Self-report Measures for Symptom Validity Assessment in Whiplash-associated Disorders

Background/Objective: Whiplash-Associated Disorders (WAD) are one of the most complex conditions to evaluate because several of its symptoms are not observable with current diagnostic methods and cannot be quantified or evaluated correctly. No method is currently available to assess the risk of malingering in the aforementioned condition efficiently. Our aim is to study the capacity of several biopsychosocial psychometric self-report instruments, such as the Brief Pain Inventory (BPI), the Cervical Disability Index (NDI), the SF-36 Health Questionnaire, the Beck Anxiety and Depression Inventories (BDI-II and BAI), or the Brief Illness Perception Questionnaire (BIPQ), to discriminate between patients diagnosed with WAD following a vehicle accident and non-clinical participants with malingering instructions. Method: A simulation design was used with 630 participants: 200 non-clinical controls with honest responding condition, 201 instructed malingerers, and 229 WAD clinical outpatients. Results: Our results showed an AUC range of .60 to .90, with the highest value being that of the BPI (.90), followed by the NDI (.88), and the lowest value that of the BIPQ (.60), followed by the BAI (.71). Conclusions: Overall, the BPI, the NDI, and SF-36 can correctly discriminate between groups with a good specificity (> 90%), while the BAI, BDI, and BIPQ showed a lower capacity, with a high rate of false positives in the case of the BDI and of false negatives in the other two. Practical and research implications are discussed. (AU)

Antecedentes/Objetivo: El Síndrome del Latigazo Cervical (WAD) es una de las condiciones más complejas de evaluar debido a que varios de los síntomas que presenta no son objetivables con los métodos diagnósticos actuales y no puede cuantificarse ni evaluarse correctamente. En la actualidad no se dispone de ningún método eficiente para valorar el riesgo de simulación en la citada condición. Nuestro objetivo es estudiar la capacidad de varios instrumentos psicométricos biopsicosociales de autoinforme, como el Inventario Breve de Dolor (BPI), el Índice de Discapacidad Cervical (NDI), el Cuestionario de Salud SF-36, los Inventarios de Ansiedad y Depresión de Beck (BDI-II y BAI) o el Cuestionario Breve de Percepción de la Enfermedad (BIPQ) para discriminar entre pacientes diagnosticados con WAD tras un accidente de circulación y participantes no-clínicos con instrucciones de simulación. Método: Se utilizó un diseño de simulación con 630 participantes: 200 controles no clínicos con condición de respuesta honesta, 201 simuladores instruidos y 229 pacientes clínicos con WAD. Resultados: Nuestros resultados mostraron un rango de AUC de .60 a .90, siendo el valor más alto el del BPI (.90), seguido del NDI (.88), y el valor más bajo el del BIPQ (.60), seguido del BAI (.71). Conclusiones: En general, el BPI, el NDI y el SF-36 pueden discriminar correctamente entre grupos con una buena especificidad (> 90%), mientras que el BAI, el BDI y el BIPQ mostraron una menor capacidad, con una alta tasa de falsos positivos en el caso del BDI y falsos negativos en los otros dos. Se discuten además las implicaciones prácticas y de investigación. (AU)

Whiplash-Associated Disorders. Biopsychosocial Profiles of Pain Perception in Forensic Cases of Victims of Motor Vehicle Accidents.

In order to make a complete diagnosis of all the factors influencing whiplash associated disorders (WAD), the evidence suggests that the condition evaluation should follow an integrated biopsychosocial model. This perspective would offer a fuller view of it, recognizing the interplay between the medical, biomechanical, social, and psychological factors. Despite the progress made in the subject, evidence of which psychosocial factors influence the experience of pain in litigant WAD patients is limited. A cross-sectional design and a cluster analysis was used to study the experience of pain and the psychosocial factors included therein in 249 patients with WAD assessed after suffering a motor vehicle accident. Three clusters were obtained: C1, with low scores of pain and a slight-moderate alteration of the Health-Related Quality of Life (HRQoL); C2, with medium scores of pain, alteration of HRQoL and a perception of moderate disability; and C3, with medium-high scores of pain, alteration of the HQoL, perception of moderate disability, presence of anxious-depressive symptomatology, poorer comprehension of the condition suffered, and the belief that it will extend over a long period of time. The results show a heterogeneous experience of pain in WAD, compatible with the biopsychosocial model of disease and the multidimensional approach to pain. The role of the psychologist in the evaluation of the condition could be useful to obtain a complete view of the condition, thus ensuring that the treatment is adapted to the needs of the patient.

Detecting malingered pain-related disability with the pain catastrophizing scale: a criterion groups validation study.

