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Gerald Young, Ph.D.

Ontario Psychological Association 68th Annual Conference

February 21, 2015

AGENDA

� Malingering

�  Part I: New Literature Review

�  Part II: Young (2014). Malingering, Feigning, and Response Bias in Psychiatric/Psychological Injury: Implications for Practice & Court.

Thanks to Joyce Chan and Anna Vehter for preparing these slides in such an appealing and efficient manner.

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New Literature Review

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New Literature Review (all paraphrased)

Bass & Halligan (2014) in The Lancet � The challenge in abnormal health-‐care-‐seeking behaviour is to establish the degree to which the complainant’s reported symptoms are due to volitional control, or psychopathology beyond volitional control, or both.

�  “Clinical skills” by themselves are not sufficient to “detect malingering.”

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Bass & Halligan (2014) in The Lancet

� Non-‐genuine case of Posttraumatic stress disorder have been noted (Rosen & Taylor, 2007), possibly because the diagnosis is based especially on the evaluee’s subjective report of symptomology (Hall & Hall, 2006).

�  In PTSD, its striking positive symptoms, such as nightmares and flashbacks, are more readily described (Hall & Hall, 2007).

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Bass & Halligan (2014) in The Lancet �  15-‐30% of evaluees with mild Traumatic Brain Injury describe continuing non-‐specific symptoms (Ferrari, 2011)

�  In a patients with complex regional pain syndrome (type 1), evaluated in disability-‐seeking contexts, at least three-‐quarters failed one indicator of performance validity (Grieffenstein, Gervais, Baker, Artiola, & Smith, 2013)

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Chafetz & Underhill (2013) � The frequency of feigning of disabling illness in evaluation of adult disability compensation in the Social Security Disability (SSD) is 45.8%-‐59.7%.

Note: Does the evidence uniformly agree on the prevalence/ base rate of malingering being this high. Some estimates are even higher, others much lower (see Young 2014a, 2014b)

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Chafetz & Underhill (2013) �  Feigning or exaggeration of symptoms for an external incentive constitutes malingering.

� Chafetz (2008) found that 45.8% of disability evaluees failed the TOMM (Tombaugh, 1996) at below-‐chance or at chance levels or they failed both the TOMM and the SVS (for Low Functioning Individuals) (Chafetz, Abrahams, & Kohlmaier, 2007).

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Chafetz & Underhill (2013) �  In this study, we estimated “The costs of malingering based on adult mental disorder data” at the Social Security Administration totaled $20.02 billion in 2011.

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Chafetz & Underhill (2013) � A letter from U.S. Senator Tom Coburn (2013), supported by all of neuropsychology’s national (US) organizations, strongly urged the funding of performance validity testing in SSD evaluations.

[Note. Young et al. (2015) I will be talking at APA in Toronto on the disability epidemic in the VA and SSA and the need for comprehensive scientifically, informed impartial assessments in disability determinations in these regards.]

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Russo (2014) �  “Conflicting ethical-‐moral and utilitarian-‐political forces” that are inherent in the VA (Department of Veteran Affairs) act to undermine “accuracy in evaluation of military veterans’ symptoms by way of both institutional-‐wide systemic practices and local medical center-‐specific pressures towards collusive lying.”

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Russo (2014) � We need to assess accurately military veteran symptom validity because of our “personal integrity” in that there is a lack of judicial overview and few external consequences for not doing it.

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Russo (2014) � VA psychologists should protect themselves from retaliation by informing veterans with a comprehensive, signed informed consent document that includes that they (a) will be treated professionally, and with courtesy and respect; and (b) are expected to “give their best and most honest effort.”

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Wygant & Lareau (2015) � The DSM definition of malingering includes that it should be considered when the evaluee displays symptoms of antisocial personality disorder.

� However, according to Rogers (2008), this screen is likely to result in an unacceptably high level of false positive determinations.

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Wygant & Lareau (2015) � There are some important considerations when PTSD is a possible diagnosis in a civil case.

� The PTSD criteria in DSM-‐5 allows for an extreme number of permutations (636,120) of symptom combinations in diagnosing PTSD (Galatzer-‐Levy & Bryant, 2013).

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Wygant & Lareau (2015) � Young, Lareau, and Pierre (2014) calculated the symptom combinations allowed by a DSM-‐5 diagnosis of PTSD and other common comorbid disorders.

� There are more than one quintillion different symptoms combinations possible when dealing with a PTSD diagnosis and common comorbidities.

�  [Note. The comorbidities include the other major psychological injuries, mTBI and chronic pain (SSD).]

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Wygant & Lareau (2015) � The major personality inventories included embedded scales that can help in forensic disability and related evaluations.

� These include the MMPI-‐2, MMPI-‐2-‐FR, and the PAI

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Sleep, Petty, & Wygant (2015) � One MMPI-‐2 over-‐reporting indicator is the Infrequency (F) scale.

�  It includes rare psychopathological symptoms endorsed by < 10% of the original MMPI normative sample.

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Sleep, Petty, & Wygant (2015) �  Some F scale items also appear in scales on psychopathology.

� Therefore, psychologically disturbed individuals might endorse many of these items.

� Also, evaluees attempting to portray themselves in an unrealistic negative light tend to endorse F scale items (Graham, 2011).

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Sleep, Petty, & Wygant (2015) � Arbisi and Ben-‐Porath (1995) developed the Fp scale to supplement it.

�  Fp was developed in order to detect exaggerated psychological symptomology, Arbisi and Ben-‐Porath (1995).

�  Its 27 items were endorsed “rarely” (by less than 20%) in two samples of psychiatric inpatients, and also in the MMPI-‐2 normative sample.

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Sleep, Petty, & Wygant (2015) � The FBS includes 43 items that were rationally selected toward assessing exaggerated post-‐injury emotional distress, while also minimizing any preexisting psychopathology.

�  [Note. The FBS had been referred to as the Fake Bad Scale but now is referred to as the Symptom Validity Scale, although the abbreviation FBS has been kept.]

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Sleep, Petty, & Wygant (2015) �  The MMPI-‐2-‐RF includes five symptom over-‐reporting respondent validity scales.

�  The infrequent Responses (F-‐r) scale consist of 32 items distributed throughout the MMPI-‐2-‐RF (and is a counterpart to the F scale).

�  As with F, it is measure of general over-‐reporting. �  It includes items that are rarely endorsed (≤ 10%) in the normative sample (Tellegen & Ben-‐Porath, 2008/ 2011).

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Sleep, Petty, & Wygant (2015) � The Infrequent Somatic Responses (Fs) scale, developed by Wygant, Ben-‐Porath, and Arbisi (2004), is a 16-‐item scale new to the MMPI-‐2-‐RF.

� This scale was developed to help identify noncredible reports of somatic symptoms.

�  Its developers employed a rare-‐symptom approach. �  Fs includes items with somatic content that are rarely endorsed by medical/ chronic pain patients.

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Sleep, Petty, & Wygant (2015) � The FBS-‐r scale, unlike the FBS, includes 12 items on other validity scales (Hoelzle et al., 2012).

� Elevated scores on FBS-‐r are indicative associated with over-‐reporting of somatic and cognitive deficits.

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Sleep, Petty, & Wygant (2015) � The Response Bias Scale (RBS; Gervais, Ben-‐Porath, Wygant, & Green, 2007) was developed based on the MMPI-‐2-‐RF but is compatible with the MMPI-‐2-‐RF.

� The RBS over-‐reporting scale was developed to identify self-‐reported symptomology (regardless of item content) that are associated with poor performance on cognitive PVTs

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Sleep, Petty, & Wygant (2015) � Wygant et al. (2011) found the Fs and FBS-‐r scales were “good at identifying noncredible neurocognitive and somatic symptoms” in evaluees undergoing litigation related compensation-‐seeking disability evaluations classified at maingering levels using related with the MND (Malingered Neurocognitive Dysfunction; Slick et al., 1999) and MPRD (Malingered Pain-‐Related Disability; Bianchini et al., 2005) criteria.

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Buddin et al. (2014) � The TOMM is the most used performance validity test (PVT) in neuropsychology, but it does not include a measure of response consistency, which is important in the measurement of credible evaluee presentation.

� To address this need, Gunner, Miele, Lynch, and McCaffrey (2012) developed the Albany Consistency Index (ACI).

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Buddin et al. (2014) � He developed the Invalid Forgetting Frequency Index (IFFI) for the same purpose.

�  In a retrospective case-‐control study of 59 forensic cases from an outpatient clinic in Southern Kansas, we found that the IFFI was superior psychometrically to both the TOMM indexes and the ACI.

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Kulas, Axelrod, & Rinaldi (2014) � The TOMM is among the more popular free-‐standing performance validity measures (PVMs).

� New indices have been developed for it: Trial 1 (Denning, 2012); TOMMe10 (Denning, 2012); and Albany Consistency Index (ACI; Gunner, Miele, Lynch, & McCaffrey, 2012).

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Kulas, Axelrod, & Rinaldi (2014) � We examined the performance of these measures in a mixed clinical sample of military veterans who were referred for neuropsychological assessment.

� All five examined measures allowed “good to excellent” discrimination of evaluees who had failed two/ three alternate measures of performance validity.

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Bashem et al. (2014) � Their study examined five widely-‐used PVTs:

�  The Test of Memory Malingering (TOMM), � Medical Symptom Validity Test (MSVT), �  Reliable Digit Span (RDS), � Word Choice Test (WCT), and �  California Verbal Learning Test – Forced Choice (CVLT-‐FC).

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Bashem et al. (2014) � They examined 51 adults with genuine moderate-‐to-‐severe TBI, along with 58 demographically-‐comparable healthy adults who were coached to simulate memory impairment.

� The results showed nearly equivalent discrimination ability as individual predictors of the TOMM, MSVT, and CVLT-‐FC,and each of the tests “markedly outperformed” the WCT and RDS in this regard.

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Bashem et al. (2014) � They also found that combining PVTs using Bayesian information criterion statistics showed that diagnostic accuracy evidenced only small to modest growth when the number of PVTs was increased beyond two.

[Note. But is their research supported in every case? For a positive response to the question, see Larrabee (2014); for a negative one, see Odland et al. (2015).]

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Larrabee (2014) � PVT error rates using Monte Carlo simulation (see Berthelson et al., 2013) were compared in two nonmalingering clinical samples.

� Berthelson et al.’s findings had queried the validity of using 2 or more PVT failures as representing probable invalid clinical neuropsychological presentation.

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Larrabee (2014) �  In his work, at a per-‐test false-‐positive rate of 10%, Monte Carlo simulation overestimated error rates.

� These clinical results support the practice of using the threshold of ≥ 2 testing validity failures as representative of probable invalid clinical neuropsychological presentation.

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Crighton et al. (2014) � Can two brief measures, Modified Somatic Perception Questionnaire (MSPQ) and the Pain Disability Index (PDI) screen effectively for malingering in relation to the MPRD criteria?

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Crighton et al. (2014) �  They compared 144 disability litigants, predominantly presenting a history of musculoskeletal injuries with psychiatric overlay, with 167 nonlitigating pain patients, predominantly in treatment for chronic back pain issues and other musculoskeletal conditions

�  The results suggested that both the MSPQ and PDI are useful in screening pain malingering in forensic evaluations

�  The MSPQ, though performed the better in differentiating the two groups.

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Crighton et al. (2014) � Although useful as screeners, the MSPQ and the PDI should not be used as a definitive source to make malingering determinations.

�  In screening in clinical settings of individuals evaluation of disability for pain, scores of ≥ 14 on the MSPQ or ≥ 54 on the PDI should be used.

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Bianchini et al. (2014) � They examined the accuracy of the MSPQ and PDI in relation to classification of evaluees according to the MPRD.

� They used a retrospective cohort of patients with chronic pain, n = 328 and a simulator group (college students, n = 98)

� Results showed that MSPQ and PCI accurately differentiated Not-‐MPRD from MPRD cases.

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Bianchini et al. (2014) �  Their Table 7 showed the following for cut scores on the MSPQ and PDI as screeners for comprehensive psychological evaluation and/ or functional capacity evaluation.

�  Score Levels: MSPQ ≥ 17; PDI ≥ 62

� With these thresholds, the recommended interpretation is that malingering is “likely involved” in evaluee presentation.

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Bianchini et al. (2014) � The authors concluded that while high scores on these screeners reflect an increased probability of malingering, no matter how high, the scores are insufficient for a diagnosis of MPRD.

