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Mild head injury is not always mild; implications for damage litigation.

The traditional view that mild head injury involves an essentially reversible physiological process is examined and is found to be largely invalid. It is concluded that long-term impairment following mild head injury is fairly common and that the degree of impairment can be assessed clinically. Such an assessment involves a combination of objective electrophysiological and psychometric investigations as well as professional interpretation. With the use of this approach the possibility of malingering can be ruled out in most cases and significant impairment, when it exists, can be demonstrated beyond reasonable doubt.

Adult↗

Work-related, noise-induced hearing loss: evaluation including evoked potential audiometry.

This article reviews the evaluation of 246 workers (492 ears) who underwent otologic and audiologic testing as part of a worker's compensation claim for work-related, noise-induced hearing loss. Tinnitus was present in 58% of the patients, but was rarely a major symptom. Other otologic symptoms or a history of ear disease were virtually nonexistent. Standard audiometry showed a downsloping, high-frequency sensorineural hearing loss in 85% of the ears tested, with only 37% having a characteristic "noise notch" at 4000 or 6000 hertz. Asymmetric hearing loss was not uncommon, with 48 patients (20%) undergoing magnetic resonance scanning, all of whom showed no central lesion responsible for the loss. Proven malingering was surprisingly uncommon (9%). In this study, evoked response audiometry was a valuable adjunct to confirm behavioral thresholds in the evaluation of possible work-related, noise-induced hearing loss. The middle latency response was more effective than the auditory brainstem response as a result of the high-frequency steepness of the audiometric curve.

Acoustic Stimulation↗

Comparability of the MMPI-2 F(p) and F scales and the SIRS in clinical use with suspected malingerers.

Relationships among Structured Interview of Reported Symptoms (SIRS) scores and Minnesota Multiphasic Personality Inventory--2 (MMPI-2) F(p) and F scores were examined for 63 suspected malingerers evaluated at either of two psychiatric facilities. Despite differences between facilities in terms of seriousness of subjects' offenses, mean scores on the malingering tests were similar. Cutting scores for F(p) and F resulting in substantial correspondence between these scales and the SIRS were derived. Use of the cut score for F(p) proposed by Arbisi and Ben-Porath (1995) resulted in less agreement with the SIRS than did a lower cut score. No substantial difference between F(p) and F in each scale's overall agreement with the SIRS was observed. A principal components analysis of the SIRS primary scales produced two factors, interpreted as Overreporting of Symptoms and Implausible Symptoms. F(p) was observed to correlate significantly with Implausible Symptoms but not with Overreporting of Symptoms; F was significantly correlated with both factors.

Adult↗

Examining the use of the M-FAST with criminal defendants incompetent to stand trial.

The Miller Forensic Assessment of Symptoms Test (M-FAST) was developed to provide evaluators with a brief, reliable, and valid screen for malingered mental illness. This study examined the initial validity of the M-FAST in a sample of 50 criminal defendants found incompetent to stand trial because of a mental illness. The M-FAST total score and items were compared with the Structured Interview of Reported Symptoms (SIRS) and the fake-bad indicators of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Results indicated good evidence of construct and criterion validity, demonstrated by t tests, receiver operating characteristics analysis, and high correlations between the M-FAST, SIRS, and the fake-bad indices on the MMPI-2. Tentative cut scores for the M-FAST total score and scales were examined and demonstrated high utility with the sample of criminal defendants incompetent to stand trial.

Adolescent↗

Sodium amytal in the diagnosis of chronic pain.

The diagnosis of chronic pain cases is now an important problem for psychiatrists and many authors have presented strong evidence for the influence of psychological factors in chronic pain conditions. The author is reporting his experience with 75 consecutive out-patient consultations. Many of the patients were foreign-born and had significant language difficulties. The main diagnostic technique described is the use of sodium amytal given intravenously over a 45 minute-period while the patient is examined physically and psychologically; his responses noted during light, midrange and deeper levels of sodium amytal sedation. Most patients fell comfortably into one of the following diagnostic groups: psychogenic regional pain, organic pain, mixed group (organic plus psychogenic regional pain), and malingering. The author suggests that sodium amytal helps to overcome language barriers, reduces the time required for proper assessment and allows the patient and the examiner to appreciate more precisely, the level of pain and the limits of physical performance as well as permitting an effective exploration of important psychodynamic issues.

