Influence of poor effort on neuropsychological test performance in U.S. military personnel following mild traumatic brain injury

Importance of validity testing in psychiatric assessment: evidence from a sample of multimorbid post-9/11 veterans

OBJECTIVE

Performance validity (PVTs) and symptom validity tests (SVTs) are necessary components of neuropsychological testing to identify suboptimal performances and response bias that may impact diagnosis and treatment. The current study examined the clinical and functional characteristics of veterans who failed PVTs and the relationship between PVT and SVT failures.

METHOD

Five hundred and sixteen post-9/11 veterans participated in clinical interviews, neuropsychological testing, and several validity measures.

RESULTS

Veterans who failed 2+ PVTs performed significantly worse than veterans who failed one PVT in verbal memory (Cohen's d = .60-.69), processing speed (Cohen's d = .68), working memory (Cohen's d = .98), and visual memory (Cohen's d = .88-1.10). Individuals with 2+ PVT failures had greater posttraumatic stress (PTS; β = 0.16; p = .0002), and worse self-reported depression (β = 0.17; p = .0001), anxiety (β = 0.15; p = .0007), sleep (β = 0.10; p = .0233), and functional outcomes (β = 0.15; p = .0009) compared to veterans who passed PVTs. 7.8% veterans failed the SVT (Validity-10; ≥19 cutoff); Multiple PVT failures were significantly associated with Validity-10 failure at the ≥19 and ≥23 cutoffs (p's < .0012). The Validity-10 had moderate correspondence in predicting 2+ PVTs failures (AUC = 0.83; 95% CI = 0.76, 0.91).

CONCLUSION

PVT failures are associated with psychiatric factors, but not traumatic brain injury (TBI). PVT failures predict SVT failure and vice versa. Standard care should include SVTs and PVTs in all clinical assessments, not just neuropsychological assessments, particularly in clinically complex populations.

Examination of the relationship between symptom and performance validity measures across referral subtypes

INTRODUCTION

The extent to which performance validity (PVT) and symptom validity (SVT) tests measure separate constructs is unclear. Prior research using the Minnesota Multiphasic Personality Inventory (MMPI-2 & RF) suggested that PVTs and SVTs are separate but related constructs. However, the relationship between Personality Assessment Inventory (PAI) SVTs and PVTs has not been explored. This study aimed to replicate previous MMPI research using the PAI, exploring the relationship between PVTs and overreporting SVTs across three subsamples, neurodevelopmental (attention deficit-hyperactivity disorder (ADHD)/learning disorder), psychiatric, and mild traumatic brain injury (mTBI).

METHODS

Participants included 561 consecutive referrals who completed the Test of Memory Malingering (TOMM) and the PAI. Three subgroups were created based on referral question. The relationship between PAI SVTs and the PVT was evaluated through multiple regression analysis.

RESULTS

The results demonstrated the relationship between PAI symptom overreporting SVTs, including Negative Impression Management (NIM), Malingering Index (MAL), and Cognitive Bias Scale (CBS), and PVTs varied by referral subgroup. Specifically, overreporting on CBS but not NIM and MAL significantly predicted poorer PVT performance in the full sample and the mTBI sample. In contrast, none of the overreporting SVTs significantly predicted PVT performance in the ADHD/learning disorder sample but conversely, all SVTs predicted PVT performance in the psychiatric sample.

CONCLUSIONS

The results partially replicated prior research comparing SVTs and PVTs and suggested that constructs measured by SVTs and PVTs vary depending upon population. The results support the necessity of both PVTs and SVTs in clinical neuropsychological practice.

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

To determine if the number of participants with psychiatric disorders increased in association with failures on symptom validity tests (SVTs) and a performance validity test (PVT) in Veterans admitted for evaluation of possible seizures.

The 254 participants were Veterans undergoing inpatient video-EEG monitoring for the diagnosis of possible seizures. DSM-IV psychiatric disorders were diagnosed with the SCID IV. Symptom exaggeration was assessed with the MMPI-2-RF and performance validity with the TOMM.

On the MMPI-2-RF, 27.6%-32.7% showed symptom exaggeration. Participants who exaggerated on the MMPI-2-RF were more often diagnosed with psychiatric disorders. The TOMM was failed by 15.4% of the sample. Participants who failed the TOMM were more often diagnosed with an Axis I disorder but not with a personality disorder. The MMPI-2-RF was invalid in more cases than the TOMM, but 7.9% of the sample generated a valid MMPI-2-RF and an invalid TOMM.

The correlational design does not allow conclusions about cause and effect. The invalid groups may have had a higher rate of psychopathology. The number of participants with psychiatric disorders increased in association with symptom exaggeration and performance invalidity. Symptom exaggeration was more frequent than performance invalidity, but the TOMM made a unique contribution to identification of invalidity. The routine clinical use of SVTs and PVTs is supported. The results also suggest the need for caution in diagnosing psychiatric disorders when there is symptom exaggeration or performance invalidity, because diagnostic validity is dependent on the accuracy of symptom reporting.

Neuropsychological Profile of Traumatic Brain Injury Patients with Medicolegal Cases: A Pilot Study

Introduction Traumatic brain injury (TBI) is a global health problem and is a silent epidemic of the modern times. Studies indicate litigation is a prominent factor that accounts for poor outcome and prolonged recovery from mild TBI. Depression is the most frequently diagnosed psychiatric disorder after TBI. Postconcussion symptoms, litigation, and suboptimal effort could contribute to the neuropsychological functioning of TBI patients medicolegal cases (MLCs). With increase in TBI and medicolegal cases, there is a requirement for comprehensive neuropsychological assessment.

