Comprehensive and user friendly, this book synthesizes the growing literature on symptom feigning in cognitive testing and translates it into evidence-based recommendations for clinical and forensic practice. A wide range of cognitive effort assessment techniques and strategies are critically reviewed, including both dedicated measures and the use of embedded indicators in standard clinical tests. The book describes approaches to distinguishing between credible and noncredible performance in specific clinical populations: persons presenting with head injury, chronic pain and fatigue, attention-deficit/hyperactivity disorder and learning disability, mental retardation, seizures, and exposure to environmental toxins. Special topics include the potentially confounding effects of psychiatric disorder and ethnocultural factors on effort testing, and cognitive assessment in the criminal forensic setting.

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Malingering or Non-Credible Performance?

The text covers the Slick et al criteria for Malingering and suggests that this be renamed "noncredible performance" since the former implies conscious effort which at this time is not quantifiable. However, they do admit, fortunately, that there is a significant qualitative difference between the malingerer and the patient with somatoform disorder discernable to medical professionals in the absence of testing protocols.

Within the confines of Neuropsychology I would not disagree.

The book covers:

1) Tests specifically targeting "non credible performance" forced choice measures and non forced choice measures with a nice collection of studies replete with sensitivity and specificity of each test. In addition there are entire sections of test comparisons and most importantly correlations which emphasize that one test, like the TOMM, is meaningless. Contrary to popular opinion the TOMM is NOT sensitive ( recall this measures the probabilistic truth of the implication: if patient is malingerer then the test is positive OR what is the same logical statement: If the test is negative then the patient is not a malinger. Hence the Mneumonic SNout - sensitive test rules out disease ). As is turns out the TOMM is not as specific as we would like it to be ( recall this measures the probabilistic truth of the implication: if patient is not malingering then the test is negative OR what is the same logical statement: If the test is positive then the patient is a malinger. Hence the Mneumonic SPin - specific test rules in disease ). In other words there is a non-zero false positive rate, albeit very very small. The authors contend that multiple minimally correlated ( at least 3 ) measures be administered increasing the specificity and sensitivity considerably. Not suprisingly, in poor effort NON simulator studies ( compensation seeking clients ) 30% of the individuals passed TOMM AND failed WMT ( Word Memory Test ). The failure was at a level worse than early confirmed Alzheimer patients and mentally retarded children lending strong support to the argument that passing the TOMM really means nothing. Yet perplexingly this is often the only formal validity test administered ( if there is one ) .
Non forced choice measures are discussed and offer the advantage of poor detection by the would be malingerer and hence less opportunity to pass validity testing yet simultaneous knowingly fail formal measures of cognitive functioning.

2) Other integrated measures which serve the dual purpose of formally measuring an ability and at the same time offering information about validity. Unfortunately most such measures are inferior to dedicated "non credible" performance testing. Eg- IQ, memory, executive function and sensorimotor tests.

3) Nice historical overview of MMPI 1 then 2 and then the addition of validity checks ( F family of imbedded scales looking at symptom exaggeration ) since it was recognized that the scales could be easily manipulated by respondents. The issue with F scales is that a negative result does not rule out malingering ( SNout- sensitivity issue ) and they have a bias towards psychotic symptoms not adequately capturing somatic symptoms. The authors then review the data of the Fake Bad Scale ( FBS ) pointing out it's use, limitations and interpretation and suggest that the MMP 2 with F scales be administered along with the FBS which increases sensitivity and specificity.

4) Several excellent chapters on cognitive effort testing in special populations ( mTBI, Multiple Chemical Sensitivity, Pain and Fatigue, Feigned Mental Retardation, Epilepsy etc

Overall a fantastic succinct overview of validity measures, uses, and error rates.

FYI the authors agree that Neuropsych testing in the absence of MULTIPLE measures of validity is suspect.

September 08, 2008

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