Malingering of Psychiatric Problems, Brain Damage, Chronic ... · Brain Damage, Chronic Pain, and Controversial Syndromes in a Personal Injury Context Steve Rubenzer i. introduction

Malingering of Psychiatric ProbleMs

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Malingering of Psychiatric Problems, Brain Damage, Chronic Pain,

and Controversial Syndromes in a Personal Injury Context

Steve Rubenzer

i.introduction

Malingeringisdefinedas“theintentionalproductionoffalseorgrosslyexaggeratedphysicalorpsychologicalsymptoms,motivatedbyexternalincentives...”bytheAmericanPsychiatricAssociation(APA).1TheAPA’sDiagnosticandStatisticalManualfurtherstatesthat,“Malingeringshouldberuledoutinthosesituationsinwhichfinancialremuneration,benefiteligibility,andforensicdeterminationsplayarole.”2Treatingclinicians,however,maynotknowthatapatienthassuchmotivationssinceapatientmaynotdiscloseapend-inglawsuit.Moreover,intreatmentsettings,fewclinicianshavereasontosuspectfeignedsymptomsandfewhavesufficienttrainingortoolstoassesstheproblem.Notsurprisingly,theyrarelyfindit.3

1 aMerican Psychiatric association, diagnostic and statistical Manual of Mental disorders iV 739 (4th ed.1994) [hereinafterDSM-IV].2 Id.at467.3 EdwardJ.Hicklingetal.,Detection of Malingered MVA Related Posttraumatic Stress Disorder: An Investigation of the Ability to Detect Professional Actors by Experienced Clinicians, Psychological Tests, and Psychophysiological Assessment,2J. forensic Psychol. Prac. 33 (2002); J.Gordon,R.Sanson-Fisher&N.A.Sanders,Identification of Simulated Patients by Interns in a Casualty Setting,22Med. educ. 533 (1988).

fdcc Quarterly/suMMer 2006

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Treatmentproviderstendtotrusttheirpatients.Often,thereisnoreasonforthemtodootherwise.Arecentsurvey 4tellinglyquotedtheresponsesofseveralpainexperts:

“Ibelievepainiswhatthepersonsaysitis.”

“Ifhesaysheissuffering,thenheissuffering.”

“Painisasubjectiveexperience.Expertsinpainaretaughttobelievethepatient’sreports.Diagnostic tests are not as useful for pain conditions as othermedicalproblems.”

Twowriters,afterexamininganumberofPostTraumaticStressDisorder(PTSD)claim-antswhohadbeenheldhostageforthreehours,statedthat,“thevictimsinvolvedinthisincidentappeartohavebeengenuine,honestpeople....Theywerelargelyalaw-abidinggroupwhohadpreviouslyshownrespectfor,andtrustin,authority.”5Despitethefactthat

4 MarcusT.Boccaccinietal.,Evaluating the Validity of Pain Complaints in Personal Injury Cases: As-sessment Approaches of Forensic and Pain Specialists,6J. forensic Psychol. Prac. 51 (forthcoming).5 OscarE.Daly&TimothyG.Johnston,The Derryhirk Inn Incident: The Psychological Sequelae,15J. trauMatic stress 461, 463(2002).

Steve Rubenzer, PhD, ABPP, is a Diplomate of the American Board of Professional Psychology in Forensic Psychology. He developed his interest in malingering while assessing de-fendants for the criminal courts of Harris County (Houston, Texas) as a court appointed examiner, a position he held for almost ten years. His areas of expertise include assessment of competency to stand trial, sanity, malingering, personal injury, risk/dangerousness, personality and intelligence, the standardized field sobriety tests, eyewitness factors, and false confessions.


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allwereinvolvedinlitigation,noassessmentofmalingeringwasdeemednecessary.Therelianceonaclaimant’sapparentgoodcharacterisprobablyill-founded.Asurveyofuniver-sitystudents,presumablyalsowithoutsignificantcriminalhistories,foundthatforty-eightpercentindicatedtheywouldfakesymptomsfollowinganaccidenttorecovermoremoneyinapersonalinjurylawsuit.6 Treatmentproviderssometimeshavebeenveryreluctanttoacknowledgethepossibilityoffakingorexaggeration,evenwiththosepatientsinvolvedinlitigation.Arecentauthorita-tiveworkonchronicpaincontainsnochapteronmalingeringorexaggeration.7WhentheClinical Journal of Painpublishedarecentspecialissueonmalingeringinpainpatients,severalcontributorsopinedthatmalingeringisinfrequentinpainpopulations,althoughonegrudginglyadmittedthatratesmaybehigherinlitigatingpopulations.8Bycontrast,arecentsurveyofpsychologistswhoevaluatepainpatients involved in litigationestimated thatapproximatelythirtypercentwereengaginginexaggerationormalingering.9Whilesomeresearchershaveinvestigatedtechniquestodetectmalingering,treatmentissuesremaintheprimaryconcern(withadashofadvocacyasreflectedintheircharacterization):“Despitethesometimespressingneedtoacquireassessmentdatafromthevictim,theultimateissueisthevictim’s continuingwell-beingandtheimportanceofavoidinganyfurtherharm.”10

Incontrasttotreatingprofessionals,forensicpsychologistsconsidermalingeringas-sessmentacrucialelementof theircraftandroutinely test for it.Because thissituationpotentially places the examiner in opposition to the examinee’s interests, evaluation inforensicsettingsisviewedasaprofessionalspecialtythatisincompatiblewithprovidingtreatment.11Otherdifferencesbetweenforensicevaluators(whomaybeclinical,forensic,orclinicalneuropsychologists)andtreatingcliniciansaresummarizedinTable1(adaptedfromS.A.Greenberg&D.W.Shuman,1997).12

6 GrantL.Iverson,A Comment on the Willingness of People to Malinger Following Motor Vehicle or Work-Related Injuries, J. cognitiVe rehab.,May/June1996,at10.7 handbook of Pain assessMent (DennisC.Turk&RonaldMelzackeds.,2ded.2001).8 MarkSullivan,Exaggerated Pain: By What Standard?,20clinical J. Pain 433 (2004).9 WileyMittenbergetal.,Base Rates of Malingering and Symptom Exaggeration,24 J. clinical & ex-PeriMental neuroPsychol. 1094 (2002).10 John briere, Psychological assessMent of adult PosttrauMatic states 59 (AmericanPsychologicalAssociation2002)(emphasisadded).11 StuartA.Greenberg&DanielW.Shuman,Irreconcilable Conflict between Therapeutic and Forensic Roles,28J. Prof. Psychol.: res. & Prac.50(1997).12 Id.


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Table 1DifferencesbetweenTreatmentandForensicRolesinPsychology

Therapists ForensicExaminers

TheClientIdentified Patient AttorneyortheCourt

Goals Providetreatmentandsupport

Objectivelyevaluateadefendantorclaimant

Data AcceptwhattheclientsaysCorroborateorrefuteexaminee’sstatementswithcollateralinformation

Emphasis Treatment;“helping” Assessmentofpsycho-legalissueatstake

Trust Assumebasichonestyofpatient

Donotblindlytrustanysource

Accountability Anticipatelittlechallengetoconclusions,diagnoses

Anticipatecross-examina-tion,consideralternativehypotheses,explanations

Privilege Governedbytherapist-clientprivilege

Governedbyattorney-clientprivilege,ifany

Knowledgeoflegal issues

Maybeunawareoflegalstandardsorrulesofevidence

Familiarwithcaselawgov-erningtheissuetobead-dressed,(i.e.,Daubert and FederalRulesofEvidencestandards)

Attitude AvoidcourtappearancesAcceptlegalproceedingsaspartofthework;developtestimonyskills


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This articlewill review issues pertaining tomalingering psychiatric and cognitiveimpairmentinapersonalinjurycontext.Assuch,itwilldiscussthetechniquesavailableandexaminesyndromeswheredefensecounselfrequentlymayfacepsychiatricfakingorexaggeration:headinjury,PTSD,depression,chronicpain,andcontroversialdiagnoses.

