the performance of schizophrenics on three cognitive tests of

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The Performance of Schizophrenics on Three Cognitive Tests of Malingering, Rey 15-Item Memory Test, Rey Dot Counting, and Hiscock Forced-Choice Method Carla Back, Kyle Brauer Boone, Carol Edwards, Carlton Parks, Karl Burgoyne and Barbara Silver Assessment 1996 3: 449 DOI: 10.1177/107319119600300411 The online version of this article can be found at: http://asm.sagepub.com/content/3/4/449

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THEPERFORMANCE OF SCHIZOPHRENICS ON THREE COGNITIVE TESTS OF MALINGERING, REY &ITEM MEMORY TEST,REY DOTCOUNTING, AND HISCOCK FORCED-CHOICE METHOD Carla Back Kyle Brauer Boone Carol Edwards Harbor-UCLA Medical Center Carlton Parks California School of Professional Psychology Karl Burgoyne Barbara Silver Harbor-UCLA Medical Center The performance of individuals with severe psychiatric disturbance such as schizophrenia on tests designed to detect malingering of cognitive symptoms (e-g., Rey 15-Item hlemory Test, RhlT; Rey Dot Counting Test, RDC; Hiscock Forced-Choice, F-C, method) has not been formally investigated. Some malingerers feign cognitive impairment in the context of a pseudopsychotic presentation; thus, it is essential that we understand how actual psychotic individuals perform on these measures. In o u r sample of 30 schizophrenic patients, 13% failed the RhlT, 13% failed the RDC, and 27% failed the F-C measure?The RhlT performance appeared to be significantly affected by lowered educational level. In contrast, both RDC and F-C performances were related to presence of cognitive impairment, and the RDC ~ v a also s significantly affected by increasing age. N o test score was significantly related to psychiatric disturbance.

Neuropsycliologists are increasingly being asked to aid in the detection of malingering of cognitive symptoms within the forensic setting (Bernard, 1990). However, studies investigating feigning on neuropsycliological test batteries and individual cognitive tests have shown that these measures are Co rres p o n de n c e concerning t 11is art i cl c s h o ti 1d be aciciressed to Carla ~ a c kucw , Neuropsyctiiatric Institute, 371131, 760 Westwood Plaza, Los Angeles, CA 90024-1759.

vulnerable to feigning, and clinicians demonstrate variability in their ability to detect malingering in these tests (Benton 8- Spreen, 1961; Bruhn &Reed, 1975; Franzen, Grant, &- hlccracken, 1990; Nies 8- Sweet, 1994; Rogers, 1988). Several tests have been specifically developed to detect malingering of cognitive symptoins or suboptimal effort on n e u r o ~ ~ ~ c l ~ o l o gtests i c a lsucll as the Rey 15-Item hlemory Test (RhlT; Rey, 1964; 449

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Back, Boone, Edwards, Parks, Burgoync, and Silver Lezak, 1983), the Rey Dot Counting Test (RDC; Rey, 1941; Lezak, 1983), and the Hiscock ForcedChoice method (F-C; developed by Pankratz, 1983, a n d revised by Hiscock & Hiscock, 1989). However, n o information has been available regarding the performance of individuals with severe psychiatric disturbance (e.g., schizophrenia) on these measures. This is a critical issue for two reasons. First, malingerers often feign cognitive impairment as a part of a pseudoschizophrenic presentation (Clark, 1988) and, as such, it is essential that we understand how actual psychotic individuals perform on these measures. Although several tests have been developed to detect malingering of psychiatric symptoms (e.g., hlinnesota hhltiphasic Personality Inventory, hlhiPI; Hathaway & hlcKinley, 1943; Structured Interview of Reported Symptoms; Rogers, Bagby, & Dickens, 1992), these tests do not provide information as to the veracity of complaints of cognitive impairment. Second, research on cognition in schizophrenia suggests schizophrenics may evidence declines in skills needed for successful performance on these tests (e.g., memory, visual perceptual skills, information processing speed; Levin, Yurgelun-Todd, & Craft, 1989) and, as a result, may be inaccurately identified as possible malingerers on these measures. If this is the case, the validity of these malingering tests is drawn into question. In fact, several published studies on the RhlT suggest that this test may be sensitive to extraneous factors, such as actual cognitive impairment or psychiatric disturbance (Goldberg & hliller, 1986; Guilmette, Hart, Guiliano, & Leininger, 1994; Hays, Emmons, & Lawson, 1993; Lee, Loring, 8c Martin, 1992; Schretlen, Brandt, Krafft, & Van Gorp, 1991), although the precise nature of the relationship between these factors and test performance has not been empirically evaluated (e.g., At what cutoff score on the hlini hlental State Exam, hihlSE; Folstein, Folstein, 8c RfcHugh, 1975, or on a psychiatric rating scale do patients begin to fail the RhlT?). The few empirical reports on the P C method suggest that this test is not related to cognitive impairment or nonpsychotic, psychiatric disorders (e.g., major depression, bipolar disorder;

