Search

Although collaborative, and more specifically, integrated models of care have existed for years, the 2010 Patient Protection and Affordable Care Act expanded their use, and Medicare has adopted a value-based payment system that further emphasizes service provision within the collaborative health care setting. Neuropsychology as a field is well-situated to work within the integrated health care setting, which presents both opportunities and challenges for clinical neuropsychologists. This education paper details how different neuropsychology clinical practice settings fit into an integrated care framework; discusses challenges to service delivery and fiscal viability in such settings and other health care related settings; and examines future directions for the role of neuropsychology within a dynamic health care system.

The symptom reports of individuals with chronic pain are multidimensional (e.g., emotional, cognitive, and somatic) and significantly contribute to increased morbidity and lost work productivity. When pain occurs in the context of a legally compensable event, reliable assessment of a patient's multifactorial symptom experience during psychological or neuropsychological evaluations is a necessity. The Validity Scales of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) have been shown useful in identifying symptom overreporting and feigning within chronic pain samples and a number of studies have emerged supporting the use of the MMPI-2-Restructured Form (MMPI-2-RF) in the detection of simulated or feigned impairment in a variety of populations. To date, only 1 other study exists examining the ability of the MMPI-2-RF to detect exaggerated complaints using a strict operationalization of malingering exclusive to chronic pain samples. The purpose of this study was to examine the classification accuracy of MMPI-2-RF Validity Scales in a group of patients with chronic pain using a criterion-groups design. The final sample consisted of 501 clinical chronic pain patients assigned to groups based on the Bianchini, Greve, and Glynn (2005) criteria for Malingered Pain-Related Disability (MPRD). Results showed that all MMPI-2-RF Validity Scales differentiated malingerers from nonmalingerers with a high degree of accuracy. At cut-offs associated with ≥95% Specificity, Sensitivities ranged from 15% (Fs) to 60% (Response Bias Scale; RBS). This study demonstrates that the MMPI-2-RF Validity Scales are capable of differentiating intentional symptom exaggeration from genuine complaints in a sample of incentivized chronic pain patients. (PsycINFO Database Record

We reply to Nichols' (2017) critique of our commentary on the MMPI-2/MMPI-2-RF Symptom Validity Scale (FBS/FBS-r) as a measure of symptom exaggeration versus a measure of litigation response syndrome (LRS). Nichols claims that we misrepresented the thrust of the original paper he co-authored with Gass; namely, that they did not represent that the FBS/FBS-r were measures of LRS but rather, intended to convey that the FBS/RBS-r were indeterminate as to whether the scales measured LRS or measured symptom exaggeration. Our original commentary offered statistical support from published literature that (1) FBS/FBS-r were associated with performance validity test (PVT) failure, establishing the scales as measures of symptom exaggeration, and (2) persons in litigation who passed PVTs did not produce clinically significant elevations on the scales, contradicting that FBS/FBS-r were measures of LRS. In the present commentary, we draw a distinction between the psychometric data we present supporting the validity of FBS/FBS-r, and the conceptual, non-statistical arguments presented by Nichols, who does not refute our original empirically based conclusions.

The American Medical Association Current Procedural Panel developed a new billing code making behavioral health screening a reimbursable healthcare service. The use of computerized testing as a means for cognitive screening and brief cognitive testing is increasing at a rapid rate. The purpose of this education paper is to provide information to clinicians, healthcare administrators, and policy developers about the purpose, strengths, and limitations of cognitive screening tests versus comprehensive neuropsychological evaluations. Screening tests are generally brief and narrow in scope, they can be administered during a routine clinical visit, and they can be helpful for identifying individuals in need of more comprehensive assessment. Some screening tests can also be helpful for monitoring treatment outcomes. Comprehensive neuropsychological assessments are multidimensional in nature and used for purposes such as identifying primary and secondary diagnoses, determining the nature and severity of a person's cognitive difficulties, determining functional limitations, and planning treatment and rehabilitation. Cognitive screening tests are expected to play an increasingly important role in identifying individuals with cognitive impairment and in determining which individuals should be referred for further neuropsychological assessment. However, limitations of existing cognitive screening tests are present and cognitive screening tests should not be used as a replacement for comprehensive neuropsychological testing.

Objective: Intentional exaggeration of symptoms is a potential problem in contexts where there are financial incentives to appear disabled. Therefore, calibration of tools to accurately evaluate ma...

The milestone publication by Slick, Sherman, and Iverson (1999) of criteria for determining malingered neurocognitive dysfunction led to extensive research on validity testing. Position statements by the National Academy of Neuropsychology and the American Academy of Clinical Neuropsychology (AACN) recommended routine validity testing in neuropsychological evaluations. Despite this widespread scientific and professional support, the Social Security Administration (SSA) continued to discourage validity testing, a stance that led to a congressional initiative for SSA to reevaluate their position. In response, SSA commissioned the Institute of Medicine (IOM) to evaluate the science concerning the validation of psychological testing. The IOM concluded that validity assessment was necessary in psychological and neuropsychological examinations (IOM, 2015 ).The AACN sought to provide independent expert guidance and recommendations concerning the use of validity testing in disability determinations.A panel of contributors to the science of validity testing and its application to the disability process was charged with describing why the disability process for SSA needs improvement, and indicating the necessity for validity testing in disability exams.This work showed how the determination of malingering is a probability proposition, described how different types of validity tests are appropriate, provided evidence concerning non-credible findings in children and low-functioning individuals, and discussed the appropriate evaluation of pain disorders typically seen outside of mental consultations.A scientific plan for validity assessment that additionally protects test security is needed in disability determinations and in research on classification accuracy of disability decisions.