ii.assessing for Malingering

Beforeproceeding,itisimportanttounderstandthatnotalldramatizationoreveninten-tionalfailurenecessarilyqualifiesasmalingering.Factitious disorderinvolvestheintentionalproductionofsymptoms,butonlyforthepurposeofbeingtreatedasasickperson–notexternalincentivesasinmalingering.However,thediagnosesarenotmutuallyexclusive.Forexample,amanwhofearslosinghiswifemightexaggeratehishealthproblemsinordertogainhersympathy.Ifthiscontinuesovertime,hiswifemaypresshimtoapplyfordis-abilityortolitigateinordertocompensateforlossofincome.Insuchacase,thehusbandmayhavenointerestinthefinancialoutcome,buthemayfearexposuretohiswife. Twootherdiagnosticpossibilitiesincludeconversion disorder and somatoform disorder.Inconversiondisorder,itisthoughtthatthesymptomisproducedunconsciouslyaspartofahystericalpersonalitystyletocopewithapsychologicalconflict.However,thisproposi-tionhasneverbeenrigorouslytestedanditisquitepossiblethatevensuchpersonalitiesareawareoftheirexaggerations.Insomatoformdisorder,thesymptomsarebelievedtobepartofaneuroticpersonalitystylethatindirectlyexpressesneedsfornurturancethroughbodilycomplaints.Thus,thedesiredrewardisattentionorsympathyfromfamilymembers,friends,ormedicalstaff.Analternative,lesspsychodynamicexplanationisthatsuchper-sonsarebiologicallydisposedtoexperiencemorenegativeemotionsandnegativebodilysensationsthanmostpeople.Peoplewhoareneurotictendtoberelativelydissatisfiedwiththeirhealth,aswellastheiremploymentormarriage.13Theymaywellexperiencemoreunpleasantbodilysensationsthanmostpeople,particularlyastheyapproachmiddleage–ortheymayjustcomplainmorethanothers. Thoroughassessmentofmalingeringusuallywillinvolvemultipleinterviewswiththeclaimant (asopposed to“patient”), reviewofpreviousmedicalandpsychiatric records,interviewsof familymembersandcollateralswithnoapparent loyalty to theexaminee(e.g.,ex-wife,ex-employer),andspecializedpsychologicaltesting.Observationsbeyondtheexaminationroomalsocanbeveryrevealing.Althoughfamilymemberscanbeveryuseful,thepossibilityofcollusionwiththeplaintiffmustbeconsidered,andfamilymembersalmostalwaysshouldbeinterviewedseparatelyfromeachotherandtheclaimant. Twotypesoftestingarelikelytobeusefulinapersonalinjurycontext.Theseincludeself-reporttestsofsymptomexaggerationandperformancetestsofintentionalpoorperfor-manceorincompleteeffort.

13 robert r. Mccrae & Paul t. costa, Jr., Personality in adulthood (2d ed. 2002).


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A. Self-Report Tests of Symptom Exaggeration TestssuchastheMinnesotaMultiphasicPersonalityInventory-2(MMPI-2)askhun-dredsofquestionsaboutpsychiatricsymptomsandproblems.Thetestitselfhasanumberofembeddedindicesofresponseconsistencyandbias.Therearescalesthatarequitesensitivetosomeformsofbothfakinggood(denyinganyfaultsorproblems)andfakingbad(exag-geratingorfakingsymptoms).Someoftheseindicesareautomaticallyscoredbytheprimarysoftwarevender,butsomearenot.Theclassic“fakebad”scaleistheInfrequency(F)scale,consistingofitemsthatarerarelyendorsedbypeoplewithoutpsychiatricillness.Itcontainssomeitemssuggestiveofpsychosis,butalsocontainsmanyitemsthatarejustoddandnotcloselyassociatedwithanyclinicalsyndrome.Althoughthereisampleevidencethatpersonswhofeignpsychosisscoremuchhigherthanbothnormalsandpsychiatricpatients,variousstudiesontheFscalerecommendwidelyvaryingcut-scorestoseparatehonestrespondersfrommalingerers.Thisisproblematic,asisthefactthattheFscalecontainsmanyitemsthatarereflectiveoftruementalillness.TheInfrequency-Psychopathology(Fp)scalewascre-atedtoovercometheselimitations.Ithasproducedconsistentcut-scoresacrossstudiesandhasdemonstratedeffectivenessatdistinguishingtruefromfeigneddepressionaswell.14

Personalinjuryclaimantsoftenreportmemoryandbodilysymptomstoagreaterdegreethanseverepsychiatricproblems.ThosewhoexaggeratetendtomaintainthesamepatternbuttoproducemoreelevatedMMPI-2profilesingeneral.15Anumberofstudieshaveex-aminedtheabilityofvariousMMPI-2scalestodistinguishlegitimatefromfeignedbraininjuries,chronicpain,andPTSD.Theresultsindicatethatthebest-establishedtraditionalvalidityindexes(F,F-K,Fp)arenotverysensitivetoexaggerationoftheseconditions.Thismaybebecausetheindexesmostlycontainitemssuggestingpsychosisorextremedeviance,neitherofwhichalitigatingplaintiffwantstoportray.Amoredesirablepresentationisthatofagood,upstandingpersonwhohassufferedaverybadinjury.Onesuch“aftermarket”index,theFakeBadScale(FBS),wasdevelopedspecificallyforpersonalinjuryclaimantsandhasshownconsiderablesuccessindistinguishingfeignedheadinjuries,16chronicpain,17

14 RichardRogersetal.,Detection of Feigned Mental Disorders: A Meta-Analysis of the MMPI-2 and Malingering,10assessMent160(2003).15 Id.16 ScottR.Rossetal.,Detecting Incomplete Effort on the MMPI-2: An Examination of the Fake-Bad Scale in Mild Head Injury,26J. clinical & exPeriMental neuroPsychol.115(2004);ChantelS.Dearthetal.,Detection of Feigned Head Injury Symptoms on the MMPI-2 in Head Injured Patient and Community Controls,20archiVes clinical neuroPsychol.95(2005);M.FrankGreiffensteinetal.,The Fake Bad Scale in Atypical and Severe Closed Head Injury Litigants,58J. clinical Psychol.1591(2002).17 GlennJ.Larrabee,Exaggerated Pain Report in Litigants with Malingered Neurocognitive Dysfunction,17clinical neuroPsychologist395(2003)[hereinafter Exaggerated Pain Report];GlennJ.Larrabee,So-matic Malingering on the MMPI and MMPI-2 in Personal Injury Litigants,12clinical neuroPsychologist 179(1998);JohnE.Meyersetal.,A Validity Index for the MMPI-2,17archiVes clinical neuroPsychol. 157(2002).


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mixedpersonalinjuryclaimants,18and(insomestudies)PTSD.19WhiletheFBSscalehasengenderedsomerecentcontroversy,20therearemanypublishedstudiesandarecentmeta-analysisthatsupportitsvalidityanduseinforensicsettings.21 SeveralotherMMPI-2indiceshavebeenshownuseful.TheseincludetheDsscale(anditsshortform,Dsr),whichassesserroneousstereotypesofneuroticmentalillness,andtheEgoStrengthscale,whichreflectsemotionalstabilityandresilience.WhiletheEgoStrengthscaleandthetraditionalvalidityscalesarescoredbytheprimarysoftwarevenderfortheMMPI-2,theFBSandDs/Dsrarenot.Thoroughassessmentofsymptomover-reportinginconditionssuchasheadinjury,PTSD,andchronicpainrequiresuseofthesespecial-izedMMPI-2scalesinadditiontoF,F-K,andFp.AnexaminershouldnotconcludethatanMMPI-2is“valid”inapersonalinjurysettingsimplybecausethetraditionalvalidityindictorsarenotelevated.Infact,onecouldarguethattheexaminershouldnevermakesuchastatementsinceitispossiblethatsuccessfulcoachingmightresultinaninaccuratepresentationthatescapesdetectiononanyofthevalidityindices.

18 WilliamT.Tsushima&VincentG.Tsushima,Comparison of the Fake Bad Scale and Other MMPI-2 Validity Scales with Personal Injury Litigants,8assessMent205(2001);GlennJ.Larrabee,Detection of Symptom Exaggeration with MMPI-2 in Litigants with Malingered Neurocognitive Dysfunction,17clinical neuroPsychologist54(2003);GlennJ.Larrabee,Exaggerated MMPI-2 Symptom Report in Personal Injury Litigants with Malingered Neurocognitive Deficit,18archiVes clinical neuroPsychol.673(2003).19 M.FrankGreiffensteinetal.,The Fake Bad Scale and MMPI-2 F-Family in Detection of Implausible Psychological Trauma Claims,18clinical neuroPsychologist573(2004);PaulR.Lees-Haley,Efficacy of MMPI-2 and MCMI-II Modifier Scales for Detecting Spurious PTSD Claims: F, F-K, Fake Bad Scale, Ego Strength, Subtle-Obvious Subscales, DIS, and DEB,48J. clinical Psychol.681(1992).20 JimN.Butcheretal.,The Construct Validity of the Lees-Haley Fake Bad Scale (FBS): Does the Scale Measure Somatic Malingering and Feigned Emotional Stress?,18archiVes clinical neuroPsychol.473(2003);PaulR.Lees-Haley&DavidD.Fox,Commentary on Butcher, Arbisi and McNulty (2003) on the Fake Bad Scale,19archiVes clinical neuroPsychol. 333(2004);KevinW.Greve,Response to Butcher et al., The Construct Validity of the Lees-Haley Fake Bad Scale ,19archiVes clinical neuroPsychol. 337(2004);PaulA.Aribisi&JamesN.Butcher,Failure of the FBS to Predict Malingering of Somatic Symptoms: Response to Critiques by Greve and Bianchini and Lees-Haley and Fox,19archiVes clinical neuroPsychol.341(2004).21 Lees-Haley&Fox,supranote20.See alsoNathanielW.Nelson,JerryJ.Sweet,&GeorgeJ.Demakis,Meta-Analysis of the MMPI-2 Fake Bad Scale: Utility in Forensic Practice, 20 clinical neuroPsycholo-gist39-58(2006).


