The fake bad scale in atypical and severe closed head injury litigants

The detection of malingering in whiplash-related injuries: a targeted literature review of the available strategies

OBJECTIVE

The present review is intended to provide an up-to-date overview of the strategies available to detect malingered symptoms following whiplash. Whiplash-associated disorders (WADs) represent the most common traffic injuries, having a major impact on economic and healthcare systems worldwide. Heterogeneous symptoms that may arise following whiplash injuries are difficult to objectify and are normally determined based on self-reported complaints. These elements, together with the litigation context, make fraudulent claims particularly likely. Crucially, at present, there is no clear evidence of the instruments available to detect malingered WADs.

METHODS

We conducted a targeted literature review of the methodologies adopted to detect malingered WADs. Relevant studies were identified via Medline (PubMed) and Scopus databases published up to September 2020.

RESULTS

Twenty-two methodologies are included in the review, grouped into biomechanical techniques, clinical tools applied to forensic settings, and cognitive-based lie detection techniques. Strengths and weaknesses of each methodology are presented, and future directions are discussed.

CONCLUSIONS

Despite the variety of techniques that have been developed to identify malingering in forensic contexts, the present work highlights the current lack of rigorous methodologies for the assessment of WADs that take into account both the heterogeneous nature of the syndrome and the possibility of malingering. We conclude that it is pivotal to promote awareness about the presence of malingering in whiplash cases and highlight the need for novel, high-quality research in this field, with the potential to contribute to the development of standardised procedures for the evaluation of WADs and the detection of malingering.

A Comparison of Performance Validity Measures in Predicting MMPI-2 Lie Scale Results

Objective: This study examined the relationship between tests of performance validity (PVT) and symptom validity (SVT) among claimants undergoing independent neuropsychological evaluations. Previous research comparing PVTs with SVTs has examined symptom validity with respect to overreporting impairment, whereas the current study focused on how PVTs predict underreporting of psychological symptoms and minimization of negative personality characteristics.Method: The sample included 99 claimants presenting with psychological and cognitive complaints who were assessed in a private practice setting. Participants were administered several SVTs (MMPI-2 Lie Scale (L), Superlative Self Presentation Scale (S), Correction Scale (K)) and PVTs, including Reliable Digit Span (RDS), California Verbal Learning Test forced choice recognition, the Victoria Symptom Validity Test (VSVT), and the Test of Memory Malingering (TOMM).Results: Analyses revealed moderate yet significant (p<.001) negative correlations between the L Scale and PVTs with exception of the VSVT. These relationships were substantiated by moderate to large effect sizes (d = 0.56-0.81) when comparing L Scale scores in above and below PVT cutoff conditions. Significant relationships between PVTs and the K and S Scales were not observed. Exploratory analyses revealed that PVT/L Scale relationships were not significantly moderated by presenting concern.Conclusions: Claimants exhibiting invalid PVT performance were more likely to endorse virtuous personality characteristics on the L Scale, supporting the idea that PVT and SVT constructs are interrelated, particularly in the domain of underreporting moral flaws.

You'd Better Believe It: The Conceptual and Practical Challenges of Assessing Malingering in Patients With Chronic Pain

Chronic pain is a prevalent and costly condition, with many patients receiving income support and funded treatment. Given that pain cannot be assessed objectively, patients may be suspected of exaggerating their pain and disability to receive additional funding. Although numerous methods of detecting malingering have been suggested, it is unclear whether clinicians can reliably identify malingering in patients with chronic pain. The present focus article was developed to assess the theoretical basis and empirical support for proposed methods of detecting malingering in patients with chronic pain. Five approaches were identified: the evaluation of behavioral signs, effort testing, pen and paper measures, symptom validity tests, and combined methods. An examination of the literature revealed that proposed assessment tools have little theoretical basis or empirical support in patients with chronic pain. Additionally, assessment tools are inconsistent with advances in pain science and scores or observations are likely to be influenced by the typical features of chronic pain, including fear-avoidance and central sensitization. Clinicians should be aware that as yet neither subjective clinical opinions nor clinical detection methods can reliably identify malingering in patients with chronic pain. Perspective: There is interest in the development of assessment tools to detect malingering in patients with chronic pain. An evaluation of methods reveals theoretical and empirical limitations that undermine the usefulness of these approaches. As yet, there is no reliable way for clinicians to identify malingering in patients with chronic pain.

