The Use of Significant Others to Enhance the Detection of Malingerers From Traumatically Brain-Injured Patients

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1 Archives of Clinical Neuropsychology, Vol. 15, No. 6, pp , 2000 Copyright 2000 National Academy of Neuropsychology Printed in the USA. All rights reserved /00 $ see front matter PII S (00) The Use of Significant Others to Enhance the Detection of Malingerers From Traumatically Brain-Injured Patients Robert J. Sbordone Private Practice Gregory D. Seyranian University of California at Irvine Ronald M. Ruff St. Mary s Medical Center Cognitive and neurobehavioral symptoms are common following traumatic brain injuries (TBIs). Because malingerers are likely to complain of such symptoms and perform poorly on neuropsychological tests, clinicians may have considerable difficulty distinguishing malingerers from TBI patients. In this study, we compared the subjective complaints of malingerers to TBI patients and then compared both groups to the problems observed by their respective significant others. We tested the assumption whether significant others could add one more piece to the challenging puzzle of diagnosing malingering. Our results demonstrated that the malingerers complained of more problems than patients who had sustained moderate or severe TBI. However, the significant others of the malingerers observed fewer cognitive, emotional-behavioral, and total problems than did the significant others of patients with severe, moderate, and even mild TBI. These findings suggest that the detection of malingering can be enhanced by interviews with significant others National Academy of Neuropsychology. Published by Elsevier Science Ltd Neuropsychologists are frequently asked by health care professionals and attorneys to determine whether a patient has cognitive difficulties, particularly if the patient complains of such difficulties after claiming to have struck his or her head during a motor vehicle or an industrial accident. Because complaints of cognitive difficulties following accidents are often compensable, patients may be inclined to exaggerate or feign such Part of this paper was presented during a poster session at the Annual Meeting of the American Neuropsychiatric Association, Orlando, Florida, on February 4, The authors wish to thank Arnold Purisch for his comments and suggestions. Address correspondence to Robert J. Sbordone, 7700 Irvine Center Drive, Suite 750, Irvine, CA

2 466 R. J. Sbordone, G. D. Seyranian, and R. M. Ruff difficulties to justify their claim for compensation or disability (Binder, 1990). Such behavior may be labeled as malingering, which according to the American Psychiatric Association (1994) is the intentional production of false or greatly exaggerated symptoms for purposes of obtaining some identifiable external reward. Neuropsychological testing appears particularly vulnerable to malingering because the patient s test performance depends on his or her cooperation or motivation to produce the best possible performance (Beetar & Williams, 1995; Rogers, Harrell, & Liff, Whereas numerous factors (e.g., fatigue, medical illness, medications, emotional factors, etc.) can affect a patient s neuropsychological test performance (Sbordone & Purisch, 1996), malingering in a neuropsychological context refers to a willful effort to perform poorly during testing in the absence of cerebral dysfunction or worse than expected (e.g., negative response bias), even if the patient had initially sustained a mild brain insult, to increase the monetary value of their legal case or industrial claim, avoid returning to work, and/or obtain prescription medication (Franzen & Iverson, 1998). However, although the ability of standardized neuropsychological tests to discriminate between malingerers and brain-injured patients has not been impressive (Faust, Hart, & Guilmette, 1988; Faust, Hart, Guilmette, & Arkes, 1988; Greiffenstein, Baker, & Gola, 1994; Heaton, Smith, Lehman, & Vogt, 1978), this might reflect the methods of data analyses utilized in these studies (Purisch, 2000; Reitan & Wolfson, 1998). The Rey 15-Item Test was one of the first symptom validity procedures utilized to detect negative response bias (Rey, 1964). This test consists of five rows of three items consisting of letters, numbers, or shapes that are presented to the subject for 10 seconds. Immediately after the test stimuli are removed, the