Malingering is a topic of extraordinary relevance and interest that has been intensely scrutinized in numerous scientific articles, professional workshops, and legal cases. One might expect a volume about malingering to appeal primarily to clinical neuropsychologists whose practice consists of predominately forensic referrals from defense attorneys in civil cases, and who would be most interested in “catching” the malingerer. Indeed, it may be fair to characterize this book as “defense-oriented” vis-à-vis civil cases. However, it would be a mistake to read this book only because you are involved in forensic neuropsychology, as its coverage of effort testing in neuropsychological evaluation goes well beyond the identification of potential malingerers.
Neuropsychology of Malingering Casebook is part of the American Academy of Clinical Neuropsychology (AACN)/Psychology Press Continuing Education Series. The goal of this series is to provide an extensive overview of cutting edge research to inform clinical practice on topics of high interest and relevance to clinical neuropsychologists. Readers of this book are able to receive APA-approved CE credit by taking a quiz on the AACN Website (www.theaacn.org). The contributors to this volume are prominent neuropsychologists who have extensive clinical and research experience in the detection of malingering and work regarding effort assessment in neuropsychological practice.
This volume contains 45 chapters divided into six sections, and six appendices. Section I, Foundations of Malingering in Neuropsychology, provides the rationale for this critically important topic. In Chapter 3, Millis provides a superb and easy to follow explanation of the psychometric and statistical underpinnings for malingering detection, including common errors in clinical decision-making and potential remedies. Section II, Civil Litigation, is divided into four parts; Traumatic Brain Injury in Adults (7 chapters), Psychiatric and Medical Disorders (9 chapters), Difficult to Diagnose or Questionable Conditions (9 chapters), and Pediatrics and Learning/Academic Disorders (3 chapters). Section III, Criminal Prosecution, includes 4 chapters covering competency to stand trial, mental status at the time of offense (sanity), and capital mitigation. Section IV, Perspective of Legal Experts and Disability Decision Makers, includes 6 chapters written by attorneys and clinicians familiar with disability insurance, workers compensation, social security, and both plaintiff and defense attorney approaches to suspected malingering. Section V covers Ethical and Professional Issues in two chapters, and discusses the advantages and disadvantages of making a formal diagnosis of malingering. Section VI, Current Status and Future Directions, summarizes the current state of the field in two chapters. Appendices A–E list seminal works in the symptom validity testing and malingering literature, including research on potentially useful embedded malingering indices in standard neuropsychological tests. Appendix F provides the “Slick criteria” for malingered neurocognitive dysfunction or MND, reprinted from The Clinical Neuropsychologist.
As Greiffenstein notes in Chapter 6, “Detection of simulation requires fundamental knowledge of direct experience with genuine organic brain syndromes, including their defining neurobehavioral manifestations and their evolution across time.” This book provides fundamental knowledge about genuine organic brain syndromes, and the authors walk the reader through each step of a potential malingering case to show how the examinee does or does not manifest expected and credible symptoms and behaviors associated with their respective neurological illness. Each case chapter provides an overview of the current literature on a particular clinical syndrome, and describes the examinee’s suspected poor effort or malingering. DeLuca, in Chapter 20 on Chronic Fatigue Syndrome, warns that neuropsychologists, especially those involved in forensic work, who are more likely to see examinees with reduced effort and motivation, should be careful not to generalize this behavior to everyone with this disease or syndrome. He admonishes that diseases that were unexplained medical mysteries in the past were later found to be legitimate medical conditions, for example, multiple sclerosis.
Current standards of practice and the latest and most replicated research on neuropsychological disorders in forensic contexts are illustrated in this volume, and this reviewer appreciated its thought-provoking nature. The test batteries and different clinical approaches of each author reflect the wide array of acceptable practice standards. Authors differed with respect to how long to interview the examinee, technician use, response to requests for third-party observers, and documentation of behavioral observations. Reading the fascinating cases, looking at the test data, and mulling over the behavioral observations, this reader wondered whether she would have called it similarly. For instance, several authors noted noncompliance with treatment as possible behavioral indices supporting a diagnosis of malingering. This reviewer works in a setting with persistently mentally ill individuals who very commonly are noncompliant with psychotropic medications or outpatient treatment. One might question whether noncompliance would have any diagnostic validity in persons with schizophrenia. Some authors use the “M word” in their report; others prefer more euphemistic descriptors. Seward and Connor, in Chapter 42, offer a persuasive argument for making a diagnosis of malingering if the criteria are met and explain why we may be reluctant to do so even when we should. Bush’s Chapter 43 on ethics posed compelling questions, for example, should we inform examinees that we are using effort measures? Do we continue testing even if we suspect malingering?
