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

Classification accuracy and resistance to coaching of the Spanish version of the Inventory of Problems-29 and the Inventory of Problems-Memory: A simulation study with mTBI patients

Objective: The present study aims to evaluate the classification accuracy and resistance to coaching of the Inventory of Problems-29 (IOP-29) and the IOP-Memory (IOP-M) with a Spanish sample of patients diagnosed with mild traumatic brain injury (mTBI) and healthy participants instructed to feign. Method: Using a simulation design, 37 outpatients with mTBI (clinical control group) and 213 non-clinical instructed feigners under several coaching conditions completed the Spanish versions of the IOP-29, IOP-M, Structured Inventory of Malingered Symptomatology, and Rivermead Post Concussion Symptoms Questionnaire. Results: The IOP-29 discriminated well between clinical patients and instructed feigners, with an excellent classification accuracy for the recommended cutoff score (FDS ≥ .50; sensitivity = 87.10% for coached group and 89.09% for uncoached; specificity = 95.12%). The IOP-M also showed an excellent classification accuracy (cutoff ≤ 29; sensitivity = 87.27% for coached group and 93.55% for uncoached; specificity = 97.56%). Both instruments proved to be resistant to symptom information coaching and performance warnings. Conclusions: The results confirm that both of the IOP measures offer a similarly valid but different perspective compared to SIMS when assessing the credibility of symptoms of mTBI. The encouraging findings indicate that both tests are a valuable addition to the symptom validity practices of forensic professionals. Additional research in multiple contexts and with diverse conditions is warranted.

Development of a measure for assessing malingered incompetency in criminal proceedings: Denney competency related test (D-CRT)

INTRODUCTION

Experts frequently assess competency in criminal settings where the rate of feigning cognitive deficit is demonstrably elevated. We describe the construction and validation of the Denney Competency Related Test (D-CRT) to assess feigned incompetency of defendants in the criminal adjudicative setting. It was expected the D-CRT would prove effective at identifying feigned incompetence based on its two alternative, forced-choice and performance curve characteristics.

METHOD

Development and validation of the D-CRT occurred in described phases. Items were developed to measure competency based upon expert review. Item analysis and adjustments were completed with 304 young teenage volunteers to obtain a proper spread of item difficulty in preparation for eventual performance curve analysis (PCA). Test-retest reliability was assessed with 44 adult community volunteers. Validation included an analog simulation design with 101 jail detainees using MacArthur Competency Assessment Test-Criminal Adjudication and Word Memory Test as criterion measures. Effects of racial/ethnic demographic differences were examined in a separate study of 208 undergraduate volunteers. D-CRT specificity was identified with 46 elderly clinic referrals diagnosed with mild cognitive impairment and dementia.

RESULTS

Item development, adjustment, and repeat analysis resulted in item probabilities evenly spread from .28 to 1.0. Test-retest correlation was good (.83). Internal consistency of items was excellent (KR-20 > .91). D-CRT demonstrated convergent validity in regard to measuring competency related information and as well as malingering. The test successfully differentiated between jail inmates asked to perforfm their best and inmates asked to simulate incompetency (AUC = .945). There were no statistically significant differences found in performance across racial/ethnic backgrounds. D-CRT specificity remained excellent among elderly clinic referrals with significant cognitive compromise at the recommended total score cutoff.

CONCLUSIONS

D-CRT is an effective measure of feigned criminal incompetency in the context of potential cognitive deficiency, and PCA is assistive in the determination. Additional validation using knowns groups designs with various mental health-related conditions are needed.

Review of Statistical and Methodological Issues in the Forensic Prediction of Malingering from Validity Tests: Part II-Methodological Issues

Forensic neuropsychological examinations to detect malingering in patients with neurocognitive, physical, and psychological dysfunction have tremendous social, legal, and economic importance. Thousands of studies have been published to develop and validate methods to forensically detect malingering based largely on approximately 50 validity tests, including embedded and stand-alone performance and symptom validity tests. This is Part II of a two-part review of statistical and methodological issues in the forensic prediction of malingering based on validity tests. The Part I companion paper explored key statistical issues. Part II examines related methodological issues through conceptual analysis, statistical simulations, and reanalysis of findings from prior validity test validation studies. Methodological issues examined include the distinction between analog simulation and forensic studies, the effect of excluding too-close-to-call (TCTC) cases from analyses, the distinction between criterion-related and construct validation studies, and the application of the Revised Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) in all Test of Memory Malingering (TOMM) validation studies published within approximately the first 20 years following its initial publication to assess risk of bias. Findings include that analog studies are commonly confused for forensic validation studies, and that construct validation studies are routinely presented as if they were criterion-reference validation studies. After accounting for the exclusion of TCTC cases, actual classification accuracy was found to be well below claimed levels. QUADAS-2 results revealed that extant TOMM validation studies all had a high risk of bias, with not a single TOMM validation study with low risk of bias. Recommendations include adoption of well-established guidelines from the biomedical diagnostics literature for good quality criterion-referenced validation studies and examination of implications for malingering determination practices. Design of future studies may hinge on the availability of an incontrovertible reference standard of the malingering status of examinees.

