Psychiatric Evaluation of Workers' Compensation Claimants Part 3

Saturday, May 20, 2006 | 0

By Rene Folse JD, Ph.D.

3) Detection of Malingering

Since the Schedule will now allow psychiatric permanent disability to be based upon subjective complaints, it would be worth while to become acquainted with the scientific literature on the topic of the detection of malingering. Richard Rogers has written the definitive guide as follows.

Detection Malingering and Deception:Second Edition by Richard Rogers. (ISBN: 1572301732)

This is perhaps the most authoritative textbook on the topic of detecting false mental health claimants. I have this textbook in my office library and have read it and referred to it extensively. There is now a second edition. Chapter eight of this textbook goes into great detail on how to use the MMPI to detect a deceitful patient. The use of the MMPI to detect faking is readily documented in scientific literature which has now been compiled to chapters of entire text books dedicated to this topic such as this one. Others who have commented on this text said this:

"This long-awaited update and complete revision of Dr. Rogers' 1988 Guttmacher-award-winning classic provides clinical and forensic professionals with the latest knowledge and research findings on malingering and deception. It brings the reader up to date on the burgeoning literature of dissimulation, testing, experimental methodology, and contemporary topics such as false memories, polygraphy, and hypnosis. Dr. Rogers and his very impressive list of contributors--from psychology, neuropsychology, psychiatry, and law--do not stray from their goal of practical integration of clinical practice and applied research in the field. They have given us a worthy successor to his earlier work." --Bill Reid, MD, MPH, Clinical and Forensic Psychiatrist; Past President, American Academy of Psychiatry and the Law; Clinical Professor of Psychiatry, University of Texas, Health Sciences Center; Former Medical Director, Texas Department of Mental Health and Mental Retardation.

"Richard Rogers has devoted his professional career to the issues of deception and malingering. This book, the second edition of a trailblazing text whose first edition won the A.P.A./A.A.P.L. Manifred S. Guttmacher Award, has been substantially rewritten....Of most importance to the clinician is the final summary chapter which, as it should be, is the longest chapter in the book....I highly recommend this volume to all clinicians and researchers who want to improve their skills." --The Journal of Nervous and Mental Disease

The MMPI-2 in General

There are six validity scales and ten basic clinical or personality scales scored in the MMPI-2, and a number of supplementary scales and subscales that may be used with the test. The validity scales are used to determine whether the test results are actually valid (i.e., if the test-taker was truthful, answered cooperatively and not randomly) and to assess the test-taker's response style (i.e., cooperative, defensive). Each clinical scale uses a set or subset of MMPI-2 questions to evaluate a specific personality trait. Ziskin extensively reviews psychological testing, and discusses the methodological problems in using clinical instruments in forensic settings. He has few kind things to say about computerized MMPI narratives. He heartily endorses the use of the MMPI to detect clinical malingering, citing a broad body of evidence supporting the value of the MMPI validity scales based upon actuarial and statistical fact rather than theoretical value.

MMPI-2 Malingering Schemas

The L, F and K scores on the MMPI-2

The L, F and K scores are the classic validity scales of the MMPI-2 and are sometimes referred to as the Lie, Fake Bad and Fake Good scales respectively, although that is an over simplification. Using this simplistic model, a malingered profile in a classical sense would be a low L, high F, low K or a so called inverted "V" and would look something like this on an MMPI-2

The "Cannot Say" Scale ("? scale") - The "?" scale is simply the number of omitted items (including items answered both true and false). The MMPI-2 manual suggests that protocols with 30 or more omitted items should be considered invalid and not interpreted. Other experts suggest interpreting with great caution protocols with more than 10 omitted items and not to interpret at all those with more than 30 omitted items.

L Scale - The L scale originally was constructed to detect a deliberate and rather unsophisticated attempt on the part of the respondent to present him/herself in a favorable light. People who present high L scale scores are not willing to admit even minor shortcomings, and are deliberately trying to present themselves in a very favorable way. Better educated, brighter, more sophisticated people from higher social classes tend to score lower on the L scale.