Guilmettc e t al., 1994; Guilmette, H a r t , & Guiliano, 1993; hlartin, Bolter, Todd, Gouvier, & Niccolls, 1993; Prigatano & Amin, 1993); however, none of the studies examined the performance of schizophrenic patients on this measure. Of the two publications we could locate on the RDC (Beetar & TVilliams, 1995; Greiffenstein, Baker, & Gola, 1994), only the Greiffenstein et al. study addressed the impact of cognitive impairment on test performance, and neither study examined the relationship of psychiatric disturbance ‘to RDC performance. T h e results of Greiffenstein et al. suggest that the RDC may not be unduly sensitive to cognitive impairment in that actual headinjured respondents appear to perform normally on the measure. The purpose of the present study was, first of all, to examine the effect of a diagnosis of schizophrenia on malingering test performance and, second, to evaluate the specific relationship between severity of psychosis-associated cognitive impairment and psychiatric disturbance and malingering test performance. In addition, we investigated the relationship of test scores to age and education.

Method Participants The sample consisted of 30 schizophrenic patients (20 outpatients and 10 inpatients) from the population of psychiatric patients at Harbor-UCLA Medical Center. Patients were considered eligible for the study if they had a diagnosis (i.e., in accordance with the revised third edition of the Diagnostic mid Statistical hlaizual of Aleiifal Disorders, DSM-III-R; American Psychiatric Association, 1987, criteria) of schizophrenic disorders with a chronic course, were fluent in English, did not have a preexisting history of neurological disorder o r positive findings on a neurological exam, and were able to provide informed consent. Schizophrenic diagnoses included 19 paranoid type, 6 undifferentiated type, 4 disorganized type, and 1 catatonic type, and most of the patients’ disorders were of a moderate severity (e.g., on the Brief Psychiatric Rating Scale, BPRS; Overall & Gorham, 1962, mean score = 40.67, SD = 11.20). Of the sample, 20 patients were male and 10 were female. hiean

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Cognitive Malingering age and educational levels were 34.86 years (SD = 1.69 years, range = 22-56 years) and 13.15 years (SD = .54 years, range = 6-18 years), respectively. The ethnic composition of the sample included 22 Caucasians, 3 African Americans, 3 Hispanics, 1 Asian, and 1 East Indian. All but o n e of the patients were on neuroleptic medication at the time of testing. Tests Administered

Malingerittg Tests Participants were individually administered three tests devised to detect malingering of cognitive symptoms, t h e RMT, t h e RDC, a n d t h e F-C method. Participants were instructed to attempt to learn the 15 items on the RMT, and the number 15 was emphasized to suggest that the task might be difficult. Participants were exposed to the stimulus page for 10 seconds and were instructed to draw the items immediately after withdrawal of the page. Failure on this measure was defined as a total number of correct responses less than 9 (e.g., Goldberg & Miller, 1986; Lezak, 1983). Participants were then administered the RDC. As recommended by Lezak (1983), the participants were shown a series of twelve 4 in. by 6 in. index cards on which were drawn dots. Participants were allowed to hold the cards and use a finger to assist in counting. Failure on this measure was extrapolated from the normative data and interpretive guidelines presented in Lezak and was defined by the following criteria: (a) a mean grouped-dot counting time greater than 4.8 seconds, and (b) a mean grouped-dot counting time that was not at least twice as fast as the mean ungrouped-dot counting time (ratio 2:l). (As reported in Lezak, brain damaged participants’ mean grouped-dot counting time was 4.8 seconds, and controls performed between 2’/2 and 3% times faster on the grouped-dots measure when compared with ungrouped dots.) As recommended by Hiscock and Hiscock (1989), the F-C method was presented on white, 3 in. by 5 in. index cards with a 5-digit stimulus typed in black. A pilot study of the original F-C method (i.e., 72 trials) was conducted, and it was found

