Neuropsychology of Malingering Casebook

The Neuropsychology of Malingering Casebook is a multiauthored work. Through its six sections, 45 chapters, and six appendices (divided into multiple subsections) it presents an extensive review of the literature over the past several decades on the subject of malingering and neuropsychological testing. Two overlapping but distinct topics are covered. The first concerns the use of specific tests to detect poor effort, symptom exaggeration, and malingering that invalidate neuropsychological test results. The development of test modalities to detect invalid test results has proceeded apace for decades. The second concerns the use of testing approaches for the diagnosis of malingering in forensic and dual agency settings where a financial incentive exists to exaggerate symptoms or malinger. The sections dealing with the perspectives of decision-makers are balanced: input is received from all sides of the question across a range of contexts. Extensive bibliographies on selected topics are provided. A detailed bibliography is provided as an appendix. Overall, the book is very well written. What could have been a nightmarish bombardment of statistics and citations is instead a good read.

Despite the case-based approach, this is not a good first book on the subject for the student or clinician. A working knowledge of test development, administration, and statistical approaches to interpretation is needed to get the most from this text. Experience with test interpretation in the context of the entire forensic evaluation, especially as it relates to a finding of malingering, is necessary. The text also assumes an appreciation of how deficits in brain systems that mediate motivational behavior present in various contexts. A review of the cases reveals that, on testing, almost anyone can show evidence of malingering, including subjects with documented moderate-severe and severe brain injury, HIV, HIV dementia, and severe depression, not to mention people with a range of psychiatric problems including factitious disorders and children. At times the text's approach to malingering brings to mind the concept of the crimen exceptum, a crime in which the normal standards of proof and procedure do not apply.¹ Witchcraft was such a crime in the 16th century. As Jean Bodin the famous French jurist put it, once suspicion is raised, the suspect “ought never be fully acquitted … unless the calumny of the accuser is clearer than the sun, inasmuch as proof of such crimes is so obscure and so difficult that not one witch [or malingerer for that matter] in a million would be accused or punished if the procedure were governed by the ordinary rules.”²

One of the ordinary rules that comes to mind is informed consent. Since this testing is done both in forensic settings and in contexts where the doctor-patient relationship exists, such as in independent medical examinations, a chapter devoted to the subject would have been of considerable interest to forensic psychiatrists.

As the text makes clear, for neuropsychologists the primary concern is with the validity of the test. Ordinary rules such as allowing an attorney to be present during a forensic evaluation conducted at the behest of the opposing side do not apply to neuropsychological testing, because of concerns that the presence of a third party would invalidate the test. Similar problems arise with respect to judicial rulings that require the disclosure of test data to attorneys and other nonprofessionals. The concerns on both sides of these arguments strike one as differences in emphasis and priority: one on legal and due process concerns, the other on the validity of the tests. In court, the reasoning behind the desire to keep raw data and testing materials from attorneys and other unqualified individuals is often misunderstood. Sometimes people seem to have a hard time understanding that exposure of the test results can render the data useless, not least because of the effects of coaching, particularly test coaching.

Factitious disorders are addressed in the book. Distinguishing these disorders from malingering on the basis of testing is an even more complex matter, since both involve the intentional production of symptoms but for different motives. It is not clear that available test modalities, on their own, can definitively discern the motivation that drives the intentional production of symptoms, especially in a context where external and internal incentives clearly co-exist. That some clients, much to the chagrin of their attorneys, can minimize, deny, or avoid discussing problems counter to their interests in a case is not addressed at all. The omission is disappointing.

Malingering is a concern in every forensic evaluation. If anything, what this book reveals is that, using the test methods available, the results, when viewed in isolation, will not be dispositive. It is often data gathered from records or collateral interviews, or information concerning the subject's behavior outside the context of the evaluation, or a subject's presentation that cannot be accounted for on the basis of psychiatric, neurological, or developmental factors, that exposes the deception.

As noted by one contributor, symptom validity testing has moderate sensitivity, and scores in the valid range therefore cannot conclusively rule out malingering (p 661). Without question, there is a role for testing of symptom validity in settings where there is an external incentive for the subject to malinger, and under these circumstances, tests of effort, symptom exaggeration, and malingering can prove helpful. In considering the uses and limitations of these tests, experienced forensic psychiatrists will want to have this book on their shelves.

• © 2013 American Academy of Psychiatry and the Law