Development and Validation of a Response Bias Scale (RBS) for the MMPI-2

This study describes the development of a Minnesota Multiphasic Personality Inventory (MMPI-2) scale designed to detect negative response bias in forensic neuropsychological or disability assessment settings. The Response Bias Scale (RBS) consists of 28 MMPI-2 items that discriminated between persons who passed or failed the Word Memory Test (WMT), Computerized Assessment of Response Bias (CARB), and/or Test of Memory Malingering (TOMM) in a sample of 1,212 nonhead-injury disability claimants. Incremental validity of the RBS was evaluated by comparing its ability to detect poor performance on four separate symptom validity tests with that of the F and FP scales and the Fake Bad Scale (FBS). The RBS consistently outperformed F, FP, and FBS. Study results suggest that the RBS may be a useful addition to existing MMPI-2 validity scales and indices in detecting symptom complaints predominantly associated with cognitive response bias and overreporting in forensic neuropsychological and disability assessment settings.

Simulation of Traumatic Brain Injury Symptoms on the Personality Assessment Inventory

The purpose of this study was to characterize the operating characteristics of the Personality Assessment Inventory (PAI) validity scales in distinguishing simulators feigning symptoms of traumatic brain injury (TBI) while completing the PAI ( n = 84) from a clinical sample of patients with TBI who achieved adequate scores on performance validity tests ( n = 112). The simulators were divided into two groups: (a) Specific Simulators feigning cognitive and somatic symptoms only or (b) Global Simulators feigning cognitive, somatic, and psychiatric symptoms. The PAI overreporting scales were indeed sensitive to the simulation of TBI symptoms in this analogue design. However, these scales were less sensitive to the feigning of somatic and cognitive TBI symptoms than the feigning of a broad range of cognitive, somatic, and emotional symptoms often associated with TBI. The relationships of TBI simulation to consistency and underreporting scales are also explored.

The MMPI-2 Symptom Validity Scale (FBS) Not Influenced by Medical Impairment: A Large Sleep Center Investigation

The Symptom Validity Scale (Minnesota Multiphasic Personality Inventory—2—FBS [MMPI-2-FBS]) is a standard MMPI-2 validity scale measuring overstatement of somatic distress and subjective disability. Some critics assert the MMPI-2-FBS misclassifies too many medically impaired persons as malingering symptoms. This study tests the assertion of malingering misclassification with a large sample of 345 medical inpatients undergoing sleep studies that standardly included MMPI-2 testing. The variables included standard MMPI-2 validity scales (Lie Scale [L], Infrequency Scale [F], K-Correction [K]; FBS), objective medical data (e.g., body mass index, pulse oximetry), and polysomnographic scores (e.g., apnea/hypopnea index). The results showed the FBS had no substantial or unique association with medical/sleep variables, produced false positive rates <20% (median = 9, range = 4-11), and male inpatients showed marginally higher failure rates than females. The MMPI-2-FBS appears to have acceptable specificity, because it did not misclassify as biased responders those medical patients with sleep problems, male or female, with primary gain only (reducing sickness). Medical impairment does not appear to be a major influence on deviant MMPI-2-FBS scores.

Distinguishing between Neuropsychological Malingering and Exaggerated Psychiatric Symptoms in a Neuropsychological Setting

It is unclear whether symptom validity test (SVT) failure in neuropsychological and psychiatric domains overlaps. Records of 105 patients referred for neuropsychological evaluation, who completed the Test of Memory Malingering (TOMM), Reliable Digit Span (RDS), and Millon Clinical Multiaxial Inventory-III (MCMI-III), were examined. TOMM and RDS scores were uncorrelated with MCMI-III symptom validity indices and factor analysis revealed two distinct factors for neuropsychological and psychiatric SVTs. Only 3.5% of the sample failed SVTs in both domains, 22.6% solely failed the neuropsychological SVT, and 6.1% solely failed the psychiatric SVT. The results support a dissociation between neuropsychological malingering and exaggeration of psychiatric symptoms in a neuropsychological setting.