Review of Statistical and Methodological Issues in the Forensic Prediction of Malingering from Validity Tests: Part I: Statistical Issues

Forensic neuropsychological examinations with determination of malingering have tremendous social, legal, and economic consequences. Thousands of studies have been published aimed at developing and validating methods to diagnose malingering in forensic settings, based largely on approximately 50 validity tests, including embedded and stand-alone performance validity tests. This is the first part of a two-part review. Part I explores three statistical issues related to the validation of validity tests as predictors of malingering, including (a) the need to report a complete set of classification accuracy statistics, (b) how to detect and handle collinearity among validity tests, and (c) how to assess the classification accuracy of algorithms for aggregating information from multiple validity tests. In the Part II companion paper, three closely related research methodological issues will be examined. Statistical issues are explored through conceptual analysis, statistical simulations, and through reanalysis of findings from prior validation studies. Findings suggest extant neuropsychological validity tests are collinear and contribute redundant information to the prediction of malingering among forensic examinees. Findings further suggest that existing diagnostic algorithms may miss diagnostic accuracy targets under most realistic conditions. The review makes several recommendations to address these concerns, including (a) reporting of full confusion table statistics with 95% confidence intervals in diagnostic trials, (b) the use of logistic regression, and (c) adoption of the consensus model on the "transparent reporting of multivariate prediction models for individual prognosis or diagnosis" (TRIPOD) in the malingering literature.

Performance and Symptom Validity in Outpatient Pediatric Neuropsychological Evaluations

This study aimed to clarify the value of using different types of validity measures in pediatric neuropsychological evaluations. We examined the relationship between performance (PVT) and symptom (SVT) validity tests as well as demographic variables and results from a screening test of learning and memory (i.e. Child and Adolescent Memory Profile [ChAMP]) in a mixed pediatric sample (n = 103). There was minimal overlap between PVT and SVT failures. Regression analyses demonstrated that PVT results, parental education, and history of special education were statistically significant predictors of ChAMP results, whereas SVT results were not.

The Pain Disability Index: Effects of performance and symptom validity in mild traumatic brain injury litigants with persistent Post-Concussion pain complaints

OBJECTIVE

Objectives of the current study were to cross validate the Pain Disability Index (PDI) as a measure of symptom validity in a large sample of mild traumatic brain injury (MTBI) litigants with persistent post-concussive pain complaints, and investigate the effects of performance and symptom validity testing on PDI scores.

METHODS

Participants included 91 adults who underwent a comprehensive neuropsychological examination. Criterion groups were formed based upon their performance on stand-alone measures of cognitive performance validity (PVT), and the MMPI-2-RF Symptom Validity Scale (FBS-r) as a measure of symptom validity (SVT).

RESULTS

Participants who failed PVT and SVT scored significantly higher on the PDI compared to participants who passed both. Failing both was associated with a large effect size. Failing PVT, but passing SVT, was associated with a medium effect on PDI scores, while passing PVT, but failing SVT demonstrated a small effect. A PDI cutscore of 49 was associated with .90 specificity and .47 sensitivity.

CONCLUSION

The PDI demonstrates external validity as a self-report measure of symptom validity in MTBI litigants with persistent post-concussive pain complaints. A dose response relationship exists between PVT, SVT and PDI scores. Forensic examiners should include both PVT and SVT to optimize clinical decision making when evaluating MTBI litigants with complaints of pain-related disability years post-incident.

Replication and cross-validation of the personality assessment inventory (PAI) cognitive bias scale (CBS) in a mixed clinical sample

Objective: This study is a cross-validation of the Cognitive Bias Scale (CBS) from the Personality Assessment Inventory (PAI), a ten-item scale designed to assess symptom endorsement associated with performance validity test failure in neuropsychological samples. The study utilized a mixed neuropsychological sample of consecutively referred patients at a large academic medical center in the Midwest. Participants and Methods: Participants were 332 patients who completed embedded and free-standing performance validity tests (PVTs) and the PAI. Pass and fail groups were created based on PVT performance to evaluate classification accuracy of the CBS. Results: The results were generally consistent with the initial study for overall classification accuracy, sensitivity, and cut-off score. Consistent with the validation study, CBS had better classification accuracy than the original PAI validity scales and a comparable effect size to that obtained in the original validation publication; however, the Somatic Complaints scale (SOM) and the Conversion subscale (SOM-C) also demonstrated good classification accuracy. The CBS had incremental predictive ability compared to existing PAI scales. Conclusions: The results supported the CBS, but further research is needed on specific populations. Findings from this present study also suggest the relationship between conversion tendencies and PVT failure may be stronger in some geographic locations or population types (forensic versus clinical patients).

