The Structured Inventory of Malingered Symptomatology (SIMS): A Systematic Review and Meta-Analysis

Symptom and performance validation in patients with subjective cognitive decline and mild cognitive impairment

Nonauthentic symptom claims (overreporting) and invalid test results (underperformance) can regularly be expected in a forensic context, but may also occur in clinical referrals. While the applicability of symptom and performance validity tests in samples of dementia patients is well studied, the same is not true for patients with subjective cognitive decline (SCD) and mild cognitive impairment (MCI). A sample of 54 memory-clinic outpatients with evidence of SCD or MCI was studied. We evaluated the rate of positive results in three validity measures. A total of 7.4% of the patients showed probable negative response bias in the Word Memory Test. The rate of positive results on the Structured Inventory of Malingered Symptomatology was 14.8% while only one participant (1.9%) scored positive on the Self-Report Symptom Inventory using the standard cutoff. The two questionnaires were moderately correlated at .67. In a combined analysis of all results, five of the patients (9.3%) were judged to show evidence of probable negative response bias (or probably feigned neurocognitive impairment). In the current study, a relatively small but nontrivial rate of probable response distortions was found in a memory-clinic sample. However, it remains a methodological challenge for this kind of research to reliably distinguish between false-positive and correct-positive classifications in clinical patient groups.

Ethical Issues to Consider Before Introducing Neurotechnological Thought Apprehension in Psychiatry

When it becomes available, neuroscience-based apprehension of subjective thoughts is bound to have a profound impact on several areas of society. One of these areas is medicine. In principle, medical specialties that are primarily concerned with mind and brain are most likely to apply neurotechnological thought apprehension (NTA) techniques. Psychiatry is such a specialty, and the relevance of NTA developments for psychiatry has been recognized. In this article, I discuss ethical issues regarding the use of NTA techniques in psychiatric contexts. First, I consider the notion of neurotechnological "thought apprehension," as well as some limitations of present-day NTA applications. Next, I identify ethical priorities for its possible future use in psychiatry. The topics I explore concern key (bio)ethical issues: confidentiality, trust and distrust, consent and coercion, and, finally, responsibility. I conclude that mental health-related use of NTA entails some specific ethical concerns that deserve careful attention before introducing these technologies in psychiatric practice.

When Patients Overreport Symptoms: More Than Just Malingering

Mental-health patients may report more symptoms than they actually experience. Experts and laypeople often view this overreporting as a sign of malingering. We show that there are multiple pathways to symptom overreporting: carryover effects from previous tests that lower the threshold for answering affirmatively to symptom items, suggestive misinformation that escalates symptom reports, inattentive responding that promotes indiscriminate endorsement of symptoms, and personality traits that bias symptom reports in an upward direction. A one-sided focus on malingering may distract from a research agenda that may contribute to knowledge accumulation in this domain.

Equivalence of the German and the French Versions of the Self-Report Symptom Inventory

Abstract. Against the background of the growing importance of symptom validity assessment both in forensic and clinical or rehabilitation contexts, a new instrument for identifying overreporting was developed. In order to study the equivalence of the German and the French versions, we divided the item pool of the Self-Report Symptom Inventory (SRSI) into two presumably equivalent half-forms. A sample of 40 adult bilingual Swiss nationals with a mean age of 39.9 years responded honestly to one of the half-forms in German and to the other in French. In a subsequent experimental malingering condition, they were asked to simulate sequelae of a whiplash injury and to respond to the SRSI again. In both conditions, they also filled out the Structured Inventory of Malingered Symptomatology (SIMS). The results showed no differences between the two language versions in both conditions. Classification accuracy was very high (100% specificity, 90% sensitivity for the standard cutoff score). Reliability estimates were 0.93 for endorsement of genuine symptoms and 0.97 for pseudosymptom endorsement. In the malingering condition, the correlation between the number of reported pseudosymptoms and the SIMS scores was 0.69. The current results add to the database available for the SRSI and support the appropriateness of the French version.

