Symptom Validity Test Failure Research Articles

Overground and Virtual Reality Gait Speed Are Associated With Atypical Symptom Reporting in Active Duty Service Members With a History of Mild to Moderate Traumatic Brain Injury.

Physical therapy following traumatic brain injury (TBI) can be negatively impacted by psychological symptoms, atypical symptom reporting, and response bias. We examined rates of Symptom Validity Test (SVT) failure in active duty military service members with a history of mild-moderate TBI and its impact on gait speed. Intensive Outpatient Program at the National Intrepid Center of Excellence at Walter Reed National Military Medical Center. Participants were 84 active duty service members with a history of mild-moderate TBI classified as SVT pass ( n = 49) or SVT fail ( n = 35). Retrospective study. Overground preferred and fast walking speed as well as Computer Assisted Rehabilitation Environment (CAREN) gait speed were recorded. Participants completed the Neurobehavioral Symptom Inventory and the Validity-10 was used to assign patients into the SVT pass and SVT fail groups. Gait speed metrics were compared across these groups and test operating characteristics were calculated. Approximately 42% of the sample was classified into the SVT fail group. All 3 gait speed measures were significantly slower in the SVT fail group than in the SVT pass group ( P s < .001, d s = 0.60-0.80). Gait speed cutoffs for screeners or indicators of atypical reporting were identified. The potential for response bias is a critical area for the clinician to consider when conducting physical therapy evaluations. Participants in the SVT fail group had slower walking speed on all 3 measures assessed. Several useful cutoffs were identified to serve as screeners or indicators of SVT failure, though these preliminary findings have limitations and need to be replicated.

Performance and symptom validity testing in neuropsychological assessments in Australia: a survey of practises and beliefs

ABSTRACT Objective: Validity test failures within neuropsychological assessments are common. This study aimed to assess current practise. Method: Australian psychologists completed an online survey evaluating their approach to validity issues. Results: There were 102 participants (75% female, mean age 41.68 (11.72), 88% clinical neuropsychologists or registrars, 35% conducting 10+ assessments in medico-legal settings, 88% conducting 10+ assessments in clinical settings). Performance validity tests were used by most clinicians in a medico-legal setting, but in less than 50% of assessments in clinical settings. Symptom validity tests were used significantly more frequently in medico-legal settings as compared to clinical settings. Less objective methods (e.g., qualitative observation) were more frequently used to evaluate validity in clinical settings. Conclusions: Overall, validity testing in Australia is not consistent with published North American guidelines or practise trends. In Australia, psychologists practising in clinical settings appear to be relying on subjective judgements more frequently than on objective test findings. Australian guidelines that reflect recent research findings regarding validity test failure rates in clinical settings are required. The most frequently cited reason for not including validity tests was insufficient time, so future research should continue to examine time-efficient ways of incorporating validity testing. Key Points What is already known about this topic: (1) Performance validity and symptom validity test failure occur in both medico-legal and clinical settings. (2) Professional guidelines for validity testing published by professional bodies in North America emphasise the importance of validity tests in medico-legal and other settings. (3) Validity test use varies between countries, with high rates in North America but lower rates in Europe and New Zealand. What this paper adds: (1) Based on North American guidelines, performance validity tests are used less frequently than recommended in clinical settings in Australia, whilst symptom validity tests are used less frequently than recommended in both clinical and medico-legal settings. (2) Lack of time is the biggest barrier to incorporating validity tests into neuropsychological assessments; more time-efficient validity testing methods would help redress this issue. (3) There is an urgent need for Australian guidelines for validity testing in neuropsychological assessments.