Examination of the MMPI-3 over-reporting scales in a forensic disability sample

Objective: The aim of this investigation was to provide information about the utility of the newly revised and renormed Minnesota Multiphasic Personality Inventory-3 (MMPI-3) over-reporting scales in a forensic disability sample. Method: Participants consisted of 550 non-head injury disability-related referrals (i.e. 95.6% for worker's compensation) and were primarily diagnosed with an adjustment disorder, depressive disorder, or posttraumatic stress disorder. Criterion measures included performance validity indicators and non-MMPI symptom validity indicators. Results: Correlation analyses showed that validity scale F was most strongly associated with non-MMPI symptom validity indicators, whereas F, Fs, FBS, and RBS were comparable to each other in their associations with performance validity indicators. Group mean comparisons between Pass versus Fail PVT groups showed that RBS consistently yielded the largest effect sizes. Using established structured criteria for Malingered Neurocognitive Dysfunction (MND), additional group mean comparisons showed that RBS, followed by Fs, F, and FBS, performed well in differentiating genuine responders from MND examinees. Classification accuracy estimates indicated that the MMPI-3 over-reporting scales performed well in the prediction of Probable/Definite MND and, as expected, to a lesser degree of Possible MND. Conclusions: Practical applications, study limitations, and directions for future research are discussed. The overall findings from this study provide empirical support for the utility of the MMPI-3 over-reporting scales in detecting negative response bias in forensic disability evaluations.

Performance on the CVLT-2 during induced pain

Objective: Chronic pain patients frequently report cognitive problems including learning and memory. However, recent research involving induced pain has demonstrated an absence of reliably detectable decrements on several standard cognitive measures, suggesting that factors other than pain likely explain perceived cognitive deficits in chronic pain patients. This study examined potential effects of induced pain on verbal learning and memory as measured by the California Verbal Learning Test (CVLT-2). Potential effects of self-reported pain intensity were also evaluated. Method: Participants (111 non-clinical undergraduate students in the Southwestern United States) completed one version (Standard or Alternate) of the CVLT-2 under normal conditions, and then were administered the other version (Alternate or Standard) either while experiencing cold pressor-induced pain (Pain condition) or non-painful warm water immersion (Control condition). Results: For the Pain condition decrements in performance across most CVLT-2 variables were observed, including a mean T-score decrease of 10.98 (SD = 10.99) for Trials 1-5, whereas the comparable decrease in the Control condition was an average of 1.5 words (SD = 8.27). Self-reported pain intensity was significantly correlated with the degree of Time 1 to Time 2 performance decrement for Short-Delay Free Recall (r = -.51, p < .050), but not for Trials 1-5 (r = -.37, p = .160). Conclusion: Induced pain produces detectable decrements in performance on a standard clinical measure of verbal learning and memory performance, suggesting that pain in clinical populations may contribute to learning and memory deficits apart from potential neurological conditions.

The Determinants and Effects of Chronic Pain Stigma: A Mixed Methods Study and the Development of a Model

People with chronic pain report experiencing stigma, but few studies have explored this in detail. This mixed-methods study aimed to investigate factors that contribute to chronic pain stigma, the effects of stigma, and to explore the stigma experiences of people with chronic pain. Participants were 215 adults with chronic pain who completed questionnaires assessing chronic pain stigma, opioid use, mental health conditions, pain, depression, disability and social support, and 179 also answered open-ended questions about stigma experiences. Linear regression and path analysis showed that greater stigma was experienced by those who used more opioids, had a mental health condition, viewed their pain as organic, and were unemployed. Stigma was associated with greater disability, depression and lower social support. Qualitative results supported quantitative findings, with 3 themes: 1. "Faking It": Others disbelieve pain and attribute it to drug seeking, laziness, or mental health problems, 2. A spectrum of stigma: Experiences of stigma vary from none to widespread, and 3. "I hide it well": Concealing pain and avoiding stigmatizing situations lead to isolation & disability. This study demonstrates the negative influence of stigma and presents a novel integrated model of chronic pain stigma which may be used to develop interventions.