Adult↗

Shadows of the truth in patients with spinal pain: a review.

OBJECTIVE: Spinal pain with or without referred pain is a major and costly health problem that can arise from many anatomical structures. Sophisticated diagnostic imaging devices cannot show some of these structures, and frequently imaging provides only a shadow of the truth. This review illustrates how symptoms may well have an organic cause that is not detectable by current methods of examination, including imaging. METHOD: This study reviews some histopathological findings that can be associated with spinal pain with or without referred pain but cannot be seen on imaging. RESULT: Some histopathological changes illustrate imaging device limitations. CONCLUSION: Awareness of the considerable limitations of even sophisticated imaging devices is necessary when managing patients with acute or chronic spinal pain with or without referred pain. Symptoms may well be genuine and not of psychogenic origin: a diagnosis of malingering, therefore, should not be made lightly.

Adult↗

Observations of shipboard illness behavior: work discipline and the sick role in a residential work setting.

In this article, the author reports on a small-scale ethnographic study of illness behavior in a residential work setting, a large merchant cargo ship with a multinational crew. Although parallels with previous observational work on illness behavior in residential settings (where illnesses result in treatment only if there is a break in accommodation to symptoms) exist, it is clear that type of setting is pivotal in shaping illness careers. Here, accommodation to symptoms was overlain by the economic imperative to keep the ship functioning: Management feared that the right to the sick role would allow "malingering," whereas workers feared adoption of the sick role would exclude them from employment. In the latter case, the worker might experience illness or disability in a manner parallel to a Marxist analysis of the product of workers'labor: as an alien object of control and oppression, grounds for his or her removal from the workforce.

Employment↗

Comparison of the Fake Bad Scale and other MMPI-2 validity scales with personal injury litigants.

Five MMPI-2 validity scales were evaluated with 120 personal injury litigation patients (LP) and 208 clinical patients (CP) along with 43 normal participants (NP). The validity measures included the Fake Bad Scale (FBS), Infrequency scale (F), Back Infrequency scale (Fb), Infrequency-Psychopathology scale (F[p]), and the Dissimulation scale-2 (Ds2). Results showed that only the FBS significantly differentiated the LP and CP, whereas the LP and CP scored significantly higher than the NP on FBS, F, Fb, and Ds2. The content of the FBS, with several items from the Hypochondriasis (Hs) and Hysteria (Hy) Scales, appears to enhance the FBS' ability to detect the somatic overreporting often observed with personal injury claimants. The authors suggest that the FBS may be a useful index of symptom magnification when employed within a comprehensive assessment of malingering in personal injury plaintiffs.

Adult↗

MMPI-2 scale F(p) and symptom feigning: scale refinement.

The F(p) scale of the MMPI-2 is widely used to help identify exaggeration of psychological problems in psychiatric, forensic, and neuropsychological settings. The scale was constructed by selecting all MMPI-2 items (N = 27) that were endorsed by less than 20% of a sample of VA psychiatric inpatients and 20% of the normative sample used in restandardizing the MMPI-2. Although F(p) is used to measure symptom exaggeration and malingering, 4 of its 27 items load on the Lie (L) scale, which is known to be a measure of defensiveness and symptom underreporting. These four items, which express a denial of occasional anger, irritability, and procrastination, could conceivably measure an uncommon expression of defensiveness. This study used 150 neuropsychological referrals to test the hypotheses that (a) the four L scale items measure defensiveness, not exaggeration, and (b) the elimination of these items improves the utility of F(p) in assessing symptom exaggeration. The results indicate that the four L scale items are associated with defensiveness, not with symptom exaggeration. One third of the patients had an average T-score artifact of 9.5 points on F(p) as a result of endorsing these L scale items, with a range of 0T to 21T. Using the K scale as a criterion for level of problem disclosure, a shortened version of F(p) (omitting the four L scale items) was superior to F(p) as a measure of symptom exaggeration (r = -.46 vs. -.36, r2 = 21% vs. 13% of the variance). The implications for clinical practice are discussed.

