NeuroRehabilitation - Volume 36, issue 4

Authors: Bush, Shane S.

Article Type: Editorial

Abstract: Rehabilitation professionals provide valuable clinical services to persons who have sustained neurologic injuries and illnesses. Accurate diagnosis and treatment planning require that neurorehabilitation professionals base their decisions on true information and genuine patient performance. That is, the patient must have responded honestly to questions and put forth adequate effort on ability measures. When in possession of valid information about the patient’s history, symptoms, and abilities levels, clinicians are well positioned to serve the patient. In contrast, inaccurate information and invalid functional presentations lead to misdiagnosis, unhelpful or potentially harmful interventions, and wasted resources. Ethically, consistent with the principles of beneficence …and justice, clinicians have a responsibility to use the assessment measures and procedures that are needed to answer clinical questions and provide appropriate services, using and conserving valuable resources in the process. With validity assessment measures and procedures comprising an important part of clinical evaluations, a formal, structured approach to validity assessment promotes ethical practice. Interdisciplinary collaboration in validity assessment in neurorehabilitation contexts can often be more thorough and efficient than evaluations performed by a single discipline. Show more

Keywords: Symptom validity, malingering, neurorehabilitation, ethics, evaluation

DOI: 10.3233/NRE-151227

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 383-386, 2015

Authors: Carone, Dominic A.

Article Type: Research Article

Abstract: BACKGROUND: In clinical neuropsychological practice, assessment of response validity (e.g., effort, over-reporting, under-reporting) is an essential component of the assessment process. By contrast, other health care professionals, including those in neurorehabilitation settings, often omit assessment of this topic from their evaluations or only rely on subjective impressions. OBJECTIVE: To provide the first comprehensive review of response validity assessment in the neurorehabilitation literature, including why the topic is often avoided, what methods are commonly used, and how to decrease false positives. METHODS: A literature review and documentation of personal experience and perspectives was …used to review this topic. RESULTS: There is a well-established literature on the necessity and utility of assessing response validity, particularly in patients who have external incentives to embellish their presentation or to under-report symptoms. There are many reasons why non-neuropsychologists typically avoid assessment of this topic. This poses a significant problem, particularly when patients exaggerate or malinger, because it can lead to misdiagnosis and it risks increasing the cost of healthcare by performing unnecessary tests and treatments, unfair distribution of disability/compensation resources, and a reduced access to these and other health resources by patients who genuinely need them. CONCLUSIONS: There is a significant need for non-neuropsychologists to develop and incorporate symptom and performance validity assessments in clinical evaluations, including those in neurorehabilitation settings. Show more

Keywords: Effort, malingering, symptom validity testing, neuropsychological testing

DOI: 10.3233/NRE-151228

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 387-400, 2015

Authors: Zasler, Nathan D.

Article Type: Research Article

Abstract: BACKGROUND: The assessment of any patient or examinee with neurological impairment, whether acquired or congenital, provides a key set of data points in the context of developing accurate diagnostic impressions and implementing an appropriate neurorehabilitation program. As part of that assessment, the neurological physical exam is an extremely important component of the overall neurological assessment. PURPOSE: In the aforementioned context, clinicians often are confounded by unusual, atypical or unexplainable physical exam findings that bring into question the organicity, veracity, and/or underlying cause of the observed clinical presentation. The purpose of this review is to provide …readers with general directions and specific caveats regarding validity assessment in the context of the neurological physical exam. CONCLUSIONS: It is of utmost importance for health care practitioners to be aware of assessment methodologies that may assist in determining the validity of the neurological physical exam and differentiating organic from non-organic/functional impairments. Maybe more importantly, the limitations of many commonly used strategies for assessment of non-organicity should be recognized and consider prior to labeling observed physical findings on neurological exam as non-organic or functional. Show more

Keywords: Neurological exam, validity assessment, effort, functional neurologic disorder, malingering, symptom exaggeration

DOI: 10.3233/NRE-151229

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 401-413, 2015

Authors: Roth, Carole R. | Cornis-Pop, Micaela | Beach, Woodford A.

Article Type: Research Article

Abstract: BACKGROUND: Reports of increased incidence of adult onset stuttering in veterans and service members with mild traumatic brain injury (mTBI) from combat operations in Iraq and Afghanistan lead to a reexamination of the neurogenic vs. psychogenic etiology of stuttering. OBJECTIVE: This article proposes to examine the merit of the dichotomy between neurogenic and psychogenic bases of stuttering, including symptom exaggeration, for the evaluation and treatment of the disorder. METHODS: Two case studies of adult onset stuttering in service members with mTBI from improvised explosive device blasts are presented in detail. Speech fluency …was disrupted by abnormal pauses and speech hesitations, brief blocks, rapid repetitions, and occasional prolongations. There was also wide variability in the frequency of stuttering across topics and conversational situations. Treatment focused on reducing the frequency and severity of dysfluencies and included educational, psychological, environmental, and behavioral interventions. RESULTS: Stuttering characteristics as well as the absence of objective neurological findings ruled out neurogenic basis of stuttering in these two cases and pointed to psychogenic causes. However, the differential diagnosis had only limited value for developing the plan of care. CONCLUSIONS: The successful outcomes of the treatment serve to illustrate the complex interaction of neurological, psychological, emotional, and environmental factors of post-concussive symptoms and to underscore the notion that there are many facets to symptom presentation in post-combat health. Show more

Keywords: Adult onset stuttering, mild traumatic brain injury, psychogenic disorder, rehabilitation

DOI: 10.3233/NRE-151230

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 415-426, 2015

Authors: Wygant, Dustin B. | Granacher, Robert P.