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Odland et al. (2015) �  The aim of the Monte Carlo simulation is to provide base rate data and recommendations for interpretation of multiple validity indicators (assuming varying correlations between each PVT ), at a range of specificity and sensitivity rates.

�  First, we validated Monte Carlo methodology across 24 embedded and standalone validity indicators in seven compensation-‐seeking clinical samples found in prior research.

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Odland et al. (2015) �  Samples included evaluees with psychotic and non-‐psychotic psychiatric disorders, as well as different neurological conditions.

� The simulation that we undertook arrived at strategies “for clinical integration of base rate data for advanced administration and interpretation of multiple validity indicators.” (p. 1)

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Odland et al. (2015) �  In this type of research, small sample sizes lower the likelihood that significant findings represent a true effect and also they exaggerate actual effects when they exist (Button et al., 2013).

� The use of research designs that cross-‐validate embedded PVTs using no-‐incentive samples selected on the basis of passing other freestanding PVTs (e.g., Victor et al., 2009)also is inadequate.

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Odland et al. (2015) �  Procedures such as this bias the samples, because evaluees who provide a credible test performance, but who happened to fail PVTs for reasons unrelated to incentive, are excluded from the final no-‐incentive sample (Bilder, Sugar, & Hellemann, 2014).

�  Such research may result in apparently well-‐validated PVTs that, in clinical practice, actually misclassify more than expected numbers of evaluees who provide credible test performance.

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Odland et al. (2015) � Other research arrives at different conclusions, such as Larrabee (2014).

� A weakness of the approach advocated by Larrabee (2014) is that combinations of embedded and/ or standalone PVTs cannot be chained using Liklihood Ratios (LRs) unless every PVT included is independent from every other PVT used.

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Odland et al. (2015) � However, the psychometric characteristics of the validity indcators cited by Larrabee (2014) were fundamentally different from those of Berthelson and colleagues (2013) that he criticized [and also those in the meta-‐analysis by Sollman and Berry (2011)].

� As more PVTs/ SVTs are used in evaluations, the probability of increases in type I error rates increases.

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Odland et al. (2015) �  There does not appear to be fixed number of PVT or SVT failures one should use in these type of assessments (e.g., two or three; e.g., Larrabee et al., 2007).

� We developed a decision-‐tree (Figure III; and Tables III-‐V and Appendices I-‐VIII) that increases efficiency during evaluations.

�  It provides feedback regarding the costs/ benefits associated with administering additional standalone PVTs in light of the number of test passes/ failures already obtained.

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Bigler (2014) �  Significantly below chance performance on relevant testing is the sine qua non indicator for malingering in neuropsychological assessment.

� However, there are substantial interpretative problems with SVT (symptom validity test) performance that is below the cut-‐point yet far above chance.

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Bigler (2014) �  This intermediate, grey-‐zone performance on SVT measure requires examining other data in an evaluation.

�  Neuroimaging results may be “key” in understanding better the meaning of such grey-‐zone SVT performance.

[Note. Does the evidence support this conclusion? Bigler (2014) used case studies to support it.]

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Bush, Heilbronner, & Ruff (2014) � The ASAPIL (Association for Scientific Advancement in Psychological Injury and Law; www.asapil.net) position statement on the need for effective assessment and testing of evaluee negative response bias and exaggerated/ malingered presentation and performance is based on articles in the journal Psychological Injury and Law (springer.com) by Bush et al. (2014) and Young (2014a).

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Bush, Heilbronner, & Ruff (2014) �  In the following, summarize the key points of the two articles

� This summary highlights the ethical underpinnings in doing this type of forensic and related work.

�  It makes no specific test recommendations, though. � This decision on the tests to use are the responsibility of each practitioner.

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Bush, Heilbronner, & Ruff (2014) � This ASAPIL position statement by Bush et al. (2014) promotes ethical psychological practice in forensics, legal contexts.

�  It reviews issues in validity assessment and their ethical foundations.

� Evaluees in psychological injury cases could have strong incentives to minimize prior problems and to emphasize postevent or posttrauma symptoms.

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Bush, Heilbronner, & Ruff (2014) � Therefore, it is essential to assess evaluee validity as part of forensic psychological evaluations.

� Psychological instruments have focused increasingly on evaluee validity scales (see Heilbronner & Henry, 2013 for a review).

� However, a multi-‐method approach is needed to determine the validity of an examinee’s overall approach in an assessment.

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Bush, Heilbronner, & Ruff (2014) �  Appropriate methods in this regard commonly include some combination of the following: �  Psychometric measures having respondent validity scales, �  Free-‐standing validity measures of validity, �  Embedded indices within tests of cognitive ability, �  Behavioral observations, �  Information in records, and �  Interviews of the evaluee and of collated sources.

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Bush, Heilbronner, & Ruff (2014) �  Even when test cutoff scores are reliable and valid, none can “capture the intent” that underlies on examinee’s invalid test results.

�  Use of probabilistic language (e.g., possible, probable, definite) based on structured diagnostic criteria should be used in determinations of malingering (MND; Slick, Sherman, & Iverson, 1999).

[Note. But how valid is the MND? (see Young, 2014b)]

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Bush, Heilbronner, & Ruff (2014) � Or, in many situations, presenting invalid evaluee results as representative of feigning should be used instead of attributing to malingering.

� Only validity measures having appropriate psychometric properties are used in malingering determinations.

� They should be selected based on the characteristics of the evaluee and on the circumstance(s) of the referral.

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Bush, Heilbronner, & Ruff (2014) � When interpreting of the results of testing, we need to consider all the relevant reliable data.

� Conclusions in opinions and testimony are developed that best fit the full data set in these regards.

� One’s conclusions are arrived at independently and not for the desires of the referral source.

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Bush, Heilbronner, & Ruff (2014) � When the evidence is insufficient with respect to motivation, volition, intention, and consciousness , evaluators are wary of making inferences on these matters.

�  However, evaluators do not avoid making a judgment on these matters when sufficient evidence allows for it.

�  “Best practices in forensic psychological evaluations consist of a multi-‐method, evidence-‐based validity assessment process that includes psychometric measures of validity.” (p. 202)

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Bush, Heilbronner, & Ruff (2014) �  Young (2014a) provided resource material to the Bush et al. (2014) authors to help in their writing ASAPIL’s position statement on performance validity testing.

�  These include material from the APA forensic practice guidelines, the APA ethics code, prior statements on PVTs and the 2014 standards for psychological testing and assessment

�  Young (2014a) organized material on the topic according to a revised 10-‐prinicle model of ethics in psychology (the APA code includes 5).

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Young (2014a) � Note that, unlike the case for the DSM, other approaches to defining malingering do not include exaggeration in their definitions.

� Given the difficulties in clearly defining malingering, it is not surprising that estimates of its base rate or prevalence vary.

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Young (2014a) � The estimates range from below 10% (even 1%) to over 50%.

� More likely, problematic presentations and performances, in general, express the latter range, with the percentage of outright malingering in the former range (as reviewed in Young, 2014b).

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Young (2014a) � DSM-‐IV-‐IR. The DSM-‐IV defines malingering as the “intentional production” of “grossly exaggerated” or “false” “psychological” and “physical” symptoms that derives from “motivation by external incentives” for example, in obtaining financial compensation.

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Young (2014b) � According to Young (2014b), an improved definition of malingering would involve exclusion of the term “production,” given its connotation of symptomology being evident, for the terms “presentation,” which is neutral in this regard, and so allows for a completely absence of genuine symptoms.

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Young (2014b) � Therefore, malingering should be defined as: the intentional presentation with false or grossly exaggerated symptoms [physical, mental health, or both; full or partial; mild, moderate, or severe], for purposes of obtaining an external incentive, such as monetary compensation for an injury and/ or avoiding/ evading work, military duty, or criminal prosecution.

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Kulas, Axelrod, & Rinaldi (2014) a. Malingering-‐related tests: RDS, CVLT-‐FC, WMT b. Malingering detection system: Failure on 2-‐3 of the

measures (suboptimal effort) c. Sample: N = 126 military (US) veterans (outpatient,

neuropsychology) d. Malingering-‐related groups: Optimal effort,

intermediate, suboptimal e. % for each group: 41 (52), 49 (62), 10 (12)

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Buddin et al. (2014) a. Malingering-‐related tests: RDS, FTT, VPA-‐II Recog,

VR-‐II recog; WMT (no/ GMIP), FBS, FBS-‐r b. Malingering detection system: MND modified (need

to fall 2 PVTs) c. Sample: N = 59 forensic outpatients

(neuropsychological) d. Malingering-‐related groups: 0, probable, definite e. % for each group: 58 (34), 39 (23), 34 (2)

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Larrabee (2014) a. Malingering-‐related tests: BVFD, FTT, RDS, CVMT;

CRM, WCST, FBS (note, raw score ≥ 21) b. Malingering detection system: MND c. Sample: N = 41 “malingering” (mTBI sample [and

N=54 clinical subjects, nonlitigating] d. Malingering-‐related groups: Probable, Definite e. % for each group: 41 (17), 59 (24)

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Crighton et al. (2014) a. Malingering-‐related tests: MMPI-‐2-‐RF, TOMM, LMT,

VSVT, SIRS-‐2 b. Malingering detection system: MPRD c. Sample: N = 133(5) forensic disability cases [and pain

patients] d. Malingering-‐related groups: 0, possible, probable/

definite e. % for each group: 53 (N=71), 24 (N=32), 24 (N=32)

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Bianchini et al. (2014) a. Malingering-‐related tests: CVLT (1, 2); MMPI-‐2; PDRT;

TOMM; WMT b. Malingering detection system: MPRD c. Sample: N = 305 clinical pain patients with incentive [and

controls; simulators] d. Malingering-‐related groups: 0; 1 ambiguity;

Indeterminate; Possible Malingering, probable, definite

e. % for each group: 10, 6, 11, 34, 27, 46%

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Table 1 Cogni<ve Biases That Could Affect in Forensic Evaluators (Adapted)

Bias Explanation

Representativeness (also Conjunction fallacy; Base rate neglect)

Overemphasizing evidence resembling a typical prototype representation (also disregarding the probability an outcome will occur (base rate) in determining a specific outcome likelihood)

Availability (also Confirmation bias; WYSIATI (What You See Is All There Is))

Overestimating the probability of an event occurrence when other instances of it are quite easy to recall (also selective data gathering/ interpretation toward favored hypothesis)

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Table 1 Cogni<ve Biases That Could Affect in Forensic Evaluators (Adapted)

Bias Explanation

Anchoring (also Framing/ Context)

Data first encountered are more influential than those encountered later (also, arriving at a different conclusion from the same data, depending on factors such as how or by whom that data is presented)

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Adapted from Neal & Grisso (2014)

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Murrie & Boccacciini (2015) �  They asked whether forensic experts can remain objective and accurate, given that when they are retained by one side or the other in adversarial legal proceedings?

�  The authors summarized recent field and experimental studies.

�  They conclude that working for one or the other side in an adversarial/ legal proceeding/ case, a “substantial portion” of opinions offered by experts drift towards the referral source, even when using apparently objective procedures and instruments.

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Murrie & Boccacciini (2015) � Murrie and Boccacciini called this process of the adversarial divide affecting expert objectively adversarial allegiance.

�  The mechanisms that underlie this process among workers in forensics are likely similar to the unconscious heuristics and cognitive biases to apparently at work in arriving at judgment in other settings, to understand.

�  Further research is needed to ultimately reduce the process of adversarial allegiance.

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Odland (2015) Emailed Review of Young (2014b) [cited with permission] �  Thank you again for the PDF of your 2014 book, and my compliments to you for constructing a very well designed and comprehensive system.

�  Your Diagnostic System for Malingering is the most comprehensive and integrative available, it is presented with meticulous detail and is intuitive, especially with the supplementary materials. In particular, I believe there is strong support for having degrees of certainty of response bias included in your system.

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Odland Review of Young (2014b) �  The dimensional approach outlined in your work answers a question I was not entirely certain of how to respond to as I wrote the recent paper for PIL: How does one make sense out of a certain number of PVT failures that is neither normal nor indicative definite invalidity -‐ the areas of gray defined in your system.

�  Assigning varying degrees of certainty with regard to classification ... intuitively seems to have improved ecological validity over extant models.

