MM lrESl=
N/\ IEM\O
]RY M\AIL N G IE IR]t N G It
Test of Memory Malingering TOMM
Tom N. Tombaugh, Ph.D. Professor of PsYchologY Director, Centre for Memory Assessment and Research Carleton Unviersity: 0ttawa, 0ntario
Preston W. Tombaugh GraPhic Art
HMHS O
1936, Multi-Health SYstems lnc' All rights reserved'
N0partofthismanualmaybereproducedbyanymeanswithoutpermissionfrom'the.publisher MHsintheUnitedStates:P0Box950'NorthTonawanda,NewYork,14120.0950 1 -800-456-3003 Ontario' M2H 3M6 MHS in Canada: 3770 Victoria Park Avenue' Toronto' 1
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1
Gontents
l---lntroduction
'W
?**{alingering: An 0verview
Qualitative Analysis of Inconsistent
Responding
........................4
Performance Analyses'.....
...........,....4 ....................6
Discrimin¿¡¡ Function
ütapter 3-Oevelopment Validation, and Normative Data Normative Testiog
11"i¡h
f{sn-flinical
Subjects
Sample........
Vafidation with a Clinical lhlidation with Simulated and "At-Risk" Malingerers l'-tlidatio¡ with Simulated \h$ddi
..............9
..................
Malingerers Malingering................
..
ft@€r 4-Administrative
........................ 12
...........,...........14 ................15 .......................... 16
Guidelines for the TOMM
Rctenüon Trial (Optional Test)
............
.................19
Chapter s--lnterpretation and Case Studies
............ Malingering................
Tmpücations for Other Tests
...................... 19
Dagnosis of
......................20
Gontents
Tables Tabte 3-1
Means and Shndard Dcviations for obtained and Estimated perfo¡mance on the *iá ó"ñi,ir"rr_Intact Adutts ........
TOMM (Four-Choice v"rrionl Table 3-2 Table 3-3
Percent of correct Responses on the Four-choice M-eans and standard
o*n""l""ll rorvrh4 (rwo_choice f3viltions v",.ioni*itr,ó"ño"or-lná";
".
Iable 3-4 Iabte 3-5
Iable 3-6
Table 3-8 Tabfe 3-9
""""""'.........
;:#J'ff:ff:Tfr'e¿urts"""""".
5-t
ro
dil.:::::...........
3*T*:Ig, ToMM'forrh'fu;d;il; fo¡
cunic¿:;;:
scores on verbar and visuar Tests of
Percent of correct Responses for Diffe¡ent cünical Groups on the Means and Shndard Deviations
.............,.13
ToMlvf
for Simulato¡s and Conbols
Means and Standard Devflo_ns for Scores on the TOMM for the Srr¿y ...._..1__-:_._::.........
........,....... 15
At-Risk-for-Matingering Table
10
............... 11 Percent of correct Responses on the Trvo-choice TOI!04 with cognitively-Intact Adurts ......,.....-12 Group Means and sta¡d¿rd As3, N-umber of years Numberof correct Responses of Educarion, and on rhe ..... Means and standard Deviations percenüre
Learning and Retenrion ror Iable 3-7
Tnrrrr ..",: ^
Ten commonly used eualitaüve signs and svmnro-o Tests of cognilve abiüt¡es ..._._.:_::...:::.."..t*t* of Matngering on
^r-"_;,__"':'
"""""""""".....'
16
..................20
About'the''Autho'r N. Tombaugh, Ph.D., is a Professor of Psychology at Carleton University'in Oüawa Canada- He has served as Chairman of theiPsychology Department, and'is Trsrn
arrcntly Director of Ca¡leton's Centre for MemoryAssessment and Research. He has prblished extensively on the subject of learning and memory, initially workinB in the fields of neuroscience and psychopharmacology and, more recentl¡ in'clinical neufopsychology. Tom Tbmbaugfi is also co-al¡thor of the Leaming and Memory Baüery {táMB), a comprehensive test for assessingleaming andmenory abilities.
A1i:li¡:: )¡ ; rr:.
i
::r
,!
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$,1:::,
vil
I
Ghapter
lntroduction **',,***
ffi**
'ntw*1ngb i¡nportant
neuropsycbologists wnre psychologists uod nust be witnesses' As such' they ro sen'e as exfleft
2. -
test
ót**t*t" the validity of neuropsychological claims' *ty l^u" a bearing on the litigant's I ,#,ú* ¡eáÉ;
'.i:r ,',
''
ffi :*r:.'""*Jffitrjn"H:?fill:;
66*e*
rEosl"'.s fo.ocial
X*'n ¡*,
t'
be or personal gains' it mrrst
U","*o*
I
is a 50-item recognition mnEnge¡ers. The TOMM a retention
trials and that includes two learning the patient is shown trials' Dqiing tbe two leaming ''.t objects for (target picores) of coTmon ','ilñ*r.¿ÉtL a! r-i*on¿ intervals' The patient is then at a tile' Each panel 50 recognition p*"1'' one wget pictures 'sodsir¡s one of tfre previously presented i1 reOuir.ed to select the red a ncw picnre' tn" puti"nt pi"tttt" thowu.during the learn,,ffinÉcl picore (i'e', the the optional ,.,,.;,.$q uial)- The ,u-" pó"do'".rt. 11 target pic¡uqgs. ar€ not re-admin-
j.,
'¡fuü*
Ct
,':ffi,6liogs "
:,'u'ffi J" """"n"i"
-:
effect permi.ts ttre fOVnvt criterion to detect maling-""".9' using be-
TOMM. The robustne"
a-"tf",
u
át*'i'
T'
-o'" traditional .nrlear¡re ;il;;;" ""*-¡ased 1r for malingering'
;#;;"
performance as the criterion
uncompücated process' One Scoring the TOMM is an answer provided by the point is given for each correct Retention Trials; Thus' patient on the Recognition and of the Recognition and Rethe ninimum score on each
M
tentionTrials(noconectanswers)is0,whilethemaxi.
to astrials alone are usually sufñcient adds üial w@aing' Ho*"uer' ose of the retention corroborate the * f** Fin¡lÉes to the test and helps TOMM (without the retenr,whs. Administration of the dqfi üiat) t*kes agproximately"15 'oinutes
iw dg
paticnts antllalinsers"or", of memory-impaired a leaming opportunity for
to malingering' it is insenWhile the TOMM is sensitive All indivi.du"t: 11;iil; neurological impairments' impairmentst hav3 a rethose with neurological "frAi"g high capacity for storiúg and retrieving pictures --t"Uly used in the ;a;;"t;eryday objects' such as those
ad €**
:
on resPo.ns: conect3. Expücit feedback to patients the gap between the ness after each item widens
their patients and should increase aIit while trials' response accuracy on subsequent pertheir track lows malingerers to more accurately formance and adjust it accordingly'
*ffi$
:
impai¡ment'
"rt.-¿¿uo** *r"t motivated
DescriPtion
:
validity as atestoflgarn¡ng as a uod.".ory. ihit d""t"*es its transparency effec{veness its t"rt of mAingering and increases faked in detecting exaggerated or deliberately
ünñ;;tigooar*"
provides
efforr is exerting his or her full
ThÉTcstofMerroryMalingeringCtoMM)providesa neuropsychologists i¡ discrimir¡*cmatic mexhd to assist patienB and n*ing betrreen bona ñde memory-impaired test for
Senutne
pictures also provides the Thepresentation of 50
memory
to'be valid' fw ceumpsychological test-:cor:s
'k.c*mc* süere test
llth
intentionally perform memory impairments and patients exert their poody, while non-malingering full effort and do well
the rn nerropsychology' With involving cases and medicolegal
M-%;;;;;;t trauma' more and *x ¡ogcaf injury' particularly head are being #
for people the test would be difficult
intentional faking or exs6 rnalingering--the d rymptoms-fo' p"rsonul gain-is becoming grow-
ro Fning
is 50' mum score (all answers correct)
Ñor*utiv" ,ron'clinical
; #;;;;. t; ga i;"-
"
*
collected data for the TOlvflvf was phase' 405 individuals aged 16
tust
a
four-
ZO'Z¡ were administered = 54'8, SD = oithe ToMYi In the second choice, no feedback version to 73 (mean = 37'8' SO = l4'2) phase, 70 people agel 11 which included the two-choice version'
the TO$vI par$asal inportant characteristics lake for detecting nllSennS' €**"1y "ffe"tin"
i""*
"a.t-tl"ttd of response' feedback regarding correctness
}..Tb¿administrationofalargenrrmberofvisual thal the test is much si"suli gi*' it'" impression is. lvfalingerers believe more diiEcult than ii really
neuropsychological assessValidation data included 138
1
T0MM-Test of Memory M'l'!qtn!g at the Veterans ments from inpatients and outpatients ¡¿-i*rt ution Medical Center in Boston' Massachusetts Rees (1996)'
in and 23 head-injured subjects described DSM-IV Diagnoses, based on DSM-III-R and
criteria for
frort ttreitinicat group included cognitive impairment
and dementia' diverse etiologies, traumatic brain injury' O*i"g develJpment of the TOMM' validation resea¡ch *." Jso,conducted using a group of individuals (n = 27)
whowereinstructedtosimulatemalingering.Theresults group (n = 22)' 6f f¡furgroup were compared to a control
ln anotier sample, f f in¿ivi¿u¿s who sufferedtraumatic t uio io¡ory *ere classified as "at-risk" fornali.ruel8; to a "not,rr"n *"r" ionolved in ütigation-and comp4red (n = 12)' group apatient control ui-átt" group = (n = 17),)tcontrol grouP (n = 1l)' a cognitivelY-intac
the User instrument must meet the criteria outüned in chapter' this Qua)ifications section of of The'ToVtrrd is not intended to be the sole instrument clinical assessment or a substitute for sound clinicaljudgsuch as ment that utilizes various sources of information' on the score low A clinical interviews and observation' TOMM
however' must or exaggerated A diagnosis of malingering'
alsodemonsnatethatthisfalsificationorexaggeration:of motivated by symptoms was intentionally produced and economiexternal incentives. TheTOMM offers areliable' a patient:is cal, and usefrrl first step to judging whether
malingering.
and
in Chapter 3' A detailed examination of the data appears
non-malingerers' but the general impücations a¡e clea¡: score very well even those with substantial impairment'
malingerers score on the TOMM. Málingerers or suspected that any on the TOMM' The research suggests
ve¡y low
Retention Trial should scóie lo*er than 45 on Trial 2 or the maxi,Jr" óono* that the individual is not putting forth
mum,effort and is ükely malingering' to tltg-lOMM' This chapter offers a general introduction thetemt developmentof and the history Chapter
i
reviews
t;-oli:rg"ring," d€fines malingering for the purposes of
to detect malinthe TOMVI; discusses va¡ious strategies specifically for gering, and examines other tests designed 3' the üeoretiit ¿ILc,ioo of malingering' In Chapter and the " TOMM the of cal rationale for the development are the as or" of the recognition:paradigm is outlined' provides derelopment' Challer 4
,iog* of.th" róuu:s
u¿ii¡rt
TOMM' utiue instructions and guidelines for'the
inte¡pretation of the Chaptqr 5 presents strategies for
TOMM,adiscussionofthediagnosisofmalingering'and
a¡e false suggests memory impairment symptoms
User Oualifications As a general principle, users of instrumentsrsuch
as
th¡
understandTest oi Memory Malingering should have an psychologiof ing of the basic principles and ümitations
cj
t"stiog, especially psychological test interpretation'
pertainto Specific issues of reüabiüty and validity as they manual' the TOMM are discussed in Chapter 3 of this
individt¡' Although the TO\A4.is easy,e.norrgh,for man; recogwho als to administer'aná score, a psychologist ümitations of such diagnostic procedures must ;;;; administration' assume the ultimate responsibilify for its scoring, and interPretation with the Potential users of the TOMM should be familiar standa¡dsforeducationatandpsychologicaltesting..de-l
Associaveloped jointly by the American Psycholo!¡ical Educain Measurement on tionl¿ the National Council also should test this tion (APA, 1985), Qualified users of a endorse of, professional associations that
be members
sétofstandardsfortheethicaluseofpsychologicaltests' professionals in psychology or an alüed field' or ücensed
contains speaseries of cünical case studies' Appendix'A
each paand radiological information on "in" tient in the normative grouP'
t"O"¿
T0MM GomPonents comPonents: The TOMM includes the following
. Trial I Stimulus Booklet (50 target line-drawings'
Uses neuropsychologists The TOMM was developed to assist fide a in assessing whether a patient has bona -memoV some ñ¡ui*"nlor is malingering on memory tests'forcan be adon, óften financial gain' As such' psychological-battery in a used as part of an extensive faciüties' hospinumber of s"ttingr, including outpatient uSers of this ,¿r; *¿ nrtuate practice offices''Potential
*:
"9Y*
50 recognition Panels)
'
Trial 2 Stimulus:Booklet (50 target line-drawings; 50 recognition Panels) Retention Test Stimulus Booklet (50 recognition panels) Response Recording Forms
Ghaptet 2 Malingering: Ah Overview Malingering, i¡ the broadest sense of the word, refers to deliberately faking or exaggerating the symptoms of an illness or disability for personal gain. According to Nies and Sweet (1994\, the term malingering was originally a miütary term used to describe soldiers who evaded duty by faking illness. Historically, it also has been an important topic in the field of rredicine (Ruff, Wyüe, & Tennant, 1993). For the general pubüc, the term malingering is most closely associated with criminal cases in which a defendant claims to be "incompetent to stand trial" or enters a plea of "not guilty by reason ofinsanity."
It has only been in the last decade that malingering has become a proninent issue in neuropsychology. This is primarily attributable to a recent rise in forensic and medicolegal cases involving neurological injury particu-
larly head trauma. Along with an increased use of neuropsychological tests to assess cognitive abiüties affected by head traumq there has beon a corresponding increase in the use of neuropsychological evidence to either support or to rebut the legitimac/ of claim5 regarding deficits in cognitive abilities. This reliance on neuropsychological evidence, has created a heightened demand for neuropsychologists to serve as expert witresulting in an increased need to demonstrate the validiry of neuropsychological test results. As La¡¡abee ¡resses,
(1990) has note4 "tests alone do not indicate brain damage; rather, it is the interpretation ofpatterns by the skilled neuropsychologist" @. 239). neuropsychologist's judgment is particularly critical wtien claims of cognitive impairrrent ca¡not be adjudicated solely on the basis of neurological or radiological
A
evidence. Oft,en, when faced with an un¡ema¡kable neurological exam and radiological evidence, ajudgment concerning the legitimacy of the litigant's complaint and putative üsabiüty may rely heavily on neuropsychological findings. A prime example is mild head injury accompanied by many symptoms which are subtle and escape . neuroradiological detection. In this cass and in simila¡ situations, the cünical neuropsychologist must make some judgmeng either, impücitly or expücitly, about whether or not the person is malingdring. That is, he or she must
Take a
judgment about the validity
of
the
nLuropsychological test res-utt(. the'afiüty of neuropsych-
ologists to make this kind of judgrrent has been widely
debated and researched (Arkes, Faust" & Guilnette; 1990;
& Hawk 1992; Bigler, 1990; Faust et al., 1988a; Faust, Hart, Guilmette, & Arkes, 1988b; Matarazzo, 1991 ; Schmidt, 1989). Barth, Ryan,
The validity of neuropsychological test scores requires, fust and foremost, that patients put forth maximum effort. If this effort is lacking, the motivation underlying suboptimal performance may stem from non.neurological sources that do not involve the conscious desire to seek external gain through deception. That is, an individual's failu¡e tci put forth maximum effort does not necessarily mean the person is malingering. It often represents a "cry for help," or it may reflect other motivational factors such as affective state, psychiahic disorders, anxiety, fulfillment of emotional needs, and unconscious desires. The va¡iety of diverse and etiologically distinct reasons which may lead to suboptimal effort a¡e referred to collecüvely as "motivational disorders." Viewed.rn this wa¡ malingering represents a specifc type of motivational disorder.
The differentiation of malingering from other types of motivational disorders A"p"ni, laigely on how it^i, ¿"fined- For g¡¡mFle, the DSM-IV (American Psychiatric Association, 1994) defines malingering as the'tntentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining fi¡ancial compensation, evading criminal prosecution or slt¡ining drugs" (p. 683). The requirement that an individual's behaüor is motivated by external goals serves to differentiate palingering from factitious disorders, (e.g., Munchausen and Ganser syndromes). Wth these disorders, an individual is motivated by a desire to assume the sick role, rather than to gain external rewa¡ds. Malingering is also differentiated from somatoform and conversion disorders by the presence of an external incentive and the intentional fabrication of symptoms.