Neuropsychological tests undergo periodic revision intended to improve psychometric properties, normative data, relevance of stimuli, and ease of administration. In addition, new tests are developed to evaluate psychological and neuropsychological constructs, often purporting to improve evaluation effectiveness. However, there is limited professional guidance to neuropsychologists concerning the decision to adopt a revised version of a test and/or replace an older test with a new test purporting to measure the same or overlapping constructs. This paper describes ethical and professional issues related to the selection and use of older versus newer psychological and neuropsychological tests, with the goal of promoting appropriate test selection and evidence-based decision making.Ethical and professional issues were reviewed and considered.The availability of a newer version of a test does not necessarily render obsolete prior versions of the test for purposes that are empirically supported, nor should continued empirically supported use of a prior version of a test be considered unethical practice. Until a revised or new test has published evidence of improved ability to help clinicians to make diagnostic determinations, facilitate treatment, and/or assess change over time, the choice to delay adoption of revised or new tests may be viewed as reasonable and appropriate. Recommendations are offered to facilitate decisions about the adoption of revised and new tests. Ultimately, it is the responsibility of individual neuropsychologists to determine which tests best meet their patients' needs, and to be able to support their decisions with empirical evidence and sound clinical judgment.

To address (1) Whether there is empirical evidence for the contention of Nichols and Gass that the MMPI-2/MMPI-2-RF FBS/FBS-r Symptom Validity Scale is a measure of Litigation Response Syndrome (LRS), representing a credible set of responses and reactions of claimants to the experience of being in litigation, rather than a measure of non-credible symptom report, as the scale is typically used; and (2) to address their stated concerns about the validity of FBS/FBS-r meta-analytic results, and the risk of false positive elevations in persons with bona-fide medical conditions.Review of published literature on the FBS/FBS-r, focusing in particular on associations between scores on this symptom validity test and scores on performance validity tests (PVTs), and FBS/FBS-r score elevations in patients with genuine neurologic, psychiatric and medical problems.(1) several investigations show significant associations between FBS/FBS-r scores and PVTs measuring non-credible performance; (2) litigants who pass PVTs do not produce significant elevations on FBS/FBS-r; (3) non-litigating medical patients (bariatric surgery candidates, persons with sleep disorders, and patients with severe traumatic brain injury) who have multiple physical, emotional and cognitive symptoms do not produce significant elevations on FBS/FBS-r. Two meta-analytic studies show large effect sizes for FBS/FBS-r of similar magnitude.FBS/FBS-r measures non-credible symptom report rather than legitimate experience of litigation stress. Importantly, the absence of significant FBS/FBS-r elevations in litigants who pass PVTs demonstrating credible performance, directly contradicts the contention of Nichols and Gass that the scale measures LRS. These data, meta-analytic publications, and recent test use surveys support the admissibility of FBS/FBS-r under both Daubert and the older Frye criteria.

The Minnesota Multiphasic Personality Inventory (MMPI)-2 Restructured Form (MMPI-2-RF) has been shown to have clinical utility in the assessment of individuals with chronic pain (e.g., predicting surgical outcomes). The purpose of this study was to explore the ability of the MMPI-2-RF Validity Scales in profiling patients with chronic pain who had external financial incentive (e.g., workers' compensation claims) and determine the associations between Validity Scale response patterns and important outcomes. Cluster analysis identified 2 similarly sized clusters of patients with very different MMPI-2-RF profiles. Cluster 1 was characterized by valid responding and showed mean elevations on the somatic and low positive emotion Restructured Clinical scales. Cluster 2 was characterized by patients overreporting on the MMPI-2-RF Validity Scales, who also demonstrated elevations on 7 of the 9 RC scales. Cluster membership was differentially associated with clinical variables: patients in Cluster 2 had greater self-reported pain and disability, were less likely to have spine-related findings on imaging and were more likely to be classified as probable or definite malingerers. These results support the utility of the MMPI-2-RF Validity scales in distinguishing between credible and noncredible responses from patients with chronic pain seen within a medico-legal context. (PsycINFO Database Record

One third of all people will experience spinal pain in their lifetime and half of these will experience chronic pain. Pain often occurs in the context of a legally compensable event with back pain being the most common reason for filing a Workers Compensation claim in the United States. When financial incentives to appear disabled exist, malingered pain-related disability is a potential problem. Malingering may take the form of exaggerated physical, emotional, or cognitive symptoms and/or under-performance on measures of cognitive and physical capacity. Essential to the accurate detection of Malingered Pain-related Disability is the understanding that malingering is an act of will, the goal of which is to increase the appearance of disability beyond that which would naturally arise from the injury in question. This paper will review a number of Symptom Validity Tests (SVTs) that have been developed to detect malingering in patients claiming pain-related disability and will conclude with a review of studies showing the diagnostic benefit of combining SVT findings from a comprehensive malingering assessment. The utilization of a variety of tools sensitive to the multiple manifestations of malingering increases the odds of detecting invalid claims while reducing the risk of rejecting a valid claim.

