Performance of older depressed patients on two cognitive malingering tests: false positive rates for the Rey 15-item memorization and dot counting tests

To our knowledge, no investigations have been undertaken to determine whether depression impacts performance on two commonly used tests to detect malingering of cognitive symptoms, the Rey 15-item Memorization Test and the Rey Dot Counting Test. This is a critical issue because of the high rate of depressive symptoms in patients with neurological conditions. It was hypothesized that depressed individuals, especially those with more severe depression, might be at risk for failing the tests, because these patients exhibit mild deficits in mental speed, visual perceptual/spatial skills, and visual memory, abilities required for successful completion of the malingering tests. However, examination of test performance in 64 older participants with major depression generally revealed very low false positive rates for most test scores, and severity of depression was unrelated to test scores. These results add to accumulating data supporting the validity of these cognitive malingering tests by documenting few false positive identifications.     

Relationships between eight measures of suspect effort

Previous studies have recommended that multiple measures be employed concurrently to provide converging evidence regarding the presence of suspect effort during neuropsychological assessment. However, if the tests are highly correlated they do not represent independent sources of information. To date, no study has examined correspondence between effort tests. The present study assessed the relationships between eight measures which can be used to assess effort (Rey 15-item, Rey Dot Counting Test, Rey Word Recognition Test, RAVLT recognition trial, Rey-Osterrieth Complex Figure Test effort equation, Digit Span, Warrington Recognition Memory Test-Words, and "b" Test) in a sample of 105 patients in litigation or attempting to obtain/maintain disability compensation and who displayed noncredible symptoms based on psychometric performance and behavioral criteria. Modest to moderate correlations were observed between test summary scores with only two measures sharing more than 50% score variance (Digit Span and Dot Counting). Moderate correlations were also observed between individual test scores reflecting indices of response time, free recall, recognition, and false positive errors, providing possible evidence that patients may use specific strategies when producing noncredible performances. Overall the results suggest that the use of these various tests generally provides nonredundant data regarding patient credibility in neuropsychological evaluations.     

Relationships Between Eight Measures of Suspect Effort

Previous studies have recommended that multiple measures be employed concurrently to provide converging evidence regarding the presence of suspect effort during neuropsychological assessment. However, if the tests are highly correlated they do not represent independent sources of information. To date, no study has examined correspondence between effort tests. The present study assessed the relationships between eight measures which can be used to assess effort (Rey 15-item, Rey Dot Counting Test, Rey Word Recognition Test, RAVLT recognition trial, Rey-Osterrieth Complex Figure Test effort equation, Digit Span, Warrington Recognition Memory Test-Words, and “b” Test) in a sample of 105 patients in litigation or attempting to obtain/maintain disability compensation and who displayed noncredible symptoms based on psychometric performance and behavioral criteria. Modest to moderate correlations were observed between test summary scores with only two measures sharing more than 50% score variance (Digit Span and Dot Counting). Moderate correlations were also observed between individual test scores reflecting indices of response time, free recall, recognition, and false positive errors, providing possible evidence that patients may use specific strategies when producing noncredible performances. Overall the results suggest that the use of these various tests generally provides nonredundant data regarding patient credibility in neuropsychological evaluations.     

Utility of the trail making test in the assessment of malingering in a sample of mild traumatic brain injury litigants

The Trail Making Test (TMT) is one of the most commonly administered tests in neuropsychological assessments. It has been shown to be a valid indicator of brain damage due to traumatic brain injury (TBI), as well as a number of other neuropathological conditions. TMT error and ratio scores have been suggested as possible markers of malingering. The present study examined the utility of various TMT scores as malingering measures in 94 TBI litigants. Litigants were divided into those suspected of (n = 27) and those not suspected of malingering (n = 67) based on scores obtained on the Test of Memory Malingering and/or the Rey 15-Item Test. TMT errors did not discriminate between suspected and nonsuspected malingerers; however, the overall level of performance on the TMT was suppressed in suspected malingerers. The TMT ratio score was significantly lower in litigants suspected of malingering, although the clinical utility of this ratio is minimal. Results of the present study suggest using caution when interpreting TMT scores as markers of malingering in TBI litigants.     