Definition While most clinical psychologists and neuropsychologists agree that,malingering is intentional and motivated'o-y external incentives, several authors have argued thát the phrase "production offelse or gr,qffiIf :x¡,g¿ffirC ¡üFrs*-
T0Mfi4-Test of Memory Malingedng narroY and rest¡ict-
is too cal or psychological symptoms" ües on a coning. They have proposed that malingering to from mild exaggeration of_symptoms
,irio*,
iaoging
1992;' Resnick'
rabi"urioo of svmptoms (MttT:' rn this lgig; nogers, 1988a, tgéb; Zielinski' 1994)'broader reflects-this -*o"f, tie term "malingering" with Nies and Sweet consistent *"*iog. fnis usage is also
1""*i
review article on malingerttrgO),;n" conciude in their generally psychologists and neuropsychologists symptoms occurs much agree that the exaggeration of Áre frequently ttra¡ the pure faking of symptons'
irg,ú
to provide a taxonomy Some attempts have been made can be identified' whereby different types of sralingerin$ three types of maFor example, Resnick (1983) describes nonexistent fitg"riog.'Po"" malingering refers to
t{n*
,Váptoi*, whitepartial malingering
refers to exaggerat-
Situational Variables ti"r" i, üttle doubt that situational va¡iables are impori" the detection of malingering' The fact that malinit gti"g i. motivated by external incentives suggests that inexpecied that ucross situations. In addition' it is
*t
iuri"J
dividualswiübeselectiveinthesymptomstheydistortand symptoms' Within in the degree to which they disort the
psychology and psychiatry' malingering should ofneuropsychological be considered whenever the outcome gain (American tests involves some type of secondary Binder' fry"ttiut i" Association 1994; Binder' 1990; Binder & Willis' Villanueva, Howieson' & Moore, 1993; Healon' Smith 190; 1991; Franzen" Iverson" & McCracken' 1992; Rogers' Martin' & Lehman, & Vo gJ, L97 8',I'rx',Loring, 1988; Zelinski' 1D0; Tn¡eblood 1994; Wigeins & Brandt'
ttre fieldS of
'
malingering
that fgg+i. nor example, the DSM-IV advises contexts (Amerishould be stongly suspected in medicolegal
type' false imputation' ing existent symPtoms' The third to an existing symptoms are falsély atfibuted
can Psychiatric Association, 199,4)'
guauiorrt
person
o."*
when
(1988a) uses three etiologically unrelatej cause' Rogers severity of distorthe on of mafngering based
These classification schemes tion: mild, moderate, or severe'
symptomexaggeration that direct attentionto the degree of occu¡s in malingering
*¿ t¡ot have conceptual and heu-
time, thgV have not ristic utility. However, at the present useful' operationalized to be clinically been sufficiently
model would preMoreoveE Rogers' (1990) adaptaüonal whenever a dict that malingering should be considered it is reasonis in an adversa¡ial position in which uUty
& Cavanaugh' 1989)' Care should
Gogers, fggO;Wasyüw is' a person te taken to avoid over-i¡clusiveness' That to be malinhvolved in ütigation should not be assumed
occurs in gering merely because malingering comnonly exagwho individual úrig**. Similarly, an uuemployed gain to a head injury gerales the copitive impairments of assumed to be'defunds for his or her family cannot be be exercised to must Caution
employed two disIn general, neuropsychologists have to identify malinti¡Jti".fy üfferent detection strategies ren rt involves a qualitative analysis of
;;;t. ír," ;p";t that occur during standa¡d neuropsychological specific tests
and may not occur in lingering may be situation specific anY other contexL
Oualitative Analysis of Responding
qualitative indices reües Detection of malingering from diawareness' knowledge' and
lnconsistent Performance (e'g'' involved Although the context of the examination it is the perfomtin ütigation) may indicate malingering' the eYidence for uo"" oo the examination that provides
or, Á" o"*opsychologisis the same skiü inagnostic skill. In essence' it requires
the patient's volved in making any diagnosis-comparing that a set of diagnostic symptorrs n ofrf" of ,"ores against characterize various diseases'
neuropsychologists' malingering. Consensus exists among that inconsistforensic psychologists, and psychiaf¡ists This inconsistency ency is ¡¡s hallmark of malingering' exaggerated grossly a from can take many forms, ranging to symptoms' fide difference between simulated andbona sense'" pattern of scores that does not make "neu¡ological
Someoftheva¡iablesandqualitativesignsusedtodetect
of amnesia or memory impairment-situand discri' inconsistent performance' ational Because below' described minant function analyses-are memory that inüviduals who feign impaired It lt intellectual other tests of cognitive and
".Aiog".iog va¡iables,
with tests ability, detection sEategies used *gitiu" abilities a¡e üscussed as weü'
i¡
other situations' in a specific context insure that a flerson who nalingers The mais not artomatically branded as a "malingerer'"
ceiú¡l
á¿outioo. The second approach involves designed to detect malingering'
*tfy ;;;Tt;'ñ;
that fabrication or exaggeration of symptoms
wouldbeanefficientwaytoachievesuccess(e.g.,evalu. ationfordisability).However,suspicionofmalingering of malingering should {rot be taken to mean evidence
Detection Strategies
it
tit"ty
a
Patientswhomalingertendtooverestimateorexaggef¿te with different types the degree of impairment associated repeatdemonstrated of trauma or illness' Research has
measuring other
4
tj:t:ü¡
edly that the performance of malingerers on standard nexropsychological tests is substantially below average and out of proportion with the severity of the feigned impainnent @ernard, 1990; Greiffenstein,.Baker, & Gola' 1994;Heaton et al., 1978; Millis, 1992; Trueblood, 1994)A gross exaggeraüon of symptoms may occur on all tests
in
an attempt to simulate global impairment, or the exag-
geration may be more selective and occur only on some tests. In either case, severity of the simulated impaimtent, as reflected
in the test scores, is not commensurate with
the severity of the injury.
A frequently reported example of malingering involves individuals who have suffered mild head injuries but who generale neuropsychological test scores comparable to those obtained frompatients with global cogniti-ve decline. lyl¡sn malingering reflects this kind of gross exaggeration of symptoms, it usually involves unsophisFcated individuals who are not awarc of the actual symptoms associated wjth their feigned impairment. In these cases' maüngering is detec¡ed with relative ease.
Not all malingerers, however, a¡e naive' In fact, it is reasonable to assume that man¡ and perhaps most malingerers have some di¡ect or indirect knowledge of the specific symptoms associated with the illness or injury they arc trying to feign. Some have direct knowledge because
the symptorns may have previously existed but are currently absent or less intense. For example' the person may have partially recovered from a head injury and may claim norc serious impairment than presently exists' Some malingercrs obtai¡ knowledge indirectly by reading extcasircb" abo{¡ithe sympoms in guestion' orby obtaining informarioa from ftieods, parients' or aftomeys. Detecting maiingering becomes more difñcult when the malingerer is knowledgeable rather than naive. The so' phisticated malingerer may simulate symPtoms which are not obviously exaggerated- Nonetheless, his or her pattern oftest scores a¡e detectable because they will not conform to the neurobehavioral profile in question. The test scores and symptoms will not make "neurological sense." One detection strategy, particularly useful for revealing profiles that do not make neurological sense' compares the relative performance on recall and recognition measMost memory-impaired subjects have . ures of memory. relatively higher recognition scores than recall scores. This relationship has been demonsaa@d repeatedly with mild to moder¿te head injury and often occurs with a variety of
individuals simulating memory impairment (or seeking financial coppensation) show the oppo,site relationship. That is, malingerers often have higher recall scores.than recognition scóres. This relationship has been particularly well documented oli word üst tests such as the Rey Auditory Verbal Leaming Test @ernard, 1990, 1991; Bernard & Fowler, 1990; Bemard, Houston, & Natoü, 1993; Binder et al., 1993; Brandt, Rubinsky, & Lassen, 1985; Greiffenstein, Bake¡ & Gola, 1994; Trueblood, 1994; Trueblood & Schmidt, 1993; Wiggins & Brandt, 1988). In many cases, inconsistent perforrrance,occurs because the person incorrectly "guessest' what a test measures. For ex^mple, when tested for memory of personal information, individuals faking amnesia may incorrectly state their name, age, or date of birth (Wiggins & Brandt, 1988). This ¡esult is contrasted to amnesic brain-damaged patients who seldom forget autobiographical information (Wa$. 1977), In this example, the faked amnesia is similar to symptoms observed with psychogenic amnesia where
individuals suddenly forget personal inforrnation. It appears the patients who faked amnesia were not familial with the types of amnesia and faked the wrong kind. Pankratz (1988) speculates that a failure to differentiate between different types of memory proeesses (e.g., remote vs. recent memory) explains why many patients who complain about a decreased ability to remember newly acquired information obtain unreasonably low scores on measures such as the Information and Comprehension subtests of the Wechsler Adult Intelligence Scale-Revised (WAIS-R: Wechsler, 1981). These tests measure cognitive abiüties that a¡e more related to remote memory and reasoning ability than to recent memory.
Similarl¡ patients frequently fail to appreciate that digit span tests measure attention and concentration, and incorrectly assume they measure memory. Measures of concentration and attention yield cünically useful data for identifying malingerers due to this misattribution. Forexample, several studies have reported that patients faking cognitive impai¡ments due to head injury frequently scor€
in the impaired range on digit span tests (Andrikopoulos, 1994; Mittenberg, Azrin, Millsaps, & Heilbronner, 1993). This outcome, of course, does not make neurological sense
given that immediate attention ¡s¡¡aing relatively intact in traumatic brain injury (fBI) and global amnesia @utters et a1., 1988; Levin, Benton, & Grossman' 1982; Schacter & Crovi¿, 1977; Squire,1987; Strub & Black,
otler neurological dysfunctions, including Korsakoff's
1985). Thus, unusually low scores on various.measures of attention, such as Digit Span and the WMS-R Atten-
syndrome, anterior communicating artery aneurysm, and herpes encephalitis. In contrast, many test profiles from
tion/Concentraüon Index, may reveal noncompüance (Andrikopoulos, 1994; Binder & Wilüs, 1991; Boyer,
-'
-
;"':::
;
Different performance on the sane test given on two ocSubcasions (e,g., digit span) may suggest malingering'
al" 1991; Crossen & Wiens, 1988; Heaton et Trueblooü Mittenberg et al., 1993; Reid & Kelly, 1991;
1978;
1994; Trueblood
the stantial discrepancies across differerit:tests measuring possibility of mas¿rme mnemonic abiüty also signal the visual or verdifferent lingering Normally; scores ftom
& Schmidt, 1993)'
comInconsistencies may also occur between memory the during plaints (or test scores) and behaviors observed testing situaadministration of the tests or outside of the describe a p' 54) (1995' tion. Schmidt and Tombaugh after a loss memory patient who complained of a seve're scores on the motor vehicle accidenL Not only were her to the neuropsychological test battery out of proportion inconsistent dramatically seveity of her injury' they were her way to with everyday actions. For exemFle, she found was able to the examiner's office without assistance and a forward digit record his phone number despite having span
bal memory tests should yield similar standa¡d scores or percentiles when compared to age-matched norms' Thus'
-."or",
ftom different measures of verbal lea¡ning (e'g" paragraph recall, word üsts, and word pairs) should be to percentiles and compared for consistency of "oou".r"¿
performance. Gross inconsistencies fromthis patüern may reflect malingering.
Although the idea of using these various invalidity indicators and patterns of inconsistency to identify malingering is conceptually appealing, its practical'application is tÁite¿ (Franzen, Iverson, & McCracken' 1990;
ofonlY 3 digits'
Mittenberg et a1', 1993; Trueblood, 1994; Trueblood & Schmidt, 1993)' This is primarily because the invalidity signs appear relatively infrequently' Trueblood and
in which an La¡rabee (1990) reports another case study but was able individual obtained spuriously low test scores (l) to recall the na¡ne of the neurologist who had con(2) to remember the ducted an assessment 4 years earlier; aprevious exalnining psychologist; (3) to
S"t -i¿i if gg3) exarnined the results of neuropsychologin¡lingerers who had been identified on cal testing fe¡ reported the basis of lower-than-chance perforrrance' They
lf
appearance of previously used; and ¿escri¡e accurately stimulus material hour visit' (4) to remember art objects seen during a lunch behavother and scores de inconsistencies between tests
that "many of the previously suggested
that invaliioral indices provided compelling evidence
tweenthem andvalid symptoms' For example' Mittenberg of lea¡net al. (1993) point out that patients with a history WMSproduce disorder ing disability or attention deficit atinüviduals R profiles similar to those produced by
as well as Inconsistent responding within a specific test' indicator of inbetween different tests, sefves as another forrrs' such many take valiüty. This inconsistency may B than Trails on as obtaining a relatively higher score than Trails A, or a higher score on Digit Span Backr¡¡a¡d soTe leam to failing addition, Fonvard- In
tempting 1s nalinger head injury' Finaliy, several studies have shown that practicing neuroinpsychologists have üfFrculty distinguishing between
on Digit Span Scaleof tne easy word pairs on the Wechsler Memory difmore the of Revised CWft¿S-nl while mastering many
dam¿irri¿u¿s @oth children and adults) simulatingbrain scores using age and those with bona fide injury when Hart' from standa¡d neuropsychological tests alone @aust' 1978)' al" et Heaton 1988b; al', et & Guilmette, 1988; Faust and Schmidt see Bigler (1990) ,Matarazzo (1991)'
suggests faking fiqutt wor¿ pairs is relatively unusual and that maevidence some also (Gronwall,lqqr). There is to answers lingerers proüde neaf misses or approximate
However,
(1989) for methodological critiques of these shrdies'
quJrtioor-ot the WAIS-R @ash & Alpert' 1980)'
it is useful to
Diseriminant Function AnalYses qualiThe faiture to find diagnosticatly useful patterns of to tative features has prompted some neirropsychologists established be can patterns determine if quantitative such as through the application of statistical procedures discriminant function analyses' This approach was'pio-
assess whether patients increase
tend to give their effort on more üfficult itens- or if tn91 due to deup quickly. The latter suggests a lack of effort distribution of "I creas"¿ motivafion. The frequency and making this don't knof' answers also may be helpful in answerl knowl' determination. A large number of "I don't
-"y
inü"ut" a lack, of effort However'.since
a lack
that neered by Heaton et al. (1978) who reported
of
judgment multivariate procedures are superior to clinical in identifying malingerers' Although other authors have proceduies' several reporte.d moderate success with these
and psychieffort is also associated with mood disorders attibuting in exercised atric iltnesses, caution must be
regardsolely to malirrgering' Nevertheless' "ffott of effort has i"s, of tt ,""soo, Lnid"o-"" suggesting a lack " smce impücations for interpreting test scores
i*t
¡igns
üdity
dated her neuropsychological test scores'
Further,
iwali{itf
invawere rare or absent'' (l. 578). Moreover, even when beexists signs are present, considerable overlap
of
employing drawbacks have beenidentified' Most studies of multiva¡iate techniques have compared performance
important
it luestions the valiüty of the results' 6
TOMM-lest of Memory tt4{lgryg Baker' & Giuliano, & Leininger, 1994; Greiffenstein' & (Bolter versions GoIa, 1994), as well as computer Hunter' & Pinch' Niccolls, 1993; Sück, Hopp, Strauss' 1995)' 1994; Rose, Hall, & Szalda-Petree' showed that worseEarly reports from clinical case stuües with subjects suspected than-chance perforrrance occurred experimental stud' of malingering. However, more recent have reported Portland the ies using-both the Hiscock and
as a test as a memory test and increases its transparency
of malingering (Guilmette, Hart, & Giuliano' 1993; et Guilmette, Hart, Giuliano, & Leininge\ 1994i Sück
to administer the a'^, t994):The amount of time required
also a drawSVTs, particulady the original version' is (1991)' Wilüs and Binder by back ninalty, as mentioneá divided in the Portland may be sensitive to impairments it difñcult to attention and recent memory' This makes to motivation' interpret errors as being solely attributable
That is' many india high iate of false-positive errors'
;dát
asked to suspected of malingering or individuals
patients persimulate the performance of brain'injured (Binder & fonned at above-chance-levels of accuracy 1993; Ma¡tin' Wilüs, 1991; Guilmette, Hart' & Giuüano' 1992; Pngatano & Gouvier, Todd, Bolter, & Niccolls' was greater-thanAmin; 1993). Although performance
chance'itwasstillsubstantiallybelowtheperformance subjects' obtained by brain-injured or intact
of malingering has Based on this observation, detection of norm-based criterelied increasingly on different types include scores ria- For example, criteria for malingering from a brain beláw the lowest score obtained occuning
a*"gJ
group @inder
á¿a¡¿ lojoty tfSI) f .¡
& Willis' 1991)'
scores falling
Brain ¿e.'iations below the average Traumatic score (Greiffenstein' Baker'
& Gola' 1994\'
orscoreslowerthang}{¡oconect(Guilmette'Hart'& Giuliano, 1993). differing degrees of sucThese approaches have met with noñnaümited in their appücation because
uriJ*" ""rr, tive data have
with been restricted primarily to individuals sinno the present time' closed head injury' Moreover' at glecriterionorcut-offscorehasbeenuniversallyadopted. also be ilre usefulness of a symPtom validity test may vaüüty face o"""ose its simpücity decreases its
uJ*á
Summary Strategies
for detecting malingering have involved two
upp*aches. First, qualitative analyses of respondused- These strategies focused on situational íog nu.r" do not m¡ke vJriables, neuropsychological profiles that Dissat"neurological sense," and multiva¡iate analyses' remeasures these of success the overall
g*oá
i*
isfaction with of nalingersulted in the development of specific tests ing. Most of these tests used some type of recognition
proprocedure. Howevei the specific types of recognition several ledur"s currently employed in these tests have accepted a universally of disadvantages, including the lack of newoscore, their sensitivity to various types
criterion their logical impairrrent, the duration of time required'for
ui-minirt ution, and their inadequate face validity
as
of the tasks' memory tests due to the perceived simpücity a subst¿ntial bod.¡ of Despite these shortconings, there is procedure isthelest üteratu¡e thal suggests a recogrrition test to detect malincandidate for developing a specific of Memory MaTest the gering. In ligbt of this eid"*",
of tlog"iog (IOI4Ivf) was developed' The dwelopmént data' valiüty O"-tO¡.Ar'f, along with the normative and are presented
i¡
the next chaPter'
Malíngering: An Overview
malingerers with that of non-cünical control subjects. Very little evidence exists that shows how well malingerers can
be differentiated from other diagnostic groups- The evidence that does exist suggests that a separate set of empirically derived discriminant functions would be needed each time a different set of tests was used or when a different diagnostic category was involved @emard, Houston, & Natoli, 1993).