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Table 2SomeMajorMMPI-2IndexesUsedtoDetectMalingering

Index Description TypicalCut-Score

F

(InfrequencyScale).Itemsthatarerarelyendorsedby“normal”peoplewhoarenotpsychiatricpatients.Maybeelevatedbycarelessrespondingorintentionalfakingofpsychiatricdisorder,especiallypsychosis.

>80

F(b)

SameasFscale,butdesignedforitemsonthebacksideoftheanswersheet.Helpsidentifyprotocolswherethesubjectlosesinterestmid-wayandrandomlycompletestheremainingtest.

>80

F(p)Itemsthatarerarelyendorsedbypsychiatricpatients–amorespecificversionofF;includesfewerlegitimatesymptomsofpsychiatricillnessthanF.

>75

KAmeasureofdefensiveness;possiblymorestableandenduringthanL(notduetoimpressionmanagement).Itisinverselyrelatedtomalingering.

< 35

F-K TherawscoreofKsubtractedfromtherawscoreofF. > 5 R

O-SThesumof“obvious”items(“Ihearvoices”)minusthesumofsubtleitems(“IthinkWashingtonwasgreaterthanLincoln”).

> 140

Ds/Dsr(DissimulationScaleanditsshortform).Itemsthatreflecterroneousstereotypesofneuroticism(vs.seriousmentalillness).

>35 R>70T

Es(EgoStrength).Lowscoresindicatethatthesubjectreportedhe/shelacksemotionalstabilityandresilience.Verylowscoressuggestexaggeration.

< 20

FBS

(FakeBadScale).Designedtoidentifyfakinginpersonalinjuryclaimants;itsitemsincludereportsofbodilycom-plaintscombinedwithaportrayalofoneselfasanhonestandvirtuousperson.

>20-27R

MVI(Meyer’sValidityIndex).Anindexcreatedbyassigning1or2pointstoindicationsonsevenotherindices,suchasF,FBS,andDs.

> 5 R

RBS (ResponseBiasScale).CreatedbyidentifyingitemsthatcorrelatewithfailureontheWordMemoryTest. > 21 R


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ScoresinthistableareTscores(Mean=50,SD=10),unlessotherwisenoted(“R”–rawscore).Mostcut-scoresinthistablearetakenfromGreve,2005.Someauthorsutilizecon-siderablyhighercut-scores,especiallyfortheFscales. Otherinstrumentsthatareusefulforevaluatingover-reportingorexaggerationinothercontextsincludetheStructuredInventoryofReportedSymptomsandtheMillerForensicAssessmentofSymptomsTest(bothstructuredinterviews)aswellasthePersonalityAssess-mentInventory.However,alloftheseinstrumentsweredevelopedandvalidatedprimarilytodetectfeignedpsychosisandnotthekindsofcomplaintstypicalofpersonalinjuryplaintiffs.Atthispoint,theMMPI-2hasnorealrivalsfordetectingover-reportingofsymptomsinpersonalinjurysettings,exceptforpatientswithchronicpaincases.22

B. Performance Tests of Suboptimal Effort/Motivated Failure Thesecondtypeoftestinginvolvesassessingtheeffortexpendedontaskswhichrequiretheexamineetosolveamentalproblem,rememberinformation,orexhibitacompetence.Neuropsychologicalandintelligencetestsassumethatthetest-takerputsforthhisorherbesteffort.Thisassumptionishighlysuspectinsituationswhereacriminaldefendantmaybefoundeligibleforthedeathpenaltyoracivilplaintiffmaybeineligibleforcompensationasaresultofgoodperformanceonatest.Therehasbeenavirtualexplosionofinterestanddevelopmentoftestsdesignedtodetectinadequateeffortorintentionalfailure.Mostaremoderatelysensitive(theywilldetectmostthoughnotallfeigners)buthighlyspecific(fewifanylegitimatepatientswillfailthem).Forthisreason,usingatleasttwoandpreferablythreeefforttestsisrecommended.23However,tworecenttestshaveshownperfectsensitivityandspecificityinpublishedstudies.Thisistrulyamilestone.Nonetheless,giventhepos-sibilityofcoachingbyplaintiffs’attorneys24asthespecifictestsbecomebetterknown,itisalsoprudenttoutilizemalingeringindicesthatareembeddedwithintraditionaltests,suchastheWAIS-III.Severalsuchindiceshavebeencross-validatedanddemonstrateaccuracyofclassificationintheseventy-fivetoeighty-fivepercentrange.25

22 SeeSectionF.,infra.23 NationalAcademyofNeuropsychologyPolicy&PlanningCommittee(2005),Symptom Validity Assess-ment: Practice Issues and Medical Necessity,20archiVes clinical neuroPsychol.419(2005);JohnE.Meyers&MarieE.Volbracht,A Validation of Multiple Malingering Detection Methods in a Large Clinical Sample,18archiVes clinical neuroPsychol.261(2003);GlennJ.Larabee,Detection of Malingering Us-ing Atypical Performance Patterns on Standard Neuropsychological Tests,17clinical neuroPsychologist 410(2003);ChadD.Vickeryetal.,Head Injury and the Ability to Feign Neuropsychological Deficits, 19 archiVes clinical neuroPsychol.37(2004).24 MarthaW.Wetter&SusanK.Corrigan,Providing Information to Clients about Psychological Tests: A Survey of Attorneys’ and Law Students’ Attitudes,26Prof. Psychol.: res. & Prac.474(1995).25 KevinW.Greveetal.,Detecting Malingered Performance on the Wechsler Adult Intelligence Scale: Validation of Mittenberg’s Approach in Traumatic Brain Injury,18archiVes clinical neuroPsychol.245(2003).


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Sincespecificinformationaboutdetectingpooreffortcouldgreatlyfacilitatecoachingifitfellintothewronghands,thisarticlewillnotprovidesuchmaterialandwillotherwiseprovideonlyselectedreferences.Asanalternative,thearticlewillfamiliarizethereaderwithsomeofthefactorsthatshouldbeconsideredwhenreviewingapsychologicalorneu-ropsychologicalreport.Italsowillprovideguidelinesforselectinganappropriateexpert,suggestingquestionstoposeattheoutsetbeforeretainingsuchanexpertaswell. Therecurrentlyareanumberofspecialized,well-researchedtestsdesignedtodetecteffort or intentional failure. Someof the best validated instruments include theTest ofMemoryMalingering,theWordMemoryTest,theComputerizedAssessmentofResponseBias,thePortlandDigitRecognitionTest,andtheVictoriaSymptomValidityTest.Asidefromheadinjury,patientswithmanyconditions(depression,chronicfatigue,chronicpain,fibromylagia)complainofcognitivesymptoms,especiallypoormemoryandconcentration.Theyalsoshowsubstantialratesofapparentmalingeringonefforttestswhenassessedinthecontextoflitigation(seeTable3).Forthesereasons,efforttestsshouldbeincludedinanyevaluationofmemoryorcognitivecomplaintsorwhentestresultsareusedtomakesuchclaims.

Table 3RateofApparentMalingeringinVariousDiagnosticGroupsinLitigation

Mildheadinjury 42% FibromylagiaorChronicFatigueSyndrome 39% Pain/somatoformdisorder 33% Neurotoxicdisorders 29% Electricalinjury 26% DepressiveDisorders 16% Moderate&severeheadinjury 9%

AdaptedfromMittenbergetal.(2002)26

iii.assessing coMMon clinical syndroMes for

exaggeration or Malingering

A. Traumatic Brain Injury Unliketheotherconditionsdiscussedbelow,cognitivedeficitsoftenaretheprimaryclaimfordamagesinallegedbraininjury.Thoroughneuropsychologicalassessmentwill

26 WileyMittenbergetal.,Base Rates of Malingering and Symptom Exaggeration,24J. clinical exPeri-Mental & neuroPsychol.1094(2002).


