Isabella J. M. Niesten

Antisocial features and "faking bad": A critical note

We critically review the literature on antisocial personality features and symptom fabrication (i.e., faking bad; e.g., malingering). A widespread assumption is that these constructs are intimately related. Some studies have, indeed, found that antisocial individuals score higher on instruments detecting faking bad, but others have been unable to replicate this pattern. In addition, studies exploring whether antisocial individuals are especially talented in faking bad have generally come up with null results. The notion of an intrinsic link between antisocial features and faking bad is difficult to test and research in this domain is sensitive to selection bias. We argue that research on faking bad would profit from further theoretical articulation. One topic that deserves scrutiny is how antisocial features affect the cognitive dissonance typically induced by faking bad. We illustrate our points with preliminary data and discuss their implications.

The 16-year course of shame and its risk factors in patients with borderline personality disorder.

The current study had two aims. The first was to examine the course of shame over 16 years of prospective follow-up among borderline patients and axis II comparison subjects. The second was to determine risk factors associated with feelings of shame among borderline patients. A total of 290 borderline inpatients and 72 axis II comparison subjects were assessed using a series of semi-structured interviews and self-report measures at baseline, and 87% of surviving patients were reassessed at eight waves of follow-up. Borderline patients reported significantly higher levels (2.6 times) of shame (assessed with one item) across 16 years of follow-up than axis II comparison subjects. However, the severity of shame decreased (78% relative decline) significantly over time for both groups. Regarding risk factors, four lifetime adversity risk factors were found to be significantly associated with feelings of shame. Two of these factors (severity of childhood sexual abuse and severity of childhood neglect) remained significant in multivariate analyses. Taken together, the results of this study suggest that borderline patients struggle with intense but decreasing feelings of shame. They also suggest that childhood adversities are significant risk factors for this dysphoric affective state.

Description and prediction of the income status of borderline patients over 10 years of prospective follow-up.

BACKGROUND Research shows that individuals suffering from borderline personality disorder are economically disadvantaged, but longitudinal data is lacking. AIM This study examined the income of borderline personality disorder (BPD) patients and axis II comparison subjects over 10 years of follow-up and assessed predictors of income among BPD patients. METHOD Data on income was obtained for 264 BPD patients and 63 axis II comparison subjects at 6-year follow-up and for surviving patients at five follow-up waves. Baseline and time-varying predictors of income were assessed using information from interviews and self-report measures. RESULTS Regardless of diagnosis, a greater proportion of people shifted into the higher income groups over time. Being in a higher income group was more likely to happen and happened more rapidly for axis II comparison subjects than for BPD patients. Results regarding the BPD patients indicated that childhood emotional, verbal and/or physical abuse were associated with a greater likelihood of being in a lower income group, whereas years of education and a higher IQ were associated with a greater likelihood of being in a higher income group. CONCLUSION Borderline personality disorder (BPD) patients show enduring lowered economic functioning. Their economic functioning seems to be negatively affected by childhood emotional, verbal and/or physical abuse but positively affected by years of education and IQ. Copyright

Prevalence and risk factors for irritable bowel syndrome in recovered and non-recovered borderline patients over 10 years of prospective follow-up

This study examined rates of irritable bowel syndrome (IBS) over 10 years of prospective follow-up among recovered and non-recovered patients with borderline personality disorder (BPD). Subsequently, risk factors for IBS were examined in female BPD patients. As part of the McLean Study of Adult Development, 264 BPD patients were assessed at baseline, and their medical conditions and time-varying predictors of IBS were assessed over five waves of follow-up (from 6-year follow-up to 16-year follow-up). Semi-structured interviews were used to assess both our IBS outcome variable and our baseline and time-varying predictor variables. Rates of IBS were not significantly different between recovered and non-recovered borderline patients when men and women were considered together and when men were considered alone. However, a significant difference in IBS rates was found between recovered and non-recovered female BPD patients, with the latter reporting significantly higher rates. The rates of IBS in women with BPD were found to be significantly predicted by a family history of IBS and a childhood history of verbal, emotional and/or physical abuse. Taken together, the results of this study suggest that both biological/social learning factors and childhood adversity may be risk factors for IBS in women with BPD.