Malingering Tests General dissatisfaction with existing detection strategies, coupled with an increasing Pressure to demonstrate the valiüty of neuropsychological tests, prompted an intensive search for a paradigm that could be used to detect malingering. Initially, research focused on existing ma-
lingering tests such the I 5-Iüem Memory Test @e¡ 1 96a). This test requires a person to remember 15 items after viewing a stimulus array for 10 seconds. In order to make the test apear more difficult than it is, the number "15" is emphasized in the instnrctions. Then a stimulus card containing fi.ve rows, with each row consisting of th¡ee figures (e.g., A, B, C;1,2,3;a"b, c), is presented. The stimuü are arranged so that only a few ideas or concepts (e.g-, first tlree letters in the alphabet) are needed for complae recall. Thus, the test was dasigaed,to be sufft-
ciently easy so that even individuals with brain impairmenf should be able to recall most of the 15 items. Unusuálly,low scores, therefore, should indicate malingering. However, results from several studies showed that the 15Item Memory Test was not able to differentiate simulators from controls (Beetar & Wilüams, 1995; Bemard, 1990; Sch¡etlen, Brandt,I(rafft, & Van Gorp, 1991). Other stuües demonstrated that the test was sensitive to differenttypes of neurological impairments (Davidson, Suffield, Orenczuk, Nantau, & Mandel, 1991; Goldberg & Miller, 1986). In addition, there does not appear to be any consensus as to which cut-off score provides the best sensitivity and specificity. Lezak (1983) suggested a cut-off score of 9 items; Bernard and Fowler (1990) recommended .using 8 items; and Ite, [.oring, and Martin"(1992) sug' gested a cut-off score of 7 items. Resea¡chers have also atüempted to determine if rralingering couldbe detected using existing neuropsychological ,
tests including the WMS-R @ernard, 1990; Berna¡d, McGrath & Houston, 1993, Mittenberg et al., 1993), Rey Auditory Verbal Leaming Test (Bernar{ 1990; Bema¡d, Houston, & Natoü, 1993; Greiffenstein, Baker, & Gota' 1994; Binder et al., 1993), Memory Assessment Scale @eetar & Williams, 1995), and Recognition Memory Test (Millis, 1992,1994; Millis & Pufna:n, 1994). While the
.. :.: :t.:
:::.:aa
t.,i.'
(¡;:r¡',:.,1r:
results from these studies were generally disappointing, they did show an inportant trend. Overall, the most sensitive tests for detecting malingering utilized some tn)e of recognition paradigm. This finding was supported by other research using non-standarüzed clinical tests (Frederick & Foster, 1991; Wiggins & BrandL 1988).
In the ñeld of malingering, one of the ea¡liest successful appücations of recognition procedures was in the detec-
tion of sensory impairmenl A forced-choice procedure was used in which the person fi¡st heard a tone (target or signat). Then, after a brief delay period, the person was required to select the target from apair oftones containing the target and a distractor @rady & Lind, 1961; Grosz & Zimmerman, 1965). Since an individual could obtain a score of 50 percent without any knowledge about the target, malingering was indicated by lower-than-chance per-
formance. Pankratz, Fausti, and Peed (1975) named this procedure "symptom validity testing" (SVT) because its purpose was to test the validity of a symptom, that is, to evaluate malingering. In a subsequent case study, Binder and Pankratz (1987) clearly demonstrated how the SVT couldbe used to detect faking of a memory disorder. Hiscock and Hiscock (1989) modified the SVT procedure by using a five-digit number as the stimulus üo be remembered across three üfferent retention ütervals. A ca¡d containing a 5-digit number w¿rs presented for a S-second study period- Then after a brief dela¡ a second ca¡d contuining the target and afoil was presented, and the person was required to identify the target. No distractor procedure was employed during the retention intewal. After 24 trials, regardless of the person's actual perfoimance, the individual was told that because he or she perforrred so well, the retention interval would be changed.to 10 séconds- After the completion of 24 additional trials, a simila¡ procedure was used to inc¡ease the inten¡al to 15 seconds. The instructions we¡e included to increase the perceived diffrculty of the task and, presumabl¡ to increase the likeühood that the error rate for malingerers would increase as the du¡ation of the delay intervals increased. The task
is not, however, more difficult with
longer delay intenrals. Thus, a significant increase in error ratc indicates malingering. The primary measure of rralingering, however, was a level of performance that fell signifrcantly below chance. Chance perfonnance was calculated using the binomial formula for a given confidence interval, usually
95Vo.\\e Portland Digit Recog-
nition Test @inder, 1990) uses a simila¡ procedure, except the person is required to count backwards duiing the
retention intervals and different retention intervals are used (5, 15, and 30 seconds). Shorter versions of both tests have been developed @inder, 1993; Guilmetle, Ha¡t,
TOMM-Test of Memory Malingering
Baker' & Giuliano, & Leininger , L994; Greiffenstein' & (Bolter Gola, 1994), as well as computer versions
& Pinch' Ñi."oilt, tég¡; stict, Hopp, Strauss, Hunter' 1994; Rose, Hall, & Szalda-Petree, 1995)' worseEarly reports from clinical case studies showedthat subjects suspected thal-chance performance occurred with stud' experimental recent more of malingering. However, reported have Portland ies using-Uoth the Hiscock and the
as a test as a memory test and increases its transparency
of malingering (Guilmette, Hart, & Giuliano' 1993; et Guilmette, Ha¡t, Giuüano, & Leininger, 1994; Sück The amount of time required to administer the a drawSVTs, particulady the original version, is also (1991)' Wilüs and back Finally, as mentioned by Binder divided in the Portland may be sensitive to impairments to attention and recent memory' This makes it difñcult motivafion' to athibutable interpret errors as being solely a1., 1994):
That is' many indi-
a high iut" of fabe-positive errors' asked to u¡¿,rás suspected of malingering or individuals patients persimulate the performance of brain'injured
& formed at above-chance-levels of accuracy @inder Martin' 1993; Wilüs, 1991; Guilmette, Hart, & Giuüano' Pigarano & 1992; Niccolls' Gouvier, Todd, Bolter, & greater-thanwas Amin, 1993). Atthough performance chance,itwasstillsubstantiallybelowtheperformance obtained by brain-injured or intact subjects' has Based on this observation, detection of malingering norm-based critereüed increasingly on different types of include scores malingering ria- For exa:nple, criteria for from a brain occurring below the lowest score obtained
scores falling aamagJ group @inder & Wilüs' 1991)'
1.3st¡ndarddeviationsbelowtheaverageTraumaticBrain Gola' 1994)'. Injury (TBI) score (Greiffenstein, Baker' &
& oi s"or"s lower than gOVo correct (Guilmette' Hart' Giuüano, 1993)'
degrees of sucThese appioaches have met with differing nocnabecause appücation ,"rr, *á are ümited in their with inüviduals to tive data have been restricted primarily sinno present time' closed head injury. Moreover, at the adopted' gle criterion oicut-off score has been universatly
ihe
may also be usefulness of a symptom vatiüty test its simpücity decreases its face validity
limited because
Summary two Stategies for detecting malingering have involved ofrespondanalyses qualitative gená approaches. Fiist, Irrg
n*"U""tt
used- These strategies fÓcused on situational
viriables, neuropsychological profiles that do not make Dissat-
"neurological sense"' and multivariate analyses' reisfaction with üe overall success of these measures maüngerof sulted in the development of specific tests ing. Most of these tests used some tyPe of recognition
proprocedure. However, the specific types of recognition several have tests these in cedures currently employed accepted disadvantages, including the lack of a üniversally criterion score, their sensitivity to various types of neurofor their togical impairrren! the duration of time required
and their inadequdte face validity as "Jministration, due to the perceived simpücity of the tasks' memory tests
body of Despite these shortcomings, there is a substantial is the best üterature that suggests a recognition procedure malindetect to test specific a candidate for developing
Magering. In light of this evidence, the Test of Memory fi"gJog CTOMM) was developed' The development of data" Oe fOVfU, along with the normative and validity are presented in the next chaPter'
Ghapter 3 Development, Validation, and Normative Data The TOMM is a S0-iten recognition test designed to help neuropsychologists discriminate between mali¡ge¡sd and
bonafide memory impairments. The ability to detectpotential falsification or exaggeration of memory dysfunction is particularly important in neuropsychology because memory deficits are associated with a wide variety of or-
ganically-based impairments (Brandt, 1988; Strub & Black, 1985). Complaints of memory impainnent frequently represent the initial symptom of organic brain damage and pmvide the focus for neumpsychological evalu-
afion. These complaints also serve as the basis for ütiga-
tion. Consequentl¡ neuropsychologiss must be able to detect malingering on tests that measurre an individual's abiüty to acquire and ret¿in newly learned informafion.
Standing, Conezio, & Haber, 1970). Forexample, Standing, Conezio, and Haber ( 1 970) showed two subjects' 1, 1 00 pictures for 5 seconds each. A-fter a 3O-minute delay interval, their recognition memory was tested by presenting 100 pairs of pictures. Each pair contained a previously shown picture and a new picture. The two subjects correctly identifid9í%o and99Vo of the pictures, respectively.
In
a second study, 120 pictures were presented for 1 second eaclr Simila¡ levels of retention were reporüed when all 120 stimuü were paired with new stimuli during the recognition test. The robustness of recognition memory for pictures has also been repoded with older adults, as well as with va¡ious neurologically-impaired populations
& Nissen, 1989; Hart & & Piercy, 1976,1978,1979;
(Freed, Corkin, Growdon, The development of the TOMM was based on research in two related but independent fields-neuropsychology and cognitive psychology. As indicated in Chapter2, the recognition paradigm has shown considerable promise
in the detection of malingering. Its cünical utiüty as a measure of malingering has bee¡ demonstrated in a variety of applications, ranging from recognition procedures
employed
in standard neuropsychological tests to sPe-
cific tests of malingering. However, the types of recognition procedures employed have several limitations. Many of these difEculties may be related to üe failu¡e to select an appropriate set of stimuü. Ideall¡ the stimulus materials used in any maüngering test should create the impression that the test is relatively difficult, while in reality producing a test that is relatively easy. Thar is, the perceived difñculty of the task should exceed its actual difñculty. Malingerers, who think the test would be üfficult for people with memory impairnents, should perform poorly, while people with impaired memory ability should have üttle trouble with the task. In other words, the test should be sensitive to malingering but insensitive to neurological impairments. Research in the field of cognitive psychology suggests that this goal can be achieved by using pictures as stimuü.
Several stuües have shown that individuals have a remarkably high capacity for storing,and rehieving visual information (Nickerson, 1965, 1968; Shepard, 1967;
O'Shaniclq 1993; Huppert
Kopebnan, 1985; Ma¡tone, Butters, & Trauner, 1986; Pa¡k, & Smith, 1986; Winograd, Smith, & Simon, 1982).
Pugüsi,
In view ofthese findings, a recognition procedure using pictures of common objects served as the basis for the development of the TOMM. The development and validation of the TOMM occurred over a 4-year period..The first stage was the development of the stimulus materials and an initial validation with a non-impaired.sarnple.
Normative Testing,:1¡vi1fu Non-Clinical Subjects Normative testing with non-clinical subjects was divided into two phases. In Phase 1, research was done using a preliminary version of the TOMM. For Phase 2; the TOMM was modifiedto be atwo-choice,ratherthan fóurchoice, recognition test, and explicit feedback was given regarding the correctness ofeach response.
Phase
I
The initial version of the,TOMM consisted of two leaming trials and a delayed retention trial. The learning trials consisted of a study phase and a test phase, In the study phase of each learning trial, 50 line-drawn picnrcs (targets) of common objects were presenúed for 3 seconds each.r
¿)t I Inorile¡to directlycompáre scores version are prorated-
frontk
first (4il'pictlres; four-choice) and fual (SOpichues; two-choice) versions of theTOMM, all scores fomthe finit
T0MM-Test of
Mtrylllr¡gllgttilg
each targei was paired During the test phase'
targets the first trial' 94Vo of the ously seen pictures' On
*:T *--":
;;ü;!;;-"::::::y,:x"f;:"n*"':fli,I""T,[: numl trials, the average
newüne-drawings(distracton).ThePositionofthet¡¡possible quadrants'
over the four get was counterbalanced test phase' consisting onlV 3lle A delayed ret"otioo t"J' two after completion of the was administered 20 minutes rethe of No feedback on the correctness To obtain an estimate provided on anv trial' asked Jüte task' subjects were of the perceiv"¿ ¿im"oiy manV each test phase to e1!na11how at the beginning of to recos-
"Jtt ;;;;;";
exceedeó997o' Table 3'1 Deviations for Obtained.and Standard and Means on the T0MM (Four-Choice Estimated Performance
**s'
--""'l"i*i*l n
thought thev would 9".10]" A briel practice Eial' nize (i.e., esdmaled beginadministered before consisüng of two
;;;;;*"sihev ning Trial 1'
p"iit^*t"l' **
specificatly for
47.5
lsD/
lz0.2l
{3.21
F.?}
405
13.1 30.3
54.8
(3.21 t11'41
QA.?l
49.8
(o'81
(o'71
40'3
M.3
F'4)
{e.0}
o.n tl,re accuracV
and education ac-
rhat age ;iffi tor ela"n triat reve¿e¿ variance Trial 1 a¡d less ;;;;;; ;t ontv 1 'SLoof the 2 and for the Retention tial
target pictures were
on Trial lhanÉÍoof the variance
(Mclntyre; 1996)'
uoottrs at-shopping They were,""*it"d"tt''outrr of emPloVSrent' and psyptI""' at social o,garri'ution" did not reword-of-mouth' They chology classes; a reremunerati-on However' ceive any type of frnancial university 26 participants received stricted subsarrpte of
*J¡'
perforrtconsistently high level of Fufther evidence for the distribution 3-2' which tftol":$t ance is shown in Table l' 54'AEó of the subjects obof correct responses' OnTrial lower 50' while o¡rlf 137o scored tained a score of 49 or 907o approximately two trials' than 45. On the remaining 37o only while perfect scores' of the participants 49)' than (i'e" scored less on" of them made more than
obÁ;
in
age
from 16 to84
y,eats (Iul
=
Aduks T0MM witn GognitivelyJntact
The participana ranged educatiol.lwel was 13'1 54.8, SD =20'2)'fn" percent of the participants years (SD = 3.2)'Forty-seven scofe on sample, the averlge were male' In the overall
uffie
subtest highly coneVocabularl subtesi-a Raw iq-*ur 49.9. (sD =__11.6)' "lotiAlt-* lared wirh FuIt scale increase ¿¿'ito 56'5' wittr a general scores ranged from and youngest in the occurring u"'o" ur"'"-'*i"ip*t forof the fewest years
ffi[erotcoractRosponses
t{}fVwouldbe
12.0%
10.7%
5.5%
1.3%
Retention
89.50,6 8.9%
1.0%
0.8% 0.0%
0.3%
Trial 2
34.0% 20.4% 90.6% 6.5%
Trial
1
0.0%
4.2% 10.6% 0.0% 0.6% 0.0% 0.0%
2.4% 0.0% 0.3%
stands in performanee ofthe subjects The highly accura@ anticipated
well the participants marked contrast to how on Trial contrast is nost evident they would perform' This (see perfoínanc€ was 30'3
Erven
Prior to testing, participants would have^o learn and a series of tests io informed remember various typ* "i*f"t'ationt f{er along *'" fOVfU was administered consent was obtaio"¿' inparticipants^were tested with a series of ottrer tesa' NII
where the average estimated Table 3-1)' This score 1.