subject is asked to reproduce the stimuli. Unfortunately, there is no clear consensus as to what cutoff score should be used to discriminate between brain-impaired patients and malingerers (Etcoff & Kampfer, 1996). For example, although Goldberg and Miller (1986), Greiffenstein et al. (1994), and Lezak (1983) recommended a cutoff score of 9 or more items, other investigators (Guilmette, Hart, Giuliano, & Leninger, 1994; Lee, Loring, & Martin, 1992) recommended a cutoff score of 7. Several investigators, however, reported that this test lacks sensitivity in identifying malingerers (Bernard & Fowler, 1990; Davidson, Suffield, Orenczuk, Nantau, & Mandel, 1991; Schretlen, Brandt, Krafft, & Van Gorp, 1991). Thus, its efficacy to detect feigned memory impairment appears to be limited (Cercy, Schretlen, & Brandt, 1997). As a consequence, the issue of whether an individual is malingering should not be based solely on this test (Pankratz & Binder, 1997). During the past 15 years, there has been a concerted effort to develop more specialized symptom validity tests and symptom validity indicators to detect malingering or exaggeration of cognitive impairment. These methods have largely involved the use of tests specifically designed to detect nonoptimal performance by utilizing a variety of forced-choice procedures. Early studies by Pankratz (1983, 1988) presented repeated trials of sensory stimuli or a simple memory task (Digit Memory Test) to subjects who claimed that they could not experience the stimuli or recall the digits. He found that by using a two-alternative forced-choice response format, malingerers reported fewer stimuli or recalled fewer digits than would have been predicted by chance. Hiscock and Hiscock (1989) modified the forced-choice procedure that had been developed by Pankratz by increasing the level of apparent difficulty on a digit-recognition task. As a consequence, they reported that they were able to identify malingerers as individuals who performed significantly below chance. Prigatano and Amin (1993) examined the effectiveness of the Hiscock and Hiscock forced-choice procedure and found that malingerers performed significantly worse than brain-impaired and normal controls. Guilmette, Hart, and Giuliano (1993) and Guilmette et al. (1994) also reported

3 Use of Significant Others in the Detection of Malingerers 467 similar findings, but recommended a 90% correct cutoff score be utilized to discriminate between brain-impaired patients and malingerers. The techniques of Pankratz (1983) and Hiscock and Hiscock (1989) were subsequently incorporated into the Portland Digit Recognition Test (PDRT) by Binder (1990, 1993). The PDRT not only included increasing levels of apparent difficulty but also included a distracting mental activity between the presentation of the stimuli to be remembered and the recognition probe. Hence, this procedure provided the patient with an opportunity to exaggerate their deficits as a result of having been informed that the task was increasing in difficulty. The PDRT appears to produce performances that are more significantly worse than chance than the Hiscock and Hiscock forced-choice, and thus more convincing psychometric evidence of malingering (Pankratz & Binder, 1997). The Victoria Symptom Validity Test is a refinement of the Hiscock and Hiscock forced-choice procedure. It consists of a 48-item computer-administered digit memory procedure that consists of three blocks of 18 items, with each block containing eight easy and eight difficult items. This test presents a digit-recognition task with ostensible manipulation of item difficulty related to response discrimination and length of the interval between the presentation of the test stimuli and the subject s response. Because the simple and difficult test items are not significantly different, the subject s response accuracy should not be affected and remain consistent. Thus, a significant decline in the subject s performance on the difficult items reflects the malingering subject s belief that the items are more difficult and that poor performance on these items is more believable (Purisch, 2000). This test has been reported to be sensitive to the negative response bias of experimental malingerers and has been designed to minimize misclassification of patients with closed head injuries as malingerers (Slick, Hopp, Strauss, Hunter, & Pinch, 1994). In addition to cognitive