the assessment of performance and self-report validity in persons claiming pain-related disability

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The Assessment of Performance andSelf-report Validity in Persons ClaimingPain-related DisabilityKevin W. Greve a b , Kevin J. Bianchini a b & Steve T. Brewer aa Department of Psychology , University of New Orleans , NewOrleans , LA , USAb Jefferson Neurobehavioral Group , Metairie , LA , USAPublished online: 16 Nov 2012.

To cite this article: Kevin W. Greve , Kevin J. Bianchini & Steve T. Brewer (2013) The Assessmentof Performance and Self-report Validity in Persons Claiming Pain-related Disability, The ClinicalNeuropsychologist, 27:1, 108-137, DOI: 10.1080/13854046.2012.739646

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The Assessment of Performance and Self-report Validity inPersons Claiming Pain-related Disability

Kevin W. Greve1,2, Kevin J. Bianchini1,2, and Steve T. Brewer1

1Department of Psychology, University of New Orleans, New Orleans, LA, USA2Jefferson Neurobehavioral Group, Metairie, LA, USA

One third of all people will experience spinal pain in their lifetime and half of these will

experience chronic pain. Pain often occurs in the context of a legally compensable event with

back pain being the most common reason for filing a Workers Compensation claim in the

United States. When financial incentives to appear disabled exist, malingered pain-related

disability is a potential problem. Malingering may take the form of exaggerated physical,

emotional, or cognitive symptoms and/or under-performance on measures of cognitive and

physical capacity. Essential to the accurate detection of Malingered Pain-related Disability is

the understanding that malingering is an act of will, the goal of which is to increase the

appearance of disability beyond that which would naturally arise from the injury in

question. This paper will review a number of Symptom Validity Tests (SVTs) that have been

developed to detect malingering in patients claiming pain-related disability and will conclude

with a review of studies showing the diagnostic benefit of combining SVT findings from a

comprehensive malingering assessment. The utilization of a variety of tools sensitive to the

multiple manifestations of malingering increases the odds of detecting invalid claims while

reducing the risk of rejecting a valid claim.

Keywords: Chromic pain; Malingering; Assessment.

INTRODUCTION

About a third of all people will experience spinal pain in their lifetimes andhalf of these will experience chronic pain (Von Korff et al., 2005). The medianprevalence of benign chronic pain is 15% (ranging from 2% to 40%, depending onthe specific study) with the most frequent pain sites being low back, neck, andshoulder (Verhaak, Kerssens, Dekker, Sorbi, & Bensing, 1998). Pain often occurs inthe context of a legally compensable event such as a work-related injury or incidentin which some other party is potentially liable, and in the United States back pain isthe most common reason for filing a Workers Compensation claim (Guo, Tanaka,Halperin, & Cameron, 1999).

Malingering is a potential problem in contexts where there are financialincentives to appear disabled. Malingering is ‘‘the intentional production of false orgrossly exaggerated physical or psychological symptoms, motivated by externalincentives such as avoiding military duty, avoiding work, obtaining financialcompensation, evading criminal prosecution, or obtaining drugs’’ (DSM-IV-TR;American Psychiatric Association, 2000, p. 739). Malingered Pain-Related

The Assessment of Performance and Self-report Validity inPersons Claiming Pain-related Disability

Kevin W. Greve1,2, Kevin J. Bianchini1,2, and Steve T. Brewer1

1Department of Psychology, University of New Orleans, New Orleans, LA, USA2Jefferson Neurobehavioral Group, Metairie, LA, USA

One third of all people will experience spinal pain in their lifetime and half of these will

experience chronic pain. Pain often occurs in the context of a legally compensable event with

back pain being the most common reason for filing a Workers Compensation claim in the

United States. When financial incentives to appear disabled exist, malingered pain-related

disability is a potential problem. Malingering may take the form of exaggerated physical,

emotional, or cognitive symptoms and/or under-performance on measures of cognitive and

physical capacity. Essential to the accurate detection of Malingered Pain-related Disability is

the understanding that malingering is an act of will, the goal of which is to increase the

appearance of disability beyond that which would naturally arise from the injury in

question. This paper will review a number of Symptom Validity Tests (SVTs) that have been

developed to detect malingering in patients claiming pain-related disability and will conclude

with a review of studies showing the diagnostic benefit of combining SVT findings from a

comprehensive malingering assessment. The utilization of a variety of tools sensitive to the

multiple manifestations of malingering increases the odds of detecting invalid claims while

reducing the risk of rejecting a valid claim.

Keywords: Chromic pain; Malingering; Assessment.

INTRODUCTION

About a third of all people will experience spinal pain in their lifetimes andhalf of these will experience chronic pain (Von Korff et al., 2005). The medianprevalence of benign chronic pain is 15% (ranging from 2% to 40%, depending onthe specific study) with the most frequent pain sites being low back, neck, andshoulder (Verhaak, Kerssens, Dekker, Sorbi, & Bensing, 1998). Pain often occurs inthe context of a legally compensable event such as a work-related injury or incidentin which some other party is potentially liable, and in the United States back pain isthe most common reason for filing a Workers Compensation claim (Guo, Tanaka,Halperin, & Cameron, 1999).

Malingering is a potential problem in contexts where there are financialincentives to appear disabled. Malingering is ‘‘the intentional production of false orgrossly exaggerated physical or psychological symptoms, motivated by externalincentives such as avoiding military duty, avoiding work, obtaining financialcompensation, evading criminal prosecution, or obtaining drugs’’ (DSM-IV-TR;American Psychiatric Association, 2000, p. 739). Malingered Pain-Related

Address correspondence to: Kevin W. Greve, Ph.D., Jefferson Neurobehavioral Group, 2901 N.

I-10 Service Road East, Metairie, LA 70002, USA. E-mail: [email protected]

Accepted for publication: October 5, 2012. First published online: November 16, 2012.

� 2013 Taylor & Francis

The Clinical Neuropsychologist, 2013

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Disability (MPRD) is the ‘‘intentional exaggeration or fabrication of cognitive,emotional, behavioral, or physical dysfunction attributed to pain for the purposesof obtaining financial gain, to avoid work, or to obtain drugs’’ (Bianchini, Greve, &Glynn, 2005, p. 407).

Conceptually, what is being malingered is disability: the altered capacity tocare for oneself or others, or to work. The two primary vectors by which malingereddisability can manifest are (1) diminished or reduced capability and/or(2) exaggerated subjective symptoms. Clinically, pain patients may claim disabilitydue to emotional or cognitive problems in addition to the physical limitations thatare typically attributed to injuries and illness. Malingered disability may alsomanifest in these domains. Thus malingering may take the form of exaggeratedphysical, emotional, or cognitive symptoms and/or under-performance on measuresof cognitive and physical capacity (Bianchini et al., 2005).

Thus disability can potentially be achieved via a variety and mixture ofpresentations. Malingering is an act of will and its specific manifestation depends onthe idiosyncrasies of the individual case, including the claimant’s beliefs regardingthe effects of their injury and efforts to avoid detection. A variety of ‘‘SymptomValidity Tests’’1 (SVT) have been developed to detect different forms of themalingering presentation. However, because of the varying malingering presenta-tions, it is unreasonable to expect any one of these SVTs to have perfect sensitivity(detection of all malingering cases). All SVTs will fail to detect some cases whenproper attention is paid to minimizing false positive (FP) errors (Greve & Bianchini,2004). Fortunately, perfect sensitivity is not essential for an SVT to be a valuabletool. Larrabee, Greiffenstein, Greve, and Bianchini (2007, p. 338, emphasis added)made this point clearly:

It is not necessary to rely on single events that unequivocally demonstrate intent

because the MND [Malingered Neurocognitive Dysfunction; Slick, Sherman, &

Iverson, 1999] and MPRD criteria are based on behaviors and symptom report that are

atypical for and not representative of expected clinical findings in legitimate,

unequivocal neurological, psychiatric or developmental disorders. Thus intent is

inferred as a result of the combined improbability of events rather than relying on a single

definitive indication of intent.

