and abnormalities of eyelid position and function. We also discuss and illustrate the methods by which the nonorganic nature of these manifestations can be determined. In many cases simple techniques performed in the clinic are sufficient to establish a diagnosis of nonorganic ocular disease, whereas in other cases ancillary studies such as electrophysiological testing may be necessary. The chapter also describes the appropriate approach that the physician should take when dealing with a patient who has proven functional ocular signs and symptoms.

Classification accuracy of the Millon Clinical Multiaxial Inventory-III modifier indices in the detection of malingering in traumatic brain injury.

The present study used criterion groups validation to determine the ability of the Millon Clinical Multiaxial Inventory-III (MCMI-III) modifier indices to detect malingering in traumatic brain injury (TBI). Patients with TBI who met criteria for malingered neurocognitive dysfunction (MND) were compared to those who showed no indications of malingering. Data were collected from 108 TBI patients referred for neuropsychological evaluation. Base rate (BR) scores were used for MCMI-III modifier indices: Disclosure, Desirability, and Debasement. Malingering classification was based on the Slick, Sherman, and Iverson (1999) criteria for MND. TBI patients were placed in one of three groups: MND (n = 55), not-MND (n = 26), or Indeterminate (n = 26).The not-MND group had lower modifier index scores than the MND group. At scores associated with a 4% false-positive (FP) error rate, sensitivity was 47% for Disclosure, 51% for Desirability, and 55% for Debasement. Examination of joint classification analysis demonstrated 54% sensitivity at cutoffs associated with 0% FP error rate. Results suggested that scores from all MCMI-III modifier indices are useful for identifying intentional symptom exaggeration in TBI. Debasement was the most sensitive of the three indices. Clinical implications are discussed.

Diagnostic utility of the structured inventory of malingered symptomatology to detect malingering in a forensic sample.

The Structured Inventory of Malingered Symptomatology (SIMS) is a 75-item, self-report measure to be used with individuals at least 18 years of age, which may be utilized to assess potential malingering of psychosis, neurologic impairment, amnesia, low intelligence, or affective disorder. However, no studies in the literature have examined the diagnostic validity of this instrument in a known-groups design involving medicolegal referrals diagnosed as malingering using the criteria outlined by Slick and colleagues [Slick, D. J., Sherman, E. M. S., & Iverson, G. L. (1999). Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13, 545-561]. The current known-groups, archival study was designed to examine the effectiveness of the SIMS at identifying malingering in patients involved in personal injury lawsuits or disability claims. Findings indicate that a higher cut score on the SIMS for identification of malingering may be appropriate for use with this population. Limitations, clinical implications, and suggestions for further research are discussed.

Rates of below-chance performance in forced-choice symptom validity tests.

The rates of significantly below-chance results on three neuropsychological symptom validity tests (SVTs) including the Portland Digit Recognition Test (PDRT), Test of Memory Malingering (TOMM), and Word Memory Test (WMT) were compared in a private practice forensic sample of 1032 examinees with alleged mild traumatic brain injury, moderate to severe traumatic brain injury, alleged toxic exposure, and reported chronic pain. The PDRT and WMT were equivalent to one another in the rates of below-chance results, with both yielding more frequent below-chance results than the TOMM. Seemingly more difficult sections of the PDRT and WMT had higher yields than seemingly easier sections. Multiple SVTs were more likely to yield below-chance results than a single test, supporting the use of multiple SVTs in forensic neuropsychological evaluations.

Malingering detection with the Wisconsin Card Sorting Test in mild traumatic brain injury.

This study evaluates the ability of several Wisconsin Card Sorting Test (WCST; Psychological Assessment Resources, 1990) variables to detect malingering in mild traumatic brain injury (TBI). The sample consisted of 373 TBI patients and 766 general clinical patients. Classification accuracy for seven indicators is reported across a range of injury severity and scores levels. Overall, most WCST scores were ineffective in discriminating malingering from non-malingering mild TBI patients. Failure-to-Maintain-Set, the Suhr & Boyer formula, and the King et al. formula detected about 30% of malingerers at cutoffs associated with a false positive error rate of < or =11%. The clinical interpretation and use of these indicators are discussed.

Verbal fluency indicators of malingering in traumatic brain injury: classification accuracy in known groups.

A known-groups design was used to determine the classification accuracy of verbal fluency variables in detecting Malingered Neurocognitive Dysfunction (MND) in traumatic brain injury (TBI). Participants were 204 TBI and 488 general clinical patients. The Slick et al. (1999) criteria were used to classify the TBI patients into non-MND and MND groups. An educationally corrected FAS Total Correct word T-score proved to be the most accurate of the several verbal fluency indicators examined. Classification accuracy of this variable at specific cutoffs is presented in a cumulative frequency table. This variable accurately differentiated non-MND from MND mild TBI patients but its accuracy was unacceptable in moderate/severe TBI. The clinical application of these findings is discussed.