*íiti't'"y
t***
mation of their p"rfo'mun""
'
a siSnifican¡-underesti-
afactthat consistently sur-
estinates The substantially higher 40'3' Re2 (Trial trials = two that occurred for the other test perthe with experience
n*J."tr
scores and estimated performance dividually. The obtained Table 3-1' are presented in
u'"
m or¡ ,¡.
fe-ñ--il
to halve oldest age groups ten¿ed mal education' were
L*'
Table 3'2 on the Four'Choice Percent of Gorrect Responses
credil
;.:ü'LJoo
49.8
performed Multiple regression analyses
sh¡dy of aging As part of an ongoing the TOMM' Atl par405 inüviduot' *"'" u¿tinistered in the co'mmunity' ticipants wer" üuio! lo¿"p"o¿"otty centers;
course
13.1
rso,
" because each drstractor pool of drawings was-needed presented
Á"
54.8
M
Line-drawings,ratherthanpt,otograpt's'wefeusedto large of tti-"lus material' A ensure gr"ut"t t'ootog*"ity was used only oo""' Onty more than once'
M
Esümated Performance
ftom a pool of approximately The stimuü were selected the TOMM'
"r""i"¿
As¡
Obtained Performance 405
"'g"it'
550 line_drawi.g,
with Gognitivelv{ntact Adults
t"*iiduals'
that tention = [z.3)suggest ttreir estimates' Neverthemitted participants to upgraOe were the rule rather
ñr'ft'r
less, undere$imatioo'
rable3-1(obtainedPerfo*'-:"1:h":t-1:nf:ln-T:' to recognize prevr-
than the excePion'
in their ability were highly accurate
10
o?"p"tfo*ance
I
Development, Validation, and Normative Data
feedback plays a distinctively different role' It allows them to track their performance more accu-
In summary, the results from the initial study substantimemory ated the original speculation thaf a recognition pertest for pictures represents a paradigm in which the difceived difficulty of the task exceeds the demonshated
rately and to adjust it accordingly. Thus, the expücit feedback should have the net effect of increasing the sensitivity of the TOMM to malingering'
ficulry This discrepaucy between expectations and extremiy high levels of performance represents an ideal situation for detecting malingering' Thus, ths TOMM
Using this mod.ified version, normative data were obtained (M = on 70 volunteers ranging in age from L7 to73 years
could serve as a sensitive instrument for measuring malingering without its purpose being obvious or unduly
37.8, SD
=
14.2).
were living independ-
All participants
ently in the community- No person received any type of financial remuneration. Fifteen participants obtained
transparent.
course credit. Sixty-three percent of the participants were male. The average number of years of education was t2J
Phase 2
of the The next stage in the development and validation be would test the TOMM was to determine how sensitive However' with different types of cognitive impairments'
years (SD
made it cations were made to the TOMM' These changes a nonfrom data necessary to collect additional normative
úaL,95.6Vo (47-BtíO) of the responses were correct' Response apcuracy on the other two trials was greater than 997o. Regression analyses performed on the accurrlcy scores for each trial showed that age a¡d education accounted for less thanTEo of the va¡iance. As in the previous study, the high levels of perforrrance ¿rccur¿rcy ex-
The average number of correct resPonses for each trial is shown in Tabte 3-3 (Obtained Performance). On the first
before beginning cünical vaüdation studies, two modifi-
cünical samPle. 1.
three The number of distractors was reduced from to one. This reduction made the TOMM a twoThe choice, rather than four-choice, recognition test' make to was prima¡y reason for this modification the actual level of chance responr'ling consistent
ceeded estimated performance. This result is particularly
evident on Trial 1 (Table 3-3, Estimated Perfonnance)'
with
Table 3-3 Means and Standard Deviations for 0btained and Estimated Performance on the TOMM flwo'Choice
Debriefthe perceived level of chance responding' many' that revealed study ing interviews in the fust generbeen had if not most, performance estimates be ated on the belief that the correct answer could guessed on
Version) with CognÍtivelyJntact Adults
l,t.r-*"
half of the trials (i'e', 25150)' Thus'
Inuo"" performance had been incorrectly assumed
Age Educ.
"
Trial
0btained Performance
M lso,¡
than based to be rel,ated to the number of trials, rather
on on the number ofresponse alternatives available poteneach trial (i.e.,lt4 = 257o). To eliminate this
70 37.8 t14.21
f
M lsDi
nie!
2
Rotont¡on
47.8 49.9 t?.41 t0.41
12.7 t1.91
Estimated Perfo¡mance
tial source of confusion and to faciütate determining when a person's performance actually fell below chance, the test trials were modified so they and one contained onlytwo altematives
70 37.8 12.1 Í14.2) ¡t.el
3',1.8
(e.sl
43.0 (B.U
49.9 (0.51
45.5 17.71
The distribution of correct responsEs is shown in Table 3-4. The table shows a skewed distribution of responses on all three trials, similar to that observed in the first
homonyincorrect. The effects of visual neglect and
placing the mous hemianopsia were minimized by picpictures vertically on the page' As befÓre, the tures were counterbalanced
= 1.9).
study @hase 1).
foi position'
correctness of this change each response. The rationale underlying was that feedback should serve a valuable-albeit for well-motivated versus ma-
Table 3"4
2. Explicit feedback was given on'the
Percent of Correet Responses on the Two'Choice TOMM with Gognitively'lntact Adults Number of Gorrect ResPonses
different-function
{9
lingering patie¡ts. For highly-motivated individuopats, tria-Uy-nial feedback provides an additional This' targets' are pictures portunity to leam which in to-, should increa$e the accwacy of responses on subsequent triali. For malingerers, trial-by-trial
I
22.8%
32.8%
17.1%
Trial 2
95.8%
1.4%
1.4%
Betenüon
92.9%
Trial
11
48
5.i%
0.0%
1l
15 45 fl-40
<40
10.0% 4.2% 7.0% 1.4% 'r.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.4% 0.0% 0.0%
4.2%
lulvllv¡-lust On Trial
ul lvlullluly lvl(lllllgcllllg
obtained from a person suspected of malingering, and TOMM sco¡es obt¿insdftoÍl patientswitha similar level of neurological insult or impalrment bütnot Suspected of
l, 55.6Vo of the individuals obtained a score of
49 or 50, while only 8.4Vo of theparücipants scored lower ttran 45. On the remaining two trials, approximately 93Vo of the participirnts obtained a perfeet scóre, while less than 3Vo made more than one error (i;e', scored less than 49)'
malingering. The following study was undertaken to provide a set of clinically-based norms.
Data were obtained from 138 consecutive neuropsychological assessments of inpatients and outpatients
Overall, the, data fiom this study bear a rema¡kable similarity,to those collected in the initial study. Taken together, the results from these two normative studies show that neurologically-intact individuals achieve exceptionally accurate levels of response on the TOMM- Comparison of the estimated and achieved levels of perfomance suggests the TOMM should have high face validity as a test
at the Veterans Administration Medical Centér, Boston, Massachusetts, and 23 head-injured subjects from a recently completed Ph.D. thesis (Rees, 1996)' Although some patients had multiple diagnoses, the primary diagnoses were divided into five major groups:
of memory when administered as part of a battery of
. No Cognitive Impairment (n = 13), . Cognitive Tmpairment (n = 42), . Aphasia (n = 2l), . Traumatic Brain Injury (n = 45), and . Dementia (n = 40).
neuropsychological tests. The results from both studies also demonsfiate that performance on the TOMM is not sensitive to age or education. This frnding is particularly important because the
abiüty of the TOMM to detect ¡lelingerin$ depends to a large degree on its insensitivity to other variables such as age, education, and neurological impairment'
None of the Tra¡¡matic Brain Injury patients were engaged in compensation hearings or ütigation. Three subjects i-n the Demetia group werc so severely impaired they corild noJ be tested and a¡e not included in the analyses described below. Thus, all analyses were based on,scores from 158 patients. All diagnoses were made on the basis of DSM'
Validation w¡th a Glinical Sample
Itr-R and DSM-IV criteria- Specific medical and radiological information on each patient is presentedin Appendix.{.
The next stage in the development and validation of the TOMM was to obtain scores from a cünical sample' In most cünical applications, neuropsychological tests are used to determine if a patient's cognitive abiüties (e'g', memory) deviate from nsrmal. Consequently, the patient's scores are compared to norms derivedfron neurologicallyintact indiüduals. This comparison, of course, assumes that the patient's scores, as well as those in the normative sample, represent optimal or near optimal performance' However, in the assessment of malingering, both the patient's motivational level and the degree of impairment must be considered- For this reason' scores from a normal con-
The TOMM was administered according to the instn¡ctions outlined in Chapter 4 oJ this manual. Particula¡ ca¡e was taken to ensure that severely impaired patients at' tended to the stimuli. For exampler on leqrning trials il was often necessary to direct the attention of dementei patients to the stimuü by pointing to each target as it wat presented. On test trials, the foüowing instructions wert repeated with each pair of test stimuü: '?oint to the pic' ture I showed you before. Was it this one (experimeirto
points to top picture) or üis one (experimenter points tt bóttom picture)?'To avoid preservative responding (e.9. always selecting either the upper or lower picture), a pa tient's response was not accepted until the experimente
üol group may not provide the best source of comparison'
Ideall¡ detecting malingering requires the comparison of the performance from patients who have equivalent lev-
had pointed to both pictures.
els of impairment but different levels of motivation' That
is, performance of traumatic brain injury CIBI) patients
.;]
It was also important to ensure that demented patient understood thar they were to select 1 of the 50 picture they had been shown rather than merely picking a iamil iar picture. In the latter case, the patient would usuall' say something like "Oh, that's a dog." Whenthis occurred
suspected of malingering shouldbe comparédto perform-
ance of.other non-malingering TBI patients' To achieve this, norms for various types of neurological impairments
must be available to provide a baseüne against which scores from suspected malingerers can be compared'
the experimenter would say "Yes, that is correct, but whicl picture üd I show you earüer? Was it this'one (points) o
With respect to the TOI\p{, a set of cünically''based norms would allow dtect comparison between TOMM scores
this one (points)?"
12
iF*i';;i#'iril',
i.ffiffi*i iiiiii!':'t,,:', i.:].'.l.:r1:::
r,r
;r
:'
Development, Validation, and Normative Data
ing task (CWI: De]is, Kramer, Kaplan, & Ober, 1987; or the Word-List subtest from the LAMB: Schmidt &
Group means for age, number of years of education, and performance on the TOMM are presented in Table 3-5.
Tombaugh, 1995) were available for 8174 ofthe non-aphasic patients. Table'3-6 shows the mean percentile scores for the verbal and üsual learning tests.
Table 3-5 Group Means and Standard Deviations for Age, Number ofYears of Education, and Number of Gorrect Responses on the T0MM for the Glinical Sample
Measure
n
Age
Educ.
Tdal
I
No Cognitive lmpairment
M
13
lsa)
45.9
13.0
47.9
(15.01
13.61
{2.1}
Cogn¡ü've lmpairment
M
(sD)
Agtasia
M
lso/
42
57.? (1s.1)
21
(sD)
Demential
M (sD)
45
31
2
Retefiion
50.0 (0.01
1?.4 43.9 48.6
(3.01 (5.31 t3.11
66.2
13.0
(1o.el
{3.51
Traumatic Brain lnjuryt
M
Trial
40.0
13.0
{15.3}
12.41
1.9
72.1
1
f7.61
t3.4t
Table 3-6
Means and Standard Deviations for Percentile Scores on Verbal and Visual Tests of Learning and Retention for the Glinical SamPle
46.3 49.3 t4.2t {1.e} 45.9 49.4 14.71 {1.3} 41.0 45.7 {6.6} fs.3}
50.0 Group
Leaming
Loaming
No Cogniüve lmpairment
49.5
M (so¡
(r.51
50.0
58.8
70.6
68.8
t29.zl
(2e.61
{32.9}
(3s.2)
Cognitive lmpairment
49.8
M (sD)
(0.6}
20.2
18.4
122.01
{21.61
52.4 (2e.1
28.7
l
(33.81
(34.41
Traumaüc Brain lnjury
49.6
(t.r
VisuaF Retontion
VerbaF Retention
(0.01
M
}
fsr/ Deme¡tia
47.0
M
(sol
{4.4}
I
No paüerfi sf üe Trd.[rEtt &dn frir¡y grup was i¡nohed wíü cornpensatim hadng or ¡ltgatin. ¡ Tlree sf üe oryr'al 40 patierts v'se m swrÚf den¡e¡ed tr be t€sEd and afe nst inc'luded ¡n the bHe.
26.5
21.7
52.3
{31.6}
(23.61
(34.11
5.1
(8.3t
I Veüd test scores are from the
CX/LT
38.4
3.1
21.5
9.5
ls.el
|'26.71
f1 7.51
or
$e Word
List from the Leáming and Memory
Banery (l,AMBl.
¡ V¡$al test scores
Table 3-5 reveals that the performance of the fi¡st fou¡ groups (No Cognitive Irrpainnent, Copitive Impairment, Aphasi4 Traunatic Brain Injury) was comparable, while the accuracy of the Dementia group was substantially lower. The robustness of the TOMM is particularly evident in Trial 2-the Dementia group obtaintd 92Vo cotrect and the remaining four gouPs responded at greater
are from Msual Reproducrion of
üe WMS-R.
Comparison of the leaming and retention scores to those obtained on üe TOMM (also see Appendix A) shows that recognition performance (as measured by the TOMM) was relatively un¡elated to free recall measures of visual and verbal learning. This observation was supported by correlational analyses showing that fhe correlation coefEcients between üe TOMM and the other learning measures for all groups ranged from 0.20 to 0.35 across the three tri-
than9TVo accuracy.
als. This lack of substantial correlation between the TOMM and free recall scores is important because it demonstates that the TOMM is relatively insensitive to measures of learning and memory dysfunctions which have been previously associated with various neurological impairmcnts. This, of course, should increase its sensitivity to malingering in patients with impaired memory abiüties.
These observations were verified by statistical analyses. ANOVAs perforrred on the scores from eachtrialrevealed significant differences among the groups (Triats 1,2, and Retention: Fs (4, 1 53) = 7 .22, 9.02, and 7 .10, respectively ; comparisons, using the harmonic mean to adjust for uneven number of patients
p <.001). Tirkey-HSD multiple
in the different groups, showed that the perfornance of
Table 3-7 shows the distribution of scores for the clinical sample. The scores from Triat 2 are particularly noteworthy. The Dementia grcup was the only group with a relatively high percentage of scores (2|Vo)below 45. Only four patients (9.6Vo) in the Cognitive Inrpairtnent group
the Dementia grcup on Trial 1 was significantly lower than that for all groups except for the Copitive Impairment group. On the otler two trials, the Dementia group was significantly lower üan the other groups, which did not differ significantly from each other.
(Appendix A: CI-17 Konakoff, CI-18 pontine infa¡ct, CI19 right frontal craniotomy, andCl-27 right thalamic infarct), and one patient (4.87o) in the Aphasia group (Ap-
Scores from a visual learning task (Visual Reproduction subtest from WMS-R: Wechsler, 1 987) and a verbal learn-
pendix A: A-14 global aphasic) scored below 45.
\3
TOMM-Test of Memory Malingering infonnation a¡e also providedfor each patient, thus documenting the degree of overall impairment. As previously stated, these patients a¡e divided into frve groups: no cognitive impairment, cognitive inpairment from diverse
Table 3-7 Percent of Gorrect Responses for Different Glinical Groups on the T0MM Illumber of Gonect Responses
{0
48
41 45 15 l{-.{0
etiologies (e.g., Konakoff's syndrome, Pa¡kinson's Disease, depression, PTSD, Huntington's Disease), aphasia (fluent and non-fluent), traumatic brain injury, and dementia (primarily Alzheimer's and vascular).
<{0
No Cognitive lmpairment [NCl]
t Trial2 Trial
23.1% 23.1%
23.1%
15.470 0.0%
7.t% 7.7%
0.0%
10ffÁ 0.0%
0.0%
0.0%
0.0%
0.0%
0.0% 0.0% 0.0% 0.0%
0.0%
0.0%
0.0% 0.0%
9.5%
7.1%
11.9%
2.4%
1.9%
4.8% 3.1%
4.8% 0.0%
2.4%
6.3%
0.0%
9.5%
19.0% 9.5%
Fetenüon 100%
0.0%
The data presented in Appendix A clearly illushate how
individuals with wide ranging and diverse clinical etiologies perform on the TOMM. Of particular impor-
Cognitive lmpairment (Cl|
Triall Trial 2
9.5% 11.9%
66.7% Retention 84.8%
I
28.6%
19.0%
0.0%
7.2%
7.4%
3.1%
3.r%
0.0%
14.3%
4.8%
0.0%
9.6% 4.8% 0.0%
11.1% 4.4%
2.2%
17.8% 15.4%
4.4% 4.8%
0-0%
2.2% 2.4%
?.2%
0.0%
0.0%
0.0%
5.4% 8.1% 7.1%
5.4%
5.4%
r8.9% 43.2%
2.7%
10.8% 16.2%
3.6%
3.6% 10.8% 7.1%
tance is the repeafed demonstration that individuals who score in the severely impaired range on standa¡dized tests of leaming and retention (e.9., WSM-R, LAITB, CWf)
Aphasia
Triall Trial2
14.3% 19.0%
76.% 14.3% 4.8% 0.0% 0.0% Retenüon 82.4% 11.8% 5.9% 0.0% 0.0%
0.0%
perform extemely well on the TOMM. Such a striking contrast in perforrrance provides further evidence that a low score on the TOMM indicates u msfiv¿dsn/halin-
0.0% 0.0%
gering üsorder.
Traumaüc Brain lnjury [tBl]
I Tnal2
31.1% 15.6% 77.9% 6.-l% Hetenüon 81.0% 4.8%
Trial
2.?oA 6.701,
7.1%
0.0%
Validation with Simulated and 'At-Risk" Malingerers
Dementia Trial
1
Trial
2
8.1%
5.4%
8.1%
27.0%
13.5%
10.8%
Retention 32.'l%
17.5%
17.9%
'
10.8%
The greatest vüdity for a malingering test is obtained from patients who have admitted to malingering. However, malingering patients will rarely make such admissions. Consequently, two paradigms have been used in resea¡ch. The first approach employs neurologically-in-
The single patient (2%) of the Traumatic Brain Injury group (TBI-40) that feü below this cutoff point by a single point (score = 44)bad borderüne intelligence. This patient's attention was also severely impaired, as shown by scores on digit span (forward Spzul = 4 digits, <3d percentile; backward span = 3 digits, 3d percentile) and Trails (A = 133 sec, <1't percentile; B = 379 sec, <1't percentile). No patient in the No Cognitive Impairnent group obtained a score lower than 45. It is also important to
tact individuals who simulate the performance of neurologically-impaired i¡dividuals (e. g., head injury). The second approach uses zubjects who have susiained some type of neurological insult a¡d who a¡e "at-risk" for malingering (e.g., compensation-seeki¡g patients). The
frit
study desc¡ibed below fr.ees & Tombaugh ,1996)
used the simulation desip, while the study reported in the next section (Gansler, Tombaugh, Moczynski, & Rees,
note that only fourDementiapatients OA.9Vo) scored less than 40 on the second trial (scores =29,33,33,and37,
1995) employed the "at-risH' for malingering procedure. Both designs used TBI patients (simulated or real) be-
respectively). All of thesepatients werejudgedto be moderately-to-severely demented (Mini-Mental Status Exam Scores = 16, 19, 15, and 7, respectively). Thus, based on these clinical data. a cut-off score of 45 on Trial 2 produces a high level of specificity. That is, it correctly classifres 95Vo of all non-demented patients (9IVo of. all pa-
cause
for most neuropsychologists they represent the largof parients likely to be suspected of malingering.
est grcup
Validation with Simulated Malingerers
tients) as not malingering.