Adult↗

Performance of the Personality Inventory for Youth validity scales.

Response sets as well as cognitive and academic deficits compromise the validity of child and adolescent self-report of emotional adjustment. Three studies using clinical and asymptomatic samples of 4th to 12th grade students detail applications of the four validity scales of the Personality Inventory for Youth (PIY), namely, (a) Validity (VAL) a scale of six highly improbable statements, (b) Inconsistency (INC) consisting of pairs of highly correlated statements, (c) Dissimulation (FB) constructed of statements that were infrequent and characteristic of intentional distortion, and (d) Defensiveness (DEF) an extension of the Lie scale of the parent-report Personality Inventory for Children. The effects of minimizing, malingering, and random response sets on the PIY validity scales are reported. The importance of such validity scales derived from child and adolescent response is discussed.

Adolescent↗

Demand characteristic effects on the subtle and obvious subscales of the MMPI.

The MMPI was administered to 40 undergraduate students with 20 subjects asked to imagine that they were applying for a job and 20 subjects asked to imagine that they were applying for psychotherapy. Subjects in the job group dissimulated (faked good) and those in the therapy group malingered (faked bad) as evidenced by differences between the subtle and obvious scores. The combined subtle and obvious score was higher for the psychotherapy group. It was concluded that the subtle, obvious, and combined subtle and obvious scores on the MMPI were a function of the demand characteristics of the testing situation.

Employment↗

Identification of random responders on MMPI protocols.

In clinical practice, indicators of random or irrelevant responses on MMPI protocols are typically not examined, and, if obtained, assumed to be the result of either gross psychopathology or attempts to malinger. A sample of 40 computer-generated random profiles and 40 profiles of forensic outpatients were compared on validity scales, clinical scales, and scales specially designed to detect randomness (TR index and Carelessness Scale). Results of discriminant analysis indicated differentiating patterns of responses with random profiles generally elevated. Further, the accuracy of several clinical decisions rules were evaluated. The "F greater than 80 and TR greater than 4" rule was found to have the greatest clinical utility at correctly classifying random responders.

Female↗

Detecting faking on the Rorschach: computer versus expert clinical judgment.

In a previous study of the ability of expert Rorschach interpreters to detect faking that used true and malingered protocols, the experts faired very poorly. In this study, 50% of these same protocols were scored by the Exner system and analyzed by Exner's Semantic Computer Interpretation program. The program indicated invalidity of protocols only on the basis of low R and designated the faked protocols high on psychotic descriptors, barely indicating psychosis for the true schizophrenic protocols. Unlike the judges, however, the computer gave no psychotic designation to the normal protocols. The scoring-computer analysis method was as susceptible to faking as were the clinical judgments.

Adolescent↗

Feigning schizophrenic disorders on the MMPI-2: detection of coached simulators.

The Minnesota Multiphasic Personality Inventory (MMPI) and, more recently, its revised version (the MMPI-2) have represented the "gold standard" in the psychometric assessment of malingering and other response styles. In this study, we provide a stringent test of the MMPI-2 validity indices and their ability to detect feigned schizophrenia in four groups of simulators (n = 72). Simulators were randomly assigned to one of four conditions: (a) coached on symptoms of schizophrenia, (b) coached on strategies for the detection of fakers, (c) coached on both symptoms and strategies, or (d) uncoached. Simulators were compared to subjects responding under an honest condition (n = 13) and a comparison group of schizophrenic inpatients (n = 37). We found knowledge of strategies alone allowed many simulators (i.e., one third or more, depending on the validity indices) to elude detection. In contrast, knowledge of the disorder appeared less useful to simulators in avoiding detection. Coaching on both strategies and symptoms was not as effective as strategies alone. Consistent with previous studies, uncoached simulators were detected with moderately high levels of accuracy.