This passage emphasizes two points that are critical to the proper assessmentof malingering. First is the idea of ‘‘improbability.’’ Generally speaking, ‘‘improb-ability’’ is determined empirically by comparing clinical patients who have beendiagnosed as malingering using explicit criteria (usually based on the Slick et al.,1999, or Bianchini et al., 2005, systems) to etiologically similar patients, who oftenhave greater objective pathology than the malingering group. This method isreferred to as ‘‘known-groups’’ (Greve & Bianchini, 2004; Rogers, 1997) or

1 It is becoming a more common practice to refer to those measures assessing the validity of performance

on ability tests as ‘‘performance validity tests’’ (PVT) and reserving the term ‘‘symptom validity test’’ for

those indicators designed to assess exaggeration of subjectively reported symptoms. These latter

indicators may also be referred to as ‘‘self-report validity tests.’’ However, for simplicity of explication

and in keeping with long-standing usage, this paper will refer to any psychometric test, score, or indicator

used to detect invalid performance on measures of cognitive or physical capacity or exaggeration of

subjective symptoms as a ‘‘symptom validity test’’.

109VALIDITY ASSESSMENT IN CHRONIC PAIN

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‘‘criterion-groups’’ (Dawes & Meehl, 1966; Frederick, 2000) validation.2 Criteriongroups validation is considered the preferred term (Heilbronner et al., 2009). Usingthis approach one can identify score levels beyond which few or no non-malingeringpatients perform. The degree of ‘‘improbability’’ is expressed concretely as the FPrate at a given score level.

The second point is the importance of combining SVTs. When a variety ofSVTs sensitive to the potential idiosyncrasies of the malingering presentation areused in combination, the likelihood that a malingerer will go undetected (FalseNegative [FN] error rate) will be significantly reduced. Moreover, as will bediscussed later, when these SVTs have low inter-correlations in non-malingeringcases then the FP rate of the battery as a whole may actually be lower than the FPrate of individual SVTs (Larrabee, 2003a; Meyers & Volbrecht, 2003; Vickery et al.,2004; Victor, Boone, Serpa, Buehler, & Ziegler, 2009). Thus an appropriatelydesigned comprehensive assessment of performance validity and symptom exag-geration will increase the confidence that the clinician or researcher has that anindividual case’s malingering status has been clearly and correctly characterized.

In this paper we will review a variety of SVTs developed to detectmalingering in patients claiming pain-related disability, all of which have beenstudied using criterion groups methodology. These SVTs assess the primarybehavioral domains relevant to MPRD (and probably all compensable injury/illness malingering presentations regardless of etiology). In most cases dataspecific to pain patients will be presented; when available and appropriate, dataderived from other clinical groups (primarily traumatic brain injury [TBI]) will bepresented for contrast. The paper will conclude with a review of the studiesshowing the diagnostic benefit of combining SVT findings from a comprehensivemalingering assessment.

METHODS OF MALINGERING DETECTION

Over the last 15 years or more, numerous SVTs have been developed andempirically validated, mostly in TBI.3 A number of cognitive, emotional, andhealth-related SVTs have now been validated in patients with chronic pain. Inkeeping with the idea that malingering can occur on two vectors, the discussion ofSVTs in pain will be divided into two sections: (1) those assessing diminished orreduced capacity (i.e., performance validity) and (2) those measuring exaggerationof subjective symptoms (self-report validity).

Assessing performance validity

Measures of performance validity are intended to determine if an individualhas under-performed on a tests of perceptual, cognitive, or physical capacity

2 ‘‘Mixed-group’’ validation (Dawes & Meehl, 1966) has certain advantages over ‘‘criterion-groups’’

validation and may result in more precise estimates of classification accuracy (Frederick, 2000; Frederick

& Bowden, 2009).3A review of this research is beyond the scope of this paper and the reader is referred to three recent

publications on this topic for more information (Boone, 2007; Larrabee, 2007; Morgan & Sweet, 2009).

3110 KEVIN W. GREVE ET AL.

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or ability. These may take two general forms (1) stand-alone SVTs; and(2) embedded indicators which are derived from clinical measures of cognitiveability.

Stand-alone SVTs. Stand-alone SVTs are independent tests specificallydesigned to detect efforts to misrepresent the status of a cognitive or perceptualfunction. Among the earliest stand-alone SVTs were those devised by Andre Reysuch as the Dot Counting Test and the 15-Item Test (for discussion, see Lezak,Howieson, & Loring, 2004). The 15-Item Test is one of the most frequently givenSVTs (Slick, Tan, Strauss, & Hultsch, 2004) despite its limited diagnostic value(Resnick, 2005). These and similar SVTs have been subjected to extensive modernresearch to determine and improve the diagnostic accuracy (for recent review, seeBoone & Lu, 2007; Nitch & Glassmire, 2007).

A second variety of stand-alone SVT, the forced-choice SVT, is of more recentvintage but has come to have a central place in the batteries of most psychologistsengaged in the assessment of persons with incentive to appear disabled. Initiallydescribed for use among patients presenting suspicious sensory-perceptual deficits(Binder, 1992a, 1992b; Brady & Lind, 1961; Grosz & Zimmerman, 1965; Pankratz,Fausti, & Peed, 1975),4 Pankratz (1983) is credited with naming this procedure‘‘symptom validity testing’’ and, in collaboration with Binder, with adapting it toquestions of exaggerated memory complaints (Binder & Pankratz, 1987).

The procedure for the forced-choice SVT involves the presentation of ato-be-remembered stimulus (target) followed by a (usually) two-choice recognitiontrial. In the absence of memory a patient should select 50% of the targets by chancealone. Significantly below chance performance on an SVT requires active avoidanceof the correct response (Frederick & Speed, 2007; Reynolds, 1998). Numerousstand-alone forced-choice SVTs using a variety of stimuli and methodologicalvariations have been published (Bianchini, Mathias, & Greve, 2001) although only ahandful are commonly used in clinical practice (Slick et al., 2004).

Among the more popular and well-studied tests are the Test of MemoryMalingering (TOMM; Tombaugh, 1996), Word Memory Test (WMT; Green, 2005;Green, Allen, & Astner, 1996), and the Portland Digit Recognition Test (PDRT;Binder, 1990, 1993). We have been using stand-alone SVTs with pain patients in ourpractice since the early to mid-1990s when these tests became commerciallyavailable, and routinely use the PDRT, TOMM, and WMT in some combination inall our pain assessments. All three have been subjected to intense scientific scrutinyincluding validation in patients with pain.

Individually the PDRT, TOMM, and WMT are equally capable of detectingMPRD at cutoffs associated with comparable FP rates (Greve, Ord, Curtis,Bianchini, & Brennan, 2008). At cutoffs recommended in their respective manuals(Binder, 1990; Tombaugh, 1996), the PDRT and TOMM were very specific(FP rate¼ 2%) in non-malingering patients with pain but they failed to detect about50% of malingerers; in contrast, at the author-recommended cutoffs (Green, 2005;Green et al., 1996), the WMT was very sensitive (80%) but prone to FP errors

4The forced-choice methodology has recently been applied to persons with primary pain complaints who

also reported impaired somatosensory function (Greve, Bianchini, & Ameduri, 2003).


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(FP rate¼ 30%). These findings emphasize the importance of proper calibrationand of reporting classification accuracy for a range of scores rather than relying ona single cutting scores as well as the reliance on appropriate research methods fordetermining classification accuracy. Moreover, failure to consider FP rates whencomparing sensitivity will result in meaningless and possibly misleading conclusions.

In replications with larger samples, at the 2% FP cutoffs identified by Greveet al. (2008), the individual subtests of the PDRT and TOMM detected 30–45% ofMPRD cases at FP rates of less than 5% (Greve, Etherton, Ord, Bianchini, &Curtis, 2009; Greve, Bianchini, Etherton, Ord, & Curtis, 2009). The WMTdemonstrated sensitivity of about 55% but the FP rates were between 7 and 15%(Greve, Ord, Etherton, Bianchini, & Curtis, 2009). The reader is referred to thesevarious papers for detailed classification accuracy data.

Greve et al. (2008) also examined the accuracy of these three SVTs incombination in pain patients (see Table 1). At cutoffs associated with low FP(e.g., 2%) for individual subtests, the joint FP rate never exceeded 5% for any pairof SVTs or all three together. However, at cutoffs associated with higher individualFP rates (i.e., 10%), the joint FP rates sometimes doubled. Requiring at least twopositive findings at this more aggressive cutoff resulted in FP rates of 10% or less).At the same time, failure on any one SVT at the 2% cutoff resulted in equal or betterclassification accuracy compared to failure of any two SVTs at the 10% level. So itmay be that little is gained by using the more aggressive cutoffs.