that the test took over a n hour to administer. Given that this length of administration wouId not be tolerated by our very disturbed population, a modified version of the F-C method was utilized: three sets of cards containing six trials each (i.e, 18 trials). Eight 5-digit numbers were used as the stimuli. The participants were shown each stimulus card, one at a time, and instructed to read and remember the 5-digit number printed on the card. After each stimulus presentation, the participant was then shown a response card containing the original 5-digit number and another 5-digit number, which differed from the original stimulus number by at least 2 digits including either the first or last digit. The participant was then asked t o choose t h e c o r r e c t 5-digit number. T h e response cards were presented following a 5-, lo-, o r 15-second delay. Aside from the abbreviated format,. administration of the F-C method followed standard procedures, as described by Hiscock and Hiscock. Per the recommendation of Guilmette et al. (1993, 1994), failure on this measure was defined as a correct performance of less than 90%.

Cognitive atid Psychiatric Tests Participants completed the MMSE, which contains 11 questions that provide information on gross cognitive functioning in several areas (e.g., orientation, attention, memory, naming, verbal and written comprehension, writing, and visuoconstructional ability). Administration followed the procedure of Folstein et al. (1975) in which backward serial 7s and spelling the word “world” backward tasks that assess attention and concentration are assumed to be interchangeable. The score used for analysis was total number correct out of a possible 30. Participants were also administered the BPRS, an 18-item rating scale that provides information on the severity of 18 psychiatric symptoms commonly associated with schizophrenia (i.e., conceptual disorganization, unusual thought content, anxiety, guilt feelings, grandiosity, depressive mood, hostili t y , h a 11u c in a t o r y b e h av i o r, s u s p i c i o u s n e s s , blunted affect , tens ion, emotional w i thd r a w l , mannerisms and posturing, motor retardation, uncooperativeness, excitement, and disorientation). Half of the symptoms are rated based on 45 1

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Back, Boone, Edwards, Parks, Burgoyne, and Silver the clinician's observations during the interview and half are based on the patient's self-report. Ratings were made on a 7-point scale ranging from 1 (Not Present) to 7 (Very Severe), a n d the score used for analyses was the total sum of the ratings on the 18 scales.

Results Of the schizophrenics tested, 13% (4 of 30) failed the RhlT using the variable of total correct out of 15, 13% failed the RDC using the criteria of a mean grouped-dot counting time greater than 4.8 seconds and a ratio of less than 2:1, and 27% failed the F-C method. T h e relative contributions of hlhlSE score and BPRS score as well as demographic variables of educational attainment and age on RMT total correct, RDC ratio score, RDC mean grouped-dot time, and F-C total score were examined using stepwise linear regression analyses. An alpha value of .05 or less was used as the criterion for inclusion in the regression model. T h e results of the regression analyses are presented in Table 1. Educational level was the only variable that accounted for a significant proportion of the variance in the RhlT total score; 37% of the RhlT total score was explained by educational level. In contrast, for the ratio score on the RDC and total score on the F-C measure, the hlhlSE was the only significant predictor of performance, accounting for 17% of test score variance on the RDC score and 22% of test score

variance on the F-C measure. For the grouped-dot counting time, both hlhlSE score and age were significant contributors to counting time, accounting for 43% and 8% of counting time variance, respectively. BPRS score was not a significant predictor of any of the four test score variables. Relationship Between MhlSE Scores and hlalingering Test Scores To further examine the effect of cognitive impairment on RDC and F-C performance, patients were divided into two groups based on MhlSE scores using the traditional cutoff score of 24 (Folstein et a]., 1975). Of the sample, 8 participants had a score of 24 or less ( M = 21, SD = 3.12), defined as cognitive impairment; 22 participants had a score of greater than 24 ( M = 28, SD = 1.48), defined as no cognitive impairment. Groups did not differ in age or gender but, not unexpectedly, did differ on educational level ( p = .02). As shown in Table 2, the normal versus cognitive impairment groups differed on the F-C score, l(28) = -2.34, p = .04, and on mean grouped-dot counting time, but did not differ-on the RDC ratio measure, t(28) = -1.63, f~ = .12. On the I;-C measure, the cognitive impairment group averaged 84.72% accuracy, whereas the no cognitive impairment group averaged 97.44% correct. Of the eight participants who failed the F-C technique, five had cognitive impairment, whereas the other three were in the normal cognition group. For the RDC ratio score, the cognitive impairment group averaged slightly less than a 2:l