A group of 27 undergraduate students (simulators) were given the following brief scenario describing an indiüdual seeking compensafion for a head injury caused by a mo-
Appendix A provides additional evidence showing how performance on the TOMM is extraordinarily resistant to various types of severe cognitive impairmenr It contains detailed information on each patient. Scoies from all three tials of the TOMM, along with percentile scores from verbal and viiual leaming tests, are p¡es'ented for each
tor vehicle accident The subjects were asked to realistically simulate the performance of this individual on neuropsychological tests. However, they were not given any specific instructions on how this should be accomptistred. A $50.00 reward was offered to the person who
member of the clinical sarnple. Medical and radiological 14
Development,
simulation All subjects were provided the most convincing allowed one week to PrePare'
Vtl¡dtlon4nd t'lglgtiut 9ut'
with a in your attempt to portray someoire l:1rnyou"J*t think
lfo* t.¿
**
if
¿i¿ Vou try? Wtrich testls)'
t*"t"1 specifically designedto
any' did
assess
malingering?")
Scenario
gioups are shown in Table 3-8' The mean scores for the two
li"ñt"-
Table 3'8 Deviations for Standard and Means
a set of tasks ;i" t*Ut you will be asked to complete types different of *" often used to measure avatiety brain-damage' Á* "n have that occur in people who you to assume the like would As you take each test' w-e some brain damage ,J"'ot ro."one who has experienced
from
Simulators and Gontrols Trial
f
Retsúion
Trial 2
a ca¡ accident'
in a head-on coUision' Pretend that you were involved windshield and were unYoo tit your head against the overfor 15 minutes' You were hospitalized over Gradually' Jgn fo, observation and then released'feel normal again' have started to the pást few months' you you that you may get However, your lawyer has informed you are the court if you look like o furr", settlem"nt from the ' world' real the In still suffering from brain damage' deterto is totake porpo* ofthe tests you are about
Simulation
M
if üe
impairments in accident harproduced any
mine darrage' your abilities because ofbrain
person' try to app¡oach each test As you portray the above would approach it if he or she as you imagine this p""o" by his or her laryyer bad been giveo the same instn¡ctions
the amount of üe or somÉone else hoping to influencc will responses on the tests üat senlement. fty to o"ut"
keepare truly brain damaged' convince the examiaer you beyour depend upon Jg in _ina,hat settlement monies AIso on these tests' ing diagnosed as cognitively-imPaired often raises pending a lawsuit
be awarc that haág the suspicion that pelople
*"V tT
to exaggerate their
resulting from üffrculties. Ttrat means your impairments
Major exaggerations' the head injury must be úeüevable' anything' remembering absosuch as not being able to do failing to respond' are easy tot"ty nott iog, or completely
32.5 (7.5)
n
48.9t
(SD)
**"io*
urua
n
Control
M (sD)
I
(1.61
35'3
30.9
(e.41
(10.61
49.9t
50.0f
(0.21
{o,o}
p than simulation scores' Control scores s¡gnificandy higher
< '001
'
Table3.8clearlydemonstratesthesuperiorperformance
on Trial 2 show group' The inüvidual scores
oir¡"
"onoot ,tt" *""¿fyio
*i
tn"
ou"'tup existed betweln the simulators All individuals in the control group
"ootrolr.
achievedascoreof4gorgreater(|oovospecificity),while
49 (937o sensitivtbesimulators scJred lower than of 45 (i'e"9oVo cutoffscore ity). Using amore conservative remained at 1007o while correct responding), specificity 93Vo of
se.,siti.,iry¿ecrinedtas}To.Whenthesamecutoffscore retention trial' specificity was applied to the scores from
*^ *.t
tn 897o' uoged while sensitivity increased
that most
questions revealed Analysis of the debriefing follow the scenario instrucioOiui¿oot, tried diügenüy to successful in thei¡ tions and felt they were moderately the TOMM J"""ptioo. Participants did not distinguish müngering' of fron other tests as a merlsure
overall,theresultsftomthisstudyshowthattheTOMM ef-
who put forth good discrinrinates between individuals from those who deliberately fake OigO specificity) Moreover' the finding that responses ¡trigrr sensitivity)' as an obvious measure of the TOMM was not p"rcived face validity as a malingering shows ittut it has high
to detect."
f"i
the following batThe simulators were then administered TOMM;.CWI; Mental t"ry of o"*psychological tests: Reproduction subtests of Control, Oigi' sp- ai¿ vi'o¿
theWMS-R;TrailsAandB;FingerTappingTest;InforRuffFigural Ruency Tes$ nation subtest of the WAIS-R; (FAS and animal naming)' and verbal fluency tests
memory test-
test batsubjects received the sarne "ooooí to of thei¡ abiüierform to út:-o::t ü ú were asked given the scenario or provided with ties. They were not injury' any idormation about brain
for Validation with Patients At'Risk Malingering
Twenty-t\ilo
was to validate the TOMM The purpose of the next study
brain injury (TBI)' with patients who suffered traumatic
in this area is litigating TBI patients to compare the performance of grouP' A recent study by a non-ütigating control
all subjects were asked to At the end of the experiment' they
design used One traditional experimental
the study and the tests complete rating scaús about do you think you were were given (e'g', "How successful
agAn*t
15
Malingering TOMM-Test of Memory
approach with the used this general (1995) al' et Gansler
ro[owing groups wereused:
üJü,*" for mali-ngering -. 17 TBI patients "not-at-risH' unit' a ;;"J;á ftom eithsr aorneurologY outPatient .
il':;;t¡*.-gt**['fi
for malingering recruited and
. 11 cognitively-intact control subjects' fo:ul' .' 12 patient controls with signific*t ' a recn¡ited ftom by staff scans interpreted
CT or MRI All TBI patients had traumaticbrain injury' compalUÑith Ue to radiologists
üi;;il.to-:'".*:*;ÍJ: r ;ffiilT i:1":' üe risk" of admr
one or more
of the following factors:
. pufsuit of a personal injury suit' and . p*roit of a disabiüty petition' neurologic disease' r slmptorns discrepant fromknown complete in the context of a The TOMM was administered were'informed in
neurological "u¿outioogenerat terms of ,rt"
a¡on. The TOMM Éve data for
The subjects
evalu-
ttAntl:Ygical nü*" "r*: as DescIiPa memory test.
**'p*'"ot"d
th*"
Table are presented in
liJ
3-9'
'11
Table 3'9
*ffi
,iili,:Jilj#¡hj'xl:ü:ffi :;:ffiil" Trial
Measu16
Cognitively-lntact0onrÑ
M
"
rsD/
1
2
Retention
4g.g
l-0.!
frial
48.4 ir.ij ro.3)
paüentControls
b0.0 12 48.4 i'lü o.bl
M lsD/
TBI)üotAt-Rrsk rsCI
,i üi I,ii
ditr"'";;; each uial' scores on all three trials the ffi;;;;.Áons showed thatwere than 'ower ;ffi.;"'il'n- *t o"tp significantly not differ ftom one
M
@
gflup''t"hi"tt
did
Summary
a sample of this chapter show that in presented data The iúgh scores.onrhe TOMM' adults achieved exceptionAny on the exceeding eebo acosa$it¿s/s0l efthe to sensitive
T Ti:,:d
** not Retention Trial' Perfoá*"" scores exof education' Obt¿ined fects of age or years that the t"o'"t oo each trial' s'ho¡vin9it actually ceeded estimated TOtr4rrt was was. Higtüy
more difficult than to ttrat obt¿ined n"lo**""' similar a cünical samwith
po""it"cio ü
****
occu¡red with non-impai¡ed adults'
*i*,t:::: TBI patients' of dementia patients was Even though tn" p"ao'--ce these individuals still lower than the other ";;;;""Ps' 2' Finallv' 1111"t was highly obtained a score "f ;;;;*'ezr' that üe TOM\'[ two experiment' ¿"-o-*o*J simulating
ple of cognitinerv-inpJ"¿
sensitive to
tt'" p"'flil*ce of individualsmaüngering'
p"tients at-risk for malingering uoa mi ToMM is a Jsults suggest that the tt together, Taken or de-
"r"
detecting exaggerated
t"'t for useful psycho-"t'i" il*","ty faked memorY imPairmenr
(o.o¡
5¡.0 (o.or
1,1lr
3Z.B' 11 ,E?r ótlt, ire'q '* ::: ::::;ffi;t'
TBIAt-Rlsk
::J,h*lii
t#il;;
newological unit'
Prior by the presence malingering was ttefined
",i9*
trials. This is in mr Lut-tisH' TBI group' ANoVAS *'" lower performanc" of yielded sigfrom all four groups oerformed oo tL" '"o'"' r\rkev-HSD mul-
those from the other another.
imPairment
l,",iilyctiJt.ogicd
'ligitfy
trryo
ussessment services'
11 TBI patients "u¡-risk" ftom the same sources'
** "-":::f::11'-:'J: #l ror ñr puti"nt' "not-at-risk" :l;JTT::#il]' control bi*-üT p"'fo""¿
the patient controls malingering
,i"r*Pty"rtiuoY unit'
t"l"'ÑJ"togical
controls and that the copitively-intact reveals table This
35'1t
I lBl At-Risk8cores significantly lorct
16
Ghapter 4 Administrative Guidelines for the TOMM and The TOMM consists of two learning trials
a
retention
trial. shows 50 pictures On each leaming trial, the examiner 50 pictures (line drawings) to the examinee' The same on each trial' However, they are presented
l.
u." ur"d
trial' in a different order during the second leaming 1-second a with Each picture is shown for 3 seconds' interval between Pictures'
After the last picture is presented' the examinee
2.
is
Each panel shown 50 two-choice recognition panels'
pictures contains one of the previously presented shown' No and a distracter picture not previously throughout distracter picture is used more than once the three trials.
3.
4.
In order to ensure the accuracy of any TOMM respondents at ments you conduct, ensure that TOMM notimeseethetest'sacronym.Thisprecautioniseasyto the test booklet to take. Before the respondent arrives, flip ensure the Also' the second page, which is blank' assess-
Form' The use of respondent does not see the Recording These are the only a ciipboard is strongly recommended' encounter that could fOVflr¿ components the respondent precautions are taken' show the name TOMM. If the above is being the respondent will not know which assessment to opportunity have not will administered, and he or she TOMM' the about use any previously learned information
Procedure trial is Trials I and 2 must be administered; the retention optional.
picture The person is required to select the correct
panel' (i.e., the one presented previously) from each feedback For each answer, the examiner provides about the correctness ofthe response'
lntroduction
Trial 1 (open to The examiner places the test booklet for and says' "This the second page) in front of the examinee remember pictures is a test of your ability to learn and to pictures' one at of common objects. First, I'll show you 50 how many of see to a time. Then, I'll give you a chance themyou canrsmember."
trial' The same procedure is used on the retention
re-administered' The except the target pictures are not
recognition examinee is shown only 50 two-choice Panels.
& If the Boston Naming Test (BNT; Kaplan' Gordglass' the neuroWeintraub, l9S3) is used as a part of administered notte psychological test battery it should the TOMM' prior to the TOMM. If administered before
Sample Trial
the two tests may ihe similarity of test material between the TOMM' on effects produce significant proactive
the first page' titled The examiner opens the test booklet to trialfrrst that Sample Trial, then says, "Let's try a sample each pictureat carefully contains only two pictures' Look the name of learn to and try to remember it. You don't have it'" picture. Just look at each one and try to remember
Administration Precautions
with a I The examiner shows each picture for 3 seconds' interval between pictures' Then the examiner
each
second
to the presents each recognition panel and says' "Point (examiner pi.ro." I showed you before' Was it this one points to bottom points to top picture) or this one (examiner
may affect the Test An easily preventable validity concem lnstances of Memory Malingering (TOMM) assessments' lnternet the searching have been reported of individuals
receiving for information about malingering tests and
picture)?"
to receive a nonassessments, including the TOMM' then complete could malingerer profile. These individuals receive a possibly ass€ssments at a clinician's offtce and
Iftheexamineehasnotrespondedafterapproximatelyl0 to guess' If seconds, he or she should be encouraged is any uncertainty either answer is incorrect, or if there
commonly-used advice about how to respond to specif,tc
This i*r"alid diagnosis stating they were not malingering' for implications legal has p*ssible *irur" of the TOMM
aboutwhethertheexamineeunderstandstheprocedure, until both the entire practice trial should be repeated
afl usars.
answers are correct.
¡i.r irl'r¡r:. l.l.:)::t::,:a:
!.ri:r..'i.:
11
É
t
t.
TOMM-Test of Memory Malingering
Trial
'l at going to show you the same 50 pictures again' Look
1
Learning
examiner says' After turning to the page titled Trial l, the
"I'm going to show you 50 pictures, one at a time'
Loo.k at
questions Jn" and try to r"member it' Do you have any "a"h we begin?" before seconds' with a The examiner presents each picture for 3 Requests to show the 1-second interval between pictures'
with the pictures at a faster rate should be answered I have that' do following comment"'I'm sorry but I can't to show you each picture for 3 seconds'" the
It is extremely important that the examiner ensures where examinee looks at each picture' In cases
should point inattentiveness is suspected, the examiner exposed' is to each picture (or tap each picture) as it the examiner Ifthe examinee begins naming each picture' the name of should say, "You don't have to remember it looks like'" A each picture, just try to remember what
examinee asks the similar comment should be made if the continues to examiner to name a picture' If the examinee should be made' name the pictures, no further comment to t1y permissible Finally, if the examinee asks if it is
'l'
questions?" The each one and try to remember it' Any with a 1examiner exposes each picture for 3 seconds' second interval between pictures'
Recognition Test turns After the last picture has been shown, the examiner
to the picture to the first recognition panel and says, "Point
I
showed You PreviouslY."
the answer After each answer' the examiner should circle examiner the is correct' on the answer sheet. If the response examiner should should say, "Correct." If it is incorrect, the and point to the say, "No, that's not right. lt was this one," correct Picture. panel' After The examinee must give a response for each The guessing' the examiner should encourage 10 seconds,
recognition same procedure is used with each two-choice should examiner the trial, the of end panel. If asked at the state how many answers were correct'
Retention Trial (0Ptional Test) l5 minutes after The Retention Trial occurs approximately tests' Trial2.The interval should be filled rvith non-visual
be The Retention Trial is optional and needs to 45' than less is 2 administered only if the score on Trial
afiirmative.
the Retention Trial Malingerers llpically perform lorver on that some pictures than on Trial 2. They incorrectly assume interval' However' should be forgotten during the retention Trial is extremely Retention the decreased performance on
Recognition Test
the examiner turns After the last picture has been shown' to the picture to the first recognition panel and says' "Point
a useful part of rate. Thus the Retention Trial can be
showed You PreviouslY"'
malingering detection'
Iftheexamineehasnotrespondedafterapproximatelyl0 to guess' After seconds, he or she should be encouraged itt".-"Ái"." selects one ofthe two pictures' the examiner sheet' If the should circle the answer on the answer "correct" (or is correct, the examiner should say
Trial in After placing the test booklet for the Retention
"Remember the front áf the examinee' the examiner says' you earlier that contained the 50
booklet
;*";t.
or,ri¿
After each answer' the picture I showed you previously'" on the answer sheet' the examiner should circle the answer should say' examiner is correct, the
for each panel' After The examinee must give a response guessing' The encourage should
If
exÑner
the response
say"No'
"Correct." lf it is incorrect, the examiner should (The examiner should that's not right. It was this one'" point to the correct Picture')
two-choice recognition same procedure is used with each
examiner should panel' If asked at the end of the trial' the Otherwise' the correct' state how many answers were trial' examiner should proceed to the second
Trial
showed
Theexaminerturnstothefirstpageandsays,..Pointto
point to the correct Picture'
10 seconds, the
I
pictures? Let's see how many you can remember'"
the examiner goád, frn", excellent, etc')' If it is incorrect' this one"' and say, "No, that's not right' It was
it
ilr ,1
ii 'ir
i
i
'{
should answer in the name for each picture, the examiner
I
:*
each panel' After The examinee must give a response for guessing' The 10 seconds, the examiner should encourage recognition same procedure is used with each two-choice
2i
panel.