Biased Symptom Reporting and Antisocial Behaviour in Forensic Samples : A Weak Link

In two studies (one with 57 forensic inpatients and one with 45 prisoners) the connection between biased symptom reporting and antisocial behaviour is explored. The findings are as follows: 1) the association between symptom over-reporting and antisocial features is a) present in self-report measures, but not in behavioural measures, and b) stronger in the punitive setting than in the therapeutic setting; and 2) participants who over-report symptoms a) are prone to attribute blame for their offence to mental disorders, and b) tend to report heightened levels of antisocial features, but the reverse is not true. The data provide little support for the inclusion of antisocial behaviour (i.e. antisocial personality disorder) as a signal of symptom over-reporting (i.e. malingering) in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). The empirical literature on symptom over-reporting and antisocial/psychopathic behaviour is discussed and it is argued that the utility of antisocial behaviour as an indicator of biased symptom reporting is unacceptably low.

A Lab Model for Symptom Exaggeration: What do we need?

This article reflects on the current state of the art in research on individuals who exaggerate their symptoms (i.e., feigning). We argue that the most commonly used approach in this field, namely simply providing research participants with instructions to overreport symptoms, is valuable for validating measures that tap into symptom exaggeration, but is less suitable for addressing the theoretical foundations of feigning. That is, feigning serves to actively mislead others and is done deliberately. These characteristics produce experiences (e.g., feelings of guilt) in individuals who feign that lab research in its current form is unable to accommodate for. Paradigms that take these factors into account may not only yield more ecologically valid data, but may also stimulate a shift from the study of how to detect feigning to more fundamental issues. One such issue is the cognitive dissonance (e.g., feelings of guilt) that – in some cases – accompanies feigning and that may foster internalized fabrications. We present three studies (Ns = 78, 60, and 54) in which we tried to abate current issues and discuss their merits for future research.

Exploring the relationship between sleep quality, emotional well-being and aggression levels in a European sample

Purpose Sleep deprivation is well known to negatively affect mood, cognition and behaviour. The purpose of this paper is to explore the relationship between sleep quantity, subjective sleep quality and aggression, hostility and well-being levels among adults in a non-clinical population. Design/methodology/approach In total, 201 participants aged 18 and above from Germany, UK and the Netherlands completed an online survey consisting of a Pittsburgh Sleep Quality Index along with measures of psychological well-being, implicit and explicit aggression, and intent attributions. Findings Sleep disturbances were related to decreased levels of psychological well-being. Subjective poor sleep quality predicted increased hostile attributions. The overall sleep experience, however, was not associated with aggression levels. Nevertheless, both a poor sleep experience and low sleep quality were related to increased reactive aggression, but only in British participants. Practical implications The importance of perceived sleep quality rather than sleep quantity in predicting hostile and aggressive behaviours is indicated. The quality of sleep and perception of this quality should be the focus of clinical intervention to limit unwanted behavioural impacts. The importance of accounting for sleep quality perception in intervention that examines attributional biases such as hostility is indicated. Differences across countries should be identified and accommodated for in intervention. Originality/value This is the first study to consider a role for sleep quality (including perception) and sleep quantity in relation to aggression and hostility in a cross-country European sample.

Alexithymia as a potential source of symptom over-reporting: An exploratory study in forensic patients and non-forensic participants

The traditional interpretation of symptom over-reporting is that it indicates malingering. We explored a different perspective, namely that over-reporting of eccentric symptoms is related to deficits in articulating internal experiences (i.e., alexithymia). Given that alexithymia has been linked to sleep problems and that fatigue may fuel inattentive responding to symptom lists, we administered measures of alexithymia (TAS-20) and symptom over-reporting (SIMS), but also sleep quality (SLEEP-50) to forensic psychiatric outpatients (n = 40) and non-forensic participants (n = 40). Forensic patients scored significantly higher on all three indices than non-forensic participants. In the total sample as well as in subsamples, over-reporting correlated positively and significantly with alexithymia, with rs being in the 0.50-0.65 range. Sleep problems were also related to over-reporting, but in the full sample and in the forensic subsample, alexithymia predicted variance in over-reporting over and above sleep problems. Although our study is cross-sectional in nature, its results indicate that alexithymia as a potential source of over-reporting merits systematic research.