Health Locus of Control and Symptom Validity Testing in a Military Context

Abstract Objective The base rate of symptom validity test (SVT) failure in the military has been the subject of recent investigation. Secondary gain is a potential factor in this population; however, frank malingering may not account for all cases of SVT failure. As a result, other psychological and social factors potentially associated with validity test failure have been suggested and include nocebo effect, diagnosis threat, and perceived injustice. Locus of Control (LOC) has been associated with a range of medical/psychological conditions/outcomes and this study examined the relationship between LOC and SVT performance. Method A retrospective review of adult patients administered the Multi-dimensional Health Locus of Control Scale (MHLCS) and the MMPI-2-RF (n = 53) or the PAI (n = 143) in the context of neuropsychological assessments in a military treatment facility was conducted. Results MHLCS Internal and Powerful Others subscales had very limited associations with the evaluated SVTs. However, the MHLCS Chance subscale was significantly correlated with MMPI-2-RF Fp (r = .37, p &lt; .05) and Fs (r = .29, p &lt; .05) and PAI NIM scales (r = .26, p &lt; .01). The MHLCS Chance subscale scores were significantly higher in those failing the PAI NIM (t = 3.0, p &lt; .01) and MMPI-2-RF Fp (t = 2.5, p &lt; .05) and FBS (t = 2.5, p &lt; .05) scales, with moderate to large effect sizes (Cohen’s d ranging from 0.76 to 0.99). Conclusions The current data indicate limited relationships between MHLC internal and powerful others subscales and SVT performance. However, higher Chance subscale scores were associated with failed SVTs.

Performance and Symptom Validity Testing as a Function of Medical Board Evaluation in U.S. Military Service Members with a History of Mild Traumatic Brain Injury.

The study was designed to replicate and extend pervious findings demonstrating the high rates of invalid neuropsychological testing in military service members (SMs) with a history of mild traumatic brain injury (mTBI) assessed in the context of a medical evaluation board (MEB). Two hundred thirty-one active duty SMs (61 of which were undergoing an MEB) underwent neuropsychological assessment. Performance validity (Word Memory Test) and symptom validity (MMPI-2-RF) test data were compared across those evaluated within disability (MEB) and clinical contexts. As with previous studies, there were significantly more individuals in an MEB context that failed performance (MEB = 57%, non-MEB = 31%) and symptom validity testing (MEB = 57%, non-MEB = 22%) and performance validity testing had a notable affect on cognitive test scores. Performance and symptom validity test failure rates did not vary as a function of the reason for disability evaluation when divided into behavioral versus physical health conditions. These data are consistent with past studies, and extends those studies by including symptom validity testing and investigating the effect of reason for MEB. This and previous studies demonstrate that more than 50% of SMs seen in the context of an MEB will fail performance validity tests and over-report on symptom validity measures. These results emphasize the importance of using both performance and symptom validity testing when evaluating SMs with a history of mTBI, especially if they are being seen for disability evaluations, in order to ensure the accuracy of cognitive and psychological test data.

Poor symptom and performance validity in regularly referred Hospital outpatients: Link with standard clinical measures, and role of incentives

We investigated the frequency of symptom validity test (SVT) failure and its clinical correlates in a large, heterogeneous sample of hospital outpatients referred for psychological assessment for clinical purposes. We studied patients (N=469), who were regularly referred for assessment to the psychology departments of five hospitals. Background characteristics, including information about incentives, were obtained with a checklist completed by the clinician. As a measure of over-reporting, the Structured Inventory of Malingered Symptomatology (SIMS) was administered to all patients. The Amsterdam Short-Term Memory test (ASTM), a cognitive underperformance measure, was only administered to patients who were referred for a neuropsychological assessment. Symptom over-reporting occurred in a minority of patients, ranging from 12% to 19% in the main diagnostic patient groups. Patients with morbid obesity had a low rate of over-reporting (1%). The SIMS was positively associated with levels of self-reported psychological symptoms. Cognitive underperformance occurred in 29.3% of the neuropsychological assessments. The ASTM was negatively associated with memory test performance. We found no association between SVT failure and financial incentives. Our results support the recommendation to routinely evaluate symptom validity in clinical assessments of hospital patients. The dynamics behind invalid symptom reporting need to be further elucidated.