Learning
2 (open to the second After placing the test booklet for Trial
says' "l'm page)'in frJnt of the examinee' the examiner
,18
Ghapter 5 lnterpretation and case studies Thial 2 or the Reten' 2. - Any score lower than 45 on
should proceed with The interpretation of the TOMM consequences for caution because there can be serious Incorrectly diagnosJsinterpretation in either direction' him- or her servdeny iog u p"rroo as a malingerer can
of malingering' Uoo Thial inücates the possibitity
Since most malingerers do not obtainbelow-chance on the second scores, most interpretations will rely on the second score decision rule. This rule uses the point of reference' Performance on Trial
There is also the possiices, financial compensation, etc'
is ütigation for liability' Even if the diagnosis "t tUe stigma of being labelled a malingerer may "oáq the individual' Negative have long{erm-impücations for promotions' and effects on employnent opportunities' to the severity overall credibility may be üsproportionate to correctly failu¡e hand' of the "crime'" On the other undebestow may identify a person who is malingering to access permit served financial compensation and/or suppiy' This failure valuable resources that a¡e in limited services to indiavailable of reducing
tial
itütt
Tables S'Z
3-4 show that more than 95Vo of
^a a score of adults üving in the community obtained 49 or 50 on the second Eial' Moreover' Table 3-7' for different clinical samples (fable 3-5' indiAppendix A), show that most non-dementsd ocThis ui¿udt obtained a perfect score on Trial 2' performance curred regardless of the individual's learning' verbal and on traditional tests of visual a score obtain did a non-demented patient
9::Y"j
(Resnick' 1988; viduals who legitimately need them
& McCracken' 1990)'
Ra¡ely palower than 45. None of the cognitively-intact below tients and only one of the TBI patients fell 44)hadborderline this level. This patient (score = problem (see intelügence and a severe attention
Decision Rules Tivodecisionrulesafeusedintheinterpretationofüe TOMM.
ChaPter 3). 45 on In view ofthese results' any score lower than concem raise should Trial 2 or on the Retention Trial efüat the individual is not putting forttr maximum the using fort and is ükely malingering' Rather than as a viewed be should it cut-off, score of 45 as a rigid increasmalingering of guideline' withthe ükeühood Lg as the score deviafes fufher from the normative
indicates 1. Scoring lower than chance on any trial the PossibilitY of malingering' person can corThis rule is based on the fact that a by guessing' Thus' rectly identify 507o ofthe pictures level of respondchance a score of 25 represents a of the biing on the TOMM' Moreover' application no*i¿ distribution (Siegel, 1956) shows that the performance 957o confidence interval for chance below scores from 18 to 32' Consequently'
baseline for each specific diagnostic group'
ranged
General lnterPretation
unlikely to occurby chance' These low scores pictures were imply that the person knew some of the ineonect pic¡¡re' conect" but intentionally picked üre 18 are
lmplications, for,0ther Tests and Intemretation of the TOMM involves many factors most At the abstraction' of -oy o""* at various levels bÑc'level of interpretation, even before the question'of TOMM has malingeting is considered, a low score on the obtained ftom serious impücations for the validity of scores At the very other neuropsychological or intellectual tests'
on any Thus, any Person scoring lower than chance However' trial should be suspected of malingering' malin8erers or experience has shown tha!-zuspectel iniivi¿u¿s simulating malingerers do not ordinarily This obobtain below-chance scores on the TOMM' forced other from servation is consistent with results Brandt' 1991; choice procedures @inder & Willis' Guilmette 1993; Giuliano' & 1988; Guilmece, Hart,
questions about least, alowTOMM score raises serious other tests and on well the person;s motivation to perfonn of scores from should raise concerns regarding' the validity
& Amin' L994;Martin et al', L992;Prigatano Brandt' 1988)' 1993: Sück et al., 1994; $nggt"s &
et
its
regardless of age' 2 is very high for non-malingerers symPtom' psychological or neurological dysfunction,
has the net effect
Franzen, Iverson,
as
a7.,
these tests. 19
li, ,:j
iti
T0MM-Test of Memory Malingering
It ciples governing all diagnostic processes' examinacareful and processes n"ct tft" same inferential other anY in tion of all relevant information tlat occur should re-
AlowToMMscoremakesitvirtuallyimpossibleto.aris forced to rive at a clinical diagnosis and the cünician
the following: '1The conclude something along the lines of to motivation and score on the TOMM, a Lst sensitive and raises sefalls considerably below expectation putting forth was "forr, Jones rious concem about whether Mr'
This makes it difEcult' his best effort on all other tests'
if
Alto validly interpret his other scores"'
results procomsubjective vide no evidence to support the patient's plaint" Sesnick, 1988, P' 87)'
present "*i-p"*fUle, ternatively, one might state that "the
Diagnosis of Malinger¡ng
or not u p"rrott is noncompüant, feigning symptoms' converon based be pottiog forth optirral effort should Inforg"nt JuiA"o"e gathered from a variety of sources' of the imabout the onset, du¡ation, and severity Lation
is availpairment is paficularly critical' This information medical source' u¡1" tont Áe intake interview, referral friends as such records, and various collateral sources' as well as and relatives. Level of pre-injury functioning' must be occurred' the context in which the examination considered.
play a nrolilnt' While a low score on the TOMM may results from whether even dominant, role in determining patient's the neuropsychological assessments represent of malingering should optim-al performance, the diagnosis of the score on the thebasis exclusively on o"t""Ue demonstrate must iOfuff"f. A diagnosis of malingering
-¿"
that the symPtoms arc:
.
The conclusion that type of neuropsychological diagnosis'
Examinationofperfonrranceonallneuropsychological
memory processes' may tests, particulady those assessing
from gross exreveJ different "invalidity signs" ranging
of symptoms to a pattern of scores that does ,rllfit u sp""ific neurological process' These "signs" were summa¡ized in described in detail in Chapter 2 and arc
aggeration
Table 5-1.
by performatrce false or exaggerated (e'g', shown on neuroPsYchological tests)'
. intentionallY Produced, and . motivated by external incentives'
ilry-d"bil'ity
the fust issue by The score on the TOMM only addresses
t"tt"tU* *at
Table 5-l and Symptoms of Ten Gommonty Used Oualitative Signs Mafingbring on Tests of Cognitivo Abilities
Evithe TOMM score itself was unlikely'
as the basis
severity of the
injury or illness.
than recall scores on Eecognition scores that are relatively lower leaming. list tests such as to leaming.and Disorooortionately impaired attention relative lndex Concentration Attentiory' s-n wnr És..
2.
motivational basis of dence about intentionality and the sources' Not only is the behavior must come from other the diagnosis this infomration necessary for establishing of malingering, it also serves
thtt is disproportionate with the
3.
íl#;il ;;;;;;
-4.
for differentiat-
and somatoform disorders' ing malingering from factitious
5. 5. -'
not jump to the conIn medicolegal contexts, one should
of symptoms clusion that all fabrications or exaggerations
lower tílan the General Memory lndex)' difficult gne^s (e'g'' hiOher Failing easy items and passing more on Trails B.vs' Trails A; on disits; ;;;;;"t;úackward us. fo*aid paired-assoctates¡' difficult paired associates vs' easy -l know' responses' don't Unusually high frequency of
measuring similar Discrepancies between scores on tests leaming' üsual or ptóótit* such as verbal
gain' Not al1ütigating or comare motivated by financial
7.
deception occurs,
8. Near misses or approximate answers' 9. Pronounced decrements in delayed recall'
individuals intentionally feign sympfensation-seeking when conscious toms to obtain external rewards' Even to rule out that possible it may not be
adaptive in preservOe fabrication, at least in part' was by unconsciously ing the person's psychological integrity
and, b?lt:I* lnconsistencies between memory complaints sltuanon' testing the outside observed during the test or
on tests and those 10. lnconsistent pattem between scores ¡njury' or illness neurological expected from
has psychological needs' Cünicalexperience not if difficult' very is shown that in most instances it falsification *ni¡sibt"' to demonstrate conclusivelYthat behavior motivated of symptoms represents an intentional solelY bY external goals'
,"liogrrn",
the following The interested reader should also consult on this discussion and references for further information & McCracken' issue: Brandt, t988; Franzen, Iverson' 1988; Rogers' 1988b; 1990; Nies & Sweet' 1994; Pankralz,
Tennant, 1993; Trueblood' 1994; Trueblood 1989; Zielinski' & Schmidt, 193; Wasyüw & Cavanaugh' 1994.
reqqires considerable Thus' the üagnosis of malingering the diagnosis of clinical ju
ofer
nof, Wyti",
diagnosis and
shouldfollowtheexistingguidelinesandconceptualprin. 20
,i
r$l:
lnterpretation and Case Studies
Gommunicating Results
After the score on the TOMM has been viewed in the can context of all other relevant information, the cünician and motivation only offer an opinion about the person's In aniving the valiüty of the neuropsychologicat results' at a final decision, several issues should be considered:
1.
most peThe diagnosis of malingering is one of the it in essence' jorative clinical judgments because, the individual of willful deceit' fraud' and accuses
perjury (Resnick, 1988; Ruff, Wyüe & Tennant' false diagnosis can have substantial negapertive consequences extendrng into all pafs ofa A[e, including relationships with family and
1ggr.A son's
business associates. Even
if the diagnosis is correct'
If, after reviewin! alt of the evidence, the clinician is convinced that the individual has fabricated or exaggerated symptoms, then hís or her conclusion must be presented in the most professional manner. Rogers (1988a) is particularly clear on this issue. He states,'oThe clinician must and address the patient's deüberateness, g4)e of distortion' degree of distortion. In supporting his or her diagnostic conclusions, the cünician should provide specific exanples.... The clinical report should include a detai-led descripüon of how the patient is responding, and describe how this resPonse style relates to both üagnostic issues and the referral question" Cr. 307)'
the long-term social, personal, and psychological of consequences may far outweigh the seriousness
Following this guideline, a descriptive slatement of malingering might state the foüowing' "Neuropsychological results indicate that Mr. Smith was exaggerating his memory impairmenL For exanrple, his score on a test of
the offence'
2.
Confi¡mation of the diagnosis is very difficultto pertablish with any degree of certainty unless the is caught son admits to malingering or if the person perforning an act incompatible with the alleged es-
recognition memory
the performance of a severely demented individual' it rarely, if ever, is obtained by a person suffering from a
mild head injury. Other examples are"""
an
individual from obtaining external rewards' its diagnosis per se has relativeiy limilsd clinical utility (Pank¡afz & Erickson' 1990)'
Reports should be written in a mauner that is factual rather thÁ accusatory. It is partiiutarly important to go beyond rnerely" labelling the person as a nnlingerer' Given the pejoraüve overtones associated with the term malingering, along with the difficulty in confirming the diagnosis'
4. It must be recognized that malingering is not an all' or-none phenonenon, but that it exists in different
the diagnosis of malingering should only be used when a the convergence of evidence provides the cünician with
degrees ranging from minor exaggeration of exist-
ing symptoms to flagrant faking of nonexistent symPtoms (Millis, L992; Ttavin & Protter' 1984; Zeünski, 1994).
5.
high degree of confidence in the üagnosis' Carefully worded statements expressing cünical impression and reservations, along with evidence showing inconsistencies, will better serve the patient than merely stating that the patient i5 Palingering.
the The existence of malingering does not exclude
that bona fide symptoms might exist possibiüty -@io¿"t, 1990; Hiscock & Hiscock, 1989' Lanabee' 1990). The person may be exaggerating existing symptonrs. Ironically, a person's at¡empt to obtain
Binder et al. (1993) state that in some cases it may be best to "comment on the ambiguity of the neuropsychological datq including motivational factors, and then state that the motivational factors Prevent accurate diagnosis rather
compensation by exaggerating symptoms often if genumakes it difñcult" if not impossible, to assess
than diaposing malingering" (p. 145)' Thus, in many cases' the most appropriate conclusion is to stafe that "inconsist-
ine imPairments actuallY exisl
6.
.
was significantly lower than
expected. While a score falling in this range may reflect
symptoms (Ilurst, 1940; Resnick, 1988)'
3. Alüough a diagnosis of malingering p¡events
[OMM)
perMalingering cannotbe legitimately üewed as a not sonality tait. Malingering in one instance does must One malinger' always will mean that the person of be ca¡eful not to dismiss Past or' future claims impairment based on a "üagnosis" of malingering'
ency of the results preclude a diagnosis at this time"' or "the results are not consistent with any known diagnosis," or "the rezults are not consistent with the presenting complaint'' rafher than state that "the person is malingering"'
Clinicalreports proüdethe greatest ssrYice, have the most therapeutic impact, and achieve the highest acceptance when they contain some information about the motivation that prompted the dissimulation' The most d¡amatic
21
Malingedng TOMM-Test of Memory
to perform
of malingering are cases and memorable examples
on the
- "*': : :Yi:":Trt;;TJ: ;; ;;; n*'""utioo Á" ffiffi
il:;ffi
with the des¡ee ot test securitv
;;;;*t;
obtaining 13"-'^"^ :^t "*n'"" other r:as-ons explain
?J'
on how tlp TOMM anüor be coached mainillustrate the.need for TOMM' Tnese exÁples
access to
involv-
many financial benefits' ltow"n"''
il;ilñ.J
Summary
the legal arena' u"ger, particularlv outside
resPonsibi{' gaining These reasons inctu¿elvoiüoe ex-
based on decision nrles' The fustis The TOMM uses two The second
ti*"í
crises and conflicts'
don, avoiding
any performance
t"*ices'
resolving current üfe L t"ta""t an institu-
i"tify'
ui"Ñnt
¿^g"r.'uJ-*jJry,
*d
retaliating against
should never be
aovanJiouty
involved in examination of all dat¡
Gase Studies
actu¿ty have iniurv) in individuals wtro during the assessment" tffiaiá";,or?'uiiu'v' rto*ever' genuine symptoms'
of are representative exarnples The following case studies Each use¿ in clinical practice' how the TOMM inforbackgound review of relevant case contains a Urief protests admi¡istered' A referral qu""ioo' and
or exaggerates the person a:npüfres items on the MIvIPI to in a manner *utogoo, "iJo.riog is noticed-by- the cli¡ician' o' F-scale, to insure f'" she 't'" a beüef that he or Perhaps this behavior on prwious occathe desi¡ed Eeatment *U without notfe "5ir*"t"e the synpio-ms woutd l3ticed
h*;;;
ft"t
mation,
with then presented' along file of the test '"'ol" is
an
recommendations' overall sumnary and
sions orthat
ffi ;F;::ll*;;::'#T,,r"S""ffi",::
He-ad lnjuries Case Study 1: Multiple Gognitive I mpairment
--ii.-d*ted
etter served -be f underlying the ex-
will
by trying to determinJiu"
Ñ"t
processes and ca¡eful same inferential Rather, it requires Oe any clinicat judgmenr
help" (or perreoresents a "cry for Malingering frequently an to' acknowledgment of appropriately-J;"'y more haos an authentic
;;;;" ffi #Hil'"T lTJ"""-*t totiuution
i*
-"
instihrtion' uoott", Person or an
;;;
**
than chance' sarrples' Scores norms from clinical uses sriterion-based the lower than 45 should raise on the second ui¿ tftoi malingering of A diagnosis suspicion of -"tiog"Jng' on rhe basis of the TOMN{'
u tt'o'ot'gt' medicaVpsycho'logical sympathy, ensuring achieving special
nmination, obtaining care or attention t'ot't-t'"
ToMM'
and
;,;":tu:.*_:::j*:*f,,HJf:#llJJ"T,:i diagnosrs'
Background
bward intershould be di¡ected Finally, some attention rangethat fall in the normal preting TOMM scores to
school' she Ofñcu1i' foUo*ing high high school wittrout
of the final
used ¿l' A high score cannotbe scores falüng individual '¡ou" t;vei:; reasons'The n¡le out -aing"'iogil' that he or ftig'ú;; havebe"" 1A:fitiW may on a rec'ytpttt
u" í*-Aui"¿ to Performance or she percein"¿ to it'is unlikely that a
ognition memory;';;; "xample' malinger o""ototy l"fi"t: would Derson faking u *oi* a specific tvpe
ffi;;"*?- J"J*
nerson feigning
deficit disorder might his or her disto be relevant to not perceive tf'" fért¡¡nf simulation attemPt'
of learning
"
di'"biltü;;;o"t'ton
Itisalsopossiblethattherealpurposeofúretestwas person' ffre- s1fristicate,d-nalingerer transparent to the in suffrcient tf'e fret¿ of memory may have resea¡ched
memory remains indepth and leamed tf'ut '""ognition impaired cases' Consetact in all but th" mo't '"nály
il'ir, *
i"o"io'
b
vehicle fractu¡es she sustained *'I11" in the accident, although the ice on ilonttrs later she slipped in her right wrist' Six to porch' Shc repofed a 10 o and hit her he¿ oo "oo"t"t" to Ms' B'-was taken a 15 minute loss of consciousness' overnight for observation' hospital where she '"tuin"¿ time she rettt" n"rt day' Since üat She was discharged She utt""tion and concentration' ported diffrculties ltiú l"tJo" brief "spells" during which stated that relatives is and forgets what she time she becomes "*'po"tiu" Ms' B' indicated talking a¡out' ttowever' was rn' asked whether she these spells' When her accidents' "t related to either-of volved in any ütigation time'" present ..oolJ** f"naing at the she repüed tt ut
*"''"::t-i::
**"
Tests Administered. Referral Ouestion and
evaluation u n""'opsychological Ms. B. *^ '"riio' her current level of cogby her neurologist io J"'"t-i"" following tests were administered: nitive functioning' The
at-
r'",r'"n"*ro 3,H;lJI"Tr';ffn* "ia"test or mali"s"i"i:-T:l: il* il;ñ;- i¿*tiliJ* somehow sam that aPerson may
;"il;' ilt
*n'-:h: completed
obtainedadiplomaasadentalhygienist.Shewasen. in a motor until she was involved ,iil* it *' "upu"ity reported consciousness was accident' No loss of
"ü*i-''ffi Hil""f;iltr'*: gicar
born in Cleveland' Ohio'
female Ms. B. is a 30-year-old a Z-y""-ota has and She is manied
possible
22
and Case Studies
Test' Hooper Visual OrAuditory Continuous Performance Battery (selected Test, Learning and Memory
;;;;;;"
iJi"ttO,
Minnesota Mini-Mentat $f¿fus Eaamination' TOMM' (lvIMPI-z)' Personality Inventory-2
ft¡"fripftÁi"
ScaleIt4¿¿te A andB, Wechsler Adultlntelligence Verbal Fluency (FAS)' Revised Getected subtests), and
irJf
SummarY and Recommendations occasions because she Vfr. g. *a" t"rt"d oo three separate
wasunabletotoleratetestingperiodslonger.thanlhour'
she had multiple Although her demeanor was cheerful' she didnot respond' briefpJriods (5 to 1O seconds) when deviate to eles-13r1ld some of these periods her on the Mini-Mental Sta""tt"; oo" ,iá" or the other' Her score in the cognitively-impaired tus:Exa:n was 20130, which is average' Tests of attenwere t*g". ir"gtage abiüties
ioJ, uiruo-rpulol ubiüty, and memory vietfa
scores
in
Her MMPI-2 the mild to moderate range of impairment invalid due to a high F-to-K rant"nt" was judged to be lower io. lt"r scores on the TOMM were substantially 35)' ¿2i Reteption = ttuo Griaf 1 = 33; Trial 2 =
According to Mr' A" interrrittent tingling in his hands' ih frequency' ranging from several l"r"
"pitoa"t;"tJ timl ner ho'ur' Mr' A' times per day to as many as th¡ee of "spelf' that resembles a also experiences a s-econd type dizry spells ,ei"*e. According to him, these begin üke aloss ofconscious awareness' convulsions' Neurological tongo" biting, and occasional inconünence'
lo,pagr"rr
t
"*Áioutioo.,
have been EEG recordings' and CT scans
unabletoconfirmthepresenceofanytypeofseizu¡eac-
awa¡ded a after the accident' Mr' A' was has been he time' nVi asaUiliE allowance' Since that the ti:ne at employed part-time as a welder' Medications propranolol' chlordiazepoxide' and
ivity. Shortly
of testing were carbamazePine.