Although it has long been proposed that performance on the Booklet Category Test (BCT) relies on a number of different cognitive abilities, including executive functioning, perceptual reasoning, and memory, only a single total error score is typically derived and interpreted in clinical practice. BCT subscales based on factor analyses of subtest errors or designed specifically to measure specific cognitive domains have been proposed to better assess the multidimensional abilities underlying BCT performance. The aim of this study was to independently replicate and extend previous findings regarding the validity of these subscales. A mixed clinical sample of 137 patients completed the BCT and a number of additional measures used to assess neuropsychological domains of selective attention, various aspects of executive functioning, intellectual functioning, and memory. Correlation and regression analyses were used to explore the convergent and discriminant validity of each subscale. Subscales varied in the number and magnitude of their significant correlations with scores derived from traditional measures. In general, findings supported the convergent validity of BCT category learning, set loss, and memory subscales. However, findings regarding discriminant validity were more variable across subscales. Results provide additional support for the multidimensional nature of the BCT and the validity of derived subscales to measure specific aspects of cognitive functioning beyond what is measured by a total errors score. The recently proposed subscales examined in the current study appear to be worthy of further investigation by clinicians and researchers to determine their clinical utility.

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.

This study examined the effects of traumatic brain injury (TBI) on Wechsler Memory Scale-III (WMS-III) performance. Since poor effort potentially contaminates results, effort was explicitly assessed and controlled using two well-validated cognitive validity indicators, the Portland Digit Recognition Test (PDRT) and Reliable Digit Span (RDS). Participants were 44 mild TBI patients with good effort, 48 mild TBI patients with poor effort, and 40 moderate-severe TBI patients with good effort. A dose-response relationship between injury severity and WMS-III performance was demonstrated. Effect size calculations showed that the good effort mild TBI patients did not differ from normal (average Cohen's d= 0.07) while moderate-severe TBI had a moderate effect on WMS-III scores (average Cohen's d=-0.52). Consistent with previous literature, the moderate-severe TBI group scored the lowest on WMS-III Visual indices. Effort had a larger effect than injury severity on WMS-III scores (average Cohen's d=-1.27). Clinical implications of these findings are discussed.

A criterion-groups validation was used to determine the classification accuracy of the Seashore Rhythm Test (SRT) and Speech Sounds Perception Test (SSPT) in detecting malingered neurocognitive dysfunction (MND) in traumatic brain injury (TBI). TBI patients were classified into the following groups: (1) Mild TBI Not-MND (n = 24); (2) Mild TBI MND (n = 27); and (3) Moderate/Severe TBI Not-MND (n = 23). A sample of 90 general clinical patients was utilized for comparison. Results showed that both SRT correct and SSPT errors differentiated malingerers from non-malingerers in the Mild TBI sample. At 96% specificity, sensitivities were 37% for SRT correct and 59% for SSPT errors. Joint classification accuracy showed that the best accuracy was achieved when using a cut-off associated with a 4% false positive error rate in the Mild TBI sample. Specificity was considerably lower in the Moderate/Severe TBI and General Clinical groups. The clinical application of these findings is discussed.

This study used criterion groups validation to determine the accuracy of the Test of Memory Malingering (TOMM) in detecting malingered pain-related disability (MPRD) across a range of cutoffs in chronic pain patients undergoing psychological evaluation (n = 604). Data from patients with traumatic brain injury (n = 45) and dementia (n = 59) are presented for comparison. TOMM scores decreased and failure rates increased as a function of greater external evidence of intentional under-performance. The TOMM detected from 37.5% to 60.2% of MPRD patients, depending on the cutoff. False positive (FP) error rates ranged from 0% to 5.1%. Accuracy data for Trial 1 are also reported. In chronic pain the original cutoffs produced no FP errors but were associated with high false negative error rates. Higher cutoffs increased sensitivity without adversely affecting specificity. The relevance of these findings to research and clinical practice is discussed.

Greve KW, Ord JS, Bianchini KJ, Curtis KL. Prevalence of malingering in patients with chronic pain referred for psychologic evaluation in a medico-legal context. Objective To provide an empirical estimate of the prevalence of malingered disability in patients with chronic pain who have financial incentive to appear disabled. Design Retrospective review of cases. Setting A private neuropsychologic clinic in a southeastern metropolitan area. Participants Consecutive patients (N=508) referred for psychologic evaluation related to chronic pain over a 10-year period (1995–2005). Interventions Not applicable. Main Outcome Measures Prevalence of malingering was examined using 2 published clinical diagnostic systems (Malingered Pain-Related Disability and Malingered Neurocognitive Dysfunction) as well as statistical estimates based on well validated indicators of malingering. Results The prevalence of malingering in patients with chronic pain with financial incentive is between 20% and 50% depending on the diagnostic system used and the statistical model's underlying assumptions. Some factors associated with the medico-legal context such as the jurisdiction of a workers' compensation claim or attorney representation were associated with slightly higher malingering rates. Conclusions Malingering is present in a sizable minority of patients with pain seen for potentially compensable injuries. However, not all excess pain-related disability is a result of malingering. It is important not to diagnose malingering reflexively on the basis of limited or unreliable findings. A diagnosis of malingering should be explicitly based on a formal diagnostic system.