Exaggerating Psychopathology Produces Residual Effects That Are Resistant to Corrective Feedback: An Experimental Demonstration

We explored the effects of feedback on symptom reporting. Two experimental groups (n = 15 each) were given a scenario with the option to exaggerate symptoms. Compared with a control condition (n = 15), both groups scored significantly higher on the Structured Inventory of Malingered Symptomatology. Next, one group was confronted in a sympathetic way about their symptom validity test failure, whereas the other group was confronted in a neutral manner. Both groups subsequently completed the Brief Symptom Inventory (BSI). BSI scores of both feedback groups remained significantly higher than those of control participants. Participants who had been provided with sympathetic feedback or neutral feedback did not differ in their BSI scores. Even participants who indicated during the exit interview that they had given up symptom exaggeration attained significantly higher BSI scores than those of controls, indicating that exaggeration has residual effects that are resistant to corrective feedback. We discuss cognitive dissonance as a model for understanding the residual effects of symptom exaggeration.

Performance on the Green Word Memory Test Following Operation Enduring Freedom/Operation Iraqi Freedom-Era Military Service: Test Failure is Related to Evaluation Context

This study investigates prior reports of high neuropsychological symptom validity test (SVT) failure rates in post-deployed Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) active and veteran military personnel, using a large, multi-site sample (N = 214) drawn from three levels of the Department of Defense/Department of Veterans Affairs (VA) Polytrauma System of Care. The sample failure rate and its relationship to research versus dual research/clinical context of evaluation were examined, in addition to secondary variables explored in prior studies. Results yielded an overall failure rate of 25%, lower than prior reports describing OEF/OIF active-duty and veteran military personnel. Findings also supported the hypothesis that SVT failure rates would differ by context (dual > research). Participants with traumatic brain injury (TBI) failed more frequently than those without TBI in the dual context but not in the research context. Secondary analyses revealed that failure rates increased in the presence of depression, posttraumatic stress disorder, and male sex but were unrelated to active versus veteran military status, service connection (SC) or percentage of SC, age, education, or ethnicity. Further research is required to elucidate the underpinnings of these findings in light of the limited literature and variability between OEF/OIF-related SVT studies, as well as the substantial diagnostic and treatment implications for VA.

Predicting Test of Memory Malingering and Medical Symptom Validity Test Failure within a Veterans Affairs Medical Center: Use of the Response Bias Scale and the Henry-Heilbronner Index

The ability of the Response Bias Scale (RBS) and the Henry-Heilbronner Index (HHI), along with several other MMPI-2 validity scales, to predict performance on two separate stand-alone symptom validity tests, the Test of Memory Malingering (TOMM) and the Medical Symptom Validity Test (MSVT), was examined. Findings from this retrospective data analysis of outpatients seen within a Veterans Affairs medical center (N = 194) showed that group differences between those passing and failing the TOMM were largest for the RBS (d = 0.79), HHI (d = 0.75), and Infrequency (F; d = 0.72). The largest group differences for those passing versus failing the MSVT were greatest on the HHI (d = 0.83), RBS (d = 0.80), and F (d = 0.78). Regression analyses showed that the RBS accounted for the most variance in TOMM scores (20%), whereas the HHI accounted for the most variance in MSVT scores (26%). Nonetheless, due to unacceptably low positive and negative predictive values, caution is warranted in using either one of these indices in isolation to predict performance invalidity.