Method The aim of the study was to evaluate the cognitive functions, postconcussion, and depressive symptoms in TBI patients with MLC and without MLCs (non-MLC). Patients were also assessed on electrophysiological parameters. An observational cross-sectional design was adopted, the sample size was 30 TBI patients in total, 15 (MLC) and 15 (non-MLC), and 11 patients from each group for electrophysiological assessment. The patients were in the age range of 18 to 50 years.

Results The MLC group had poor performance compared with the non-MLC group on both neuropsychological and electrophysiological measures. There was evidence of significant difference in verbal working memory, verbal learning, and memory and visuoconstructive ability. In the MLC group, postconcussion and depressive scores were negatively correlated with visuospatial span.

Conclusion Findings from this study indicate differences in the neuropsychological performance and electroencephalographic measures in between MLC and non-MLC groups. The results could be indicative of persistent cognitive problems associated with TBI for patients pursuing litigation. Poor performance could also be attributed to suboptimal level of effort. However, being a preliminary study with a small sample size, the findings need to be treated with caution.

The Rey Dot Counting Test as a Tool for Detecting Suboptimal Performance in Athlete Baseline Testing

OBJECTIVE

The limitations of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)'s embedded validity measures (EVMs) are well-documented, as estimates suggest up to 35% of invalid baseline performances go undetected. Few studies have examined standalone performance validity tests (PVT) as a supplement to ImPACT's EVMs.

METHOD

College athletes (n = 1,213) were administered a preseason baseline assessment that included ImPACT and the Rey Dot Counting Test (DCT), a standalone PVT, among other measures.

RESULTS

Sixty-nine athletes (5.69%) met criteria for suboptimal effort on either ImPACT or the DCT. The DCT detected more cases of suboptimal effort (n = 50) than ImPACT (n = 21). A χ2 test of independence detected significant disagreement between the two measures, as only two individuals produced suboptimal effort on both (χ2(2) = 1.568, p = .210). Despite this disagreement, there were significant differences between the suboptimal effort DCT group and the adequate effort DCT group across all four ImPACT neurocognitive domains (U = 19,225.000, p < .001; U = 17,859.000, p < .001; U = 13,854.000, p < .001; U = 17,850.500, p < .001).

CONCLUSIONS

The DCT appears to detect suboptimal effort otherwise undetected by ImPACT's EVMs.

Performance validity and symptom validity tests: Are they measuring different constructs?

OBJECTIVE

To evaluate the relationships among performance validity, symptom validity, symptom self-report, and objective cognitive testing.

METHOD

Combat Veterans (N = 338) completed a neurocognitive assessment battery and several self-report symptom measures assessing depression, posttraumatic stress disorder (PTSD) symptoms, sleep quality, pain interference, and neurobehavioral complaints. All participants also completed two performance validity tests (PVTs) and one stand-alone symptom validity test (SVT) along with two embedded SVTs.

RESULTS

Results of an exploratory factor analysis revealed a three-factor solution: performance validity, cognitive performance, and symptom report (SVTs loaded on the third factor). Results of t tests demonstrated that participants who failed PVTs displayed significantly more severe symptoms and significantly worse performance on most measures of neurocognitive functioning compared to those who passed. Participants who failed a stand-alone SVT also reported significantly more severe symptomatology on all symptom report measures, but the pattern of cognitive performance differed based on the selected SVT cutoff. Multiple linear regressions revealed that both SVT and PVT failure explained unique variance in symptom report, but only PVT failure significantly predicted cognitive performance.

CONCLUSIONS

Performance and symptom validity tests measure distinct but related constructs. SVTs and PVTs are significantly related to both cognitive performance and symptom report; however, the relationship between symptom validity and symptom report is strongest. SVTs are also differentially related to cognitive performance and symptom report based on the utilized cutoff score. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cognition and Other Predictors of Functional Disability Among Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder

BACKGROUND

Limitations in everyday functioning are frequently reported by veterans with a history of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD). Multiple factors are associated with functional disability among veterans, including depression, poor social support, cognition, and substance use. However, the degree to which these factors, particularly cognitive capacities, contribute to functional limitations remains unclear.

METHODS

We evaluated performance on tests of processing speed, executive functioning, attention, and memory as predictors of functioning on the World Health Organization Disability Assessment Scale (WHODAS) 2.0 in 288 veterans. Participants were placed in one of the following groups: PTSD-only, mTBI-only, mTBI + PTSD, and neither PTSD nor mTBI (deployed control group). Cognitive test performances were evaluated as predictors of WHODAS 2.0 functional ratings in regression models that included demographic variables and a range of mood, behavioral health, and postconcussive symptom ratings.

RESULTS

Multiple cognitive test performances predicted WHODAS 2.0 scores in the deployed control group, but they generally did not predict functioning in the clinical groups when accounting for demographics, mood, behavioral health, and postconcussive symptoms.

CONCLUSIONS

In veterans with mTBI and/or PTSD, cognitive test performances are less associated with everyday functioning than mood and postconcussive symptoms.

Validity testing in veterans with epileptic seizures and psychogenic nonepileptic seizures

OBJECTIVE

Identification of clinically meaningful subgroups among patients with psychogenic nonepileptic seizures (PNES) or epileptic seizures (ES) is of potential value for assessing prognosis and predicting therapeutic response. Invalid performance on validity tests has been associated with noncredible complaints and worse cognitive test scores, and may be one such classification criteria. We studied invalid performance in Veterans with PNES or ES, and the association of invalid performance with cognitive test scores and subjective complaints.

