Interestingly, the survey revealed substantially lower prevalence estimates of malingering in own clinical and forensic assessments than in general Figure 2. Neuropsychologists appear to be hesitant to acknowledge the occurrence of malingering in their own patients. Perhaps neuropsychologists are still too much inclined to believe what a patient says and does during an assessment. This stresses the importance of using objective methods for evaluating symptom validity.
Prevalence estimates of malingering: Interquartile ranges were 19, 5, 30, and 10, respectively. So, what are the tools and tests neuropsychologists use to evaluate the validity of the obtained diagnostic data?
[Evaluación de la validez de los sÃntomas en Europa: evolución y situación actual]
The five methods most frequently indicated for the determination of symptom validity were in rank order: All objective empirically validated methods e. Looking at the analyses per society, there were two exceptions: The most commonly used PVTs were: This supports the notion that important cultural differences still exist in how neuropsychologists in the various European countries relate to the topic of symptom validity. In conclusion, on the positive side there is acknowledgement that non-credible symptom reports and malingering occur.
The surveys' findings, however, also show that the use of clinical impressions still prevails over the use of empirically validated tests to determine the symptom credibility. Although these subjective methods certainly have their value, it is vital that they are being used in conjunction with empirically validated tests. In the last few decades, several research teams and lines have been established in Spain regarding research on malingering and SVA in different domains such as the neuropsychological context e.
Spanish adaptations of the internationally most widespread tests used for the assessment of symptom validity and malingering have fostered scientific, forensic, and medico-legal applications among psychological and neuropsychological practitioners. Remarkably, a significant number of Spanish-adapted symptom validity assessments rapidly became available to clinical and forensic professionals within less than half a decade e.
Moreover, specific forensic protocols were developed e. However, in spite of this promising research panorama there are numerous shadows regarding the professional practice of SVA and malingering assessment. Firstly, there is no reliable data available of applied assessment SVA protocols in different contexts.
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Furthermore, SVA and the question of possible malingering are not yet regularly taken into account in many forensic and medico-legal contexts. A guide for good practice is still in demand. A general professional debate and discussion have not yet occurred in Spain, as is the case in other European countries, like Germany and Switzerland. This is the case when instruments are used in isolation and without an adequate conceptual and methodological knowledge on the part of the test user who may see a "magic road" to the detection of deception in these tests.
Multidimensional and multi-method approaches may contribute to avoid inaccurate diagnoses and to decrease the rate of false positive and false negative classification errors, both having a considerable economic and psychosocial impact. In summary, although there are quality seeds available to get a good harvest in Spain, further research and educational effort will be necessary for establishing sound practice guidelines and protocols, both for researchers and professionals.
They should aim to 1 extend a regular use of SVA to any context where negative response biases can occur clinical, forensic, and medico-legal ; 2 adapt SVA to specific disorders like pain disorder, anxiety and affective disorders, amnesia, posttraumatic stress, sequelae of sexual assault and abuse, etc. In , a Dutch textbook on clinical neuropsychology was published that nicely illustrated the skepticism and controversies on the topic of malingering, which dominated at that time in the Netherlands. In the same book, the authors of a chapter on the chronic whiplash syndrome stated: In those early days, it was believed that malingering was only a problem in the United States and not in Europe, due to the American claim culture with huge financial stakes e.
Neuropsychologists were reluctant to introduce SVTs, because they felt it as a sign of mistrust towards the patient, opposing their primary task of determining the veracity of the complaints. The use of SVTs implies misinforming the patient, which was considered to conflict with the ethical code of psychologists. As formulated by a prominent colleague: From the nineties, SVA has nevertheless been an active research topic in the Netherlands. As in Northern America, the initial focus was on the detection of malingering in forensic assessments with SVTs, in those days often referred to as "malinger tests".