�  Re-‐analysis of already published data using your system, as I'm sure you are aware, could reshape the fields conceptualization of validity, base rates, and interpretive approach.

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Odland Review of Young (2014b) �  The set of 60 weighting rules that accompanies the system is also straight forward, and in agreement with our recent study in PIL.

�  After reading through the rules, I found myself wondering why such efforts had not previously been made given that the utility of any model hinges on veracity of its underlying assumptions.

�  This is a long overdue component to any malingering system, and is a major contribution in that it removes the guesswork from determining what factors suffice in the rubric of a larger classification system.

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Odland Review of Young (2014b) �  It is refreshing to see such precision in outlining how validity

measures are to be used within the system structure. �  The 60 rules appear well supported by a large body of literature.

E.g., Rule 11: “…5-‐8 of them indicates significant doubt about the credibility of the evaluee...”

�  This is consistent with population estimates of false-‐positive rates associated with failing 5-‐8 out of10-‐15 measures, given previous mention that all tests are valid and each have a false-‐positive rate less than or equal to 10% (Sollman & Barry Metanalysis).

�  From my perspective, other logic-‐driven rules also have strong psychometric support ... (e.g., Rule 33.).

�  As an aside, in addition to the Malingering Detection System, I found your analysis of base rates in Chapter 2 quite enlightening.

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References Arbisi, P. A., & Ben-‐Porath, Y. S. (1995). An MMPI-‐2 infrequent response scale

for use with psychopathological populations: The infrequency-‐ psychopathology scale, F(p). Psychological Assessment, 7, 424-‐431.

Bashem, J. R., Rapport, L. J., Miller, J. B., Hanks, R. A., Axelrod, B. N., & Millis, S. R. (2014). Comparisons of five performance validity indices in Bona fide and simulated traumatic brain injury. The Clinical Neuropsychologist, 28, 851-‐875.

Bass, C., & Halligan, P. (2014). Factitious disorders and malingering: Challenges for clinical assessment and management. The Lancet, 383, 1422-‐1432. Berthelson, L., Mulchan, S. S., Odland, A. P., Miller, L. J., & Mittenberg, W. (2013). False positive diagnosis of malingering due to the use of multiple effort

tests. Brain Injury, 27, 909-‐916. Bianchini, K. J., Aguerrevere, L. E., Guise, B. J., Ord, J. S., Etherton, J. L., Meyers, J. E., Soignier, R. D., Greve, K. W., Curtis, K. L., & Bui, J. (2014). Accuracy of the modified somatic perception questionnaire and pain disability index

in the detection of malingered pain-‐related disability in chronic pain. The Clinical Neuropsychologist, 28, 1376-‐1394.

Bianchini, K. J., Greve, K. W., & Glenn, G. (2005). Review article: On the diagnosis of malingered pain-‐ related disability: Lessons from cognitive

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traumatic brain injury. Brain Injury, 28, 1623-‐1638. Bilder, R. M., Sugar, C. A., & Hellemann, G. S. (2014). Cumulative false positive rates given

multiple performance validity tests: Commentary on Davis and Millis (2014) and Larrabee (2014). The Clinical Neuropsychologist, 28, 1212-‐1223.

Buddin Jr., W. H., Schroeder, R. W., Hargrave, D. D., Von Dran, E. J., Campbell, E. B., Brockman, C. J., Heinrichs, R. J., & Baade, L. E. (2014). An examination of the frequency of invalid forgetting on the test of memory malingering. The Clinical Neuropsychologist, 28, 525-‐542.

Bush, S. S., Heilbronner, R. L., & Ruff, R. M. (2014). Psychological assessment of symptom and performance validity, response bias, and malingering: Official position of the Association for Scientific Advancement in Psychological Injury and Law. Psychological Injury and Law, 7, 197-‐205.

Button, K. S., Loannidis, J. P. A., Mokrysz, C., Nosek, B. A., Flint, J., Robinson, E. S. J., & Munafo, M. R. (2013). Power failure: Why small sample size undermines the reliability of neuroscience. Nature Reviews Neuroscience, 14, 365-‐376.

Chafetz, M. D. (2008). Malingering on the Social Security disability consultative examination: Predictors and base rates. The Clinical Neuropsychologist, 22, 529-‐ 546.

Chafetz, M., D., Abrahams, J. P., & Kohlmaier, J. (2007). Malingering on the Social Security disability consultative examination: A new rating scale. Achieves of Clinical Neuropsychology, 22, 1-‐14.

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Archives of Clinical Neuropsychology, 28, 633-‐639. Coburn, T. (2013). Letter to SSA Commissioner Michael Astrue urging the

requirement of validity testing in disability determinations. Retrieved from http://www.aalj.org/system/files/documents/01.30.13lettertossaresvts.pdf.

Crighton, A. H., Wygant, D. B., Applegate, K. C., Umlauf, R. L., & Granacher, R. (2014). Can brief measures effectively screen for pain and somatic malingering? Examination of the modified somatic perception questionnaire and pain disability index. The Spine Journal, 14, 2042-‐ 2050.

Denning, J. H. (2012). The efficiency and accuracy of the Test of Memory Malingering trial 1, errors on the first 10 items of the test of memory malingering, and five embedded measures in predicting invalid test performance. Archives of Clinical Neuropsychology, 27, 417-‐432.

Ferrari, R. (2011). Minor head injury: Do you get what you expect? Journal of Neurology, Neurosurgery, & Psychiatry, 82, 826.

Galatzer-‐Levy, I. R., & Bryant, R. A. (2013). 636,120 ways to have posttraumatic stress disorder. Perspectives on Psychological Science, 8, 651-‐662.

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References Gervais, R. O., Ben-‐Porath, Y. S., Wygant, D. B., & Green, P. (2007). Development

and validation of a Response Bias scale (RBS) for the MMPI-‐2. Assessment, 14, 196-‐208.

Graham, J. R. (2011). The MMPI-‐2: Assessing personality and psychopathology (5th ed.). New York: Oxford University Press.

Greiffenstein, M., Gervais, R., Baker, W. J., Artiola, L., & Smith, H. (2013). Symptom validity testing in medically unexplained pain: A chronic regional pain syndrome type 1 case series. The Clinical Neuropsychologist, 27, 138-‐147.

Gunner, J. H., Miele, A. S., Lynch, J. K., & McCaffrey, R. J. (2012). The Albany Consistency Index for the Test of Memory Malingering. Archives of Clinical Neuropsychology, 27, 1-‐9.

Hall, R. C. W., & Hall, R. C. W. (2006). Malingering of PTSD: Forensic and diagnostic considerations, characteristics of malingerers and clinical presentations. General Hospital Psychiatry, 28, 525-‐535.

Hall, R. C. W., & Hall, R. C. W. (2007). Detection of malingered PTSD: An overview of clinical, psychometric, and physiological assessment: Where do we stand? Journal of Forensic Sciences, 52, 717-‐725.

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magnification in mild traumatic brain injury cases. In D. A. Carone, & S. S. Bush (Eds.), Mild traumatic brain injury: Symptom validity assessment and malingering (pp. 193-‐202). New York: Springer Publishing

Company. Hoelzle, J. B., Nelson, N. W., & Arbisi, P. A. (2012). MMPI-‐2 and MMPI-‐2-‐

Restructured Form validity scales: Complementary approaches to evaluate response validity. Psychological Injury and Law, 5, 174-‐191.

Kulas, J. F., Axelrod, B. N., & Rinaldi, A. R. (2014). Cross-‐validation of supplemental test of memory malingering scores as performance validity measures. Psychological Injury and Law, 7, 236-‐244.

Larrabee, G. J. (2014). False-‐positive rates associated with the use of multiple performance and symptom validity tests. Archives of Clinical Neuropsychology, 29, 364-‐373.

Larrabee, G. J., Greiffenstein, M. F., Greve, K. W., & Bianchini, K. J. (2007). Refining diagnostic criteria for malingering. In G. J. Larrabee (Ed.), Assessment of malingered neuropsychological deficits (pp. 334-‐372). New York: Oxford University Press.

Murrie, D. C., & Boccaccini, M. T. (2015). Adversarial allegiance among forensic evaluators. Annual Review of Law and Social Science, 15.

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forensic mental health evaluations. Psychology, Public Policy, and Law, 20, 200-‐211.

Odland, A. (2015). Emailed personal communication of his review of Young (2014b).

Odland, A., Lammy, A., Martin, P., Grote, C., & Mittenberg, W. (2015). Advanced administration and interpretation of multiple validity tests. Psychological Injury and Law, 8.

Rogers, R. (2008). Detection strategies for malingering and defensiveness. In R. Rogers (Ed.), Clinical assessment of malingering and deception (3rd ed., pp. 14-‐38). New York: The Guilford Press.

Rosen, G. M., & Taylor, S. (2007). Pseudo-‐PTSD. Journal of Anxiety Disorders, 21, 201-‐210.

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Sleep, C. E., Petty, J. A., & Wygant, D. B. (2015). Framing the results: Assessment of response bias through select self-‐report measures in psychological injury evaluations. Psychological Injury and Law,

8.

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References Sollman, M. J., & Berry, D. T. R. (2011). Detection of inadequate effort on

neuropsychological testing: A meta-‐analytic update and extension. Archives of Clinical Neuropsychology, 26, 774-‐789.

Tellegen, A., & Ben-‐Porath, Y. S. (2008/ 2011). MMPI-‐2-‐RF (Minnesota Multiphasic Personality Inventory-‐2 Restructured Form): Technical manual.

Minneapolis, MN: University of Minnesota Press. Tombaugh, T. N. (1996). TOMM: Test of memory malingering. North Tonawanda,

NY: Multi-‐Health Systems. Victor, T. L., Boone, K. B., Serpa, J. G., Buehler, J., & Ziegler, E. A. (2009).

Interpreting the meaning of multiple symptom validity test failure. The Clinical Neuropsychologist, 23, 297-‐313.

Wygant, D. B., Anderson, J. L., Sellbom, M., Rapier, J. L., Allgeier, L. M., & Granacher, R. P. (2011). Association of the MMPI-‐2 Restructured Form (MMPI-‐2-‐RF) validity scales with structured malingering criteria. Psychological Injury and Law, 4, 13-‐23.

Wygant, D. B., Ben-‐Porath, Y. S., & Arbisi, P. A. (2004, May). Development and initial validation of a scale to detect infrequent somatic complaints. Poster presented at the 39th Annual Symposium on Recent Developments of the MMPI-‐2/ MMPI-‐A, Minneapolis, MN.

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References Wygant, D. B., & Lareau, C. R. (2015). Civil and criminal forensic psychological

assessment: Similarities and unique challenges. Psychological Injury and Law, 8.

Young, G. (2014a). Resource material for ethical psychological assessment of symptom and performance validity, including malingering. Psychological Injury and Law, 7, 206-‐235.

Young, G. (2014b). Malingering, feigning, and response bias in psychiatric/ psychological injury: Implications for practice and court. Dordrecht: Springer Science + Business Media.

Young, G., Lareau, C., & Pierre, B. (2014). One quintillion ways to have PTSD comorbidity: Recommendations for the disordered DSM-‐5. Psychological Injury and Law, 7, 61-‐74.

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Implications for Practice and Court Gerald Young, PhD

New York: Springer SBM 2014

About this book � What is psychological injury?

�  PTSD, chronic pain, TBI (esp. mTBI) � How to detect malingering, feigning and related response biases in psychological/psychiatric injury cases?

� Takes a look at approaches to and inconsistencies in the field, even in defining malingering and establishing its base rate

� Proposes solutions for these concerns in practice and in court

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Introduction to the Field of Psychological Injury

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Field of Psychological Injury and Law �  Intersection of:

�  forensic psychology �  law (e.g., evidence, tort, insurance) �  assessment/ testing, including of malingering �  disability and return to work �  trauma psychology �  chronic pain �  neuropsychology �  rehabilitation �  harassment/ discrimination

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What is “Psychological Injury”? � Psychological or psychiatric condition associated with an event that leads, or may lead, to a lawsuit in tort action or other legal-‐related claims. �  For example: �  Tort, e.g., after a motor vehicle collision, and

�  Worker Compensation, �  Veteran’s Administration (VA), and �  Social Security Administration (SSA)

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What is “Psychological Injury”? (contd.) � PTSD, mTBI, and persistent postconcussive symptoms (PPCS, aftereffects of a concussion) and chronic pain may be involved in psychological injury cases.