This study used criterion groups validation to determine the classification accuracy of the Portland Digit Recognition Test (PDRT) at a range of cutting scores in chronic pain patients undergoing psychological evaluation (n = 318), college student simulators (n = 29), and patients with brain damage (n = 120). PDRT scores decreased and failure rates increased as a function of greater independent evidence of intentional underperformance. There were no differences between patients classified as malingering and college student simulators. The PDRT detected from 33% to nearly 60% of malingering chronic pain patients, depending on the cutoff used. False positive error rates ranged from 3% to 6%. Scores higher than the original cutoffs may be interpreted as indicating negative response bias in patients with pain, increasing the usefulness and facilitating the clinical application of the PDRT in the detection of malingering in pain.

This study examined the persistent effects of traumatic brain injury (TBI) on Wisconsin Card Sorting Test (WCST) performance. Since poor effort can contaminate results in populations with incentive to perform poorly, performance validity was explicitly assessed and controlled for using multiple well-validated cognitive malingering indicators. Participants were 109 patients with mild TBI and 67 patients with moderate-to-severe TBI seen for neuropsychological evaluation at least one year post injury. Patients with diffuse neurological impairment and healthy controls were included for comparison. Results suggested a dose-response effect of TBI severity on WCST performance in patients providing good effort; the mild TBI group did not differ from controls while increased levels of impairment were observed in the moderate-to-severe TBI group. Effort during testing had a larger impact on WCST performance than mild or moderate-to-severe TBI. Clinical implications of these findings are discussed.

We address issues raised by Butcher et al. (Psychological Injury and the Law 1:191–209, 2008) in their critique of the Minnesota Multiphasic Personality Inventory-2 Symptom Validity Scale (FBS) and show that their analyses and conclusions are based on faulty premises, a misunderstanding of basic concepts in the assessment of overreporting, a selective review of the literature and mischaracterization of the findings they do cite, problematic analyses of a dataset that had already been similarly analyzed, and a flawed analysis of a legal case they discuss. We complement the review of existing research with some new findings that provide further empirical support and clarification of current interpretive recommendations for proper use of the FBS in evaluations of personal injury litigants and claimants.

Individual and joint malingering detection accuracy of the Portland Digit Recognition Test (PDRT), Test of Memory Malingering (TOMM), and Word Memory Test (WMT) was examined in traumatic brain injury (TBI; 43 non-malingering, 27 malingering) and chronic pain (CP; 42 non-malingering, 58 malingering) using a known-groups design. At published cutoffs, the PDRT and TOMM were very specific but failed to detect about 50% of malingerers; the WMT was sensitive but prone to false positive errors. ROC analyses demonstrated comparable accuracy across all three tests. Joint classification accuracy was superior to that of the individual tests. Clinical and research implications are discussed.

A known-groups design was used to determine the classification accuracy of verbal fluency variables in detecting Malingered Neurocognitive Dysfunction (MND) in traumatic brain injury (TBI). Participants were 204 TBI and 488 general clinical patients. The Slick et al. (1999) criteria were used to classify the TBI patients into non-MND and MND groups. An educationally corrected FAS Total Correct word T-score proved to be the most accurate of the several verbal fluency indicators examined. Classification accuracy of this variable at specific cutoffs is presented in a cumulative frequency table. This variable accurately differentiated non-MND from MND mild TBI patients but its accuracy was unacceptable in moderate/severe TBI. The clinical application of these findings is discussed.

The classification accuracy of the Portland digit recognition test (PDRT) in detecting cognitive malingering was studied in patients claiming cognitive deficits due to exposure to environmental or industrial toxins. Twenty-nine patients alleging toxic exposure and who met Slick et al. [Slick, D. J., Sherman, E. M. S., & Iverson, G. L. (1999). Diagnostic criteria for malingering neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13, 545-561] criteria for malingered neurocognitive dysfunction were compared to 14 toxic exposure patients negative for evidence of malingering. The published cutoffs were associated with a false positive error rate of 0% and sensitivity of more than 50%. When criterion for a PDRT failure was a positive PDRT finding on more than one section, the FP rate remained 0% while sensitivity improved to about 70%. The results indicate that a failed PDRT is an indication of malingering and not the neurological effect of a toxic substance or some other clinical phenomenon. The PDRT can be used with confidence as an indicator of negative response bias in cases of alleged exposure to neurotoxic substances.

