Psychological Injury and Law

Beyond Rare-Symptoms Endorsement: a Clinical Comparison Simulation Study Using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) with the Inventory of Problems-29 (IOP-29) Abstract To date, the MMPI-based, rare-symptom detection strategy is considered one of the most effective ones in symptom validity assessment. Because many of the items of the Inventory of Problems-29 (IOP-29) were designed specifically to provide incremental validity over the MMPI F scales, this study tested whether using the IOP-29 in combination with the MMPI-2 would provide higher classification accuracy compared to using either instrument alone. A total of 155 Italian adult individuals contributed to this study. About half (n = 93) were experimental malingerers (expMAL) instructed to simulate depression without being detected as feigners. The others were either (a) depressed patients in treatment (n = 36) or (b) individuals evaluated for possible malingering associated with work-related stress and considered to be genuinely affected by depression (n = 26). All were administered the Italian versions of both the MMPI-2 and the IOP-29. As expected, both instruments were highly effective in discriminating feigned from bona fide depression, with AUC values ranging from .77 to .90. More importantly, when entering the IOP-29 after each of the MMPI-2 scales under consideration (i.e., F, Fb, and Fp), the logistic regression models predicting group membership (0 = patient; 1 = expMAL) improved significantly. Likewise, each of the three MMPI-2 scales under consideration also significantly improved the prediction of group membership, when entered after the IOP-29. These findings thus indicate that using the MMPI-2 together with the IOP-29 could provide incremental validity over using either instrument alone, when testing depression-related complaints.

Demographically Adjusted Validity Cutoffs on the Finger Tapping Test Are Superior to Raw Score Cutoffs in Adults with TBI Abstract This study was designed to develop validity cutoffs within the Finger Tapping Test (FTT) using demographically adjusted T-scores, and to compare their classification accuracy to existing cutoffs based on raw scores. Given that FTT performance is known to vary with age, sex, and level of education, failure to correct for these demographic variables poses the risk of elevated false positive rates in examinees who, at the level of raw scores, have inherently lower FTT performance (women, older, and less educated individuals). Data were collected from an archival sample of 100 adult outpatients (MAge = 38.8 years, MEducation = 13.7 years, 56% men) consecutively referred for neuropsychological assessment at an academic medical center in the Midwestern USA after sustaining a traumatic brain injury (TBI). Performance validity was psychometrically defined using the Word Memory Test and two validity composites based on five embedded performance validity indicators. Previously published raw score-based validity cutoffs disproportionately sacrificed sensitivity (.13–.33) for specificity (.98–1.00). Worse yet, they were confounded by sex and education. Newly introduced demographically adjusted cutoffs (T ≤ 33 for the dominant hand, T ≤ 37 for both hands) produced high levels of specificity (.89–.98) and acceptable sensitivity (.36–.55) across criterion measures. Equally importantly, they were robust to injury severity and demographic variables. The present findings provide empirical support for a growing trend of demographically adjusted performance validity cutoffs. They provide a practical and epistemologically superior alternative to raw score cutoffs, while also reducing the potential bias against examinees inherently vulnerable to lower raw score level FTT performance.

Post-Exertion Neuropsychological Testing in the Management of Sport-Related Concussion Abstract The objective of this study was to determine the effect of physical exertion on computerized neuropsychological test performance in high school athletes as part of concussion return-to-play protocols. ImPACT data and consultation records were retrospectively reviewed among athletes undergoing their physical stepwise progression for return-to-play following sport-related concussion. Two hundred forty athletes met inclusion criteria and participated in the study. 36.7% of concussed athletes who were symptom-free and had reached an advanced stage of their return-to-play protocol demonstrated cognitive decline following a moderate level of physical exertion. Cognitive changes occurred on all four cognitive ImPACT composites after physical exertion. There was no difference with respect to post-concussive symptoms among within RCI (W-RCI) and below RCI (B-RCI) groups. Return-to-play protocols should include post-exertion neuropsychological testing, as relying on athlete symptom report will miss a significant portion of athletes who are continuing to recover from sport-related concussion, putting them at additional risk for repeat or catastrophic injury.

What Attorneys and Factfinders Need to Know About Mild Traumatic Brain Injuries

The Importance of Demographically Adjusted Cutoffs: Age and Education Bias in Raw Score Cutoffs Within the Trail Making Test Abstract This study was designed to develop validity cutoffs by utilizing demographically adjusted T-scores on the trail making test (TMT), with the goal of eliminating potential age and education-related biases associated with the use of raw score cutoffs. Failure to correct for the effect of age and education on TMT performance may lead to increased false positive errors for older adults and examinees with lower levels of education. Data were collected from an archival sample of 100 adult outpatients (MAge = 38.8, 56% male; MEd = 13.7) who were clinically referred for neuropsychological assessment at an academic medical center in the Midwestern USA after sustaining a traumatic brain injury (TBI). Performance validity was psychometrically determined using the Word Memory Test and two multivariate validity composites based on five embedded performance validity indicators. Cutoffs on the demographically corrected TMT T-scores had generally superior classification accuracy compared to the raw score cutoffs reported in the literature. As expected, the T-scores also eliminated age and education bias that was observed in the raw score cutoffs. Both T-score and raw score cutoffs were orthogonal to injury severity. Multivariate models of T-score based cutoff failed to improve classification accuracy over univariate T-score cutoffs. The present findings provide support for the use of demographically adjusted validity cutoffs within the TMT. They produced superior classification to raw score-based cutoffs, in addition to eliminating the bias against older adults and examinees with lower levels of education.