Subjective memory complaints in an elderly sample: a cross-sectional study

BACKGROUND: Community based studies show that neurological or psychiatric symptoms are very frequent among the elderly population, with poor memory complaints being the most common. However, the relationship between poor memory complaints and objective memory performance is unclear. We designed this study to evaluate whether subjective memory complaints (SMC) are associated with objective cognitive performance or depression amongst the elderly Brazilian generation. METHODS: A cross-sectional study was carried out in 114 patients who were 50+, with or without SMC having no obvious cognitive impairment at its baseline (this was screened by the Mini-Mental State Examination with cut-off values adapted according to the subjects' educational background). Subjects were assessed regarding memory difficulty complaints, demographic data and underwent a neuropsychological assessment made up of nine cognitive tests (Rey Auditory Verbal Learning Test, Visual Reproduction Test, Logic Memory--History A, Free and Cued Selective Reminding Test, Stroop Test, Digit Span, Digit Symbol, Trail Making Test, fluency tests: naming animals and fruits) and the Geriatric Depression Scale. RESULTS: Twenty-one percent of the subjects had subjective memory complaints. The scores in the cognitive assessment of subjects with SMC did not differ from the scores of subjects without SMC. However, patients with subjective memory complaints had lower scores in the fluency test--category animals and the Geriatric Depression Scale. CONCLUSIONS: These results support the finding from other cross-sectional studies showing that subjective memory complaints are associated with depressive symptoms rather than objective cognitive performance.     

Use of specific malingering measures in a Spanish sample

There are an increasing number of tests available for detecting malingering. However, these tests have not been validated for using in Spanish speakers. The purpose of this study is to explore the value of three specific malingering tests in the Spanish population. This study used a known-groups design, together with a group of analog students. The results show that both the Victoria Symptom Validity Test and the b Test can be used to detect malingering in Spanish population. However, some restrictions must be applied when the Rey 15-Item Test is administered and interpreted.     

Mediating Effects of Cognitive Effort and Depression on Intelligence,Memory, and Executive Functions in Individuals with Mild Traumatic Brain Injury

Objective

Mild traumatic brain injury (mTBI) is frequently associated with psychiatric symptoms and cognitive dysfunction, as well as with the receipt of workers'' compensation, as many mTBIs occur due to work-related accidents. We hypothesized that depression and insufficient cognitive effort mediate the relationship between sociodemographic variables and cognitive dysfunction in mTBI.

Methods

A retrospective chart review study was conducted using 115 records of patients with mTBI. Cognitive effort was measured based on scores on the Rey 15-Item Test. Multivariate linear regression analysis was performed to examine factors predictive of cognitive functions. Path analysis was subsequently performed to investigate the mediating effects of depression and cognitive effort in relation to receipt of workers'' compensation and demographic variables.

Results

Fifteen of the 115 participants (13.0%) received failing scores on the Rey 15-Item Test, which indicated insufficient cognitive effort. Path analysis indicated that cognitive effort mediated the effects of age and workers'' compensation on cognitive functions.

Conclusion

Given the significant mediating effects of cognitive effort on cognitive performance, it is important to address patient motivation and encourage mTBI patients covered by workers'' compensation to perform tests with authentic effort.     

The Performance of Individuals with Mental Retardation on Cognitive Tests Assessing Effort and Motivation

The purpose of this study was to determine which tests of effort and motivation would be appropriate for use with patients with mental retardation when feigning of cognitive deficits is suspected. The seven measures evaluated included the WMS-III Rarely Missed Index Test, forced-choice recognition portion of the California Verbal Learning Test-II, Reliable Digit Span test, Rey 15-Item Test, Rey Dot Counting Test, the Rey 15-Item Test with Recognition Trial, and the Vocabulary (V)-Digit Span (DS) difference score. Results indicated that the forced-choice portion of the CVLT-II, the V-DS difference score, and the Rarely Missed Index Test from the WMS-III might be appropriate for use with this population with passing rates of 89%, 98%, and 91% respectively.     

Cognitive correlates of visual hallucinations in non-demented Parkinson's disease patients

BackgroundVisual hallucinations (VH) in Parkinson's disease (PD) are associated with PD dementia and have been related to cognitive impairments in non-demented PD patients. Reports on the specific cognitive domains affected are conflicting. The aim of the present study was to investigate the presence of specific cognitive impairments in non-demented PD patients with VH, compared to those without VH.MethodsWe compared the clinical characteristics and neuropsychological test scores of 31 non-demented PD patients with VH with those of 31 PD patients without VH that were carefully matched for sex, age, disease duration and educational level. Several non-motor symptoms, including depression, anxiety and sleep disturbances, were also taken into account, as these may influence cognitive performance.ResultsThe PD with VH group performed significantly worse on the Trail Making Test part A (p = 0.01) and the Rey Auditory Verbal Learning Test, immediate recall (p = 0.01). In addition, PD patients with VH were more anxious, more depressed and reported more sleep disturbances. Verbal learning scores were not associated with levels of anxiety, depression or sleep disruption, whereas worse Trail Making Test A performance was associated with concomitant sleep disturbances.ConclusionsIn non-demented PD patients, the presence of VH is associated with a cognitive profile characterized by impairments in verbal learning and probably attention. Since these cognitive functions are believed to be non-dopaminergic mediated functions, the present results support the hypothesis that multiple neurotransmitter systems, other than dopamine, contribute to the pathophysiology of VH in PD.     