Objective: Intentional exaggeration of symptoms is a potential problem in contexts where there are financial incentives to appear disabled. Therefore, calibration of tools to accurately evaluate malingering in these contexts is important. The present study used a criterion groups validation design to determine the ability of the Pain Catastrophizing Scale (PCS) to detect Malingered Pain-Related Disability (MPRD). Method: Individuals meeting inclusionary/exclusionary criteria were selected for this study (n = 219) from a larger dataset of chronic pain patients referred for a psychological evaluation. Patients were classified into malingering groups using the Bianchini, Greve, and Glynn classification system for MPRD. PCS T scores were compared in patients who met MPRD criteria and those who showed no indication of malingering on multiple validity tests. Results: No group differences were observed regarding medicolegal and injury characteristics. Group analyses showed that the Not MPRD group had a significantly lower PCS score (Estimated Marginal Mean [EMM] = 62.3) than all other groups. The Probable and Definite MPRD groups (which together comprise the MPRD group) had the highest PCS T scores (EMM = 77.2 and EMM = 83.8, respectively). A PCS T score of 81 was associated with a 7% false-positive (FP) error rate, sensitivity of 47%, likelihood ratio (LR) of 6.7, and a positive predictive value (PPV) of .74 at base rates around 30%. Conclusions: PCS T scores greater than 81 should raise concerns about the validity of the PCS report and provide additional information that can be helpful in identifying intentional symptom exaggeration in patients with chronic pain.

Classification accuracy of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)-Restructured form validity scales in detecting malingered pain-related disability.

The symptom reports of individuals with chronic pain are multidimensional (e.g., emotional, cognitive, and somatic) and significantly contribute to increased morbidity and lost work productivity. When pain occurs in the context of a legally compensable event, reliable assessment of a patient's multifactorial symptom experience during psychological or neuropsychological evaluations is a necessity. The Validity Scales of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) have been shown useful in identifying symptom overreporting and feigning within chronic pain samples and a number of studies have emerged supporting the use of the MMPI-2-Restructured Form (MMPI-2-RF) in the detection of simulated or feigned impairment in a variety of populations. To date, only 1 other study exists examining the ability of the MMPI-2-RF to detect exaggerated complaints using a strict operationalization of malingering exclusive to chronic pain samples. The purpose of this study was to examine the classification accuracy of MMPI-2-RF Validity Scales in a group of patients with chronic pain using a criterion-groups design. The final sample consisted of 501 clinical chronic pain patients assigned to groups based on the Bianchini, Greve, and Glynn (2005) criteria for Malingered Pain-Related Disability (MPRD). Results showed that all MMPI-2-RF Validity Scales differentiated malingerers from nonmalingerers with a high degree of accuracy. At cut-offs associated with ≥95% Specificity, Sensitivities ranged from 15% (Fs) to 60% (Response Bias Scale; RBS). This study demonstrates that the MMPI-2-RF Validity Scales are capable of differentiating intentional symptom exaggeration from genuine complaints in a sample of incentivized chronic pain patients. (PsycINFO Database Record

Clusters of financially incentivized chronic pain patients using the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF).

The Minnesota Multiphasic Personality Inventory (MMPI)-2 Restructured Form (MMPI-2-RF) has been shown to have clinical utility in the assessment of individuals with chronic pain (e.g., predicting surgical outcomes). The purpose of this study was to explore the ability of the MMPI-2-RF Validity Scales in profiling patients with chronic pain who had external financial incentive (e.g., workers' compensation claims) and determine the associations between Validity Scale response patterns and important outcomes. Cluster analysis identified 2 similarly sized clusters of patients with very different MMPI-2-RF profiles. Cluster 1 was characterized by valid responding and showed mean elevations on the somatic and low positive emotion Restructured Clinical scales. Cluster 2 was characterized by patients overreporting on the MMPI-2-RF Validity Scales, who also demonstrated elevations on 7 of the 9 RC scales. Cluster membership was differentially associated with clinical variables: patients in Cluster 2 had greater self-reported pain and disability, were less likely to have spine-related findings on imaging and were more likely to be classified as probable or definite malingerers. These results support the utility of the MMPI-2-RF Validity scales in distinguishing between credible and noncredible responses from patients with chronic pain seen within a medico-legal context. (PsycINFO Database Record

Further validation of booklet category test subscales for learning, set loss, and memory in a mixed clinical sample.

Although it has long been proposed that performance on the Booklet Category Test (BCT) relies on a number of different cognitive abilities, including executive functioning, perceptual reasoning, and memory, only a single total error score is typically derived and interpreted in clinical practice. BCT subscales based on factor analyses of subtest errors or designed specifically to measure specific cognitive domains have been proposed to better assess the multidimensional abilities underlying BCT performance. The aim of this study was to independently replicate and extend previous findings regarding the validity of these subscales. A mixed clinical sample of 137 patients completed the BCT and a number of additional measures used to assess neuropsychological domains of selective attention, various aspects of executive functioning, intellectual functioning, and memory. Correlation and regression analyses were used to explore the convergent and discriminant validity of each subscale. Subscales varied in the number and magnitude of their significant correlations with scores derived from traditional measures. In general, findings supported the convergent validity of BCT category learning, set loss, and memory subscales. However, findings regarding discriminant validity were more variable across subscales. Results provide additional support for the multidimensional nature of the BCT and the validity of derived subscales to measure specific aspects of cognitive functioning beyond what is measured by a total errors score. The recently proposed subscales examined in the current study appear to be worthy of further investigation by clinicians and researchers to determine their clinical utility.