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likelybenecessary,andthisshouldalwaysentailassessmentofeffortandintentionalfailure.TheNationalAcademyofNeuropsychologyrecentlyissuedaformalpolicystatementthatsymptomvalidity(effort)testingismedicallynecessaryforallneuropsychologicalevalua-tions.27Performanceonneuropsychologicalmeasuresofattention,memory,andothercogni-tiveandmotorfunctionsdependgreatlyontheamountofeffortexpended;intheabsenceofdemonstratedgoodeffort,resultsmaybemeaninglessorhighlymisleading.28 Therearetwomajortypesofbraininjuries:closedheadinjuries,inwhichtheskullisnotbreached,andopenheadinjuries,suchasthosethataccompanyagunshotwoundtothehead.Paradoxically,closedheadinjuriescanbemoreseriousbecausetheytypicallyaffectlargerportionsofthebrain.Becausethebrainisgelatinousandnotsecurelyattachedtotheskull,amotorvehicleaccidentorothersharpblowtotheheadcanresultininjuriesthroughout thebrainas it literallybouncesoff the insideof theskullandshearsneuralconnectionstothespinalcordandlowerbraincenters.Thisarticlewillfocusprimarilyonclosedheadinjuries. Head injuries are classified in terms of their severity according to several factors.Amongthemostimportantaremedicalfindings(CT,MRIscans);thelengthofanyperiodofunconsciousness;theperiodofpost-traumaticamnesia(periodofmemorylossfollowingtheinjury);andthelengthoftimeaftertheinjuryuntilthepatientiscapableoffollowingaverbalcommand.Increasingly,emergencyroomsandhospitalsformallyrecordtheseob-servationsintheformofastandardizedscalesuchastheGlasgowComaScale.Mildheadinjuriesarethosethatresultinlessthanone-halfhourofunconsciousness,aGlasgowComaScalescoreofthirteentofifteen,anddonotproduceabnormalfindingsontheCATorMRIscan.Sincesuchclaimsoftenwillbemadeintheabsenceofobjectivemedicalfindings,andevidenceofsubstantialratesofexaggerationormalingeringexistsinthispopulation,29 thisarticlewillfurtherfocusonmildheadinjuries. VictimsofheadinjuriesoftenarereportedtosufferfromPostconcussion Syndrome. Itssymptomsincludememorydifficulties,fatigue,headaches,confusion,difficultiesmultitask-ing,anddepression.Notsurprisingly,whensuchsymptomsfollowaheadinjury,theyareoftenattributedtothiscause.Recentresearch,however,findsthatthelevelofpostconcus-sionsymptomsisnotpredictedbyseriousnessofheadinjurybutbythepatient’sdegreeofdepression.30Infact,thesamegroupofsymptomsappearinanumberofill-definedand

27 NationalAcademyofNeuropsychologyPolicyandPlanningCommittee,supra note23.28 PaulGreenetal.,Effort Has a Greater Effect on Test Scores than Brain Injury in Compensation Claim-ants,15brain inJury1045(2001);PaulGreenetal.,The Word Memory Test and the Validity of Neuropsy-chological Test Scores,2J.forensic neuroPyschol.97(2002).29 Mittenbergetal.,supranote26.30 JohnGunstad&JulieA.Suhr,“Expectation as Etiology” versus “The Good Old Days”: Postconcus-sion Syndrome Symptom Reporting in Athletes, Headache Sufferers, and Depressed Individuals,7J.int’l neuroPsychol. soc’y323(2001);JohnGunstad&JulieA.Suhr,Factors in Postconcussion Syndrome Symptom Report,19archiVes clinical neuroPyschol.391(2004).


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controversialdisorders.31Symptomssuchasreportedmemoryproblemsandothersassoci-atedwithpostconcussionsyndromearenotspecifictoanyparticulardisorderandhavelittleornodiagnosticvalue. Intheoverwhelmingmajorityofcases,theexpectedoutcomefromamildtraumaticbraininjury(withnoabnormalityonmedicaltestsorsubsequentcomplication)iscompleterecoverywithinthreemonths.32Althoughtherehavebeensomereportsofpersistingdefi-citsinconcentrationormemorypastthistime,suchdeficitsdisappearwhenpatientswhofailefforttestsareexcludedfromthegroup.33Psychologistshaveonlyrecentlytakenfullaccountofhowmalingeringorexaggerationmayhavecontaminatedpreviousconclusionsaboutthecourseofrecoveryfromheadinjury.Ifone-thirdofsuchpatientsaremalingering,thiscouldeasilyresultinthefalseconclusionthatpersistingdeficitsarecommon. Amongthemostimportantpiecesofdatainassessingheadinjuryaretheemergencyroomrecords.Theseshouldindicateobservationsofthepatientintheimmediateaftermathoftheinjury.Bydefinition,ifthepatientisalert,responsive,andnotconfusedwithinthefirsthalfhour;doesnotshowaskullfractureorabnormalCATorMRI;anddoesnotex-perienceasubsequentcomplicationsuchasahematoma,theheadinjuryismildandfullrecoverytopreviouslevelsoffunctioningisexpected.Itisnotuncommonforthosewhoexaggerateormalingertomisreporttheirlevelofimpairmentduringthefirstfewdaysorweeksfollowingtheinjury.Andalthoughthispaperwillfocusonmildtraumaticheadinjury(MTBI),itshouldbenotedthatevensomepatientssufferingmoderateandsevereinjuriesmayexaggerateorfake,asseveralrecentcasestudieshavedemonstrated.34

Theamountofimpairmentfromaheadinjuryshouldbeproportionatetoitsseverity:amildheadinjuryshouldproducemilddeficits(ifany);asevereinjury,moresignificantones.Intheabsenceofasubsequentcomplication,theexpectedrecoverycoursefromaheadinjuryisoneofprogressiveimprovement–impairmentshouldbeworstimmediatelyaftertheinjuryandimprovementshouldbefairlysteady.Thisdoesnotapply,ofcourse,ifapatientsubsequentlydevelopsahematoma(bloodmass),andmaynotapplyifdepressioncomplicatesthepicture.Inthelattercase,ofcourse,thedeficitsobservedshouldnotbeattributedtobraindamage.

31 LaurenceM.Binder,Forensic Assessment of Medically Unexplained Symptoms,in forensic neuroPsy-chology: a scientific aPProach 298(GlennJ.Larrabeeed.,2005).32 DavidJ.Schretlen&AnneM.Shapiro,A Quantitative Review of the Effects of Traumatic Brain Injury on Cognitive Functioning,15int’l reV. Psychiatry341(2003);LaurenceBinderetal.,A Review of Mild Head Trauma Part 1: Meta-analytic Review of Neuropsychogical Studies,19J. clinical & exPeriMental neuroPsychol.421(1997);SureyyaS.Dikmanetal.,Neuropsychological Outcome at 1-year Post Head Injury,9neuroPsychology80(1995).33 Greenetal.,supranote28.34 KevinJ.Bianchinietal.,Definite Malingered Neurocognitive Dysfunction in Moderate/Severe Traumatic Brain Injury,17clinical neuroPyschologist574(2003).