Comparability of Neuropsychological Test Profiles in Patients with Chronic Substance Abuse and Mild Traumatic Brain Injury

The purpose of this study was to compare 104 patients with acute uncomplicated mild traumatic brain injury (MTBI) to a sample of 104 patients from an inpatient substance abuse program to determine whether these patients could be differentiated by their pattern of relative cognitive strengths and weaknesses. Patients were matched on age, education, and gender. Eight cognitive measures were used that included tests of attention, memory, and processing speed. There were no statistically significant differences between the two groups on any of the cognitive measures. Using a two-step cluster analysis procedure (i.e., hierarchical and k-means analyses), seven common profiles were identified. There was no significant difference in the proportions of patients from the MTBI or substance abuse group in each of the seven profiles. These results show that patients with uncomplicated MTBIs could not be reliably differentiated from patients with substance abuse problems on these cognitive measures. This is of particular concern for clinicians evaluating the neuropsychological effects of MTBI in individuals with a comorbid history of substance abuse.

Response validity in forensic neuropsychology: exploratory factor analytic evidence of distinct cognitive and psychological constructs

Forensic neuropsychology studies usually address either cognitive effort or psychological response validity. Whether these are distinct constructs is unclear. In 122 participants evaluated in a compensation-seeking context, the present Exploratory Factor Analysis examined whether forced-choice cognitive effort measures (Victoria Symptom Validity Test, Test of Memory Malingering, Letter Memory Test) and Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) validity scales (L, F, K, FBS, Fp, RBS, Md, Dsr2, S) load on independent factors. Regardless of factor rotation strategy (orthogonal or oblique), four response validity factors emerged by means of both Principal Components Analysis (82.7% total variance) and Principal-Axis Factor Analysis (74.1% total variance). The four factors were designated as follows: Factor I, with large loadings from L, K, and S--underreporting of psychological symptoms; Factor II, with large loadings from FBS, RBS, and Md-overreporting of neurotic symptoms; Factor III, with large loadings from VSVT, TOMM, and LMT--insufficient cognitive effort; and Factor IV, with the largest loadings from F, Fp, and Dsr2--overreporting of psychotic/rarely endorsed symptoms. Results reflect the heterogeneity of response validity in forensic samples referred for neuropsychological evaluation. Administration of both cognitive effort measures and psychological validity scales is imperative to accurate forensic neuropsychological assessment.

The MMPI-2 Fake Bad Scale: Concordance and Specificity of True and Estimated Scores

A number of recent studies have supported the use of the MMPI-2 Fake Bad Scale (FBS) as a measure of negative response bias, the scale at times demonstrating greater sensitivity to negative response bias than other MMPI-2 validity scales. However, clinicians may not always have access to True FBS (T-FBS) scores, such as when True-False answer sheets are unavailable or published research studies do not report FBS raw scores. Under these conditions, Larrabee (2003a) suggests a linear regression formula that provides estimated FBS (E-FBS) scores derived from weighted validity and clinical T-Scores. The present study intended to validate this regression formula of MMPI-2 E-FBS scores and demonstrate its specificity in a sample of non-litigating, clinically referred, medically intractable epilepsy patients. We predicted that the E-FBS scores would correlate highly (>.70) with the T-FBS scores, that the E-FBS would show comparable correlations with MMPI-2 validity and clinical scales relative to the T-FBS, and that the E-FBS would show an adequate ability to match T-FBS scores using a variety of previously suggested T-FBS raw score cutoffs. Overall, E-FBS scores correlated very highly with T-FBS scores (r = .78, p < .0001), though correlations were especially high for women (r = .85, p < .0001) compared to men (r = .62, p < .001). Thirty-one of 32 (96.9%) comparisons made between E-FBS/T-FBS correlates with other MMPI-2 scales were nonsignificant. When matching to T-FBS "high" and "low" scores, the E-FBS scores demonstrated the highest hit rate (92.5%) through use of Lees-Haley's (1992) revised cutoffs for men and women. These same cutoffs resulted in excellent overall specificity for both the T-FBS scores (92.5%) and E-FBS scores (90.6%). The authors conclude that the E-FBS represents an adequate estimate of T-FBS scores in the current epilepsy sample. Use of E-FBS scores may be especially useful when clinicians conduct the MMPI-2 short form, which does not include all of the 43 FBS items but does include enough items to compute each of the validity and clinical T-Scores. Future studies should examine E-FBS sensitivity in compensation-seekers with incomplete effort.