METHODS

Patients were consecutive admissions to three veterans affairs (VA) epilepsy monitoring units. Evaluations included two validity tests: the Test of Memory Malingering (TOMM); and the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) over-reporting validity scales. We compared the frequency of invalid performance on the TOMM or MMPI-2-RF in patients diagnosed with PNES vs. ES. We evaluated the association of invalid performance with scores on the Repeatable Battery for Assessment of Neuropsychological Status (RBANS), and four subjective symptom measures including the Beck Depression Inventory-II, and Quality of Life in Epilepsy-31.

RESULTS

Invalid TOMM performance was found in 25.3% of Veterans diagnosed with PNES and 10.8% of those with ES (p = .03). Invalid reporting on the MMPI-2-RF was found in 35.9% of the PNES group vs. 15.3% of the ES group (p = .01). Effects of valid vs. invalid reporting on external measures were similar for ES and PNES groups. Patients with invalid vs. valid TOMM performance had lower scores on the RBANS (p < .001). Patients with invalid performance had greater complaints on all subjective measures, with largest effect sizes for the MMPI-2-RF validity scales (p < .001).

SIGNIFICANCE

In Veterans admitted for evaluation of poorly controlled seizures, invalid performance on validity tests was not uncommon. Cognitive test results and subjective reports from patients with invalid performance may not be credible. These observations have implications for the analysis of clinical trials, where primary and secondary outcomes often rely on self-report measures.

Clinical utility of the TOMMe10 scoring criteria for detecting suboptimal effort in an mTBI veteran sample

In the context of diminishing reimbursement and patient access demands, researchers continually refine performance validity measures (PVMs) to maximize efficiency while maintaining confidence in obtained data. This is particularly true for high PVM failure populations (e.g., mTBI patients). The TOMMe10 (number of errors on first 10 TOMM items) is one method this study utilized for classifying PVM performance as pass/fail (fail defined as failure on 2 of 6 PVM scores, pass defined as 0/1 failures). The present study hypothesized that the TOMMe10 would have equitable sensitivity/specificity for identifying non-credible cognitive performance among veterans with mTBI compared to previous research findings and commonly used performance validity measures (e.g., TOMM or WMT). Data were analyzed from 54 veterans assigned to a pass and fail group based on their performance across six recognized PVMs. Results revealed pass/fail groups were not significantly different regarding age, educational, or racial background. ROC analyses found the TOMMe10 demonstrated excellent discriminability (AUC = .803 ±.128), indicating that the TOMMe10 could have clinical utility within an mTBI veteran sample, particularly in conjunction with a second PVM. Specific population limitations are discussed. Additional research should elucidate this measure's performance with additional populations, including non-veteran mTBI, dementia, moderate-severe TBI, and inpatient populations.

A Meta-Analysis of Neuropsychological Effort Test Performance in Psychotic Disorders

Psychotic disorders are characterized by a generalized neurocognitive deficit (i.e., performance 1.5 SD below controls across neuropsychological domains with no specific profile of differential deficits). A motivational account of the generalized neurocognitive deficit has been proposed, which attributes poor neuropsychological testing performance to low effort. However, findings are inconsistent regarding effort test failure rate in individuals with psychotic disorders across studies (0-72%), and moderators are unclear, making it difficult to know whether the motivational explanation is viable. To address these issues, a meta-analysis was performed on data from 2205 individuals with psychotic disorders across 19 studies with 24 independent effects. Effort failure rate was examined along with moderators of effort test type, forensic status, IQ, positive symptoms, negative symptoms, diagnosis, age, gender, education, and antipsychotic use. The pooled weighted effort test failure rate was 18% across studies and there was a moderate pooled association between effort failure rate and global neurocognitive performance (r = .57). IQ and education significantly moderated failure rate. Collectively, these findings suggest that a nontrivial proportion of individuals with a psychotic disorder fail effort testing, and failure rate is associated with global neuropsychological impairment. However, given that effort tests are not immune to the effects of IQ in psychotic disorders, these results cannot attest to the viability of the motivational account of the generalized neurocognitive deficit. Furthermore, the significant moderating effect of IQ and education on effort test performance suggests that effort tests have questionable validity in this population and should be interpreted with caution.

Validating the usefulness of the NSI validity-10 with the MMPI-2-RF

Purpose/Aim of the Study: The Neurobehavioral Symptom Inventory (NSI) is a 22-item self-report measure created to quantify the somatosensory, cognitive, and affective symptoms of Post-concussive Syndrome. Developers of the NSI used a subset of 10 items, the Validty-10, to measure symptom overreporting. We compared the Validity-10 versus the remaining NSI items (i.e., the Remaining-12) for how accurately they detect symptom exaggeration on the Minnesota Multiphasic Personality Inventory Second Edition - Restructured Form (MMPI-2-RF).Materials and Methods: We used a sample of 45 veterans evaluated in a Polytrauma/TBI Clinic of a Midwest VA Healthcare System who completed the NSI and MMPI-2-RF.Results: The Vaidity-10, Remaining-12, and Total Score all strongly correlated with mean of the MMPI-2-RF validity scales (r = .65, .67, and .70, respectively), illustrating equivalency among the various NSI scores. Groups were created based on significant T score elevation on any MMPI-2-RF validity scale (i.e. F-r > 119, or Fp-r, F-s, FBS, or RBS > 99). ROC analyses demonstrated that areas under the curve were equivalent for NSI Total Score (.84), Validity-10 (.81), and Remaining-12 (.81) in detecting overreporting.Conclusions: These findings do not support the notion that the Validity-10 has unique utility as an embedded symptom validity scale and highlights the likelihood that NSI Total Score can also serve this function.

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

OBJECTIVE

Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance.

