Assessing Performance and Symptom Validity during Neuropsychological Evaluation

Cure America of Anosognosia

Assessing Performance and Symptom Validity during Neuropsychological Evaluation

Contributor: Zach Greth, BS –University of North Carolina at Charlotte
Topic Overview
Concerns over malingering and invalid symptom reporting continue to escalate within clinical and forensic settings. Recent rates suggest some 19-68% of U.S. Social Security Administration (SSA) disability claims have been reported to include elements of compromised effort and feigning during clinical evaluation [6]. This can be problematic if claimants are erroneously compensated for cognitive dysfunction that is not valid. Total losses due to malingered neurocognitive disorder are elusive because the SSA’s fraudulent disability classification is broad. Some reports revealed nearly $2-5 billion in “improper payments” in 2015 alone [5]. A calculated, multifactorial approach to assessment is therefore necessary to help characterize the nature and severity of sequelae, if any, following neurological insult. The American Academy of Clinical Neuropsychology (AACN) provided some of the following recommendations for proper evaluation in such cases:

  • Use of a scientific framework, backed by current research and literature
  • Comprehensive assessment of cognitive, emotional, and physical functioning
  • Self-report measures of neuropsychological and psychological functioning 
  • Sufficient use of standalone and embedded measures of performance and symptom validity
  • Clinical interview with claimant and informants
  • Review of medical records and findings from evaluation(s)
  •  Analysis of test data, and any inconsistencies in performance against relevant literature, medical history, self-reports, and collateral reports   

 The need for neuropsychological input in medico-legal cases is increasingly paramount [2,7].
Clinical cases that include litigation for protracted recovery of concussion are especially relevant [1,4,6,8,9]. Robust literature highlights infrequent performance patterns for some individuals with post-concussive complaints that are not congruent with the extent of injury, or duration of continued symptom presentation [1,4,6,8,9]. Performance validity testing (PVT) and symptom validity testing (SVT) can help determine the nature of these neurocognitive inconsistencies (i.e., malingering, variable motivation). Results on both are compared to base rates in several other clinical populations. For example, several PVTs (e.g., Test of Memory Malingering, Medical Symptom Validity Test) are generally insensitive to cognitive impairment, meaning those with genuine, neurocognitive dysfunction can still perform above established cutoffs [2,8]. Research has shown that post-concussive patients have higher failure rates than genuinely impaired patients on PVTs [1,3,4,6,8,9]. Similarly, they may over-report the severity of their symptoms at a rate unusual even for patients with severe psychopathology [3,9]. The use of PVT’s and SVT’s is thereby incumbent to the neuropsychological assessment [2,3,9].
PVT’s and SVT’s are often used interchangeably in the literature. However, recent research suggests that PVT’s and SVT’s are mutually exclusive, and should be examined independently of each other [9]. Feigned cognitive impairment is not synonymous with symptom exaggeration. Examinees may “pass” several standalone and embedded PVTs, but endorse several symptomatic complaints that are vague, infrequent, or inconsistent [3, 9]. This can have major implications on the entire evaluation, including the clinician’s interpretation, treatment planning, and patient recovery. The clinician may need to further evaluate the individual’s psychological overlay, and increase communication with other treating clinicians. Van Dyke, Millis, Axelrod, and Hanks highlighted these differences, and encourage providers use a multifaceted approach to their work [9].
The current study aimed to clarify the relationship among the constructs involved in neuropsychological assessment, including cognitive performance, symptom self-report, performance validity, and symptom validity. Participants consisted of 120 consecutively evaluated individuals from a veteran’s hospital with mixed referral sources. Measures included the Wechsler Adult Intelligence Scale-Fourth Edition Full Scale IQ (WAIS-IV FSIQ), California Verbal Learning Test-Second Edition (CVLT-II), Trail Making Test Part B (TMT-B), Test of Memory Malingering (TOMM), Medical Symptom Validity Test (MSVT), WAIS-IV Reliable Digit Span (RDS), Post-traumatic Check List-Military Version (PCL-M), MMPI-2 F scale, MMPI-2 Symptom Validity Scale (FBS), MMPI-2 Response Bias Scale (RBS), and the Postconcussive Symptom Questionnaire (PCSQ). Six different models were tested using confirmatory factor analysis (CFA) to determine the factor model describing the relationships between cognitive performance, symptom self-report, performance validity, and symptom validity. The strongest and most parsimonious model was a three-factor model in which cognitive performance, performance validity, and self-reported symptoms (including both standard and symptom validity measures) were separate factors. The findings suggest failure in one validity domain does not necessarily invalidate the other domain. Thus, performance validity and symptom validity should be evaluated separately.

Van Dyke, S., Millis, S., Axelrod, B., & Hanks, R. (2013). Assessing effort: Differentiating performance and symptom validity. The Clinical Neuropsychologist27(8), 1234-1246.

 Multimedia Sources on Performance and Symptom Validity Testing:

Symptom Validity Testing (SVT)
The speakerin this video provides a brief overview of SVTin the context of neuropsychological assessment, as well as examples of common validity measures used. See related videos on side panel for additional information.
Dr. Rick Frederick on Multiple Measures of Malingering
Dr. Frederick, a forensic psychologist, presents a lecture about the nature and assessment of malingering during evalutation. He explains how administering too many PVTs can become problematic.
Additional References:
[1] Denning, J. (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 NeuropsychologyThe Official Journal of the National Academy of Neuropsychologists27(4), 417-432.
[2] Heilbronner, R., Sweet, J., Morgan, J., Larrabee, G., & Millis, S. (2010). American Academy of Clinical Neuropsychology consensus conference statement on the neuropsychological assessment of effort, response bias, and malingering. The Clinical Neuropsychologist23(7), 1093-1129.
[3] Holdnack, J., Millis, S., Larrabee, G., & Iverson, G. (2013). Assessing performance validity with the ACS.WAIS-IV, WMS-IV, and ACS: Advanced Clinical Interpretation. 331-365. 10.1016/B978-0-12-386934-0.00007-9.
[4] O’Bryant, S., Engel, L., Kleiner, J., Vasterling, J., & Black, F. (2007). Test of Memory Malingering (TOMM) trial 1 as a screening measure for insufficient effort. The Clinical Neuropsychologist21(3), 511-521.
[5] Probasco, J. (2015). Social Security fraud: What is it costing taxpayers? Investopedia, LLC.
[6] Psychological Testing in the Service of Disability Determination (1st ed.). (2015). Washington, DC: National Academies Press.  
[7] Schoenberg, M., & Scott, J. (2011). The little black book of neuropsychology: A syndrome-based approach. New York, NY: Springer Science+Business Media.
             [8] Tombaugh, T. (1996). Test of Memory Malingering. Toronto, Canada: MultiHealth               Systems.
[9] Van Dyke, S., Millis, S., Axelrod, B., & Hanks, R. (2013). Assessing effort: Differentiating performance and symptom validity. The Clinical Neuropsychologist27(8), 1234-1246.


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