MMPI-2 validity, clinical and content scales, and the Fake Bad Scale for personal injury litigants claiming idiopathic environmental intolerance

BACKGROUND

Idiopathic environmental intolerance (IEI) is a descriptor for nonspecific complaints that are attributed to environmental exposure.

METHODS

The Minnesota Multiphasic Personality Inventory 2 (MMPI-2) was administered to 50 female and 20 male personal injury litigants alleging IEI.

RESULTS

The validity scales indicated no overreporting of psychopathology. Half of the cases had elevated scores on validity scales suggesting defensiveness, and a large number had elevations on Fake Bad Scale (FBS) suggesting overreporting of unauthenticated symptoms. The average T-score profile for females was defined by the two-point code type 3-1 (Hysteria-Hypochondriasis), and the average T-score profile for males was defined by the three-point code type 3-1-2 (Hysteria, Hypochondriasis-Depression). On the content scales, Health Concerns (HEA) scale was significantly elevated.

CONCLUSION

Idiopathic environmental intolerance litigants (a) are more defensive about expressing psychopathology, (b) express distress through somatization, (c) use a self-serving misrepresentation of exaggerated health concerns, and (d) may exaggerate unauthenticated symptoms suggesting malingering.

The Henry-Heilbronner Index: A 15-Item Empirically Derived MMPI-2 Subscale for Identifying Probable Malingering in Personal Injury Litigants and Disability Claimants

A new 15-item MMPI-2 subscale, the Henry-Heilbronner Index (HHI), representing a "pseudosomatic factor," was empirically derived from both the 43-item Lees-Haley Fake Bad Scale (FBS) and the 17-item Shaw and Matthews' Pseudoneurologic Scale (PNS). The HHI was superior to both the FBS and PNS in identification of symptom exaggeration in personal injury litigants and disability claimants compared to non-litigating head-injured controls. Logistic regression analyses revealed that a cutscore of > or = 8 on the HHI was associated with good specificity (89%) and sensitivity (80%). These results suggest that the HHI may be useful in identifying personal injury litigants and disability claimants who exaggerate, overreport, or malinger physical symptoms on the MMPI-2 related to their current health and/or litigation status.

Compensation and Malingering in Traumatic Brain Injury: A Dose-Response Relationship?

The purpose of this study was to determine if there is a dose-response relationship between potential monetary compensation and failure on psychological indicators of malingering in traumatic brain injury. 332 traumatic brain injury patients were divided into three groups based on incentive to perform poorly on neuropsychological testing: no incentive; limited incentive as provided by State law; high incentive as provided by Federal law. The rate of failure on five well-validated malingering indicators across these groups was examined. Cases handled under Federal workers compensation laws showed considerably higher rates of failure and diagnosable malingering than cases handled under State law. The findings indicate that monetary compensation associated with workers compensation claims is a major motive for exaggeration and malingering of problems attributed to work-related brain injuries. The clinician's index of suspicion regarding exaggeration and malingering of symptoms and deficits should be much higher in the context of Federal workers compensation claims, particularly in patients who have suffered only mild traumatic brain injury.

Sensitivity and Specificity of MMPI-2 Validity Scales and Indicators to Malingered Neurocognitive Dysfunction in Traumatic Brain Injury

The present study used a known-groups design to determine the classification accuracy of 10 MMPI-2 validity scales and indicators in the detection of cognitive malingering in traumatic brain injury. Participants were 259 traumatic brain injury and 133 general clinical patients seen for neuropsychological evaluation. The TBI patients were subdivided into groups based on a comprehensive examination of effort following Slick, Sherman, and Iverson's (1999) criteria. More extreme scores demonstrated excellent specificity; often impressive sensitivity was seen even while maintaining a low false positive error rate. Specificity was good even in stroke, memory disorder, and psychiatric patients without incentive. The results of this study are presented in frequency tables that can be easily referenced in clinical practice.

