Mgr. Jeroným Klimeš, Ph.D.
The need for short neurological screening is common for many areas of psychology. Even when we work in clinical psychology, we might find ourselves in doubts whether problems we faced with a patient are of organic or psychic origin. This need is even more punctuated when there are signs of malingering, or in general faking either good or bad. Paradoxically, even clients in situations tempting to fake good are not always showing their best. On contrary, in some cases they may show passive resistance, as not outspoken protest against the testing as such. Drawing of such clients might be have signs of dementia, despite the fact the clients are perfectly normal. Bad drawing is only a covered message to the psychologist that it was not a good idea to let them draw. In such cases, the psychologist is in doubts whether there is only passive resistance or organic impairment or both. A complete neuropsychological evaluation is very resources consuming, and therefore short screening tests are of big help in decision considerations.
Indication of screening tests in neurological praxis
Screening neuropsychological examination is indicated when (according to http://www.brainsource.com/np_scrn.htm):
Full neuropsychological examination is indicated when:
Requirements on screening test
A good neurological screening test should have at least following features:
We can divide neurological screening tests according complexity:
Simple tasks are very useful for unexpected testing in a field (accidents at expeditions, trips away from civilization) or in a bed. This flexibility compensates their little validity. What can a psychologist do?
Stability of stand with closed eyes, walk along a straight line
Motor coordination (Touch your nose, touch your point fingers, make a topknot with closed eyes)
Evaluation of visual field
Smooth gaze pursuit of a moving point
Lateral sensitivity, bilateral extension
Lateral disparity between the strength of a grip at a psychologist forearm.
Clock drawing test (”I want you to draw the face of a clock with all the numbers on it. Make it large.” After completing the task add: ”Now, draw the hands pointing at 20 to 4.” ; or different times: 11:10, 8:20, etc.)
Trail making test (Connect numbers and letters in sequence)
Digit span forwards and backwards
Subtracting 7 from 100.
Copy of a complex figure, immediate and delayed recall
Memorizing a list of 5 words.
Results of these or similar simple tasks can help in decision say whether to return from an expedition after an accident or not. And every psychologist should have them in his or her possibilities for first aid help.
Particular subtests of neurological batteries
Subtests have an advantage that we have population norms on them. Their disadvantage is length and specialization. So we use them only in indicated cases.
Specialized screening batteries
A) Mini-mental state examination (MMSE)
mmse.htm - Czech version
Eleven tasks take usually 5 - 11 minutes to administer. An evaluation is straightforward.
Spell the WORLD backwards. The score is the number of letters in correct order. E.G. dlrow =5, dlorw = 3. Word World should be spelled forward and corrected prior spelling backwards.
Both items (spelling and subtracting) should be given, but only the higher of the two should be used.
Patient should carry out command only after all three instruction have been given. Score 1 point for each part correctly executed. (3 points)
Total number of possible score is 30 points.
Norms depends on an education and age a lot. Completed elementary school and higher educated people have mean 28-29 with standard deviation 2. Slight decline does not start until at 70 years and goes to 85 (mean 24)
MMSE is quite easy test and biased to words, so it is neither much sensitive (identifying impairment) nor specific (identifying not impaired).
Overestimate dementia with aphasic patients
Insensitive to amnestic and right hemisphere disturbances
A lot of false negative results
Good for dementia and old-age decline (Alzheimer disease impacts memory, Huntington attention-concentration items)
B) Cognistat (The neurobehavioral cognitive status examination)
First administer screen test, if successful no further testing is necessary. If fails, examiner administers the metric – a series of test items of increasing difficulty. (20 % of normal population fail in screening.)
Unfortunately you cannot evaluate Cognistat without having the manual at hand.
Other screening tests
Dementia rating scale
Spanish version of Mental status questionnaire
Information-memory concentration test
Orientation-memory concentration test
Mgr. Jeroným Klimeš, Ph.D.
APA 1994: Malingering is ”intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.”
Malingering can coexist with real impairments.
Intentional, conscious coexists with unconscious.
Malingers are very inventive. Some overplay specific symptoms, other simulate realistic overall levels of impairment.
Conventional measures (F, F-K scores in MMPI, CPI, other test that are sensitive to malingering, Eysenck)
Specific tests to detect malingering (e.g. Rey‘s 15-item visual memory test)
Rey fifteen item memory test FIT
Symptom validity testing – method for detecting poor effort or malingering – probabilistic analysis of patient performance on forced-choice tests. A two-choice response format. Recognition memory test.
