PVTs

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Bishop's University *

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PBI288

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Psychology

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Oct 30, 2023

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Lecture 3 Performance Validity Test

Performance validity indicators are based on the premise that simple tasks that appear relatively difficult will be passed by actual patients with brain injury, but failed by noncredible test takers.

Example of PVT: STROOP TEST -it is difficult to name the ink color of a color word if there is a mismatch between ink color and word -Have an understanding of how long the delay for non-congruent stimuli is for various neurocognitive conditions -Therefore, you know when someone is taking too long

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Performance validity testing (PVTs) refers to neuropsychologists' methodology for determining whether neuropsychological test performances completed in the course of an evaluation are valid (ie, the results of true neurocognitive function) or invalid (ie, overly impacted by the patient's effort/engagement in testing) PVTs Problem: how to identify a non-credible performance during neurocognitive testing Recommendations: PVTs are to be interspersed throughout the evaluation: • “freestanding” PVTs • “embedded” PVTs Greher MR, Wodushek TR. Performance Validity Testing in Neuropsychology: Scientific Basis and Clinical Application-A Brief Review. J Psychiatr Pract . 2017;23(2):134-140. doi:10.1097/PRA.0000000000000218 Digit Symbol Coding: sensitive to brain damage, dementia, age and depression

Negative Response Bias (NRB): systematic tendency to produce more deficient scores than would be expected based on the skill level of the person Freestanding PVTs (fPVTs) Freestanding PVTs: 1. Single purpose = assessing for negative response bias The Rey 15 Item Test (FIT) is used to assess symptom validity or feigned memory impairment Patients are shown the items in the figure on the center of this page for 10 seconds and then asked to reproduce these items from memory. Repeating pattern makes it easy reproduce

Embedded PVTs. (ePVTs) BENEFITS • No extra test administration time • shielded from coaching/education • “real time” evaluation of performance validity • fPVTs = results from PVTs administered at one point in the exam be used to determine validity of neurocognitive test performance at a different point in the testing dedicated and embedded PVTs both have sensitivity rates within the range of >20% to 80% 1.Embedded Indictors = derived from standard neurocognitive tests -serve“double duty” both as measures of performance validity but also as techniques to evaluate neurocognitive function Subjects are read a sequence of numbers and asked to repeat the same sequence back to the examiner in order (forward span ) or in reverse order (backward span )

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Further, even within the same claimed condition, test takers may adopt differing approaches to underperformance. What do I get wrong? Negative response: • minority of noncredible patients engage in negative response bias on every measure administered • Majority “pick and choose” tests on which to demonstrate impairments • belief = poor performances on all tasks not credible? • time ( “fatigued”) • deficits on particular tasks/ measure consistent with their claimed condition

Two Cases differing strategies of simulating symptoms claimed mTBI

CASE 1 ❖ 41-year-old female litigant worked in public relations and had completed an AA degree ❖ motor vehicle accident ❖ sustained at most mTBI ❖ no retrograde/anterograde amnesia ❖ alert /oriented in the hospital and released the same day of accident ❖ continued to work ❖ handled all activities of daily (ADL) ❖ Tested 5 years later: headaches, back pain, numbness/tingling in her right arm, cognitive difficulties including “struggles” with memory, and anxiety/depression Background 1. Patient = headaches = mTBI 2. Patient = well-documented headaches, history of chronic pain and vague medical symptoms, prior to the accident

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CASE 1 ❖ Failed PVTs confined to verbal memory, she passed indicators from nine other tests mostly tapping other cognitive domains ❖ Across Battery: ❖ scores = average range/higher ❖ exception of a borderline score in math calculation ability ❖ low average score in delayed verbal recall ❖ Previous Battery 6 months after accident: ❖ scores = average range/higher ❖ math calculation ability = average ❖ verbal memory = average/high average weaknesses observed on current testing were not corroborated on testing completed closer in time to the injury. Participants are given a list of 15 unrelated words repeated over five different trials and are asked to repeat. Another list of 15 unrelated words are given and the client must again repeat the original list of 15 words and then again after 30 minutes. Approximately 10 to 15 minutes is required for the procedure (not including 30 min. interval).