There are provocative discussions about using the term malingering in reports. For instance, Sargent and Fuller in Chapter 37 write: “In my professional experience working with psychiatric claims for over 20 years, I cannot recall a single instance in which an IME by a psychiatrist or psychologist rendered a diagnosis of malingering. Does this represent a problem with the definition of malingering, a problem with IME clinicians, a challenge in evaluating highly educated and skilled professionals, or unrealistic expectations by the insurance industry?” (p. 471). However, most authors reported that they use the term malingering in their reports, but this is a select sample. DeBofsky, in Chapter 38, discusses the disability evaluation from the claimant perspective: “even where the validity of the test instruments can be scientifically proven, an opinion of ‘malingering’ has a very powerful effect in the courtroom and cannot be used to characterize the claimant’s credibility in general. On the other hand, an opinion of malingering tailored toward challenging the validity of a determination of impairment is entirely appropriate” (p. 487).
While not an epidemiology survey, it was striking to see the commonalities in the cases selected for inclusion in the unexplained illness and TBI sections. A few cases could be considered frank psychopaths who were clearly gaming the system, but many of the individuals seemed to perceive themselves as chronically ill, disabled, and victimized even when medical science found only mild or no signs of injury. Many claimants had complex psychosocial histories and were from disadvantaged circumstances, including limited educational and occupational success and poor coping skills. They had developed many illness behaviors that were reinforced by treatment for their “disorder” and by others, including family members and well-meaning treatment providers making attribution errors regarding the source of their chronic difficulties. Perhaps the claimants were hoping that receiving a large settlement would be the deus ex machina they had been seeking to improve their lives.
The section on psychiatric and medical disorders highlighted the importance and treatability of psychological factors, pointed out that psychological and cognitive symptom exaggeration can be, and often is, independent, and emphasized the pertinent role of psychological factors in the litigation of complex cases. There is no single cause and effect in many suspected malingering cases and, as many of the authors point out, malingering and injury are not mutually exclusive. For instance, in Chapter 9, Baker noted the difficulty of convincing attorneys, juries, and lay people that someone who has a genuine injury may also be capable of malingering or exaggerating. This book demonstrates how neuropsychologists, by their clinical training and access to tools and techniques grounded in psychometric science, are best positioned to unravel the Gordian Knot of differential diagnoses and symptom validity in forensic contexts.
As with many edited volumes, the writing style varies widely and is individualistic. Some authors chose to write in the first person, while others took a more formal approach. In several chapters, one could almost detect the author’s smirk or rolling of their eyes as they described the unsophisticated malingerer’s transparent attempts to feign pathology, including patently noncredible symptoms and well below chance performance on Symptom Validity Tests (SVTs) (e.g., Chapter 23). This reviewer especially appreciated those authors who maintained a more neutral and professional tone, even when describing outlandish behaviors by claimants. Artiola i Fortuny’s two chapters on Factitious Disorder and Mold Toxicity were particularly enjoyable to read as they exemplified the best of both scholarship and clinical acumen, and presented these bizarre cases in a most professional and respectful tone.
Berry and Granacher, in Chapter 15, recommended screening for psychiatric, neurocognitive, and somatic feigning for all forensic neuropsychological evaluations. Numerous authors (e.g., Millis, Bergman, and Sweet) argue that SVTs should be part of all neuropsychological evaluations, not just to detect malingering, but to detect poor effort that invalidates test results. Millis cites Gorissen, Sanz de la Torre, & Schmand (Reference Gorissen, Sanz de la Torre and Schmand2005) showing that persons with schizophrenia (PWS) evidenced a staggering 72% failure rate on the Word Memory Test. These PWS were not tested in a secondary gain context, so the authors surmised that negative symptoms (anergia, amotivation), which are part of the disease, negatively affected engagement in testing and potentially invalidated the results. This reviewer agrees wholeheartedly with the recommendation to included SVTs in all evaluations, in order to be confident that our data are valid and interpretable.
An interesting postscript in many of the chapters is that the neuropsychologists had knowledge of how the cases were resolved in the courts. It was instructive to see whether the neuropsychological testimony was used, how it was used, and how it affected the final disposition of the case.
This book highlights various neuropsychology scenarios and covers almost any controversy involving symptom validity. The case study format using real forensic examinees to illustrate the complexities of effort evaluation in neuropsychological testing is utterly captivating and highly effective. Some of the most vexing and controversial clinical syndromes in a clinical neuropsychologists’ caseload are vividly described, complete with recent scientific references. Not only is it exceedingly informative, it is a fascinating and entertaining read that makes the reader critically consider one’s own approach to effort evaluation. An added bonus is that the reader can go to the AACN website, take a continuing education quiz, and obtain 9 APA-approved CE credits. This reviewer took the quiz and found the internet site and format to be user-friendly, time efficient, and at reasonable cost. The Neuropsychology of Malingering Casebook provides essential knowledge and would be an excellent addition to the library of every neuropsychologist in active practice. It turned out to be one of this reviewer’s favorite nonfiction selections for summer reading!