METHOD

Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass).

RESULTS

Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition.

CONCLUSION

Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.

Clinical utility of WAIS-IV 'excessive decline from premorbid functioning' scores to detect invalid test performance following traumatic brain injury

Objective: Excessive Decline from Premorbid Functioning (EDPF), an atypical discrepancy between demographically predicted and obtained Wechsler Adult Intelligence Scale-4th Edition (WAIS-IV) scores, has been recently proposed as a potential embedded performance validity test (PVT). This study examined the clinical utility of EDPF scores to detect invalid test performance following traumatic brain injury (TBI).Methods: Participants were 194 U.S. military service members who completed neuropsychological testing on average 2.4 years (SD = 4.0) following uncomplicated mild, complicated mild, moderate, severe, or penetrating TBI (Age: M = 34.0, SD = 9.9). Using TBI severity and PVT performance (i.e., PVT Pass/Fail), participants were classified into three groups: Uncomplicated Mild TBI-PVT Fail (MTBI-Fail; n = 21), Uncomplicated Mild TBI-PVT Pass (MTBI-Pass; n = 94), and Complicated Mild to Severe/Penetrating TBI-PVT Pass (CM/STBI-Pass; n = 79). Seven EDPF measures were calculated by subtracting WAIS-IV obtained index scores from the demographically predicted scores from the Test of Premorbid Functioning (TOPF). Cutoff scores to detect invalid test performance were examined for each EDPF measure separately.Results: The MTBI-Fail group had higher scores than the MTBI-Pass and CM/STBI-Pass groups on five of the seven EDPF measures (p<.05). Overall, the EDPF measure using the Processing Speed Index (EDPF-PSI) was the most useful score to detect invalid test performance. However, sensitivity was only low to moderate depending on the cutoff score used.Conclusions: These findings provide support for the use of EDPF as an embedded PVT to be considered along with other performance validity data when administering the WAIS-IV.

Medical Evaluation Board Involvement, Non-Credible Cognitive Testing, and Emotional Response Bias in Concussed Service Members

Introduction

Military Service Members (SMs) with post-concussive symptoms are commonly referred for further evaluation and possible treatment to Department of Defense Traumatic Brain Injury Clinics where neuropsychological screening/evaluations are being conducted. Understudied to date, the base rates of noncredible task engagement/performance validity testing (PVT) during cognitive screening/evaluations in military settings appears to be high. The current study objectives are to: (1) examine the base rates of noncredible PVTs of SMs undergoing routine clinical or Medical Evaluation Board (MEB) related workups using multiple objective performance-based indicators; (2) determine whether involvement in MEB is associated with PVT or symptom exaggeration/symptom validity testing (SVT) results; (3) elucidate which psychiatric symptoms are associated with noncredible PVT performances; and (4) determine whether MEB participation moderates the relationship between psychological symptom exaggeration and whether or not SM goes on to demonstrate PVTs failures - or vice versa.

Materials and Methods

Retrospective study of 71 consecutive military concussion cases drawn from a DoD TBI Clinic neuropsychology clinic database. As part of neuropsychological evaluations, patients completed several objective performance-based PVTs and SVT.

Results

Mean (SD) age of SMs was 36.0 (9.5), ranging from 19-59, and 93% of the sample was male. The self-identified ethnicity resulted in the following percentages: 62% Non-Hispanic White, 22.5% African American, and 15.5% Hispanic or Latino. The majority of the sample (97%) was Active Duty Army and 51% were involved in the MEB at the time of evaluation. About one-third (35.9%) of routine clinical patients demonstrated failure on one or more PVT indicators (12.8% failed 2) while PVT failure rates amongst MEB patients ranged from 15.6% to 37.5% (i.e., failed 2 or 1 PVTs, respectively). Base rates of failures on one or more PVT did not differ between routine clinical versus MEB patients (p = 0.94). MEB involvement was not associated with increased emotional symptom response bias as compared to routine clinical patients. PVT failures were positively correlated with somatization, anxiety, depressive symptoms, suspicious and hostility, atypical perceptions/alienation/subjective cognitive difficulties, borderline personality traits/features, and penchant for aggression in addition to symptom over-endorsement/exaggeration. No differences between routine clinical and MEB patients across other SVT indicators were found. MEB status did not moderate the relationship between any of the SVTs.

Conclusion

Study results are broadly consistent with the prior published studies that documented low to moderately high base rates of noncredible task engagement during neuropsychological evaluations in military and veteran settings. Results are in contrast to prior studies that have suggested involvement in MEB is associated with increased likelihood of poor PVT performances. This is the first to show that MEB involvement did not enhance/strengthen the association between PVT performances and evidence of SVTs. Consistent with prior studies, these results do highlight that the same SMs who fail PVTs also tend to be the ones who go on to endorse a myriad of psychiatric symptoms and proclivities. Implications of variable or poor task engagement during routine clinical and MEB neuropsychological evaluation in military settings on treatment and disposition planning cannot be overstated.

The Influence of Cognitive Reserve on Recovery from Traumatic Brain Injury

Objective

we sought to determine the degree to which cognitive reserve, as assessed by the Test of Premorbid Functioning in combination with demographic variables, could act as a buffer against the effect of traumatic brain injury (TBI) on cognitive test performance.

Method

retrospective analysis of a cohort of 121 persons with TBI who completed the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) within 1-12 months after injury.

Results

regression analyses indicated that cognitive reserve was a statistically significant predictor of all postinjury WAIS-IV factor index scores, after controlling for various premorbid and comorbid confounding variables. Only for Processing Speed did injury severity make an additional statistically significant contribution to the prediction model.