Adult↗

Detecting feigned depression and schizophrenia on the MMPI-2.

Increasingly, investigations evaluating the effectiveness of the MMPI-2 in the assessment of malingering employ methodologies whereby research participants are asked to feigned specific disorders rather than just to "fake bad." Yet there is little research addressing the issue of whether different validity scales and indicators work differently in the detection of different feigned disorders. In this study the comparative effectiveness of a number of validity scales and indicators on the MMPI-2 to assess feigned depression and feigned schizophrenia were evaluated. Overall, the validity scales and indicators were better at detecting feigned schizophrenia than they were in detecting feigned depression, attributable, most likely, to closer familiarity with depressive experiences. The validity scales F, Fb, and F(p) best distinguish patients with schizophrenia from participants feigning schizophrenia, and F and Fb best distinguish patients with depression from participants feigning depression.

Adult↗

A survey of psychological test use patterns among forensic psychologists.

Clinical psychologists are frequently called on to testify in court regarding mental health issues in civil or criminal cases. One of the legal criteria by which admissibility of testimony is determined includes whether the testimony is based on methods that have gained "general acceptance" in their field. In this study, we sought to evaluate the psychological tests used in forensic assessments by members of the American Psychology-Law Society Division of the American Psychological Association, and by diplomates in the American Board of Forensic Psychology. We present test results from this survey, based on 152 respondents, for forensic evaluations conducted with adults using multiscale inventories, single-scale tests, unstructured personality tests, cognitive and/or intellectual tests, neuropsychological tests, risk assessment and psychopathy instruments, sex offender risk assessment instruments, competency or sanity-related instruments, and instruments used to evaluate malingering. In addition, we provide findings for psychological testing involving child-related forensic issues.

Adult↗

Assessment of genuine and simulated dissociative identity disorder on the structured interview of reported symptoms.

Little is known about how to detect malingered dissociative identity disorder (DID). This study presents preliminary data from an ongoing study about the performance of DID patients on the Structured Interview of Reported Symptoms (SIRS, Rogers, Bagby, & Dickens, 1992), considered to be a "gold standard" structured interview in forensic psychology to detect feigning of psychological symptoms. Test responses from 20 dissociative identity disorder (DID) patients are compared to those of 43 well informed and motivated DID simulators. Both the simulators and DID patients endorsed such a high number of symptoms that their average overall scores would typically be interpreted as indicative of feigning. The simulators' mean scores were significantly higher than those of the DID patients on only four out of 13 scales. These results provide preliminary evidence that well informed and motivated simulators are able to fairly successfully simulate DID patients and avoid detection on the SIRS. Furthermore, many DID patients may be at risk for being inaccurately labeled as feigning on the SIRS.

Adult↗

[Münchhausen syndrome: diagnosis and management].

The authors review the literature on Münchhausen syndrome, and ilustrate the clinical features of the disorder with the description of a characteristic case. Diagnosis and differential diagnosis are discussed with regard to other somatoform disorders such as conversion disorder and somatization disorder as well as to malingering and schizophrenia. The awareness of general practitioners and surgeons regarding this syndrome may avoid the exposure of these patients to serious complications of unnecessary medical and surgical procedures. The management of Müchhausen syndrome is aggravated by the low compliance in these patients. Early diagnosis could to a considerable extent prevent the iatrogenic risks. The authors recommend that patients presenting the psychopathological features of a Münchhausen syndrome should be conservatively observed and an attempt to clarify both the medical and the psychiatric diagnosis should be made before any invasive procedure is undertaken.

Adult↗