� Note that these are not necessarily DSM disorders � Disorders that involve mood or emotions, such as depression, anxiety, fear or phobia, and adjustment disorder are also typically manifested.

� These conditions/ disorders may occur separately or in combination (co-‐morbidity).

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Claimable injuries

� They might result from events at issue only, such as a motor vehicular collision or other negligent action.

� They might be exacerbations of pre-‐existing conditions or vulnerabilities, and the event at issue is not a sole cause but a material one in the multifactorial causal nexus

�  Functionally, they might cause impairments, limitations, and disabilities

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Legal defini<on � Considered a:

� mental harm, �  suffering, �  damage, �  impairment, or �  dysfunction

�  It is caused to a person as a direct result of some action or failure to act by some individual, perhaps as an exacerbation of a pre-‐existing condition

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Admissibility in court � Daubert v. Merrell Dow Pharmaceuticals, Inc. (1993)

�  Supreme Court case in the United States of America that provided basis for admissibility of scientific evidence in court.

� The Daubert criteria establish the parameters of goof compared to poor or junk science, e.g., not just general acceptance but also peer review, falsifiability, etc.

� Other cases/ rulings have been made and they constitute the “Daubert trilogy”

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Admissibility in court (contd.) � General Electric Co. v. Joiner (1997) and Kumho Tire Co. v. Carmichael (1999) are the two other cases comprised of the “Daubert trilogy”

� R. v. Mohan (1994) �  Canadian case with similar outcome

� However, some states still abide by the Frye standard og general acceptance for scientific admissibility in court (Frye v. United States, 293 F. 1013, 34 ALR 145 (D. C. Cir 1923).

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Malingering Definitions and Base Rates

Defini<on of Malingering � Psychiatrists and the DSM-‐5:

�  […] “intentional production of false or grossly exaggerated physical or psychological symptoms” that derives from “motivation by external incentives” (in the DSM-‐IV-‐TR, DSM-‐5).

�  For example: obtaining financial compensation � APA (American Psychological Association) Dictionary: �  Exaggeration is not referenced in the definition of malingering.

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Defini<on of Malingering (contd.) �  In the APA’s dictionary of psychological terms:

� Malingering is the deliberate feigning of an illness or disability that is motivated to achieve a particular specific external factor or outcome

�  For example: faking illness in order to obtain financial gain

� Black’s law dictionary contains a similar definition: �  It includes feigning for external incentives, but there is no reference to an exaggeration component.

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DSM-‐IV-‐TR & DSM-‐5 � Malingering is further e;laborated; it may involve a combination of four factors: �  (a) the referral context is medicolegal; �  (b) the objective findings are “markedly” discrepant with the evaluee’s claimed “stress or disability;”

�  (c) the evaluee exhibits a lack of cooperation with the assessment procedure or with suggested treatments; and

�  (d) he or she is diagnosed with antisocial personality disorder.

�  If there is any combination of these factors, malingering should be strongly suspected.

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Base Rate Inconsistency in DSM � Mittenberg et al. (2002) undertook an often-‐cited study of the base rate of malingering. It involved a survey of professionals in the field.

�  Several inconsistencies were discovered in my reading: �  The definitions of malingering and exaggeration were not provided to the respondents in the study

�  Exaggeration was not specified for severity � Malingering was conflated with exaggeration in the percentages offered

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Consistencies -‐ Boone �  Boone (2011a) examined the psychological testing needed to infer an attribution of malingering.

�  Her references cited that failure on two or more tests of effort can best discriminate between credible and non-‐credible populations (e.g., Victor, Boone, Serpa, Buehler, & Ziegler, 2009).

�  The more there are “failed indicators,” the more confidence one can have in conclusions.

�  Numerous failed tests can be used as irrefutable evidence in court.

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Boone (contd.) �  She referred to “differential diagnosis” in ruling malingering in or out.

�  I noted that according to the DSM-‐IV-‐TR, malingering is not a diagnosis, but rather a class of behaviours given a “V-‐code”.

�  Further, the use of qualitative and idiographic data gathered from interviews of evaluees does not mean that “art” rather than science is being used when conducting forensic mental health assessments.

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Boone (contd.) �  In the practice of differential diagnosis of malingering (Heilbrun et al., 2009, on FMHA): �  (a) all the relevant data are gathered in a comprehensive manner, including from testing and interviews;

�  (b) all possible hypotheses are considered for the conclusions; and

�  (c) the final conclusions reached are supported by both the evidence gathered and the state-‐of-‐the-‐art science in the literature that is applicable to the case at hand.

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Consistencies – Rogers and Granacher (2011) � They reviewed the conceptualization and assessment of malingering.

� And specified that gross exaggeration in the DSM-‐IV-‐TR’s definition of malingering is unlikely to involve “minor or isolated amplifications of symptoms.”

� This is consistent with the present view that the DSM approach to defining malingering as involving only gross exaggerations and not also minor ones is valid.

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Consistencies – Sollman & Berry (2011)

� The evidence of base rates for “suboptimal effort” (generic term instead of malingering) in clinical practice is equal to or greater than 40% in some settings.

� They believed that mild exaggeration may also be referred to in regards to suboptimal effort.

� By including all types of suboptimal effort and reasons for them, the base rate may be more than 40%

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Consistencies -‐ Others � Merckelbach, Jelicic, and Pieters (2011)

�  In a study with undergraduates students, conscious feigning may eventually lead to symptom conviction and actual somatoform disorders.

� Merckelbach and Merten (2012) elaborated that: �  Conscious other-‐deception could turn into unconscious self-‐deception

� That being said, Medically Unexplained Symptoms (MUS) might develop via anxiety or over-‐focus on the symptoms.

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Consistencies -‐ Others (contd)

�  Larrabee, Millis, and Meyers (2009) �  The standard base rate of malingering in the field should be acknowledged as 40% plus/ minus 10.

�  Larrabee (2007) & Mittenberg et al. (2002) �  Persistent neuropsychological deficit in cases of mTBI, may increase the malingering rate to as high as 88%.

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Consistencies – Others (contd.) � However, I note that it is premature to presume malingering if: �  (a) if the basic definition of malingering is unclear, �  (b) if intent is hard to assess, �  (c) if the assessment instruments themselves have disparate even if relevant findings, etc.

� Thus, when results are not definitive, assessors should use terms other than malingering for doubt about an evaluee’s symptom presentation/ performance. �  For example: lack of credibility or feigning

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Malingering Maximized � Greve, Ord, Bianchini, and Curtis (2009) conducted a review of over 500 consecutive referrals to a private practice. � Of the 508 patients, up to 36% were classified as probable or definite malingerers, with 10.4% as definite malingerers (using the MPRD).

�  The authors concluded that the prevalence of malingering to be between 20% and 50%, depending on the type of analysis undertaken.

� However, I noted that authors’ estimated is actually more toward 10% according to their own data.

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Greve et al. (2009) � They added that nearly half of their participants showed evidence of “symptom magnification”. �  This concept is broader than malingering and includes symptom exaggeration

�  1/3 of the sample met the criteria for “possible” MPRD (Malingered Pain-‐Related Disability)

�  2/3 of the sample showed “some form of exaggeration” � However, I note: not all exaggeration reflects malingering

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Wygant et al. (2011) � They looked at 251 individual compensation-‐seeking cases

� They applied both the MND (Malingering of Neurocognitive Dysfunction) and MPRD diagnostic systems to classify individuals as: �  incentives only, �  possible malingering, �  probable malingering, and �  definite malingering

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Wygant et al. (2011) -‐ Results �  I calculated in their data that 30.7% were classified in the probable/ definite malingering group �  Consistent with prior estimates that malingering-‐related classifications should be in the 30-‐50% range.

� Definite malingering was found at only 8% in this study, �  Consistent with other research that the figure for outright malingering should be about 10%.

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Lee at al. (2012) – Gender differences �  They investigated gender differences on the FBS in claimants who had undergone non-‐neurological medico-‐legal disability assessments.

�  They used the Slick et al. MND criteria and SVT results (WMT, TOMM, CARB, etc.) �  For definite malingering, they needed a score below chance on an

SVT and, for probable malingering, it involved a below cut score on one or more SVTs.

�  Of 1,209 patients, �  Over 30% met the criteria for non-‐credible responders (definite,

probable), �  But, only 1.5% (19) met the criteria for definite malingering.

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Conclusions by Rogers and Bender (2012) �  Rogers and Bender (2012) suggested that the previous research on malingering base rates may be accurate, but the publications have conceptual and methodological limitations.

�  They also described that there are multiple explanations for incomplete/ suboptimal effort in testing other than the reason of malingering. �  Such as, pain, depression, stress, and expectation of failure on the

part of the evaluee and reaction to evaluator factors.

�  Elhai et al. (2012) indicated that other evaluee factors, such as being ill, poor sleep, and medication side effects, might also affect results.

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Detecting Malingering

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MND – Malingering of Neurocogni<ve Dysfunc<on

Definition: Volitional exaggeration or fabrication of cognitive dysfunction for the purpose of obtaining substantial material gain, or avoiding or escaping formal duty or responsibility.

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MND (Contd.) �  Substantial material gain includes money, goods, or services of nontrivial value (e.g., financial compensation of personal injury).

�  Formal duties are actions that people are legally obligated to perform (e.g., prison, military, or public service, or child support payments or other financial obligations).

�  Formal responsibilities are those that involve accountability or liability in legal proceedings (e.g., competency to stand trial).

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Definite MND �  Individual presents clear and compelling evidence of volitional (conscious) exaggeration or fabrication of cognitive dysfunction and the absence of plausible alternative explanations.

�  There is specific diagnostic criteria to be met: 1.  Presence of a substantial external incentive [Criterion A] 2.  Definite negative response bias [Criterion B1] 3.  Behaviors meeting necessary criteria from group B are not

fully accounted for by Psychiatric, Neurological, or Developmental Factors [Criterion D]

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MND criteria – Rogers vs Boone �  Rogers et al. (2011a) described and critically analyzed the Slick et al. (1999) diagnostic criteria for MND �  They believed that the different levels in certainty of response bias/ malingering (possible, probable, and definite) lead to the over-‐classification of malingering.

�  Rogers et al. (2011) conducted a literature review of MND and found: �  The base rate for malingering over the studies was only 5.3% on average.

�  The rate for probable malingering was 21.2% and, further, it was as high as 50% in one study.

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MND criteria – Rogers vs Boone (Contd.) � Boone (2011) argued that Rogers et al. (2011) exaggerated the failings of the MND model.

�  She also believed that the model is accurate in identifying feigners/malingerers.

� However, she argued that there should be revision to the B2 MND criterion to require failure on three or more SVTs (“>2 SVTs”).

�  She also recommended to stop the use of malingered ND as a description of evaluees and rather use a term such as “noncredible neurocognitive dysfunction.”

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MND criteria – Rogers vs Boone Conclusion

� Rogers et al. (2011b) noted that there is more agreement than disagreement between Rogers et al. (2011a) and Boone (2011) about the MND model.

� Overall, recommendations from both parties would go very far in improving the MND definition and criteria.

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Young (2008) � Young (2008) recommended that the prevalence of wider noncredible neurocognitive dysfunction, such as regarding chronic pain and PTSD in tort claims for personal injury and in litigation, should be considered more broadly.

� He argued that the prevalence rate of wider noncredible neurocognitive dysfunction and related dissimulation could potentially be even higher than 50% by having a broader outlook than the narrow construct of malingering.

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Response Bias � McGrath et al. (2010) reviewed response bias as a source of error variance in clinical assessments.

� They reviewed response bias indicators as suppressors or moderators of the validity of various substantive psychological indicators.

� Only 12 out of 44 sets of data examined supported the effectiveness of response bias measurement.

� However, Rohling et al (2011) provided multiple reasons and referred to data why response bias measurement in forensic disability cases is pertinent.

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Wiggins et al. (2012) � Wiggins et al.’s (2012) study supported the validity, value, and need to verify response bias in forensic disability and related assessments via the use of MMPI-‐2-‐RF validity scales.

� They found a 25% base rate level for significant negative response bias. This 25 % level found includes malingering, per se, as only one possibility.

� Overall, the research is accumulating that the position of McGrath et al., despite its contrary nature on the matter, does not diminish the relevance of psychometric testing in malingering determination.