F Scale - The F Scale originally was developed to detect deviant or atypical ways of responding to test items. Several of the F Scale items were deleted from the MMPI-2 because of objectionable content, leaving the F Scale with 60 of the original 64 items in the revised instrument. The F Scale serves three important functions:

1. It is an index of test-taking attitude and is useful in detecting deviant response sets (i.e. faking good or faking bad).
2. If one can rule out profile invalidity, the F Scale is a good indicator of degree of psychopathology, with higher scores suggesting greater psychopathology.
3. Scores on the F Scale can be used to generate inferences about other extratest characteristics and behaviors.

K Scale - Compared to the L Scale, the K Scale was developed as a more subtle and more effective index of attempts by examiners to deny psychopathology and to present themselves in a favorable light or, conversely, to exaggerate psychopathology and to try to appear in a very unfavorable light. Some people refer to this scale as the "defensiveness" indicator, as high scores on the K Scale are thought to be associated with a defensive approach to the test, while low scores are thought to be indicative of an unusually frank and self-critical approach.

Subsequent research on the K Scale has indicated that the K Scale is not only related to defensiveness, but is also related to educational level and socioeconomic status, with better-educated and higher socioeconomic-level subjects scoring higher on the scale. It is not unusual for college-educated persons who are not being defensive to obtain T-scores on the K Scale in a range of 55 to 60, and persons with even more formal education to obtain T-scores in a range of 60 to 70. Moderate elevations on the K Scale sometimes reflect ego strength and psychological resources.

Back F (Fb) Scale - The Fb scale consists of 40 items on the MMPI-2 that no more than 10 percent of the MMPI-2 normative sample answered in the deviant direction. It is analogous to the standard F scale except that the items are placed in the last half of the test. An elevated Fb scale score could indicate that the respondent stopped paying attention to the test items that occurred later in the booklet and shifted to an essentially random pattern of responding.

The VRIN and the TRIN index

These are both validity scales on the MMPI-2. The VRIN is the Variable Response Inconsistency Scale. The TRIN is the True Response Inconsistency Scale. A common interpretation guide for these scales is as follows.

VRIN > 12 Probably invalid; random response set
VRIN < 12 Valid response set
TRIN > 12 Probably invalid; all true response set
TRIN = 6 to 12 Valid
TRIN < 6 Probably invalid; all false response set

VRIN Scale (Variable Response Inconsistency) - The VRIN scale was developed for the MMPI-2 as an additional validity indicator. It provides an indication of the respondents' tendencies to respond inconsistently to MMPI-2 items, and whose resulting protocols therefore should not be interpreted. It consists of 67 pairs of items with either similar or opposite content. Each time a person answers items in a pair inconsistently, one raw score point is added to the score ont he VRIN scale. It is suggested that a raw score equal to or greater than 13 indicates inconsistent responding that probably invalidates the resulting protocol, although this scale is still experimental.

TRIN Scale (True Response Inconsistency) - The TRIN scale was developed to identify persons who respond inconsistently to items by giving true responses to items indiscriminately or by giving false responses to items indiscriminately. The TRIN scale consists of 23 pairs of items that are opposite in content. Two true responses to some item pairs or two false responses to other item pairs would indicate inconsistent responding. The MMPI-2 manual suggests that as rough guidelines TRIN raw scores of 13 or more or of 5 or less may be suggestive of indiscriminate responding that might invalidate the protocol, however, this scale is still considered experimental.

Beyond these classic validity measures, there are many others that have been developed over time. It would be useful to know some of them.

===================================== The Gough Dissimulation Scale-Revised (Ds-r)

The Gough Dissimulation Scale (Ds) (Gough, 1950) and its revised version (Ds-r2; Gough),is one of several scoring protocols to detect malingering using the MMPI.. The scale of consists of 58 items of the MMPI which were developed on true neurotics verses normals faking neurosis, Ds-r measures exaggeration of neurotic symptoms.

F - K Index

Gough, H. G. (1950) determined that subtracting the raw K score from the raw F score would produce a cut off score that would define malingering. A number of studies have proposed various cut-off scores for the F-K study. Ziskin recognizes malingering at a much lower threshold than most psychologists and particularly the disciples of MMPI authors McKinley and Hathaway who use the caveat of F-K > 11 as indicative of malingering. He convincingly argues for a cutoff point on the F-K index of +5 "for forensic purposes the probability that only 6.5% of genuine profiles would be considered malingered at that cutoff point, while 83% would correctly indicate malingering according to Gough's data...for example, if there is an F-K of +10, testimony can show that according to Gough's research, there are less than three chances in 100 of error in viewing the MMPI as malingered."