Meta-Analysis of the MMPI-2 Fake Bad Scale: Utility in Forensic Practice

Some clinical researchers disagree regarding the clinical utility of the MMPI-2 Fake Bad scale (FBS ) within forensic and clinical settings. The present meta-analysis summarizes weighted effect size differences among the FBS and other commonly used validity scales (L, F, K, Fb, Fp, F-K, O-S, Ds2, Dsr2 ) in symptom overreporting and comparison groups. Forty studies that included FBS were identified through exploration of online databases, perusal of published references, and communication with primary authors. Nineteen of the 40 studies met restrictive inclusion criteria, resulting in a pooled sample size of 3664 (1615 overreporting participants and 2049 comparison participants). The largest grand effect sizes were observed for FBS (.96), followed by O-S (.88), Dsr2 (.79), F-K (.69), and the F- scale (.63). Significant within-scale variability was observed for seven validity scales, including FBS (Q = 119.11, p < .001). Several subsequent FBS moderator analyses yielded moderate to large effect sizes and were statistically significant for level of cognitive effort, type of overreporting comparison group, and condition associated with overreporting (e.g., traumatic brain injury, posttraumatic stress, chronic pain). Findings suggest that the FBS performs as well as, if not superior to, other validity scales in discriminating overreporting and comparison groups; the preponderance of the present literature supports the scale's use within forensic settings.

On the diagnosis of malingered pain-related disability: lessons from cognitive malingering research

BACKGROUND CONTEXT

Pain-related disability is a complex phenomenon. Malingering is a potential factor in the management of patients with pain. Methodological problems and inappropriate expectations regarding diagnostic accuracy have hampered the study of malingering detection in pain. In contrast, the study of cognitive malingering in neuropsychology has led to the development of many highly accurate and reliable detection techniques. This paper applies the methods and logic that have been successful for identifying cognitive malingering to the problem of malingering in patients with pain.

PURPOSE

Outline the logic of a research methodology for studying malingering detection in pain and introduce a system for the diagnosis of malingering in pain.

STUDY DESIGN

Literature review and conceptual synthesis.

METHODS

Examination of the research methodology and diagnostic scheme used in the study of cognitive malingering; adaptation of these methods to the problem of malingering in pain.

RESULTS

Lessons derived from the study of cognitive malingering were used to generate recommendations to enhance research into detection and diagnosis of malingered pain-related disability. A comprehensive, multidimensional system for diagnosing malingering in pain-related disability was proposed.

CONCLUSIONS

Pain-related disability is a multifaceted phenomenon, therefore malingering can occur in different and sometimes multiple dimensions. It is presently possible to accurately detect and diagnose malingering in some patients with pain. More work is needed for some detection techniques to be appropriately calibrated in pain populations. This work must focus on controlling the false positive error rate.

Outcome from mild traumatic brain injury

PURPOSE OF REVIEW

The focus of this review is outcome from mild traumatic brain injury. Recent literature relating to pathophysiology, neuropsychological outcome, and the persistent postconcussion syndrome will be integrated into the existing literature.

RECENT FINDINGS

The MTBI literature is enormous, complex, methodologically flawed, and controversial. There have been dozens of studies relating to pathophysiology, neuropsychological outcome, and the postconcussion syndrome during the past year. Two major reviews have been published. Some of the most interesting prospective research has been done with athletes.

SUMMARY

The cognitive and neurobehavioral sequelae are self-limiting and reasonably predictable. Mild traumatic brain injuries are characterized by immediate physiological changes conceptualized as a multilayered neurometabolic cascade in which affected cells typically recover, although under certain circumstances a small number might degenerate and die. The primary pathophysiologies include ionic shifts, abnormal energy metabolism, diminished cerebral blood flow, and impaired neurotransmission. During the first week after injury the brain undergoes a dynamic restorative process. Athletes typically return to pre-injury functioning (assessed using symptom ratings or brief neuropsychological measures) within 2-14 days. Trauma patients usually take longer to return to their pre-injury functioning. In these patients recovery can be incomplete and can be complicated by preexisting psychiatric or substance abuse problems, poor general health, concurrent orthopedic injuries, or comorbid problems (e.g. chronic pain, depression, substance abuse, life stress, unemployment, and protracted litigation).

Methodological Problems in the Neuropsychological Assessment of Effects of Exposure to Welding Fumes and Manganese

Recently, Kaiser (2003) raised concerns over the increase in brain damage claims reportedly due to exposure to welding fumes. In the present article, we discuss methodological problems in conducting neuropsychological research on the effects of welding exposure, using a recent paper by Bowler et al. (2003) as an example to illustrate problems common in the neurotoxicity literature. Our analysis highlights difficulties in conducting such quasi-experimental investigations, including subject selection bias, litigation effects on symptom report and neuropsychological test performance, response bias, and scientifically inadequate casual reasoning.