Detecting over-reporting of symptoms: the French version of the self-report symptom inventory

OBJECTIVE

Symptom exaggeration and malingering are core issues in forensic and clinical evaluation. Generally, experts use two main types of instruments to assess the credibility of symptoms: performance validity tests that aim to detect underperformance and self-report validity tests that appraise over-reporting of symptoms. However, while many tools can be used to assess underperformance, far fewer instruments are available to evaluate over-reporting of symptoms.

METHODS

In this study, we adapted the Self-Report Symptom Inventory (SRSI) for use with French-speaking participants and tested its psychometric properties on a sample of 575 healthy adults (aged from 18 to 65 years), alongside various smaller subgroups.

RESULTS

Exploratory and confirmatory factor analyses supported a two-factor structure for the scale, with a first factor including items questioning genuine symptoms and a second factor including items questioning bizarre or rare symptoms (i.e., pseudosymptoms). Additional analyses emphasized the SRSI's excellent internal reliability and good convergent validity. Furthermore, our results revealed that both the symptom and pseudosymptom subscales were able to discriminate between participants who were asked to feign cognitive impairments (i.e., malingerers), healthy controls, and patients with genuine cognitive symptoms.

CONCLUSION

Overall, these results suggest that the SRSI may be considered a promising tool to assess the credibility of symptoms in patients evaluated in forensic contexts.

Detecting malingering mental illness in forensics: Known-Group Comparison and Simulation Design with MMPI-2, SIMS and NIM

BACKGROUND

Criminal defendants may often exaggerate psychiatric symptoms either to appear non-accountable for their actions or to mitigate their imprisonment. Several psychometric tests have been proposed to detect malingering. These instruments are often validated by Simulation Design (SD) protocols, where normal participants are explicitly requested to either simulate a mental disorder or respond honestly. However, the real scenarios (clinical or forensic) are often very challenging because of the presence of genuine patients, so that tests accuracy frequently differs from that one obtained in well-controlled experimental settings. Here we assessed the effectiveness in criminal defendants of three well-known malingering-detecting tests (MMPI-2, SIMS and NIM) by using both Known-Group Comparison (KGC) and Simulation Design (SD) protocols.

METHODS

The study involved 151 male inmates. Participants to the KGC protocol were all characterized by a positive psychiatric history. They were considered as genuine patients (KGC_Controls) if they had some psychiatric disorders already before imprisonment and scored above the cutoff of SCL-90-R, a commonly used test for mental illness, and as suspected malingerers (KGC_SM) if they were diagnosed as psychiatric patients only after imprisonment and scored below the SCL-90-R cutoff. Participants to SD protocol had no history of psychiatric disease and scored below the SCL-90-R cutoff. They were randomly assigned to either group: Controls (requested to answer honestly, SD_Controls) and simulated malingerers (requested to feign a psychiatric disease, SD_SM). All participants were then submitted to MMPI-2, NIM and SIMS.

RESULTS

Results showed that while MMPI-2, SIMS and NIM were all effective in discriminating malingerers in the SD, SIMS only significantly discriminated between KGC_Controls and KGC_SM in the Known-Group Comparison. Receiver Operating Characteristic (ROC) curves analysis confirmed the better sensitivity of SIMS with respect to the other tests but raised some issues on SIMS specificity.

DISCUSSION

Results support the sensitivity of SIMS for the detection of malingering in forensic populations. However, some specificity issues emerged suggesting that further research and a good forensic practice should keep into account multiple measures of malingering, including psychometric data, clinical and social history and current clinical situation. These methodological constraints must be kept in mind during detection of malingering in criminal defendants reporting psychiatric symptoms.

The Modified Stroop Task Is Susceptible to Feigning: Stroop Performance and Symptom Over-endorsement in Feigned Test Anxiety

Some researchers argue that the modified Stroop task (MST) can be employed to rule out feigning. According to these authors, modified Stroop interference effects are beyond conscious control and therefore indicative of genuine psychopathology. We examined this assumption using a within-subject design. In the first session, students (N = 22) responded honestly, while in the second session they were asked to read a vignette about test anxiety and then fake this condition. During both sessions, we administered an MST consisting of neutral, anxiety-related, and test anxiety-related words. Participants also completed the Self-Report Symptom Inventory (SRSI; Merten et al., 2016) that focuses on over-reporting of pseudosymptoms. Our feigning instructions were successful in that students succeeded in generating the typical MST effect by providing longer response latencies on anxiety related (r = 0.43) and test anxiety-related (r = 0.31) words, compared with neutral words. Furthermore, students endorsed significantly more pseudosymptoms on the SRSI (r = 0.62) in the feigning session than in the honest control condition. We conclude that the MST effect is not immune to feigning tendencies, while the SRSI provides promising results that require future research.