When used in combination, failure on one or more of these three SVTs atcutoffs associated with an individual subtest FP rate of 2% results in the detectionof 69% of MPRD cases while maintaining a joint FP rate of 5%. Also included inTable 1 is the Likelihood Ratio (LR; LR¼ sensitivity/FP error rate). The LRindicates the likelihood that a score was produced by a malingerer relative to non-malingerers. An LR value of 1.0 indicates that the score does not differentiatebetween groups whereas a higher LR value indicates a higher probability thatsomeone is malingering versus not (Grimes & Schulz, 2005). At the 2% FP cutoffs,the LR’s are extremely high, indicating that the tests are excellent at discriminatingmalingering from non-malingering cases.

The value of stand-alone SVTs in the detection of MPRD is evident: they areprobably among the most accurate of SVTs. However, stand-alone SVTs do havesome disadvantages. First, even when used jointly they fail to detect 30% or more ofMPRD cases. Being sensitive primarily to feigned memory impairment, theyprovide limited coverage of relevant behavioral domains. So if an individualmalingerer chooses to exaggerate physical or psychological problems rather thanmemory problems, they will go undetected. Moreover, these SVTs may bevulnerable to active efforts to avoid detection (e.g., coaching). Since they arereadily identifiable by their format and because there is considerable informationavailable about them on the internet (Bauer & McCaffrey, 2006) some malingerersmay go undetected. Finally, stand-alone SVTs require additional testing time andthey do not speak directly to the validity of performance on standard clinicalmeasures.

Embedded SVTs. Embedded or internal SVTs are derived from standardclinical tests and procedures that are used as a routine part of the psychological test


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battery rather than being an independent test. They may consist of a single speciallydeveloped test score (e.g., Reliable Digit Span [RDS], Greiffenstein, Baker, & Gola,1994), multiple scores combined in various ways (e.g., Vocabulary minus Digit Spanfrom the Wechsler Adult Intelligence Scale [WAIS], Mittenberg, Theroux-Fichera,Zielinski, & Heilbronner, 1995; Linear Shrinkage Model for the California VerbalLearning Test [CVLT], Millis & Volinsky, 2001), or simply a standard clinical scorethat has demonstrated validity in differentiating malingering from non-malingeringcases (e.g., Working Memory Index [WMI] from the WAIS-III, Etherton,Bianchini, Ciota, Heinly, & Greve, 2006).

Table 1. Sensitivity, False Positive Error Rate, Positive Predictive Power, and Likelihood

Ratio for each SVT individually and in combination using cutoffs associated with

approximately 2% and 10% false positive error rates in chronic pain patients

�2% FP cutoff Sens FP LR

PDRT (E� 21, H� 18,T� 44) 47 2 24

TOMM (T2� 48, Ret� 44) 50 2 25

WMT (IR, DR� 77.5, CNS� 70.0) 53 2 27

PDRT and/or TOMM 60 2 30

PDRT and/or WMT 64 5 32

TOMM and/or WMT 62 5 31

PDRT and TOMM 36 2 18

PDRT and WMT 36 0 36

TOMM and WMT 41 0 36

Failed any one 69 5 14

Failed any two 48 2 24

Failed all three 33 0 33

�10% FP cutoff Sens FP LR

PDRT (E� 24, H� 19,T� 44) 59 12 5

TOMM (T2, Ret5 48) 60 21 6

WMT (IR� 70.0, DR� 77.5, CNS� 72.5) 64 17 4

PDRT and/or TOMM 73 26 3

PDRT and/or WMT 76 21 4

TOMM and/or WMT 71 31 2

PDRT and TOMM 47 7 7

PDRT and WMT 47 7 7

TOMM and WMT 53 7 8

Failed any one 79 33 2

Failed any two 60 12 5

Failed all three 43 5 9

E, H, T¼Easy, Hard, and Total trials of the Portland Digit Recognition Test (PDRT);

FP¼ approximate false positive error rate for the indicated cutoff; IR, DR,

CNS¼ Immediate Recognition, Delayed Recognition, and Recognition Consistency of

the Word Memory Test (WMT); LR¼ likelihood ratio; Sens¼ sensitivity at the indicated

cutoff; T2, Ret¼Trial 2 and Retention Trial of the Test of Memory Malingering (TOMM).


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Embedded SVTs have drawn considerable research and clinical interestbecause (1) they enhance the sensitivity of the entire malingering battery withoutrequiring extra administration time; (2) they can provide direct information aboutthe validity of performance on specific tests (Mathias, Greve, Bianchini, Houston, &Crouch, 2002; Meyers & Diep, 2000; Meyers & Volbrecht, 1998); (3) they may beless susceptible to coaching than SVTs (Ashendorf, O’Bryant, & McCaffrey, 2003;Mathias et al., 2002); and (4) they can be used to evaluate performance validity inthe absence of specialized techniques.5 The development of malingering detectiondata for standard clinical measures has become a popular enterprise in the last 15years as the content of the Boone (2007) and Larrabee (2007) texts demonstrate.

Our full psychological pain evaluation battery includes two measures ofcognitive ability: the Wechsler Adult Intelligence Scale-III (WAIS-III) and theCalifornia Verbal Learning Test-II (CVLT-II). These measures are included becausepain patients regularly complain of cognitive changes which they attribute to theirinjuries, and because cognitive status, whether altered or not, has implications forfuture vocational prospects if the patient cannot return to their job of injury. Wealso include the Finger Tapping Test (FTT) as a measure of physical capacity.Arguably this test might be considered a stand-alone SVT in this battery but it is aroutine clinical measure in neuropsychological test batteries (Rabin, Barr, &Burton, 2005), so we are including it in this section on embedded indicators.

The Wechsler Adult Intelligence Scale-III (WAIS-III; Wechsler, 1997) is themost commonly used intelligence test in North America (Rabin et al., 2005) and ithas received considerable attention as a source of evidence of malingering.Mittenberg et al. (1995) have developed two embedded indicators from WAISsubtests. The first, referred to as the Mittenberg formula, was derived usingdiscriminant function analysis. The second was theoretically derived and is simplythe difference between the Vocabulary and Digit Span subtest scores. Originallydeveloped in the WAIS-R, these two SVTs have now been tested in the WAIS-III(Greve, Bianchini, Mathias, Houston, & Crouch, 2003; Mittenberg et al., 2001).Recent research (Curtis, Greve, & Bianchini, 2009) in traumatic brain injury hasraised concerns about the ability of these SVTs to accurately detect malingering.They have not been tested in chronic pain. In contrast, the Reliable Digit Span test(Greiffenstein et al., 1994) has proven effective in detecting malingering in a varietyof patient populations including chronic pain. The Working Memory Index andPossessing Speed Index, though not as well studied, have also proven useful.

Reliable Digit Span (RDS) is calculated by summing the longest forward andbackward digit strings (both trials must be completed without error) from the DigitSpan test. RDS and Digit Span (from which it is derived) are generally preserved inpersons with brain dysfunction (Greiffenstein et al., 1994; Heinly, Greve, Bianchini,Love, Brennan, 2005; Iverson & Franzen, 1994, 1996; Iverson & Tulsky, 2003)including those with amnestic disorders (Butters & Cermak, 1980). RDS may be oneof the most-well-validated clinical malingering indicators, with more than a dozen

5Being able to apply embedded indicators retrospectively is very helpful in research projects using

archival data in which stand-alone SVTs may not have been used. See Larrabee, Millis, and Meyers

(2008) for a good example of this application. Use of embedded indicators may also be helpful when

examining data from a forensic evaluation when stand-alone SVTs were not used or were inadequate.


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validation studies in the published literature (for a review of many of these studies,see Suhr & Barrash, 2007). Overall, existing research demonstrates that RDS is asensitive and specific indicator of intentional under-performance and malingering ina variety of patient populations including traumatic brain injury (TBI),toxic exposure, and chronic pain (for comparisons of RDS in these groups seeGreve et al., 2007).