Table 7 S i o n v i a ~of Best Predictors for Hierarchical Regression Aiialjsis for Variables Predicting iUa1ingeriiig Test Scores

Criterion

I'redi ct or

P

SE p

RhlT F-C Ratio

Education

Grouped

hiAiSE

.629 237 .117 -273

-159

AlhlSE hlhlSE Age

.050

.087

.050 -061 .023

Increase in R2

R2

-

368 .215 .170

.427

-

.084

.511 ~~

p I.03 was usctl :is [lie criterion for inclusion iii the regression niodel. RXLT = Rcy 15-Ite111hlcniov Test; F-C = Hiscock ForcedChoice proccdurc; Ratio = 2:1 iiic'an grouped-dot counting tinic on thc Rcy Dot Counting Test conipnrcd with the i n c n ~ iungroupctl-clot counting tinic; Grouped = nienn grouped-dot counting timc on the RDC; MAISE = hlini hlciitnl State Esnni.

A'ole.

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Cognitive hlalingering ratio of grouped- to ungrouped-dot counting time (A1 = 1.96 seconds, SD = 0.96 seconds), whereas the no cognitive impairment group was found to have a grouped- to ungrouped-dot counting time ratio of over 2.5:l (ill = 2.67 seconds, SD = 1.09 seconds). On grouped-dot counting time, the cognitive impairment group averaged 4.6 seconds, whereas the normal cognition group averaged well under 3 seconds.

years; defined as high education), and 8 participants finished less than 12 years (ill = 9.62 years, SD = 1.99 years; defined as low education). Groups did not differ in age o r gender distribution.

As shown in Table 3, the two education groups significantly differed in RkiT performance, l(27) = -3.06, /I = .005, suggesting that level of education does affect RhlT performance. The mean score of the low education group was only slightly above the cutoff of 9 items correct (low education 111 = 9.57, SD = 2.99; high education i\l = 13.09, SD = 2.54). Of the four participants who failed the RhlT, two were in the low education group and two were in the high education group.

Of the four participants who failed the RDC, three were in the cognitively inipaired group, whereas only one was in the normal cognition group.

Relationship Between Education and Malingering Test Scores To further explore the effect of education on RMT performance, patients were divided into two groups based on whether they had completed high school. Of the sample, 22 participants completed 12 years of education ( M = 14.34 years, SD = 1.99

Relationship Between Age and Grouped-Dot Counting Performance To further examine the effect of age on groupeddot counting time, participants were divided into two age groups: 40 years old or younger (n = 22)

Table 2 Comparisons of Cognitive Iinpnirnienl Lmels 011 Rey 15-Item hleinoq Test Scores, Rey Dot Counting Test Scores, Hiscock Forced-Choice hlethod Scores, Age, a n d Education in tile Schizophrenic Sainple ~

Cognitive i m p 'irrnent Impaired"

Variable Age (in years) Education (in years)

A1

SD

flf

SD

P

35.62 10.87

10.79 3.18

34.59 14.02

8.89 2.33

.943 .024

Gender hiale

5

Female RhlT Total RDC Ungrouped

Grouped Ratio

Not impairedh

15 7

3

10.12

2.90

12.86

2.78

.025

7.76 4.61 1.96

2.96 2.04 0.96

6.42 2.73 2.67

1.91 1.30 1.09

.005

.115

15.25

2.71

17.54

1.01

.048

.155

F-C

Correct

A'ofe. RXIT = Key 15-Item Alemory Test; RDC = Rey Dot Counting Test; F C = Iliscock ForcedChoice procedure; Ungroupetl = mean tiiigrouped-dot counting tirile on tlie KDC; Grouped =

iiiean groupecl-dot counting time on the RDC, Ratio = 2:l inem grouped-dot counting time on the RDC coniparcd with the mean iiiigrouped-dot counting titnc. "63% \Viiite; n = 8. "3% \iriiite; n = 22.

