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The potential for malingering must always be considered among patients presenting with pain. When malingering is identified, care may be discontinued. This case report describes a patient who feigned sickle cell crisis, a painful condition, in the presence of other identifiable and potentially painful medical illnesses.
Thirty-nine patients in a forensic mental hospital were evaluated using the Structured Interview of Reported Symptoms (SIRS) and several tests used for detecting malingered psychiatric and neuropsychological dysfunction. Patients were initially classified by a multidisciplinary team as nonmalingering participants (n = 12) and known malingerers (n = 9). All participants in both groups were pretrial and had been found incompetent to stand trial by the court. Eighteen more patients found to be not guilty by reason of insanity by the courts were included in the study. Using the SIRS alone, 95% overall classification accuracy was obtained. When the scores on the Dot Counting Test, Memory for Fifteen Items Test, and the M-Test were added to the discriminant function, all patients were correctly classified to the respective groups. The results are discussed in terms of complimenting interdisciplinary team diagnosis with psychological tests for malingering.
The effect of a warning regarding detection of simulated cognitive and motor deficits on the Wechsler Memory Scale-Revised (WMS-R; Wechsler, 1987) and Grooved Pegboard (Klove, 1963; Matthews & Klove, 1964) was examined. Undergraduates (N = 87) were randomly assigned to one of three conditions: simulators without warning, simulators with warning, and controls. It was predicted that warning participants that simulation efforts will be detected would reduce malingering behavior and this hypothesis was generally supported. Analyses indicated simulators with warning frequently approximated control group performances and were significantly better than simulators without warning on some measures. Stepwise discriminant function analysis accurately classified 57% of all participants. Results provide support for effectiveness of warning in reducing malingering behavior on selected measures and are discussed in terms of the use of warning as an adjunct to existing procedures, role of the neuropsychologist, and informed consent for assessment in personal injury litigation.
We investigated the effects of faking bad on the Wisconsin Card Sorting Test, comparing the performance of simulating malingerers (M; n = 24) to controls (C; n = 21), closed head-injured patients (CHI, n = 70), and patients with mixed CNS pathology other than CHI alone (CNS; n = 89). Stepwise discriminant functions achieved good accuracy (91-96%), sensitivity (58-100%), and specificity (92-100%) in differentiating simulating malingerers from these groups. The Categories score was a consistent significant independent discriminating variable. Categories alone could differentiate between the M and C groups. However, in discriminating between simulating malingerers and both CHI or CNS patients, more complex patterns of performance emerged, consisting of relatively poorer performance ratios on Categories compared to Perseverative Errors. This supported the Pattern of Performance theory of the effects of simulating malingering on neuropsychological tests, which holds that people simulating malingering do more poorly on obvious vs. subtle tasks compared to people with verified brain damage. Due to the difficulty of tracking one's performance on several different indices simultaneously, known patterns of performance for patients with verified brain dysfunction should be very difficult to fake, even with coaching.
The predictive accuracy of Andre Rey's malingered amnesia measures (Memory for Fifteen Items and Word Recognition List) was examined. Discriminant function and crosstabulation analytic strategies were applied to predict membership in either a traumatically brain injured group (n = 60) or in a litigated minor head injury group claiming permanent severe disability (n = 90). Satisfactory hit rates were achieved with Rey's original scoring methods, but improved hit rates were obtained with scoring modifications. Removal of dense amnesiacs from the sample resulted in even better hit rates. Rey's measures appear to be valid for the assessment of cognitive malingering in settings where litigated disability claims are out of proportion to injury characteristics. Rey's measures are not appropriate for globally and severely impaired patients in clinical settings.
The detection of dissimulated cognitive deficits is an important issue in many clinical assessment situations. Specific procedures designed to aid in this detection can be useful additions to standard assessment protocols. The present study investigates the potential utility of a modification of the forced-choice, symptom validity paradigm to the assessment of memory deficits. Previous research indicated that the procedure could discriminate between college students instructed to malinger memory impairment and college students instructed to perform at their best ability. The present study administered a forced-choice memory assessment instrument to 60 psychiatric patients, 60 normal community volunteers, and 60 neuropsychological patients. Thirty psychiatric patients and 30 community volunteers were given instructions to malinger. Discriminant function analyses yielded an overall correct group classification rate of 90.6%, with 5% of the nonmalingering subjects and 18.3% of the experimental malingerers incorrectly classified.
