Developments in the area of malingering detection parallel several of Thomas Kuhn's observations concerning the nonlinear trend of progress in the history of science (Kuhn, 1962). For example, the naive assumption that traditional neuropsychological assessment procedures would straightforwardly generalize to compensation-seeking populations characterized an earlier status quo, a period Kuhn referred to as normal science. The central fallacy of this assumption was the idea that litigants and other claimants did not, as a group, behave differently from those seen in strictly clinical settings. The untenable presumption that astute clinicians were generally capable of forming accurate judgments about the validity of effort on the basis of observation was another received belief that characterized this now archaic era of practice.
Sparked by surprising insights derived from the clinical application of the binomial theorem, the field of neuropsychology entered a new developmental epoch. The rapid expansion of awareness of anomalous data and the discovery of novel facts defined this developmental stage, all of which posed an enormous challenge to preexisting paradigms. Beginning with the early case study approach of Pankratz et al. (1975) and followed by the work of Pankratz et al. (1987) and Hiscock and Hiscock (1989), it became clear that people sometimes perform close to or below chance-level on simple forced-choice measures for reasons not explained by intellectual limitations or neurocognitive impairment. These early studies triggered a transformational period in our field, translating to a conceptual revolution or paradigm shift in the Kuhnian sense (Kuhn, 1962).
As Kuhn (1962) pointed out, a field's textbooks must be rewritten in the aftermath of a scientific revolution. Fortunately, particularly for those on the front lines of forensic neuropsychology practice, Larrabee's Assessment of Malingered Neuropsychological Deficits reflects the collective effort of many of those who have produced much of the most original and significant research in this area. These authorities provide overviews of the entire malingering research infrastructure, including detailed summaries of evidence-based assessment procedures and considerations of future trends in the definition and detection of malingering. The tables alone are worth the price of admission, and the book follows a highly coherent organizational scheme, making it easy to find pertinent facts and figures. The book is an immediately indispensable resource for every neuropsychologist working in or interested in working in the forensic arena.
Chapters 1 and 2, by Larrabee and Larrabee and Berry, respectively, discuss definitions, research designs, base rate issues, and the fundamentals of classification accuracy statistics. Some readers may object to the fact that other authors revisit the topics of research design and classification statistics in subsequent chapters, but others, especially those who are not fully conversant with the sophisticated quantitative procedures upon which much of this research is based, will benefit from some degree of overlap across instructors. One of the principle tenets of malingering detection is that proper diagnosis rests on multiple sources of evidence, while minimizing the risk of false-positive errors (i.e., maintaining high specificity). Implicit in this point is the idea that a determination of malingering, like all diagnoses in neuropsychology, is the byproduct of a careful inferential process, which integrates diverse sources of information. Larrabee and Berry's use of the term “malingering tests” in Chapter 2 is unfortunate because it suggests that the test, not the clinician, determines the presence or absence of the condition. This small confusion is, however, entirely forgivable. Covered in all of 25 pages, Chapters 1 and 2 are as clear a presentation of the basics as I have read.
Beginning with Chapter 3, a review of non–forced-choice effort tests by Boone and Lu, the next several chapters are organized according to domain type. Lest they be unnecessarily neglected in favor of more sophisticated measures, Boone and Lu state that cross-validation data justify the ongoing use of non–forced-choice measures. In Chapter 4, Grote and Hook remind us that effect sizes of forced-choice tasks generally trump those of non–forced-choice procedures (Vickery et al., 2001). Grote and Hook reiterate that intentionality, the sine qua non of malingering, is difficult to operationalize. However, Chapter 13, Refining Diagnostic Criteria for Malingering by Larrabee, Greiffenstein, Greve, and Bianchini, the most original chapter and one that could have been fittingly subtitled What and How Much We've Learned, provides a compelling operational explanation of intentionality, easily the most novel insight of the entire volume. As application of the Slick criteria (Slick et al., 1999) has enabled the reliable formation of known groups, the outrageously thorny problem of trying to infer intent from single events or behaviors is circumvented by considering multiple, highly improbable events as indicative of intent. This observation sets up recommendations for improving the Slick criteria. Emerging trends in malingering research are discussed; when certain conditions are met, the aggregation of multiple independent indicators has been shown to be associated with virtually perfect specificity (further elaborated by Larrabee, in press).