Assessing Negative Response Bias Using Self-Report Measures: New Articles, New Issues

In psychological injury and related forensic evaluations, two types of tests are commonly used to assess Negative Response Bias (NRB): Symptom Validity Tests (SVTs) and Performance Validity Tests (PVTs). SVTs assess the credibility of self-reported symptoms, whereas PVTs assess the credibility of observed performance on cognitive tasks. Compared to the large and ever-growing number of published PVTs, there are still relatively few validated self-report SVTs available to professionals for assessing symptom validity. In addition, while several studies have examined how to combine and integrate the results of multiple independent PVTs, there are few studies to date that have addressed the combination and integration of information obtained from multiple self-report SVTs. The Special Issue of Psychological Injury and Law introduced in this article aims to help fill these gaps in the literature by providing readers with detailed information about the convergent and incremental validity, strengths and weaknesses, and applicability of a number of selected measures of NRB under different conditions and in different assessment contexts. Each of the articles in this Special Issue focuses on a particular self-report SVT or set of SVTs and summarizes their conditions of use, strengths, weaknesses, and possible cut scores and relative hit rates. Here, we review the psychometric properties of the 19 selected SVTs and discuss their advantages and disadvantages. In addition, we make tentative proposals for the field to consider regarding the number of SVTs to be used in an assessment, the number of SVT failures required to invalidate test results, and the issue of redundancy when selecting multiple SVTs for an assessment.

Performance Validity Testing in Patients Presenting to a Specialty Clinic With a Mild Traumatic Brain Injury

OBJECTIVE

To evaluate predictors of performance validity testing (PVT) and clinical outcome in patients presenting to a specialty clinic with a mild traumatic brain injury (mTBI).

SETTING

An outpatient mTBI specialty clinic.

PARTICIPANTS

Seventy-six (47% female) patients aged 16 to 66 (mean = 40.58, SD = 14.18) years within 3 to 433 days (mean = 30.63, SD = 54.88, median = 17.00) of a suspected mTBI between 2018 and 2019.

DESIGN

A cross-sectional, observational study comparing patients who passed PVT (n = 43) with those who failed (n = 33). A logistic regression (LR) was conducted to evaluate factors that predicted failed PVT. Independent-samples t tests and general linear model were used to evaluate PVT groups on clinical outcomes. The LR with a receiver operating characteristic (ROC) curve was conducted to evaluate embedded validity indicators.

MAIN MEASURES

Performance validity testing, computerized neurocognitive testing, vestibular/oculomotor screening, symptom reports.

RESULTS

At their initial clinic visit 43% of patients failed PVT. PVT failure was predicted by presence of secondary gain (odds ratio [OR] = 8.11, P = .02), while a history of mental health predicted passing of PVT (OR = 0.29, P = .08). Those who failed PVT performed significantly worse on computerized neurocognitive testing (P < .05) and took an average of 33 days longer to return to work (P = .02). There was no significant difference (P = .20) in recovery time between failed/passed PVT groups when covarying for those who sustained a work injury. Word memory learning percentage less than 69% and design memory learning percentage less than 50% accurately classified patients who failed PVT (area under the ROC curve = 0.74; P < .001).

CONCLUSION

Secondary gain was the best predictor of failed PVT. Patients presenting for mTBI evaluation and rehabilitation who fail PVT demonstrate worse performance on cognitive testing and take longer to return to work post-injury, but recover in a similar time frame compared with those who pass PVT. Clinicians should be cautious in discounting patients who yield invalid test results, as these patients appear to be able to achieve recovery in a treatment setting.

How Plausible Is the Implausible? Students’ Plausibility and Prevalence Ratings of the Self-Report Symptom Inventory

Some self-report symptom validity tests, such as the Self-Report Symptom Inventory (SRSI), rely on a detection strategy that uses bizarre, extreme, or very rare symptoms. Thus, items are constructed to invite respondents with an invalid response style to affirm pseudosymptoms that are usually not experienced by genuine patients. However, these pseudosymptoms should not be easily recognizable, because otherwise sophisticated over-reporters could strategically avoid them and go undetected. Therefore, we tested how well future psychology professionals were able to differentiate between genuine complaints and pseudosymptoms in terms of their plausibility and prevalence.

Psychology students (N = 87) received the items of the SRSI online and were given the task to rate each item as to its plausibility and prevalence in the community.

Students evaluated genuine symptoms as significantly more plausible and more prevalent than pseudosymptoms. However, 56% of students rated pseudosymptoms as moderately plausible, whereas 17% rated them as moderately prevalent in the general public.

Overall, it appears that psychology students are successful in distinguishing bizarre, unusual, or rare symptoms from genuine complaints. Yet, the majority of students still attributed relatively high prima facie plausibility to pseudosymptoms. We contend that if such a trusting attitude is true for psychology students, it may also be the case for young psychology practitioners, which, consequently, may diminish the probability of employing self-report validity measures in psychological assessments.