In recent years, much research has focused on developing tests to detect malingering. A drawback of existing tests is their poor ability to detect malingerers possessing more "sophisticated" knowledge of neuropsychological deficits. The current study presents preliminary validation data on a new measure, the Word Completion Memory Test (WCMT), which is the first malingering test to utilize a sophisticated coaching methodology in its development. The WCMT was administered to control participants, memory-impaired patients, and coached simulators. The coached simulators were provided with specific information about and examples of memory deficits commonly experienced following closed head injury (CHI; e.g., anterograde vs. retrograde amnesia). They also read a detailed scenario describing the lifestyle and motivations likely experienced by CHI litigants, and then practiced their roles by taking a quiz about their deficits. Results showed that 93% of coached simulators and 100% of control and memory-impaired participants were correctly classified by the WCMT.
Research on the Test of Memory Malingering (TOMM) [Tombaugh, T. N., 1996. The Test of Memory Malingering. Toronto, Canada: Multi-Health Systems], has consistently shown that it is sensitive to exaggerated or deliberate faking of memory impairment, but it is relatively unaffected by a wide variety of neurological impairments causing genuine memory dysfunction. However, there is little research on the effects that affective disorders have on the TOMM. The current study examined how inpatients diagnosed with major depression performed on the TOMM. Results show that the TOMM is unaffected by affective state. These results, combined with those from previous research, provide converging evidence that performance on the TOMM below a cutoff score of 45 cannot be attributable to depression, neurological impairment, age or education.
We administered the b Test, a new measure to identify malingering requiring recognition of overlearned information, to 34 suspected malingerers and to 161 subjects in various clinical groups (moderate to severe head injury, elderly depressed, learning disability, schizophrenia, right and left CVA, and elderly normals). Comparisons of groups revealed more commission and omission errors in the suspected malingerers relative to all groups except the right stroke patients. In addition, suspected malingerers took longer to complete the task than all groups except right and left stroke patients and normal elderly. A cutoff of >2 commission errors produced a sensitivity of 76.5% and specificity for all comparison groups combined of 82.6%. Lower sensitivity rates were documented for omissions (58.8 using cutoff of >40) and time (57.6% using cutoff of >12 minutes), but specificity remained high at 85.1% and 83.9%, respectively. Thus, the b Test shows considerable potential as a malingering detection tool.
Using the Halstead-Reitan Battery profiles of 796 people, a formula for the detection of malingering was cross-validated to assess the false positive rate. Subjects included normals, psychiatric cases, and all major types of organics. The formula incorrectly designated 27% of the sample as fakers (i.e., as false positives). Of the 120 head trauma cases, 27 (22.5%) obtained Fake scores, while 93 (77.5%) were correctly assessed as not malingering.
The utility of various measures of malingering was evaluated using an analog design in which half the participants (composed of three groups: naive healthy people, professionals working with head-injured people, individuals who suffered a head injury but not currently in litigation) were asked to try their best and the remainder was asked to feign believable injury. Participants were assessed with the Reliable Digit Span (RDS) task, the Victoria Symptom Validity Test (VSVT), and the Computerized Dot Counting Test (CDCT) on three separate occasions in order to determine whether repeat administration of tests improves prediction. The results indicated that regardless of an individual's experience, consideration of both level of performance (particularly on forced-choice symptom validity tasks) and intraindividual variability holds considerable promise for the detection of malingering.