Conclusions

cognitive reserve has a protective effect with regard to the impact of TBI on cognitive test performance but this effect is imperfect and does not completely negate the effect of injury severity.

Reliable Digit Span: Does it Adequately Measure Suboptimal Effort in an Adult Epilepsy Population?

Objective

Assessment of performance validity is a necessary component of any neuropsychological evaluation. Prior research has shown that cutoff scores of ≤6 or ≤7 on Reliable Digit Span (RDS) can detect suboptimal effort across numerous adult clinical populations; however, these scores have not been validated for that purpose in an adult epilepsy population. This investigation aims to determine whether these previously established RDS cutoff scores could detect suboptimal effort in adults with epilepsy.

Method

Sixty-three clinically referred adults with a diagnosis of epilepsy or suspected seizures were administered the Digit Span subtest of the Wechsler Adult Intelligence Scale (WAIS-III or WAIS-IV). Most participants (98%) passed Trial 2 of the Test of Memory Malingering (TOMM), achieving a score of ≥45.

Results

Previously established cutoff scores of ≤6 and ≤7 on RDS yielded a specificity rate of 85% and 77% respectively. Findings also revealed that RDS scores were positively related to attention and intellectual functioning. Given the less than ideal specificity rate associated with each of these cutoff scores, together with their strong association to cognitive factors, secondary analyses were conducted to identify more optimal cutoff scores. Preliminary results suggest that an RDS cutoff score of ≤4 may be more appropriate in a clinically referred adult epilepsy population with a low average IQ or lower.

Conclusions

Preliminary findings indicate that cutoff scores of ≤6 and ≤7 on RDS are not appropriate in adults with epilepsy, especially in individuals with low average IQ or below.

Performance Validity, Neurocognitive Disorder, and Post-concussion Symptom Reporting in Service Members with a History of Mild Traumatic Brain Injury

Objective

To examine the influence of different performance validity test (PVT) cutoffs on neuropsychological performance, post-concussion symptoms, and rates of neurocognitive disorder and postconcussional syndrome following mild traumatic brain injury (MTBI) in active duty service members.

Method

Participants were 164 service members (Age: M = 28.1 years [SD = 7.3]) evaluated on average 4.1 months (SD = 5.0) following injury. Participants were divided into three mutually exclusive groups using original and alternative cutoff scores on the Test of Memory Malingering (TOMM) and the Effort Index (EI) from the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): (a) PVT-Pass, n = 85; (b) Alternative PVT-Fail, n = 53; and (c) Original PVT-Fail, n = 26. Participants also completed the Neurobehavioral Symptom Inventory.

Results

The PVT-Pass group performed better on cognitive testing and reported fewer symptoms than the two PVT-Fail groups. The Original PVT-Fail group performed more poorly on cognitive testing and reported more symptoms than the Alternative PVT-Fail group. Both PVT-Fail groups were more likely to meet DSM-5 Category A criteria for mild and major neurocognitive disorder and symptom reporting criteria for postconcussional syndrome than the PVT-Pass group. When alternative PVT cutoffs were used instead of original PVT cutoffs, the number of participants with valid data meeting cognitive testing criteria for neurocognitive disorder or postconcussional syndrome decreased dramatically.

Conclusion

PVT performance is significantly and meaningfully related to overall neuropsychological outcome. By using only original cutoffs, clinicians and researchers may miss people with invalid performances.

The Minnesota Multiphasic Personality Inventory-2-RF in Treatment-Seeking Veterans with History of Mild Traumatic Brain Injury

OBJECTIVE

This study examined the Minnesota Multiphasic Personality Inventory-Second Edition-Restructured Form (MMPI-2-RF) to better understand symptom presentation in a sample of treatment-seeking Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with self-reported history of mild traumatic brain injury (mTBI).

METHOD

Participants underwent a comprehensive clinical neuropsychological battery including performance and symptom validity measures and self-report measures of depressive, posttraumatic, and post-concussive symptomatology. Those with possible symptom exaggeration (SE+) on the MMPI-2-RF were compared with those without (SE-) with regard to injury, psychiatric, validity, and cognitive variables.

RESULTS

Between 50% and 87% of participants demonstrated possible symptom exaggeration on one or more MMPI-2-RF validity scales, and a large majority were elevated on content scales related to cognitive, somatic, and emotional complaints. The SE+ group reported higher depressive, posttraumatic, and post-concussive symptomatology, had higher scores on symptom validity measures, and performed more poorly on neuropsychological measures compared with the SE- group. There were no group differences with regard to injury variables or performance validity measures. Participants were more likely to exhibit possible symptom exaggeration on cognitive/somatic compared with traditional psychopathological validity scales.

CONCLUSIONS

A sizable portion of treatment-seeking OEF/OIF Veterans demonstrated possible symptom exaggeration on MMPI-2-RF validity scales, which was associated with elevated scores on self-report measures and poorer cognitive performance, but not higher rates of performance validity failure, suggesting symptom and performance validity are distinct concepts. These findings have implications for the interpretation of clinical data in the context of possible symptom exaggeration and treatment in Veterans with persistent post-concussive symptoms.

Detecting memory performance validity with DETECTS: A computerized performance validity test

Evaluating performance validity is essential in neuropsychological and forensic assessments. Nonetheless, most psychological assessment tests are unable to detect performance validity and other methods must be used for this purpose. A new Performance Validity Test (DETECTS - Memory Performance Validity Test) was developed with several characteristics that enhance test utility. Moreover, precise response time measurement was added to DETECTS. Two groups of participants (normative and simulator group) completed DETECTS and three memory tests from the Wechsler Memory Scale III. Simulators achieved considerably lower scores (hits) and higher response times in DETECTS compared with the normative group. All participants in the normative group were classified correctly and no simulator was classified as having legitimate memory deficits. Thus, DETECTS seems to be a valuable computerized Performance Validity Test with reduced application time and effective cut-off scores as well as high sensitivity, specificity, and positive and negative predictive power values. Lastly, response time may be a very useful measure for detecting memory malingering.

