Two views of malingering

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.

Race, health, and socioeconomic disparities associated with malingering in psychiatric patients at an urban emergency department

OBJECTIVE

To examine clinical and sociodemographic differences between psychiatric patients suspected of malingering and non-malingering controls in an urban emergency department (ED) setting.

METHODS

We used retrospective chart review to compare 57 psychiatric patients suspected of malingering with 195 date-matched controls. We examined evidence used for malingering and documented secondary gains.

RESULTS

The prevalence of malingering was 5.6-7.1%, with documented evidence consistent with DSM-V guidelines. Malingering patients were more likely to be male (p < .001), > 45 years old (p = .002), Black (p = .049), unhoused (p < .001), and frequent users of ED (p < .001). Psychiatric diagnoses were found in ~75% of malingerers. Diagnosis of antisocial personality (OR = 8.03, p = .013) and substance use disorder (OR = 2.05, p = .018) predicted increased probability of malingering. Malingering encounters were more likely to result in discharges (p < .001). The most common secondary gains were unmet clinical needs.

CONCLUSIONS

Results support adaptational models of malingering. Malingering patients are more likely to have sociodemographic vulnerabilities. A disproportionate number of malingering patients have unmet needs for psychiatric treatment and resources. The study provides further evidence for inequities that may be related to social and structural determinants of health.

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.

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 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.

[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.

Malingering-by-proxy: need for child protection and guidance for reporting

The feigning of disabling illness for compensation at the direction or pressure by others, which is called malingering by proxy (MBP), has been the subject of several spirited articles. Chafetz and Prentkowski (2011) suggested that MBP has the potential for real harm to the child. In a poster at the AACN scientific session in 2011, Chafetz and Binder (2011) pursued a case of MBP that showed the child had clearly suffered and failed to progress in the 6 years that had passed since she was first evaluated as an 11 year old. In the present article, we identify three cases that compare and contrast effects of MBP, illustrating that child abuse and/or neglect can be a serious and reportable consequence of MBP behavior. To illustrate how MBP behavior can cause child abuse, we compare MBP behavior with Munchausen Syndrome by Proxy (MSBP), another condition of volitional noncredible behavior produced in a vulnerable person at the direction or pressure by others. Guidance criteria for reporting MBP as child abuse/neglect are introduced in this article.

Malingering in the medical setting

Malingering of mental illness has been studied extensively; however, malingered medical illness has been examined much less avidly. While in theory any ailment can be fabricated or self-induced, pain--including lower back pain, cervical pain, and fibromyalgia--and cognitive deficits associated with mild head trauma or toxic exposure are feigned most frequently, especially in situations where there are financial incentives to malinger. Structured assessments have been developed to help detect both types of malingering; however, in daily practice, the physician should generally suspect malingering when there are tangible incentives and when reported symptoms do not match the physical examination or no organic basis for the physical complaints is found.

Neuropsychological Assessment of Suspected Malingering: Research Results, Evaluation Techniques, and Further Directions of Research and Application

Possibilities for neuropsychological assessment of suspected malingering are addressed. First, various forms of deception (malingering, factitious disorders, hysteria) and their implications for clinical neuropsychology are discussed. Then, threshold models for the detection of malingering as well as specially designed assessment techniques (e. g., individual tests, deficit testing, tests specifically for malingerers, and symptom validity testing) are described. Finally, the current status of clinical methods and research strategies is summarized, and recent and further developments of assessment and research are reported.

Validity of neuropsychological test results in disability evaluations

A group of 50 disability claimants referred by the Social Security Administration for neuropsychological screening were administered a 36-item, forced-choice, digit-recognition method of detecting malingering to assess effort and motivation to perform well. This abbreviated form of the 1989 Hiscock and Hiscock Forced-choice Procedure has been shown to be quite easy even for individuals with severe organic brain dysfunction. A perfect performance of 36 correct on this digit-recognition task is obtained by most individuals with moderate to severe brain damage. A performance of less than 90% correct is due more likely to poor effort or even malingering rather than brain damage. In this sample, 18% (n = 9) obtained scores of less than 90% correct, i.e., < 33, which calls into question the reliability and validity of test data obtained. An additional 20% (n = 10) obtained intermediate scores of 33 to 35 correct. These intermediate scores are more difficult to interpret although at least some proportion of those scores reflects poor motivation. The results over-all indicate that nearly one-fifth of potential disability claimants produced invalid and uninterpretable neuropsychological test protocols and an additional one-fifth obtained protocols that should be well scrutinized for evidence of poor effort as well. Neuropsychologists conducting disability evaluations are urged to use measures designed specifically to assess effort and motivation.

Effects of sophistication and motivation on the detection of malingered memory performance using a computerized forced-choice task

The present study employed a computerized forced-choice recognition memory task, the Multi-Digit Memory Test (MDMT), to examine the effects of instructional set (i.e., dissimulation information provided subjects) and motivation (i.e., monetary incentive) on simulated malingering behavior in a group of 119 university undergraduate students and 33 patients sustaining varying severity of closed-head injury. For the nonpatient groups, a significant effect of instructional set was revealed. Motivational incentive, however, did not affect forced-choice performance. Overall, significant performance differences emerged between all groups with nonmalingering students performing nearly perfectly, the brain-injured patients performing well above chance levels, sophisticated student malingers performing at chance, and naive student malingers performing well below chance levels. These results suggest the MDMT may offer a clinically useful and convenient addition to a neuropsychological assessment when there is suspicion of feigned memory problems. These data also support the use of naive and sophisticated malingering subjects in further analog studies addressing this topic.

Malingering on neuropsychological memory tests: potential objective indicators

We evaluated five potential indicators of malingering on the Rey Memory Test (RMT), Hebb's Recurring Digits (HRD), the Wechsler Memory Scale-Revised (WMS-R), the Complex Figure Test (CFT), and the Auditory Verbal Learning Test (AVLT). Fifty-seven subjects were assigned randomly to either a control group or a simulated malingering group. Two indicators-discriminant functions derived from the WMS-R and from the CFT/AVLT-achieved classification accuracy of 88% and 86%, respectively, without misidentifying controls as malingerers. Among the remaining indicators, there were problems with the recommended RMT cut-off, but it and the HRD show some promise. Subjects who simulated malingering did so by suppressing performance on tasks that involve recall as well as recognition memory and are relatively easy, but not obviously so.

The evaluation of truthfulness in alleged sex offenders' self-reports: 16PF and MMPI validity scales

The evaluation of response bias (i.e., minimization or exaggeration) is central to forensic psychological evaluations. Yet few studies have assessed forensic samples to investigate the ability of psychological tests to detect response bias. We studied the relationship between the Sixteen Personality Factors Questionnaire (16PF) and the Minnesota Multiphasic Personality Inventory (MMPI) validity scales for 65 alleged sex offenders and assessed the effects of different cutoff scores for the 16PF validity scales. Results indicate consistent significant correlations between the validity scales of the 16PF and the MMPI for measures of minimization and exaggeration. use of a priori cutoff scores resulted in the classification of our sample in proportions parallel to those found in previous research for the 16PF Fake-Good scale but not the Fake-Bad scale. Our results indicate that 16PF validity scales are useful, but interpretations must take into account different base rates of response bias between sex offenders and the general population.