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Detec<on instruments � There are three classes of instruments that permit testers to identify malingering, feigning, and related response biases: �  personality tests, �  stand-‐alone tests (forced-‐choice tests, structured interviews, and others), and

�  embedded neuropsychological tests

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Personality tests – MMPI �  FBS -‐ Symptom Validity Scale (formerly referred to as the Fake Bad Scale)

� Nelson et al. (2010) conducted a meta-‐analysis on the FBS via 32 studies.

� They found a large omnibus effect size. There were large effect sizes when: �  Participant effort was known to be insufficient �  Assessments took place for traumatic brain injury (TBI)

� Thus, there is strong support for the use of the FBS in forensic neuropsychology practice.

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Reseach on the MMPI-‐2-‐RF � Detection of feigned psychiatric disorders (Marion et al., 2011).

� Discriminate a malinger group from controls (Wygant et al., 2011).

� Used in research with cognitive impairments or disorders related to epilepsy (Locke et al., 2010; Rogers et al., 2011).

� Differentiate valid and invalid somatic and pain complaints (Burchett & Ben-‐Porath, 2010, 2011; etc.)

� Used in a study of Attention Deficit Hyperactivity Disorder (ADHD) (Harp et al., 2011).

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Personality tests – PAI � There is less substantive research for the PAI than there is for the MMPI for psychological injury, however it still has utility with: �  Pain-‐related samples �  PTSD samples

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Personality test – MMCI-‐III � MMCI-‐III -‐ Millon Clinical Multiaxial Inventory, Third Edition

� There are opposing opinions on its use in the field of psychological injury: �  Kane and Dvoskin (2011) recommended against its usage in the psychiatric/ psychological injury context.

� Whereas, Aguerrevere, Greve, Bianchini, and Ord (2011) demonstrated that it may be useful in identifying intentional symptom exaggeration in TBI claimants

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Stand-‐Alone Test – SIRS & SIRS-‐2 �  SIRS -‐ Structured Interview of Reported Symptoms �  Rogers et al., (2009) indicated that SIRS may have some utility in the psychiatric/psychological injury population.

�  SIRS-‐2 has received some mix reviews and requires further research and validation to identify its usefulness.

�  In response to some negative reviews, Rogers & Bender (2012) indicated that it has the ability to differentiate feigned and genuine responding, with effect sizes being large to very large.

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Stand-‐Alone Test – TOMM � TOMM – Test of Memory Malingering

� There has been a surge of research on the validity of this test.

� Brooks et al. (2011) found the first TOMM trial to be a valid indicator.

�  [Note. The research on the TOMM is flourishing]

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Green and SVTs � Green developed several SVTs (Symptom Validity Tests) �  the WMT; �  the MSVT, Medical Symptom Validity Test; Green 2004b;

�  the NV-‐MSVT, Nonverbal Medical Symptom Validity Test; Green, 2008

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Briere and PTSD � Briere developed tests that contain scales to evaluate respondent validity when assessing PTSD. � DAPS, Detailed Assessment of Posttraumatic Stress; the TSI-‐2, Trauma Symptom Inventory, Second Edition; Briere, 2011

� Gray et al. (2010) demonstrated that the Atypical Response Scale of the TSI-‐2 helped discriminate simulated from genuine PTSD

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Embedded Neuropsychological tests

� There are many embedded neuropsychological indices within commonly used assessments, which help determine examinee credibility. � Digit Span from WAIS-‐R and WAIS-‐III �  Reliable Digit Span (RDS), Logical Memory Recognition (LMR) and Discriminant Function (DF) from WMS-‐R and WMS-‐III

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Embedded Neuropsychological tests (Contd.)

� There are also individual indices that can be embedded into the used batteries. � WCST – Wisconsin Card Sorting Test �  AVLT RMT – Rey Auditory Verbal Learning Test Recognition Memory Test

�  CVLT – California Verbal Learning Test �  FTT – Finger Tapping Test �  RCFT – Rey Complex Figure Test

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Boone (2013) on Malingering �  1) Boone (2013) gave little importance to the Malingered Neurocognitive Dysfunction (MND) approach of Slick et al. (1999) for the detection of malingering in the forensic neuropsychological examination. [In contrast to Boone (2011).]

�  2) She supported the use of the MMPI-‐2-‐RF to help in malingering and related negative response bias detection.

�  3) She de-‐emphasized the specific calculation procedures promoted by Larrabee (2008) in combining SVTs to determine the probability of feigning.

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Symptom Validity Tests (SVTs) � Boone (2013) explained

�  1) How do they work? �  2) How are they validated? �  3) Test selection �  4) Discounting failed and passed SVTs

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1) How do SVTs work? �  SVTs can be in a “forced-‐choice” format, where an evaluee must choose between two possible answers.

�  They have a 50% chance of selecting the correct answer. �  Scores significantly below chance indicate noncredible performance.

�  About 15% of real-‐world noncredible evaluees will score in this “significantly below” range.

�  Two or more failures can provide a more accurate result. �  On these tests, noncredible evaluees will score below the probability level at p = .05, which translates to a score of <19/ 50 on the TOMM.

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2) How are SVTs validated? �  In order for a test to be effective, it needs to be highly sensitive and specific.

�  Sensitivity and specificity are in reciprocal balance (as one gets higher, the other gets lower).

� Generally, specificity is set at ≥ 90%.

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3) Test Selec<on �  For sensitivity, values of < 40 % are considered low, whereas those at 40 – 69% are moderate, and those at or above 70% are high.

�  SVTs should be chosen to allow for repeated testing of response bias throughout the evaluation (Boone, 2009).

� To avoid redundancy, SVTs could be minimally or moderately correlated with each other, but not strongly.

�  Some tests are easier to coach or are more readily available on the internet for self-‐coaching

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4) Discoun<ng Failed and Passed SVTs � According to Boone (2013), there are various factors that could account for failed SVTs, such as: �  Lower intelligence or dementia, as opposed to feigning. �  Cultural factors may also be of influence

� However, depression and pain should not affect the results.

�  In some cases, Boone believed that passed SVTs should be discounted.

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One issue with Boone (2013) �  She indicated that validity indicator failure, such as on an F scale, should not be considered a cry for help, but rather be considered an act of feigning/exaggeration.

�  Iverson’s (2006) ethical stance about how to interpret failed SVTs does not necessarily exclude explaining them as a cry for help.

� Therefore, these scores could also be a sign of catastrophizing or of valid desperation (cry for help).

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Proposed Criteria for Diagnosis of Malingered Pain-‐related Disability � There are 5 proposed criteria to assist in an effective diagnosis of malingered pain-‐related disability: �  Criteria A: Evidence of significant external incentive.

�  i.e., personal injury settlement or disability pension

�  Criteria B: Evidence from physical evaluation. �  Physical evaluations are consistent with exaggeration or feigning of physical disability.

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Proposed Criteria for MPRD (Contd.)

�  Criteria C: Evidence from cognitive/perceptual (neuropsychological) testing. �  Patient’s cognitive capacities are consistent with exaggeration or feigning of cognitive disability.

�  Criteria D: Evidence from self-‐report. �  Reported symptoms, complaints, or limitations are consistent with exaggeration or feigning of physical, cognitive and emotional disability.

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Proposed Criteria for MPRD (Contd.)

�  Criteria E: Behavior meeting necessary criteria from groups B, C, and D are not fully accounted for by psychiatric, neurologic, or developmental factors. �  Likely volitional act aimed at achieving some secondary gain �  The presence of a documented pathology, illness, or injury (including psychiatric illness) does not automatically exclude the possibility of a MPRD diagnosis.

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Malingered PTSD Detection System

Covered In This Chapter �  Presents a diagnostic model to detect malingered PTSD in forensic disability and related evaluations.

�  There is no adequate malingered PTSD detection system, thus Young (2014) based his recommendation on: �  The Slick et al. MND criteria and recommendations by Rogers et al (2011a,b) and Boone (2011).

�  The MPRD criteria system created by Bianchini et al. (2005). �  Suggestions made by Rubenzer (2009) to detect malingered PTSD (he used a point system).

�  Revisions of already-‐developed models for neurocognitive and pain domains (MND and MPRD).

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Model for Response Styles/Biases �  Young (2014) also offers a survey in the form a questionnaire to help determine the prevalence/base rates for these response styles and biases (Figure 5.2).

�  There is a 7-‐point range of potential response styles and biases derived from Slick et al. (1999) MND testing approach. �  (a) definite malingering; �  (b) definite response bias, to �  (c) probable, �  (d) probable/ possible (gray zone), �  (e) possible, and then �  (f) minimal negative response bias; and �  (g) absent bias.

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Comparison to Slick et al. (1999) MND model �  Slick et al. (1999) terms

�  (a) overt malingering, �  (b) noncredible gross

exaggeration/ inconsistency, �  (c) noncredible moderate

exaggeration/ inconsistency, �  (d) indeterminate gray zone, �  (e) credible but possible moderate

exaggeration/ inconsistency, �  (f) credible but mild exaggeration/

inconsistency, and �  (g) no exaggeration/

inconsistency.

�  Young (?) terms �  (a) definite malingering; �  (b) definite, �  (c) probable, �  (d) probable/ possible (gray

zone), �  (e) possible, �  (f) minimal negative response

bias; and �  (g) absent bias.

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Figure 5.2a Self-‐Unfavorable Presenta<ons/ Performances (Psychological, Psychiatric) in Evaluees According to Response Biases (R/B) in Tes<ng and/ or Inconsistencies/ Discrepancies (I/D).

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Figure 5.2b Self-‐Unfavorable Presenta<ons/ Performances (Psychological, Psychiatric) in Evaluees According to Response Biases (R/B) in Tes<ng and/ or Inconsistencies/ Discrepancies (I/D).

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Figure 5.2 Explained � Presents an integrated model related to malingering and other response styles/ biases and motivations.

�  It also suggests an approximate normal distribution that these styles, biases and motivations should take.

� The terms used in this figure acknowledge that there are many cases in these assessments that can fall into an indeterminate or gray zone.

� The most difficult cases to assess are those that fall into these “gray zones”.

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The “Gray Zone” �  The gray zone may vary in size and direction depending the assessor.

�  Variance may depend on the plaintiff or the source of referral.

�  The margin of the gray zone may become better defined by: �  Conducting thorough research of both models. �  Apply the models with equal rigor across all sources of referral.

�  Therefore, there needs to be a comprehensive, impartial, scientifically-‐informed approach to studying these models.

�  This zone corresponds to the real world of evaluees and evaluators –> ecological and face validity.

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Inconsistencies/Discrepancies in the MND and MPRD Systems (Contd.) �  It appears that multiple types of inconsistencies/ discrepancies used by Slick et al. and Bianchini et al., overlap in the two systems. They are related to: �  (a) standard test data; �  (b) self-‐report; �  (c) observations; �  (d) known patterns of brain functioning; �  (e) known patterns of physiological functioning; �  (f) collateral information; and �  (g) documented information. 156

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Inconsistencies/Discrepancies in the MND and MPRD Systems (Contd.) �  Information in these inconsistency/ discrepancy categories could be about pre-‐event, event, or post-‐event factors. It might refer to either pre-‐event history, such as prior police or criminal record, or event/ post-‐event symptoms, impairments, dysfunctions, and disabilities, if any.

� The inconsistencies/ discrepancies could be compelling/ marked/ substantial or otherwise, but no clear guidelines are offered to help distinguish the compelling type.

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Inconsistencies/Discrepancies in the MND and MPRD Systems (Contd.) � Test data for the systems derive from measures of exaggeration, fabrication, and suspected malingering, such as in SVTs (symptom validity tests), but also tests like the MMPIs, which include clinical scales, as well.

� Better ways of combining the different types of tests data in detecting malingering need to be created.

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Young (2014) Detec<on Model � Proposed are more types and more combinations of inconsistencies/ discrepancies, as well as permitting their notation within categories.

� Better definition and clarification of terminology. � Adopted a three-‐level system:

�  First tier of compelling inconsistencies into less and more extreme versions

�  The third tier relates to moderate and nontrivial inconsistencies/ discrepancies.

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Feigned Posirauma<c Stress Disorder Disability/ Dysfunc<on system (F-‐PTSDR-‐D) � The model proposed for evaluating whether there is non-‐credible, feigned, or malingered PTSD-‐related presentation or performance response bias is called the Feigned Posttraumatic Stress Disorder Disability/ Dysfunction system (F-‐PTSDR-‐D).