measures, personality tests such as the Minnesota Multiphasic Personality Inventory (MMPI) or MMPI-2 can provide several quantitative means of dissimulation and defensiveness in patients who present with psychiatric symptoms. For example, the dissimulation index (F-K; Gough, 1950) was developed to detect exaggerated or feigned psychiatric symptoms. Berry, Baer, and Harris (1991) concluded, based on their meta-analysis of the MMPI literature, that the largest effect sizes were associated with the F scale, the original Dissimulation Scale, and the F-K Index (Gough, 1950). Subsequently, Rogers, Sewell, and Salekin (1994), in their meta-analysis of the MMPI-2, found that the F, F-K, and the obvious minus subtle score produced the greatest effect sizes for both normal controls and psychiatric comparison groups. Butcher, Graham, and Ben-Poratz (1995), however, did not find any advantage in using the F-K Index in lieu of the raw F score because both measures were effective in detecting fake-bad profiles. The MMPI-2 may be useful in detecting the type of response bias that is often seen in personal injury or disability cases. Such individuals are more likely to present with an incongruous fake-good/fake-bad response set (Lees-Haley, English, & Glenn, 1991). For example, they may present themselves as premorbidly well adjusted, high-functioning, scrupulous, conscientious, and hardworking, but as psychologically traumatized or disabled following an accident. These authors, utilizing the 42-Item Fake-Bad Scale, were able to correctly classify 83% to 96% of the individuals who were malingering personal injury. Subsequently, Lees-Haley (1992) demonstrated that this scale was able to identify approximately 75% of individuals who were malingering symptoms of a posttraumatic stress disorder. The use of the MMPI-2 validity scales to differentiate between subjects instructed to fake closed head injury symptoms and patients with closed head injuries was investigated by Berry et al. (1995). They found that experimental malingerers had higher F-K, Ds2 (psychomotor retardation), and Fp (backside F scale) scores, but lower K scores.

4 468 R. J. Sbordone, G. D. Seyranian, and R. M. Ruff They also found that compensation-seeking closed head injury patients had higher F-K and Ds2, and lower K scores than noncompensation-seeking closed head injury patients. Whereas Youngjohn, Burrows, and Erdal (1995) reported that closed head injury patients who were involved in litigation or seeking financial compensation had higher scores on the Hs (hypochondriasis) and Hy (hysteria) scales than patients in previous studies with confirmed brain damage, Greiffenstein, Gola, and Baker (1995) found that the F and F-K validity scales were not helpful in predicting malingering of neurobehavioral deficits. For example, they pointed out that persons feigning severe brain dysfunction typically did not attempt to feign psychiatric symptoms because they were usually sophisticated enough to recognize that psychotic symptoms were not characteristic of traumatic brain injuries. Thus, it may be difficult to distinguish between brain-injured patients and malingerers solely on the basis of personality tests such as the MMPI-2. As a consequence, Etcoff and Kampfer (1996) recommended that the MMPI-2 be utilized in conjunction with symptom validity tests and indicators when malingering of cognitive impairment is suspected. The self-reported complaints of patients who have sustained TBIs (e.g., Binder, 1990; Gouvier, Cubic, Jones, Brantley, & Cutlip, 1992) are frequently utilized by neuropsychologists to corroborate their test data. Unfortunately, the base rates of such complaints are routinely reported by individuals who have never sustained a TBI, nor who have any history of documented neurological impairment (e.g., Gouvier, Presthold, & Warner, 1988). Furthermore, Lees-Haley and Brown (1993) reported that individuals who are involved in personal injury litigation, with no history of brain injury, toxic exposure, or documented neuropsychological impairment are likely to complain of high rates of symptoms that are commonly associated with TBI patients. In addition, Wong, Regennitter, and Barrios (1994) reported that normal subjects had no difficulty simulating the symptoms of mild TBIs on a self-report questionnaire. However, if neuropsychologists rely on both the individuals subjective complaints and their test data, the detection of