Kyle Brauer Boone

Recently published practice standards recommend that multiple effort indicators be interspersed throughout neuropsychological evaluations to assess for response bias, which is most efficiently accomplished through use of effort indicators from standard cognitive tests already included in test batteries. The present study examined the utility of a timed recognition trial added to standard administration of the WAIS-III Digit Symbol subtest in a large sample of “real world” noncredible patients (n=82) as compared with credible neuropsychology clinic patients (n=89). Scores from the recognition trial were more sensitive in identifying poor effort than were standard Digit Symbol scores, and use of an equation incorporating Digit Symbol Age–Corrected Scaled Scores plus accuracy and time scores from the recognition trial was associated with nearly 80% sensitivity at 88.7% specificity. Thus, inclusion of a brief recognition trial to Digit Symbol administration has the potential to provide accurate assessment of response bias.

Several studies have examined the usefulness of the Warrington Recognition Memory Test–Words as a measure to detect suspect effort, although samples have generally been small and/or comprised of simulators rather than “real world” credible and noncredible patients. The current study examined the Warrington Recognition Memory Test–Words total score and response time of “real world” noncredible patients (as determined by motive to feign, failure on ≥2 independent measures of response bias, low cognitive scores inconsistent with normal ADLs; n = 190) versus credible patients (as determined by no motive to feign, failure of ≤1 measure of response bias; n = 124) derived from an archival database of individuals from the Harbor-UCLA Medical Center, Department of Psychiatry, Outpatient Neuropsychology Service, and the private practice of the second author. Noncredible patients obtained significantly lower total scores and longer times to complete the task. A total correct cutoff of ≤42 was found to have excellent specificity (91.9%) and sensitivity (88.9%), whereas a time cutoff of ≥207″ was associated with 65.5% sensitivity at 90.7% specificity, and when the time cut-score was used in combination with the total score cutoff, an additional 5% of the noncredible participants were captured, raising overall sensitivity to 93.7% (at 87.1% specificity). Thus, the Warrington Recognition Memory Test–Words, although not originally created for the purposes of measuring suspect effort, appears to be an excellent measure for detecting response bias on neuropsychological testing.

A subset of patients who present for neuropsychological testing report dysfunction in daily life activities secondary to cognitive deficits, but are found on formal testing to have no objective abnormalities, raising the possibility of “neurocognitive hypochondriasis.” Such a case is presented, and the factors that appear to give rise to this presentation are explored. Cases of hypochondriacal overconcern regarding cognitive function are likely not rare, particularly given research showing there is little correlation between objective report of cognitive dysfunction and actual test scores in such conditions as mild traumatic brain injury, chronic fatigue syndrome, fibromyalgia, toxic mold exposure, and post-polio syndrome.

While most neuropsychologists are now administering measures of response bias in neuropsychological evaluations, it is still likely that detection of non-credible test performance is inadequate due to faulty assumptions regarding poor effort, namely that it remains constant across a battery of tests. Four cases are described that illustrate the variability in negative response bias that occurs during neuropsychological evaluations; if effort had not been periodically sampled with heterogeneous types of effort indicators during these examinations, the suspect performance would not have been detected. These examples argue for both continuous and comprehensive sampling of effort, specifically that negative response bias be routinely monitored throughout neuropsychological evaluations, and that effort indicators involving differing cognitive abilities be employed to assess for feigning of selective deficits.

Kyle Brauer Boone, Tara L. Victor, Johnny Wen, Jill Razani, Marcel Pontón; Erratum to “The association between neuropsychological scores and ethnicity, languag

Kyle Brauer Boone; Commentary on “Cogniform disorder and cogniform condition: Proposed diagnoses for excessive cognitive symptoms” by Dean C. Delis and Spencer

Ecological validity studies that have examined the relationship between cognitive abilities and employment in psychiatric and medical populations have found that a wide range of cognitive domains predict employability, although memory and executive skills appear to be the most important. However, no information is available regarding a patient's self-perceived work attributes and objective neuropsychological performance, and whether the same cognitive domains associated with successful employment are also related to a patient's self-perception of work competence. In the present study, 73 medical and psychiatric patients underwent comprehensive neuropsychological assessment. Step-wise multiple regression analyses revealed that the visual-spatial domain was the only significant predictor of self-perceived work attributes and work competence as measured by the Working Inventory (WI) and the Work Adjustment Inventory (WAI), accounting for 7% to 10% of inventory score variability. The results raise the intriguing possibility that targeting of visual spatial skills for remediation and development might play a separate and unique role in the vocational rehabilitation of a lower SES population, specifically, by leading to enhanced self-perception of work competence as these individuals attempt to enter the job market.

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.