�  7 principles were used in its construction.

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The 7 Principles behind the F-‐PTSDR-‐D �  Principle 1:

�  The range of malingering and related biases is expanded by placing them on a continuum of seven categories – �  (a) definite malingering; �  (b) definite, �  (c) probable, �  (d) probable/ possible (gray zone), �  (e) possible, �  (f) minimal negative response bias; and �  (g) absent bias.

�  In between the probable and possible negative bias points, there is so-‐called gray zone.

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The 7 Principles behind the F-‐PTSDR-‐D (Contd.) �  Principle 2:

The F-‐PTSDR-‐D system has more extensive clarification on: � How to test results related to failing/ missing critical thresholds � Inconsistencies/ discrepancies in evaluee presentation and performance that will be use to determine whether there is a presence of malingering and related biases.

� The model was created similar for PTSD, pain and TBI, but PTSD-‐specific examples were included. � These examples concerned response to psychological and pharmacological interventions, in particular.

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The 7 Principles behind the F-‐PTSDR-‐D (Contd.) � Principle 3:

Within the one rating scheme of the F-‐PTSDR-‐D system, there are various types of psychological comprehensive and scaled measures. For example:

�  (i) personality inventories, such as the MMPI family ones; �  (ii) stand-‐alone validity/ effort tests, including forced-‐choice

ones that have two relevant criteria -‐-‐ at or below-‐chance accuracy level (e.g., in a two-‐alternative test) and a less rigorous pass-‐fail level (related to cut scores); and

�  (iii) embedded measures in cognitive/ neurological tests, such as those related to digit span.

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The present system provides a comprehensive list of 60 rules for weighing the tests/ measures/ scales/ indicators so that they are used effectively.

� Principle 5: There are elaborate cautions provided at the end of the system, which are meant to assure reliability and validity.

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The 7 Principles behind the F-‐PTSDR-‐D (Contd.) �  Principle 6:

Normally, 5-‐8 failed test results are needed for malingering and related attributions when there is nothing else in the assessment at hand. However, personality inventories, such as the MMPI-‐2-‐RF, can contribute up to four of the five validity indicator failures. Moreover, even clinical patterns on them can be used in system ratings.

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The 7 Principles behind the F-‐PTSDR-‐D (Contd.)

Aside from cases with extremely compelling evidence, such as frank admission or indisputable videographic evidence,

definite malingering can be attributed in cases in which (a)  two or more forced-‐choice measures are failed at the below-‐chance

level, or (b)  there are five or more test failures on other valid psychometric

measures, or (c)  there are three or more compelling inconsistencies, (d)  any combinations of these types of evidence are found, or (e)  other evidence replaces the weighting of these three types of evidence,

such as extreme scores on valid psychometric tests or an overall judgment of the file that adds weight.

When the latter obtains then, when numerical data can be gathered, three

test failures could be sufficient to attribute malingering, everything else being equal.

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The 7 Principles behind the F-‐PTSDR-‐D (Contd.)

As for assigning definite response bias, the criteria above apply, except that they involve one-‐forced choice test, not two, four other

tests, not five or more, and two compelling inconsistencies, not three or more, with none of the extreme nature involved.

In terms of probable response bias, the criteria exclude forced-‐choice

test failure, but consider three other test failures, not four, and one compelling inconsistency, not two.

To conclude, the reader will note that Larrabee (2012) emphasized

three if not two failures on relevant tests as very strong evidence of malingering., All things considered, the present system arrives at a protocol that might give a comparable weighting to such test failures.

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There is a three-‐level system of degree. The levels of inconsistencies/ discrepancies in the present system that are:

�  (a) most or extremely compelling, as per frank admission, videographic evidence, etc.;

�  (b) compelling with respect to other file material that is to the level of a marked/ substantial inconsistency/ discrepancy; and

�  (c) moderate/ nontrivial ones.

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10 Specific Changes to the MND/ MPRD Systems (1) Aside from below-‐chance performance on a forced-‐choice measure, definite negative response bias can be assigned based on performing below cut-‐off on five or more well-‐validated tests designed to measure psychiatric/ psychological exaggeration or fabrication.

(2) The sequence of definite, probable, and possible response bias involves failing four, three, and two such tests, respectively.

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10 Specific Changes to the MND/ MPRD Systems (Contd.) (3) The measures to detect feigning/ malingering and related biases might derive from any of personality inventories, stand-‐alone tests, and those aimed at detecting improbable symptoms and the like (e.g., SIRS-‐2).

(4) Other measures might be informative in this regard, such as PTSD-‐dedicated ones (DAPS, Detailed Assessment of Posttraumatic Stress; Briere, 2001) and embedded cognitive (neuropsychological) indices.

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10 Specific Changes to the MND/ MPRD Systems (Contd.) (5) Where warranted, and if properly validated for the question at hand, the most recent, valid tests should be used, such as the MMPI-‐2-‐RF, the SIRS-‐2, and the TSI-‐2 (Trauma Symptom Inventory, Second Edition; Briere, 2011).

[Note. As of 2014, the evidence supports use of the MMPI-‐2-‐RF in the present system but not yet the SIRS-‐2 or the TSI-‐2.]

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10 Specific Changes to the MND/ MPRD Systems (Contd.) (6) Inconsistencies/ discrepancies in self-‐report, reliable documents, collateral information, behavioral observations, etc., that are compelling, marked, and substantial, in particular, are adjunct sources of valid data in malingering determinations. When psychological testing is impossible, inconsistencies/ discrepancies can be used by themselves to determine malingering and other response bias. This would allow psychiatrists and other mental health workers to use the system, albeit with less data available.

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10 Specific Changes to the MND/ MPRD Systems (Contd.) (7) Causality needs to be considered, as well, as part of non-‐testing factors; for example, pre-‐existing and/ or extraneous, nonevent-‐related concurrent causal factors could fully explain an evaluee’s presentation and performance after an index event. (8) Provisos are added that the diagnostic system should be used prudently and conservatively because of the harm that could be caused by false attributions of malingering and related biases.

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10 Specific Changes to the MND/ MPRD Systems (Contd.) (9) The data set gathered should be comprehensive, scientifically-‐informed, and impartial, and interpretations should consider all the reliable data from a scientific reasoning basis.

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10 Specific Changes to the MND/ MPRD Systems (Contd.) (10) Motivation should not be imputed, for example, that malingering is present, without irrefutable or incontrovertible evidence. However, the astute assessor will know how to use language that denies the credibility of the patient, and even to significant degrees, when the data warrant this conclusion. In this regard, the system is meant to cover the full range of response biases, from mild exaggeration to clearly malingered, so that unlike the case for MND and MPRD, its title involves the word “feigned” instead of “malinger.”

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D)

Criterion A: Evidence of significant external incentive.

Criterion B: Evidence from psychological testing.

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A. Different Degrees of Certainty of Response Bias, According to Psychological Testing A1) Definite Malingering. The evidence is incontrovertible A2) Definite negative response bias e.g., Below chance performance (p<.05) on one forced choice measure A3) Probable negative response bias.

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A. Different Degrees of Certainty of Response Bias, According to Psychological Testing A3-‐4) Intermediate (Probable to possible, gray zone) negative response bias A4) Possible negative response bias. A5) Minimal negative response bias. A6) No evident response bias.

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) Weighting Rules for Test Batteries 60 rules are quite explicit: Rule 1: Two pathways; Rule 2: Forced-‐choice; Rule 3: Tests; Rule 4: MMPI family; Rule 5: Other tests needed; Rule 6: Improbable symptoms, etc.; Rule 7: PTSD; Rule 8: Pain; Rule 9: Cognitive (embedded); Rule 10: 10-‐15 Primary; Rule 11: 5-‐8 Critical; Rule 12: Not at cut-‐off; Rule 13: Neuropsychology; Rule 14: Supplementary tests; Rule 15: Secondary information; Rule 16: Pattern analysis; Rule 17: Limited cognitive testing; Rule 18: Neuropsychological path; Rule 19: Test independence; Rule 20: Prioritizing; Rule 21: Exception 1; Rule 22: Exception 2; Rule 23: Exception 3; Rule 24: Exception 4; Rule 25: Maximum use 1; Rule 26: Omnibus tests; Rule 27: Dedicated tests; Rule 28: Nondedicated tests; Rule 29: Maximum use 2; Rule 30: Adjusted rating, lowering it; Rule 31: Adjusted rating, raising it; Rule 32: Patterns; Rule 33: Preselection; Rule 34: Fishing expeditions; Rule 35: No exceptions; Rule 36: Ecological validity; Rule 37: Warnings; Rule 38: Qualifications; Rule 39: State-‐of-‐the-‐art; Rule 40: No harm; Rule 41: Cognitive/ Neuropsychological testing; Rule 42: Rating cognitive/ neuropsychological tests; Rule 43: Cognitive/ Neuropsychological and Regular rating; Rule 44: Positive results for only one of the two paths; Rule 45: Cognitive/ Neuropsychological path alone; Rule 46: Test selection; Rule 47: Minimal testing; Rule 48: Less than minimal testing; Rule 49: Less testing yet doing enough; Rule 50: Larrabee (2012); Rule 51: Justify less testing; Rule 52: Supplementary evaluators; Rule 53: Seconding team work; Rule 54: Leading team work; Rule 55: Interdisciplinary assessments; Rule 56: Specific dedicated tests; Rule 57: Altering rules on testing and test battery; Rule 58: Special populations; Rule 59: Consider whole file; Rule 60: Combining test data with inconsistencies/ discrepancies.

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) Criterion C: Evidence from Inconsistencies/ Discrepancies a) Inconsistencies/ Discrepancies in Conjunction with Testing

a1) Inconsistency/ Discrepancy between cognitive/ neurocognitive test data and known patterns of brain functioning. (Inconsistency #1)

a2) Inconsistency/ Discrepancy, either marked/ substantial or moderate/ nontrivial, between test data of PTSD-‐related symptoms after event at claim and known patterns of physiological reactivity. (Inconsistency #2)

a3) Inconsistency/ Discrepancy, either marked/ substantial or moderate/ nontrivial, between test data and self-‐report. (Inconsistency #3)

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) a4) Inconsistency/ Discrepancy, either marked/ substantial or moderate/ nontrivial, between test data of PTSD-‐related symptoms after event at claim and verbal and/ or nonverbal observed behavior/ symptoms/ complaints/ limitations/ functions. (Inconsistency #4) a5) Inconsistency/ Discrepancy, either marked/ substantial or moderate/ nontrivial, between test data and information reported by reliable informants/ collaterals. (Inconsistency #5) a6) Inconsistency/ Discrepancy, either marked/ substantial or moderate/ nontrivial, between test data of PTSD-‐related symptoms after event at claim and information reported in reliable documents. (Inconsistency #6)

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) b) Inconsistencies/ Discrepancies in Conjunction with Self-‐Report (other than with testing) Inconsistency/ Discrepancy between such self-‐report and any of the following:

b1) Known patterns of brain function. (Inconsistency #7) b2) Known patterns of physiological function. (Inconsistency #8) b3) Observed behavior/ symptoms/ complaints/ limitations/ functions. (Inconsistency #9) b4) Information reported by reliable informants/ collaterals, such as primary care physicians and spouses. (Inconsistency #10) b5) Information reported in reliable documents, such as by primary care physicians and other mental health professionals. (Inconsistency #11)

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) c) Inconsistencies/ Discrepancies in Conjunction with Observations (other than with testing and with self-‐report) Inconsistency/ Discrepancy between such observations and any of the following:

c1) Known patterns of brain function. (Inconsistency #12) c2) Known patterns of physiological function. (Inconsistency #13) c3) Information reported by reliable informants/ collaterals. (Inconsistency #14) c4) Information reported in reliable documents. (Inconsistency #15)

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) d) Inconsistencies/ Discrepancies in Conjunction with Collateral Information (other than with testing, self-‐report, and observations) Inconsistency/ Discrepancy between such information and any of the following:

d1) Known patterns of brain function. (Inconsistency #16) d2) Known patterns of physiological function. (Inconsistency #17) d3) Information reported in reliable documents. (Inconsistency #18)

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) e) Inconsistencies/ Discrepancies in Conjunction with Documentation (other than with testing, self-‐report, observations, and collateral information) Inconsistency/ Discrepancy between such documentation and any of the following:

e1) Known patterns of brain function. (Inconsistency #19)

e2) Known patterns of physiological function. (Inconsistency #20)

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) f) Inconsistencies/ Discrepancies Within Major Data Sources (not between them which are scored above)

f1) Known patterns of brain function (Inconsistency #21) f2) Known patterns of physiological function. (Inconsistency #22) f3) Self-‐report. (Inconsistency #23) f4) Observed behavior/ symptoms/ complaints/ limitations/ functions. (Inconsistency #24) f5) Information reported by reliable informants/ collaterals. (Inconsistency #25) f6) Information reported in reliable documents. (Inconsistency #26)

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g) Other, Miscellaneous Inconsistencies/ Discrepancies

g1) No causality attributable to the event at claim, despite the evaluee’s insistence. (Inconsistency #27) g2) Only minimal causality attributable. (Inconsistency #28) g3) Material-‐level causality but not to the degree insisted. (Inconsistency #29) g4) Other. (Inconsistency #30)

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) B. Different Degrees of Certainty of Response Bias, According to Inconsistencies/ Discrepancies

B1) Definite Malingering. B2) Definite negative response bias. B3) Probable negative response bias. B3-‐4) Intermediate (Probable to possible, gray zone) negative response bias.