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Therearenumerousvalidatedtechniquestoassessthegenuinenessofaheadinjuryclaimant’spresentation.Typically,neuropsychologicaltestingwillbethemajorfocusofa psychologist’s evaluation in a head injury case.Neuropsychological testing involvesassessmentofintellectual,motor,andcognitivefunctionssuchasattention,memory,andperception.Atypicalassessmentmaytakemorethantwelvehoursandinvolvemanytests,someofwhichhavedozensofindividualindices.Thereisincreasingevidencethat,whenformallyevaluated,patternsofperformancewithintestscanidentifythosewhoexagger-ateorfakewithmoderatelyhighlevelsofsensitivityandspecificity.Specificindiceshavebeenidentifiedandcross-validatedfortheWechslerAdultIntelligenceScale-IIIandtheCaliforniaVerbalLearningTest,twoverypopularneuropsychologicalinstruments.Some-timesapatientwillprovidehighlyunusualresponsesthatcanserveasredflagsofatypicalperformance.SuchindicatorshavebeenidentifiedforthepopularTrailMakingTestandtheWechslerMemoryScale-III.Theseanomaliesarehighlyspecific(highlydiagnosticoffakingwhentheyoccur),butareproducedbyrelativelyfewmalingerers.Thus,theyhavelowsensitivity.Relyingononlyoneorafewsuchindicatorswillfailtoidentifymanyofthosewhodonotexerttheirbesteffort. Ifmultipleevaluationshaveoccurred,comparisonsbetweenthetwoormoreevalua-tionscanbehighlyinformative.Formalresearchusingbothtestscoresanditemresponses,comparedacrossthetwoadministrations,hasdisplayedperfectclassificationinonestudy—somethingrarelyachievedinpsychologicalresearch. Althoughmosttestsemployedtoassessbraindamageareperformance-basedmeasures,thereisanincreasingroleforself-reportinventoriessuchastheMMPI-2.Althoughthetra-ditionalvalidityindiceshavepoorsensitivitywhenusualcut-scores(whichweredevelopedfordetectingfeignedpsychosis)areused,theycanperformrespectfullywhencut-scoresderivedinpersonalinjurysettingsareimplemented.35TheFBSscalehasbeenthesubjectofnearlyadozenstudieswithgenerallypositiveresults,andsomehavefoundittobethebestresponsebiasscaleforheadinjuryclaimants.36SeveralstudiesalsohavefoundtheDsrscaletobequiteuseful.37

35 KevinW.Greveetal.,Sensitivity and Specificity of MMPI-2 Validity Scales and Indicators to Malingered Neurocognitive Dysfunction in Traumatic Brain Injury,20clinical neuroPsychologist(forthcoming).36 Larrabee,supranote18; Griffensteinetal.,supranote19;Rossetal.,supranote16.37 Greve,etal.,supranote25;Dearthetal.,supranote16;Larrabee,supranote18.


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B. PTSD When introduced in theDiagnosticandStatisticalManual-III (DSM-III) in1980,adiagnosisofPTSDrequiredastressorthatwaslife-threatening,beyondordinaryhumanexperience,andlikelytoevokesignificantdistressinnearlyeveryone.InDSM-IV,thecri-teriaweremodifiedtoincludesomeone“whoexperienced,witnessed,orwasconfrontedwithaneventoreventsthatinvolvedactualorthreateneddeathorseriousinjury,orathreattothephysicalintegrityofselforothers[if]theperson’sresponseinvolvedintensefear,helplessness,orhorror.”38OriginallyproposedintheVietnameratocovercombatveterans,39 “criterioncreep”hadledtosuitsallegingPTSDduetosexualharassmentorexposuretorepeatedfoullanguageatwork–andthelatterwassuccessfultothetuneof$21million.40 Despiteanenthusiasticembraceby“traumatologists,”morescholarlyprofessionalshaveemphasizedthepoliticaloriginsofthediagnosisandnumerousfactsandfindingsthatcon-tradicttheclinicians’assumptions.41 Publishedestimatesofmalingeringratesfollowingpersonalinjuryvaryfromonetooverfiftypercent.42FollowingtheVietnamWar,thegovernmentprintedflyerstohelpveteransrecognizecharacteristicsymptomsandpromptthemtoapplyforallocatedbenefits.AmongthesymptomsofPTSDintendedforlistingwas“survivor’sguilt.”However,aprintingerrorinoneregionresultedinanumberofveteranswhoshoweduptofiletheirclaimscarry-ingtheir“survivor’squilt.”SomeveteransclaimingPTSDhavebeenfoundnevertohaveexperiencedcombator,insomecases,nevereventohavebeeninthearmedservices.43

Almostfromthebeginning,observershavecommentedonthetendencyofPTSDpatientstoproduceevaluatedscoresonMMPIvalidityindices.Atfirst,manyviewedthisasafunctionoftheseverityofthedisorderandthevarietyofitssymptoms.Overtime,however,otherscommentedthattheextremelypathologicaltestscoresobservedwereinconsistentwiththe

38 DSM-IV,supranote1,at 467.39 BenShepard,Risk Factors and PTSD: A Historian’s Perspective, in PosttrauMatic stress disorder: issues and controVersies 39(G.M.Rosened.2004);D.ChristopherFruehetal.,Unresolved Issues in the Assessment of Trauma Exposure and Posttraumatic Reactions, at63.40 RichardJ.McNally,Conceptual Problems with the DSM-IV Criteria for Posttraumatic Stress Disorder,in PosttrauMatic stress disorder: issues and controVersies 1(G.M.Rosened.2004).41 Id.42 JenniferGuriel&WilliamFremouw,Assessing Malingered Posttraumatic Stress Disorder: A Critical Review,23clinical Psychol. reV.881(2003).43 RichardJ.McNally,Progress and Controversy in the Study of Posttraumatic Stress Disorder,54ann. reV. Psychol. 229(2003);B.ChristoperFruehetal.,Apparent Symptom Overreporting in Combat Veterans Evaluated for PTSD,20clinical Psychol. reV.853(2000);Jeannine;Monnier,ToddBKashdan,JulieASauvageot.MarkBHamner,B.G.Burkett,&GeorgeW.Arana,Documented Combat Exposure of US Veterans Seeking Treatment for Combat-Related Post-Traumatic Stress Disorder, 186 brit. J. Psychiatry 467-72(2005).


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outpatientstatusofmostPTSDpatients,andthatthedisabilityratefarexceededthatseeninpreviouswarsortragedies.44IntheAleutian Enterprisesinking,eighty-sixpercentofsurvivorsreportedPTSDsymptoms,farexceedingthemoretypicalfiguresoftwenty-fivetofortypercentinsimilartragedies.Post-litigationinterviewswiththeseclaimants,however,foundthatmosthadcommunicatedwithotherclaimantsandwerecoachedbyattorneys.45

Adistinctliteraturehasdevelopedforsurvivorsofmotorvehicleaccidents.46Likemanytreatingclinicians,theseauthorsappearoverlytrustingabouttheirpatients’honesty:theydiscountMMPI-2findingsbelievingtheymayfalselylabeltheirpatientsasexaggeratinganddonotcollectmedicalrecords—althoughtheyadviseotherstodoso.47 TheliteratureonPTSDmaybebadlycompromisedbythefailureofresearcherstorigorouslyscreenformalingeringamongpresentingpatients.48Thisfailurepotentiallycon-taminatesmuchofwhatisknownaboutthedisorder.Forexample,onecorrelateofPTSDisantisocialpersonalitydisorder,whichdenotesapersonalitystylemarkedbydeception,exploitation,andsubstanceabuse.AuthorsoftenrefertoantisocialbehavioranddruguseasaconsequenceofPTSDwithoutmakinganyseriousattempttodetermineifsuchtraitswerepresentbeforetheallegedinjury.Further,antisocialpersonalitydisorderisoneoffourDSM-IVindicatorsofpotentialmalingering.Thefailuretoconsidermalingeringhasresultedinapublishedrecommendationthatjournaleditorsdemanddisclosureofthelitigationstatusofstudyparticipants,andthatthosewithincentivestoexaggeratebeidentifiedand(ataminimum)analyzedseparatelyfromthosewithoutsuchmotivations.49Somegeneralindica-torsofpossiblePTSDmalingeringarelistedinTable3.Withtheexceptionof“unvarying,repetitivedreams,”theseapplytootherdisordersaswell.

44 Id.45 GeraldM.Rosen,The Aleutian Enterprise Sinking and Posttraumatic Stress Disorder: Misdiagnosis in Clinical and Forensic Settings,26Prof. Psychol.: res. & Prac.82(1995).46 edward b. blanchard & edward J. hickling, after the crash: Psychological assessMent and treat-Ment of surViVors of Motor Vehicle accidents (2ded.2004).47 Id.48 GeraldM.Rosen,Malingering and the PTSD Data Base,in PosttrauMatic stress disorder: issues and controVersies 85(G.M.Rosened.2004);GeraldM.Rosen,Litigation and Reported Rates of Post-traumatic Stress Disorder,36Personality & indiVidual differences 1291(2004);McNally,supra note43,at225.49 GeraldM.Rosen,Litigation and Reported Rates of Posttraumatic Stress Disorder, supranote48.