Yes-no – probability is around 50 %, depending on the number questions there is confidence interval about the chance-level. Scores within the confidence interval assume severe impairment or possibly exaggeration of deficits. High or low scores that are out side this large confidence interval are highly unlikely by chance alone. Such scores are assumed to be the product of purposeful selection of correct or incorrect answers – in either case depending on intact memory, with latter being suggestive of exaggerated of faked memory deficits.
A) Give an impression of a HARD memory test, stressed 15 items
B) Show folowing table on a sheet of paper of a letter size in portrait orientation
C) Show for 10 seconds and then ask the client to draw the card from memory.
COUNT number of total items recalled correctly regardless of their spatial location.
number of correct rows in proper sequence
Not very reliable – only 50 %
When a clinical assessment is compulsory, clients tend to show passive resistance and try to hide important facts from their life. The dissimulation is the more easy the more we departure from measuring brain function. It is impossible to fake genial memory and superior IQ, when we do not have it, but it is relatively easy to hide a big argument before the visit of a psychologist.
Unfortunately the faking good in combination with passive resistance not always leads to higher motivation or better results. For instance, the results of such clients are systematically worse in drawing tests - sometimes at the edge of organic diagnosis.
Dissimulation is multifactor phenomenon, which includes client’s sometimes very simple ideas of mental health. Clients sometimes think that it is a sign of sound relationship to deny presence of any argument, any problem. (Something hypocritical as many answers at the question: ”How, are you?” ”I’m fine, thank you.”) But they cannot realize that total absence of arguments is often an indirect sign ubiquitous tension, which uses to be even more destructive for pair wellbeing than occasional arguments. The same way, they are convinced that being suitable for step-parenthood is correlated with their social achievements, so they try to parade at an assessment with all their academic successes.
Tests with yes – no answers are very sensitive to dissimulation. Much better are tests with pseudoipsative answers, like Gordons personality inventory (Which of following statements apply to you most and least?). Or use tests with combined lie–score, as MMPI, CPI, or other more sophisticated tests.
When testing pairs you can monitor crossed answers about partner and self: How much alcohol does your partner drink a week? How much alcohol do you drink a week? This way we have two and two answers which are supposed to match.
Dissimulation (faking good) in such cases is much different from malingering (faking bad) in denial of symptoms and problems, lack of spontaneous speech, or on contrary attempts to lead all the conversation all the time.
How to report malingering?
To avoid accusations, usage of the detailed factual description is desirable: ”Results from the neuropsychological examination raise the concern that Ms. Jones may be exaggerating her memory complaints. Thus, her scores on a number of forced-choice recognition tests (e.g. VSVT, 21-Items, TOMM) were significantly lower than expected. While such low scores can occur in severely demented individuals, they are rarely, if ever, obtained by normal people or individuals suffering from mild brain injury. In addition, Ms. Jones...”
Sometimes is most appropriate conclusion where malingering is suspected to comment on the invalidity of the testing and make no diagnosis. The examiner might state that ”the inconsistency of the results precludes a diagnosis at this time,” or ”the results are not consistent with any known diagnosis” or ”the results are not consistent with presenting complaint”.
Clinical reports are most useful when they contain some information about motivation that prompted the dissimulation. Such reasons may reflect a desire to avoid responsibility, a plea for acknowledgement of an injury or an attempt to obtain medical or special care services. The report should also include suggested therapeutic interventions.
Hall H.V., Pritchard D.A. 1996 Detecting Malingering and Deception. Forensic decision analysis. Delray Beach, fl. St. Lucie press
Binder L. M. 1990: Malingering following minor head trauma. The clinical neuropsychologist, 4, 25-36
Iverson Franzen in a journal: Law and human behavior
Davis: Colorado malingering test package
Clinical assessment of malingering and deception / edited by Richard Rogers. New York : Guilford Press, c1988
Mgr. Jeroným Klimeš, Ph.D.
1) Client data
2) Reason for referral
3) Relevant history
4) Review of relevant previous reports
5) Client’s current concerns
6) Report of informant(s)
7) Observations during history talking and testing
8) Test results
9) Interpretation of test results and observation
10) Diagnostic summary
12) Vocational implications
13) Appendix: Tests administered
Mgr. Jeroným Klimeš, Ph.D.
”I want you to draw the face of a clock with all the numbers on it. Make it large.” After completing the task add: ”Now, draw the hands pointing at 20 to 4.” (or different times: 11:10, 8:20, etc.)
Hemianopsia, right (but not left) visual neglect, dementia, visuospatial disorders, constructional apraxia, various dementions including Alheimers one, and aging.