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Psychiatry : the science of lies
\"For more than half a century Thomas Szasz has devoted much of his career to a radical critique of psychiatry. His latest work, Psychiatry: The Science of Lies, is a culmination of his life's work: to portray the integral role of deception in the history and practice of psychiatry.\" \"Szasz argues that the diagnosis and treatment of mental illness stands in the same relationship to the diagnosis and treatment of bodily illness that the forgery of a painting does to the original masterpiece. Art historians and the legal system seek to distinguish forgeries from originals. Those concerned with medicine, on the other hand - physicians, patients, politicians, health insurance providers, and legal professionals - take the opposite stance when faced with the challenge of distinguishing everyday problems in living from bodily diseases, systematically authenticating nondiseases as diseases. The boundary between disease and nondisease - genuine and imitation, truth and falsehood - thus becomes arbitrary and uncertain.\"--Jacket.
Book
Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI
Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance.
Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass).
Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition.
Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.
Journal Article
Invited Commentary: Advancing but not yet Advanced: Assessment of Effort/Malingering in Forensic and Clinical Settings
Neuropsychologists’ conclusions and courtroom testimony on malingering can have profound impact. Intensive and ingenious research has advanced our capacities to identify both insufficient and sufficient effort and thus make worthy contributions to just conflict resolution. Nevertheless, given multiple converging factors, such as misleadingly high accuracy rates in many studies, practitioners may well develop inflated confidence in methods for evaluating effort/malingering. Considerable research shows that overconfidence often increases diagnostic and predictive error and may lead to fixed conclusions when caution is better advised. Leonhard’s work thus performs an important service by alerting us to methodological considerations and shortcomings that can generate misimpressions about the efficacy of effort/malingering assessment. The present commentary covers various additional complicating factors in malingering assessment, including other factors that also inflate confidence; subtle and perhaps underappreciated methodological flaws that are inversely related to positive study outcomes (i.e., the worse the flaws the better methods appear to be); oversimplified classifications schemes for studying and evaluating effort that overlook, for example, common mixed presentations (e.g., malingering and genuinely injured); and the need to expand research across a greater range and severity of neuropsychological conditions and diverse groups. More generally, although endorsing various points that Leonhard raises, a number of questions and concerns are presented, such as methods for calculating the impact of case exclusions in studies. Ultimately, although Leonhard’s conclusions may be more negative than is justified, it seems fair to categorize methods for assessing malingering/effort as advancing, but not yet advanced, with much more needed to be done to approach that latter status.
Journal Article
Factitious disorders and malingering: challenges for clinical assessment and management
Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.
Journal Article
Performance Validity and Symptom Validity in Neuropsychological Assessment
Failure to evaluate the validity of an examinee's neuropsychological test performance can alter prediction of external criteria in research investigations, and in the individual case, result in inaccurate conclusions about the degree of impairment resulting from neurological disease or injury. The terms performance validity referring to validity of test performance (PVT), and symptom validity referring to validity of symptom report (SVT), are suggested to replace less descriptive terms such as effort or response bias. Research is reviewed demonstrating strong diagnostic discrimination for PVTs and SVTs, with a particular emphasis on minimizing false positive errors, facilitated by identifying performance patterns or levels of performance that are atypical for bona fide neurologic disorder. It is further shown that false positive errors decrease, with a corresponding increase in the positive probability of malingering, when multiple independent indicators are required for diagnosis. The rigor of PVT and SVT research design is related to a high degree of reproducibility of results, and large effect sizes of d=1.0 or greater, exceeding effect sizes reported for several psychological and medical diagnostic procedures. (JINS, 2012, 18, 1–7)
Journal Article
Review of Statistical and Methodological Issues in the Forensic Prediction of Malingering from Validity Tests: Part II—Methodological Issues
Forensic neuropsychological examinations to detect malingering in patients with neurocognitive, physical, and psychological dysfunction have tremendous social, legal, and economic importance. Thousands of studies have been published to develop and validate methods to forensically detect malingering based largely on approximately 50 validity tests, including embedded and stand-alone performance and symptom validity tests. This is Part II of a two-part review of statistical and methodological issues in the forensic prediction of malingering based on validity tests. The Part I companion paper explored key statistical issues. Part II examines related methodological issues through conceptual analysis, statistical simulations, and reanalysis of findings from prior validity test validation studies. Methodological issues examined include the distinction between analog simulation and forensic studies, the effect of excluding too-close-to-call (TCTC) cases from analyses, the distinction between criterion-related and construct validation studies, and the application of the Revised Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) in all Test of Memory Malingering (TOMM) validation studies published within approximately the first 20 years following its initial publication to assess risk of bias. Findings include that analog studies are commonly confused for forensic validation studies, and that construct validation studies are routinely presented as if they were criterion-reference validation studies. After accounting for the exclusion of TCTC cases, actual classification accuracy was found to be well below claimed levels. QUADAS-2 results revealed that extant TOMM validation studies all had a high risk of bias, with not a single TOMM validation study with low risk of bias. Recommendations include adoption of well-established guidelines from the biomedical diagnostics literature for good quality criterion-referenced validation studies and examination of implications for malingering determination practices. Design of future studies may hinge on the availability of an incontrovertible reference standard of the malingering status of examinees.