CASE 2 ❖ 59-year-old female litigant worked as a mid-level executive and had completed an MBA ❖ motor vehicle accident ❖ loss of consciousness ❖ did not seek medical attention except for chiropractic care ❖ active in her profession and church ❖ continued to work ❖ handled all activities of daily (ADL) ❖ Patient Reported: multiple cognitive difficulties including lack of focus, mental slowness, difficulty processing information, “dyslexia,” prob- lems in multitasking, and becoming “visually lost,” as well as orthopedic pain, difficulty hearing, development of sleep apnea, and emotional dyscontrol

CASE 2 ❖ Failed PVTs involving processing speed/vigilance, visual perception/spatial skill/memory, basic attention, finger speed and sensation (passed all verbal memory PVTs) ❖ Across Battery: ❖ Impaired scores: motor dexterity ❖ Impaired- low average scores : processing speed and visual perceptual/constructional skills ❖ LowAverage = Basic Attention ❖ all other scores were average or higher ❖ Previous Battery 2 years after accident: ❖ Testing completed two years after the injury, all scores on measures of attention, processing speed, and motor dexterity were average ❖ math calculation ability = average ❖ verbal memory = average/high average ❖ Multiple scales were elevated : anxiety, depression, cycling mood disorder, and anger-related disorder. There was also complaints of headac, loss of hearing, and sleep apnea Symptoms not linked to mTBI the patient’s complaints of chronic failed PVT performances predicted which standard cognitive scores were lowered abnormal neurocognitive scores, if accurate, would be inconsistent with the patient’s functionality in all activities of daily living

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PVT Group Validity PVT cutoffs are traditionally set to allow a false positive rate of < 10% PVT with credible patients but = perform abnormally • 10% of credible patients who fail the measure? • administer multiple PVTs • single failure is not unusual • failure on multiple is rare • ex. 5% of their credible sample failed two PVTs

If you have a multiple Does a “passed” PVTs “cancel out” any failures • specificity of individual PVTs is > 90%, • sensitivity rates range from < 50% to 80% • scores on individuals PVTs will be more effective in ruling in than ruling out noncredible performance 10 cards contain a number of randomly arranged black dots, individual asks to indicate how many dots.

*particularly in the context of a forensic exam in which there is compensation seeking or other external motive to present oneself as more impaired than is actually the case Current Standing in the Field 1. Multiple PVTs are to be administered 2. PVTs are interspersed throughout the exam (many) domains covered 3. Performance validity is repeatedly sampled

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What to check… Evidence of a Non- Credible Performance (1) Failing scores on PVTs, (2) Nonsensical change in scores on sequential neuropsychological examinations (particularly declines not related to injury) (3) Mismatch between performance on PVTs vs activities of daily living; (4) Non-plausible symptoms (5) Evidence from personality inventories (exaggeration) with denial of antisocial and exploitive behaviors

Two Exceptions We will examine the case of dementia but would be equivalent procedure in Low IQ Dementia (1) and Low IQ Patients = dementia or low IQ • fail PVTs at a high rate with credible performance • patients with dementia or low IQ, • “simple” tasks = difficult How to arrive at an accurate differential diagnosis of actual versus feigned dementia or intellectual disability.

CASE 3 ❖ 69-year-old Taxi-driver patient with eight years of education and subsequent attainment of a GED ❖ motor vehicle accident ❖ sustained at most mTBI ❖ self-extricated at the scene ❖ standing at the accident ❖ alert and oriented with no loss of consciousness ❖ subsequently: some mild confusion and amnestic for the event ❖ suturing of a laceration on his head, and was found to have a left hand fracture ❖ Symptoms. :decline in memory, reduced balance, back and right leg pain, pain at the fracture site, periodic head- aches, insomnia, and depression and anxiety ❖ CT was normal ❖ MRI obtained (2 days later): acute infarction/ischemia in the left basal ganglia and left cerebral peduncle region, ❖ mild atrophy and periventricular/WM changes - related to chronic ischemic white matter disease ❖ Released three days later Files a LAWSUIT 1. mTBI caused stroke 2. mTBI caused cognitive impairment Can no longer work - needs compensation

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Medical History Its EXTENSIVE MH: -chronic hypertension -high cholesterol -elevated blood sugar levels -low testosterone -possible sleep apnea -lengthy smoking history -treatment for gastrointestinal (GI) (six months of chemotherapy), -chronic depression -thyroid and parathyroid dysfunction -possible excessive alcohol use -difficulty “concentrating” in school, no diagnosis

neurocognitive testing revealed a. high level of impairment (possibly) to the level of a dementia Does the dementia accounts for the widespread PVT failures? Failed 100% of PVTs administered Patient’s performance : noncredible performance or dementia? (a) the patient’s functionality in ADLs to see if it is consistent with dementia (b) the patient’s test scores and spontaneously displayed skills for evidence of consistency of impairment (c) performance on PVTs matches that expected for dementia (d) patient still fails PVTs when cut- offs are adapted (credible dementia patients) (e) when a patient has been repeatedly tested, consistency of test scores across exams can be analyzes

If interested your text has literature review and current standings on PVTs in Dementia

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