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Back, Boone, Edwards, Parks, Burgoyne, and Silver Table 3 Cotnfiarisons of Education Levels on Rq, 15-Item Afeemory Test Scores, Rey Dot Counting Test Scores, Hiscock Forced-Choice lzlefhod scores, Age, and AfAfSE Scores in the Schizophrenic Sample ~

Education level Highb

Low3

Variable

SD

Af

411

SD

P

Age (in years)

31.85

7.64

36.27

9.58

.272

MMSE

24.28

4.42

26.63

3.45

.111

Gender hlale

14 8

6 2

Female RMT Total RDC Ungrouped

Grouped Ratio

9.57

2.99

13.09

2.54

.004

7.88 3.00 2.77

3.04 1.41 0.93

6.46 3.12 2.47

1.97 1.65 1.12

-158 ,856 .517

17.00

1.52

16.90

2.06

-535

F-C

Correct

= < 12 years of school; High education = > 12 years of school; hihiSE = hiini hfental State Exam; RhiT = Rey 15-Item hiemoly Test; RDC = Rey Dot Counting Test; F-C = Hiscock Forced-Choice procedure; Ungrouped = mean ungroupeddot counting time on the RDC; Grouped = mean groupeddot counting time on the RDC; Ratio = 2:l mean groupeddot counting time on the RDC compared with the mean ungroupeddot counting time. a50% White; ti = 8. b77% IVhite; n = 22.

A’ole. Low education

and older than 40 years (n = 8). The groups did not significantly differ on education and gender. Both groups averaged well under the cutoff of 4.8 seconds (I40 years, M = 3.0 seconds, SD = 1.4 seconds; > 40 years, M = 4.0 seconds, SD = 2.3 sec-, onds), and no significant differences were found between groups in counting time, t(28) = -1.13, p = .29. Of the four participants who failed the RDC, three were over age 40 (i.e., 46, 49, and 49, respectively).

Discussion Findings from the current study indicate that a relatively small percentage of participants with a diagnosis of schizophrenia are misidentified as possible malingerers or as having put forth suboptimal effort on the RhlT (i.e., 13%, using the criteria of less than 9 items correct) and the RDC

(i.e., 13%, using the criteria of mean grouped-dot counting time 4.8 seconds and ungrouped-dot counting time/grouped time < 2 seconds). Of greater concern, more than one fourth of participants failed our abbreviated F-C method (i.e., 27%, using a criterion of less than 90% correct). We employed an abbreviated version of the P C technique incorporating 25% of the original items, because the length of the full version of the test (i.e., at least 40 min per Binder, 1993 and over 60 min in our experience) was not a realistic option in our severely disturbed population. Thus, our findings may not be generalizable to the test in its complete form. However, the failure rate of 27% in o u r sample is particularly worrisome, because the shortened administration time actually should have inflated the percentage of correct responses, given that the task was less taxing than the full test. Although our findings regarding the

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Cognitive hlalingering F-C method point to potential problems, more studies using the full version of the test are needed before any definitive conclusions can be drawn. Examination of the contribution of cognitive impairment, severity of psychiatric disturbance, age, a n d education to malingering test performance revealed that (a) education level was the only significant predictor of RhlT performance, accounting for a substantial amount (e.g., 37%) of test score variance; (b) cognitive status was the only significant predictor of performance for the F-C measure and the ratio score for the RDC, accounting for a rather modest amount of test score variance (e.g., 17%-22%); (c) cognitive status and increasing age were significant predictors of RDC grouped-dot counting time, with cognitive impairment accounting for a major proportion of time variance (e.g., 43%) and age explaining a small amount of variance (i.e., 8%); and (d) severity of psychiatric disturbance did not account for a significant proportion of variance of any test score. Additional analyses indicated that presence of cognitive impairment (e.g., RlMSE score I 24) was associated with significantly poorer performance on the F-C measure and mean grouped-dot counting time, whereas having less than a high school education was associated with significantly poorer performance on the RMT. Although previous research has shown that cognitive status is associated with reduced performance on the RAlT (Goldberg & hGller, 1986; Guilmette et al., 1994; Hays et al., 1993; Lee et al., 1992; Scliretlen et al., 1991), it appears that educational level may be the more pertinent factor. The fact that lowered educational level is associated with poorer performance on the RhlT suggests that use of the RhlT with participants of low educational level may be particularly problematic; participants with less than a high scliool education on average performed only slightly above the cutoff of 9 items correct. In contrast, the RDC and the F-C method appear to be more appropriate for use with this population, given that they appeared to be relatively impervious to the impact of educational level.

