Forensic Neuropsychological Evaluations: Issues and Controversies L. Randolph Waid, Ph.D. Clinical Psychologist/Neuropsychologist Clinical Associate Professor in Psychiatry and Neurology Medical University of South Carolina, Charleston, SC

I. Evaluation of Testing Effort/Malingering Malingering: The diagnostic and Statistics Manual of Mental Disorders, Fourth Edition (1994) defines malingering as, “…the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.” p. 683 Malingering can occur in one of three patterns in neuropsychological settings: (A) false or exaggerated reporting of symptoms (B) intentionally poor performance on neuropsychological tests (C) a combination of symptom exaggeration and intentional performance deficit

Significant increase in research on developing specialized procedures to detect malingering include: (A) Stand alone tests/symptom validity tests (B) Patterns of malingering on standard clinical tests (C) Fabrication and exaggeration of symptoms on psychological measures/validity scales

Properties of a good stand alone test (Hartman, 2003) Measure willingness to exert basic effort and are insensitive to the cognitive dysfunction being assessed (sensitivity and specificity). Appear to the patient to be a realistic measure of the cognitive modality under study (face validity). Measure abilities that are likely to be exaggerated by patients claiming brain damage. Have a strong normative basis underlying test results to satisfy scientific and Daubert concerns. Are based on validation studies that include normals, patient populations and individuals who are suspected and/or verified malingerers in actual forensic or disability assessment conditions. Should be difficult to fake or coach. Should be relatively easy to administer. Are supported by continuing research.

Stand Alone Tests/Symptom Validity Test Test of Memory Malingering (TOMM) Word Memory Test Validity Indicator Profile Structured Interview of Reported Symptoms-II (SIRS-II)

Formulas using Existing Tests Digit Span Test (Reliable Digit Span) Measures on Recognition Memory (CVLT-II) Measures of Problem Solving Ability

Detection of Symptom Exaggeration Minnesota Multiphasic Personality Inventory-II F family of scales F, Fb, F (p) FBS scale

Detection of Cognitive Malingering (Slick et al 1999) A multi-dimensional approach Malingering vs. Less than optimal testing effort Consideration of evidence from neuropsychological testing and self report

Detection of Cognitive Malingering Evidence from Neuropsychological Testing includes: (A) Definite negative response bias (B) Probable response bias

Detection of Cognitive Malingering Evidence from Neuropsychological Testing also includes: (A) Discrepancies between test data and patterns of brain functioning (B) Discrepancies between test data and observed behavior (C) Discrepancies between test data and reliable collateral reports (D) Discrepancies between test data and documented background history

Detection of Cognitive Malingering Evidence from self report includes: (A) Self report history discrepant with documented history (B) Self reported symptoms discrepant with known patterns of brain functioning (C) Self reported symptoms discrepant with behavioral observations (D) Self reported symptoms discrepant with information obtained from collateral informants (E) Also includes evidence of exaggerated or fabricated psychological dysfunction on well validated validity scales (e.g. MMPI-2)

Definite Malingering Presence of a substantial external incentive (Criterion A). Definite negative response bias (Criterion B). Behaviors meeting necessary criteria from group B are not fully accounted for by psychiatric, neurological, or developmental factors (Criterion D).

II. Estimating Pre-morbid Intelligence Obtainment of previous educational records including standardized Educational test scores/military records, etc. Level of educational/occupational attainment Current test results The problem of above and below average intelligence

Estimating Premorbid Intelligence Four general methods used to estimate premorbid IQ (A) The best performance method (B) Subject’s performance on intelligence subtests that are thought to be relatively insensitive to the effects of brain damage (e.g. vocabulary, information) (C) Tests of overlearned skills such as reading which are highly correlated with intelligence (e.g. NART, WRAT-4, WTAR) (D) Actuarial methods that use demographic data such as age, sex, race, education, and occupation to estimate premorbid IG (e.g. Barona Index) (E) WAIS-IV Advanced Clinical Solutions

Mild Traumatic Brain Injury Accounts for 72% of all traumatic brain injury The issues of the incidence, cause, and persistence of deficits following MTBI remains controversial Iraq war veterans and sports psychology/NFL Recent research-Simple blood test to identify mild brain trauma New research on higher resolution imaging

Mild Traumatic Brain Injury Diagnosing (A) Direct observation (B) Retrospective determination

Mild Traumatic Brain Injury Definition (ACRM 1993) 1. Any period of loss of consciousness 2. Any loss of memory for events immediately before or after the accident 3. Ant alteration of mental state at the time of the accident (e.g. feeling dazed, disoriented, or confused) 4. Focal neurological deficit(s) that may or may not be transient 5. Exclusion Criteria 6. Compared to DSM-IV diagnosis

Acute Symptoms of MTBI Nausea Vomiting Blurred vision Somnolence

Symptoms of Post-Concussive Syndrome (PCS) Headaches Fatigue Insomnia Irritability Emotional lability Anxiety Is a concussion the same as a Post-Concussive Disorder Depression Photosensitivity Dizziness Attentional Problems Memory Deficits Intolerance to alcohol

Can We Rely on Objective Evidence? Neuroimaging – CT and MRI Scans Diffuse axonal injuries possibly associated with MTBI are typically not visible on static neuroimaging. PET and SPECT Scans EEG/Brain Mapping and Computerized EEGs

Mild Traumatic Brain Injury Post-concussion Disorder refers to somatic, cognitive and emotional residuals that should be classified as follows: Acute: lasting up to one month post-injury Sub-acute: lasting greater than one month and less than 12 months Chronic: duration greater than one year

Cultural/Language Differences The Hispanic brain damaged worker How to evaluate 1. Review the physics of the accident; the acute neurological sequelae; neuroradiographic studies; and emergent medical records most important. Neuropsychological testing is a sampling of behaviors but lacks validity due to language/cultural differences. Use of translator and Spanish version of tests The value of a neuropsychological evaluation