Exaggerated Functional Impairment due to Malingered Neurocognitive Dysfunction Following Mild Traumatic Brain Injury

Objective

Functional impairment associated with Neurocognitive Disorder is often claimed in medico-legal settings after mild Traumatic Brain Injury (mTBI). This case–control study examined self-reported functional impairment and the plausibility of chronic disability claims following uncomplicated mTBI.

Method

Independent Medical Evaluations included a battery of performance and symptom validity tests, along with self-reports of physical or emotional complaints and functional impairment. Slick and colleagues’ (Slick, D. J., Sherman, E. M., & Iverson, G. L. (1999). Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13, 545–561.) criteria ruled out probable malingering in 21 mTBI cases without psychiatric comorbidity and their self-reports were compared to those of seven non-malingering cases with a psychiatric comorbidity, 17 who were probable malingerers, and 31 orthopedic pain sufferers. Coherence Analysis of medical documentation corroborated assignment of mTBI cases to non-malingering versus probable malingering groups.

Results

Probable malingerers reported more postconcussion symptoms than non-malingerers (d = 0.79) but they did not differ significantly on tests of neurocognitive performance. Probable malingerers and orthopedic pain patients gave significantly higher ratings of functional impairment (d = 1.28 and 1.26) than non-malingerers. Orthopedic pain patients reported more disability due to pain than non-malingerers (d = 1.03), but pain catastrophizing was rated more highly by the probable malingerers (d = 1.21) as well as by the orthopedic pain patients (d = 0.98). The non-malingerers reported lower emotional distress than the other three groups, but only the probable malingerers reported elevated depression symptoms compared to the non-malingerers (d = 1.01).

Conclusions

The combined evaluation of performance validity, function, and coherence analysis would appear to enhance the difficult clinical evaluation of postconcussion symptoms in the medical-legal setting.

Concordance validity of PVTs in a sample of veterans referred for mild TBI

Concordance validity of commonly used performance validity tests (PVTs) was assessed in a sample of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans referred to an mTBI screening clinic in a south-eastern Veterans Affairs hospital. Veteran service members (total n = 184) completed the Rey-15, Repeatable Battery of the Assessment for Neuropsychological Status Effort Index (RBANS EI), and Reliable Digit Span (RDS) from the Wechsler Intelligence Scales. Kappa coefficients and percentage of agreement were established to determine the level of concordance between the three measures. PVT failure rate ranged from 7.4% of the sample (Rey-15) to 26.1% (RBANS EI Liberal). The highest concordance was found between the Rey 15 and RBANS EI "highly suspicious" cut-off, with the lowest agreement noted between all PVTs and the RBANS EI "liberal" cut-score. All concordance coefficients fell within the fair to moderate levels. Overall, the observed agreement between the explored measures was generally consistent with or greater than other studies of PVT concordance. Given the rates of concordance, the current results continue to suggest that PVTs are likely to measure a construct separate from the typical cognitive domains.

Utility of the Validity-10 scale across the recovery trajectory following traumatic brain injury

The Validity-10 scale was recently developed to screen for symptom exaggeration in patients following traumatic brain injury (TBI). However, it has only been validated on patients with TBI largely in the chronic phase of recovery. The influence of time since injury on the Validity-10 scale was investigated in 2,661 male servicemembers with TBI presenting to six U.S. Defense and Veterans Brain Injury Centers. Participants completed the Neurobehavioral Symptom Inventory (NSI). The Validity-10 scale and NSI total score were both weakly statistically significantly (1) positively correlated with time since injury, (2) negatively correlated with bodily injury severity, and (3) higher in participants undergoing medical board evaluations than in participants who returned to duty or were still hospitalized. Participants were statistically more likely to screen positive for possible symptom exaggeration on the Validity-10 scale as time since injury increased. However, the Validity-10 scale was only weakly related to time since injury, TBI severity, bodily injury severity, disposition, age, and return to duty status. That false positives are not increased in the acute phase of recovery and that the Validity-10 scale is not strongly related to clinical factors support the use of the Validity-10 scale in the acute recovery phase and across the TBI recovery trajectory.

White Matter Associations With Performance Validity Testing in Veterans With Mild Traumatic Brain Injury: The Utility of Biomarkers in Complicated Assessment

OBJECTIVE

Failure on performance validity tests (PVTs) is common in Veterans with histories of mild traumatic brain injury (mTBI), leading to questionable validity of clinical presentations.

PARTICIPANTS

Using diffusion tensor imaging, we investigated white matter (WM) integrity and cognition in 79 Veterans with history of mTBI who passed PVTs (n = 43; traumatic brain injury [TBI]-passed), history of mTBI who failed at least 1 PVT (n = 13; TBI-failed), and military controls (n = 23; MCs) with no history of TBI.

RESULTS

The TBI-failed group demonstrated significantly lower cognitive scores relative to MCs and the TBI-passed group; however, no such differences were observed between MCs and the TBI-passed group. On a global measure of WM integrity (ie, WM burden), the TBI-failed group showed more overall WM abnormalities than the other groups. However, no differences were observed between the MCs and TBI-passed group on WM burden. Interestingly, regional WM analyses revealed abnormalities in the anterior internal capsule and cingulum of both TBI subgroups relative to MCs. Moreover, compared with the TBI-passed group, the TBI-failed group demonstrated significantly decreased WM integrity in the corpus callosum.