The Effect of Menstrual Cycle Phase and Hormonal Contraceptive Use on Post-concussive Symptom Reporting in Non-concussed Adults Abstract Post-concussion symptoms are notoriously non-specific and overlap with menstrual symptoms. The goal of the present study was to investigate the relationship between symptoms at different points in the menstrual cycle. Forty-four females, 23 who used hormonal contraceptives, and 34 males completed the Post-Concussive Symptom Scale (PCSS) and the Depression, Anxiety, and Stress Scale on two occasions. There were substantial group differences with regard to test-retest reliability and agreement, with unacceptably low reliability on the PCSS for females on hormonal birth control. Eumenorrheic females had systematic changes in individual symptoms, whereas females taking hormonal contraceptives showed no differences over time. The results highlight the importance of considering hormonal influences in the assessment of post-concussion and psychiatric symptoms in females post-injury.

The Myth of High False-Positive Rates on the Word Memory Test in Mild TBI Abstract This study was designed to replicate previous reports of elevated false-positive rates (FPR) on the Word Memory Test (WMT) in patients with mild traumatic brain injury (TBI) and to evaluate previous claims that genuine memory deficits and non-credible responding are conflated on the WMT. Data from a consecutive case sequence of 170 patients with mild TBI referred for neuropsychological assessment were collected. Failure rate on the WMT was compared to that on other performance validity tests (PVTs). The clinical characteristics and neuropsychological profiles of patients who passed and those who failed the WMT and other PVTs were compared. Base rate of failure was the highest on the WMT (44.7%), but comparable to that on other established PVTs (39.4–41.8%). The vast majority of patients (94.7%) who failed the WMT had independent evidence of invalid performance, refuting previous estimates of 20–30% FPR. Failing the WMT was associated with globally lower scores on tests measuring various cognitive domains. The neurocognitive profile of individuals with invalid performance was remarkably consistent across various PVTs. Previously reported FPR of the WMT were not replicated. Failing the WMT typically occurred in the context of failing other PVTs too. Results suggest a common factor behind non-credible responding that is invariant of the psychometric definition of invalid performance. Failure on the WMT should not be discounted based on rational arguments unsubstantiated by objective data. Inferring elevated FPR from high failure rate alone is a fundamental epistemological error.

Geographic Variation and Instrumentation Artifacts: in Search of Confounds in Performance Validity Assessment in Adults with Mild TBI Abstract Regional fluctuations in cognitive ability have been reported worldwide. Given perennial concerns that the outcome of performance validity tests (PVTs) may be contaminated by genuine neuropsychological deficits, geographic differences may represent a confounding factor in determining the credibility of a given neurocognitive profile. This pilot study was designed to investigate whether geographic location affects base rates of failure (BRFail) on PVTs. BRFail were compared across a number of free-standing and embedded PVTs in patients with mild traumatic brain injury (mTBI) from two regions of the US (Midwest and New England). Retrospective archival data were collected from clinically referred patients with mTBI at two different academic medical centers (nMidwest = 76 and nNew England = 84). One free-standing PVT (Word Choice Test) and seven embedded PVTs were administered to both samples. The embedded validity indicators were combined into a single composite score using two different previously established aggregation methods. The New England sample obtained a higher score on the Verbal Comprehension Index of the WAIS-IV (d = .34, small-medium). The difference between the two regions in Full Scale IQ (FSIQ) was small (d = .28). When compared with the omnibus population mean (100), the effect of mTBI on FSIQ was small (d = .22) in the New England sample and medium (d = .53) in the Midwestern one. However, contrasts using estimates of regional FSIQ produced equivalent effect sizes (d: .47–.53). BRFail was similar on free-standing PVTs, but varied at random for embedded PVTs. Aggregating individual indices into a validity composite effectively neutralized regional variability in BRFail. Classification accuracy varied as a function of both geographic region and instruments. Despite small overall effect sizes, regional differences in cognitive ability may potentially influence clinical decision making, both in terms of diagnosis and performance validity assessment. There was an interaction between geographic region and instruments in terms of the internal consistency of PVT profiles. If replicated, the findings of this preliminary study have potentially important clinical, forensic, methodological, and epidemiological implications.

Use of Validity Indicators on the Personality Assessment Inventory to Detect Feigning of Post-traumatic Stress Disorder Abstract This study examined the ability of several Personality Assessment Inventory (PAI) validity indicators to detect feigning of post-traumatic stress disorder (PTSD). Participants included 491 individuals recruited through Amazon Mechanical Turk (MTURK): 44 participants were asked to feign PTSD, 25 participants carried a diagnosis of PTSD and demonstrated at least moderate levels of current symptom, and 422 served as control subjects. Results indicated that all of the PAI negative distortion validity indicators significantly distinguished the true PTSD from the feigned PTSD group. The indicators with the largest effect sizes were the Hong Malingering Function and the Multiscale Feigning Index, both of which demonstrated moderate sensitivity to feigned PTSD with specificity above 90%.

Correction to: Further Validation of the Test of Memory Malingering (TOMM) Trial 1 Performance Validity Index: Examination of False Positives and Convergent Validity Correction of mistake in the original version of this paper, "Further Validation of the Test of Memory Malingering (TOMM) Trial 1 Performance Validity Index: Examination of False Positives and Convergent Validity", the sentence "As indicated in Table 7, TOMM T1 ≤ 40 exhibited sensitivity of .86.

Alexandros Sfakianakis
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