Although other studies have suggested that the F-C technique is not impacted by lowered cognitive ability (Guilmette et al., 1993, 1994; Martin et al., 1993; Priptano & Amin, 1993), our data indicate that an MIMSE score explains a significant portion of test score variance. Of particular concern, cognitive impairment (e.g., mean AlhlSE score = 21) was associated with an accuracy rate that fell below the 90% cutoff recommended by Guilmette et al. (1993, 1994). Several of t h e previous studies (Guilmette et al., 1993, 1994; Prigatano & Amin, 1993) defined their brain impaired groups based on declines in memory scores on neuropsychological testing. However, it has been sugsested that the F-C measure may actually assess concentration or immediate attention span similar to the ability to recall a string of digits, rather than mernory ability per se (Prigatano 8c Amin, 1993). In fact, of the eight participants in our study who failed the P C measure, five made errors on the attention and concentration section of the hlhlSE. Examination of the neuropsychological test scores reported in the previous studies suggests that- attention and concentration skills were intact in the brain impaired groups, which may have accounted for their normal performance on this test. In addition, although a majority of the cognitively impaired participants in t h e Guilmette et a]. (1993) study performed above the 90% cutoff score, 10% of the participants still scored below this cutoff. Martin et al. (1993) utilized a different administration of the F-C method than we used in our study (e.g., shorter delays between stirnulus and response presentations and computer administration of the task), and this altered administration may have, in some way, facilitated performance in their headinjured group. The results of the present study do not support the an-oss-the-board use of a less conservative cutoff score of 90%, in that 26% of the schizoplirenics performed below the 90% level. Of the 22 schizophrenics who passed the P C method, 19 were in the no cognitive impairment group. A cutoff of 70% may be more appropriate in a population suspected of faking, in that 29 of 30 actual schizophrenics met this standard. 455

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Back, Boone, Edwards, Parks, Durgoyne, and Silvcr Although the one previous study that examined the relationship between cognitive dysfunction and RDC performance (Greiffenstein et al., 1994) failed t o f i n d any association, o u r findings revealed that hfMSE scores accounted for a significant proportion of both ratio and grouped-dot counting time variance. Further, significant group differences in performance were documented between participants with cognitive versus no cognitive impairment, with the cognitive impairment group performing just below the cutoff of 4.8 seconds for mean grouped-dot counting time. The Greiffenstein et a]. finding that the F-C measure is not impacted by lowered cognitive ability may be a result of their use of percentile scores rather than seconds required to count the dots to determine failure. Percentile scores restrict variation at the extremes of score distributions, which may have accounted for their nonsignificant findings. Our results suggest that the RDC may not be appropriate to use with cognitively impaired groups, although it might be possible to rehabilitate some of the scores (e.g., mean grouped-dot counting time) by adjusting cutoffs. For example, as no schizophrenic in the present study obtained a mean grouped-dot counting time greater than 7.8 seconds, performance in excess of this cutoff might be used to indicate the presence of suboptimal performance.

N o significant re1at i o 11ship was documented between severity of psychosis (as measured by total score on the BPRS) and test scores. Thus, the three malingering tests appear to be rather robust regarding any effects of psychiatric symptomatology on test performance. If severely disturbed patients fail the malingering tests, it would appear to be due to other related characteristics (e.g., low educational level, cognitive impairment) rather than psychiatric illness. Increasing age was found to predict only a single test score (e.g., RDC grouped-dot counting time). Although no group differences in performance were documented between participants below and above age 40, it is of concern that, of the four participants who failed the RDC, three were in thcir 40s. These data suggest that the other malingering tests may be more appropriate for use with older

populations. If the RDC test is used with older participants, test interpretation should focus on the use of less stringent cutoff scores than we utilized in our study, o r possibly use of scores that are unrelated to specd of performance (e.g., number of errors). In conclusion, the results of the present study suggest that the RDC, the RhfT, and the PC method may be appropriate for use with psychiatric patients suspected of malingering or putting forth suboptimal effort; however, caution should be exercised when utilizing these measures with individuals of lolver education levels, cognitive impairment, or increasing age as the tests appear to be differentially impacted by these extraneous variables.

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