Beferral Ouestion and Tests Administered evaluation Mr. A. was referred for neuropsychological concentrate and progresbecause of decreased abiüty to
sivedecüneinmemory.Neuropsychologicaltesüngin. Naming fe1 cluded the following tests: Boston !-os1o1 Verbal California Battery' Visual-Spatial Quantitative
histhan would be expected f¡om her
Test" Learnl,earning Test, Hooper Visual Organization tasks' ing and Memory Battery Luria's reOelti1e¡notor Trail Making RJy-Ostenieth Complex Figure' TOMM' WAIS-R' A & B, word fluency tests, and the
on the "o"óiti"At-i-pai¡ed ,"ñt n"u¿ t".iuty' In üght of her performa¡ce was intent her MMPI-2, it was uncertain as to whether lack her if was uncertain conscious or unconscious' It also her current life situation by was motivated solely
Summary and Recommendations he a¡rived at the Mr. A. ryas admated and excited when his past history and hospital. He was very candid about associated with it' including de-
"^p""t"d
tests Overall, the findings from the neuropsychological suggested that Ms'
B' attempted to portray herself as more
of effort
pattern' It if it reflected a more chronic maladaptive in explored ** r""tt-"nded that these issues be further
theLotional ,"qo,iu
and depression' scriptions of prolonged periods of anger his declining Mr. A.'s major complaints centered a¡ound evaluation' he expücitly memory. Several times during the apologized for forgetting asked the examiner's name and repeatedly about the difficulty of the tests
or
it is still evaluation' Despite these results' had been compottiul" that Ms. B.'s cognitive abiüties B' may have Ms' that even likely'
;;ñ;;
pr"*it"¿. It is possible,
it. IIe remarked andhowhehadtroubleansweringmanyofthequestions.
exaggeÉted or amplified mitO cogaitive deficits that she during testing.
results showed conMr. A.'s profile of neuropsychological between tests' For siderable variabiüty, both within a¡d Figure and example, his copy score on the Rey Complex
Gase,study 2: An lndustrial Accident' Seizures, and'Malinger¡ng
Design were averhis performance on the WAIS-R Block a score that typica[y is age, but his score on the Hooper' with normal performance on these two
Background
Nova Scotia 42'y eu'oLd male born in Halifax' completed eight years He is the fourth of 10 children' and
Mr.
t
is
ftlgnfy correlated
a
perform*:".oo t"Jtr, *o, significantly impaired' His visualandverballeamingtestsfellintheseverelyimand recoepipaired range. His scores on the cued-recall
offormaleducation.Hisdevelopmentathistoryisunre-
markable.AtageZ4,hesustainedaheadinjurywhile to Mr' A" a 4' x 4' working in a ship yard' According 'wooden beam fell from a scaffold and struck him on the of the btow knocked side of the head. Although the impact
hi¡ off his,feeL
p*
of the learning and memory tests suggestedthat envi¡onmental cues he would have trouble recognizing However' and finding his way a¡ound his envi¡onment' the testing room' oo t*o'o""^ions he was able to leave room without testing the to find the bathroom, and return to answer any apparent problems' His repeated refusal and his brief answers to many questions sug-
,ioo
no loss of consciousness or retrograde
amnesiaoccurred.ShortlyafterthEaccidenthe.reported
oecu¡red suddenly and having dizzy spells. These episodes warning. During these spells he'fee-ls 'unsasy'
qolstiont
without
numbness with breaks into a cold sweat, and experiences ?3
TOMM-Test of Memory Malingering was average'
bal fluency, and complex visuo-perception tasks of fine motor He performed at impaired levels on
his best effort' This gested that he was not putting forth
on the was validated by his performance significantly wtt"r" his scores onboth trials were was con¿ l2)'lt (Trial L l3i Trial2
"rogg"rtioo
tófovÍ,
UuÑ
=
"na"e on ttre TOMM' This cluded that Mr' A. was malingering f¿ctors menüoned fact, in combination with the other test results or to his Jou", made it impossible to interpret any type of from Ja*rrrrio" if, in fact, he was suffering mémory imPairment'
education' his-
grade Mt M. is a 3#year-old male with a 10ü tf"'** itt" inb"on"', Colorado' His developmental
unrema¡kable' Mr' M' reported thztatage26he at the ,uá"*a a severe head injury when he fell asleepHe retn¡ck a by hit w¿¡s whJ of his ca¡ and his c¿u (time p""J *t" he fractured his skull and was in a coma in the was At the time of trre a7o7o sewice-conUS Ar:ny and subsequently received syndrome'.' brain At"olüty for'brganic 1:decüne in that since the accident he has had a substantial Mr' concentration, and topographical orienfation' additional medical problems beyond
,* **
a{ae1f
i;**ri"Ol
1 substantially below expectation Cfrial 35, Retention = 33).
ao*,
Gase Study
¿iinot report denied' He stated his head injury. Substance abuse was last 3 or 4 years' the that he has been unemployed for jobs in the heviously, he had many different unskilled of testing' he was apconstruction industry' At the time plying for a review of his disability allowance'
rr,r.
Background
in educaMr. R. is a 47-yeat-old male with a BA degree informaLittle Missouri' Louis, tion. He was bom in St. tioriwasavailableonhisdevelopmentalhistory.Priorto
as a 5ü grade his traumatic brain injury, he was employed fracture when he teacher. In 1988, he sustai¡ed a skull head with a was assaulted and struck in the back of the disora seizure pipe. After the assault, M¡. R' developed
Referral 0r¡estion and Tests Administered psychiatry clinic Mt L,f" was referred from the outpatient was to rule referral tA hospital. The purpose of the conrelative describe the out an amnestic syndrome and to psychological tributions of functional versus "organiC' brain traumatic his tliat have taken place since adwere tests "fr-r", io.¡*i. The following neuropsychological Word Oral rioirt"r"¿, Boston Naming Test' Controlled
Most experienced a variety of cognitive deficits' His alexia was notable was a decreased ability to read' his teachresuming from sufficiently severe to PreYent him abildecreased a ing career. Personality distu¡bances and with his disabilities were also noteü Medical itito "op" illness that records revealed ahistory of manic-depressive to admitted R' Mr predated his traumatic iread injury' admission' lu-"roo, psychiatric admissions' At time of assistMr. R. was üving in a boa¡ding house on social Zantac' Dila¡tin' included ance. Medications on admission Ativan, Elavil, and lithium.
i". *¿
;i;
Visual
Test' Hooper Association Task, Grooved Pegboard Exam' TOMM' Status Organization Test, Mini-Mental
(LogtTest A and B' WAIS-R' and WMS-R
cal Memory and Visual Reproduction)'
Recommtndllo:t. was socially fu,r*gftoot testing, Mr' M''s behavior Summary and
;;-;A;tt
Referral fluestion and Tests Administered cognitive abiüMr. R. was referred for evaluation of his toward assessment ties, with pa*icular attention directed a full battery of of language. Mr. R. was administered DiagnosBoston o"*ofryÁotogical tests, including the Battic Aphasia Test, Boston Visual-spatial Quantitative
ap-
his Jbserved affect was tense and-irritable'
oj-Seneltg Spontaneous comments sugg-ested EooO f1t ZVIO ol tlrc and skepicism' Mr' lvl' scored
l"¿ -r*
frli*-ftfa",¡,StatusExam,placinghisperformanceinthe with sigrange' nis lq was low average ;Ñ;;"d
l?áii"*-rest
4: Severe Head lniury,
Aphasia, and Prior Psychiatric History
;;;;,
táU*ing
=
predict Mr' M''s funcIt was concluded that any attenrpt to test profile was tion status from his neuropsychological and the possicompromised by uneven effort, dysphoria' occuned of ani"r and oppositional reaction that presence and-the during the evaluation. His past history of measures of pÁeverative intrusion errors on sev-eral some degree of leaming and menory strongly suggested the complex nature traumatic encephalopatby' However' made it perfonnance of factors impinging upon his test level precise the difficul! if not impossible, to determine va¡ied ,p*in" nature of impaimrent (which could have test results' brain fmm mild to severe). Reüance on previous recommended was data of data and other sources evaluation' present U."u-ot" of the limited utility of the
t"ryf
;*J
=25;Tial2
iit"f""o
lniury and Gase Study 3: Traumatic Brain DisabilitY Allowance Background
ontrol @ilaterally)' leamin-S 11d rememsocial judgment' U"riog, orientation to place and time¡ the TOMM were and clmplex attention. I{is scores on sp"Jd aod motor
Luria repetitive tery,^Hooper Visual Organization test'
of verscitter' His performance on tests 24
ffiii'i' ijr.'t{fii.i,. r ,lj:'.:,i l; :'
lnterpretation and case studies
lems. These problems included an inabiüty to remember the rules of field hockey"even though she had played it
motor tests, TOMM, Visual Cancellation Tests, WAIS-R, and WMS-R.
competitively in high ichool, a failure to remembei many of the details of the hoqse where she lived as a teenager, and a degreased ability to remember the names of many
Test Results
Mr. R. appeared to be awa¡e of his problems. Some word retrieval problems were noted- Despite these problems, his speech was fluent and his comprehension was excel-
high school friends. In addition, her friends tsld her that she has become more forgetful in her daily life. Concerned about these problems, she contacúed a women's health clinic.
lent. However, severe alexia without agraphia was present' Arithmetic, right/teft orientation, and finger gnosis were
Referral 0üestion and Tests Administered Ms. C. was referred for neuropsychological evaluation of her mnestic abiüties with particular emphasis on how they were related to her mood state and personality. The following tests were administered: Boston Naming Test'
impaired. Many errors of rotation and reversal interfered with performance of visuo-spatial tasks. Some problems with learning and menory in both the verbal and nonverbal domains were evident. Particularly noteworthy was his tendency to conñ¡se details from different sources' A pronounced drowsiness interfered with sustained perform' ance and extremely long response latencies occurred on many tests. Mr. R. also exhibited approximate answers to many formal and inforrral questions. It was felt that this
Califomia Veñat Irarning Test, Minnesota Multiphasic Personality Inventory-2, Profile of Mood Statbs, ReyOstenieth Complex Figure, TOMM, Trail Making A & B, Wechsler Adult Inteltigence Scale-Revised (selected subtests), Wechlser Memory Scale-Revised (selected subtests), and Verbat Fluency @AS and Animals).
degree of approximate answers were atypical for a closed head injury. The scores on the TOMM were as follows:
Trial 1 = 22, Tnal 2 = 25- Extremely long response
Summary and Recommendations
latencies occurred on each trial.
Ms. C. was cooperative tluoughout testing. Behavioral observations revealed mild impulsivity and distractibiüty. Her intelligence was estimated to be average based on her education, work history, and scores on the WAIS-R. Per-
Summary and Recommendations Mr. R.'s overall presentation suggested that his test scores probably reflected a motivational disorder superimposed on a baseline of genuine cognitive deficits caused by his
formance on attentional tasks was va¡iable' Digit span was impaired at 5 digits forward and 3 digits backwa¡d. However, performance on Trails A and B exceeded the 90ú percentile. Laagaage and visuo-spatial abilities were
previous head injury. His psychiatric history suggested that his low scores on the TOMM, as well as the other indicato¡s of invalidity, were due at least in pa¡t to a desire to adopt and to maintain the role of a patient With this in mind, Mr. R was encouraged to join a closed head injury support Foup. However, he did not feel that he needed a supPort group and was not interested in participating. A similar response was forthcoming when he was referred. to speech therapy and other rehabilitation programs. Given his low level of compüance, as well as his decreased ability to accept responsibility for managing his problems, he was üscharged from the hospital' He
average. Verbal and visual learning were average, with the exception of the Rey-Osterrieth Complex Figure where immediate and delayed recall were severely impaired. Both
drawings consisted of unconnected lines and distorted segments. The overall quality of her drawing suggested a
severity of visuo-spatial impairment that was inconsistent with her history and general neuropsychological pro-
file. Scores on the TOMM were witlin normal limits (trial 1 = 41; TrraJz= 47, Retention = 50). Her MMPI-2 profile indicated that she was anxious, drained with suicidal ideation.
was offered the opportunity to return to the hospital as an outpatienl Predictabl¡ he refused.
lonel¡ and emotionally
Overall, her neuropsychological evaluation showed that Ms. C. had average cognitive abiüties' The only possible exception was her impaired performance on the ReyOsterrieth Complex Figure, which she attributed to its
Gase Study 5: PsYchogen¡c Amnesia ANd PTSD
lack of aesthetic qualities. Accorüng to her, it was irregular and nnsymmetrical. Qualitative analysis of her responses, as well as the scores on the TOMM, suggested that she had put forth her best effort and was not attempting to portray herself in an unfavo¡able üght. Thus, it was concluded that her o¡rerall profile provided little evi-
Background
Ms. C. is a 3O-year-old female' She was born in Chicago' trlinois. She is divoreed and lives alone. She reported being gang raped twice as a teenager. After graduating from high school, she moved to Cleveland, Ohio, where she found employment as a waitress, secretary, property manager, and postal clerk. Following a visit home to see her patents, she began experiencing long-term memory prob-
dence that her reported memory problems had a neuro-
25
TOMI#{ést'of,@nr1ryMalingt1inlq
conplaints' q:.i logical,basis. He¡ memory i indicated that her probscores' lvtrvPl-i and hethistory of that context
basis' rt wiu recommended with a felong-term osychotherlP-¡
;#.#-;-Ñchogenic she be.referred'for
traininS in rea$ng male thétapist'who"hJ specialized P[SD' il"¡ft-Jo.* individuals suffering ftom
26
llt,,iiir::
;ii:
-::
l';l:11': r":'
¡
i
--: ,
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Shepard, R. (1967). Recognition memory for words, sentences and pictures. Iournal ofVerbal Learning and Verbal Beh¿vior 6, 156-163.
Reid; D.8., & Kelly, M,P. (1991)' A study of the Wechsler Memory Scale-Revised in closed head injury. Journal of Clinical and Experimental NeurcPsYclwlogY, I 3, 20.
Siegel, S. (1956). Nonparatnetric startstics for the behovioral sciences, New York McGraw-Hill'
of posttraumatic of disorders. In R. Rogers @d"); Clinical assessment
Resnick P.L.
(1988). Malingering
Sück, D., Hopp, G., Strauss, E., Hunter, M', & Pinch, D. (1994)' Detectiag dissimulation: Profiles of simulated malingerers, traumatic brain'inju¡Y patients, and normal controls on a revised version of Hiscock and Hiscock's forced-choice memory test'
malingering and decepüon (pp' 84-103)' New York: GuiHord hess. Rey, A. (1964). L-examen psychologique dans les cas de d' encephalopathie traumati que' Archív e s P sychologíe, 28, 28G340'
Journal of Ctinicol and Experímental Neuropsy¿hology, 16,472481.
Rogers, R. (1988a). Current st¿tus of clinical methods' lo R. nog"tt @-), Clinical assessment of malínger'
Squire, L. R. (1987). Memory and brain' New York:
Oxford UniversitY Press.
ing and deceptíon (pp- 293408)' New York:
Guilford
Press.