Humor appreciation deficit in schizophrenia: the relevance of basic neurocognitive functioning

The purpose in undertaking the present study was to investigate humor appreciation in patients with schizophrenia. Moreover, we sought to explore the potential relationship of humor appreciation with measures of psychopathology and cognitive functioning among the patients. Thirty-six patients with schizophrenia were compared with 31 normal controls matched for age, sex, and education on a computerized test comprising captionless cartoons: Penn's Humor Appreciation Test (PHAT). The patients were also evaluated on the symptom dimensions derived from the Positive and Negative Symptom Scale (positive symptoms, negative symptoms, cognitive symptoms, depression, and excitement), as well as a battery of neuropsychological tests measuring executive functions, attention, working memory, verbal and visual memory, visuospatial ability, and psychomotor speed. Patients with schizophrenia had significantly lower scores on the PHAT than normal controls. The patients' performance on the PHAT correlated with scores on Penn's Continuous Performance Test, the Stroop Color-Word Test, and the phonological subscale of the Greek Verbal Fluency Test. Our findings indicated impaired humor appreciation among patients with schizophrenia. The relationship found between the appreciation of captionless cartoons involved an incongruous detail and performance on a broad neuropsychological battery suggested that the deficit in humor appreciation in schizophrenia could be attributed to impairment in more basic neurocognitive domains, namely, selective and sustained attention as well as phonological word fluency.     

Detecting Malingering in Traumatic Brain Injury and Chronic Pain: A Comparison of Three Forced-Choice Symptom Validity Tests

Individual and joint malingering detection accuracy of the Portland Digit Recognition Test (PDRT), Test of Memory Malingering (TOMM), and Word Memory Test (WMT) was examined in traumatic brain injury (TBI; 43 non-malingering, 27 malingering) and chronic pain (CP; 42 non-malingering, 58 malingering) using a known-groups design. At published cutoffs, the PDRT and TOMM were very specific but failed to detect about 50% of malingerers; the WMT was sensitive but prone to false positive errors. ROC analyses demonstrated comparable accuracy across all three tests. Joint classification accuracy was superior to that of the individual tests. Clinical and research implications are discussed.     

The utility of the Rey Word Recognition Test in the detection of suspect effort

The Rey Word Recognition Test potentially represents an underutilized tool for clinicians to use in the detection of suspect effort. The present study examined the predictive accuracy of the test by examining the performance of three groups of participants: (a) 92 noncredible patients (as determined by failed psychometric and behavioral criteria and external motive to feign), (b) 51 general clinical patients with no motive to feign, and (c) 31 learning disabled college students. Results demonstrated gender differences in performance that necessitated separate cutoff scores for men and women. Use of a cutoff score of < or = 7 words correctly recognized identified 80.5% of noncredible female patients while maintaining specificity of > 90%. However, to achieve this level of specificity in male noncredible patients, the cutoff score had to be lowered to < or = 5, with resultant sensitivity of only 62.7%. A combination variable (recognition correct minus false positive errors + number of words recognized from the first 8 words) showed enhanced sensitivity in identifying suspect effort in a subset of the noncredible sample who were claiming cognitive symptoms secondary to traumatic brain injury (i.e., cutoff score of < or = 9 = 81.6% sensitivity with 90% specificity). Results indicate that the Rey Word Recognition Test is an accurate and cost-effective method for the detection of noncredible cognitive performance.     

A longitudinal study of the evolution of cognitive function and affective state in patients with amyotrophic lateral sclerosis.

OBJECTIVES: The study aimed to evaluate cognitive function and emotional reactivity in 18 patients with ALS, compared to 19 matched controls, and assess their evolution over a 12-month period. METHODS: 18 ALS patients and 19 matched controls were included, and assessed at inclusion, six months and twelve months later. Depression was evaluated with the Geriatric Depression Scale, and cognitive function with the Folstein Mini Mental State. A battery of psychometric tests (Wisconsin Card Sorting Test (WCST), the numerical Empan test, the Trail-making test, the Boston Naming Test, the 15-word Rey memory test, the Benton visual retention test and the Raven Progressive Matrix) was used to measure frontal processing and non-frontal function. Emotional reactivity was measured with the film-evoked emotions test. RESULTS: ALS patients were significantly more depressed than controls, as measured on the Geriatric Depression Scale, and depression increased over the study period. There was a very mild defect in cognitive function, and a performance deficit in the Trail-making test, a measure of frontal processing. These deficits, unlike neuromuscular function and depression, did not aggravate over the 12 months of the study. There was no observable change in non-frontal function. Emotional reactivity did not differ significantly between ALS patients and controls. CONCLUSIONS: This study provides further evidence for a mild defect in frontal cognitive processing in ALS patients that evolves only slowly, if at all, with time.     