In pain samples RDS differentiates non-malingering pain patients from thosewho meet the Bianchini et al. (2005) criteria for MPRD. However, in contrast tosome other measures of performance validity, RDS is relatively coarse because thereare so few score levels, the accuracy rate jumps substantially from score to score.For example, the LR goes from 1.90 to 3.29 to 21.4 at cutoffs of 5¼8, 5¼7, and5¼6, respectively. In patients with pain and most other populations of interest(e.g., TBI, toxic exposure), cutoffs greater than 7 are too non-specific and those lessthan 6 are unnecessarily insensitive. We have typically argued against identifyingany specific cutoff for a test. However, in this case recommending a cutoff of RDS5¼6 as evidence of intentional under-performance seems justified and is consistentwith previous findings in patients with pain (Meyers & Volbrecht, 2003).

RDS is unaffected by chronic pain, associated clinical litigation-relatedfactors, and all but the most severe brain trauma. However, in patients with seriousobjective neuropathology (e.g., stroke and dementia) scores of 4 or even 3 may benecessary to raise concerns about performance validity (Heinly et al., 2005). WhileRDS of 7 may raise concern about performance validity, the accumulated researchindicates that RDS5¼6 is most consistently associated with FP rates less than 10%in populations commonly seen in a medico-legal context.

Processing Speed Index (PSI) and Working Memory Index (WMI) derivedfrom the WAIS-III have proven effective in detecting under-performance in patientswith pain. The PSI of the WAIS-III consists of two subtests, Digit Symbol andSymbol Search, which involve processing visual information and responding undertime constraint. The WMI taps both simple and complex attention processes andmeasures an individual’s ability to retain and manipulate information mentallythrough tasks involving attention to increasing amounts of information or attendingto more than one task at a time. The WMI is a composite of performance on threeWAIS-III subtests: Arithmetic, Letter-Number Sequencing, and Digit Span tests.

Etherton and colleagues (Etherton, Bianchini, Ciota, et al., 2006; Etherton,Bianchini, Heinly, & Greve, 2006) studied the effect of pain-related disability onWAIS WMI and PSI scores and found that these two indices were capable ofaccurately detecting MPRD. They also reported FP rate data for moderate-severeTBI and dementia patients. PSI scores of less than 75 detect over 60% of MPRDcases with FP rates of less than 10%. However, PSI is affected by objective severebrain dysfunction associated with TBI and dementia. WMI scores in the same rangedetect slightly fewer MPRD cases but are also less sensitive to genuine brainpathology. These findings have now been replicated in concussion patients and inpatients with stroke (Curtis et al., 2009).

The WAIS-IV (Wechsler, 2008) included embedded indicators as part of itsdevelopment. As yet, the primary research focus has been on RDS (Jasinski, Berry,Shandera, & Clark, 2011; Reese, Suhr, & Riddle, 2012; Young, Sawyer, Roper, &Baughman, 2012). Young et al. (2012) and Reese et al. (2012) both demonstrated


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that RDS scores of 6 or less from the WAIS were associated with acceptablespecificity replicated the FP results from the WAIS-3 and WAIS-R. The meta-analysis of Jasinski et al. (2011) supports that conclusion. Although the validationof RDS in the WAIS-IV is limited in its direct application to patient with chronicpain, the fact that the WAIS-IV-derived RDS has similar accuracy to RDS from theWAIS-R and WAIS-3 means that RDS validation data from those tests canreasonably be applied to RDS derived from the latest WAIS revision.

The California Verbal Learning Test (CVLT; Delis, Kramer, Kaplan, & Ober,1987) is among the most frequently used methods for evaluating learning andmemory in North America (Rabin et al., 2005). The detection of malingering withthe CVLT has been approached in two ways. The first method uses the raw testscores individually (e.g., Total Correct from Trials 1 through 5 [Total 1–5] andRecognition Hits, see Ashendorf et al., 2003; Millis, Putnam, Adams, & Ricker,1995; Sweet et al., 2000). The second approach involves the development ofempirically derived composites of the original raw scores. Millis and colleagues(Martens, Donders, & Millis, 2001; Millis & Putnam, 1997; Millis et al., 1995; Millis& Volinsky, 2001). Curtis, Greve, Bianchini, and Brennan (2006) recommended theLinear Shrinkage Model (Millis & Volinsky, 2001) and Recognition Hits for usebased on a number of considerations. Recognition Hits is produced by the scoringprogram and easily calculated by hand. However, as a single score it may bevulnerable to coaching. The derivation of the Linear Shrinkage Model is morecomplex, but its complexity may make it more resistant to coaching. Both were ofcomparable accuracy in detecting malingering.

A revision of the CVLT (CVLT-II) became available in 2000 (Delis, Kramer,Kaplan, & Ober, 2000). Greve, Curtis, Bianchini, & Ord (2009) examined theequivalence of the CVLT-1 and CVLT-2 in the detection of malingering in TBI andchronic pain. This is the only study to date involving pain patients. The two CVLTversions were roughly equivalent in TBI. However, pain patients generallyperformed more poorly on the CVLT-II and the differences necessitated the useof different normative data. These findings mean that at the same cutoffs,malingering indicators on the CVLT-2 will be associated with a higher rate of FPerrors than on the CVLT-1 in chronic pain. Table 2 presents classification accuracydata for Recognition Hits and Linear Shrinkage Model in patients with pain.

As can be seen, the difference between the two versions was most pronouncedwhen cutoffs associated with lower FP rates were examined. CVLT-1 cutoffsassociated with FP error rates of approximately 10% (a conservative upper bound)always resulted in CVLT-2 FP error rates of 15% or more, even in TBI. In the TBIpatients cutoffs associated with a 5% FP error rate in the CVLT-1 resulted insimilar FP rates in the CVLT-2. In the pain sample Recognition Hit accuracy wascomparable but the cutoffs for the Linear Shrinkage score needed to be adjustedupward to maintain a comparable FP rate. These findings mean that CVLT-1decision rules can be safely applied to the CVLT-2 in patients with TBI claims. Inpatients with chronic pain only the decision rules for Recognition Hits can bedirectly applied.

Overall, these data suggest that, in pain, the Linear Shrinkage Model is moreaccurate than Recognition Hits. The classification accuracy of these indicators inthe CVLT-2 is comparable to that of the CVLT-1, but the cutoffs are different. The


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norms are not interchangeable. Moreover, genuine neurocognitive impairment caninfluence both indicators so one must take care to use the most appropriatenormative comparisons for a given case. A number of new validity indicatorsderived from the CVLT-2 have been reported and studied (Wolfe et al., 2010) buthave yet to be applied to chronic pain samples.

A variety of motor tasks including grip strength measurements, peg boardtasks, and finger tapping have studied in the context of malingering. Only a limitedamount of research on the accuracy of motor tasks for the detection of malingeringin pain patients has been done. Greiffenstein (2007) and Arnold and Boone (2007)have reviewed many of these techniques. More research has been done outside ofpsychology/neuropsychology although this research is not as conceptually orstatistically sophisticated (for an illustration of the breadth and problems in thisliterature, see Fishbain, Cutler, Rosomoff, & Rosomoff, 1999; Lechner, Bradbury,& Bradley, 1998). For example, many of these studies are limited in that they usesimulator designs rather than clinical malingering samples, report only groupstatistics (e.g., mean comparisons), and do not describe individual classificationaccuracy. When classification accuracy is reported there has often been a misplacedemphasis on sensitivity, which has led to rejection of techniques that mightotherwise be of value. Validation of physical capacity measures for the detection ofmalingering is currently under way in our laboratory and in Europe (J. Kool,personal communication, January 28, 2009).

Table 2. Cumulative percentages of pain patients with scores equal to or lower than the indicated

score Recognition Hits and Linear Shrinkage Model on the California Verbal Learning Test (original

and 2nd eds.)

Recognition Hits Linear Shrinkage Model

CVLT-1 CVLT-2 CVLT-1 CVLT-2

Not

Mal Mal LR

Not

Mal Mal LR

Not

Mal Mal LR

Not

Mal Mal LR

0 0 0

1 2 2

2 2 2 11

3 0 2 – 2 10 0

4 1 8 8 2 9 2

5 2 9 4.5 5 8 0 2 – 0

6 2 11 5.5 15 7 1 4 4 2

7 2 13 6.5 0 15 – 6 1 6 6 2

8 3 17 5.7 3 24 8 5 1 9 9 0 10 –

9 3 21 7 5 37 7.4 4 2 11 5.5 3 17 5.7

10 3 25 8.3 11 44 4 3 3 13 4.3 3 27 9

11 6 34 5.7 18 56 3.1 2 3 19 6.3 5 42 8.4

12 10 49 4.9 32 63 1.9 1 5 34 6.8 18 54 3

13 23 60 2.6 47 81 1.7 0 10 45 4.5 34 81 2.4

14 40 76 1.9 63 85 1.3 �1 26 62 2.4 58 90 1.6

15 59 85 1.4 90 95 1.1 �2 66 83 1.3 84 100 1.2

16 100 100 1 100 100 1 �3 91 100 1.1 95 – –

CVLT¼California Verbal Learning Test; LR¼Likelihood Ratio; Mal¼malingering.


