False positive diagnosis of malingering due to the use of multiple effort tests

Lena Berthelson · Siddika S. Mulchan · Anthony P. Odland · Lori Miller · Wiley Mittenberg

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Abstract

OBJECTIVE: Effort indicators are used to determine if neuropsychological test results are valid measures of a patient's cognitive abilities. The use of multiple effort measures is often advocated, but the false positive rate for multiple indicators depends on the number of measures used and the correlation among indicators. This study presents a meta-analysis of correlations among effort measures. False positive rates for multiple correlated indicators are then estimated using Monte Carlo simulations. METHODS: a literature search of published studies identified 22 independent samples in which 407 correlations among 31 effort measures were available in 3564 participants with normal effort. Participants were patients with neurological or psychiatric disorders and healthy volunteers. RESULTS: Meta-analysis showed a mean correlation among effort indicators of 0.31. Monte Carlo simulation based on a 15% false positive rate for individual indicators showed that, when 10 effort indicators are used together, 38% of patients with valid performance will be incorrectly identified as malingering if two failures is the diagnostic standard. Failure on five of 10 measures is required for a false positive rate of 10% or less. If five effort indicators are interpreted, a false positive rate of 19% results when two test failures are assumed to characterize poor effort and failure on three measures is required to maintain 90% specificity. CONCLUSIONS: False positive rates for effort tests increase significantly as the number of indicators that are administered is increased.

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References

2002Base Rates of Malingering and Symptom Exeggeration 1999Diagnostic Criteria for Malingered Neurocognitive Dysfunction: Proposed Standards for Clinical Practice and Research 2009American Academy of Clinical Neuropsychology Consensus Conference Statement on the Neuropsychological Assessment of Effort, Response Bias, and Malingering 2011Reliable Digit Span 2008Aggregation Across Multiple Indicators Improves the Detection of Malingering: Relationship to Likelihood Ratios 2008The Need For Continuous and Comprehensive Sampling of Effort/Response Bias During Neuropsychological Examinations 2006Sensitivity and Specificity of Various Digit Span Scores in the Detection of Suspect Effort 1996An empirical approach to determining criteria for abnormality in test batteries with multiple measures.

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