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) This list can be used in Intermediate Negative Response Bias a) Personality disorder of a problematic nature. b) Blaming everyone and anything, overly suspicious. c) Not trying to mitigate loss. d) Unduly adopting the sick role. e) Somatization. f) Failure to treat substance abuse impeding progress. g) Failure to take recommended medications. h) Refusing a work-‐hardening trial, modified duties, retraining. i) Catastrophizing/ crying out for help. j) Any other confound that is documentable, such as attorney or similar coaching.

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) As well, five factors derived from the pre-‐event: k) Psychiatric/ self harm/ substance abuse history. l) Criminal/ legal/ problematic military history; history of deceit/ fraud. m) History of irregularity in/ dissatisfaction with work or other role at issue. n) History of irregularity in/ dissatisfaction with family, partners. o) History of financial stresses/ bankruptcies/ unsupported claims.

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Table 5.4 Outline of Proposed Criteria for Non-‐credible Feigned Posirauma<c Stress Disorder and Related Disability/ Dysfunc<on (F-‐PTSDR-‐D) B4) Possible negative response bias. B5) Minimal negative response bias. B6) No evident response bias.

Criterion D: Behaviors meeting necessary criteria from groups B and C are not fully accounted for by psychiatric, neurologic, developmental, or other factors. Abbreviations. PTSD = posttraumatic stress disorder. Adapted from Bianchini, Greve, & Glynn (2005), which in turn was adapted from Slick, Sherman, & Iverson (1999).

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Ambiguity of Malingering by Faust et al. (2012a, b)

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Faust et al. (2012a, b) Commentary �  In comparison to definitive or nearly definitive cases of malingering, there is not nearly enough research on the ambiguous cases.

� Most research centers around the extremes on the continuum: definite malingering and absent bias.

� Due to this lack of research, there is a lack of representativeness and generalization.

�  Faust et al. (2012a) believe that there should be focus on results stemming from both clinical practice and research using known-‐groups.

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Faust et al. (2012a, b) Commentary � They believed that malingering is a hypothetical construct that is inferred from data rather than being directly observed.

� The field needs clear definitions.

� Nevertheless, in identifying malingering, practitioners should not overvalue operational definitions or the provided diagnostic criteria due to the lack of scientific research available. �  This is especially true in the legal setting.

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Diagnos<c Con<nuum �  Faust et al. (2012a) believed that an evaluator may find themselves on a continuum of completely accurate to completely inaccurate in their malingering assessments due to many factors. Such as: �  Inaccurate data due to measurement error �  Evaluee’s lack of sleep the night prior to the assessment

� Overall, the evaluator might be wrong to prematurely conclude whether there was a case of malingering or its absence.

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How to improve assessment? �  Faust et al. (2012a) believe that there needs to be better understanding of test results of malingering, effort, clinical and forensic neuropsychological functioning and their interrelationships.

�  All sources of inaccuracy, misrepresentation, and their intentional or non-‐intentional bases must be considered when evaluating forensic and clinical cases involving potential malingering.

�  Overall, inaccuracies can stem from both evaluators and evaluees. Therefore, I add that there is a need for comprehensive, impartial, and scientifically-‐informed assessments.

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Evaluator and Evaluee Errors �  Faust et al. separated evaluator and evaluee factors that could influence a diagnosis.

� Evaluators: Most sources of error are avoidable due to the underutilization of the available scientific knowledge. �  i.e. Testing an evaluee excessively – lowering their effort and motivation to complete the task. �  Could lead to a malingering diagnosis

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Four Biasing Evaluator Factors � Faust et al. (2012a) described 4 biasing evaluator factors in undertaking assessments and arriving at conclusions, such as:

�  1) Confirmatory bias �  Tendency for an evaluator to maintain a belief despite “convincing” counter-‐evidence.

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Four Biasing Evaluator Factors (Contd.)

�  2) Premature closure �  Arriving at first conclusions too rapidly and evaluator self-‐fulfilling prophecies.

�  There may be a biased selection of instruments leading to greater/lesser false-‐positive or false-‐negative errors.

�  Evaluator behaviour may influence how the evaluee behaves in order to confirm their hypothesis.

�  There needs to be systematic use of the available resources and procedures in order to decrease potential evaluator bias.

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�  3) Illusory correlation

�  For example, an evaluator might believe that an evaluee is nervous because he or she is malingering, even though it may be an ordinary reaction to an assessment that holds a lot at stake.

�  Evaluators may apply potential malingering indicators prior to using well-‐validated indicators of methods in detection of deception.

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� 4) Overconfidence �  Potential for dangerous “pernicious” assessments.

�  Some evaluators may use “an arbitrary or inconsistent” procedure for malingering determination: �  The more malingering measures used, the greater the possibility that errors across the tests will be compounded.

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Poten<al Assessment Errors � Another assessment error in this regard is to give more tests than is appropriate and then counterbalance that decision by setting “high cut-‐offs” for each of the tests.

� The tests have not been studied in combination, so by combining tests in an assessment, the evaluator is not working with a “known accuracy rate.”

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Integra<ng All Data �  Some evaluators may believe that the best way to assess clients would be to integrate all available data in order to arrive at their conclusion.

�  Faust et al. (2012a) argued that this method is inefficient and may lead to include weak predictors, consider validity as cumulative, and not consider validity as incremental. �  This may in fact cause more harm than good.

�  Thus, they suggest that evaluators only include the available information that increases accuracy and should exclude any information that does not.

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The Work of Richard Rogers

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Rarity of Malingering � Rogers dealt with misconceptions and fallacies in the field, such as: � Malingering is rare à false

�  Tables 11.8 states it is rare and 11.7 states it is very rare

� He stated that “possible malingering” could be over 50%.

� The base rate could however be as low as 10%

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Fallacies and Misconcep<ons � Rogers and Bender (2012) identified other new misconceptions: � Malingering is common �  Exact diagnostic capacity of cut scores �  Exact diagnostic capacity of the DSM-‐IV-‐TR

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Assessing Psychological Injuries and Malingering: Disability and Report Writing

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Defini<ons �  Impairment:

�  Important deviation, loss, or loss of use of a psychological/ psychiatric function.

�  Disability: �  The functional consequences of the impairment.

�  For example, in term of activity limitations, participation restrictions, or both.

�  Handicap: �  More of a social rather than legal term.

�  For example, how one perceives oneself or how society perceives the person with impairment/disability.

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Impairment and Disability � Peterson and Paul (2009) said that in order to understand impairment and disability, one has to consider the interaction of the relevant symptoms and functional effects in terms of the context and environment.

� They must be compared to generally accepted norms and the general population.

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Figure 14.4 The Six-‐Step Process of a Disability Evalua<on

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Figure 14.4 Cap<on A model of the steps in disability evaluation that includes standards, functions, causes and impairments. Adapted from Piechowski (2011)

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Figure 14.4 Explana<on �  Piechowski offered an approach to evaluate disability

�  She said the evaluator must consider: �  Occupational standard involved, �  The components of the relevant job duty, �  The relationship of the residual functional abilities with the work demands, etc.

�  In the workers compensation context, relating functional impairments to work demands is critical in disability evaluations.

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Table 14.7 Factors Contribu<ng to Difficul<es in Evalua<ons: Assessment

Type

Examples

General

Impartial

Comprehensive

Scientific

Interview Not get all data needed

Ignore certain data

Mental status Cognitive

Behavioral

Emotional

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Assessment Context

Work/ school/ role

Social/ family

Other (i.e., finances)

Records/ collaterals All requested records/ documents

All collaterals (personal, work, role, professional) consulted

Only reliable ones used

Tests/ measures Chosen to fit question at hand

Multitrait, multimethod

Psychometrically sound

With appropriate norms, cut-‐offs, etc., for question

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Assessment Symptom Validity

Tests (SVTs)

Stand-‐alone

Two-‐alternative forced choice

Embedded in personality inventories

Embedded in neurocognitive batteries

Structured interview ones

Inconsistencies/

discrepancies

(within, across)

each of the

following:

Interview

Observations

Tests

Reliable records/ documents

Reliable collateral information

Known effects/ expected symptoms

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Assessment Event at claim

Fact vs. perception

Dose-‐response relationship, absence

Provider Advocate?

Dismissive?

Evaluator Biases at play?

Adversarial divide at play?

Blaming victim/ extreme entitlement in victim?

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Assessment Evaluation

inconsistencies

Magnify/ minimize pre-‐event status

Magnify/ minimize event and immediate reaction

Magnify/ minimize post-‐event symptoms and functions

Evaluee (verbal) Reliable historian/ respondent?

Inconsistent/ discrepant/ vague?

Evasive/ uncooperative/ resisting/ refusing?

Past treatments Therapies followed?

Medications taken?

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Assessment Evaluee (other)

Overdramatization?

Catastrophizing?

Crying for help?

Response bias Feigning, fabrication

Gross exaggeration

Exaggeration

Other

Malingering Full

Partial

Mixed

Ambiguous/ gray zone

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Assessment Intent in deception Deliberate/ conscious, unconscious?

For secondary gain?

Idiographic/

nomothetic

Consider evaluee as individual and according to normative research

Individual differences

Cultural, minority differences

Sex differences

Research Absence of relevant research?

Relevant research analyzed?

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Assessment Scientific process Methods scientifically informed?

Scientific reasoning in conclusions? Interpretation

Consider all symptoms/ functions/ roles in arriving at disorders/ diagnoses/ disabilities/

dysfunctions/ impairments

If there are any implicated roles/ disorders/ diagnoses/ disabilities/ dysfunctions/ impairments,

do all data support them?

Present all evidence for the favored conclusion, for and against, and all the evidence for other

conclusions rejected, for and against

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Assessment Differential

diagnosis

Genuine conditions

Related conditions to malingering (i.e., factitious disorder)

Diagnosis DSM difficulties

Polytrama/ comorbidities

Subsyndromal/ partial/ features

In remission

Disabilities Job/ role duties

Residual abilities, impairments

Transferable skills, retrainable?

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Assessment Prognosis

Probable course?

Permanent?

Treatable?

Causal factors Pre-‐event related

Event-‐related

Post-‐event related

Extraneous/ unrelated/ auxiliary

Blaming event at issue for everything

Whitewashing past problems

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Assessment

Insurance process Litigation

Iatrogenesis

Causation Event at claim material contributor?

Thin/ crumbing skill considered? (i.e., pre-‐existing responsible in full, in part)

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Assessment Abbreviation. DSM = Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000).

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Beginning an Assessment �  Psychological assessments must be:

�  impartial, �  comprehensive, and �  scientifically-‐informed

�  Evaluator must aim to get as much data as possible and not ignore any.

�  It is important to start by interviewing the evaluee to see if they have a good mental status for psychological testing.

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Assessment � The interview should take a holistic approach and examine the whole person in their context.

� Not only should classic tests like the MMPI-‐2 be used, but symptom validity tests (SVTs) as well.

� Clinicians must not only look for malingering characteristics throughout the interviews and tests, but must also search for inconsistencies in all sources and documents available.

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Assessment (Contd.) � Clinicians must verify whether there is a dose-‐response relationship between the injuries sustained and the psychological effects reported.