Scores on the MMPI-2-RF Scales as a Function of Increasing Levels of Failure on Cognitive Symptom Validity Tests in a Military Sample

This research examined associations between the full range of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) validity and substantive scales and increasing levels of cognitive symptom validity test (SVT) failure in a sample of 501 military members who completed a neuropsychological evaluation primarily for mild traumatic brain injury resulting from a closed head injury and blast exposure or heat injury. SVT failure was associated with significant linear increases in all of the over-reporting MMPI-2-RF validity scales and most of the substantive scales. For the validity scales, all over-reporting scales had large effect sizes (ESs) when comparing a group that failed no SVTs with a group that failed three SVTs. A comparison between these two groups for the substantive scales revealed the largest ESs for scales related to somatic/cognitive complaints and emotional dysfunction. RBS (Response Bias Scale) had the largest ES of all scales (d = 1.69), followed by FBS-r (Symptom Validity Scale; d = 1.34), AXY (Anxiety, d = 1.21), and COG (Cognitive Complaints, d = 1.19). The scales related to behavioral dysfunction had the smallest ESs of all of the substantive scales, and there were no significant associations between the vast majority of these scales and SVT failure. With respect to clinically significant elevations, those who did not fail SVTs had clinically significant elevations only on COG and NUC (Neurological Complaints), and MLS (Malaise) approached clinical significance. For those who failed SVTs, RBS was the only over-reporting scale that was elevated across all failure groups. Those who failed any SVT had clinically significant elevations on COG, MLS, NUC, and AXY. Those who failed three SVTs had additional elevations on scales related to emotional dysfunction.

Examining the potential for gender bias in the prediction of symptom validity test failure by MMPI-2 symptom validity scale scores.

Using a sample of individuals undergoing medico-legal evaluations (690 men, 519 women), the present study extended past research on potential gender biases for scores of the Symptom Validity (FBS) scale of the Minnesota Multiphasic Personality Inventory-2 by examining score- and item-level differences between men and women and determining the extent to which FBS scores were able to correctly identify men and women who were divided into credible responders (n = 837) and noncredible responders (n = 372) on the basis of performance on symptom validity tests. Results indicated that women had slightly higher raw FBS scores than men (d = .29), and significant differences between men and women in item endorsement were demonstrated for 14 FBS items. Step-down hierarchical logistic regression procedures indicated predictive bias (χ²Δ = 23.72, p < .001). Follow-up analyses indicated intercept bias (χ²Δ = 23.51, p < .001) but not slope bias (χ²Δ = 0.22, p = .64). However, using the test publisher's recommended FBS cutoff scores (Ben-Porath, Graham, & Tellegen, 2009), classification accuracies were similar for women and men (T > 80, h = -.02; T > 100, h = -.22, respectively). On the basis of these results, we conclude there is no evidence of clinically meaningful bias in predictions of symptom validity test failure made using FBS scores for men and women.

The implications of symptom validity test failure for ability-based test performance in a pediatric sample.

If an examinee exerts inadequate effort to perform well during a psychological or neuropsychological exam, the resulting data will represent an inaccurate representation of the individual's true abilities and difficulties. In adult populations, methodologies to identify noncredible effort have grown exponentially in the last 2 decades. Though a comparatively modest amount of work has focused on tools to identify noncredible effort in pediatric populations, recent research has demonstrated that children can consistently pass several stand-alone symptom validity tests (SVTs) using cutoffs established with adults. However, no identified studies have examined the implications of pediatric SVT failure for ability-based test performance. The current sample consisted of 276 children aged 8-16 years referred consecutively for outpatient clinical neuropsychological consultation following mild traumatic brain injury (TBI). An earlier subgroup of this same case series that also included 17-year-olds was presented in Kirkwood and Kirk (2010). Nineteen percent of the current sample performed below the actuarial cutoff on the Medical Symptom Validity Test (MSVT). No background or injury-related variable differentiated those who passed from those who failed the MSVT. Performance on the MSVT was correlated significantly with performance on all ability-based tests and explained 38% of the total ability-based test variance. Participants failing the MSVT performed significantly worse on nearly all neuropsychological tests, with large effect sizes apparent across most tests. The results provide compelling evidence that practitioners should add objective SVTs to the evaluation of school-aged youth, even when secondary gain issues might not be readily apparent and particularly following mild TBI.

