Assessment of Malingered Neuropsychological Deficits

This book, which was written for forensic neuropsychologists, may be useful to forensic psychiatrists who may be cross-examined about the validity of neuropsychological testing used to confirm a clinical diagnosis. Each of the book's 13 chapters contains a thorough review of research on neuropsychological tests and clinical diagnostic methods.

The introduction of the book contains alarming statistics about malingering. Glenn Larrabee states that in 2004, when the cost of Social Security Disability Insurance (SSDI) to the federal government was more than $80 billion, more than 72 percent of applicants for SSDI met criteria for either definite or probable malingering. He cites research that shows that the base rate for malingering by litigants who allege mild head injuries is as high as 40 percent. The base rate for malingering in both criminal and civil settings is as high as 50 percent.

The most fascinating chapter for clinicians is probably “Coaching and Malingering: A Review.” Coaching is defined as the provision of information to evaluees that facilitates malingering. Examples include taking repeated tests to prepare for the clinical examination, compiling feedback from examiners and clinicians about symptoms of specific diseases, attending support groups where medical disorders are discussed, researching diseases and diagnostic tests on the Internet, and receiving education about disease symptoms by attorneys or their designees.

Some attorneys believe that preparation of clients for the testing process is necessary. Authors of the chapter, Julie Suhr and John Gunstad, describe a subgroup of attorneys who engage in excessive client preparation by educating them about what to do during the clinical examination, including symptom presentation, and how to respond to items embedded in tests that are designed to detect malingering. Legal education course instructors who teach attorneys how to coach their clients contend that client preparation is a necessary precursor to obtaining the client's consent to participate in the testing procedure. The dilemma in ethics is obvious, but the attorney-client privilege prevents the evaluator and the court from determining the extent to which coaching has occurred.

Coaching has been a contentious topic among psychologists. Although some argue that a client cannot properly give informed consent to proceed with psychological testing until all information is fully disclosed, the American Psychological Association specifically forbids the practice of coaching by its members. The authors state that individual neuropsychologists differ even in their willingness to specify which individual tests will comprise the battery they will be administering, to a particular evaluee, in an effort to foil the malingering efforts of coached evaluees.

Two chapters provide excellent overviews of malingering in neuropsychological testing for forensic psychiatrists and neurologists. In Chapter 9, “Detection of Feigned Psychiatric Symptoms During Forensic Neuropsychological Examinations,” authors David Berry and Lindsey Schipper emphasize the danger of limiting assessments of mental disorders to patient self-reports. Forensic mental health professionals must combine objective tests with clinical experience to discern the coherence of the litigant's presentation and the likelihood of malingering.

Two of the better neuropsychological instruments for psychiatrists to request are the Minnesota Multiphasic Personality Inventory (MMPI)-2 and the Structured Inventory of Reported Symptoms (SIRS). The authors say that the MMPI-2, which has been validated for detecting feigning in neurological and psychiatric control groups, is the most frequently utilized test in forensic psychological testing. Although use of the MMPI-2 is supported by a substantial body of research and meta-analyses, researchers still debate which of the four subscales is most useful for identifying malingering. The SIRS has been validated in truly ill and simulating patient populations and in adolescents. The authors note that the SIRS is relatively less vulnerable to coaching than some other tests.

Chapter 12, “Features of the Neurological Evaluation That Suggest Noncredible Performance,” opens with a disclaimer about the known disconnect between functional pathology and structural neuropathology of disease and injury as validated by objective tests such as magnetic resonance imaging and electromyography. James Albers and Randolph Schiffer explain that functional pathology represents the illness and the structural pathology is the disease. As the disparity between the two widens, the likelihood of a court adjudication of noncredible pathology increases. Note that a determination of noncredible is not a commentary about the motivation of the litigant, although a litigant who malingers may misinterpret normal physiological phenomena or otherwise strive to mislead the examiner. The goal in forensic settings is to provide evidence of the presence or absence of noncredible symptomatology. Correlating neuropsychological findings with the clinical examination helps the clinical evaluator achieve this goal. When a neurological examination is requested to determine the presence of disease, it should have enough redundancy to help the examiner determine the credibility of the signs and symptoms.

Larrabee has achieved a remarkable feat by combining an exhaustive review of the research literature with salient information for the forensic mental health evaluator.

• American Academy of Psychiatry and the Law