Forensic%20Neuropsychological%20Evaluations:%20Issues%20and%20Controversies

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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

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I. Evaluation of Testing Effort/MalingeringMalin
gering 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. 683Malingering 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
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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

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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.

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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)

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Formulas using Existing Tests

• Digit Span Test (Reliable Digit Span)
• Measures on Recognition Memory (CVLT-II)
• Measures of Problem Solving Ability

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Detection of Symptom Exaggeration

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

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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

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Detection of Cognitive Malingering

• Evidence from Neuropsychological Testing
  includes
• (A) Definite negative response bias
• (B) Probable response bias

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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

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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)

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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).

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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

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Estimating Premorbid Intelligence

• Four general methods used to estimate premorbid
  IQ
• (A) The best performance method
• (B) Subjects 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

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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

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Mild Traumatic Brain Injury

• Diagnosing
• (A) Direct observation
• (B) Retrospective determination

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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

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Acute Symptoms of MTBI

• Nausea
• Vomiting
• Blurred vision
• Somnolence

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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

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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

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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

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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