The Assessment of Feigned Cognitive Impairment: A Neuropsychological Perspective

Forensic psychiatrists have relied increasingly on the results of neuropsychological evaluations to inform their opinions regarding the nature, extent, and credibility of claimed cognitive impairments. Practitioners seeking guidance in categorizing and appreciating the strengths and weaknesses of these instruments may find The Assessment of Feigned Cognitive Impairment: A Neuropsychological Perspective, edited by Kyle Brauer Boone, a timely publication.

Although its intended audience is practicing psychologists and graduate students, Boone's book will help forensic psychiatrists become better informed consumers of neuropsychological effort testing.

Boone and the contributing authors describe new research in three key areas: novel instruments for detecting feigned cognitive deficits; psychometric properties of existing instruments; and existing psychological tests used to describe performance patterns that are specific to malingering.

The book is divided into three sections. The first section, which contains two chapters, provides an overview of malingering of physical and psychological symptoms. Chapter 1 contains an insightful and engaging survey of malingering taken from history, religion, and the literature. Chapter 2 examines emerging research into the role of functional neuroimaging in the detection of deception and malingering.

Section 2 provides a detailed review of effort testing and the strategies used to detect suboptimal effort on standard memory, motor, and intelligence tests. The section begins with an examination of tests, such as forced-choice, that have been developed specifically to detect poor effort. This section also introduces studies designed to identify patterns associated with poor effort on standard psychological tests, such as intelligence, memory, and motor tests. Readers will be able to identify profiles that indicate malingering on standard psychological tests.

The third section reviews the efficacy of effort testing in special populations, including ethnic minorities, criminal forensic evaluees, and cognitively impaired individuals with mental retardation, epilepsy, or chronic pain. This section provides an accessible reference for clinicians. It summarizes data on detecting poor effort in specific clinical populations. For example, a psychiatrist evaluating a subject with mental retardation may wonder what weight to assign a low score on the Test of Memory Malingering (TOMM), a tool commonly used to detect poor effort or feigning. In Chapter 14, the authors describe data suggesting that individuals with mental retardation face a greater risk of being erroneously classified as malingerers when evaluators use the TOMM.

The book is a well-organized and useful reference for forensic psychiatrists. Although it has multiple authors, it reads like a single-author text. Boone authored or coauthored 10 of the 20 chapters and maintained a fairly consistent structure across the chapters, making the book eminently readable. Each chapter presents an overview of the topic, a literature review, and a summary. The summaries help the reader to integrate the information and are sufficiently detailed to serve as stand-alone references for the reader who is looking for a concise overview of a topic.

I found Chapter 19, “Malingering in Criminal Forensic Neuropsychological Settings,” especially helpful. The author, Robert Denney, reviews the epidemiology of malingering in correctional and pretrial settings. He offers suggestions for designing forced-choice tests to detect malingered amnesia and feigned incompetence to stand trial.

The authors describe the importance of accurately evaluating malingering during forensic evaluations. The stakes associated with these evaluations have increased. Criminal defendants who are labeled malingerers can face longer sentences in some jurisdictions. In United States v. Greer, 158 F.3d 228, 234 (5th Cir. 1998), the Fifth Circuit Court of Appeals upheld a sentencing enhancement for feigned incompetence to stand trial and characterized malingering as obstruction of justice. The Eighth and Third Circuits upheld similar enhancements for malingering during a competence evaluation in United States v. Binion, 132 Fed. Appx. 89 (8th Cir. 2005), and United States v. Batista, 483 F.3d 193 (3rd Cir. 2007), respectively. In fact, as the authors point out, the accurate determination of cognitive ability can be a matter of life or death for defendants in capital cases, since the Supreme Court held in Atkins v. Virginia, 536 U.S. 304, 321 (2002), that the execution of mentally retarded offenders is unconstitutional.

The topic of neuropsychological effort testing can admittedly be a daunting one. Fortunately, this book presents it in a highly comprehensible manner. Boone and her collaborators have synthesized recent scientific advances in the area of effort testing into a text that will become an invaluable tool for all practitioners who rely on neuropsychological testing data.

• American Academy of Psychiatry and the Law