Associations Between Symptom Validity Test Failure and Scores on the MMPI–2–RF Validity and Substantive Scales

This study examined the association between Symptom Validity Test (SVT) failure and the Minnesota Multiphasic Personality Inventory–2 Restructured Form (MMPI–2–RF; Ben-Porath & Tellegen, 2008), in the Forensic Disability Claimant samples described in the MMPI–2–RF Technical Manual (Tellegen & Ben-Porath, 2008a, 2008b). SVTs used included the Word Memory Test (Green, 2003), the Computerized Assessment of Response Bias (Allen, Conder, Green, & Cox, 1997), the Medical Symptom Validity Test (Green, 2004), and the Test of Memory Malingering (Tombaugh, 1996). SVT failure was associated with significant elevations throughout the MMPI–2–RF overreporting validity scales and substantive scales. Pairwise contrasts between groups failing 0 and 3 SVTs revealed predominantly large effect sizes for the overreporting validity scales (d = 0.78–1.11), and many of the substantive scales, including the Cognitive Complaints (COG) scale. Results of this study demonstrate an association between SVT performance and elevated scores on the MMPI–2–RF. These results suggest that exaggeration of cognitive symptoms as demonstrated by SVT failure is also associated with overreported emotional, somatic, and neurocognitive complaints on the MMPI–2–RF.

Comparison of the Repeatable Battery for the Assessment of Neuropsychological Status Effort Index and Stand-Alone Symptom Validity Tests in a Military Sample

The current study sought to report the base rates of Symptom Validity Test (SVT) failure in an active duty military sample as well as to compare the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Effort Index (EI) to stand-alone measures of symptom validity. SVT failure varied from previous studies and even among different subgroups in the current sample, ranging from 8% to 30%. The RBANS EI demonstrated modest sensitivity in the detection of suboptimal effort when compared with stand-alone SVTs. Although the index appears to add some utility to the detection of suboptimal effort, sole use of the EI as a measure of symptom validity could conceivably result in an unnecessarily high rate of false negatives.

A Case of Malingering by Proxy in a Social Security Disability Psychological Consultative Examination

The term “malingered neurocognitive dysfunction by proxy” was discussed by Slick, Sherman, and Iverson (1999) as part of the differential for defining malingering when a patient is responding to directions or pressure from others. In Chafetz (2008), rates of symptom validity failure in children whose parents are seeking Social Security Disability (SSD) on their behalf were presented and showed 20% to 26% symptom validity test failure rates at chance or below-chance levels. The objective of the current case study was to determine whether the requirements of malingering were met in a 9-year-old whose parent was seeking SSD on his behalf. A retrospective approach was employed using an archived case from one of the author's records. This case shows a practical application of a symptom validity scale for low-functioning individuals (Chafetz, Abrahams, & Kohlmaier, 2007), which was designed initially for use with adult and child SSD claimants. The egregious nature of symptom validity failure, coupled with SSD seeking for the whole family, along with conduct disorder symptoms provided a strong suggestion of malingering by proxy. The present results are discussed with respect to low-functioning claimants.

The relation between symptom validity testing and MMPI-2 scores as a function of forensic evaluation context

The association between scores on MMPI-2 scales and cognitive symptom validity test (SVT) failure was investigated in 127 criminal defendants evaluated for competency to stand trial, criminal responsibility, and drug dependence, and 141 personal injury and disability claimants. Results indicated that SVT failure was associated with exaggerated symptom presentation involving somatic complaints in civil litigants and more global exaggeration of psychopathology and somatic complaints in criminal defendants. Scores on the MMPI-2 Fake Bad Scale (FBS) were associated with SVT failure in both civil and criminal litigants, whereas scores on the MMPI-2 F P scale were associated with SVT failure in criminal defendants, but not in civil plaintiffs. These results support the utility of the FBS as an indicator of non-credible presentation of somatic and cognitive complaints in both civil and criminal forensic psychological assessments, and indicate that the lack of association between the MMPI-2 infrequency scales and SVT failure is limited to civil forensic settings.