malingering of cognitive dysfunction becomes even more difficult (Gouvier et al., 1992; Lees-Haley & Brown, 1993). Thus, a malingerer may prove a TBI by complaining of cognitive difficulties that are known to be characteristic of TBI patients, and do poorly on neuropsychological test measures that they perceive assess such cognitive functions. Thus, cognitive and psychodiagnostic tests, combined with a clinical interview, may be helpful in detecting malingering. The intent of our study was to explore whether an interview with significant others could add a further piece to the puzzle. Family members and significant others are often able to detect relatively subtle changes in the TBI patient s cognitive, behavioral, and emotional functioning (Sbordone, 1991). Because their ability to detect such changes is likely to be based on their frequent repeated observations of TBI patients in real world and unstructured settings, their observations would be expected to have greater ecological validity than the patient s neuropsychological test scores (Sbordone, 1996). Because Sbordone, Seyranian, & Ruff (1998) recently reported that family members and significant others of TBI patients, regardless of the severity of the initial TBI and the duration of time they were interviewed postinjury, typically observed significantly more cognitive, behavioral, and emotional problems than the TBI patients reported, we decided to examine the subjective complaints of TBI patients and malingerers and compare them to the observations of their respective significant others to determine if the observations of the significant others of malingerers would be different than the observations of the significant others of TBI patients. We hypothesized that the significant others of malingerers would most likely report fewer problems than the malingerers because their

5 Use of Significant Others in the Detection of Malingerers 469 observations would presumably be based on the malingerers normal behavior in real world settings. METHODS One hundred fourteen subjects, consisting of 50 patients (33 males and 17 females) who had previously received the diagnosis of TBI, 7 individuals who had been previously diagnosed as malingerers based on a review of their medical records, neurological examinations, and neuropsychological test results, and their respective 57 significant others were used in this study. Although each of the malingerers claimed that they had sustained a brain injury during an accident and had been rendered unconscious for a substantial length of time (e.g., up to 7 days), a review of their medical records including the paramedic reports and emergency room records revealed that each of the malingerers had denied any loss of consciousness and exhibited no evidence of head trauma or any signs or symptoms of a closed head injury (e.g., posttraumatic amnesia (PTA), altered consciousness). Each of the malingerers also provided highly inaccurate and misleading educational, medical, and employment histories (e.g., stating that they had graduated from high school with As and Bs even though they had made Ds and Fs and had dropped out of high school in the 9th or 10th grade). During neuropsychological testing, the malingerers showed overwhelming evidence of dissimulation on forced-choice tests designed to detect malingering. In addition, their response style (e.g., they frequently missed easy items and got more difficult items correct) and test performances (e.g., their memory recognition test scores were frequently worse than their free recall test scores on the RAVLT), was strongly suggestive of malingering. Each TBI patient and malingerer had either filed a workers compensation claim or personal injury claim prior to being included in this study. Table 1 presents the means and standard deviations of TBI patients and malingerers according to their age, time since injury, sex, education, and type of significant other. No statistically significant dif- TABLE 1 Demographic Characteristics of Malingering and TBI Patients Malingerers (n 7) TBI (n 50) Age (years) M t.756, ns SD Months since injury M t 1.104, ns SD Sex a Male 5 (71.4 %) 33 (66.0 %) Female 2 (28.6 %) 17 (34.0 %) , ns Years of education M t 1.46, ns SD Significant other a Spouse 3 (42.9 %) 12 (24.0 %) Parent 1 (14.3 %) 32 (64.0 %) Sibling 0 (0.0 %) 1 (2.0 %) Other 3 (42.9 %) 5 (10.0 %) , ns a Number of subjects in each group. TBI traumatic brain injury.