Article Type: Research Article

Abstract: BACKGROUND: Forensic neuropsychiatric assessment requires thorough consideration of malingering and response bias. Neuropsychiatric evaluations are complicated due to the multiple domains in which symptoms and impairment present. Moreover, symptom exaggeration in these evaluations can also present along various symptom domains (e.g., psychological, neurocognitive, somatic). Consequently, steps must be taken to ensure adequate coverage of response bias across all three domains of function. PURPOSE: The following article reviews the conceptualization of malingering in neuropsychiatric settings, as well as various approaches and measures that can be helpful in the assessment of malingering and response bias. …CONCLUSIONS: Forensic neuropsychiatric assessment requires thorough consideration of malingering and response bias. These evaluations are complicated due to the multiple domains in which symptoms and impairment present. Performance and symptom validity measures should be routinely included in these evaluations. Collaboration between psychiatry and psychology can provide the optimal multi-method approach needed for thorough neuropsychiatric assessment in forensic cases. We illustrate our points with two case studies from forensic traumatic brain injury neuropsychiatric evaluations. Show more

Keywords: Malingering, response bias, neuropsychiatry, forensic

DOI: 10.3233/NRE-151231

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 427-438, 2015

Authors: Kirkwood, Michael W.

Article Type: Research Article

Abstract: BACKGROUND: Youth have been assumed historically to be less capable of deception than adults, even though acts of deception in childhood are not uncommon. Relatively little attention has focused on how frequently they feign or exaggerate during healthcare evaluations. PURPOSE: The current article reviews the literature relevant to using validity tests in children and adolescents, as well as provides a case example of a young adolescent providing noncredible effort and exaggerated symptomatology during neuropsychological evaluation after a mild traumatic brain injury. CONCLUSION: Numerous case reports and case series have documented clearly that …medical and neuropsychological noncredible presentations occur in children, likely more often than many practitioners believe. Thus far, research has found that the base rates of pediatric noncredible presentations are highest in children seen frequently by rehabilitation providers (i.e., children with persistent problems after mild traumatic brain injury and children from families seeking disability benefits on their behalf). Subjective clinical judgment is apt to be ineffective in consistently detecting noncredible presentations. Fortunately, recent research supports the use of several stand-alone validity tests in identifying noncredible pediatric data including the Test of Memory Malingering, Word Memory Test, and Medical Symptom Validity Test. If feigning and exaggeration are not considered in work-ups by rehabilitation practitioners, mismanagement and iatrogenic harm to the child can result. Show more

Keywords: Validity testing, noncredible performance, suboptimal effort, malingering, neuropsychological assessment, children

DOI: 10.3233/NRE-151232

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 439-450, 2015

Authors: Bush, Shane S. | Bass, Carmela

Article Type: Research Article

Abstract: BACKGROUND: Veterans with polytrauma have suffered injuries to multiple body parts and organs systems, including the brain. The injuries can generate a triad of physical, neurologic/cognitive, and emotional symptoms. Accurate diagnosis is essential for the treatment of these conditions and for fair allocation of benefits. To accurately diagnose polytrauma disorders and their related problems, clinicians take into account the validity of reported history and symptoms, as well as clinical presentations. OBJECTIVES: The purpose of this article is to describe the assessment of validity with polytrauma Veteran populations. METHODS: Review of scholarly and …other relevant literature and clinical experience are utilized. RESULTS: A multimethod approach to validity assessment that includes objective, standardized measures increases the confidence that can be placed in the accuracy of self-reported symptoms and physical, cognitive, and emotional test results. CONCLUSIONS: Due to the multivariate nature of polytrauma and the multiple disciplines that play a role in diagnosis and treatment, an ideal model of validity assessment with polytrauma Veteran populations utilizes neurocognitive, neurological, neuropsychiatric, and behavioral measures of validity. An overview of these validity assessment approaches as applied to polytrauma Veteran populations is presented. Veterans, the VA, and society are best served when accurate diagnoses are made. Show more

Keywords: Symptom validity, performance validity, polytrauma, Veterans

DOI: 10.3233/NRE-151233

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 451-462, 2015

Authors: Silver, Jonathan M.

Article Type: Research Article

Abstract: BACKGROUND: In the evaluation of neurorehabilitation patients involved in compensation or litigation, it is often assumed that poor performance or exaggerated symptoms reflects an intentional attempt to game the system. PURPOSE: The purpose of this article is to review multiple issues that can contribute to invalid symptom reporting and performance. CONCLUSIONS: Multiple factors relevant to normal behavior, including observations from social psychology and behavioral economics, are important in the context of invalid symptom reporting and performance. These factors, which include pre-injury traits and beliefs (e.g., beliefs about prognosis and symptoms after TBI), …factors at the time of initial treatment (e.g., expectations of recovery, nocebo effects, stereotype threat), and thoughts and feelings during evaluations (e.g., anger, resentment, injustice), may be important explanations. To best serve our patients, further research is needed to illuminate these relative effects on performance compared to “not trying.” Show more

Keywords: Concussion, validity, effort, stereotype threat, injustice, malingering

DOI: 10.3233/NRE-151234

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 463-469, 2015

Article Type: Other

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 471-474, 2015

Article Type: Other

Citation: NeuroRehabilitation, vol. 36, no. 4, pp. 475-476, 2015