Meyers, Millis, and Volkert [Meyers, J. E., Millis, S. R., & Volkert, K. (2002). A validity index for the MMPI-2. Archives of Clinical Neuropsychology, 17, 157-169] developed a method to detect malingering in chronic pain patients using seven scales from the Minnesota Multiphasic Inventory-2 (MMPI-2). This method may be impractical because two of the scales (Obvious minus Subtle and Dissimulation-revised) are not reported by the commercially available Pearson computerized scoring system. The current study recalculated the Meyers Index using the five Pearson-provided scales in the chronic pain data sets of Meyers et al. [Meyers, J. E., Millis, S. R., & Volkert, K. (2002). A validity index for the MMPI-2. Archives of Clinical Neuropsychology, 17, 157-169] and Bianchini, Etherton, Greve, Heinly, and Meyers [Bianchini, K. J., Etherton, J. L., Greve, K. W., Heinly, M. T., & Meyers, J. E. (in press). Classification accuracy of MMPI-2 validity scales in the detection of pain-related malingering: A known-groups approach. Assessment], and the traumatic brain injury data of Greve, Bianchini, Love, Brennan, and Heinly [Greve, K. W., Bianchini, K. J., Love, J. M., Brennan, A., & Heinly, M. T. (2006). Sensitivity and specificity of MMPI-2 validity scales and indicators to malingered neurocognitive dysfunction in traumatic brain injury. The Clinical Neuropsychologist, 20, 491-512]. Classification accuracy of the abbreviated Meyers Index was comparable to the original. These findings demonstrate that the abbreviated Meyers Index can be used as a substitute of the original Meyers Index without decrements in classification accuracy.

Two commonly used symptom validity tests are the Test of Memory Malingering (TOMM) and Word Memory Test (WMT). After examining TOMM-WMT failure concordance rates, Green [Green, P. (2007). Making comparisons between forced-choice effort tests. In K. B. Boone (Ed.), Assessment of feigned cognitive impairment (pp. 50-77). New York: Guilford] urged widespread adoption of the WMT, arguing the TOMM is insensitive to feigned impairment. But Green (2007) used a skewed concordance method that favored WMT (one TOMM subtest vs. three WMT subtests). In the present study we compare pass/fail agreement rates with different combinations of TOMM and WMT subtests in 473 persons seeking compensation for predominately mild neurological trauma. We replicated Green (2007) using his asymmetrical method, but otherwise we found the WMT and TOMM produce comparable failure rates in samples at-risk for exaggeration with balanced comparison (three TOMM subtests vs. three WMT). Further work is necessary to compare WMT and TOMM specificities, as failure concordance designs establish reliability but are insufficient for proving validity.

Booksh, Aubert, and Andrews have written to critique our recent paper (Greve & Bianchini, 2006a) examining the clinical implications of omitting the Retention Trial of the Test of Memory Malingering (TOMM; Tombaugh, 1996) when Trial 2 is passed. We appreciate being offered the opportunity to respond. In reading Booksh, Aubert, and Andrews (in press) it was difficult to discern a central theme to their critique, as the authors obliquely allude to many topics but without any sustained thinking on any one idea. Overall, they appear motivated by their opposition to using the Retention Trial of the TOMM and strongly object to what they believe was our conclusion: “Greve and Bianchini (2006) suggest the Retention Trial should always be administered.” They have misstated our position. Because of the risk of missing some clearly and independently defined malingers when only Trial 2 is administered, we concluded that “the present study suggests that so long as at least one other well validated forced-choice SVT is also administered the Retention Trial can be dropped. The Retention Trial should never be dropped if the TOMM is the only SVT given” (Greve & Bianchini, 2006a, p. 119). This concern and conclusion have been reiterated in two recent papers (Greve, Bianchini, & Doane, 2006a; Greve et al., 2006b). Given their apparent position, it is worth further clarifying the consequences of not administering the Retention Trial. Greve et al. (2006a) reported that 42% of independently diagnosed malingerers claiming brain trauma scored less than 45 on Trial 2, a false negative (FN) error rate of 58%. In contrast, the FN rate for the Retention Trial was 43%, 15% less than Trial 2. Greve et al. (2006b), like Greve & Bianchini (2006a) found that some malingerers passed Trial 2 only to fail (and thus be correctly detected by) the Retention Trial. In short, the Retention Trial provides additional, non-redundant information about the malingering status of individual patients. These data indicate that Booksh et al.’s (in press) assertion that including the Retention Trial when Trial 2 is passed “does not appear to increase its [the TOMM’s] usefulness in detecting malingering” lacks empirical support. In any case, the logic underlying the optional discontinuation rule is unsound. Passing a single malingering test provides no reliable information about the malingering status of that individual (Greve & Bianchini, 2004; Iverson, 2006; Millis & Volinsky, 2001; Slick, Sherman, & Iverson, 1999). As Iverson (2006) notes, “false-negative rates can be quite high on tests designed to detect poor effort because researchers tend to select cutoff scores designed to minimize

Objective Directly estimate the prevalence of cognitive malingering in persons claiming exposure to occupational and environmental substances. Methods Retrospective review of 128 neuropsychological cases with financial incentive. Estimates were based on two methods: (1) clinical identification using the Slick, Sherman and Iverson criteria for malingered neurocognitive dysfunction (MND), and (2) statistical modeling based on patient performance on several individual psychometric indicators of malingering. Results The prevalence based on the clinical method was 40%. The statistically based estimates ranged from 30% to more than 45% depending on model parameters. Different incentive parameters may influence prevalence. Conclusions Cognitive malingering in toxic exposure is common and must be adequately addressed in the clinical neuropsychological assessment of toxic exposure and in research on its neurocognitive effects or findings will likely over-estimate the degree of cognitive impairment and related disability.