6 470 R. J. Sbordone, G. D. Seyranian, and R. M. Ruff ferences were found between any of these demographic variables (all p values.05) using t-tests. The severity of each patient s initial TBI was determined by interviewing each TBI patient and their respective significant other as well as reviewing their medical records to determine their duration of unconsciousness (LOC) or coma, the Glasgow Coma Scale score (GCS), duration of PTA, evidence of skull fracture, and intracranial hematoma (ICH). The initial severity of each TBI was classified as either mild, moderate, or severe, based on the following criteria: Mild TBI (LOC 20 minutes, GCS 12, PTA 24 hours, no skull fractures or ICH); Moderate TBI (LOC 20 minutes, GCS between 9 and 12, PTA 1 7 days, and possible skull fracture or ICH); Severe TBI (coma duration of 6 hours, GCS 8 or less, PTA 8 days, and skull fractures and/or ICH). Based on these criteria, 11 patients were identified as having mild TBI, 6 patients were identified as having moderate TBI, and the remaining 33 patients were identified as having severe TBI. Even though each of the malingerers had claimed a loss of consciousness and PTA, a careful review of their medical records revealed that none of the malingerers had actually sustained a loss of consciousness, reported amnesia, or exhibited any signs or symptoms of a closed head injury at the scene of the accident or while they were seen in the emergency room. Table 2 presents the demographic characteristics of mild, moderate, and severe TBI patients. No statistically significant differences were found between these groups in terms of the following variables: age, time since injury, sex, years of education, and type of accident (all p values.05). Each subject was interviewed by a board-certified neuropsychologist. Each TBI patient and malingerer was asked to verbally report their current subjective complaints. Each significant other was asked to verbally identify all of the current problems they had TABLE 2 Demographic Characteristics of TBI Patients Mild (n 11) Moderate (n 6) Severe (n 33) Age (years) M F , ns SD Months since injury M F , ns SD Sex a,b Male 7 (63.6 %) 3 (50.0 %) 23 (69.7 %) Female 4 (36.4 %) 3 (50.0 %) 10 (30.3 %) , ns Years of education M F , ns SD Significant other a,b Spouse 4 (36.4 %) 1 (16.7 %) 7 (21.2 %) Parent 5 (45.4 %) 5 (83.3 %) 22 (66.7 %) Sibling 1 (9.1 %) 0 (0.0 %) 0 (0.0 %) Other 1 (9.1 %) 0 (0.0 %) 4 (12.1 %) , ns Type of injury a,b Motor vehicle accident 3 (27.3 %) 1 (16.7 %) 16 (50.0 %) Pedestrian/auto 2 (18.2 %) 2 (33.3 %) 7 (21.9 %) Blunt head trauma 3 (27.3 %) 2 (33.3 %) 2 (6.3 %) Fall 2 (18.2 %) 1 (16.7 %) 2 (6.3 %) Other 1 (9.0 %) 0 (0.0 %) 5 (15.6 %) , ns a Number of subjects in each group. b Computed using Fisher s Exact. TBI traumatic brain injury.

7 Use of Significant Others in the Detection of Malingerers 471 observed in either the TBI patient or malingerer. Each reported problem was categorized as cognitive, emotional-behavioral, or somatic. A complete list of the problems reported by each subject can be found in the Appendix. RESULTS The total number of subjective complaints of TBI patients and malingerers, and the problems observed by their respective significant others were analyzed by a 2 (type of diagnosis) 2 (type of person interviewed) ANOVA using an alpha level of.05. A significant interaction was found between the type of diagnosis and the person interviewed, F(1, 113) 16.48, p Post-hoc analyses utilizing Fisher s protected t-test at an alpha level of.01 revealed that malingerers complained of more overall problems than TBI patients; that is, malingerers complained of a mean of 11.4 (SD 4.81) problems, whereas TBI patients complained of a mean of only 6.66 (SD 5.42) problems. These analyses also revealed that the significant others of TBI patients observed significantly more problems than the significant others of malingerers. Specifically, they observed a mean of (SD 9.4) problems in comparison to the significant others of malingerers, who reported a mean of only 4.86 (SD 2.48) problems. The three-way interaction between type of diagnosis, person interviewed, and type of problem was found to be significant, F(2, 330) 3.39, p Post-hoc analyses using Fisher s protected t-test at an alpha level of.01 revealed the following significant differences: Whereas malingerers complained of a mean of 5.57 (SD 4.58) emotionalbehavioral problems, TBI patients complained of a mean