Misrepresenting Health Conditions Through Fabrication and Exaggeration: An Adaptation and Replication of the False Alarm Effect

This article reports on a series of studies of the false alarm effect (FAE), suggesting that individuals' perceptions that relational partners are fabricating and exaggerating their health conditions are negatively associated with perceptions of health condition credibility, which in turn are associated with decreases in individuals' protective behaviors and attitudes. In Study One (N = 216), we took a mixed-methods approach to test an initial model predicting that health condition credibility mediates associations between individuals' perceptions that partners are fabricating and exaggerating and the extent to which individuals provide support, seek information about the condition, feel efficacious in their ability to assist partners, and believe that the condition is serious. We also analyzed open-ended responses to parse the source(s) of credibility lost when individuals believe partners are fabricating and exaggerating their health conditions. We found that they express doubt not only about the credibility of the health condition itself, but also about their partner's credibility in terms of trustworthiness. We then refined our conceptual model to account for these two sources of credibility and tested it with a path model in a second study utilizing a nationally representative sample (N = 508). Results supported our hypotheses. We discuss the implications of this research for how people present themselves as ill in personal relationships, and what happens when these presentations are unconvincing.

Testing Claims of Crime-Related Amnesia

Many violent offenders report amnesia for their crime. Although this type of memory loss is possible, there are reasons to assume that many claims of crime-related amnesia are feigned. This article describes ways to evaluate the genuineness of crime-related amnesia. A recent case is described in which several of these strategies yielded evidence for feigned crime-related amnesia.

Moral Reminders Do Not Reduce Symptom Over-Reporting Tendencies

Is presenting patients with moral reminders prior to psychological testing a fruitful deterrence strategy for symptom over-reporting? We addressed this question in three ways. In study 1, we presented individuals seeking treatment for ADHD complaints (n = 24) with moral primes using the Mother Teresa Questionnaire and compared their scores on an index of symptom over-reporting (i.e., the Structured Inventory of Malingered Symptomatology, SIMS) with those of unprimed patient controls (n = 27). Moral primes slightly decreased SIMS scores, but the effect was not significant. In study 2, we took a different approach to activate moral categories: we recruited individuals seeking treatment for ADHD complaints and asked some of them to sign a moral contract (i.e., prime; n = 19) declaring that they would complete the tests in an honest way and compared their scores on the SIMS and standard clinical scales measuring self-reported psychopathology with those of unprimed patient controls (n = 17). Again, we found no convincing evidence that moral cues suppress symptom over-reporting. In study 3, we gave individuals from the general population (N = 132) positive, negative, or neutral moral primes and implicitly induced them to feign symptoms, after which they completed a brief validated version of the SIMS and an adapted version of the b Test (i.e., an underperformance measure). Again, primes did not affect over-reporting tendencies. Taken together, our findings illustrate that moral reminders are not going to be useful in clinical practice. Rather, they point towards the importance of studying contextual and individual difference factors that guide moral decision-making in patients and may be modified to discourage symptom over-reporting.

Differentiating Factitious from Malingered Symptomatology: the Development of a Psychometric Approach

Psychometric symptom validity assessment is becoming increasingly part and parcel of psychological and neuropsychological assessments. An unresolved and rarely addressed issue concerns the differentiation between factitious and malingered symptom presentations: present-day symptom validity tests can assess whether an examinee presents with noncredible symptomatology, but not why an examinee does so. We explored this issue by developing the Symptom and Disposition Interview (SDI); a symptom validity test that incorporates strategies intended to gauge internal incentives associated with factitious disorder. The merits of the SDI were explored and compared to a traditional symptom validity test (the Structured Inventory of Malingered Symptomatology) in two analogue studies, each with factitious and malingering conditions (n = 24-30 per condition) and a clinical control group (n = 34, n = 40). Overall, the results were positive: The SDI was as effective in detecting feigned symptom presentations as a traditional symptom validity test and superior in differentiating factitious from malingered symptom presentations. We conclude that the SDI is not ready for clinical use, but that psychometric approaches to the assessment of factitious symptomatology, such as the SDI, appear sufficiently promising to warrant future research.