This study has redesigned the Rey 15-item Visual Memory Test (1964) by introducing more complex figures and by increasing internal logic and pattern redundancy. Standardized administrative procedures and rules for a simple qualitative scoring system were established. Performance on the original Rey continued to be significantly contaminated by ability components and illness while performance on the Rey II qualitative scoring system was not significantly related to intelligence, age, mental status or memory. The Rey II demonstrated improved face validity. Linear Discriminant Function Analysis indicated that the qualitative scoring system had a higher classification accuracy than the quantitative system on both instruments; the Rey II qualitative scoring system accurately detected 31% more college malingerers than the Rey quantitative and 21% more clinical malingerers than the Rey II quantitative. A malingering cut-off of two qualitative errors gave the Rey II a 79% higher sensitivity in the college malingerers and 29% higher specificity in the clinical population than the standard quantitative Rey cut-off of nine items.
Test results from 90 personal injury claimants were used to explore the relationship between personality disorders (Dependent, Histrionic, Compulsive, Schizoid, Schizotypal, Paranoid, Narcissistic, Borderline, Antisocial, Avoidant, and Passive-Aggressive) as assessed by the MCMI-II and response style measured by MMPI-2 validity scales (F, K, L, F-K, O-S, Es, and FBS). With the exception of the Dependent and Narcissistic scales, all personality disorder scales were found to have a significant relationship with validity indicators in the direction of faking bad. These results suggest that the presence of characterological factors (i.e., a personality disorder), rather than malingering, contributes to exaggerated results in a forensic setting. Implications for future research are addressed.
Mixed group validation (MGV) is offered as an alternative to criterion group validation (CGV) to estimate the true positive and false positive rates of tests and other diagnostic signs. CGV requires perfect confidence about each research participant's status with respect to the presence or absence of pathology. MGV determines diagnostic efficiencies based on group data; knowing an individual's status with respect to pathology is not required. MGV can use relatively weak indicators to validate better diagnostic signs, whereas CGV requires perfect diagnostic signs to avoid error in computing true positive and false positive rates. The process of MGV is explained, and a computer simulation demonstrates the soundness of the procedure. MGV of the Rey 15-Item Memory Test (Rey, 1958) for 723 pre-trial criminal defendants resulted in higher estimates of true positive rates and lower estimates of false positive rates as compared with prior research conducted with CGV. The author demonstrates how MGV addresses all the criticisms Rogers (1997b) outlined for differential prevalence designs in malingering detection research.
Along the processing chain in the visual pathway the pattern electroretinogram (PERG) is a better indicator of the peripheral function than the visual evoked potential (VEP). Therefore the PERG and the VEP will be impaired equally by disturbances before the ganglion cell layer (e.g., blurred image or retinal disease) and differently by further centrally located diseases (e.g., tumor compression of the optic nerve). Thus in patients complaining of reduced visual acuity who show disturbed VEP but a normal PERG, malingering can be definitely ruled out. Representative combinations of PERG and VEP findings are described.
Assessment of motivation using forced-choice testing is described and illustrated with case reports. Two injured workers with protracted disability complained of numbness and loss of sensation in their fingers. Each patient received a forced-choice, multiple-choice finger graphesthesia test, with a 0.5 probability of guessing correctly on each item. Both patients performed significantly below the chance level, indicating that they had deliberately provided wrong answers. One patient did not exaggerate until the difficulty level of the task was enhanced. Forced-choice testing, particularly with enhancement of difficulty levels, is proposed as a specific measure to detect faked poor performance. Identification of malingering reduces the risk of iatrogenic damage. The subjective complaints of malingerers must be viewed with skepticism.
The ability of the Test of Memory Malingering (TOMM; Tombaugh, 1996) to detect feigned-memory impairment was explored. The TOMM was administered to three groups: (a) a control group instructed to perform optimally, (b) a symptom-coached group instructed to feign memory problems after being educated about traumatic brain injury symptomatology, and (c) a test-coached group instructed to feign memory problems after being educated about test-taking strategies to avoid detection. The recommended cutoff scores (Tombaugh, 1996) on Trial 2 and the Retention Trial produced overall classification accuracy rates of 96%, with high levels of sensitivity and specificity. Although the symptom-coached group performed more poorly on the TOMM relative to the test-coached group, the test was equally sensitive in detecting suboptimal effort across the different coaching paradigms.
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.