of only 2.46 (SD 2.88) emotional-behavioral problems. Conversely, the significant others of TBI patients observed significantly more cognitive problems (mean 5.6, SD 4.12) than did the significant others of malingerers (mean 0.714, SD 0.95). The significant others of TBI patients also observed more emotional-behavioral problems (mean 9.74, SD 5.97) than the significant others of malingerers (mean 3.57, SD 1.72). No difference was found between the number of somatic problems observed by the significant others of TBI patients and the significant others of malingerers or the subjective complaints reported by TBI patients and malingerers (all p values.05). These results are summarized in Figure 1. A three-way analysis of variance between type of diagnosis, type of complaint, and person interviewed was found to be statistically reliable, F(11, 330) 20.64, p Figure 1 presents the mean number of subjective complaints/observations made by TBI patients, malingerers, and their respective significant others. Post-hoc analyses yielded no significant differences between malingerers and TBI patients in the number of cognitive, emotional-behavioral, or somatic complaints (all p values.01). However, the significant others of mild TBI patients observed significantly more cognitive, emotionalbehavioral, and total problems than did the significant others of malingerers. No differences were found in the number of somatic problems reported by the significant others of TBI patients or malingerers (p.01). These results are summarized in Figure 2. DISCUSSION The significant others of mild TBI patients observed significantly more cognitive, emotional-behavioral, and total current problems than did the significant others of malingerers. However, the malingerers themselves complained of significantly more cognitive, emotional-behavioral, and total problems than even the TBI patients with moder-

8 472 R. J. Sbordone, G. D. Seyranian, and R. M. Ruff FIGURE 1. Mean number of subjective complaints/observations made by TBI patients, malingerers, and their respective significant others. ate or severe TBIs. Thus, the level of subjective complaints by the malingerers was not corroborated by their significant others, even though the magnitude of their complaints was in excess of patients who had sustained severe TBI. Because it is difficult, given the current state of the art, to identify malingerers primarily on the basis of their subjective complaints (Binder, 1990; Gouvier et al., 1992; Lees- Haley & Brown, 1993; Wong et al., 1994), our data suggest that the detection of malingering can be enhanced by interviews with significant others, particularly if a workers compensation claim or personal injury lawsuit has been filed. Contrasting the subjective complaints of such individuals to the observations of their significant others may shed light on the veracity of such complaints, particularly if their complaints are based on frequent and repeated observations of the claimant s behavior. Such observations, if accurate, could potentially have more ecological validity than the claimant s subjective complaints and neuropsychological test data (Sbordone, 1991, 1996). Unfortunately, many malingerers frequently arrive for their scheduled medical or neuropsychological testing appointments alone even when they are asked to bring a significant other along. Furthermore, when a significant other accompanies a malingerer to neuropsychological testing, the significant other may be instructed by the malingerer s attorney not to speak to the opposing neuropsychologist. Thus, although such data may assist the neuropsychologist in distinguishing between TBI patients and malingerers, it may be difficult to obtain. Nonetheless, our data do suggest that in addition to the clinical interview, medical record review, neurocognitive testing, and psychodiagnostic evaluation, an interview with the significant other can enhance the challenging task of identifying a malingerer. We did not utilize self-report checklists in our study because Wong et al. (1994) reported that the use of these measures may not only produce the unanticipated consequence of teaching malingerers how to simulate symptoms of TBI but may also inadvert-

9 Use of Significant Others in the Detection of Malingerers 473 FIGURE 2. Mean number of subjective complaints of TBI patients and observed problems reported by significant others versus malingerers and their significant others.