This study used a known-groups design to determine the classification accuracy of the Test of Memory Malingering (Tombaugh, 1996, 1997) in detecting cognitive malingering in traumatic brain injury (TBI). Forty-one of 161 TBI patients met Slick, Sherman, and Iverson (1999) criteria for Malingered Neurocognitive Dysfunction. Twenty-two no-incentive memory disorder patients were also included. The original cutoffs (

This study used a known-groups design to examine the classification accuracy of the Test of Memory Malingering in detecting cognitive malingering in patients claiming cognitive deficits due to exposure to environmental and industrial toxins. Thirty-three patients who met Slick et al. criteria for Malingered Neurocognitive Dysfunction were compared to 17 toxic exposure patients negative for evidence of malingering, 14 TBI patients and 22 memory disorder patients, both groups without incentive. The original cutoffs (45) for Trial 2 and Retention demonstrated perfect specificity (0% false positive error rate) and impressive sensitivity (50%). These findings indicate the TOMM can be used with confidence as an indicator of negative response bias in cases of cognitive deficits attributed to exposure to alleged neurotoxic substances.

Background context Pain patients often report cognitive symptoms, and many will include them in their claims of disability. There is empirical evidence that patients with pain do experience problems on attention-demanding cognitive tasks, but the results are mixed and the potential impact of exaggeration in the context of pain-related litigation has not been addressed. Purpose 1) Examine the impact of pain and malingering on attention; 2) determine if the Working Memory Index (WMI) of the Wechsler Adult Intelligence Scale-3 (WAIS-III) can reliably detect malingering. Study design/setting Study 1: simulator design; Study 2: clinical known-groups design. Patient sample Study 1 used healthy college students; Study 2 used chronic pain patients and neurological patients. Outcome measures The WMI and its constituent subtests. Methods Study 1: College students were administered the WMI under three conditions: standard administration, with cold-pressor induced pain, or with instructions to simulate impairment due to pain. Study 2: Known-groups design in which the WMI was examined in nonmalingering and definite malingering chronic pain patients, nonmalingering moderate–severe traumatic brain injury, and memory disorder patients seen for routine psychological evaluation. Malingering was operationalized using published criteria. Results There were no group differences in WMI or its subtests among nonmalingering groups, but some individual clinical patients with pain did score at a level suggestive of attentional impairment. The lowest scores were found in the simulated malingering college students and definite malingering clinical pain groups, in which about half scored worse than 95% of the nonmalingering clinical patients. Conclusions This study demonstrated that even when controlling for exaggeration some pain patients do exhibit problems with attentional function. However, significant impairment in WMI performance (eg, index score≤70), particularly in the absence of brain dysfunction, cannot reasonably be attributed to the effects of either acute or chronic pain, even at moderate to severe levels, and likely reflects intentional exaggeration.

Background context Pain-related disability is a complex phenomenon. Malingering is a potential factor in the management of patients with pain. Methodological problems and inappropriate expectations regarding diagnostic accuracy have hampered the study of malingering detection in pain. In contrast, the study of cognitive malingering in neuropsychology has led to the development of many highly accurate and reliable detection techniques. This paper applies the methods and logic that have been successful for identifying cognitive malingering to the problem of malingering in patients with pain. Purpose Outline the logic of a research methodology for studying malingering detection in pain and introduce a system for the diagnosis of malingering in pain. Study design Literature review and conceptual synthesis. Methods Examination of the research methodology and diagnostic scheme used in the study of cognitive malingering; adaptation of these methods to the problem of malingering in pain. Results Lessons derived from the study of cognitive malingering were used to generate recommendations to enhance research into detection and diagnosis of malingered pain-related disability. A comprehensive, multidimensional system for diagnosing malingering in pain-related disability was proposed. Conclusions Pain-related disability is a multifaceted phenomenon, therefore malingering can occur in different and sometimes multiple dimensions. It is presently possible to accurately detect and diagnose malingering in some patients with pain. More work is needed for some detection techniques to be appropriately calibrated in pain populations. This work must focus on controlling the false positive error rate.

The reliable digit span (RDS) performance of chronic pain patients with unambiguous spinal injuries and no evidence of exaggeration or response bias (n = 53) was compared to that of chronic pain patients meeting criteria for definite malingered neurocognitive dysfunction (n = 35), and a group of nonmalingering moderate-severe traumatic brain injury (TBI) patients (n = 69). The results demonstrated that scores of 7 or lower were associated with high specificity (> .90) and sensitivity (up to .60) even when moderate to severe TBI are included. Multiple studies have demonstrated that RDS scores of 7 or lower rarely occur in TBI and pain patients who are not intentionally performing poorly on cognitive testing. This study supports the use of the RDS in detecting response bias in neuropsychological patients complaining of pain as well as in the assessment of pain-related cognitive impairment in patients whose primary complaint is pain.

The Test of Memory Malingering (TOMM) is a well-validated and widely used forced-choice symptom validity test. However, little is known about how TOMM performance is affected by pain. The present study evaluated the sensitivity of the TOMM to pain induced in healthy participants via the cold-presser test. Participants (n = 20 per group) were administered the TOMM under one of three conditions: (1) standard instructions; (2) instructions to simulate pain-related memory deficit in pursuit of personal injury litigation; (3) while experiencing cold-induced pain. Results indicate that TOMM performance was unaffected by laboratory-induced moderate to severe pain and support the TOMM's use in evaluating clinical patients with pain.