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Table 3IndicationsofPossiblePTSDMalingering

Poorworkrecord Priorincapacitatinginjuries Discrepantcapacityforworkandrecreation Unvarying,repetitivedreams Antisocialpersonalitytraits Overidealizedfunctioningbeforethetrauma Evasiveness Inconsistencyinsymptompresentation50

SomePTSD experts built their reputations by developing checklists or interviewschedulestoidentifyPTSDpatientsandtohelpthemfullydescribetheirexperiencesandsymptoms.Thisfocuson“finding”thedisorderhashelpedcreateacultureinwhichthevalidityofPTSDreportsislargelyassumed.Theprogramforthe20thannualmeetingoftheInternationalSocietyforTraumaticStressStudiesmakesnomentionofmalingeringinanyofitsdozensoftraumasymposia.OneresearcherreportedthathiseffortstodevelopameasureofPTSDmalingeringweremetwithhostilitybyonePTSDpioneer.51

C. Assessment of Malingering in PTSD MostPTSDdiagnosticinterviewsandself-reportscalesrepresentstraightforwardqueriesaboutsymptomsandallowmotivatedpersonstopresentthemselvesashavingtherequisitesymptomstomeetthediagnosticcriteria.52Fewinstrumentshaveanymeanstodetectexag-gerationorunreliableresponding.Onesuchinterviewschedule,theClinician Administered PTSD Scale,hasaconsistencyscaletoassessunreliableresponding,but theonlystudythatexamineditsutilityfounditcompletelyineffectiveatidentifyingexaggeration.53The

50 PhilipJ.Resnick,Guidelines for Evaluation of Malingering in PTSD,in PosttrauMatic stress disorder in litigation 194(R.I.Simoned.2003).51 PersonalCommunicationfromKennethR.Morel(onfilewiththeauthor)(2004).52 C.Burges&T.M.McMillan,The Ability of Naïve Participants to Report Symptoms of Post-traumatic Stress Disorder,40brit. J. clinical Psychol.209(2001);EdwardJ.Hicklingetal.,Detection of Malin-gered MVA Related Posttraumatic Stress Disorder: An Investigation of the Ability of Professional Actors by Experienced Clinicians, Psychological Tests and Psychological Assessment,2J. forensic Psychol. Prac. 33(2002).53 Hickling,etal.,supranote52,at42.


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Atypical Responding Scale onthe Trauma Symptom Inventory,aself-reportinventory,hasshownonlymixedresults.54

TheMMPI-2hastwoscales,PSandPK,whicharedesignedtoassessPTSDsymptoms.Thesescales,however,appearhighlysensitivetogeneraldistressandarenotspecifictoPTSD.55MoreusefularetheMMPI-2validityscales,whicharecapableofdistinguishingmalingerersfromthosewithgenuinePTSD.AlthoughseveralstudiesfoundtheFpscaletobethemosteffectivescaleandtheFBSscaletobeineffective,56thesestudieshadseriousdesignflaws:theycomparedstudentsaskedtosimulatePTSDwithclaimantsorveterans(whoareeligibleforpermanentdisabilityandhaveaveryhighincidenceofmalingering57)diagnosedwithPTSD–buttheclaimantswerenotassessedformalingering!Theeffective-nessofFpwithbetter-designedstudiesismixed,58withonesuchstudyshowingFBStobetheonlyvalidindicator.59AnotherfoundbothtraditionalindicesandFBStoeffectivelyseparatesimulatorsorpseudo-PTSDpatients(thoseclaimingPTSDsymptomsbutlackingaqualifyingstressor).60Lastly,althoughknowledgeofPTSDsymptomsmayhelpaclaim-antpresentaconvincingfacadeinaface-to-faceintervieworonself-reportscales,suchknowledgedoesnothelpfeignersevadedetectionontheMMPI-2validityscales.61 Anothertest,specificallydevelopedtodistinguishfeignedPTSD,istheMorel Emo-tional Numbing Test (MENT).NormsareavailableforlegitimatePTSDpatients(andother

54 JohnF.Edensetal.,Susceptibility of the Trauma Symptom Inventory to Malingering,71J. Personality assessMent379(1998);GeraldM.Rosenetal.,The Risk of False Positives When Using ATR Cut-Scores to Detect Malingered Posttraumatic Reaction on the Trauma Symptom Inventory (TSI),86J. Personality assessMent329(2006);JenniferGurieletal.,Impact of Coaching on Malingered Posttraumatic Stress Symptoms on the M-FAST and the TSI,4J. forensic Psychol. Prac.37(2004).55 SusanneScheibeetal.,Assessing Posttraumatic Disorder with the MMPI-2 in a Sample of Workplace Accident Victims,13Psychol. assessMent369(2001).56 JonD.Elhaietal.,The Detection of Malingered Posttraumatic Stress Disorder with MMPI-2 Fake Bad Indices,8assessMent221(2001);JonD.Elhaietal.,Cross-Validation of the MMPI-2 in Detecting Malingered Posttraumatic Stress Disorder,75J. Personality assesssMent 449(2000);AlisonS.Bury&R.MichaelBagby,The Detection of Feigned Uncoached Posttraumatic Stress Disorder with the MMPI-2 in a Sample of Workplace Accident Victims,14Psychol. assessMent472(2002).57 B.ChristopherFreuhetal.,Apparent Symptom Overreporting in Combat Veterans Evaluated for PTSD,20 clinical Psychol. reV.853(2000).58 M.FrankGreiffensteinetal.,The Fake Bad Scale and MMPI-2 F-Family in Detection of Implausible Psychological Trauma Claims,18clinical neuroPsychologist573(2004).59 Id.60 Lees-Haley,supranote 19.61 MarthaW.Wetteretal.,MMPI-2 Profiles of Motivated Fakers Given Specific Symptom Information: A Comparison of Matched Patients,5Pyschol. assessMent317(1993);GinaL.Walters&JamesR.Clopton,Effect of Symptom Information and Validity Scale Information on the Malingering of Depression on the MMPI-2,75J. Personality assessMent183(2000).


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psychiatricgroups)andforpatientsidentifiedasprobablyexaggerating.NoneoftheformergroupfailedtheMENT,asopposedtoeightypercentofthelattergroup.62 BecausecomplaintsofmemoryandconcentrationproblemsarecommoninPTSD,63despitefewdemonstratedcognitiveimpairments,64failureonefforttests(suchastheTOMM,WMT)canprovidestrongevidenceofmalingering.Poorperformanceonthesecognitivetestsrequiresintentionalfailureorpooreffort(exceptincasesofretardationordemention),whichisdistinctfromover-reportingorexaggeration.Thus,failurecannotbeexplainedbytheclaimthatdramatizationisessentialtoPTSD.

D. Who Develops PTSD; In Whom Does It Persist? Significant literature exists regarding the factors associatedwith developingPTSDfollowingexposuretotrauma.Arecentmeta-analysisofseventy-sevenstudiesfoundthatpreviouspsychiatrichistory,childhoodabuse,andfamilypsychiatrichistorywereconsis-tentlyassociatedwithdevelopingPTSD.Lessconsistentpredictorsincludedgender,race,age,education,previoustrauma,andgeneralchildhoodadversity.65Anotherreviewreportedlowerintelligence,neuroticism,negativisticpersonalitytraits,anddissociationsurroundingthetraumaaspredictorsofsubsequentPTSDdiagnosis.66Thus,thedatasuggestthatpeoplewholaterreportsymptomsofPTSDareoftenvulnerableindividualswhoshowneurotictendenciesbeforetheindexaccident/trauma.Preexistinganxiety,depressionanddissatisfac-tion,whichmightbeexacerbatedfollowingthetrauma,graduallyabatetobaselinelevelsoffunctioning–butstillare(mis)interpretedasPTSD. Follow-up studies of those initially diagnosedwithPTSD show that sixty percentcontinuetoreportsignificantsymptomsatsixmonths.ThemostreliablepredictormaybedissociationatthetimeofthetraumaandPTSD-likesymptomsintheimmediateaftermath.AcuteStressDisorder(ASD)entailsthesamesymptomsasPTSDbutdoesnotrequiretheone-monthdelaybetweenthetraumaticeventandthediagnosis.Notsurprisingly,thepres-enceofsuchsymptomsbeforeonemonthpredictsthepresenceofsuchsymptomsafteronemonth.

62 KennethR.Morel,Development and Preliminary Validation of a Forced-Choice Test of Response Bias for Posttraumatic Stress Disorder,70 J. Personality assessMent299(1998).63 NeenaSachinvalaetal.,Memory, Attention, Function, and Mood among Patients with Chronic Post-traumatic Stress Disorder,188J. nerVous & Mental disease818(2000).64 ElizabethW.Twamleyetal.,Neuropsychological Function in College Students with and without Post-traumatic Stress Disorder,126Psychiatry res.265(2004).65 ChrisR.Brewinetal.,Meta-analysis of Risk Factors for Posttraumatic Stress Disorder in Trauma-Exposed Adults,68J. consulting & clinical Psychol.748(2000).66 McNally,supranote43.