American Academy of Clinical Neuropsychology (AACN) 2021 consensus statement on validity assessment: Update of the 2009 AACN consensus conference statement on neuropsychological assessment of effort, response bias, and malingering

Objective: Citation and download data pertaining to the 2009 AACN consensus statement on validity assessment indicated that the topic maintained high interest in subsequent years, during which key terminology evolved and relevant empirical research proliferated. With a general goal of providing current guidance to the clinical neuropsychology community regarding this important topic, the specific update goals were to: identify current key definitions of terms relevant to validity assessment; learn what experts believe should be reaffirmed from the original consensus paper, as well as new consensus points; and incorporate the latest recommendations regarding the use of validity testing, as well as current application of the term 'malingering.' Methods: In the spring of 2019, four of the original 2009 work group chairs and additional experts for each work group were impaneled. A total of 20 individuals shared ideas and writing drafts until reaching consensus on January 21, 2021. Results: Consensus was reached regarding affirmation of prior salient points that continue to garner clinical and scientific support, as well as creation of new points. The resulting consensus statement addresses definitions and differential diagnosis, performance and symptom validity assessment, and research design and statistical issues. Conclusions/Importance: In order to provide bases for diagnoses and interpretations, the current consensus is that all clinical and forensic evaluations must proactively address the degree to which results of neuropsychological and psychological testing are valid. There is a strong and continually-growing evidence-based literature on which practitioners can confidently base their judgments regarding the selection and interpretation of validity measures.

Consistency does not aid detection of feigned symptoms, overreporting does: Two explorative studies on symptom stability among truth tellers and feigners

Practitioners always want to exclude the possibility that a patient is feigning symptoms. Some experts have suggested that an inconsistent symptom presentation across time (i.e., intraindividual variability) is indicative of feigning. We investigated how individuals with genuine pain-related symptoms (truth tellers; Study 1 n = 32; Study 2 n = 48) and people feigning such complaints (feigners; Study 1 n = 32; Study 2 n = 28) rated the intensity of their symptoms across a 5-day period. In both studies, feigners reported on all 5 days significantly higher symptom intensities than people with genuine complaints, but the two groups did not differ with regard to symptom (in)consistency. Thus, persistently inflated, rather than inconsistent, reports of symptom intensity over time are suggestive of feigning. The implications and limitations of our work are discussed.

Cogstate Brief Battery: Cognition and the feigning of cognitive impairment in chronic pain

Chronic pain (CP) is often associated with cognitive impairment. The Cogstate Brief Battery (CBB), a computerized assessment battery, has been studied in several neuropsychiatric disorders but not in CP. Since feigning of cognitive impairment is common in CP, the current study aimed to assess the CBB's utility in differentiating CP patients (n = 64) from healthy participants (n = 33), as well as to assess the effect of simulating cognitive impairment by CP patients on performance in the battery. CP outpatients were randomly assigned to one of two groups: (a) Patients performing the CBB to the best of their ability. (b) Patients simulating cognitive impairment. Independent-samples t-tests indicated that three of four CBB tasks successfully differentiated CP patients from matched healthy controls. Additionally, an analysis of covariance (ANCOVA) indicated that CP patients who simulated cognitive impairment performed more poorly in all four CBB tasks, with the detection task having the strongest discrimination capacity. This is the first study to point toward the usefulness and sensitivity of the CBB for assessment of cognition and detection of feigned cognitive impairment in CP. Further studies are required to validate these preliminary findings and assess the CBB's utility in daily clinical practice.

Complex regional pain syndrome - Autoimmune or functional neurologic syndrome

Complex regional pain syndrome (CRPS) purports to explain extremity pain accompanied by a variety of subjective complaints, including sensitivity to touch, fatigue, burning sensations, allodynia and signs consistent with voluntary immobilization, including skin changes, edema and trophic changes. By its own definition, CRPS pain is disproportionate to any inciting event or underlying pathology, which means that the syndrome describes non-anatomic and exaggerated symptoms. Although CRPS was coined in the early 1990s, physicians have described unexplained exaggerated pain for centuries. Before a small group of researchers assigned this historical phenomenon with the name CRPS, other physicians in various subspecialties investigated the existence of a common pathophysiologic mechanism but found none. The literature was searched for evidence of a reproducible pathologic mechanism for CRPS. Although some have suggested that CRPS is an autoimmune disease, there is a paucity of evidence to support this. While cytokines such as IL-1β, IL-6 and TNF-α have been detected during the early phases of CRPS, this cannot lead to the conclusion that CRPS is an autoimmune disease, nor that it is an autoinflammatory disorder. Moreover, intravenous immunoglobulin has showed inconsistent results in the treatment of CRPS. On the other hand, CRPS has been found to meet at least three out of four criteria of malingering, which was previously a DSM-IV diagnosis; and its diagnostic criteria are virtually identical to current DSM-5 Functional Neurological Disorder ("FND"), and proposed ICD-11 classification, which includes FND as a distinct neurological diagnosis apart from any psychiatric condition. Unfortunately, the creation of CPRS is not merely misguided brand marketing. It has serious social and health issues. At least in part, the existence of CRPS has led to the labeling of many patients with a diagnosis that allows the inappropriate use of invasive surgery, addictive opioids, and ketamine. The CRPS hypothesis also ignores the nature and purpose of pain, as a symptom of some organic or psychological process. Physicians have long encountered patients who voice symptoms that cannot be biologically explained. Terminology historically used to describe this phenomenon have been medically unexplained symptoms ("MUS"), hysterical, somatic, non-organic, psychogenic, conversion disorder, or dissociative symptoms. The more recent trend describes disorders where there is a functional, rather than structural cause of the symptoms, as "functional disorders." Physicians report high success treating functional neurological symptoms with reassurance, physiotherapy, and cognitive behavior therapy measured in terms of functional improvement. The CRPS label, however, neither leads to functional improvement in these patients nor resolution of symptoms. Under principles of evidence-based medicine, the CRPS label should be abandoned and the syndrome should simply be considered a subset of FNDs, specifically Functional Pain Disorder; and treated appropriately.