Plausibility Judgments of Atypical Symptoms Across Cultures: an Explorative Study Among Western and Non-Western Experts

Symptom validity tests (SVTs) are predicated on the assumption that overendorsement of atypical symptoms flags symptom exaggeration (i.e., questionable symptom validity). However, few studies have explored how practitioners from different cultural backgrounds evaluate such symptoms. We asked professionals working in Western (n = 56) and non-Western countries (n = 37) to rate the plausibility of uncommon symptoms taken from the Structured Inventory of Malingered Symptomatology (SIMS), dissociative symptoms from the Dissociative Experience Scale (DES-T), and standard symptoms (e.g., anxiety, depression) from the Brief Symptom Inventory-18 (BSI-18). Western and non-Western experts gave similar plausibility ratings to atypical, dissociative, and standard symptoms: both groups judged BSI-18 symptoms as significantly more plausible than either dissociative or atypical symptoms, while the latter two categories did not differ. Our results suggest that the strategy to detect symptom exaggeration by exploring overendorsement of atypical items might work in a non-western context as well.

PTSD in Court III: Malingering, assessment, and the law

This journal's third article on PTSD in Court focuses especially on the topic's "court" component. It first considers the topic of malingering, including in terms of its definition, certainties, and uncertainties. As with other areas of the study of psychological injury and law, generally, and PTSD (posttraumatic stress disorder), specifically, malingering is a contentious area not only definitionally but also empirically, in terms of establishing its base rate in the index populations assessed in the field. Both current research and re-analysis of past research indicates that the malingering prevalence rate at issue is more like 15±15% as opposed to 40±10%. As for psychological tests used to assess PTSD, some of the better ones include the TSI-2 (Trauma Symptom Inventory, Second Edition; Briere, 2011), the MMPI-2-RF (Minnesota Multiphasic Personality Inventory, Second Edition, Restructured Form; Ben-Porath & Tellegen, 2008/2011), and the CAPS-5 (The Clinician-Administered PTSD Scale for DSM-5; Weathers, Blake, Schnurr, Kaloupek, Marx, & Keane, 2013b). Assessors need to know their own possible biases, the applicable laws (e.g., the Daubert trilogy), and how to write court-admissible reports. Overall conclusions reflect a moderate approach that navigates the territory between the extreme plaintiff or defense allegiances one frequently encounters in this area of forensic practice.

Symptom overreporting and dissociative experiences: A qualitative review

We discuss a phenomenon that has received little attention to date in research on dissociative phenomena, namely that self-reports of these phenomena overlap with the tendency to overendorse eccentric items. We review the literature documenting the dissociation-overreporting link and then briefly discuss various interpretations of this link: (1) overreporting is an artifact of measuring dissociative symptoms; (2) dissociative psychopathology engenders overreporting of eccentric symptoms through fantasy proneness or impairments in internal monitoring; (3) an overreporting response style as is evident in malingerers, for example, promotes reports of dissociative symptoms. These three interpretations are not mutually exclusive. Also, the dissociation-overreporting link may have different origins among different samples. Because overreporting may introduce noise in datasets, we need more research specifically aimed at disentangling the dissociation-overreporting link. We suggest various avenues to accomplish this goal.

