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 financialincentive is the only window we have into a patientsmotivation, we may be missing interesting and potentiallyimportant data which could improve our assessments, aswell as the patients treatment. Those who have lookedbeyond dichotomous classification of financial incentive(Bianchini et al., 2006; Greiffenstein et al., 1995; Lanyon &Almer, 2002) have found a more complex picture.
The role experimental malingering simulationparadigms play in the quest to accurately identify andpotentially diagnose those who give incomplete effortis to expose the strategies non-head injured people useto portray themselves as head injured. In controlledsettings, experimental neuropsychologists can varycoaching directions, warnings about exaggeration, oreven the study participants motivation and identifyhow the neuropsychological test performance changeswith different instructional sets. This has been particu-larly illustrative in identifying how coaching and warn-ing can affect neuropsychological test performance(Cato, Brewster, Ryan, & Giuliano, 2002; Dunn, Shear,Howe, & Ris, 2003; Erdal, 2004a; Johnson & Lesniak-Karpiak, 1997; Powell, Gfeller, Hendricks, & Sharland,2004; Tan et al., 2002). What has been less well studiedto this point is the impact that different motivationshave on neuropsychological test performance. Erdal(2004) found that when motivation was manipulated,those who were instructed to fake a head injury forcompensation malingered more flagrantly than both thoseinstructed to fake a head injury to avoid blame for amotorvehicle accident and those in a no motivation control con-dition. What has yet to be explored is how malingeringmotivations (i.e., those associatedwith tangible incentives)would compare with more factitious motivations, such asattention-seeking, in the testing profile.
In experimental paradigms, efforts to identify howdifferent motivations affect test performance have beenfruitful, but are often criticized for their lack of externalvalidity. While it is accurate to say that simulated malin-gerers perform significantly worse than real suspectedmalingerers, it has recently been found that the majorityof simulatingmalingerers scores correspond to themajor-ity of suspected malingerers scores, and that their groupdifferences rarely lead to different clinical interpretations(Brennan & Gouvier, 2006). This should encourage confi-dence that the patterns that emerge in simulation researchprovide viable paths to follow in clinical settings.
WHY ONE FAKES A HEAD INJURY 43
The current study was a simulated malingeringexperiment. Four types of Motivation given to the par-ticipants in the experimental vignettes (no motivationgiven, avoiding blame, compensation, attention-seeking)were compared on their impact on neuropsychologicaltest performance. It was hypothesized that, consistentwith past research, those with a compensation motiva-tion would malinger more flagrantly than those withblame avoidance and no given motivations. It was alsohypothesized that, consistent with comparisons ofmalingerers and factitious groups on personality tests(Rogers, Jackson, & Kaminski, 2005), those withattention-seeking motivations would perform compar-ably to those with compensation-seeking motivationsas both were seeking rewards for their behavior.
Undergraduate students (n 240) were recruited frompsychology department classes. Their mean age was19.88 (SD 1.49). The participants were paid $5 fortheir participation.
Participants data were excluded if they or a memberof their immediate family had a neurological illness orreported loss of consciousness in the last five years(n 32). Six participants data were excluded due toreporting less than minimal motivation in followingtheir faking instructions ( .05.
Dot Counting Test (Rey, 1941)
The DCT is a test of dissimulation which presentsstimuli of different difficulty levels in a random fashionto assess whether the patients responses and errors areassociated with the tasks difficulty. The patient isshown two sets of six cards with varying numbers ofdots on them and is timed while s=he counts the dots.The first six cards have the dots randomly placed onthe cards (ungrouped), whereas the second six have thedots grouped, which enable them to be counted moreeasily. Variables included the number of ungroupedand grouped cards correct (each out of six), andungrouped and grouped time. Test-retest reliability hasbeen shown to be high (.75.90) for response time, butlower for number correct (.51.70; Paul, Franzen,Cohen, & Fremouw, 1992). Brennan and Gouvier(2006) found no significant differences in performanceon the DCT between their simulated and suspectedmalingering groups.
California Verbal Learning Test (Delis, Kramer,Kaplan, & Ober, 1987)
The CVLT assesses immediate memory span, learn-ing curve, interference, short-term and long-term reten-tion, and recognition in a list-learning activity. The16-item list, which is initially presented in five trials, ismade up of four four-word subcategories to facilitateconceptualization. Variables assessed were total immedi-ate recall (sum of trials 15), the long-term recognitionscore, and the false positive score. Split-half reliabilitycoefficients have been reported to be .77.86 (Delis,Kramer, Fridlund, & Kaplan, 19...