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Grip strength measured with the JAMAR hand dynamometer has beenstudied extensively and appears to be a good indicator of poor effort (see Greve &Bianchini, 2012). Robinson, Geisser, Hanson, and O’Connor (1993), demonstratedsensitivity of 39% in simulators. Unfortunately the more important false-positiveerror rate was not reported so the value of the reported sensitivity level could not bedetermined. In contrast, Smith, Nelson, Sadoff, and Sadoff (1989) and Chengalur,Smith, Nelson, and Sadoff (1990) established cutoffs based on specificity: ‘‘thecriterion values for the sincere and faking categorization, were determined to be atthe 95% levels of the sincere trials of the injured and non-injured hands’’ (Chengaluret al., 1990, p. 151, italics added). They reported sensitivity ranging from 23% and85% depending on the particular variable or combination of variables and thegender of the participant, even when the false-positive error rate was held to 5%.When classification accuracy is calculated from reported group statistics, sensitivityvaried widely as a function of the variable examined, but it was as high as 60% forsome variables as cutoffs associated with 100% specificity.

Larrabee (2003a) found that a combined bilateral finger tapping raw score ofless than 63 detected 40% of malingering personal injury claimants compared toonly 6.5% of non-malingering patients. Arnold et al. (2005) reported a variety offinger tapping scores separately for men and women in patients with a variety ofconditions. At Larrabee’s cutoff, 17% of non-malingering women and 8% of non-malingering men failed. However, sensitivity was similar, ranging from 30% to50%. Shifting the cutoff for women to 58 resulted in an FP rate of 9% whilemaintaining sensitivity at 50%. Curtis, Brasseux, Greve, and Bianchini (2008) gotcomparable results in TBI claimants. Aguerrevere, Guise, Greve, and Bianchini(2009) studied tapping in patients with pain. Among the men scores of 80 or lesswere associated with FP rates of 10% and sensitivity of 68%. Using Larrabee’scutoff, the FP rate was 3% and sensitivity was 58%. In short, finger tapping datafrom criterion groups research are consistent in their ability to detect malingering.

These findings indicate that finger tapping is an accurate indicator of pooreffort and malingering. Of course, it is important to consider objective physicalpathology that might affect finger tapping such as conditions and pathologyinvolving the motor regions of the brain or the peripheral nerves (e.g., cervicalcompressions, carpal tunnel syndrome) as well as orthopedic or rheumatoidconditions affecting the upper extremities. With the exception of Larrabee’s study,finger tapping diagnostic accuracy data are available for dominant and non-dominant hands separately. Gender is also accounted for in those studies. Insummary, finger tapping is a valuable addition to the SVT battery not only becauseit accurately detects malingering but because it is one of the only measures ofphysical capacity validated for this purpose.

Assessing self-report validity. Measures of self-report validity have beendeveloped to assess exaggeration of emotional/psychological, somatic/health-related, and cognitive symptoms and complaints. These may take the form ofstand-alone scales and validity scales that are components of omnibus personalityor health scales. The focus in this section is on two major personality inventories(i.e., the Millon Multiaxial Clinical Inventory-III and the Minnesota MultiphasicPersonality Inventory) and two brief screens (the Modified Somatic Perception


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Questionnaire and the Pain Disability Inventory) because these have been subjected

to criterion groups validation in patients with pain.The Minnesota Multiphasic Personality Inventory (MMPI and MMPI-2;

Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) is one of the most

widely used clinical psychological assessment instruments (Lubin, Larsen, &

Matarazzo, 1984; Rabin et al., 2005). The MMPI includes numerous scales

designed to detect and quantify over- and under-reporting of symptoms. The

effectiveness of MMPI validity scales in detecting exaggeration and/or malingering

of symptoms in a range of conditions has been examined in a number of previous

studies (for reviews, see in particular Lees-Haley, Iverson, Lange, Fox, & Allen,

2003; Rogers, Sewell, Martin, & Vitacco, 2003).The MMPI has been used with pain patients for decades (Deardorff, Chino, &

Scott, 1993; Gatchel, Polatin, & Kinney, 1995; Keller & Butcher, 1991; Robinson,

Swimmer, & Rallof, 1989; Slesinger, Archer, & Duane, 2002). Only recently has its

ability to detect malingered pain-related disability been assessed (Bianchini,

Etherton, Greve, Heinly, & Meyers, 2008). The following paragraphs briefly

review the findings of four sets of MMPI scales (F-family, Symptom Validity Scale,

Meyers Index, Hypochondriasis & Hysteria) relative to the detection of malingering

in general and patients with pain in particular.The MMPI-2F-Family validity scales include F (Infrequency), Fb (Back

Infrequency), and Fp (Infrequency Psychopathology) and detect exaggeration using

a ‘‘rare-symptoms’’ (or infrequency) strategy. The general features of F and Fb are

well-known. Fp, however, is a newer scale (Arbisi & Ben-Porath, 1995) designed to

detect intentional exaggeration of psychiatric symptoms in a way that is not affected

by general psychological distress the way F and Fb are. Thus Fp contains only items

rarely endorsed by known psychiatric patients. In criterion-groups studies

(Bianchini et al., 2008; Greve, Bianchini, Love, Brennan, & Heinly, 2006;

Larrabee, 2003b; McCusker, Moran, Serfass, & Peterson, 2003), Fp is more

sensitive to malingering in settings in which severe psychological disturbances may

be more valuable (psychiatric forensic settings) than in TBI and chronic pain

samples where cognitive and/or physical symptoms may be more valuable. Overall,

for Fp, critical T-scores cutoffs associated with FP rates of 10% are in the range of

65 to 70 while T-scores of 70 to 75 are required to reach recommended conservative

FP levels in patients with TBI and pain. See Table 3 for detailed classification

accuracy data.The MMPI-2 Symptom Validity Scale (FBS; Lees-Haley, English, & Glenn,

1991) was developed based on observations that many personal injury malingerers

present with a mixed fake-good/fake-bad presentation. In August 2006 FBS was

added to the standard Pearson MMPI-2 materials. FBS has been studied extensively

and there are published specificity and sensitivity data on the FBS that have been

derived from methodologically sound studies. Most of the literature on the validity

of FBS has been reviewed in three papers: Ben-Porath, Greve, Bianchini, and

Kaufmann (2009); Greiffenstein, Fox, and Lees-Haley (2007); and Nelson, Sweet,

and Demakis (2006). A full discussion of all aspects of FBS is beyond the scope of

this paper; the reader is referred to those papers for detailed reviews of the FBS

literature.


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Regarding the use of FBS in the detection of malingering of patients with pain,Bianchini et al. (2008) found that FBS scores of 28 or higher were associated withan FP error rate of 5% while detecting almost 70% of definitivelydiagnosed malingerers. Overall, existing research indicates that FBS is generallynot elevated (i.e., 428) in patients without external incentive regardless of theseverity of their injury/illness and related disability. In TBI, FBS scores tend to be

Table 3. Cumulative percentages of patients with scores above the indicated t-score for MMPI-2

F-Family validity scales (F, Fb, Fp)

Clinical pain patients Published no incTBI

No

Inc

Inc

Only

All Not

MPRD

Def

MPRD Sim TBI1 Pain2 Clin1Def

MND1

N 23 34 57 32 26 18 100 133 14

F

490 41 35 0 1 21

485 41 42 1 1 21

480 0 0 50 46 1 3 29

475 0 3 2 50 50 6 5 43

470 13 6 9 66 58 13 7 64

465 13 15 14 72 65 0 18 11 71

460 35 24 28 81 77 11 30 23 79

Fb 132

490 50 35 – 2 50

485 0 0 53 35 – 3 57

480 3 2 59 39 – 4 64

475 3 2 59 46 0 – 5 71

470 0 9 7 69 54 6 – 12 71

465 4 12 12 78 62 6 – 16 71

460 4 27 18 81 65 38 – 23 79

455 13 35 26 84 73 33 – 32 79

Fp 130

485 0 0 19 15 2 5 21

480 4 2 25 23 3 5 21

475 4 2 31 35 3 5 21

470 4 0 2 34 35 6 9 29

465 4 6 5 38 54 0 8 9 29

460 9 12 11 53 58 11 14 18 50

450 30 29 30 72 81 39 38 35 57

The tabled value is the percentage of patients performing ABOVE (more extreme than) the given score.