Comparison of Subtle v Obvious Items. (OS)

Weiner and Harmon obvious and subtle items (Weiner, 1948), known as OS, has also received attention as an index of symptom exaggeration. This scale was specifically designed to detect both overreporting and underreporting of psychopathology within the MMPI (Walters, White, & Greene, 1988; Weiner, 1948). Particularly, the scales ability to identify the endorsement of emotional disturbance was indicated by utilizing 146 easy to detect obvious items and 110 hard to detect subtle items (Weiner, 1948). While individuals faking psychopathology could easily obtain high scores on obvious items, it was much harder for them to score highly on subtle items, and the score discrepancies between obvious and subtle items were the means to identifying those individuals who were malingering. An individual achieving a T-score greater than 80 for obvious scales and a T-score of 50 on the subtle scales was recognized as attempting to overreport psychopathology (Weiner, 1948).

Infrequency-Psychopathology Scale (Fp)

The Infrequency Psychopathology [F(p)] scale was recently developed by Arbisi and Ben-Porath (1995, 1997) and consists of 27 items that were endorsed by normal and psychiatric patients at low frequency rates of less than 20 percent (Greene, 2000). The critical difference between F(p) and the F and Fb scales is that the items on the F(p) scale are unlikely to be endorsed by any respondent regardless of clinical status, while infrequency on F and Fb was determined only for normal respondents. The scale aims to detect potential malingering as a reflection of overt symptom exaggeration (Arbisi & Ben-Porath, 1995). The scale covers content areas that identify role confusion, unethical and dishonest attitudes, abnormal habits and severe psychotic symptoms (Greene, 2000). Arbisi and Ben-Porath (1995) developed the F(p) scale to employ in settings where prevalence of significant psychiatric psychopathology is relatively high. Therefore, elevations in this scale represent individuals attempting to "fake-bad".

Lees-Haley - Fake Bad Scale (FBS)

The FBS scale was developed by Lees-Haley, English & Glen (1991) and was formed to identify malingering specially among personal injury litigants. The scale consists of 43 items and has been reported effective in detecting the overreporting of somatic symptoms within the personal injury setting (Larrabee, 1998; Lees-Haley, English, & Glen, 1991). The FBS scale contains 43 items endorsed frequently by personal injury malingerers and has significant item overlap with the Infrequency-Psychopathology F(p) scale (Greene, 2000). The optimal cut score used to classify somatic malingerers was reported at a value of 20 and resulted in correct classifications 96% of the time (Lees-Haley, English, & Glenn, 1991).

As a successful measure of malingering in personal injury settings, Tsushima and Tsushima (2001) found that the FBS is more competent in differentiating clinical patients from personal injury litigants than any other validity scale (F, Fb, Fp, Ds). As a consequence, Tsushima and Tsushima (2001) suggest that clinicians should incorporate the FBS when interpreting the MMPI-2 for compensation seeking claimants. Confirming support for the use of the FBS, Greiffenstein, Baker, Gola, Donders and Miller (2002) in a study examined litigating moderate-severe and non-litigating moderate-severe head injury populations and concluded that the scale showed promise in analyzing validity concerns in litigated neurological claims as it was sensitive to litigation status as well as conforming and non conforming symptom courses. The researchers however highlighted that the FBS should not be used as a primary tool of symptom exaggeration but works best when in conjunction with other methods (Greiffenstein et al., 2002).

More evidence to support the FBS as a scale used to detect exaggerated somatic complaints derives from a study conducted by Larrabee (2003a). This study and others have found that the FBS was more sensitive to symptom exaggeration than either F, Fb or F(p) (Fox, Gerson, & Lees-Haley, 1995; Larrabee, 2003a, 2003b). In addition, Larabee (1998) found that the FBS was elevated in 11 out of 12 cases for neurologically normal litigants asserting brain damage, while the F scale was only elevated in 3 of the 12.