10 474 R. J. Sbordone, G. D. Seyranian, and R. M. Ruff ently convince TBI patients that they have the symptoms listed on such checklists. Wong et al. (1994) strongly recommended that the method utilized to determine the subjective complaints of TBI patients should permit TBI patients to freely describe their subjective symptoms without prompting them to complain of symptoms that would not otherwise concern them. With this caveat in mind, we asked each TBI patient and malingerer in this study to tell us all of the problems that they were currently having. At no time did we ask them or suggest that they were having any specific problems (e.g., memory difficulties, irritability, etc.). Similarly, we asked each significant other to tell us all of the current problems that the TBI patient or malingerer was having based on their observations. At no time did we suggest or ask them if they had observed any specific problems. Each interview ended when the subject was unable to identify any additional problems. It is this type of open-ended interview that appears to be particularly sensitive to differentiate between differences of symptom endorsements between patients and their significant others. Our results suggest that the information obtained from significant others can not only assist the clinician in identifying the cognitive, behavioral, and emotional problems of TBI patients in real world settings (e.g., home, community, etc.) in spite of their impaired self-awareness (Sbordone et al., 1998), but also identify persons who are malingering such problems. We feel that the observations of significant others can be utilized to identify brain-injured patients and malingerers by contrasting their subjective complaints to the observations of their respective significant others. For example, whereas brain-injured patients are likely to complain of significantly fewer cognitive, emotional, or behavioral problems than are observed by their significant others, malingerers, on the other hand, are likely to complain of significantly more problems than are observed by their significant others. This latter finding is generally consistent with the definition of malingering put forth by the American Psychiatric Association (1994), as the malingerers in our study complained of significantly more problems than were observed by their significant others or reported by TBI patients who had sustained severe brain damage. Although tests of malingering of brain dysfunction have typically focused on test performances that are significantly worse than chance, this approach generally ignores the patient s behavior in more ecologically valid settings. Unfortunately, an increasing number of attorneys have become knowledgeable about specialized tests of neuropsychological malingering and may coach their clients to recognize such tests during a neuropsychological examination. As a consequence, malingerers may perform well on specialized tests of malingering and poorly on standardized neuropsychological measures to demonstrate that their cognitive deficits are legitimate. We recommend the use of a multimodal assessment approach that incorporates clinical interviews with significant others as part of the assessment process because this information should provide the clinician with additional data to determine whether an individual who is involved in litigation has or is malingering cognitive dysfunction. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Beetar, J. T., & Williams, J. M. (1995). Malingering response styles on the memory assessment scales and symptom validity tests. Archives of Clinical Neuropsychology, 10, Bernard, L. C., & Fowler, W. (1990). Assessing the validity of memory complaints: Performance of brain-

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13 Use of Significant Others in the Detection of Malingerers 477 APPENDIX Total list of Subjective Complaints/Observations Made by TBI Patients, Malingerers, and Their Respective Significant Others Emotional/Behavioral Problems Cognitive Problems Somatic Problems Anger/aggression/violent Academic difficulty Accident prone Anxiety Arithmetic difficulty Clumsiness/balance Apathy/increased passivity/loss of interest Attention/concentration Headaches in previous activities Changes in affect Circumstantial/tangential thinking/ Neglect/hemiparesis loses train of thought Changes in eating habits Confusion/disorientation Loss of smell/taste Changes in personal grooming/hygiene Extremism in evaluations Motor problems Critical of others Inability to multitask/do sequential Rapid fatigue tasks/do complex tasks Demanding Increased sensitivity to noise and Sleep disturbances environmental stimuli Dependency Intellectual difficulty/ Somatic problems problem solving Depression/pessimism Language difficulty/word finding/ Tinnitus communication Difficulty with daily living Learning new material Weight loss/gain Dillusional beliefs Poor judgment Diminished awareness to surrounds/ Poor planning and organization environment Diminished concern for welfare of others Poor safety awareness Diminished quality of life Reasoning/decision-making Diminished self-esteem Recent memory Diminished responsibility Remote memory Distractible Rigid/inflexible thinking Doesn t follow through Slowed thinking Easily influenced/manipulated Unaware of deficits/ inability to recognize errors Egocentric Unrealistic plans/expectations Emotional lability/mood swings Visual acuity/perceptual problems Excessive guilt Well-learned task performance difficulty Excessive TV viewing Family/marital Feelings of frustration Hyper religiosity/morality Immaturity Impatience Initiation Irritable Motivation Odd mannerisms/impulsive/inappropriate/ irrational behavior Paranoia/defensiveness Persevation/obsessive/ruminative thinking Personality change Requires structure Seeks attention/crying out for help Seizures Sexual Social/interpersonal Stress/frustration Unable to manage finances/work