CONCLUSIONS

Findings revealed that, within our sample, WM abnormalities are evident in those who fail PVTs. This study adds to the burgeoning PVT literature by suggesting that poor PVT performance does not negate the possibility of underlying WM abnormalities in military personnel with history of mTBI.

Word Memory Test Performance Across Cognitive Domains, Psychiatric Presentations, and Mild Traumatic Brain Injury

Objective

The current study addressed two aims: (i) determine how Word Memory Test (WMT) performance relates to test performance across numerous cognitive domains and (ii) evaluate how current psychiatric disorders or mild traumatic brain injury (mTBI) history affects performance on the WMT after excluding participants with poor symptom validity.

Method

Participants were 235 Iraq and Afghanistan-era veterans (Mage = 35.5) who completed a comprehensive neuropsychological battery. Participants were divided into two groups based on WMT performance (Pass = 193, Fail = 42). Tests were grouped into cognitive domains and an average z-score was calculated for each domain.

Results

Significant differences were found between those who passed and those who failed the WMT on the memory, attention, executive function, and motor output domain z-scores. WMT failure was associated with a larger performance decrement in the memory domain than the sensation or visuospatial-construction domains. Participants with a current psychiatric diagnosis or mTBI history were significantly more likely to fail the WMT, even after removing participants with poor symptom validity.

Conclusions

Results suggest that the WMT is most appropriate for assessing validity in the domains of attention, executive function, motor output and memory, with little relationship to performance in domains of sensation or visuospatial-construction. Comprehensive cognitive batteries would benefit from inclusion of additional performance validity tests in these domains. Additionally, symptom validity did not explain higher rates of WMT failure in individuals with a current psychiatric diagnosis or mTBI history. Further research is needed to better understand how these conditions may affect WMT performance.

Exploring the sensitivity of the Personality Assessment Inventory symptom validity tests in detecting response bias in a mixed neuropsychological outpatient sample

OBJECTIVE

Few studies have evaluated the symptom validity tests (SVTs) within the Personality Assessment Inventory (PAI) in a neuropsychological assessment context. Accordingly, the present study explored the accuracy of PAI SVTs in identifying exaggerated cognitive dysfunction in a mixed sample of outpatients referred for neuropsychological assessment.

METHOD

Participants who failed two or more Performance Validity Tests (PVTs) were classified as having exaggerated cognitive dysfunction (n = 49). Their responses on PAI SVTs were compared to examinees who did not fail PVTs (n = 257).

RESULTS

Multivariate analysis of variance indicated the Negative Impression Management (NIM) scale most strongly discriminated between those with exaggerated cognitive dysfunction from honest responders (Cohen's d = .58). Nonetheless, its classification accuracy was low (area under the curve [AUC] = .65). A k-means cluster analysis and a subsequent multinomial logistic regression indicated evidence for two distinct groups of exaggerators. In particular, one group seemed to exaggerate symptoms, whereas another presented in a defensive manner, implying that individuals with positive and NIM biases on the PAI were apt to display invalid performance on PVTs.

CONCLUSIONS

Findings indicated that exaggerated cognitive dysfunction tends to be present when NIM is very high and that evidence exists for a defensive response style on the PAI in the context of PVT failure.

Elevated rates of memory impairment in military service-members and veterans with posttraumatic stress disorder

INTRODUCTION

Studies investigating the neurocognitive effects of posttraumatic stress disorder (PTSD) routinely find "deficits" in various cognitive domains. However, the rate of cognitive impairment in individuals with PTSD remains unclear, as studies have focused on null hypothesis testing (NHT) and inferring patterns of impairment rather than empirically determining the rate of cognitive impairment in this sample.

METHOD

This study examined rates of cognitive impairment using a domain-specific approach in non-treatment-seeking Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn service members and veterans with (n = 92) and without (n = 79) PTSD and without substance abuse/dependence who passed a performance validity measure and were matched on age, education, estimated IQ, and ethnicity. Chi-square analyses were used to compare the rate of cognitive impairment across groups based on normative scores using three cutoffs (-1, -1.5, and -2 SDs). NHT was also used to compare performances across groups.

RESULTS

Individuals with PTSD showed higher rates of impairment in memory (-1-SD cutoff) than controls, but equivalent rates of impairment in attention, processing speed, and executive functioning; no significant differences were found on NHT. Impairment in any domain was also more prevalent in PTSD (-1-, -1.5-, and -2-SD cutoffs). No differences were found on NHT or rates of impairment in individuals with PTSD with (n = 34) and without (n = 58) depression.

CONCLUSIONS

Patients with PTSD were more likely to meet criteria for memory impairment and to show impairment in any domain than controls. Patients with PTSD and comorbid depression were no more likely to be impaired in any cognitive domain or to have lower scores on individual cognitive tasks than patients with PTSD alone. Clinicians noting cognitive impairment in individuals with PTSD should exercise caution before ascribing that impairment to another etiology if deficits are limited to memory.

Neuropsychological test validity in Veterans presenting with subjective complaints of 'very severe' cognitive symptoms following mild traumatic brain injury

OBJECTIVE

This study explored the utility of combining data from measures of performance validity and symptom validity among Veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI).

BACKGROUND

Persistent cognitive impairments following mTBI are often reported by returning combat veterans. However, objectively-measured cognitive deficits are not common among individuals with mTBI, raising the question of whether negative impression management influences self-ratings.

