Forced choice test score of p ≤ .20 and failures on ≥ six performance validity tests results in similar Overall Test Battery Means.

Objective: To determine if similar levels of performance on the Overall Test Battery Mean (OTBM) occur at different forced choice test (FCT) p-value score failures. Second, to determine the OTBM levels that are associated with failures at above chance on various performance validity (PVT) tests. Method: OTBMs were computed from archival data obtained from four practices. We calculated each examinee's Estimated Premorbid Global Ability (EPGA) and OTBM. The sample size was 5,103 examinees with 282 (5.5%) of these scoring below chance at p ≤ .20 on at least one FCT. Results: The OTBM associated with a failure at p ≤ .20 was equivalent to the OTBM that was associated with failing 6 or more PVTs at above-chance cutoffs. The mean OTBMs relative to increasingly strict FCT p cutoffs were similar (T scores in the 30s). As expected, there was an inverse relationship between the number of PVTs failed and examinees' OTBMs. Conclusions: The data support the use of p ≤ .20 as the probability level for testing the significance of below chance performance on FCTs. The OTBM can be used to index the influence of invalid performance on outcomes, especially when an examinee scores below chance.

The rate of psychiatric disorders in veterans undergoing intensive EEG monitoring is associated with symptom and performance invalidity.

To determine if the number of participants with psychiatric disorders increased in association with failures on symptom validity tests (SVTs) and a performance validity test (PVT) in Veterans admitted for evaluation of possible seizures.The 254 participants were Veterans undergoing inpatient video-EEG monitoring for the diagnosis of possible seizures. DSM-IV psychiatric disorders were diagnosed with the SCID IV. Symptom exaggeration was assessed with the MMPI-2-RF and performance validity with the TOMM.On the MMPI-2-RF, 27.6%-32.7% showed symptom exaggeration. Participants who exaggerated on the MMPI-2-RF were more often diagnosed with psychiatric disorders. The TOMM was failed by 15.4% of the sample. Participants who failed the TOMM were more often diagnosed with an Axis I disorder but not with a personality disorder. The MMPI-2-RF was invalid in more cases than the TOMM, but 7.9% of the sample generated a valid MMPI-2-RF and an invalid TOMM.The correlational design does not allow conclusions about cause and effect. The invalid groups may have had a higher rate of psychopathology. The number of participants with psychiatric disorders increased in association with symptom exaggeration and performance invalidity. Symptom exaggeration was more frequent than performance invalidity, but the TOMM made a unique contribution to identification of invalidity. The routine clinical use of SVTs and PVTs is supported. The results also suggest the need for caution in diagnosing psychiatric disorders when there is symptom exaggeration or performance invalidity, because diagnostic validity is dependent on the accuracy of symptom reporting.

The patient-psychologist relationship and informed consent in neuropsychological evaluations.

Objective: To discuss specific issues regarding consent for neuropsychological evaluation and the patient-psychologist relationship within the context of the Ethics Code of the American Psychological Association and relevant literature. Method: The author makes recommendations based on the Ethics Code and published sources. This article is advisory and does not prescribe ethical practice. Conclusions: The presence or absence of a patient-psychologist relationship is an essential consideration. The consent process varies, depending on the absence or existence of a patient-psychologist relationship and the type of evaluation. Circumstances when the examiner has the option of establishing a patient-psychologist relationship and guidelines regarding multiple relationships affecting legal testimony by treating providers are considered. Differences in the consent process between clinical and forensic evaluations, and the need for tailoring the consent process for the specific type of clinical or forensic evaluation, are emphasized. Specific provisions that can be included in consent forms in clinical and forensic evaluations, the rationale for their inclusion, and the benefits of consent to both the examiner and the examinee are considered. Circumstances are defined that dictate the need for assent rather than consent. The consent process is discussed in relation to evaluations of fitness for duty and civil capacity. Mandatory reporting of impaired drivers in some jurisdictions, fee agreements, and other issues are considered. Guidance is provided on role limitations in legal testimony by a clinical evaluator that addresses conflicting recommendations now in the literature.

