Consideration of Symptom Validity as a Routine Component of Forensic Assessment

Erin Eggleston PhD DipClinPsychReg. Clinical Psychologist

What I mean by Symptom Validity….

The measurement or observation of bias in test behaviour and self reported psychopathology.response biasmotivational inhibition / test underperformancedissimulation / intentional feigning self debasementself enhancement / denial of everyday life complaints/ presenting overly favourably symptom exaggeration / magnificationsymptom under reporting

What I mean by the forensic…

Expert provision of clinical evidence to inform decision making or court proceedings.

In New Zealand psychologists have long been used as experts in the Family Court.

This type of assessment role is growing as what we can do becomes better understood.

Pitfalls when psychology interfaces with law…

“If I talk with you, you’ll find out things about me and then the Parole Board will find out and keep me in longer” (offender, abridged)

“You Psychologists just say I’m high risk – that doesn’t help me. So no I don’t consent” (offender, abridged)

Making the Case….

for knowing about and being able to deliver basic Symptom Validity tests as part of clinical screen in forensic settings.

For being willing to test the validity and robustness of our psychological findings

Regarding the risks of not being sure about symptom validity.

Incidence

The known base rate internationally for symptom exaggeration in neuropsychological field ranges from 7.5% to 33% in clinical settings.

30-40% in settings where incentive exists…..e.g compensation, classification and parole..but to be fair we don’t know in NZ.

Not sure of the numbers in the opposite direction where incentive exists..e.g denial, symptom minimisation.

Donders and Boonstra, 2007, Green, Rohling, Lees-Haley & Allen 2001; Binder and Rohling, 1996; Lees-Haley, 1992; Trueblood & Schmidt, 1993:

What does the psych board say?

The psychologist should be alert to motivational factors which may bias the results in a particular direction. Do we consider these factors?

Where there is reason to question effort, symptom validity assessment may be included… Hmm

Be careful…they are worried about us talking about Malingering… Do we?

While psychologists often want to avoid having this uncomfortable discussion, there is an obligation to feedback the results of the assessment to the client. Do we agree?

Draft Guidelines on Use of Psychometric Tests NZ Psychologist Board (Dec 2011)

Psychometric review – tests examine:

Psychiatric Symptoms (Rare, Improbable Absurd combinations, Severity, Consistency, and Report Versus Observed).

Self Deception Validity Scales on Personality Tests Memory symptoms IQ (VIP) Substance Abuse Somatic Perception Embedded measures across test batteries

Best practice suggests converging test data.

Four Case Studies

Case One: s38 Sexual Offender

Psychiatrist says fit to plead and no evidence of intellectual impairment

Lawyer says clear ID.

Only a psychologist can sort this out

Testing

Passed TOMM x2 FSIQ in range of <60 (no difference across subtests) Very good at saying yes. BURT 6.5 year reading age Vineland II across two raters consistent with ID Special schooling, no employment, limited coping skills

It was the symptom validity test that stood out strongly in court to show this was a valid assessment of functioning.

Case Two: ACC Data Assessment(Risky/ SV testing recommended)

PAI: strong negative bias DAPS: strong negative bias VIP / TOMM: valid. MSPQ: four times above cut-off for

back pain K10: severe CES-D: v.severe in range where

inpatient care should be considered.

Where we got to with some feedback… Some rapport was established by meeting twice. Client agreed with strong negative bias Client agreed with paranoid ideation and

pervasive distrust, aggrieved, suspected that others plotting against him. This was the substantive barrier to change.

Noted incentives Does meet criteria for PTSD but is difficult to

treat. Warrants specialist treatment (Psychiatry,

Clin.Psychology)

Case Three: s333 Youth court

Youth considered by Social Worker based on previous psychology report to have ID and would likely be placed in Youth ID Service

Wanting to know what it would mean if he scored lower vs. higher

Knows that offending is serious and persistent enough to lead to district court sentencing.

Prior test results…

WAIS IV (previous psych) Scores spanned from the extremely low range – scaled

score of 1 to the average range - scaled score of 10. Matrix reasoning- which is a robust indicator of overall

intelligence that is not impacted by schooling was in the average range;

Client admitted to engaging in previous tests with low effort and that he was considering doing so with me because he considered being found to be low functioning would be useful in his court (incentive);

Case Four: [ACC] PTSD as a consequence of physical injury

Referral: Assessment of the likely pre-injury mental health condition and any mental condition (using DSM-IV) that is subsequent to this and can be reliably linked to the covered physical injury.    This should include close examination of the possibility of Post Traumatic Stress Disorder any other cognitive, behavioural or emotional patterns that might explain reported findings.

Symptom Validity findings…

The pattern detected across psychometric tests, clinical interview data and corroborative sources indicated that while Ms Jones did not actively or intentionally feign illness or falsify symptoms, self-report was unreliable and likely to include exaggerated symptoms. Ms Jones’s approach to cognitive testing was reported as inconsistent; that is, there was evidence of periods of optimum and sub-optimum effort. Structured Inventory of Reported SymptomsMillon Clinical Multiaxial Inventory –IIIValidity Indicator Profile Behavioural Evidence Personal MotivatorsObserved Testing Behaviour

Injury Focused Formulation

(deleted)

Practice points Be a scientist practitioner and strengthen psychological

contribution to forensic environment by openly testing alternative hypotheses and the validity of our conclusions.

Learn from the forensic field: Assess patterns across test data, note clinical and behavioural observations, consider incentives and use a range of corroborative sources.

Develop rapport and inform clients of the components of the assessment

Describe and formulate on response style. Develop this component of your forensic report.

Consider the utility of feedback and how best to communicate your results both in terms of developing your formulation and being fair to the client in terms of hearing your findings first from you.