For non-malingering patients this is the False Positive error rate (complement of specificity); for

malingering-patients this is the Sensitivity rate.

DEF¼Definite MPRD or MND; Inc Only¼ Incentive-Only; MPRD¼Malingered Pain-Related

Disability; No Inc¼No-Incentive; MND¼Malingered Neurocognitive Dysfunction; Clin¼mixed

clinical sample; TBI¼ traumatic brain injury.1From Greve et al. (2006).2From Meyers et al. (2002).


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higher in patients with less severe injuries. Similarly, pain patients diagnosed asdefinitively malingering had less objective physical pathology than non-malingeringpain patients and scored higher on FBS. In contrast, the probability of having apositive FBS score increases with the strength of independent evidence ofmalingering. See Table 4 for detailed classification accuracy data.

TheMeyers validity scale composite index (Meyers, Millis, & Volkert, 2002) forthe MMPI-2 was designed to assess exaggeration of self-reported psychologicalsymptoms by weighting and integrating seven individual MMPI-2 validity scales.Each scale score is weighted 0, 1, or 2 depending on how strongly the score indicatesexaggeration. The Meyers Index was originally developed comparing chronic painpatients with external incentive to exaggerate symptoms, chronic pain patientswithout incentive, and medically sophisticated but uninjured simulators (e.g.,nurses).

An abbreviated version of this index which uses only the scores produced bythe standard Pearson print-out has also been validated (Aguerrevere, Greve,Bianchini, & Meyers, 2008). This paper reports the included scales and score weightsfor both versions as well as accuracy data from several published studies. Themaximum score is 14 for the original Meyers Index and 10 for the abbreviated

Table 4. Cumulative percentages of patients with scores above the indicated raw score for MMPI-2

Scale FBS (Symptom Validity Scale)

Clinical pain patients No-incentiveTBI

No

Inc

Inc

Only

All Not

MPRD

Def

MPRD Sim TBI1 Pain2 Clin1Def

MND1

N 23 34 57 32 26 18 100 132 14

FBS

�34 22 23 14

�33 0 0 31 31 21

�32 3 2 34 31 36

�31 3 2 44 39 50

�30 3 2 53 50 0 64

�29 3 2 62 62 0 2 0 71

�28 9 5 69 65 11 9 1 71

�27 12 7 72 69 17 11 2 79

�26 0 12 7 81 69 17 16 4 86

�25 4 21 14 91 73 17 16 6 93

�24 4 32 21 94 77 22 22 8 93

�23 13 38 28 94 81 22 28 9 93

�22 17 47 35 94 89 22 34 14 93

�21 26 53 42 97 89 22 43 19 100





Disability; No Inc¼No-Incentive; MND¼Malingered Neurocognitive Dysfunction; Clin¼mixed

clinical sample; TBI¼ traumatic brain injury.1From Greve et al. (2006).2From Meyers et al. (2002).


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version. Raw scores above 5 or 6 for the original and 3 or 4 for the abbreviated

Meyers Index are strong indications that symptoms are being intentionally

exaggerated regardless of the alleged cause of the claimed disability. About half

of malingerers are detected at these levels. See Table 5 for detailed classificationaccuracy data.

Hypochondriasis (Hs), Hysteria (Hy) Scales are indicators of somatization

(Friedman, Glesser, Smeltzer, Wakefield, & Schwartz, 1983;Marks & Seeman, 1963),

Table 5. Cumulative frequencies for the four TBI groups, the three chronic pain group, the two student

simulator group by Meyer Index score

Traumatic brain injury Chronic pain

No

Inc

Clin

No

Inc

Inc

Only

All Not

MND

Prob

MND

Def

MND

All

MND

No

Inc1Inc

Only

All Not

MPRD

Def

MPRD Sim2

N 18 73 91 80 14 94 123 34 157 32 56 129

Original Meyers Index

14 1 7 2 6 5

�13 4 7 4 9 16

�12 11 14 12 16 23

�11 13 21 14 31 35

�10 14 21 15 38 50

�9 0 0 15 43 19 38 59 0

�8 1 1 24 43 27 47 61 2

�7 1 1 29 43 31 0 0 47 63 2

�6 3 2 38 50 39 3 2 47 70 3

�5 7 6 44 71 48 0 3 2 63 74 5

�4 11 9 53 86 55 2 12 8 75 74 6

�3 0 25 20 61 86 65 6 18 13 81 77 9

�2 11 33 29 66 93 69 15 32 24 88 84 15

�1 28 52 47 79 93 81 37 50 45 97 90 29

�0 100 100 100 100 100 100 100 100 100 100 100 100

Abbreviated Meyers Index

10 3 7 3 6 9

�9 8 21 10 9 23

�8 13 21 14 31 39

�7 0 0 14 21 15 38 47 0

�6 1 1 21 36 23 47 55 1

�5 4 3 34 43 35 0 0 47 61 2

�4 4 3 44 57 46 0 6 4 66 72 4

�3 0 14 11 55 86 60 2 6 4 78 75 7

�2 6 27 23 65 86 68 11 23 17 88 82 11

�1 28 51 46 78 93 80 31 49 42 97 87 26

�0 100 100 100 100 100 100 100 100 100 100 100 100

Inc¼ Incentive; Prob¼Probable; Def¼Definite; Sim¼Simulators; Clin¼Clinical;

MND¼Malingering Neurocognitive Dysfunction; MPRD¼Malingering Pain-Related Dysfunction.1combined No-Inc chronic pain groups of Bianchini et al. (2008; n¼ 23) and Meyers et al., (2002;

n¼ 100).2combined simulators of Bianchini et al (2008; n¼ 26) and Meyers et al., 2002; n¼ 30).


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the tendency to express emotional distress in terms of physical symptoms and/ordevelop physical symptoms in response to psychosocial stressors. Hs and Hy indicatethe presence of greater diversity of physical symptoms than can be explained bygenuine injury and illness alone. Elevations on these scales do not necessarily indicateintentional exaggeration, but non-malingering patients seen in a compensation-seeking setting were three to four times more likely to have T-scores greater than 80on these scales compared to persons not seeking compensation (Bianchini et al.,2008). Persons independently identified as malingering pain-related disability scoredeven higher on these two scales. Malingerers and Simulators scored about 10 pointshigher than these compensation-seeking non-malingering patients and were almostfour times more likely to score 90 or higher. When a certain score level is observed inpatients who are malingering, but rarely or never in patients who are physicallyinjured and/or experiencing the interpersonal circumstances, psychosocial forces, andstresses of litigation, this argues that scores at that level and higher are the result ofintentional exaggeration and not the psychosocial processes associated with injury inthe context of litigation, including somatization (Bianchini et al., 2008). See Table 6for detailed classification accuracy data.

The MMPI-2 Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen,2008) includes updated version of older validity scales (e.g., F, FBS) as well as theintroduction of a number of newer scales (Infrequent Somatic Responses [Fs],Response Bias Scale [RBS]). See Ben-Porath (2012) for a complete review of thisrevised and updated MMPI. Fs may be of particularly value in the chronic painpopulation. Fs may be particularly valuable in the chronic pain population. Thisscale consists of 16 items rarely endorsed by medical patients and was designedspecifically to detect over-reporting of somatic symptoms (Ben-Porath & Tellegen,2008). Using a simulator design, Sellbom, Wygant, and Bagby (2012) examined theability of these scales to differentiate feigned somatic symptoms from genuinemedical illness and somatoform disorder. This study found that the MMPI-2-RFvalidity scales (particularly Fp-r and Fs) readily discriminated college studentsasked to simulate physical health symptoms from patients with genuine medicalillness but were less accurate in differentiate the simulators from persons withsomatoform disorder. In a criterion-groups validation study using neuropsycholo-gical (brain injury) samples (not chronic pain), sensitivity ranged from 48% forFBS-r down to 10% (K-r) when the false positive error rate was held to 10%(Schroeder et al., 2012).