This paper sought to demonstrate that diagnosable malingering does occur in Electrical Injury (EI) and examine the relationship of malingering to potential indicators of the presence and severity of neurological injury. Eleven consecutive EI patients seen for neuropsychological evaluation were presented. Over half the patients met the Slick et al. (1999) criteria for at least Probable MND. Most of the MND patients lacked evidence of a biologically meaningful exposure to electrical current. These findings highlight the importance of considering biological markers of neurological injury and of non-neurological factors, including effort/malingering, in the study of the neurocognitive consequences of EI.

Reliable Digit Span (RDS) is an indicator used to assess the validity of cognitive test performance. Scores of 7 or lower suggest poor effort or negative response bias. The possibility that RDS scores are also affected by pain has not been addressed thus potentially threatening RDS specificity. The current study used cold pressor-induced pain to investigate the effect of pain on RDS scores. Sixty undergraduate volunteers randomly assigned to one of three conditions (control, simulator, pain) completed the Digit Span subtest from the Wechsler Adult Intelligence Scale-III from which the RDS is derived. No differences in RDS scores were found between the control and pain groups, and neither group scored below 8. Sixty-five percent of the simulator group scored 7 or below. These results suggest that RDS is not affected by pain, and scores of 7 or less in persons with pain can be more confidently attributed to negative response bias.

Objective: We sought to assess the emotional effects of a major community toxic release while controlling the potential effects of response bias associated with litigation. Methods: Participants included 152 exposed adult litigants and a matched unexposed comparison group (n = 76). Psychological assessment methods included: (1) Minnesota Multiphasic Personality Inventory-2; (2) Symptom Checklist-90-Revised; and (3) Impact of Event Scale-Revised. Results: Ten to 40% of the exposed group demonstrated emotional distress (compared with a 5 % comparison baseline) depending on indicator and cutoff score used. Conclusions: The psychological consequences of a community toxic exposure were present even when exaggeration was carefully controlled. Accounting for exaggeration in the assessment of subjective psychological complaints provides a more accurate view of the subjective emotional state of persons who have experienced toxic exposure thereby facilitating appropriate clinical management of their mental health needs.

Presented are four patients with work-related pain in whom cognitive malingering was diagnosed using the Slick et al. (1999) criteria for Malingered Neurocognitive Dysfunction (MND). These cases demonstrate that cognitive malingering does occur in pain and that neuropsychological techniques for the detection of malingering can be effective in this population. They also illustrate the application of the Slick criteria to pain patients. Although the Slick criteria were not developed specifically for use with a pain population, the fact that some pain patients malinger cognitive disability allows for the application of these criteria. Moreover, the Slick system represents a model from which to develop a more comprehensive system to diagnose malingering in pain.

Malingering in neuropsychological assessment has been the subject of intense research for more than a decade and the detection methods arising from this work are diverse and sophisticated. However, the empirical findings are often presented in ways that limit the clinical utility of these techniques and may threaten their admissibility into legal proceedings. The purpose of this paper is to outline an approach for setting cut-offs on techniques designed to identify the presence of negative response bias. The use of this approach will result in the explicit specification of the error rate(s) of a given technique which can easily be applied by clinicians in the course of their practice and be admissible in court.

Toxic torts are increasing across the country and often the results of the neuropsychological evaluation are crucial for defining damages. Therefore, the accurate differentiation of those damaged by toxic exposure from those exaggerating or fabricating deficits is important. However, there is little research on malingering in this context. Presented are four patients claiming cognitive deficits after apparent occupational neurotoxic exposure who were diagnosed as malingering using the Slick, Sherman, and Iverson criteria. The goals of this article were to (1) illustrate the application of the Slick Criteria; (2) discuss current knowledge about the neurological and neurocognitive effects of toxic substances and its impact on clinical decision-making; (3) discuss the application of the Slick Criteria, specifically, and malingering research, generally, to toxic exposure cases; and (4) propose a paradigm in which medical, toxicological and neuropsychology professionals coordinately evaluate cases of alleged neurotoxic chemical exposure.

The loss of sensation is not an uncommon associated finding after injury to the peripheral nerves and the spinal cord. However, the sensory examination is prone to the influence of nonphysiologic factors, and one cannot use it to determine whether functional sensory loss reflects unconscious or intentional symptom production. This distinction has important implications for differential diagnosis and for decision making in the context of workers' compensation claims and personal injury litigation. We present 3 cases of patients with chronic pain and nondermatomal patterns of loss of fine-touch sensation, whose sensory loss was examined by a sensory forced-choice symptom validity test. Their below-chance scores showed intentionally produced sensory symptoms. The use of this methodology in differential diagnosis is discussed.