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E. Depression MalingereddepressionpresentssomeofthesameproblemsasPTSD:thesymptomsarefamiliarandwidelydisseminated,therearenodefinitivemedicalorpsychologicaltests,andthediagnosistypicallydependslargelyonself-report.SomedepressedpersonsobtainelevatedscoresonsomestandardvalidityscalesliketheMMPI-2Fscale.TheMMPI-2’snewer,specialmalingeringscales,particularlyF(p)andDs(Dissimulation),appeartobeeffectiveandproducereasonablyhighcorrectclassification(seventy-fivetoeighty-fiveper-cent)ratesinclassifyinglegitimateandfeigneddepression.67Anewly-developedscale,Md(MalingeredDepression),appearstoprovidesomeadditionaldiscriminationwhenfeignershavebeencoachedaboutthecontentofdepressionscalesandthevalidityindicatorsusedtodetectexaggeration.68Itisclear,however,thatcoachingaboutvalidityscalesdoesreducetheireffectiveness. Personswhoaredepressedoftencomplainaboutmemoryproblemsanddifficultycon-centrating.Nonetheless,theytypicallyperformnormallyonformalmemorytests,69 unless thereisevidenceofpooreffort.70Thus,aswithPTSD,failureonefforttestsliketheTOMMorWMTcanprovidepotentiallypowerfulcorroboratingevidenceofintentionalfailure.

F. Chronic Pain Painthatisunresponsivetopainmanagementtechniquesisanotherfrequentcauseofclaims.Aswithmildbraininjury,suchcomplaintsmaylackobjectivemedicalfindingstocorroboratethem.Althoughthereareseveralstandardizedquestionnairestoassesspainanditsimpactonfunctioning,onlysomeassistinassessingwhetherreportsofpainareexag-gerated.71 Chronicpainpatientsoftenreportdepression,andtreatmentwithantidepressantsoftenhelpswithbothmoodsymptomsandphysicaldiscomfort.OntheMMPI-2,suchpatientshaveaprototypicalprofilewhichisdistinguishablefromthoseinlitigationwhoarebelievedtobeexaggeratingbasedonotherindicators.AswithheadinjuryandPTSD,someofthestandardvalidityscalesarenotparticularlygoodindicators,andsupplementalscalesshouldbeexamined.BasedonacombinationofsixvalidityscalesandtheFBS,oneindexshowed

67 Rogersetal.,supranote14;JarrodS.Steffanetal.,An MMPI-2 Scale to Detect Malingered Depression (Md Scale),10assessMent382(2003).68 Steffanetal.,supranote67.69 AliH.Kizilbashetal.,The Effects of Depression and Anxiety on Memory Performance,17archiVes clinical neuroPsychol.57(2002).70 PaulGreen&LyleM.Allen,The Differential Effects of Depressive Symptoms on Self-Report and Per-formance Based Neurocognitive Measures in Patients Demonstrating Good Effort During Assessment,14archiVes clinical neuroPsychol.741(1999).71 Larrabee,Exaggerated Pain Report, supranote17.


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substantialdifferencesbetweenpainpatientswhowereinlitigationandthosewhowerenot.Thatindexachievedgreaterseparationbetweenthegroupsthananyoftheindividualscalesincludedintheindex.72Severalstudieshavereportedgoodtoexcellentdiscriminationofexaggeratorsfromlegitimatepatientsonthebasisofsymptomprofiles,73gripstrength,74 bodyextension,75andmotorperformanceduringneuropsychologicaltesting.76 Manychronicpainpatientscomplainofmemoryproblemsanddifficultyconcentrat-ing.Findingsofimpairmentonneuropsychologicaltestshavebeensomewhatinconsistent,however.Aswithmildheadinjuryanddepression,whenpatientsshowinggoodorpooreffortonmalingeringtestsareseparated,fewcognitivedeficitsareobservedintheformergroup.77Aswithotherdisorders,efforttestingshouldberoutine. Finally,thereisatleastonemedicalproceduredesignedtoassessthevalidityofpaincomplaints.Diagnostic blocksinvolvethesystematicadministrationofanalgesics,injectedintoneurologicallyrelevantsites,tomaptheenervationandthepatient’sverbalresponsetomedicationthatshouldcompletelyblockthereportedpain.78Becausedifferentformulationscarrydifferentexpectedperiodsofeffectiveness,thepatient’sreportcanbecomparedwiththeexpectedpharmacologicalprofileofthedrugadministered.Substantialmismatchessug-gestthepossibilityoffalsereporting.Therationaleisthatpeoplecannotaccuratelyreportthepresenceorabsenceofpainiftheydonotlegitimatelyfeelit.

72 JohnE.Meyerset al., A Validity Index for the MMPI-2,17archiVes clinical neuroPsychol. 157(2002).73 Larrabee,Exaggerated Pain Report,supra note17.74 GeraldA.Smithetal.,Assessing Sincerity of Effort in Maximal Grip Strength Tests,68aM J. Physical Med. & rehabilitation73(1989);SomadeeptiN.Chengaluretal.,Assessing Sincerity of Effort in Maximal Grip Strength Tests,69aM. J. Physical Med. & rehabilitation148(1990).75 ZeeviDvir,The Measurement of Isokinetic Fingers Flexion Strength,12clinical bioMechanics473(1997);ZeeviDvir&JenniferKeating,Reproducibility and Validity of a New Test Protocol for Measuring Isokinetic Trunk Extension Strength,16clinical bioMechanics627(2001);ZeeviDvir&JenniferKeating,Trunk Extension Effort in Patients with Chronic Low Back Dysfunction,28sPine685(2003).76 Larrabee, supranote18.77 RogerO.Gervaisetal.,Effects of Coaching on Symptom Validity Testing in Chronic Pain Patients Presenting for Disability Assessment,2J. forensic neuroPsychol.1(2001).78 NikolaiBogduk,Diagnostic Blocks: A Truth Serum for Malingering,20clinical J. Pain409(2004).


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G. Controversial Diagnoses Thereareanumberofdiagnoses,inadditiontothosealreadydiscussed,thatsharethefollowingconstellationoffeatures:

• Vague,subjectivesymptoms

• Lackofobjectivelaboratoryfindings

• Quasi-scientificexplanations

• Mutualskepticism(physician/patient)withtraditionalmedicalpractices

• Denialofpsychiatric/stresscontributors

• Subjectivecomplaintsthatgreatlyexceedreliablelaboratoryfindings

• Highrateoffailureonefforttestsinclaimants.

Theseincludewhiplash,fibromylagia,non-epilepticseizures,ChronicFatigueSyndrome,MultipleChemicalSensitivities,ToxicMoldandSickBuildingSyndrome,SiliconBreastImplantcomplaints,andGulfWarSyndrome.79Somehaveconsideredthesetobemaskedpsychiatricsyndromes,whileothershavepointedtoveryhighfailureratesonefforttestswhenevaluationsareconductedwithin thecontextof litigation. Inall theseconditions,subjectivecomplaintsincludefatigue,depression,anxiety,painorheadache,poormemoryandconcentration,dizziness,andirritability.TheoverlapwithPostconcussionSyndromeshouldbeapparent,andthesameissuesapply. Electricalinjuriespresentmanyoftheissuesformildtraumaticbraininjury,althoughthereisspeculationthattheimpairmentsproducedmaybemorepersistentorevenprogres-sive.Aswithbraininjury,theabsenceofobjectivesignsofphysicalinjury,suchasentryandexitwounds,isrelatedtotestindicationsofmalingering.80Arecentreportfoundhighratesofprobablemalingeringusingstandardtestsandcriteriaappliedtoheadinjurypatientsamongelevenelectricalinjurypatientsreferredfordisabilityevaluation.81 Exposuretoweldingfumesandmanganesealsohasbeencitedasacauseofneurologicaldamageand,accordingtoarecentarticleinSciencemagazine,“thenumberofclaimscouldrivalthoseforasbestos-relatedlungdisease.”82Arecentneuropsychologicalinvestigation

79 Binder,supranote31.80 KevinBianchinietal.,Detection and Diagnosis of Malingering in Electrical Injury,20archiVes clini-cal neuroPsychol.365(2005).81 Id.82 JocelynKaiser,Manganese: A High-Octane Dispute,300science926,927(2003).