Biased Symptom Reporting and Antisocial Behaviour in Forensic Samples: A Weak Link

In two studies (one with 57 forensic inpatients and one with 45 prisoners) the connection between biased symptom reporting and antisocial behaviour is explored. The findings are as follows: 1) the association between symptom over-reporting and antisocial features is a) present in self-report measures, but not in behavioural measures, and b) stronger in the punitive setting than in the therapeutic setting; and 2) participants who over-report symptoms a) are prone to attribute blame for their offence to mental disorders, and b) tend to report heightened levels of antisocial features, but the reverse is not true. The data provide little support for the inclusion of antisocial behaviour (i.e. antisocial personality disorder) as a signal of symptom over-reporting (i.e. malingering) in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5). The empirical literature on symptom over-reporting and antisocial/psychopathic behaviour is discussed and it is argued that the utility of antisocial behaviour as an indicator of biased symptom reporting is unacceptably low.

Validity of symptom reports of asylum seekers in a psychiatric hospital: A descriptive study

Our study involved three samples (N=85; N=38, and N=27) of asylum seekers in a Dutch psychiatric hospital. We looked at how often they reported severe dissociative episodes (i.e., not recognizing oneself in a mirror; seeing traumatic images in a mirror) and whether these symptoms were related to deviant performance on Symptom Validity Tests (SVTs), notably items from the Structured Inventory of Malingered Symptomatology (SIMS; Widows & Smith, 2005) and a forced-choice task modeled after the Morel Emotional Numbing Test (MENT; Morel, 1998). We also examined whether poor language proficiency and the presence of incentives to exaggerate symptoms might affect scores on SVTs. Dissociative target symptoms were reported by considerable percentages of patients (27-63%). Patients who reported these symptoms had significantly more often deviant scores on SVT items compared with those who did not report such symptoms. With a few exceptions, deviant scores on SVT items were associated with incentives rather than poor language skills. We conclude that the validity of self-reported symptoms in this target group should not be taken for granted and that SVTs may yield important information.

Detecting feigned postconcussional and posttraumatic stress symptoms with the structured inventory of malingered symptomatology (SIMS)

The Structured Inventory of Malingered Symptomatology (SIMS) is a standalone symptom validity test (SVT) designed as a screening measure to detect a variety of exaggerated psychological symptoms. A number of studies have explored the accuracy of the SIMS in litigious and clinical populations, yet few have examined the validity of the SIMS in detecting feigned symptoms of postconcussional disorder (PCD) and posttraumatic stress disorder (PTSD). The present study examined the sensitivity of the SIMS in detecting undergraduate simulators (N = 78) feigning symptoms of PCD, PTSD, and the comorbid presentation of both PCD and PTSD symptomatologies. Overall, the SIMS Total score produced the highest sensitivities for the PCD symptoms and PCD+PTSD symptoms groups (.89 and .85, respectively), and to a lesser extent, the PTSD symptoms group (.69). The Affective Disorders (AF) subscale was most sensitive to the PTSD symptoms group compared to the PCD and PCD+PTSD symptoms groups. Additional sensitivity values are presented and examined at multiple scale cutoff scores. These findings support the use of the SIMS as a SVT screening measure for PCD and PTSD symptom exaggeration in neuropsychological assessment.

Poor symptom and performance validity in regularly referred Hospital outpatients: Link with standard clinical measures, and role of incentives

We investigated the frequency of symptom validity test (SVT) failure and its clinical correlates in a large, heterogeneous sample of hospital outpatients referred for psychological assessment for clinical purposes. We studied patients (N=469), who were regularly referred for assessment to the psychology departments of five hospitals. Background characteristics, including information about incentives, were obtained with a checklist completed by the clinician. As a measure of over-reporting, the Structured Inventory of Malingered Symptomatology (SIMS) was administered to all patients. The Amsterdam Short-Term Memory test (ASTM), a cognitive underperformance measure, was only administered to patients who were referred for a neuropsychological assessment. Symptom over-reporting occurred in a minority of patients, ranging from 12% to 19% in the main diagnostic patient groups. Patients with morbid obesity had a low rate of over-reporting (1%). The SIMS was positively associated with levels of self-reported psychological symptoms. Cognitive underperformance occurred in 29.3% of the neuropsychological assessments. The ASTM was negatively associated with memory test performance. We found no association between SVT failure and financial incentives. Our results support the recommendation to routinely evaluate symptom validity in clinical assessments of hospital patients. The dynamics behind invalid symptom reporting need to be further elucidated.