[What remains? Expert opinion aspects of mental sequelae of accidents]

An evidence-based psychotraumatological expert assessment should include a thorough clarification of the diagnoses on different levels of findings and an inclusion of modern methods to clarify the authenticity. The surgical examiner is of great importance in the cooperation since he mostly undertakes the initial documentation, including psychological damage, and ultimately evaluates the overall damage after an assessment. A good interdisciplinary understanding and appreciation are therefore the prerequisite for a comprehensible expert assessment.

Deception is different: Negative validity test findings do not provide "evidence" for "good effort"

OBJECTIVE

The purpose of this paper is to determine whether negative validity test findings should be used in the Bayesian aggregate along with positive test findings for the determination of malingering as the condition of interest (COI). Method: Evidence-based diagnostic methods for conditions in neuropsychology and medicine were reviewed for comparison with their use in cases of malingering. Logical and Bayesian analyses of these cases were applied. A case study showed that negative validity test findings did not indicate "good effort". Results: Deception about illness is fundamentally different from other constructs/diseases in evidence-based medicine and neuropsychology. This is because deception involves a deliberate process that may involve coaching, claimant research, and/or focusing the deception on one aspect (e.g., slowness) as opposed to other neurocognitive problems (e.g., memory). Comparatively, other conditions in medicine and neuropsychology are unlikely to be manipulated by the patient. Conclusions: The assertion by Frederick (2015) and Black, Necrason, and Omasta (2016) that both positive and negative validity test findings must be used together in the aggregate does not stand up to this comparative scrutiny. The fundamental assumption by these authors that a negative test finding concerning malingering represents "good effort" is flawed; it simply represents lack of evidence of malingering, which cannot be construed as evidence of lack of malingering. We recommend that in forensic determination of malingering, negative validity test findings should not be used in a Bayesian aggregation. This conclusion is consistent with current practices in the field.

The Self-Report Symptom Inventory as an Instrument for Detecting Symptom Over-Reporting

Abstract. The recently developed Self-Report Symptom Inventory (SRSI) intends to provide an alternative approach to the detection of symptom over-reporting. Unlike other measures, the SRSI includes both non-existent symptoms (i.e., pseudosymptoms) and genuine symptoms. Previous research using the German SRSI showed that people who exaggerate their complaints over-endorse both types of symptoms. In the current simulation experiment, we tested whether the Dutch and English SRSI are effective in identifying over-reporting by comparing SRSI scores of an honest group ( n = 51) with those of two experimental simulator groups (pain, n = 54; anxiety, n = 53). The pain and anxiety simulators endorsed significantly more genuine symptoms and pseudosymptoms than honest participants (ηp2 = .50 and ηp2 = .30, respectively). Furthermore, pain and anxiety over-reporters specifically over-endorsed symptoms corresponding to their simulation instructions (Cohen’s ds > 0.77). Using the recommended cut-off score, the SRSI detected 48% of pain over-reporters and 73% of anxiety over-reporters, with areas under the curve (AUC) ranging from .88 to .91. These results indicate that the SRSI is a promising tool for identifying over-reporting, but further research with clinical samples is needed.

Multidimensional Malingering Criteria for Neuropsychological Assessment: A 20-Year Update of the Malingered Neuropsychological Dysfunction Criteria

OBJECTIVES

Empirically informed neuropsychological opinion is critical for determining whether cognitive deficits and symptoms are legitimate, particularly in settings where there are significant external incentives for successful malingering. The Slick, Sherman, and Iversion (1999) criteria for malingered neurocognitive dysfunction (MND) are considered a major milestone in the field's operationalization of neurocognitive malingering and have strongly influenced the development of malingering detection methods, including serving as the criterion of malingering in the validation of several performance validity tests (PVTs) and symptom validity tests (SVTs) (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(4), 545-561). However, the MND criteria are long overdue for revision to address advances in malingering research and to address limitations identified by experts in the field.