[Formula: see text]Determination of the smoking gun of intent: significance testing of forced choice results in social security claimants.

OBJECTIVE: Significantly below-chance findings on forced choice tests have been described as revealing "the smoking gun of intent" that proved malingering. The issues of probability levels, one-tailed vs. two-tailed tests, and the combining of PVT scores on significantly below-chance findings were addressed in a previous study, with a recommendation of a probability level of .20 to test the significance of below-chance results. The purpose of the present study was to determine the rate of below-chance findings in a Social Security Disability claimant sample using the previous recommendations. METHOD: We compared the frequency of below-chance results on forced choice performance validity tests (PVTs) at two levels of significance, .05 and .20, and when using significance testing on individual subtests of the PVTs compared with total scores in claimants for Social Security Disability in order to determine the rate of the expected increase. RESULTS: The frequency of significant results increased with the higher level of significance for each subtest of the PVT and when combining individual test sections to increase the number of test items, with up to 20% of claimants showing significantly below-chance results at the higher p-value. CONCLUSIONS: These findings are discussed in light of Social Security Administration policy, showing an impact on policy issues concerning child abuse and neglect, and the importance of using these techniques in evaluations for Social Security Disability.

Sensory sensitivity in operation enduring freedom/operation Iraqi freedom veterans with and without blast exposure and mild traumatic brain injury.

To examine factors associated with noise and light sensitivity among returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with a self-reported history of mild traumatic brain injury (mTBI) due to blast exposure, we compared the self-report of noise and light sensitivity of 42 OEF/OIF Veterans diagnosed with mTBI resulting from combat blast-exposure to that of 36 blast-exposed OEF/OIF Veterans without a history of mTBI. Results suggest a statistically significant difference between Veterans with and without a history of mTBI in the experience of noise and light sensitivity, with sensory symptoms reported most frequently in the mTBI group. The difference remains significant even after controlling for symptoms of PTSD, depression, and somatization. These data suggest that while psychological distress is significantly associated with the complaints of noise and light sensitivity, it may not fully account for the experience of sensory sensitivity in a population with mTBI history.

Comparing the Neuropsychological Test Performance of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with and without Blast Exposure, Mild Traumatic Brain Injury, and Posttraumatic Stress Symptoms.

To compare neuropsychological test performance of Veterans with and without mild traumatic brain injury (MTBI), blast exposure, and posttraumatic stress disorder (PTSD) symptoms. We compared the neuropsychological test performance of 49 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans diagnosed with MTBI resulting from combat blast-exposure to that of 20 blast-exposed OEF/OIF Veterans without history of MTBI, 23 OEF/OIF Veterans with no blast exposure or MTBI history, and 40 matched civilian controls. Comparison of neuropsychological test performance across all four participant groups showed a complex pattern of mixed significant and mostly nonsignificant results, with omnibus tests significant for measures of attention, spatial abilities, and executive function. The most consistent pattern was the absence of significant differences between blast-exposed Veterans with MTBI history and blast-exposed Veterans without MTBI history. When blast-exposed Veteran groups with and without MTBI history were aggregated and compared to non-blast-exposed Veterans, there were significant differences for some measures of learning and memory, spatial abilities, and executive function. However, covariation for severity of PTSD symptoms eliminated all significant omnibus neuropsychological differences between Veteran groups. Our results suggest that, although some mild neurocognitive effects were associated with blast exposure, these neurocognitive effects might be better explained by PTSD symptom severity rather than blast exposure or MTBI history alone.

Intent to fail: significance testing of forced choice test results.

A score that is significantly below the level of chance on a forced choice (FC) performance validity test results from the deliberate production of wrong answers. In order to increase the power of significance testing of a below chance result on standardized FC tests with empirically derived cutoff scores, we recommend using one-tailed tests of significance and selecting probability levels greater than .05 (.20 for most standardized FC tests with empirically derived cutoff scores). Under certain circumstances, we also recommend combining scores from different sections of the same FC test and combining scores across different FC tests. These recommendations require modifications when applied to non-standardized FC tests that lack empirically derived cutoff scores or to FC tests with a non-random topographical distribution of correct and incorrect answers.