The Utility of the Rey Word Recognition Test in the Detection of Suspect Effort

The Rey Word Recognition Test potentially represents an underutilized tool for clinicians to use in the detection of suspect effort. The present study examined the predictive accuracy of the test by examining the performance of three groups of participants: (a) 92 noncredible patients (as determined by failed psychometric and behavioral criteria and external motive to feign), (b) 51 general clinical patients with no motive to feign, and (c) 31 learning disabled college students. Results demonstrated gender differences in performance that necessitated separate cutoff scores for men and women. Use of a cutoff score of ≤7 words correctly recognized identified 80.5% of noncredible female patients while maintaining specificity of >90%. However, to achieve this level of specificity in male noncredible patients, the cutoff score had to be lowered to ≤5, with resultant sensitivity of only 62.7%. A combination variable (recognition correct minus false positive errors + number of words recognized from the first 8 words) showed enhanced sensitivity in identifying suspect effort in a subset of the noncredible sample who were claiming cognitive symptoms secondary to traumatic brain injury (i.e., cutoff score of ≤9 = 81.6% sensitivity with 90% specificity). Results indicate that the Rey Word Recognition Test is an accurate and cost-effective method for the detection of noncredible cognitive performance.     

Normative Data for Neuropsychological Tests in a Rural Elderly Chinese Cohort

Normative information is important for appropriate interpretation of cognitive test scores as a critical component of dementia diagnosis in the elderly population. A cross-sectional evaluation of 1826 participants aged 65 years and older from four rural counties in China was conducted using six cognitive instruments including tests of global cognitive function (the Community Screening Instrument for Dementia), memory (Word List Learning and Recall tasks from the Consortium to Establish a Registry for Alzheimer's Disease, IU Story), language (Animal Fluency Test), and executive function (IU Token). Multiple regression models adjusting for demographic variables were used to provide standardized residuals z-scores and corresponding percentile ranking for each cognitive test. In all cognitive tests older age was associated with worse test performance while exposure to education was related to better cognitive test performance. We also detected a significant gender difference with men scoring better than women and a significant gender by education interaction on two tests. The interaction indicates that gender difference in test scores was much smaller in participants with more education than those who had less or no education. These demographically adjusted, regression-based norms can be a useful tool to clinicians involved with differential diagnosis of cognitive and memory disorders in older adults in rural China.     

Post-Daubert admissibility of scientific evidence on malingering of cognitive deficits

In Daubert v. Merrell Dow Pharmaceuticals, Inc. (1993) the Supreme Court held that evidence must be "reliable" to be admissible and for scientific evidence "evidentiary reliability" is based on scientific validity. This article addresses the question "Do the Rey 15-Item Test ('FIT'), the Test of Memory Malingering ('TOMM'), and the Validity Indicator Profile ('VIP') likely meet the Daubert standard for admissibility of scientific evidence?" Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and base rates of 30 and 15 percent were calculated for each test. Given the existing literature on malingering and the implications of a misclassification of malingering, we discuss the findings for each of the three tests using a PPV > or = 80 percent with a base rate of malingering of < or = 30. Our analyses indicate that the Rey 15-FIT fails to meet this standard of scientific validity. In contrast, the TOMM shows high specificity and PPV, and our findings suggest cautious optimism regarding the VIP. These results are discussed within the context of the courts' guidelines for the Daubert standard.     

Relationship of affect recognition with psychopathology and cognitive performance in schizophrenia.

