Why One Fakes a Head Injury Affects How One Fakes a Head Injury
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Why One Fakes a Head Injury Affects How One Fakes aHead InjuryKristi Erdal aa Department of Psychology , The Colorado College , Colorado Springs, ColoradoPublished online: 10 Feb 2009.
To cite this article: Kristi Erdal (2009) Why One Fakes a Head Injury Affects How One Fakes a Head Injury, AppliedNeuropsychology, 16:1, 42-48, DOI: 10.1080/09084280802644136
To link to this article: http://dx.doi.org/10.1080/09084280802644136
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Why One Fakes a Head Injury Affects How One Fakesa Head Injury
Department of Psychology, The Colorado College, Colorado Springs, Colorado
Identifying suspect effort in neuropsychological assessments has been investigated inclinical samples and experimental simulation paradigms. While patients incentives,such as compensation, are commonly thought to impact motivation, other motivationalinfluences, such as attention-seeking, have been largely unexplored. To this end,undergraduates (n 202) were asked to fake a head injury on the Dot Counting Test,California Verbal Learning Test, and Benton Visual Retention Test. Participants wereassigned to one of four Motivation conditions (no motivation, avoiding blame, compen-sation, attention-seeking). Analyses revealed that those with compensation- andattention-seeking motivations performed significantly worse than those with blameavoidance and no motivations, suggesting that type of motivation affects performanceon neuropsychological assessment. The relative similarity between compensation-seekers and attention-seekers, however, suggests that the two groups would be difficultto differentiate. Preliminary findings suggest that compensation-seekers may favorerrors of omission and attention-seekers may favor errors of commission in their perfor-mance; however this finding requires replication.
Key words: malingering, motivation, neuropsychological assessment, simulation, traumatic braininjury
Questionable performance on neuropsychologicalassessment may be labeled as incomplete effort,symptom exaggeration, or malingering, amongother terms. In arriving at these conclusions, clinicalneuropsychologists typically look at the context of thepatients claims in combination with their test
performance. Context variables typically includewhether or not a person is involved in a medico-legalaction or has substantial external incentive (e.g., Henry,2005; Meyers & Volbrecht, 1998; Reynolds, 1998; Slick,Hopp, Strauss, & Spellacy, 1996; Slick, Sherman, &Iverson, 1999). Neuropsychologists also attempt toidentify whether test data are discrepant from knownbrain functioning, observed behavior, and collateralreports (Slick et al., 1999). While these variables andcriteria have been used with relative success to identifythose who give incomplete effort, motivation to performin a particular way on neuropsychological assessmentsmay be complicated by additional psychological factors.
Numerous studies have compared patients with externalincentives, typically financial, to patients without and havefound that those with financial incentives perform morepoorly on neuropsychological assessments (e.g., Greve,Bianchini, Mathias, Houston, & Crouch, 2003; Larrabee,2003; Youngjohn, Davis, & Wolf, 1997). Both Bianchini,
Note: This paper was accepted under the editorship of Cecil R.
Reynolds.This research was supported by the John D. and Catherine T.
MacArthur Foundation and Colorado College Natural Science
Division Grants. Portions of this research were presented at the 27th
Annual Meeting of the National Academy of Neuropsychology,
Scottsdale, AZ, November 2007. The author wishes to thank Patrick
Shannon, Kara Lindstrom, Whitney Dunn, Jenni Martin, Jill
Gilkerson, Jen Small, Abbie Weiss, PJ Hoberman, Amber Bailey,
Mary Rosenblatt, Elisha Nottingham, and Amanda Chapman for
assistance in data collection.Address correspondence to Kristi Erdal, Department of Psychol-
ogy, The Colorado College, 14 East Cache La Poudre Street, Colorado
Springs, CO 80903. E-mail: kerdal@ColoradoCollege.edu
APPLIED NEUROPSYCHOLOGY, 16: 4248, 2009
Copyright # Taylor & Francis Group, LLCISSN: 09084282 print=15324826 online
Curtis, and Greve (2006) and Greiffenstein, Gola, andBaker (1995), however, studied patients who varied in theirfinancial incentives and found that patients who werepursuing large compensation claims scored significantlymore poorly on neuropsychological tests and malingeringindicators than patients who were pursuing smaller claims.The authors concluded that type of litigation (i.e., degree ofexternal incentive) should be considered when assessingpatients, suggesting that a dichotomous view of com-pensation motivation provides only limited information.
The presence of a medico-legal context is essential tonote in assessment; however, as Lanyon and Almer(2002) recognized, having the opportunity to litigate isnot the same as availing oneself of that opportunity.In studying disability claimants, the authors found thatthose who chose to litigate their claims had significantlyhigher scores on the Minnesota Multiphasic PersonalityInventory-2 subscales of Hs, D, and Hy, possibly indi-cating greater somatization and self-focus driving theirmotivation to litigate and pursue external incentives.These data were consistent with Youngjohn, Burrows,and Erdal (1995) and Youngjohn et al. (1997), whofound Hs, D, and Hy elevations among their litigatinghead injury patients. In Lanyon and Almers sample,however, even the nonlitigating patients Hs, D, andHy scores were elevated, suggesting either that disabilityaffected the patients emotionally or that patientsshowed premorbid, self-focused, and attention-seekingbehavior, regardless of litigation status.
Attention-seeking is a relatively unexplored motiva-tion in neuropsychology, likely due to the historicalfocus on compensation motivation. Attention-seekingis better classified as a factitious motivation than a mal-ingering motivation by virtue of its lack of tangibleexternal incentives (American Psychiatric Association,2000; Slick et al., 1999), but factitious behaviors are dif-ficult to discriminate from malingering in clinical prac-tice due to requiring an assessment of the conscious orunconscious motivation of the symptom production.Recently, it has been argued that the diagnostic criteriafor factitious disorder should be reformulated to addressthis dilemma, as well as to differentiate specificallybetween milder forms of the disorder, such as lyingabout illness behavior and the more dramatic instancesof self-harm (Ford, 2005; OShea, 2003; Turner, 2006).Hamilton and Janata (1997) suggested that the ends ofthe factitious behavior spectrum may represent differentmotivations and etiologies altogether, and that milderlying behaviors, the most common type, might representa self-enhancement strategy, where the patient associatesillness with courage, care, and nurturance. Typical facti-tious cases begin with actual illness or injury, duringwhich time the patients become accustomed to the ben-efits they receive from the patient role (Hamilton &Janata). This scenario is consistent with head injury
cases where there is usually a genuine precipitating event(i.e., motor vehicle accident), after which the factitiousproduction of symptoms may perpetuate the appearanceand diagnosis of brain injury.
It is understood that nonlitigating mild head injurypatients with persistent symptoms are rare (Youngjohnet al., 1995), and that factitious motivations leading toincomplete effort are likely not the most common causeof poor performance. However, if we feel that financi