METHOD

The MND criteria were critically reviewed, updated with reference to research on malingering, and expanded to address other forms of malingering pertinent to neuropsychological evaluation such as exaggeration of self-reported somatic and psychiatric symptoms.

RESULTS

The new proposed criteria simplify diagnostic categories, expand and clarify external incentives, more clearly define the role of compelling inconsistencies, address issues concerning PVTs and SVTs (i.e., number administered, false positives, and redundancy), better define the role of SVTs and of marked discrepancies indicative of malingering, and most importantly, clearly define exclusionary criteria based on the last two decades of research on malingering in neuropsychology. Lastly, the new criteria provide specifiers to better describe clinical presentations for use in neuropsychological assessment.

CONCLUSIONS

The proposed multidimensional malingering criteria that define cognitive, somatic, and psychiatric malingering for use in neuropsychological assessment are presented.

The Modified Somatic Perception Questionnaire: Operating characteristics in non-pain forensic samples

The objective of the current archival study was to investigate the ability of the Modified Somatic Perception Questionnaire (MSPQ) to discriminate between noncredible and credible neurocognitive dysfunction in a large mixed non-pain forensic sample comprised of personal injury litigants and disability claimants. Participants included 149 adults who underwent comprehensive neuropsychological examination. Criterion groups were formed, i.e., Credible Group (CG), or Noncredible Group (NCG) based upon their performance on stand-alone performance validity tests (PVT) including the Word Memory Test (WMT), and/or Test of Memory Malingering (TOMM), and Victoria Symptom Validity Test (VSVT). After excluding examinees with evidence of somatization participants in the NCG scored significantly higher on the MSPQ compared to participants in the CG. Scores on the MSPQ were not only related to cognitive performance validity but also amplified by the co-existence of somatization. There were no significant effects of gender, age, or race on MSPQ scores. We conclude that the MSPQ demonstrates external validity as a self-report measure of symptom validity that is sensitive to somatic and autonomic complaints in non-pain forensic samples. Future research is needed to develop MSPQ cutscores with external validity pertinent to other non-pain populations.

The other face of illness-deception: Diagnostic criteria for factitious disorder with proposed standards for clinical practice and research

Objective: This paper aims to develop diagnostic criteria for factitious disorder (FD) and a heuristic for research by creating standards for delineating criterion groups.Method: Both FD and malingering are conceptualized within a rubric of illness-deception. The history of FD research was compared to the research history on malingering. Differences in the measurement of these constructs were described. The potential utility of performance validity tests (PVTs) and symptom validity tests (SVTs) in FD is discussed in light of successful applications in malingering. Methods for obtaining evidence for FD are delineated in a table of diagnostic criteria.Results: The comparison of FD and malingering research shows that the scientific measurement of malingering evolved rapidly with the introduction of forced-choice validity testing and cogent guidelines for the formation of criterion groups. Likewise, PVTs and SVTs hold promise as methods of measuring deceptive behavior in FD. The most salient differences between FD and malingering are understood to be matter of context/setting: malingering occurs in an external incentive context, while FD occurs in a medical/psychological context. Guidelines to assess FD are developed to fill the need for known-groups research.Conclusions: Evidence for FD, a form of illness-deception, can be obtained by using validity testing, which, together with careful clinical observation, allows for the development of probabilistic diagnostic criteria. Similar to the other form of illness-deception - malingering - these criteria can be used to form known groups for research.

Deconstructing Pain Disability through Concept Analysis

OBJECTIVE

Pain disability is a complex and challenging problem that impacts the daily lives of individuals living with persistent pain. Although this concept is measured throughout pain populations, conceptual clarity is needed to identify the defining characteristics and further understand what comprises this experience for clinical translation.

DESIGN

We completed a concept analysis to identify major attributes and provide a broad framework of pain disability for improved recognition throughout the discipline of nursing.

DATA SOURCES

Literature searches in PubMed, CINAHL, PsychINFO, and Scopus identified 39 relevant cross-disciplinary articles published between January 1990 and November 2017.

REVIEW/ANALYSIS METHODS

We implemented Avant and Walker's method of concept analysis to establish the attributes, antecedents, and consequences of pain disability.

RESULTS

Two major attributes of pain disability are discussed, including (1) physical and/or psychological responses leading to a functional loss; and (2) the degree of ability to fulfill role expectations. The antecedent to the development of pain disability is a painful trigger. Three leading consequences are identified as suffering, pain reactivity, and secondary loss.

CONCLUSIONS

Pain disability is a fluid concept that is characterized by the subjective experiences of the individual. A new conceptualization of pain disability is offered as the inability to maintain role expectations due to the result of a painful trigger and subsequent physical and/or psychosocial dysfunction.