Accuracy of the Modified Somatic Perception Questionnaire and Pain Disability Index in the detection of malingered pain-related disability in chronic pain.

The Modified Somatic Perception Questionnaire (MSPQ) and the Pain Disability Index (PDI) are both popular clinical screening instruments in general orthopedic, rheumatologic, and neurosurgical clinics and are useful for identifying pain patients whose physical symptom presentations and disability may be non-organic. Previous studies found both to accurately detect malingered pain presentations; however, the generalizability of these results is not clear. This study used a criterion groups validation design (retrospective cohort of patients with chronic pain, n = 328) with a simulator group (college students, n = 98) to determine the accuracy of the MSPQ and PDI in detecting Malingered Pain Related Disability. Patients were grouped based on independent psychometric evidence of MPRD. Results showed that MSPQ and PDI scores were not associated with objective medical pathology. However, they accurately differentiated Not-MPRD from MPRD cases. Diagnostic statistics associated with a range of scores are presented for application to individual cases. Data from this study can inform the clinical management of chronic pain patients by screening for psychological overlay and malingering, thus alerting clinicians to the possible presence of psychosocial obstacles to effective treatment and triggering further psychological assessment and/or treatment.

Classification accuracy of the Millon Clinical Multiaxial Inventory-III modifier indices in the detection of malingering in traumatic brain injury.

The present study used criterion groups validation to determine the ability of the Millon Clinical Multiaxial Inventory-III (MCMI-III) modifier indices to detect malingering in traumatic brain injury (TBI). Patients with TBI who met criteria for malingered neurocognitive dysfunction (MND) were compared to those who showed no indications of malingering. Data were collected from 108 TBI patients referred for neuropsychological evaluation. Base rate (BR) scores were used for MCMI-III modifier indices: Disclosure, Desirability, and Debasement. Malingering classification was based on the Slick, Sherman, and Iverson (1999) criteria for MND. TBI patients were placed in one of three groups: MND (n = 55), not-MND (n = 26), or Indeterminate (n = 26).The not-MND group had lower modifier index scores than the MND group. At scores associated with a 4% false-positive (FP) error rate, sensitivity was 47% for Disclosure, 51% for Desirability, and 55% for Debasement. Examination of joint classification analysis demonstrated 54% sensitivity at cutoffs associated with 0% FP error rate. Results suggested that scores from all MCMI-III modifier indices are useful for identifying intentional symptom exaggeration in TBI. Debasement was the most sensitive of the three indices. Clinical implications are discussed.

Executive dysfunction in traumatic brain injury: the effects of injury severity and effort on the Wisconsin Card Sorting Test.

This study examined the persistent effects of traumatic brain injury (TBI) on Wisconsin Card Sorting Test (WCST) performance. Since poor effort can contaminate results in populations with incentive to perform poorly, performance validity was explicitly assessed and controlled for using multiple well-validated cognitive malingering indicators. Participants were 109 patients with mild TBI and 67 patients with moderate-to-severe TBI seen for neuropsychological evaluation at least one year post injury. Patients with diffuse neurological impairment and healthy controls were included for comparison. Results suggested a dose-response effect of TBI severity on WCST performance in patients providing good effort; the mild TBI group did not differ from controls while increased levels of impairment were observed in the moderate-to-severe TBI group. Effort during testing had a larger impact on WCST performance than mild or moderate-to-severe TBI. Clinical implications of these findings are discussed.

Detecting malingering in traumatic brain injury and chronic pain with an abbreviated version of the Meyers Index for the MMPI-2.

Meyers, Millis, and Volkert [Meyers, J. E., Millis, S. R., & Volkert, K. (2002). A validity index for the MMPI-2. Archives of Clinical Neuropsychology, 17, 157-169] developed a method to detect malingering in chronic pain patients using seven scales from the Minnesota Multiphasic Inventory-2 (MMPI-2). This method may be impractical because two of the scales (Obvious minus Subtle and Dissimulation-revised) are not reported by the commercially available Pearson computerized scoring system. The current study recalculated the Meyers Index using the five Pearson-provided scales in the chronic pain data sets of Meyers et al. [Meyers, J. E., Millis, S. R., & Volkert, K. (2002). A validity index for the MMPI-2. Archives of Clinical Neuropsychology, 17, 157-169] and Bianchini, Etherton, Greve, Heinly, and Meyers [Bianchini, K. J., Etherton, J. L., Greve, K. W., Heinly, M. T., & Meyers, J. E. (in press). Classification accuracy of MMPI-2 validity scales in the detection of pain-related malingering: A known-groups approach. Assessment], and the traumatic brain injury data of Greve, Bianchini, Love, Brennan, and Heinly [Greve, K. W., Bianchini, K. J., Love, J. M., Brennan, A., & Heinly, M. T. (2006). Sensitivity and specificity of MMPI-2 validity scales and indicators to malingered neurocognitive dysfunction in traumatic brain injury. The Clinical Neuropsychologist, 20, 491-512]. Classification accuracy of the abbreviated Meyers Index was comparable to the original. These findings demonstrate that the abbreviated Meyers Index can be used as a substitute of the original Meyers Index without decrements in classification accuracy.