Although most disability claimants accurately report their symptoms and limitations during an independent medical examination (IME) it is a fact of life that not all claimants are credible. For this reason psychologists use a range of psychological tests to objectively evaluate claimant reliability.
It is important that doctors administer such validity tests in all forensic mental health evaluations, not just ones that have been flagged as questionable. This is because initial cursory case reviews often inaccurately identify which claimants are truthful.
A hundred years of research shows that objective psychological tests can be far more accurate than doctors’ subjective opinions. There is no other finding in social science research that has been more firmly established than the superiority of objectively based psychological assessment over clinical judgments alone regarding many psychological and psychiatric issues. Fortunately, such tests have largely been validated and can be used effectively with individuals coming from many different cultures around the world. A claims assessor should therefore appoint an appropriately qualified independent doctor who can incorporate objective test findings into their assessments.
About validity tests
Validity tests help independent doctors determine if claimants:
- Are putting forth full effort on mental abilities tests (such as memory and intelligence quotient);
- Are reliably reporting their symptoms, such as depression;
- Understand the meaning of test questions; and
- Have cultural backgrounds that might affect other test results.
In many countries, there is strong evidence that validity tests greatly improve the independent doctor’s ability to fairly evaluate a claimant’s effort and honesty during evaluations. This is particularly valuable to the insurer because if a claim is appealed, objective data is available to support the doctor’s opinions. Overall, objective psychological testing should remove concerns over subjective bias, reassuring both insurer and claimant that the evaluations have been conducted fairly.
Objective tests evaluate two types of claimant reliability: symptom validity and performance validity. Symptom validity tests help the examining psychologist evaluate the reliability of what a person says about his or her psychological symptoms such as depression and anxiety. Performance validity tests, on the other hand, measure the credibility of demonstrated abilities during testing (for example, how credible was the claimant’s performance on memory testing).
Symptom validity testing
Perhaps the best-known symptom validity scales are found on the Minnesota Multiphasic Personality Inventory (MMPI), which is available in many languages. The MMPI is the most commonly used psychological test in the world and currently is represented by the second version of the MMPI, the MMPI-2, and by a more recent version, the MMPI-2-RF (Restructured Form). The MMPI-2-RF (“RF”) is a shorter test and is completed much more quickly than the MMPI-2. The RF is valid and useful even though it has about 240 fewer items than the MMPI-2. The RF can be completed in 60-75 minutes, while the MMPI-2 typically takes 90 minutes to two hours to complete. Most licensed clinical and forensic psychologists as well as neuropsychologists are qualified to administer and interpret this test.
No other test is as well-researched or as well-developed as the MMPI for evaluating symptom credibility. Other personality assessments, such as the Personality Assessment Inventory (PAI), have validity scales, but they do not provide the same scope or depth of the MMPI validity scales. Some pain and physical functioning inventories also comment on the credibility of response, but they primarily address whether claimants have taken on the role of being disabled.
When interpreting claimant MMPI responses, examiners first consult the MMPI validity scales. If the results show that the claimant’s self-report is unreliable, the psychologist usually does not also interpret the other MMPI scales related to emotional problems such as depression and anxiety. If the validity scale results show the claimant was being truthful, the psychologist can use the rest of the MMPI data to more accurately assess claims of issues such as depression, anxiety and somatic worries. This greater precision helps doctors conduct scientifically sound evaluations with a better chance of withstanding challenges in court.
Performance validity testing
Performance validity tests typically assess the plausibility of cognitive complaints. These include claims of trouble with memory, focus, and concentration. Many but not all of the appropriately qualified professionals who administer these tests are board-certified neuropsychologists. So while the MMPI provides an evaluation of the reliability of symptoms such as depression, performance validity tests actually measure cognitive abilities by the performance exhibited by the claimant. For example, these tests can help answer the question about whether a claimant’s display of memory problems in the neuropsychologist’s office is credible.
There are five main standalone performance validity tests, which are designed to evaluate only credibility. They include: the Test of Memory Malingering (TOMM); the Validity Indicator Profile (VIP); the Word Memory Test (WMT); the Medical Symptom Validity Test (MSVT); and the B Test. Other such tests include the Victoria Symptom Validity Test, the Nonverbal Medical Symptom Validity Test, the Portland Digit Recognition Test, and the Dot Counting Test.
In contrast to these standalone measures, neuropsychologists also examine claimant test scores on measures originally designed to assess cognitive skills such as memory. These test scores are generally referred to as “embedded measures of malingering.” The most common embedded measure of malingering is from the Wechsler Adult Intelligence Scale Digit Span subtest, and is known as “Reliable Digit Span.”
Standalone performance validity tests do add time to the IME, but they often have the advantage of better evaluating performance credibility. Most standalone tests take at least 15 minutes to administer, and almost all of them focus on measurement of performance on memory tasks. The VIP takes longer to administer, but it measures credibility of performance on tasks involving intelligence, reasoning and verbal ability. There is a consensus among neuropsychologists that such performance standalone and embedded validity measures are a critical portion of any medical/legal assessment of cognitive skills.
In summary, good IME evaluations of emotional and cognitive problems almost always include direct evaluation of claimant credibility with validity tests. IME evaluations without a fully developed objective assessment of credibility often fall below the standard of care in forensic mental health assessment.