Journal Article
Prevalence of Symptom Overreporting in the Structured Inventory of Malingered Symptomatology (SIMS) in Clinical Patients: A Meta-Analysis
Background: Failure on symptom validity tests may occur in a variety of contexts and situations, including routine clinical settings. To date, no meta-analysis has targeted the failure rate of the Structured Inventory of Malingered Symptomatology (SIMS) in clinical assessments, nor the factors that may moderate this rate. Method: We used a binomial-normal random-effects meta-analysis to estimate the pooled failure rate of SIMS among patients with a clinical diagnosis who were evaluated in a non-forensic setting. Results: 34 studies and 40 samples were included. The total sample size was 8844 patients. The mean total SIMS score was 15.9 (SD = 5.2). The estimated overall failure rate of SIMS was 36% (95% CI: 30%-43%; I 2 = 96.6%, p < .001). Conclusions: There is an elevated failure rate on the SIMS in clinical patient populations; however, these positive results are not necessarily false positives. The methodological challenge to tell true and false positives apart appears to be of primary importance and should dictate both careful planning of future studies and circumspection when interpreting rates of validity test failure in clinical assessments.
Journal Article
Eliciting Response Bias Within Forced Choice Tests to Detect Random Responders
The Forced Choice Test (FCT) can be used to detect malingered loss of memory or sensory deficits. In this test, examinees are presented with two stimuli, one correct and one incorrect, in regards to a specific event or a perceptual discrimination task. The task is to select the correct answer alternative, or guess if it is unknown. Genuine impairment is associated with test scores that fall within chance performance. In contrast, malingered impairment is associated with purposeful avoidance of correct information, resulting in below chance performance. However, a substantial proportion of malingerers intentionally randomize their responses, and are missed by the test. Here we examine whether a ‘runs test’ and a ‘within test response ‘bias’ have diagnostic value to detect this intentional randomization. We instructed 73 examinees to malinger red/green blindness and subjected them to a FCT. For half of the examinees we manipulated the ambiguity between answer alternatives over the test trials in order to elicit a response bias. Compared to a sample of 10,000 cases of computer generated genuine performance, the runs test and response bias both detected malingered performance better than chance.
Journal Article
Why functional neurological disorder is not feigning or malingering
Functional neurological disorder (FND) is one of the commonest reasons that people seek help from a neurologist and is for many people a lifelong cause of disability and impaired quality of life. Although the evidence base regarding FND pathophysiology, treatment and service development has grown substantially in recent years, a persistent ambivalence remains amongst health professionals and others as to the veracity of symptom reporting in those with FND and whether the symptoms are not, in the end, just the same as feigned symptoms or malingering. Here, we provide our perspective on the range of evidence available, which in our view provides a clear separation between FND and feigning and malingering. We hope this will provide a further important step forward in the clinical and academic approach to people with FND, leading to improved attitudes, knowledge, treatments, care pathways and outcomes.In this Perspective, Edwards and colleagues present their opinion that functional neurological disorder is categorically different from feigning and malingering. They discuss clinical, epidemiological and experimental evidence in support of this view.
Journal Article
Quo Vadis Forensic Neuropsychological Malingering Determinations? Reply to Drs. Bush, Faust, and Jewsbury
The thoughtful commentaries in this volume of Drs. Bush, Jewsbury, and Faust add to the impact of the two reviews in this volume of statistical and methodological issues in the forensic neuropsychological determination of malingering based on performance and symptom validity tests (PVTs and SVTs). In his commentary, Dr. Bush raises, among others, the important question of whether such malingering determinations can still be considered as meeting the legal Daubert standard which is the basis for neuropsychological expert testimony. Dr. Jewsbury focuses mostly on statistical issues and agrees with two key points of the statistical review: Positive likelihood chaining is not a mathematically tenable method to combine findings of multiple PVTs and SVTs, and the Simple Bayes method is not applicable to malingering determinations. Dr. Faust adds important narrative texture to the implications for forensic neuropsychological practice and points to a need for research into factors other than malingering that may explain PVT and SVT failures. These commentaries put into even sharper focus the serious questions raised in the reviews about the scientific basis of present practices in the forensic neuropsychological determination of malingering.
Journal Article