� Clinicians must also verify the reliability of past treatment providers and verify their own biases.

� They must critically analyze evaluee responses and compare them to the factual data and information.

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�  It is possible that poor test performance and effort can be due to other factors than simply malingering.

� Other factors may be: �  being overwhelmed, �  catastrophizing, and �  crying out for help.

� Many evaluees will present and perform their symptomology in ambiguous, mixed and uncertain ways à grey-‐zone

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Grey-‐zone �  An evaluee that presents symptoms in the “grey-‐zone” is difficult.

�  How to minimize the uncertainty? �  know the scientific literature well, �  use scientifically-‐informed methods and procedures, �  use scientific reasoning, �  respect the individual differences �  evaluator needs to consider distinctions between symptoms versus impairments, and

�  Consider distinctions between disorders/ diagnoses versus disabilities/ dysfunctions

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Grey-‐zone (Contd.) �  Finally, has all the reliable evidence been considered?

� Has the event at claim has been a material contributor to the psychological condition presented?

� Are pre-‐existing factors responsible in full or in part?

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� Table 14.8 examines the range of pre-‐existing factors that might influence disability determinations in the forensic context.

� Table 14.9 emphasizes that events at claim might lead to physical injuries, psychological injuries, or both, and the injuries might be at either minor or major levels.

� Table 14.10 points that the evaluee might also be unduly influenced by the litigation process and iatrogenic factors.

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Legal Aspects and Tes<mony � After the referral, the evaluator must assess not only the details of the event at claim but also its credibility.

� After the completion of the evaluation and the written report, in court judges may determine the testimony/ report’s admissibility. �  Legal decisions will hinge on issues of functional impairment, disability, permanence of the damages.

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� Table 14.12 further specifies that the functional outcome in disability cases could examine: �  quality of life, �  pain and suffering, and �  the catastrophic nature of the injury involved

� The causality analysis might lead to conclusions that malingering, more than anything else, had been involved.

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Effec<ve Forensic Wri<ng � DeMier (2013) noted 3 central points:

�  (a) First, essential points need to be included, such as use of third-‐party information and description of functional abilities.

�  (b) Second, the report should show clearly how clinically findings relate to the legal question at hand, so that psycholegal opinions are clearly justified.

�  (c) Third, the issue of whether forensic psychologists should address ultimate issues is actually secondary to the quality of the data gathered and justification of the interpretations and conclusions presented.

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Most Recent Journal Article Review

Bigler & Larrabee (2012a,b) � Engaged in dialogue about symptom validity testing in neuropsychological assessment.

� Bigler: �  SVT testing can help infer symptom and performance invalidity.

�  Below-‐chance SVT scores are clear and indisputable indices of invalid test performance.

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Bigler & Larrabee (2012a,b) � He queried the meaning and interpretation of SVTs. �  Just fail SVTs, also known as near-‐pass SVT performance, might do so for valid reasons �  i.e. valid underlying neuropathology � He noted that there is no systematic research of the effects of lesions on SVT performance.

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SVT Selec<on and Use � There are no clean guidelines that evaluators use to select SVTs �  There is no known number to use, order, context or what do with passes and failures on some tests.

� Most evaluators will end up using their subjective personal judgement.

� Cut-‐score selection should be wary of one-‐size-‐fits-‐all approaches

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Bigler & Larrabee (2012a,b) �  For Larrabee (2012a, b), the science and research behind the approach to use dichotomous pass-‐fail cut scores and also algorithms to combine tests are valid and avoid inappropriate attributions. �  So, factors such as expectation and stress alleged to explain poor performance on the tests have little weight.

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Bigler & Larrabee (2012a,b) � Both conduct research in the area of malingering detection, but have contrasting opinions. �  Either more scientific refinement is needed to reduce such contrasting opinions.

� OR, both parties’ arguments require careful scrutiny for errors of omission and commission.

� This book offers many guidelines to help resolve these issues.

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Bigler (2012a,b) �  He refers to litigation science to help improve SVT research. �  Although I agree that this type of research could present biases, the same applies to any science, even if non-‐litigation.

�  As long as litigation science is conducted transparently, it should not be labeled beforehand as invalid

�  Bigler’s most important contribution with respect to SVTs in neuropsychological assessment relates to the lack of guidelines for their proper use in practice. �  **These cautions are similar to the ones I have raised in the present book.

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Larrabee (2012a,b) �  Larrabee (2012a, b) added: �  Certain types of case control research designs meet the highest quality of standards in research. �  High degree of replicability of the results in the research on symptom validity.

�  Effect sizes in this type of research are quite large -‐-‐ for example, for the RDS (Reliable Digit Span), the MMPI-‐2’s FBS, and the DMT.

�  He cited research showing illness behavior and diagnosis threat do not appear to affect performance on SVTs.

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Hall and Hall (2012)/ Silver (2012) � Hall and Hall (2012) called for attribution of compensation neurosis when it seems warranted in assessments, a construct which is conceptually related to malingering on the continuum of possible response biases (see Figure 17.1).

�  In contrast, Silver (2012) believed it’s too difficult to attribute malingering, since so many factors can contribute to poor effort on SVTs.

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Never the Twain Shall Meet (Contd.) � Compensation neurosis concerns symptom exaggeration related to not only the prospect of secondary gain but also to internal motivations (e.g., stress from the case, or from treatment issues, and its effects on somatization and aspects of personality, such as dependence).

� Compensation neurosis is different from malingering as it also takes internal motivations into account on top of external motivation, unlike malingering.

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Never the Twain Shall Meet (Contd.) � Compensation neurosis does not refer to symptom absence, there are physical symptoms involved, but the causes for the symptoms do not involve real injuries related to the event at hand �  they reflect psychosomatic processes at work.

�  Individuals might be prone to react to events at claim this way.

� The stress of the case includes conscious and unconscious pressures not to improve.

� The legal and disability arena is iatrogenic. 245

Hall and Hall (2012) �  I note: Not only can the iatrogenic effect be due to conscious or unconscious motivation for financial compensation, but also from: �  Insurance pressures, IEs and, Unjust denials of claims

�  An even-‐handed approach to the question would acknowledge the presence of stress for the evaluee from all corners of the system.

�  It would be difficult to diagnose compensation neurosis due to the need to differentiate conscious from unconscious motivations, and internal from external incentives, etc.

�  The process of symptom hardening is complex and it might exclude the event at claim as a cause.

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Silver (2012) �  Silver (2012) noted that symptom severity is influenced by multiple non-‐TBI factors, pre-‐existing factors, etc. For example: �  Expectations that symptoms reflect TBI �  Stereotypic threat, and �  Ego depletion (which might be a form of stereotypic threat)

�  The compensation/ insurance/ litigation process includes an adversarial component. �  This may increase psychological costs (more anger, wanting

revenge, loss aversion, i.e., generally the reward to loss ratio should be about 2:1), which can affect symptoms.

�  Thus, cheating a “little” might be normal in these circumstances, as well. “A lot” of cheating is not the norm.

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Silver (2012) Contd. �  Suboptimal effort or symptom magnification is evident in neuropsychological assessment. �  They may occur for many reasons other than conscious effort and malingering.

�  Stress of the compensation/ insurance/ litigation process might lead evaluees to try too hard rather than less hard. �  They would possibly use a thinking process that is slower, deliberate, and conscious on tests of effort, which normally should elicit thinking that is fast, non-‐effortful, and automatic.

�  Their altered cognitive style might give a false impression of malingering.

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Young (2014) �  Silver (2012) has not considered certain factors in his arguments

rendering the attribution of malingering to be very difficult:

1)  Insurance process might be stressful or effortful not only because of trying harder, but because of efforts to falsely present or produce symptoms.

2)  There is no empirical evidence to support the statement that only a “little cheating” can be expected in forensic disability and related contexts, in this case for assessing MTBI.

�  Throughout the present book, I have argued that better surveys on this matter need to be conducted.

3)  To conclude, there are alternate interpretations of poor effort unrelated to negative response bias, when evaluees perform poorly on testing.

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Book Conclusions

Disability Evalua<ons: Psychologist �  Piechowski (2012) noted that disability evaluations differ from evaluations conducted by treatment providers especially in the emphasis on functional capacity evaluation compared to diagnosis.

�  She stated that disability is defined functionally, as an inability to undertake behaviors of a specified task or role in context.

�  As for causality, the assessor must show that the disability is causally related to the condition of the patient.

�  She added that secondary factors such as “financial problems, personal lifestyle choice, legal issues, and family demands” might affect work functioning.

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Table 34.1 Topics for the Interview

Topic

Description

Social history

Childhood, family children, etc.

Educational history Academic and behavioral performance

Occupational history Satisfaction and dissatisfaction with work, etc.

Legal history Involvement with the criminal justice system, etc.

Medical history Current or past health problems, etc. 252

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Interview Mental health history Impatient and outpatient treatment, current and past

psychotropic medications, etc.

Substance abuse history Use of alcohol, illegal drugs, abuse of prescription medications,

etc.

Job duties Detailed description of duties, working conditions, schedule,

and pace of work done just prior to the onset of the claimed

disability

Current daily activities How the claimant currently spends the day

Disability onset Detailed description of the onset of the difficulties

Functional impairments Detailed description of how functioning has been affected

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Disability Evalua<ons: Psychologist �  Samuel and Mittenberg (2005) found that estimates of the base rate for malingering in disability claimants varied between 7.5 and 33%.

� Also, Sumanti, Boone, Savodnik, and Gorsuch (2006) investigated “non-‐credible” symptoms in workers claiming “stress”, they found that 9 to 29% of the workers endorsed non-‐credible psychiatric symptoms, along with 8 to 15% for non-‐credible cognitive symptomatology.

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Malingering and SVTs �  Failing to meet the threshold on these tests does not automatically imply that malingering has taken place (Lilienfeld et al., 2013).

�  Furthermore, malingering is not a dichotomous concept (present, absent), rather it is dimensional.

� Malingering testing yields only moderate correlations, at best, and several separate factors, depending on the study.

� Psychopathological and cultural influences have not been sufficiently investigated, among others.

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Malingering and SVTs �  Lilienfeld et al. (2013) concluded that such tests “surely” assess variance related not only to response sets but also to “genuine psychopathology.”

� Thus, the “precise meaning” of scores obtained on many SVTs need “clarification.”

�  In addition, the manner in which they can be combined has not been conclusively established.

�  In fact, any new information that they may provide might “worsen” clinical judgment and prediction. �  e.g., if the information is of nonexistent or negligible validity.

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�  If SVTs are going to demonstrate their clinical utility, the “V” portion (or validity portion) of their intent must be better demonstrated.

�  I would add this refers to: �  (a) their capacity to differentiate in research “known” malingerers from “genuine” responders,

�  (b) the research base on their clinical utility in applied practice (do they add “incremental validity” in malingering attribution), and

�  (c) their ability to meet the challenge posed by McGrath, Mitchell, Kim, and Hough (2010) that they have yet to demonstrate sufficient “convergent” validity (but see the response by Rohling, Larrabee, Greiffenstein, Ben-‐Porath, Lees-‐Haley, Green, & Greve, 2011).

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Malingering and SVTs �  Overall, the Lilenfeld et al. (2013) article cautions the way in how SVTs are used and interpreted for court purposes.

�  Perhaps it is wise to conclude a book on possible malingering by the evaluee with a note of caution on possible bias in the evaluator.

�  Kassin, Dror, and Kukucka (2013) referred to a forensic confirmation bias, Murrie, Boccaccini, Guarnera, and Rufino (2013) to an allegiance effect, and Stanovich, West, and Toplak (2013) to a myside bias.

�  These studies were not related to the forensic civil disability, and related context, but their concerns resonate for this area of practice.

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Malingering and SVTs In essence, evaluators, evaluees, and third party stakeholders form an integrated system in which science must be the best source of evidence for court to dispel bias from any side of the process in court.

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Who We Are

�  Association for Scientific Advancement in Psychological Injury and Law: A Society (www.asapil.net)

�  Psychological Injury and Law (PIL): Our Journal (springer.com)

�  For mental health professionals and legal professionals working together

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Thank You

Gerald Young, Ph.D., C. Psych. Editor-in-Chief, Psychological Injury and Law President of ASAPIL Association Email: [email protected] Phone: 416-247-1625 clinical office/ 416-726-2709 cell Please contact me if you want more slides.

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