In contrast, Arbisi and Butcher (2004) argue that the FBS lacks construct validity and psychometric rigor. They propose that the FBS has not shown to efficiently detect individuals who malinger any form of psychiatric illness but only those who malinger neurocognitive deficits relevant to general maladjustment and somatic complaints (Arbisi & Butcher, 2004; Butcher, Arbisi, Atlis, & McNulty, 2003). Therefore, suggesting that the FBS does not represent malingering in the manner that other scales constructed for the FBS does not represent malingering in the manner that other scales constructed for the MMPI-2 do, such as F, Fb and Fp (Butcher et al, 2003). This FBS negatively correlates with the MMPI-2 validity scales that are associated with "faking-good" (Butcher et al., 2003). FBS does not examine extreme or rare symptoms of psychopathology but rather examines physical complaints rendering this scale vulnerable to identifying individuals who are experiencing genuine psychological distress as a result of their physical complaints as malingerers (Butcher et al., 2003).

In reply to criticism of the FBS, Lees-Haley and Fox (2004) indicated that Butcher, Arbisi, Atlis and McNulty (2003) misunderstood the interpretation of the FBS and made inaccurate judgments about malingering. They highlighted that the study conducted by Butcher used 5 out of 6 samples which were not relevant to the settings for which the FBS was specifically designed to detect somatic malingering. Lees-Haley and Fox (2004) also stipulated that the FBS was not designed as a substitute for F, Fb or F(p) but rather only outperformed these scales when detecting somatic malingering/ exaggeration.

Meyers Index

Validity scales F, Fb, F(p), FBS, F-K, S, L, K all maintain they individually are effective in detecting atypical responding on the MMPI-2. However, to invalidate a MMPI-2 protocol for potential faking-bad, more than one validity scale needs to be examined and considered for possible deviant responding. Consequently, a method has been developed recently that combines several different validity scales for the MMPI-2 together to assess malingering among a sample of chronic pain patients. The Meyers Index, developed by Meyers, Millis and Volkers (2002) unites the F, Fp, FBS, Gough Dissimulation Index (F-K), Gough Dissimulation Scale (Ds-r), Ego Strength scale (Es) and Obvious-Subtle Scale (O-S) to assess exaggeration of symptoms and malingering. A number of the measures used for the Meyers Index have previously been discussed (F, Fp, FBS). Therefore, the remaining F-K, Ds-r, Es and O-S scales utilized for the Meyers Index will be briefly discussed here.

By combining traditional Validity scales F (Infrequency) and K (Correction) Gough developed the Dissimulation Index (F-K) (1947). Differences in raw scores between the traditional scales F and K, resulting in a value of greater than 9 depicts a protocol that has overreported psychopathology, while a value of less than 0 depicts a protocol that has underreported psychopathology (Greene, 2000). Many researchers have conducted studies that confirm the effectiveness of the F-K index in identifying individuals who overreport symptoms of psychopathology (Austin, 1992; Cofer, Chance & Judson, 1949; Graham, Watts, & Timbrook, 1991; Woychyshyn, McElheran, & Romney, 1992). However, although the scale is effective it has been established that the F-K scale is not as efficient or successful in detecting overreporting of psychopathology as the traditional F scale (Bagby, Buis, & Nicholson, 1995; Graham et al., 1991; Hunt, 1948; Woychyshyn et al., 1992).

The Gough Dissimulation (Ds-r) revised scale, revised by Gough (1957) consists of 40 items. The scale was devised to differentiate samples of neurotic patients from a sample of professional psychologists and university students instructed to simulate response sets similar to neurotic patients for the MMPI (Greene, 2000). It was found that the professional psychologists and students attempting to malinger scored at least three times higher on the Ds-r scale than neurotic patients (Greene, 2000). Rogers, Bagby and Charkraborty (1993) found that when the Ds-r had a raw cut-off score of greater than 15, groups of individuals coached to malinger symptoms of schizophrenia were detected accurately and classified accurately 80% of the time.

Developed by Barron (1953) the supplementary Ego Strength scale (Es) contains 52 items on the MMPI-2 and was established to attempt to predict outcomes of individuals currently in psychotherapy. According to Barron (1953) the Es scale assessed the latent ego of an individual and high scores represent a person who has good resources and positive attributes while low scores indicate an inability to cope with pressures. It is the sensitivity of low scores on the Es scale to exaggeration of symptoms that has led to its inclusion on the Meyers' Index.

The final scale utilized for the Meyers' Index, included the Obvious-Subtle scale (O-S) developed by Wiener and Harmon in 1948 (Wiener, 1948).

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