This study assesses the effectiveness of the Wechsler Adult Intelligence Scale (WAIS) performance validity markers devised by Mittenberg et al. [Prof. Psychol.: Res. Pract. 26 (1995) 491] in the detection of malingered neurocognitive dysfunction (MND). Subjects were 65 traumatic brain injury (TBI) patients referred for neuropsychological evaluation. Twenty-eight met the Slick et al. [Clin. Neuropsychol. 13 (1999) 545] criteria for at least probable MND. The control group was comprised of 37 patients without external incentive and who thus did not meet the Slick et al. criteria. All subjects completed the Wechsler Adult Intelligence Scale-Revised (WAIS-R or WAIS-III). The discriminant function score (DFS) and the vocabulary-digit span (VDS) difference score were calculated and sensitivity, specificity, and predictive power were examined for several cut-offs for each marker individually and the two combined. Classification accuracy for the DFS was acceptable and better than for VDS. The use of the two markers in combination resulted in no incremental increase in classification accuracy. Issues related to the clinical application of these techniques are discussed.

The present study examined the classification accuracy of four potential Wisconsin Card Sorting Test malingering indicators (Bernard and Suhr formulas and two types of Unique responses). Participants were 89 traumatic brain-injury (TBI) patients assigned to malingering and nonmalingering groups on the basis of the Slick, Sherman, and Iversion (1999) criteria. Individual Sensitivities were greater than .33 with acceptable Specificity. Combined Sensitivity for two of the indicators was greater than.60. Overall, this study demonstrated three distinct approaches to the WCST used by probable malingerers. The clinical relevance of these findings and directions for future research are discussed.

The Modified Somatic Perception Questionnaire (MSPQ) and the Pain Disability Index (PDI) are both popular clinical screening instruments in general orthopedic, rheumatologic, and neurosurgical clinics and are useful for identifying pain patients whose physical symptom presentations and disability may be non-organic. Previous studies found both to accurately detect malingered pain presentations; however, the generalizability of these results is not clear. This study used a criterion groups validation design (retrospective cohort of patients with chronic pain, n = 328) with a simulator group (college students, n = 98) to determine the accuracy of the MSPQ and PDI in detecting Malingered Pain Related Disability. Patients were grouped based on independent psychometric evidence of MPRD. Results showed that MSPQ and PDI scores were not associated with objective medical pathology. However, they accurately differentiated Not-MPRD from MPRD cases. Diagnostic statistics associated with a range of scores are presented for application to individual cases. Data from this study can inform the clinical management of chronic pain patients by screening for psychological overlay and malingering, thus alerting clinicians to the possible presence of psychosocial obstacles to effective treatment and triggering further psychological assessment and/or treatment.

This study examined the classification accuracy of the Portland Digit Recognition Test (PDRT) in traumatic brain injury (TBI). It differs from past studies in assigning patients to malingering and control groups on the basis of compensation-seeking status and the presence of external markers for malingering. Sensitivity and Specificity were.77 and 1.00, respectively. Past research comparing compensation-seekers to noncompensation-seekers reported Sensitivities of.33 or lower (Specificity is always high). This study demonstrates that past research has seriously underestimated the Sensitivity of the PDRT and raises questions about the true Sensitivity of other malingering techniques as well.

Head injured patients show an IQ subtest pattern that can be discriminated from the profile produced by individuals who attempt to malinger intellectual decline due to head trauma. The current paper demonstrates that previously replicated methods for making this discrimination on the WAIS - R generalize to the WAIS - 3. The discriminant function equation accurately classified 83% of nonlitigating head-trauma patients with documented injuries and 72% of persons simulating intellectual impairment due to head trauma. A total of 45% of litigating mild head-trauma patients with purported intellectual decline but no documented loss of consciousness, hospitalization, or CT abnormality were classified as malingering by the discriminant function. A Vocabulary-Digit Span difference score provided 71% overall diagnostic accuracy, and may be informative when screening profiles by visual inspection or when complete WAIS - 3 results are unavailable.

This study demonstrates the reliability of 3 Clock Drawing Test (CDT) scoring systems when applied to the protocols of stroke patients. The sample included 20 randomly selected sets of both freehand and predrawn circle versions ofthe CDT completed by patients undergoing comprehensive stroke rehabilitation. The protocols were scored independently by 2 raters using each of 3 published scoring systems (Freedman et al., 1994; Libon, Malamut, Swenson, Sands,Cloud, 1996; Rouleau, Salmon, Butters, Kennedy,McGuire, 1992). Interrater agreement and intrarater consistency were measured using the intraclass correlation coefficient (ICC). The results demonstrate that the raters used comparable criteria for each score (high interrater reliability) and that each applied similar scoring criteria throughout the set of protocols (high intrarater consistency). Scores related to the overall contour of the clockface tended to have lower ICCs. Reliability coefficients were comparable for both CDT versions. The results provide evidence for the accurate and consistent scoring of the CDT in stroke.

This paper provides a comprehensive review of the published literature on symptom validity tests (SVT) and, with the accompanying tables, serves as a reference to assist in their selection, interpretation, and defense. Because malingering is inherently an applied problem that frequently arises in a medico-legal context, the use of SVTs must meet certain standards. Thus, a number of methodological and theoretical weaknesses of SVT research which limit the use of SVTs as clinical tools and sources of evidence are highlighted. These criticisms incorporate recommendations which must be addressed if conclusions based on SVT data are to meet the increasingly rigorous standards for the admissibility of scientific evidence.