The Millon Multiaxial Clinical Inventory-III (MCMI-III) is the latest versionof the Millon Clinical Multiaxial Personality Inventories (Millon, 1994). TheMCMI-III contains scales intended to assess selected Axis I and II disorders fromthe fourth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV; American Psychiatric Association, 2000). To determine response bias theMCMI inventories include three modifier indices; Disclosure, which assesses howmuch information the patient is revealing on the test; Desirability, which assessesunder-reporting of psychiatric symptoms; and Debasement, which assesses over-reporting of psychological and somatic problems (Millon, Davis & Millon, 1997).

Research on the detection of malingering has generally focused on traumaticbrain injury and psychological distress; both the MCMI-II and MCMI-III havebeen studied. The MCMI-II modifier indices appear to be reliable indicators of


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symptom exaggeration (Bagby, Gillis, Toner, & Goldberg, 1991; Grossman &Craig, 1995; Lees-Haley, 1992; Retzlaff, Sheehan, & Fiel, 1991). For example, Lees-Haley (1992) demonstrated that Disclosure and Debasement differentiated pseudo-Post Traumatic Stress Disorder (pseudo-PTSD) patients from those with genuinepsychological impairment. At scores of 60 or higher, both scales had FP rates of 3%with sensitivity of 73% for Disclosure 87% for Debasement.

Using the MCMI-III modifier indices, Daubert and Metzler (2000) found thatcutoffs at FP rates ranging from 11% to 19% in adult psychiatric outpatientsdetected 55% to 74% of non-clinical simulators. Schoenberg, Dorr, and Morgan(2003) examined hospitalized psychiatric patients and student simulators. Theyreported FP rates ranging from 12% to 34% and sensitivity ranged from 35% to59%. These findings reflect the higher modifier index scores of psychiatric inpatients.

Table 6. Cumulative percentages of patients with scores below the indicated t-score for MMPI-2

Hypochondriasis (Hs) and Hysteria (Hy) scales

Clinical pain patients No-incentiveTBI

No

Inc

Inc

Only

All Not

MPRD

DefMPR

D Sim TBI1 Pain2 Clin1Def

MND1

N 23 34 57 32 26 18 100 133 14

Hs

4105 0 0

4100 0 0 6 0 0 7

495 4 0 2 22 15 1 0 7

490 4 9 7 44 39 0 3 1 29

485 4 18 12 59 46 6 8 2 57

480 9 29 21 78 62 6 14 4 79

475 17 47 35 84 77 17 25 11 93

470 35 65 49 94 85 22 36 21 93

Hy

4105 3 2 9 8 0 29

4100 6 4 19 15 2 29

495 6 4 25 26 0 4 0 43

490 12 7 47 46 6 4 2 43

485 0 27 11 59 62 6 13 4 50

480 4 41 26 72 77 6 18 10 71

475 9 53 35 84 81 17 28 17 86

470 22 59 44 91 85 33 42 26 93





Disability; No Inc¼No-Incentive; MPRD¼Malingered Pain Related Disability. MND¼Malingered

Neurocognitive Dysfunction; Clin¼mixed clinical sample.1From the MMPI-2s of patients reported in Greve et al. (2006).2From the MMPI-2s of the patients reported in Meyers et al. (2002)


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Aguerrevere, Greve, Bianchini, and Ord (2011) studied the MCMI-IIImodified indices in traumatic brain injury patients divided into malingering andnon-malingering groups. All three scales accurately differentiated malingering fromnon-malingering TBI patients. Debasement was the most accurate index, detecting55% of malingerers at the cutoff associated with 4% FP rate (BR470) and 51% ofmalingerers at the cutoff associated with no FP errors (BR� 75). When indices wereexamined together at cutoffs associated with an FP rate of approximately 5%,sensitivity increased to 68% but the joint FP rate also increased to 12%. These datasupport the use of the MCMI-III in TBI. However, as with the Schoenberg et al.(2003) study, the MCMI-III was unable to differentiate malingering TBI patientsfrom psychiatric inpatients.

In our chronic pain sample (Greve, Aguerrevere, Bianchini, Etherton, &Heinly, 2009) FP rates were higher than at the same cutoffs in TBI patients. ForDebasement the cutoff had to be increased to 85 to achieve an FP rate comparableto that seen at 70 in the TBI patients. At cutoffs associated with FP rates of 10% orless, LRs were in the 3 to 4 range. Given the high rate of psychopathology inpatients with chronic pain, one has to wonder about the pre-morbid and co-morbidpsychiatric influences in even non-malingering chronic pain patients. It appears thatthe MCMI-III modifier indices need to be used with caution in patients with chronicpain, particularly if they have a history of serious psychiatric illness.

Numerous questionnaires assessing pain-related problems and health concernare in use and some have built in validity scales (e.g., Battery for HealthImprovement-2 [BHI]; Bruns & Disorbio, 2003) or have cutoffs related to symptomexaggeration (e.g., Dallas Pain Questionnaire; Lawlis, Cuencas, Selby, & McCoy,1989). However, there is presently no research demonstrating the ability of most ofthese measures to differentiate between the exaggeration of symptoms associatedwith somatization (Gatchel, 2004) and malingering. Thus scores on these measuresmay be capable of determining whether psychosocial factors are influencing/complicating the clinical pain presentation but they cannot define the mechanismmore clearly.

However, Larrabee (2003c) has specifically addressed the exaggeration of paincomplaints by probable malingerers. He reported cut-offs, sensitivity, and predictivepower associated with FP rates of 10%, 5%, and 1% for the McGill PainQuestionnaire (MPQ; Melzak, 1975), the Pain Disability Index (PDI; Tait, Chibnall,& Krause, 1990), and the Modified Somatic Perception Questionnaire (MSPQ;Main, 1983). The patients in the malingering group met the Slick et al. (1999)criteria for Probable MND and none had objective medical findings that couldaccount for their pain complaints. The MPQ was unable to accurately identifymalingering at acceptable FP levels. The PDI performed better, identifying 38% ofmalingerers at the cutoff associated with the 5% FP rate (4¼57). The MSPQ wasextremely accurate, identifying 69% of the MND cases with only a 1% FP rate(4¼14). The relatively small sample size of this study and the fact that injurycharacteristics were not reported limits its usefulness with patients with knownphysical injuries.

Bianchini et al. (2012) examined the diagnostic accuracy of the MSPQ and PDIin 51 not-MPRD pain patients and 105 patients classified as MPRD. Studentsimulators (n¼ 36) were included for comparison. The not-MPRD group scored


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lower than the allMPRDand Simulator groups, which did not differ from each other.Sensitivity at particular cutoffs was similar to that reported by Larrabee (2003c)but FP rates at those cutoffs were substantially higher. In this study, at the cutoffsassociated with a 10% FP rate, sensitivity was 48% for the MSPQ (4¼16) and38% for the PDI (4¼59). The higher cutoffs in patients seen specifically forpersisting pain reflect the high rate of somatization in the chronic pain populationand the need to differentiate exaggeration due to malingering from that related tosomatization.

Combined improbability

The preceding section demonstrated that it is possible to accuratelydifferentiate malingering from non-malingering chronic pain cases using SVTs.Also evident is the fact that no single SVT is perfectly accurate. In general,sensitivity ranges from about 40% (sometimes lower) to 60% (sometimes higher) atreasonable FP levels (e.g., 5–10%). Thus the reliance on a single SVT will result insome malingering cases going undetected. At the same time, single SVT failures arecommon, particularly when there is severe pathology (Dean, Victor, Boone, &Arnold, 2008; Meyers & Volbrecht, 2003). In the context of external incentive, nosingle failure is sufficient to meet published criteria for malingering.6

It has been the convention in the study of cognitive malingering to require twopositive SVT findings or inconsistencies for a diagnosis of malingering(Greiffenstein et al., 1994; Greiffenstein, Gola, & Baker, 1995; Millis, Ross, &Ricker, 1998; Mittenberg et al., 2001; Slick et al., 1999). Larrabee (2008) andReynolds (1998) have made similar points about the relevance of increasingevidence of inconsistency for the determination that disability is being malingered.Thus SVTs must be used in combination to reliably detect malingering. This is notmerely a conceptual or theoretical position, but one which has been justified onstatistical grounds (Boone & Lu, 2003; Larrabee, 2003a) and which is supported byempirical data compiled over the past decade demonstrated empirically.