In Chapter 6, one of the most informative in the book, Greiffenstein takes up the previously obscure topic of sensory and motor test manifestations of malingering. Unawareness of these data is hazardous; anomalous motor findings occur at very high rates among postconcussive claimants. Some of the very best tables in the book appear in Suhr and Barrash's chapter on attention, memory, and psychomotor speed tasks (Chapter 7). The practicing forensic neuropsychologist can make excellent use of the tables summarizing Reliable Digit Span (RDS) studies, as well as data relevant to a determination of noncredible performance on the Auditory Verbal Learning Test (AVLT) and California Verbal Learning Test (CVLT). In Chapter 8, Greve and Bianchini deliver a scholarly review of so-called frontal lobe tests, which could stand on its own as an historical statement. Due to the uniquely disabling nature of executive dysfunction, careful assessment of motivational impairment in the context of executive tests is critically important. The empirical basis for malingering assessment with measures of executive functioning is not robust, however, leading these authors to counsel caution, especially when dealing with serious injuries. In Chapter 9, Berry and Schipper take up the detection of feigned psychiatric symptoms. Beyond the MMPI-2, there is not a great deal of ground to cover here and some of the newer promising measures have not been around long enough to accumulate much support.
Larrabee contributed chapters on the analysis of atypical neuropsychological test patterns (Chapter 5) and the evaluation of exaggerated health and injury symptomatology (Chapter 10). Both chapters expand on the central theme of Larrabee's research; an examination of the empirical foundation of matters directly relevant to the practice of evidence-based forensic neuropsychology. As usual with Larrabee's work, there is always something new and useful. Rounding out the book are chapters on coaching by Suhr and Gunstad (Chapter 11) and noncredible features of the neurological exam by Albers and Schiffer (Chapter 12). In an era when threats to the security of neuropsychological tests have never been greater, neuropsychologists need to know that forced-choice measures are highly vulnerable to coaching effects. Albers and Schiffer are both neurologists, and there is much to like about their chapter. They state their preference for using the term noncredible to refer to non-neurological illness behavior and exaggerated exam findings, as this does not commit them to opining about underlying motivation. Of course, many forensic neuropsychologists may feel less constrained because they believe they have more to go on. Nevertheless, it would have been nice to learn about the language the other authors use to describe feigned or exaggerated performance because there is so much variability across practitioners and the descriptive language is often tricky for both experienced and novice neuropsychologists.
Albers and Schiffer use a wonderful term—“symptoms of life”—to refer to high base rate, nonspecific symptoms, which are often relied on in the extreme to justify inferences of traumatic brain injury and other neuropsychological conditions. Some readers will puzzle over their claim that the objectivity of neuropsychological tests is no greater than the neurological examination; one assumes they mean that behavior in both contexts is effort-dependent, but the clarity of this statement needed to be sharpened. When commenting on pain in forensic settings, Albers and Schiffer neglected to cite Bianchini et al. (2005), a seminal work on malingered pain-related disability. Anyone somewhat familiar with this literature will note this glaring omission, which, ironically, was published in a medical journal. In contrast to most of the rest of the book, the Albers and Schiffer chapter contains no technical or quantitative data and uses clinical vignettes. As such, this chapter provides something of an intellectual counterpoint and many readers would appreciate it being placed more in the middle of the book instead of toward the end.
It was not that long ago that any earnest neuropsychologist could maintain a single file of articles on malingering. The file would not even be that thick, and it would more or less contain all the substantive work in this area and a photocopy of the Rey 15-Item stimulus page to boot. Times have changed, of course. The application of neuropsychology in medical–legal settings has led to the development of a serious science of malingering detection. Larrabee's Assessment of Malingered Neuropsychological Deficits sets the new gold standard in this genre, at least until the second edition of this book is published.
