Steven H. Putnam

The California Verbal Learning Test in the detection of incomplete effort in neuropsychological evaluation

This study determined whether performance patterns on four California Verbal Learning Test variables (CVLT ; Trials 1-5 List A, discriminability, recognition hits, and long-delay cued recall) could differentiate participants with moderate and severe brain injuries from those with mild head injuries who were giving incomplete effort. Litigating mild head injury participants (n = 23) performing at chance level or worse on a forced-choice test obtained significantly lower scores on the four CVLT variables than participants with moderate and severe brain injuries (n = 23). The linear discriminant function accurately classified 91%, and the quadratic function, 96%. The discriminability cutoff score accurately classified 93% of the cases ; recognition hits, 89% ; long-delay cued recall, 87% ; and CVLT total, 83%.

Insomnia in a post-acute brain injury sample

Objective : The purpose was to establish the frequency of insomnia within the post-acute TBI population and compare it with insomnia rates among other rehabilitation outpatients. Design : A prospective study was undertaken of 50 consecutive post-acute TBI admissions and a comparison group of 50 rehabilitation outpatients evenly divided between spinal cord injury (SCI) and musculoskeletal (MSK) cases. Setting : Subjects were recruited at various outpatient clinics of a major rehabilitation hospital. Patients : Among the TBI subjects, the predominant cause of injury was motor vehicle accident; both mild and severe injuries were well represented in the sample; and, on average, patients were almost 4 months post-injury. The comparison and TBI groups did not differ significantly with respect to education or marital status. However, the MSK group was older and a higher proportion of the SCI group was female. Measures : The Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and sleep diaries were administered to the TBI group. Only the PSQI and BDI were completed by the comparison group. Results : Thirty per cent of the patients were found to suffer from insomnia. Sleep initiation was a problem almost twice as often as sleep duration. An additional 12% did not meet the DSM-IV criteria for insomnia but, nevertheless, experienced a degradation of sleep quality, as measured by the PSQI. Conversely, only slightly more than half (58%) of the TBI sample reported sleep to be relatively normal and satisfactory. Insomnia was also commonly reported by the patients in the rehabilitation comparison groups. They generated significantly higher mean PSQI Global Scores relative to the TBI group and the frequency of poor sleep quality was elevated significantly above the TBI rate. Relative to the TBI cases, twice as many comparison group patients were classified by the PSQI as insomniacs. Conclusion : Poor sleep quality and insomnia were definitely problems for the TBI group, although the magnitude of these problems was much greater for the rehabilitation comparison group. Degraded and disordered sleep may represent widespread challenges within the rehabilitation population in general.

Detecting Incomplete Effort on the MMPI-2: An Examination of the Fake-Bad Scale in Mild Head Injury

The current study is an investigation of the MMPI-2 Fake Bad Scale (FBS) in the detection of incomplete effort in mild head injury (MHI). Using ROC curve analysis, we found that a cutoff score of 21 had a sensitivity of 90% and specificity of 90%, providing an overall correct classificatory rate of 90%. In addition, traditional indices of faking bad on the MMPI-2, the F and F–K indices, fared relatively poorly by comparison and added no predictive power over the FBS. Finally, multivariate analyses revealed that although the FBS shares a number of items with Hs and Hy scales, the FBS carried the majority of variance in predicting incomplete effort in our MHI sample. Overall, these findings indicate that the FBS has high sensitivity and specificity in identifying incomplete effort in mild head injury.

The Recognition Memory Test in the Assessment of Memory Impairment after Financially Compensable Mild Head Injury: A Replication

The current investigation replicated the findings from a 1992 study by Millis. 20 subjects with claimed mild head injury who were seeking financial compensation obtained significantly lower scores on both subtests of the Recognition Memory Test than did 66 rehabilitation inpatients with documented moderate and severe traumatic brain injuries. The direct discriminant function derived by Millis was cross-validated on the current sample and yielded an improved over-all correct classification rate of 83%, with 85% and 82% of the mild and severe traumatic brain-injured subjects classified correctly, respectively. Over-all correct classification rate in the original study was 76%.

Another Look at Paradoxical Severity Effects in Head Injury With the Personality Assessment Inventory

Abstract Previous investigations of psychiatric symptomatology after head injury using the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) have consistently revealed greater Basic scale elevations in mild injuries versus more severe injuries. In this study, we tested this pattern of paradoxical severity effects using the Personality Assessment Inventory (Morey, 1991). We gathered PAI and MMPI-2 data from 34 patients with moderate-to-severe head injuries and from 52 patients with mild head injuries. MMPI-2 Basic scale profiles were consistent with the paradoxical severity effect; mild injury patients had significantly more elevated scores on four Basic scales (Scales 1, 2, 3, and 7). PAI Clinical scale profiles showed significantly more elevated scores among mild injury patients on 2 scales, Somatization and Depression, and more elevated scores among moderate-to-severe patients on 2 scales, Antisocial Features and Alcohol Problems. We consider unique contributions of the PAI for the psychological assessment of head injury

Psychological Disturbance, Incomplete Effort, and Compensation-Seeking Status as Predictors of Neuropsychological Test Performance in Head Injury