The purpose of the present study was to explore the relationship between emotion perception and both psychopathology and cognitive functioning in a group of Greek patients with schizophrenia. Thirty-five patients with schizophrenia were assessed with computerized tests of emotion perception, using visual faces (Kinney's Affect Matching Test, KAMT), prosody (Affective Prosody Test, APT), and visual everyday scenarios (Fantie's Cartoon Test, FCT), as well as a facial recognition test (Kinney's Identity Matching Test, KIMT). The patients were also evaluated with the symptoms dimensions derived from the PANSS (positive, negative, cognitive, depression, and excitement) and a battery of neuropsychological tests measuring executive functions, attention, working memory, verbal and visual memory, visuospatial ability, and visual scanning/psychomotor speed. The three emotion perception and face recognition tests correlated significantly with each other. The KAMT was significantly related to the cognitive symptoms dimension of the PANSS and executive functions. The FCT was significantly related to level of education and attention. Finally, the APT was significantly related to the cognitive symptoms dimension, executive functions, and attention. Our findings regarding the significant relationships of affect perception, both facial and vocal, as well as in everyday scenarios, with several cognitive abilities support the notion that deficits in decoding affective information in schizophrenia could be attributed to impairment in more basic neurocognitive domains.     

The Relationship Between Performances on Neuropsychological Symptom Validity Testing and the MCMI-III in Patients With Fibromyalgia

Fibromyalgia is a disorder that frequently presents with both cognitive complaints and psychiatric symptoms. This study investigated the association between Symptom Validity Test (SVT) performance and psychiatric symptoms as measured by the Millon Clinical Multiaxial Inventory-III (MCMI-III), a common measure of psychopathology. A total of 72 fibromyalgia patients at a tertiary care clinic completed the MCMI-III, an embedded cognitive symptom validity test (Reliable Digit Span), and a stand-alone cognitive symptom validity test (the Word Memory Test or Test of Memory Malingering). Of these patients, 21% failed a stand-alone SVT, whereas an additional 15% failed both a stand-alone and embedded SVT. Individuals who failed both stand-alone and embedded cognitive SVTs had higher scores on a number of MCMI-III personality subscales and had elevated scores on MCMI-III modifying indices compared to individuals who passed cognitive SVTs. Moreover, SVT performance was significantly correlated with multiple MCMI-III scores, including modifying indices, as well as the somatoform, depression, and anxiety subscales. In sum, cognitive and psychological symptom validity scores were significantly related. Given the new emphasis on cognitive complaints as part of the fibromyalgia diagnostic criteria, neuropsychological evaluation of both cognitive and psychological symptom validity should be a part of a comprehensive diagnostic assessment.     

Specificity of Malingering Detection Strategies in Older Adults Using the CVLT and WCST

Strategies for the detection of possible malingering have largely taken two forms. First is the development and validation of domain-specific measures of malingering designed specifically for the detection of malingering (e.g., Test Of Memory Malingering, Word Memory Test, and Word Completion Memory Test). The second has been the development and evaluation of performance patterns and cutoff scores applicable to commonly used neuropsychological instruments. Two such instruments that have been examined are the Wisconsin Card Sorting Test (WCST) and the California Verbal Learning Test (CVLT). While several studies propose possible cutoff scores and actuarial judgement strategies for these tests, the specificity of these strategies within older, nonimpaired adults has not been established. Without proper evaluation of potential age-related effects within these strategies, the actual utility of the strategies within suspected malingerers who are older adults is unknown. Therefore, the present study was conducted to evaluate the specificity of the proposed strategies for detecting possible malingering with the WCST and the CVLT in a sample of older, community-dwelling, nonimpaired adults. The results suggest that the currently existing WCST formulas may have limited utility for the detection of malingering with older adults while the CVLT strategies do appear to have potential clinical utility. The potential of these formulas for use with older adults is discussed.     

The relationship between performances on neuropsychological symptom validity testing and the MCMI-III in patients with fibromyalgia

Fibromyalgia is a disorder that frequently presents with both cognitive complaints and psychiatric symptoms. This study investigated the association between Symptom Validity Test (SVT) performance and psychiatric symptoms as measured by the Millon Clinical Multiaxial Inventory-III (MCMI-III), a common measure of psychopathology. A total of 72 fibromyalgia patients at a tertiary care clinic completed the MCMI-III, an embedded cognitive symptom validity test (Reliable Digit Span), and a stand-alone cognitive symptom validity test (the Word Memory Test or Test of Memory Malingering). Of these patients, 21% failed a stand-alone SVT, whereas an additional 15% failed both a stand-alone and embedded SVT. Individuals who failed both stand-alone and embedded cognitive SVTs had higher scores on a number of MCMI-III personality subscales and had elevated scores on MCMI-III modifying indices compared to individuals who passed cognitive SVTs. Moreover, SVT performance was significantly correlated with multiple MCMI-III scores, including modifying indices, as well as the somatoform, depression, and anxiety subscales. In sum, cognitive and psychological symptom validity scores were significantly related. Given the new emphasis on cognitive complaints as part of the fibromyalgia diagnostic criteria, neuropsychological evaluation of both cognitive and psychological symptom validity should be a part of a comprehensive diagnostic assessment.