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foundevidenceofsignificantimpairmentbasedonweldingfumeexposure.83However,thisanalysisanditsconclusionsweresavagedinanarticlebymalingering-savvyscholars,whopointedouthugedifferencesbetweencontrolandexperimentalgroupsoneducation,poorscreeningformalingering,andinconsistenciesinthedata,suggestingmotivatedfailure.84

iV.eValuating a rePort

Psychologicalevaluations thatarepreparedforuse in judicialproceedingsaresub-ject to the specialtyguidelines for forensicpsychologists.85Although theguidelinesareaspirationalandnotbindingonstandardsofpractice,theydospecifypractical,reasonableexpectationsthatmaynotbemetintypicalevaluations.Amongthemostimportantofthesearethatpsychologistsconsidermultiple,rivalhypothesestoexplaintheirdata,andthatthebasesfor theirconclusionsbeadequatelydocumented in thereport. Inotherwords, theexaminershouldconsiderotherpossiblecausesfordeficitsthataredisplayedorreported,includingpooreffortorpreviousinjuryorcondition.Giventhisguideline,thestatementintheDSM-IVabouttheneedtoruleoutmalingeringinforensiccontexts,andtheNationalAcademyofNeuropsychologists’positionstatementonefforttesting,acasecouldbemadethatanexaminer’sfailuretorigorouslyassessformalingeringinapersonalinjurycontextismalpractice. Thereportshouldidentifytestsorindicesthatwereusedtoevaluateeffortorsymp-tomexaggeration,oralternatelydescribetheminsuchawaythatanotherexaminerwouldknowwhichtechniquewasused.Thereshouldbeacleardiscussionofthelevelofeffortexpended,basedonformaltestsandindices,aswellastheeffectofanysuchproblemsonthetestscoresobtainedinotherareas.Statementsthattheexaminee“appearedtoputforthgoodeffort”basedonunaidedobservationsareinadequate.Unfortunately,evenwhentheseissuesareaddressedappropriately,unfavorablefindingsaresometimescommunicatedin-directly.Arecentsurveyofneuropsychologicalpracticessuggestedthatmanypractitionersarereluctanttodiagnosemalingeringortomakestrongstatementsonthistopic.86Inonerecentcase,theneuropsychologistpossesseddefinitiveevidenceofmalingeringyetreported

83 R.M.Bowleretal.,Neuropsychological Sequelae of Exposure to Welding Fumes in a Group of Oc-cupationally Exposed Men,206int’l J. hygene & enVtl. health517(2003).84 PaulT.Lees-Haleyetal.,Methodological Problems in the Neuropsychological Assessment of Effects of Exposure to Welding Fumes and Manganese,18clinical neuroPsychologist 449(2004).85 CommitteeonEthicalGuidelinesforForensicPsychologists,Specialty Guidelines for Forensic Psy-chologists,15law & huMan behaV.655(1991).86 DanielJ.Slicketal.,Detecting Malingering: A Survey of Experts’ Practices,19archiVes clinical neuroPsychol.465(2004).


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hisfindingsinthisway:“DatathereforecertainlysuggestthateitherMr.Misaseverelydementedindividualorlowinmotivation,butsuchperformanceisrarely,ifever,obtainedbypersonssufferingfrommildtomoderateheadinjury.”87TheclaimantobtainedascoreofthreecorrectoutoffiftyontheTestofMemoryMalingering.Someonewhotookthetestblindfoldedwouldbeexpectedtoscoretwenty-five(fiftypercentoffiftyitems),plusorminussix,simplybyguessing.Ascoreofthreeissofarbelowchancethatablindfoldedsubjectwouldhavetotakethetestapproximatelyfifty-fourbilliontimestoturninascorethislow.Thisinformationwasnotapparentlyunderstoodbythereferringphysician,whowroteareportthathelpedtheplaintifftorecoveramultimilliondollarsettlement.Itdidnothelpthat,throughoutthereport,theneuropsychologistdescribed“deficits”inmotor,speech,andmemoryasifthequestionofpooreffortdidnotexist. Attorneysalsomayencounterneuropsychologicalreportsthatutilizenoformalefforttests.Fortunately,manyofthefrequently-usedtestshavebeenstudiedforuseinassessingexaggerationorfaking.Researchershaveidentifiedpatternsandindividualresponsesthatcanbehighlyusefulinthisrole.Often,suchindiceswillnothavebeenscoredbytheex-aminingpsychologist,butcanbescoredquicklyandcost-effectivelybyaknowledgeablereviewer.Someoftheseindiceshavefairlygoodsensitivityandexcellentspecificity.

V.finding an exPert

Onemightassumethatfindingaboardcertifiedexpertintheareaofclaimeddamages(e.g.,painmedicine)isthelogicalchoice.However,thismakesacrucialassumptionthatisrarelytrue:expertiseintreatingaconditiontranslatesintoexpertiseindistinguishingtrueandfalsepresentationsofthatcondition.Inthecontextoflitigation,thisisperhapsthemostimportantdifferentialdiagnosis.Howcanoneidentifysuchanexpert?Anexpert’spublica-tionhistorycanbeaguide,althoughmanyqualifiedexpertsmaynotpublish.Furthermore,asseeninthediscussionofPTSD,someexpertswhopublishmayhavebiases,employpoordesignsandcometohighlyquestionableconclusions.Inadditiontoreferralsfromotherattorneys,onemightwishtopostsomeofthefollowingquestionstopotentialexperts:

87 Quotationfromreportonaparticularclaimantinauthor’spossession.


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• What are some of the major goals of your assessment? Theexpertshouldspon-taneouslystatethatassessmentofeffortorgenuinenessoftheconditionisoneoftheprimarypurposesoftheassessment.

• How common do you think malingering or exaggeration is in mild head injury/chronic pain patients who are involved in litigation?Thebestestimatesofthesefiguresareaboutfortypercentfortheformerandthirtypercentforthelatter.Ananswersignificantlydiscrepantfromthisrangeshouldbecauseforconcern.

• How do you assess the possibility of exaggeration or faking?Theexpert’san-swershouldclearlyindicatethatthisisanareaofexpertiseandthattheexpertcompetentlyusesmultiple,sensitive,andestablishedtechniques.However,someexpertsmaybereluctanttodisclosetheirtechniques,suspectingthattheattorneymaybemisrepresentinghissituationorinterestedincoachingaclient.

• Are the techniques you use widely accepted in your field? Will the techniques that you use pass a Daubert challenge?Theexpertshouldhaveanunderstand-ingoftheDaubertstandards(ifinaDaubertjurisdiction),andshouldbeableto speak intelligently regarding thegeneralacceptance,error rate,andotherfactorsrelevanttoadmissibility.

Vi.conclusion

Malingering and exaggeration are common amongpeoplewho litigate for injuriesinvolvingmildheadinjury,chronicpain,andposttraumaticstressdisorder.Therealsomaybeasubstantialnumberofpersonswhosincerelyexperiencesymptomsbuttestnegativeonmedicalandpsychologicaltests.Suchpeoplemaymistakenlyattributesymptomsandproblemstoanaccidentorincident.Insuchcases,assessmentofSomatizationandperson-alityarelikelytobeimportant. Anypsychologicalreportsthataresubmittedbytheplaintiffshouldbereviewedbyanotherqualifiedpsychologistwhoisproficientindetectingmalingering,pooreffortandSomatization.ShouldanIndependentMedicalExamination(IME)benecessary,thesamequalificationsapply.Oneshouldnotassumeexpertiseindetectionofmalingeringbasedonanyspecialtyorformalcredential.Althoughbothforensicpsychologyandneuropsychol-ogyhavedevelopedmeasuresofresponsestyle,thereisawiderangeofproficiencyamongpractitioners—evenboardcertificationineitherspecialtyisnoguarantee.Armedwiththeinformationinthisarticleandthesamplequestionsnotedabove,however,attorneysshouldbeabletoevaluatecandidatesanddecideupontherightexpertforanygivencase.


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Table 4Report/EvaluationFeaturesImportanttoAssessingMalingeringorPoorEffort

1.Explicitconsiderationanddiscussionofeffort/malingering2.Listingofspecifictestssensitivetoeffort3.Attemptstocontactneutralornon-supportivesourcesofinformation4.Recognitionthatthepatient,familymembersandtreatmentprovidersmaybesympathetic,potentiallybiased,orpossiblyhavedeceivedthemselves5.Explicitconsiderationofalternativecausesforthedeficitsobserved;avoidsuseofphraseslike“consistentwith,”whichimplyconsiderationofonlyasinglehypothesis6.Frankdiscussionoftestresults7.Avoiduseofsuggestiveorconclusivelanguage(i.e.,“suffersfrom;”reportingpatientstatements,orthoseofanysource,asconclusivefacts)


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Malingering of Psychiatric Problems, Brain Damage, Chronic ... · Brain Damage, Chronic Pain, and Controversial Syndromes in a Personal Injury Context Steve Rubenzer i. introduction

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