Indices from the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) representing cognitive and emotional disturbance as well as incomplete effort on the Recognition Memory Test (RMT; Warrington, 1984) were examined as predictors of performance on the Halstead-Reitan Neuropsychological Test Battery (HRB; Reitan & Wolfson, 1993). In the current study, which included a large sample (N = 369) of patients referred for neuropsychological (NP) evaluation after presumptive head injury, MMPI-2 measures of psychological disturbance accounted for as much as 25% of the variance in HRB test scores, resulting in a moderate overall effect size (median Adj. R2 = .16; R = .40). When demographic variables, head injury severity, and compensation-seeking status were entered in previous steps, incomplete effort as defined by chance performance on the RMT accounted for between 2% and 13% of the variance in HRB test scores, with modest overall effect size (median R2 Δ = .07; R = .26) in multiple regression equations. Additionally, when MMPI-2 indices of psychological disturbance were included in the last step, they accounted for 2% to 11% of additional variance, retaining a modest overall effect (median R2 Δ = .03; R = .17). Compensation-seeking status and injury severity as measured by duration of post-traumatic amnesia were, at best, modestly related to NP test performance. Findings confirm the reliable relationship between test performance and psychological disturbance as well as incomplete effort when assessing dysfunction following head injury. In contrast to previous studies, incomplete effort was unrelated to compensation-seeking status.

MMPI-2 indices of psychological disturbance and attention and memory test performance in head injury

A number of studies have investigated the relationship between psychological disturbance and neuropsychological (NP) test performance. The current study is a replication and extension of who found that MMPI-2 indices of psychological disturbance are related to performance on NP tests of attention and memory in psychiatric and head-injured patients. In a large sample (N=381) referred for evaluation after sustaining presumed head injury, we examined the relationship between MMPI-2 indices of psychological disturbance and measures of attention and memory from the Wechsler Memory Scale-Revised (WMS-R), Wechsler Adult Intelligence Scale-Revised (WAIS-R), California Verbal Learning Test (CVLT), and the Memory Assessment Scales (MAS). Although related to other domains, MMPI-2 variables were most consistently related to measures of attention and List Learning. Even when demographic variables, injury severity, and litigation status were controlled, MMPI-2 indices significantly predicted performance on six out of eight tests. However, the correspondence between similar indices on the WMS-R and MAS were relatively low, especially for Verbal Memory and Visual Reproduction. Further, litigation was significant in predicting only 2 of 8 attention and memory indices.

Detecting insufficient effort using the seashore rhythm and speech-sounds perception tests in head injury

This study examined the capacity of the Seashore Rhythm Test (SRT) and the Speech-Sounds Perception Test (SSPT) to detect insufficient effort in a clinical sample. Forty-six participants with financially compensable mild head injury who obtained scores indicative of insufficient effort on multiple measures were compared to 49 participants with brain injury who were not involved in litigation. Receiver operating characteristic (ROC) curve analysis indicated that both the SRT (AUC = .84) and SSPT (AUC = .80) were significant (p < .001) predictors of insufficient effort. Maximizing sensitivity and specificity, the optimal cutoff scores were 8 errors on the SRT and 10 errors on the SSPT. Combining both variables into a logistic regression function increased the diagnostic efficiency.

Cross-validation of predicted Wechsler memory scale - Revised scores

Equations for prorating the Wechsler Memory Scale-Revised General Memory (GM) and Delayed Recall (DR) index scores (J. L. Woodard & B. N. Axelrod, 1995) were confirmed in a new clinical sample of 258 patients. Raw score results for Logical Memory, Visual Reproduction, and Verbal Paired Associates were entered into the prediction equations. Predicted GM and DR scores fell within 6 points of obtained scores for 94% and 97% of the sample, respectively. A multiple regression analysis yielded multiple R 2 of.976 and.984 for GM and DR, respectively. In addition, the unstandardized regression weights were virtually identical to those initially presented by Woodard and Axelrod. These prediction equations for the GM and DR summary scores have validity for patient samples similar to those of the present study.

The Memory Assessment Scales in the Detection of Incomplete Effort in Mild Head Injury

Despite differences in the constructs measured, the Memory Assessment Scales (MAS) remain an alternative to the Wechsler Memory Scales (WMS) as a broad-band instrument for assessing multiple aspects of attention and memory. Although a number of studies have examined indices of the WMS as indicators of malingering, few studies have similarly investigated the MAS. In this study, we examined the degree to which the MAS was effective in detecting incomplete effort in a clinical sample of patients referred for neuropsychological evaluation after mild head injury. Included in the sample were 21 financially compensable (FC) participants with alleged mild head injury and 21 participants who were not involved in litigation and suffered more serious head injuries. Examination of the four MAS domain indices indicated that Short-Term Memory was most useful at identifying incomplete effort. We also examined subscales of the MAS. Consistent with previous findings, brief tests such as Verbal and Visual Span had high rates of diagnostic sensitivity and specificity. Although tests based on a forced-choice recognition paradigm (e.g., Immediate and Delayed Visual Recognition) predicted group membership above chance levels, they failed to significantly add to prediction above Verbal and Visual Span subtests.