Meyers and Volbrecht (2003) studied nine different (mostly embedded)validity indicators in a diverse sample of 796 patients. Only 5% of the 399 non-litigating patients failed more than two validity checks compared to 83% ofgraduate students asked to simulate brain damage. Of the litigating patients 30%failed more than two checks, a finding consistent with estimates of the prevalence ofmalingering in litigating brain injured samples (Larrabee, 2005). Similar results werereported by Vickery et al. (2004) who randomly assigned non-litigating persons witha history of moderate-severe TBI and community volunteers to either a control orsimulator test condition (n¼ 23 per group). Simulators were given a monetarybonus if they successfully avoided detection. Each participant was administeredthree stand-alone SVTs. Failure on any one SVT was associated with an FP rate of6.5% and sensitivity of 89.1% (Likelihood ratio¼ 13.7).

6 The exception is the case of a significantly below chance performance on a forced-choice SVT, a finding

which is considered definitive evidence of intentional under-performance (Frederick & Speed, 2007;

Reynolds, 1998) and which along with the presence of external incentive meets criteria for a diagnosis of

malingering (Bianchini et al., 2005; Slick et al., 1999).


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Larrabee (2003a) studied the individual and combined accuracy of fiveindicators (four embedded indicators, one self-report indicator) in non-malingeringpatients (n¼ 54) and clinically diagnosed malingering cases (n¼ 41) in two studies.The average FP rate across all indicators was 9.3% and sensitivity was 53.6%.However, failure on any two or more indicators results in a decrease in the FP rateto 5.6% and an increase in sensitivity to 87.8%. In a similar study using patientreferrals defined as presenting with ‘‘credible’’ (n¼ 66) or ‘‘noncredible’’ (n¼ 37)cognitive deficits, Victor et al. (2009) studied the accuracy of four embeddedindicators. The average FP rate across all indicators was 14.4% and sensitivity was64.4%. However, as with Larrabee’s (2003a) study, when a failure was defined astwo or more positive SVT results, the FP rate dropped to 5.9% while sensitivityincreased to 87.5%. Chafetz (2011) similarly demonstrated that in Social SecurityDisability evaluations, the FP error rate decreased with increasing numbers of failedSVTs and with three or more failed SVTs the FP error rate was essentially 0.

These studies demonstrate that combining indicators sensitive to malingeringof different aspects of disability results in FP rates that are improved over those ofthe individual indicators and increased sensitivity. These studies support the idea ofusing multiple SVTs in the assessment of malingering and requiring two or morepositive findings as a minimum criterion for to diagnose malingering. However, thepreceding studies have focused on patients with or claiming brain dysfunction. Dothe findings hold in patients with pain? There is limited research in this regard.Meyers and Diep (2000) examined the effectiveness of six indicators in litigating(n¼ 55) and non-litigating (n¼ 53) patients claiming pain-related cognitive deficits.As with the Meyers and Volbrecht (2003) study described above, 29% of thelitigants failed two or more SVTs while none of the non-litigants did.

Approaching the same question from a different angle, Greve et al. (2008)found that pain patients classified as malingering using only embedded indicatorsand self-report measures did not differ from simulators reported in the publishedliterature on RDS, PDRT, TOMM, WMT, and FBS. At the same time, the painpatients with incentive who passed all selected SVTs did not differ from chronicpain patients described in the published literature who had no known externalincentive to appear disabled.

In a similar study of chronic pain patients (n¼ 536), Greve, Aguerrevere, et al.(2009) found essentially no difference between patients identified as malingering onthe basis of multiple SVT failures (Probable MPRD), those who scored significantlybelow chance (Definite MPRD) on a forced choice SVT, and from simulators onclinical tests of memory (CVLT), psychological state (MCMI-III), and motorspeed (finger tapping). Moreover, the pain patients who were classified as notMPRD by virtue of having passed all selected SVTs always performed significantlybetter than those determined to be intentionally exaggerating or faking theirdisability.

Taken together, these findings support Larrabee’s (2008) conclusion that wasbased on statistical arguments ‘‘that multiple SVT failures . . . provide strongevidence for probable malingering when two SVTs are failed, and very strongevidence for probable malingering, if not definite malingering, when three SVTs arefailed’’ (p. 677). The one caveat is that the SVTs must be relatively independent innon-malingering populations; the likelihood of non-independence can be increased


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by a priori selection of SVTs from different behavioral and cognitive domains.Moreover, with properly selected SVTs that assess these different behavioraldomains, passing all indicators at cutoffs associated with high sensitivity is a strongindication that a patient is not malingering.

CONCLUSIONS

The purpose of this paper was to review the science on SVTs available for usein patients claiming disability associated with chronic pain as well as the empiricaland conceptual basis for particular choices of methods. The forgoing text suggests anumber of general conclusions and recommendations.

(1) Assess malingering and validity comprehensively with well-calibrated tools.Many of these tools and their calibration data have been described in this articleand the primary source material is readily available. There remains aconsiderable amount of work to be done in the calibration of SVTs in chronicpain and physical effort measures which offers particularly fertile ground forresearch.

(2) An appropriately designed assessment with appropriately calibrated tools willincrease the likelihood that real malingering will be detected and decrease thelikelihood of an erroneous determination of malingering. The focus should beon the combined improbability of failed SVTs. Failure on two or three relativelyindependent SVTs is strong evidence that pain-related disability is beingintentionally exaggerated. In the context of multiple failed SVTs, passing otherSVTs does not significantly decrease the probability of malingering.

(3) Just because a person does not meet the minimum criteria for a diagnosis ofmalingering doesn’t mean they are not intentionally exaggerating theirdisability. There may be some positive findings that are so strong (e.g., achance [not below chance] level forced-choice SVT finding, FBS of 37) that it isnecessary to explicitly note that malingering could be influencing a patient’sclinical presentation.

(4) A valid presentation in one behavioral domain does not imply that thepresentation in other domains is also valid. In our experience, it is notuncommon for a pain patient to emphasize their physical disabilities whileminimizing psychological problems. Often cognitive impairment is emphasizedless in pain than in TBI. Malingering is a means to an end (apparent increaseddisability) and the specific approach is individualized.

(5) The more atypical or improbable the findings, the more likely the patient’s painrelated disability is being intentionally exaggerated. In this context, it isimportant to be sensitive to the qualitative inconsistencies (as opposed to thepsychometric inconsistencies which have been the subject of this paper). Thesequalitative inconsistencies can complement psychometric findings but need tobe used with caution.

(6) Conversely, if validity is comprehensively assessed and the patient is negative onALL indicators at cutoffs associated with high sensitivity (e.g.,460%), then onecan reasonably rule out malingering. However, any positive SVT result meansthat malingering is a concern.


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SUMMARY

Essential to the accurate detection of intentional exaggeration of disability isthe understanding that malingering is an act of will the goal of which is to increasethe appearance of disability beyond that which would naturally arise from the injuryor illness in question. Unlikely genuine clinical pathology whose related symptomsand disability are limited by natural underlying processes, the clinical presentationof a person choosing to malinger has no boundaries. In practice the presentation islimited only by the knowledge and beliefs of the individual and may be broadlyshaped by the nature of the claim. Therefore the clinician cannot make assumptionsabout the presentation (e.g., evaluation for cognitive malingering in TBI andexaggerated physical symptoms in pain) of a given case when one develops anassessment strategy. One simply does not know how the next case will present.Assessing validity with a variety of tools sensitive to the multiple manifestations ofmalingering will increase the odds of detecting invalid disability claims whilesimultaneously reducing the risk of falsely rejecting a valid claim.

ACKNOWLEDGMENT

The material in this article was originally published in German as the following:Greve, K. W., & Bianchini, K. J. (2009). Schmerz und Beschwerdenvalidierrung[Symptom validity testing in pain]. In T. Merten & D. Dettenborn (Eds.), Diagnostikder Beschwerdenvaliditat (pp. 193–229. Berlin: Deutsch Psychologen Verlag GmbH.This updated article is now published for the first time in English with the kindpermission of Deutscher Psychologen Verlag, Berlin.

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