However, SVTs were soon applied in clinical settings. Van der Werf, Prins, Jongen, van der Meer, and Bleijenberg noted that a modest proportion of patients with chronic fatigue syndrome showed non-credible performance. Lower scores on the WMT were associated with higher levels of negative symptoms and it was hypothesized that an underlying motivational deficit could explain the WMT failure rate in this sample. These studies are exemplary of the transitional period towards a better understanding of what SVTs actually measure i. The nomenclature expanded and terms such as "suboptimal effort", "cognitive underperformance", and "symptom exaggeration" were being used interchangeably, even as synonyms of the concept of malingering.
The conceptual confusion surrounding SVA has certainly hampered resolving the controversies among Dutch neuropsychologists. The initially assumed dichotomy between true patients and malingerers and the lack of conceptual clarity probably evoked a counter reaction. In recent years, many Dutch neuropsychologists have stressed that cognitive underperformance and symptom exaggeration are not necessarily conscious behaviors nor behaviors motivated by external gains.
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Instead, emphasis is placed on explanations such as pain, fatigue, and emotional factors e. Currently, the majority of Dutch neuropsychologists acknowledge cognitive underperformance and symptom over-reporting as threats to the validity of the test results and most of them, at least in forensic assessments, use SVTs.
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However, the idea that symptom invalidity can arise from deceitful behavior of the examinee still seems to be a taboo. Recent research activities have focused on symptom validity in patients clinically referred for neuropsychological assessments. The WMT has also been researched in memory clinic patients.
Failing the effort indices of the WMT negatively impacted the association between hippocampal damage and memory performance Rienstra, Groot et al. Thus, SVTs may even be used to aid the early diagnostics of dementia. Also, there have been experimental studies into the residual effects of feigning. Volunteers instructed to first malinger psychological symptoms and then to give up their role and act honestly continued to show heightened symptom levels on re-administration of a symptom list as compared to participants being asked to fill out the list twice in an honest manner.
Cognitive dissonance is hypothesized as the underlying mechanism. Despite this lack of popularity, their importance is recognized by the British Psychological Society BPS , who has written a position paper on performance validity testing, which recommends their use in clinical and medico-legal practice McMillan et al. The majority of British PVT research has focused on test validation but there is a paucity of research, showing that GB's need and interest in PVTs is not reflected in the evidence base. This worse than chance performance methodology was applied in the very early development of PVTs Pankratz, , but since this time methodology has become much more sophisticated, given its likely limited sensitivity with "known groups" of clinical malingerers.
Nevertheless, the CIHT remains a useful bedside screen. The remaining British PVT validation studies have tended to be with stand-alone measures which are rarely used e. The lack of litigant studies with the exception of Moss et al. There is also a lack of British PVT studies with chronic pain or in the context of criminal forensic neuropsychological assessments and this is also reflected in clinical practice with few neuropsychologists providing these specialist assessments.
Interestingly, all of the British studies have used simulation validation paradigms and there are no British known-groups studies with clinical malingerers. This trend to use simulation paradigms is behind the North American literature, which has shifted from simulation designs to known-groups studies, the latter often regarded to be a more sophisticated approach. The lack of known-groups studies may stem partly from the lack of acceptance that "known group" designs actually reflect "malingerers".
Overall, there is clearly a substantial need for PVTs in GB with the growing claims culture but this is not reflected in the sophistication of the application of PVTs or the British research evidence base. German neuropsychologists were primarily identified with a clinical and therapeutic relationship to their patients and were little acquainted with the strictly impartial role a forensic expert has to assume.
Still, in , a prominent German neuropsychologist pronounced, in the context of assessing possible malingering, in a public neuropsychological newsgroup: In the context of the ongoing debate about SVA, this is reflected by a statement of Noeker and Petermann , who maintained that low scores on PVTs may erroneously suggest malingering in patients with functional and somatoform syndromes. Even if such patients produced an excessive array of symptoms, they nevertheless responded "in a subjectively truthful manner" p.
A series of articles examining base rate estimates of negative response bias in forensic populations found numbers comparable to those known from North America e. Similarly to what is known from North America in the s, referral agencies stipulate and stimulate the progress in the field. Today we have a somewhat paradoxical situation in Germany: PVT usage in medico-legal contexts appears to be fully accepted by neurologists , but the neuropsychological community continues to be divided. Many neuropsychologists are still hesitant to integrate modern approaches to SVA even into their forensic work.