Meta-analytic methods and the importance of non-TBI factors related to outcome in mild traumatic brain injury: response to Bigler et al. (2013).

Bigler et al. (2013, The Clinical Neuropsychologist) contend that weak methodology and poor quality of the studies comprising our recent meta-analysis led us to miss detecting a subgroup of mild traumatic brain injury (mTBI) characterized by persisting symptomatic complaint and positive biomarkers for neurological damage. Our computation of non-significant Q, tau(2), and I(2) statistics contradicts the existence of a subgroup of mTBI with poor outcome, or variation in effect size as a function of quality of research design. Consistent with this conclusion, the largest single contributor to our meta-analysis, Dikmen, Machamer, Winn, and Temkin (1995, Neuropsychology, 9, 80) yielded an effect size, -0.02, that was smaller than our overall effect size of -0.07 despite using the most liberal definition of mTBI: loss of consciousness less than 1 hour, with no exclusion of subjects who had positive CT scans. The evidence is weak for biomarkers of mTBI, such as diffusion tensor imaging and for demonstrable neuropathology in uncomplicated mTBI. Postconcussive symptoms, and reduced neuropsychological test scores are not specific to mTBI but can result from pre-existing psychosocial and psychiatric problems, expectancy effects and diagnosis threat. Moreover, neuropsychological impairment is seen in a variety of primary psychiatric disorders, which themselves are predictive of persistent complaints following mTBI. We urge use of prospective studies with orthopedic trauma controls in future investigations of mTBI to control for these confounding factors.

Psychogenic stuttering and other acquired nonorganic speech and language abnormalities.

Three cases are presented of peculiar speech and language abnormalities that were evaluated in the context of personal injury lawsuit or workers compensation claims of brain dysfunction after mild traumatic brain injuries. Neuropsychological measures of effort and motivation showed evidence of suboptimal motivation or outright malingering. The speech and language abnormalities of these cases probably were not consistent with neurogenic features of dysfluent speech including stuttering or aphasia. We propose that severe dysfluency or language abnormalities persisting after a single, uncomplicated, mild traumatic brain injury are unusual and should elicit suspicion of a psychogenic origin.

Computerized neuropsychological assessment devices: joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology.

This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability, and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care.

Computerized neuropsychological assessment devices: joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology.

This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care.

Deceptive examinees who committed suicide: report of two cases.

Deceptive behavior by neuropsychological examinees does not preclude the presence of significant psychopathology. To illustrate this fact we present two cases. Case 1 had a diagnosis of factitious disorder and clear evidence on neurological and neuropsychological exams of exaggeration. Case 2 had a somatoform disorder and provided a deceptive social history. Long after the neuropsychological evaluations, both persons committed suicide. These cases provide anecdotal evidence that deceptive behavior does not preclude the presence of serious psychopathology, and that deceptive behavior and self-destructive behavior sometimes coincide.

A meta-analysis of neuropsychological outcome after mild traumatic brain injury: re-analyses and reconsiderations of Binder et al. (1997), Frencham et al. (2005), and Pertab et al. (2009).

The meta-analytic findings of Binder et al. (1997) and Frencham et al. (2005) showed that the neuropsychological effect of mild traumatic brain injury (mTBI) was negligible in adults by 3 months post injury. Pertab et al. (2009) reported that verbal paired associates, coding tasks, and digit span yielded significant differences between mTBI and control groups. We re-analyzed data from the 25 studies used in the prior meta-analyses, correcting statistical and methodological limitations of previous efforts, and analyzed the chronicity data by discrete epochs. Three months post injury the effect size of -0.07 was not statistically different from zero and similar to that which has been found in several other meta-analyses (Belanger et al., 2005; Schretlen & Shapiro, 2003). The effect size 7 days post injury was -0.39. The effect of mTBI immediately post injury was largest on Verbal and Visual Memory domains. However, 3 months post injury all domains improved to show non-significant effect sizes. These findings indicate that mTBI has an initial small effect on neuropsychological functioning that dissipates quickly. The evidence of recovery in the present meta-analysis is consistent with previous conclusions of both Binder et al. and Frencham et al. Our findings may not apply to people with a history of multiple concussions or complicated mTBIs.