Decreasing Invalid Symptom Reporting : A Comment on Horner, Turner, VanKirk, and Denning (2017)

Recently, Horner, Turner, VanKirk, and Denning (2017) posited that invalid performance stems from a rational cost–benefit analysis and may be discouraged by warning individuals about both cost and benefits of the behavior (i.e., deterrence theory; Becker, 1968). They gave patients (n = 121; intervention group) a handout that listed consequences of valid and invalid responding, stressed the importance of effort, and required their signature. The handout also raised awareness of Performance Validity Tests (PVTs) in the test battery and warned that if invalid responding were to be detected, a report would be sent to the patient’s treatment team. Controls (n = 122) received a handout with general information about neuropsychological testing. Interestingly, a lower proportion of PVT-failure was observed only for those in the intervention group with a selfreported interest in disability benefits (i.e., 44% vs. 65% of controls). This led the authors to conclude that “even if it [the intervention] were effective only in a minority of cases, it would still provide substantial benefit with essentially no cost” (Horner et al., 2017; p. 9). We argue that several limitations call for a reassessment of this conclusion. First, the researchers only report percentages of PVT-failure. This may invite readers to overvalue the data due to “collective statistical illiteracy” (Gigerenzer, Gaissmaier, Kurz-Milcke, Schwartz, & Woloshin, 2007): people—including (health) professionals—are not equipped to interpret numbers and more complex statistics in particular. Reporting raw frequencies instead—or in addition—improves transparency and interpretation. Table 1 depicts the absolute numbers of patients in Horner et al.’s study who failed or passed in each condition per self-reported disability-seeking status. The intervention handout led to a gain of six passes among patients who reported interest in benefits when compared to those who reported such interest but received the control handout. Among those not reporting interest in benefits there were five more failures in the intervention as opposed to the control condition. Effect sizes were not reported by the authors, but our calculation for the interaction between intervention and disability-seeking status (N = 243, X = 3.89) yields a modest effect, Cohen’s d =.255. Second, the findings rely heavily on self-report. Does the group that reported seeking benefits reflect the actual number of patients interested in benefits? The authors report that 182 patients were known to receive benefits, whereas 70 self-reported they were currently seeking them. While receipt of benefits does not necessarily imply current interest, these divergent numbers may suggest that some patients underreported the role benefits play in their symptom reporting. Relatedly, the impact of the intervention was determined by the Medical Symptom Validity Test (MSVT; Green, 2005) and clinicians’ judgment based on the results of this particular PVT—combined with sources not provided in the paper. Both approaches revealed a significant effect among patients reporting interest in benefits. However, if clinicians’ determination of invalid reporting is largely based on the MSVT—and why would it not be?—their judgment does not remediate the shortcoming that the battery included only one PVT; to the extent that clinical judgment is dependent on the MSVT reporting it as an additional route to scrutinize the data might lead the less cautious reader to interpret the finding as additional support for a robust effect of the intervention. Third, studies on warning-based interventions and coaching suggest that warnings may help patients evade detection. Consequently, authors have advised against their use to ensure test-security (Suhr & Gunstad, 2000; Youngjohn et al., 1999). Horner et al. report data on the free recall trial of the MSVT to demonstrate that lower MSVT failure rates reflect honest responding: On this trial, those reporting interest in benefits who received the intervention performed similar to controls

Raadpleeg niet de DSM, maar de wetenschappelijke literatuur.: Simulanten “spotten”

SamenvattingHoe stel je vast of klachten authentiek zijn of door de patiënt worden voorgewend? In oktober 2015 organiseerden verzekeringsartsen in opleiding het symposium ‘Truth or Lie?’ waarbij zij experts uit verschillende disciplines – de filosofie, psychiatrie, en psychologie – uitnodigden om clinici hierin enige handvatten te bieden. Recentelijk werd in dit tijdschrift een samenvattend verslag gepubliceerd.1 In dit stuk becommentarieer ik enkele misvattingen over klachtensimulatie die gedurende het symposium en in het verslag als feitelijkheden werden weergegeven. Deze misvattingen zijn wijdverbreid en worden gevoed door de in de Diagnostic and Statistical Manual of Mental Disorders (DSM) te vinden beschrijving van klachtensimulatie die, ondanks haar zwakke empirische basis, een sterke – en hoofdzakelijk negatieve – invloed uitoefent op het differentiaal-diagnostisch proces.