In psychiatry , there is an even deeper division. On the one hand, a growing number of psychiatrists appear to appreciate working closely with psychologists and include SVA results to make determinations about the genuineness of symptom report and the validity of profiles e. On the other hand, a group of influential German psychiatrists undertook to question the appropriateness of SVA in the context of forensic examinations in patients with mental disorders e.
For a discussion of this deeply rooted controversy which has a profound impact on forensic psychiatric practice at the present time, see Schmidt, Lanquillon, and Ullmann and Merten and Merckelbach b ; an analysis of potential pitfalls for opponents of SVA was presented by Green and Merten Remarkably, some sceptics or opponents to SVA appear to adopt the published English-language literature in a distorted way.
To give a most striking example, the term malingering is wrongly understood as referring exclusively to symptom invention or "pure" malingering , while other aspects of malingering are neglected. Thus, base rate estimates for malingered symptomatology are questioned on the basis of a wrong conceptualization e. However, a number of professional guidelines appear to be more circumspect, more open to include modern methods of SVA, and do not restrict psychiatric determinations to clinical decision making e. State of the art, recent developments, and outlook. Within the continent, neuropsychology certainly finds itself in diverse stages of development, and the role of forensic neuropsychology in the legal systems is probably as diverse moreover, the states partly adhere to the inquisitorial, partly to the adversarial system, with different roles of the forensic expert within the legal system.
A similar diversity can be found in documented SVA practice and research activities as has been outlined above. In some countries, major developments have occurred to a degree that the gap between American and local SVA practice appears to have been narrowed while there is no documented proof of systematic SVA usage from most European countries. Yet, professional guidelines for forensic assessment appear to include increasingly firm statements about SVT usage.
However, as far as can be seen, Great Britain is the only country so far in which a special professional guideline dealing with SVA has been passed McMillan et al. Adoption of SVA in the majority of European countries is hampered by the diversity of national languages within the continent. However, even adaptations of foreign language tests require proper validation. Moreover, the majority of practically working neuropsychologists in some major nations like Germany, France, and Spain are not used to resort to English language resources in their daily routines.
To facilitate access to current developments, publications in their national languages appear to be mandatory e. However, in a number of other countries like The Netherlands and the Scandinavian nations , command of English language is a basic requirement for professionals. Apart from the three major European symposia on Symptom Validity Assessment, a number of other events have marked the last few years.
In , a workshop on the assessment of malingering and related response styles was held by Dr. Richard Rogers in Basel, Switzerland. With regard to SVA in Europe, it may be said that we have come a long way, but there is an even longer way before us.
Whenever neuropsychologists enter the legal arena as independent experts, they have to deal with an elevated rate of invalid test profiles in claimants. SVA will help them to make valid determinations about possible response bias and to answer the legal questions with more confidence and more convincingly than if they rely on their clinical intuition. As a consequence, an appropriate and responsible use of these methods can -and will- enhance the competence and the esteem of neuropsychologists in the legal arena.
In clinical and rehabilitation contexts SVA can play a significant role in differential diagnosis and help clarifying the nature of certain symptom constellations as well as factors contributing to the course of reported symptoms. In these contexts, however, the way to go is even longer. No conflicts of interest were declared by the other authors. D - Berlin, Germany. Post-qualification training day on symptom validity testing attracts capacity audience.
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Luiz Marcellino de Oliveira. Temas em Psicologia, 14 , Conselho Federal de Psicologia Behavior and Social Issues, 6 , Psicologia, Teoria e Pesquisa, 23 , Teoria e Pesquisa, 23 , Maria Clotilde Therezinha Rossetti Ferreira. The pioneer contribution of Luiz Marcellino de Oliveira to experimental analysis of behavior and psychobiological investigation in Brazil. Cadernos Prohasa, 1 , Boletins de Psiquiatria, 17 , Carolina Bori, Viva para sempre!.
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