Relative subtest scatter in the WAIS-IV standardization sample.

The frequencies of differences between highest and lowest subtest scores as a function of highest subtest score (relative scatter), are reported for the standardization sample of the Wechsler Adult Intelligence Scale-IV (WAIS-IV). Large differences between highest and lowest subtest scores were common. The degree of relative scatter was related to the height of the highest subtest score. For the 10 core WAIS-IV subtests, the correlation between the level of the highest subtest score and the amount of scatter was r = .62; for all 15 subtests the correlation was. 63. The level of the highest subtest score was more strongly related to scatter than was Full Scale IQ. Clinical implications for inferring cognitive impairment and estimating premorbid abilities are discussed. When considering the possibility of acquired cognitive impairment, we recommend caution in the interpretation of subtest score differences.

Comparison of oral and computerized versions of the word memory test.

A computer-administered version of the Word Memory Test (WMT) was compared with the orally administered version in two clinical samples to assess equivalency of the two versions. The two samples included inpatients at an epilepsy center (n = 67) and forensic and clinical referrals to a private practice (n = 58). A randomized procedure was used to assign participants to either version of the WMT. Only the results of the WMT primary effort measures were analyzed. Between-group comparisons of the WMT effort measures were conducted using Mann-Whitney nonparametric analysis. No significant differences were found between versions for several diagnostic subgroups. The data generally support equivalency of the orally administered version and the computerized version of the WMT effort measures in a mixed outpatient sample.

MMPI-2 profiles: fibromyalgia patients compared to epileptic and non-epileptic seizure patients.

We compared MMPI-2 profiles of Gulf War veterans with fibromyalgia (FM) to epileptic seizure (ES) patients, psychogenic non-epileptic seizure (PNES) patients, and Gulf War veteran healthy controls. Both PNES and FM are medically unexplained conditions. In previous MMPI-2 research PNES patients were shown to have significantly higher Hs and Hy clinical scales than ES patients. In the present research the FM group had significantly higher Hs and Hy scale scores than both the ES group and the healthy control group. There was no significant difference between the FM and PNES Hs scale scores; however, the FM Hy scale score was significantly lower than the PNES Hy scale score. Present findings indicate a high level of psychological distress in the FM group.

To err is human: "abnormal" neuropsychological scores and variability are common in healthy adults.

Normative studies of variability in performance by healthy adults on neuropsychological batteries are reviewed. Regarding test score scatter, normative participants often have large discrepancies between best and worst scores. When "abnormality" was defined as a score more than one standard deviation below the mean, in test batteries with at least 20 measures, the great majority of normative participants had one or more abnormalities. Restricting samples to participants with above average IQ or educational levels and using more conservative definitions of abnormality, such as two standard deviations below the mean did not eliminate the presence of abnormal scores. We conclude that abnormal performance on some proportion of neuropsychological tests in a battery is psychometrically normal. Abnormalities do not necessarily signify the presence of acquired brain dysfunction because low scores and large intraindividual variability often are characteristic of healthy adults. We recommend that test battery developers provide data on the amount of variability in normal samples and also provide base rate tables with false positive rates that can be used clinically when interpreting test performance.

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.

Psychogenic nonepileptic seizures.

Neurological, neurodiagnostic, and neuropsychological aspects of psychogenic nonepileptic seizures (PNES) are reviewed, including psychosocial, psychiatric, cognitive, and MMPI-2 findings.