Impact of criterion measures on the classification accuracy of TOMM-1

This study was designed to examine the effect of various criterion measures on the classification accuracy of Trial 1 of the Test of Memory Malingering (TOMM-1), a free-standing performance validity test (PVT). Archival data were collected from a case sequence of 91 (M _Age = 42.2 years; M _Education = 12.7) patients clinically referred for neuropsychological assessment. Trials 2 and Retention of the TOMM, the Word Choice Test, and three validity composites were used as criterion PVTs. Classification accuracy varied systematically as a function of criterion PVT. TOMM-1 ≤ 43 emerged as the optimal cutoff, resulting in a wide range of sensitivity (.47-1.00), with perfect overall specificity. Failing the TOMM-1 was unrelated to age, education or gender, but was associated with elevated self-reported depression. Results support the utility of TOMM-1 as an independent, free-standing, single-trial PVT. Consistent with previous reports, the choice of criterion measure influences parameter estimates of the PVT being calibrated. The methodological implications of modality specificity to PVT research and clinical/forensic practice should be considered when evaluating cutoffs or interpreting scores in the failing range.

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.

[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.

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

BACKGROUND CONTEXT

Waddell et al. identified a set of eight non-organic signs in 1980. There has been controversy about their meaning, particularly with respect to their use as validity indicators.

PURPOSE

The current study examined the Waddell signs in relation to measures of somatic amplification or over-reporting in a sample of outpatient chronic pain patients. We examined the degree to which these signs were associated with measures of over-reporting.

STUDY DESIGN/SETTING

This study examined scores on the Waddell signs in relation to over-reporting indicators in an outpatient chronic pain sample.

PATIENT SAMPLE

We examined 230 chronic pain patients treated at a multidisciplinary pain clinic. The majority of these patients presented with primary back or spinal injuries.

OUTCOME MEASURES

The outcome measures used in the study were Waddell signs, Modified Somatic Perception Questionnaire, Pain Disability Index, and the Minnesota Multiphasic Personality Inventory-2 Restructured Form.

METHODS

We examined Waddell signs using multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA), receiver operating characteristic analysis, classification accuracy, and relative risk ratios.

RESULTS

Multivariate analysis of variance and ANOVA showed a significant association between Waddell signs and somatic amplification. Classification analyses showed increased odds of somatic amplification at a Waddell score of 2 or 3.

CONCLUSIONS

Our results found significant evidence of an association between Waddell signs and somatic over-reporting. Elevated scores on the Waddell signs (particularly scores higher than 2 and 3) were associated with increased odds of exhibiting somatic over-reporting.

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.

Malingering in Toxic Exposure

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

Kriterien zur Bestimmung des Schweregrades einer neuropsychologischen Störung sowie Zuordnungen zur Funktions- und Arbeitsfähigkeit

Zusammenfassung. Im Folgenden wird ein Beurteilungssystem zur Einschätzung des Schweregrades von neuropsychologischen Störungen vorgestellt. Insbesondere umfasst es spezifische Kriterien zur Ermittlung des Schweregrades einer Störung, die wiederum in Beziehung zur Funktions- und Arbeitsfähigkeit eines Patienten oder Versicherten gesetzt werden. Das Beurteilungssystem beruht auf den in der Suva-Tabelle 8 zur Einschätzung der psychischen Folgen einer Hirnverletzung definierten Kriterien. Infolgedessen ist es auch grundsätzlich damit vereinbar, stellt aber aufgrund des Miteinbezugs von neuropsychologischen Testergebnissen in Form von Standardwerten als Beurteilungskriterium sowie verbunden mit den Erläuterungen zu deren Interpretation und Anwendung eine wesentliche Weiterentwicklung dar. Im Gegensatz zur Suva-Tabelle 8 ist das Beurteilungssystem unabhängig vom kausalen Versicherungskontext des UVG. Es kann somit unter anderem auch in Rahmen des IVG und KVG/VVG angewandt werden. In diesem Sinne ist es sowohl unabhängig von der Ätiologie des jeweiligen Beschwerdebildes wie auch unabhängig von der artifiziellen dichotomen Unterscheidung zwischen „organischen“ und „nichtorganischen“ psychischen Störungen. Mit der Erstellung und Publikation dieser neuen Kriterien-Tabelle soll ein Beitrag zur weiteren Verbesserung der Interrater-Reliabilität im Rahmen der Beurteilung des Schweregrades von neuropsychologischen Störungen sowie der Einschätzung der Funktionsfähigkeit geleistet werden. Nicht zuletzt ist das Beurteilungssystem auch kompatibel mit den im DSM-5 festgelegten Kriterien zur Einschätzung des Schweregrades einer neurokognitiven Störung.