METHODS

Self-report ratings were obtained for memory, concentration, decision-making, and processing speed/organization using a 5-point scale ranging from 'none' to 'very severe'. Veterans also completed brief neuropsychological testing which included measures of performance validity.

RESULTS

Study 1 examined data from 122 participants and demonstrated that veterans reporting a 'very severe' cognitive deficit were over three times as likely to demonstrate poor effort on a validity test than those without a very severe rating. Study 2 replicated these findings in an independent sample of 127 veterans and also demonstrated that both severity of self-report ratings and performance on an embedded measure of effort were predictive of poor effort on a stand-alone performance validity test.

CONCLUSION

Veterans with suspected mTBI who report 'very severe' cognitive impairment have a greater likelihood of putting forth sub-optimal effort on objective testing.

Assessment of Performance Validity Using Embedded Saccadic and Manual Indices on a Continuous Performance Test

OBJECTIVE

In addition to manual (i.e., "button press") metrics, oculomotor metrics demonstrate considerable promise as tools for detecting invalid responding in neurocognitive assessment. This study was conducted to evaluate saccadic and manual metrics from a computerized continuous performance test as embedded indices of performance validity.

METHOD

Receiver operating characteristic analyses, logistic regressions, and ANOVAs were performed to evaluate saccadic and manual metrics in classification of healthy adults instructed to feign deficits ("Fake Bad" group; n = 24), healthy adults instructed to perform their best ("Best Effort" group; n = 26), and adults with a history of mild traumatic brain injury (TBI) who passed a series of validity indices ("mTBI-Pass" group; n = 19).

RESULTS

Several saccadic and manual metrics achieved outstanding classification accuracy between Fake Bad versus Best Effort and mTBI-Pass groups, including variability (consistency) of saccadic and manual response time (RT), saccadic commission errors, and manual omission errors. Very large effect sizes were obtained between Fake Bad and Best Effort groups (Cohen's d range: 1.89-2.90; r range: .75-.78) as well as between Fake Bad and mTBI-Pass groups (Cohen's d range: 1.32-2.21; r range: .69-.71). The Fake Bad group consistently had higher saccadic and manual RT variability, more saccadic commission errors, and more manual omission errors than the Best Effort and mTBI-Pass groups.

CONCLUSIONS

These findings are the first to demonstrate that eye movements can be used to detect invalid responding in neurocognitive assessment. These results also provide compelling evidence that concurrently measured saccadic and manual metrics can detect invalid responding with high levels of sensitivity and specificity.

Reconsidering the Word Memory Test as a Memory Measure in Traumatic Brain Injury

OBJECTIVE

This study examined relationships among traumatic brain injury (TBI) severity, the Word Memory Test (WMT), and California Verbal Learning Test-Second Edition (CVLT-II).

METHOD

Participants (N = 104) passed WMT validity indices and were categorized by TBI severity on the basis of medical records. Outcome measures included norm-referenced scores on the CVLT-II and WMT.

RESULTS

Participants grouped by TBI severity significantly differed on the CVLT-II but not WMT. Post-traumatic amnesia (PTA) significantly correlated with the CVLT-II but not WMT. In a non-medicolegal sample subset (N = 61), TBI severity groups significantly differed on CVLT-II and WMT FR; PTA significantly correlated with the CVLT-II and WMT FR. CVLT-II impairment groups differed on all WMT variables. Participants grouped by neuroimaging findings differed on CVLT-II but not WMT. WMT FR predicted two-level TBI severity using logistic regression but did not contribute in a model including the CVLT-II.

CONCLUSION

Overall, WMT memory subtests appeared less sensitive to TBI severity than the CVLT-II.

Auditory difficulties in blast-exposed Veterans with clinically normal hearing

Vast numbers of blast-injured Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn personnel report postconcussive symptoms that include headache, dizziness, poor memory, and difficulty concentrating. In addition, many report hearing problems, such as difficulty understanding speech in noise, yet have no measureable peripheral auditory deficits. In this article, self-report and performance-based measures were used to assess 99 blast-exposed Veterans. All participants reported auditory problems in difficult listening situations but had clinically normal hearing. Participants' scores on self-report questionnaires of auditory difficulties were more similar to scores of older individuals with hearing impairment than to those of younger individuals with normal hearing. Participants showed deficits relative to published normative data on a number of performance-based tests that have demonstrated sensitivity to auditory processing deficits. There were several measures on which more than the expected number of participants (15.9%) performed one or more standard deviations below the mean. These were assessments of speech understanding in noise, binaural processing, temporal resolution, and speech segregation. Performance was not universally poor, with approximately 53% of participants performing abnormally on between 3 and 6 of the 10 measures. We concluded that participants exhibited task-specific deficits that add to the evidence suggesting that blast injury results in damage to the central auditory system.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov; Approaches to Auditory Rehabilitation for Mild Traumatic Brain Injury (mTBI); NCT00930774; https://clinicaltrials.gov/ct2/show/NCT00930774?term=NCT00930774&rank=1.

Comparison of Neuropsychological and Balance Performance Validity Testing

Performance validity testing in the context of neuropsychological assessment is well established. While such measures are also available with balance testing, little research has investigated these two domains in concert. The purpose of this study was to compare scores on two measures of performance validity across cognitive and balance modalities. Seventy-eight subjects independently evaluated by a neuropsychologist and an otolaryngologist in the context of disability evaluations were administered the Word Memory Test and Computerized Dynamic Posturography. Results of the measures were significantly correlated (r_φ = 0.35, p = .002) and demonstrated 70.5% agreement. These data suggest that if symptom exaggeration occurs within one modality, other modalities may also be exaggerated and should be independently evaluated.