Stanüng, L., Conezio, J., & Haber, N. (1970)' Percep' tion and memory for pictures: Single-trial learning
Rogers, R' (1988b). Clinical a'ssessment of malingering and d'eception. New York Guilford hess'
of 2500 visual stimuü. Psychorwmíc Scíence, 19,
73:74.
Rogers, R. (1990). Models of feignedmental illness' ractic e' P rofessional P sy choto gy : Re s e arch and P
21,182-L8B
Res earch
Schmidt, J.P., & Tombaugh, T.N- (1995). Learning and Memory Battery !A'MB). Toronto: Multi-Health
Rees, L.M., & Tombaugh, T.N. (1996) ' Validation of the Test of Memory Malingering (TOMM) using a simulation paradigm. Poster presented at the Annual Meeting of the International Neuropsychological SocietY, Chicago'
&
Strub, R.t,, & Black, F.W. (1985). The mental statu;s examínation in neurology (2nd Ed')' Philadelphia'
'
PA: F. A. Davis ComPanY'
30
References
Tfavin, S., & hotler, B. (1984). Malingering and malingering-like behavion Some cünical and conceptual issues. Psychiatric Quanerly, 56, 189-197. Trueblood, W. (1994). Qualitative and quantitative characteristics of malingered and other invaüd WAIS-R and cünical memory data- Journal of Clínical and Exp erintzntal N europ sycholo gy, I 6,
597407. Trueblood, W., & Schmidt, M. (1993). Malingering and other validity considerations in the neuropsychological evaluation of mild head injury. foumal of Clinical and Experímental Neuropsychol'
ogy,15,578-590. Wasyüw, O.E., & Cavanaugh, J.L. (1989). Sinulation of brain damage: Assessment and decision rules. Bull¿tin of the American Academy of Psychiatry and
lnw
17,3'73-386.
Wechsler, D. (1981). Wechsler Adult Intelligence Scale-Revised. San Antonio, TX: Psychological
Corporation.
Manualfor the Wechsler Memory Scale-Revised. San Antonio, TX: Psychological
Wechsler, D. (1937).
Corporation. Wiggins, E.C., & Brandt, J. (i988). The detection of simulated arnesia Law and Hurnan Beha'iouri 12,
57:t8. Winograd,8., Smith, A.D., & Si:non, E.W. (1982). Aging ancl the picture superiority effect in recall. Journal of Gerontologl, 37, 7 O-7 5.
Zelinski,
J.f .
$994). Matingering and defensiveness in
the neuropsychologicat assessment of rrild traumatic brain injury. Clinical Psychology: Science and
Practíce,1, 169-183.
31
Appendix A Glinical Sample Scores from all
Appendix A shows how each member of the clinical sample performed on the TOMM. For each patient' performance on the TOMM is also compared with performance on standardized tests of learning and retention' The cüni-
tials of the TOMM, along with
percen-
tile scores from visual and verbal learning tests, are presented for each member of the clinical sample. Medical and radiological information are also provided for each patient, thus documenting the degee of overall impairmenl
cal sample (n = 161) is divided into five major groups:
. No Cognitive ImPairment (n = L3), . Cognitive TmPairment (n = 42), . Aphasia (n=21), . Traumatic Brain Injury (n = 45), and . Dementia (n = 40)'
The information contained in the appendix shows that patients obtain consistently high scores across a variety of meücal conditions and radiological evideniO. It also demonstrates repeatedly that individual patients who score in the severely impaired range on free recall measures of learning and retention obtain extrenely high scor€s on
the ToMM.
Appendix Abbreviations ACA
Anterior Cerebral Artery
ADD
Attention Defi cit Disorder
AVM
Arteriovenous Malformation
cHl
Closed Head Injury
CNS
Central Nervous SYstem
CVA
Cereb¡ovascula¡ Accident
COPD
Chronic Obstructive Pulmonary Disorder
CT
Computed TomograPhY
L0c
Loss ofConsciousness
MCA
Middle Cerebral Artery
MRI
Magnetic Resonance Imaging
MVA
Motor Vehicle Accident
PCA
Posterior Cerebral Artery
PTA
Post-Traumatic Amnesia
PTSD
Post-Traumatic Stress Disorder
SPECT
Single Photon Emission Computed TlomographY
TB
Tt¡berculosis
TBI
Traumatic Brain Injury
TIA
Transient Ischemic Attack
33
T0MM-Test of Memory Malingering
No Gognitive lmpáirment (NGl) (age)
T0MM Scores Retain
NC1-1
48 50
Patient
1 2
50
(43)
4t 50 50
NCI-2 t62! NCI-3
49 50
50
48 50
50
Learning
I
Verbal
Medical History
Retentionr Visual
L=24s*
L= 19s
R:28ú
H=18ñ
L=55m
L=76ü
R:84ü
R=98s
Radiology (CT/MRU
Polysubstance abuse.
(301
NCI-4
Alcohol abuse.
(471
45
NCI-5
L=32nd L=54"
50
(711
50 50
NCr-6
50
(401
47
NCI-7
r32l
I
L=61f
L=99n R=99$
R=50ü
so 50
50
49 50
50
49 50 50
R:l6ó PresymPtomatic Huntington's
50
48 50
50
R=506 L:24ü*
50 50
50
(44)
NCI-13 {60}
when ürese were not WMS.R. Scores from
L:97ü R=99h
L=93d* L=98s
43 50
(70)
NCI-12
L=51d' R=45ü
B:96ü L=gü
(3s) NCI-11
Marked generalized atroPhY'
disease.
t34) NCI-10
Seizure disorder, alcohol abuse'
Small infarct in left centrum semiovale'
L=31d
I
NCI-9
'
R=24ñ
L:98ü fl:99s
50
(2el
NCI-8
B=84ü
Unremarkable'
B=94m
L=99ñ R=86ú
L:34ü
B:30ú R=74s L= 55ü L=99' R:21d
PresymPtomatic Huntington's ¡li c oacc PresymPtomatic Huntington's .liepaqc
Multiple chemical sensitivitY'
Unremarkable.
Polysubstance abuse, head iniuries'
Myocardial infurction.
R=82nd
MemlrY ua¡ery came from üe C¡r'LT o¡ tie Leaming a¡d scores were from ñe leaming/rete¡rtion t'l*tl nr utto' *r" rI.jji:.jy:1x?#fffrIfl,nilx'*;:ilnffIiJ*'eLvLlguEel¡nllgoll9.''-ü-illn..p'l,I'*,onsubtestofthe ,r*ro ,i,i",
,*¡r.¡r., ,.0L", io'niiirüg:*iür,nory
*i-ñ
the WMS-B' the Log¡cal Memory subtest of
34
r'-i.ii
Clinical Sample
Gognitive lmpairment (Cl) Patient (age) cl-1
T0MM Scores
1 2 Betain
Learning & Retentiont
4s 50 50
Verbal
Visual
L:1r
L:88ü
R:<1$ R:
(s1)
Radiology (CT/MRl)
Medical History
Colloid cyst in 3d ventricle, PTSD,
Post-surgical changes in paramedian
borderline personalitY dísorder,
aspect of right frontal lobe, heads of
alcohol abuse, hypothYroidism.
fomices. and left caudate.
COPD.
cr-2
M5050
L=32nd L: < 1d R=31" R:(13t L: <1r l:l2na R:<,|" B:<1s
(451
ct-3
49 50
50
{75}
Bilateral ischemic gliotic changes within
Multiple sclerosis.
centrum semiovale bilaterallY. Chronic paranoid schizoPhrenia,
Moderate cerebnl atroPhY.
alcohol abuse, toxic poisoning (insecticide). syphilis, TB.
cl-4
40
46
(68)
cr-5
49 50
50
L:4ú L=40s R:<1s R:<1r
anemia, impaired hearing. C0PD.
in deep white matter and Pons' Mammillary bodies not seen.
L=86s
Alcohol abuse, perforated duodenal
Generalized atrophy in cerebral cortical
ulcer, C0PD.
cerebellar and central structures.
L:52"d
fl_Qlnd R=<1r
(67)
Korsakoff
's syndrome, malaria,
Lacune in head of right caudate. Changes
Subdural hygromas. Evidence suggesting subdural hemonhage in area adjacent to parietal cortex and ischemic events in superior division of left MCA. Lt-b
38 50
L:1
50
6ü
R:42na
(7s)
L:42ú R:22rd
Atpical depression, sleeP
aPnea,
colon cancer, transurethral
lschemic gliotic changes within centrum semiovale bilaterallY.
resection of prostate, obesitY.
ct-7
34 49
48
l47l cl-8
46 50
50
L:l9s
L:88ü
Hypertension, polysubstance abuse,
R=42td
R=73d
spinal stenosis.
L:55s
L:99ü
Left frontal stroke, right Pontine
Encephalomalacia in anterior left frontal
R=94m
stroke, diabetes,
lobe. Small lesion in right,Pons.
R:84ü
{5s}
Unremarkable.
urínary incontinence. cr-9
48 50
l72l cl-10
37 49
50
{31}
cl-l1
39 47
16n L:44ü R=6s R:lr
Myocardial infarction, peptic ulcel
Minimal scattered focal ischemic gliotic
Parkinsonian symptoms.
changes within deeP white matter.
L:14h R:3d
L=90h
Attention deficit disorder, alcohol
R:1
and cocaine abuse.
L:2ls*
L=40ü
Left occipital stroke (residual right
Encephalomalacia in left occipital lobe
H-22nd
neglect), seizure disorder hYPer-
and left medial temporal lobe. l¡cunes
tension, diabetes, coronary artery
within left thalamus. Significant stenosis
disease.
of right intemal carotid artery.
L=
50
45
(701
cl-12
42 50
L=7fr R=5ü
50
(37)
ct-13
48 50
50
(431
3ü
L=6fr'
Huntington's disease, borderline 10.
R=3d
L=30ü L:l8ü
Severe leaming disability, seizure
B=42rd R:5ú
disorder, alcohol abuse, depression,
Unremarkable.
diabetes, hypertension, asthma. obesity. 9nüon19r.es.9a-19fromüreCVLTortheLeamingandMemoryBattery(lAMB-Ustteamingl. \tr,NlS-R.
'
Scores ftom üre l-oglcal Memory subtest of
üe
WMS-R'
35
TOMM-Test of Memory Malingering
Patient
T0MM Scores
{age)
1 2 Retain
ct-14
47 50
50
44 49
50
41
49
(63)
Medical History
Radiolosy (CT/MRl)
Visual
L:99s
R:50ñ R:99ü L:60ú L=60ü H:48ú R=50ú L:546 l:42nt B:506 fl=ZTnd
(871
ct-r 6
Verbal
L:32"d
(3S)
cr-r 5
Learning É Retention
Polysubstance abuse.
Colonoscopy.
Right MCA stroke, seizure disorder.
Large right-hemisphere lesions in
hypoglycemia, glaucoma, hYPer-
superior and inferior temporal lobe, deep
cholesterolemia.
white matter, putamen, middle and inferior aspects of frontal lobe. Small lesion in left caudate.
ct-17
25
L:4ü L:77ú fr:4lrt R: <1r
35
(56)
Korsakoff
's syndrome, tuberculosis.
Moderate centnl and cortical cerebral atrophy. Moderate cerebellar atrophy. Lacunar infarcts within left putamen and
globus pallidus. ct-18
40
41
t68l
Hypertension, diabetes. renal
Pontine infarct. lnfarct in right
transplant. Mild confusional state
frontoparietal cortex and deep white matter consistent with a stroke in right
during testing.
superior düsion of MCA. Multiple deep lacunar infarcts in bilateral basal ganglia,
intemal capsule and centrum semiovale' cl-19
37
Rupture of right AVM with frontal lobe craniotomy {residual left side
L:<1n R: <11
41
t47)
Evidence of right fiontal craniotomy.
neglect and mild left hemiPlegia)' seizure disorder, alcohol abuse, hypertension, anemia. Probable subclinical seizure during testing. Respite*.
ct-20
41 48
50
(4sl
L:2na R:16ü
to insecücide, ulcerative
L:63d
Exposure
R=33d
colitus, PISD, chronic fatigue syndrome.
ct-21
s0 50
gray/ Right CVA (residual left hemiparesis), lnfarction in right parietal area. Poor frontal in right differentiation matter white coronary hypertension. diabetes,
50
{68)
artery disease, angina. atrial flutter,
lobe. l¡cunes in right caudate head due
peripheral vascular disease,
to microvascular disease.
glaucoma. Respite. ct-22
47 50
49
(761
L=21ú' L:52d R=38ü R= ( 1r
Depression. stable angina.
lschemic demyelination or gliosis within
ruptured disks. arthritis, colon
white matter. Some atroPhY.
polyps. kidney stones. cr-23
46 50 50
(6s)
cl-24 (6el .
50 50
50
L=246*
L=67s
R-gl'
R=3Bs
L=
1
8s
L:30s
R_42na R:S?d
Sudden-onset amnesia (19891' unconfi rmed seizure disorder, peptic
'liny lacunar infarcts in right and left pons. Mild ischemic/gliotic changes within left
ulcer disease.
corona radiata.
Hypertension, alcohol abuse, kidney
lnfarcts in left cerebellum and left frontal
stones.
lobe. Moderate amount of cerebral atrophy.
¡ Respite-lbtients
were in hospital for a week !0 proüde respiE for caretakers'
36
Clinical SamPle
Patient
Verbal
1 2
(age)
48 50
cl-25
Visual MCA stroke, cerebral vascular carotid disease. stenosis of right depression' disorder, artery seizure
l=lod
50
R=Znd
(7s)
RadiologY (CT/MRl)
Medical History
Learning & Retention
TOMM Scores Retain
in left lnfaicts in right MCA territory' caudate. and in left internal capsule'
diabetes, hYPothYroidism'
cr-26
(61)
I
50
L=Ss
50
R=(1s R:<1d -
I
L=16ú* L:1
39M42
cl-27 (s3l
48 50
cr-28
L:34s
R=Sn
1ü
R=15ü
aPnea' Parkinson's disease, sleeP rliahetes- hvoothvroidism' Alcohol abuse, gait disturbance'
Moderate to severe atrophy' R¡ght thalamic lucunar infurct'
C0PD' P[SD, anorexia, PePtic ulcer'
disorder' Parkinson's disease, seizure disorder' personality alcohol abuse.
50
joint disease' arthritis, degenerative
(70)
Respite.
43 50
cr-29
L=lnd R=<1f
50
l42l cl-30
(1!t R=<1f
L=20ñ R=7ü
Possible sleeP disorder'
l-=
42 48
50
L=6ü L=246 R=(1r R=7ü
Schizoaffective disorder, tuberculosis, tardive dYskinesia, urinary
L=7s R:(1s
chronic Carpal tunnel sYndrome,
42 50
50
t3e)
ct-33
^r^^x^t oh'rca PTSÍ)
50
(s3l
cr-32
B=246
Left hemi-sensory loss, olÍactory hallucinations, migraine headaches'
47 50
(42) cl-31
L:40ü
46 50
L=20s
49
hemaRight frontoparietal subdural hYPertension, diabetes, toma,
R=20ü
(761
incontinence, alcohol abuse'
R=29s
L=54ü
Unremarkable.
coronary artery disease, atfial
Unremarkable.
with Right-side subdural hematoma subtulcine ¡ght-to-left midline shift and herniation.
fibrillation. cl-34
46
L:
50
(32)
cl-35
50 50
50
'(401
cl-36
M49
t63l cl-37
49 50
50
43 50
50
t4e)
cl-3s
49
50
(60)
cr-40
46 50
50
49 50
50
t48l
cl4t (631
cl-42
36
47
L:56s
R=(1d R:75s L=706 L:98s R=50s
R=96ó
L=6s R:9ü L=llnt
L=57s R:17d'
B='16ü
(301
cr-38
<1*
L=96s R=95s
14ü L:54s R=
L=
Bipolar disorder-
Unremarkable.
Carbon monoxide exPosure, chronic nain
Hypertension, diabetes. I lAs'
in¡unes' Polysubstance abuse. head
Depressed (suicide attemPt),
alcohol abuse. 0epression.
Multiple scleros¡s.
Diabetes, hYPertenston, Parkinsonian features.
Left MCA stroke.
{761
37
right Lacunar infarcts in Pons and putamen.
Aphasia TOMM Scores
Patient (age) A-1
1 2 Retain
Verbal
43 50
L=20ü
50
I
t40)
49 50
A-2
R=E*
RadiologY (CT/MRl)
Medical History
Learning & Retentiont Visual
cranioFluent aphasia, left temporal hemiano right (residual tomy, stroke
L:68ü R=94ú
;.r'
¡onatitis B and C' pancreatitis'
Left temporoparietal encephalomalacia temporal with ex vacuo dilatation of left hn¡n
infarct in MCA tenitory wlth MCA stroke' Large left Ñon-fluent aphasia. left gliosis and encephalomalacia' 812 deficiency' sub"corticat alcohol abuse. gout, border zone of MCA and within lnfarct peptic ulcer disease' ResPite't pCl. Wrttttitn degeneration in mid brain
50
(73)
.+ toft narehral oeduncle.
45 50
A-3
Fluent aPhasia. 50
(731
41 49
A-4
ilnt
(1r L=52"d R:<1d R-<1"
L=
50
(85)
aphasia, left parietaVoccipital hYPertension, diabetes'
stroke.
hea¡ing pacemaker, bilateral neural
loss. ResPite'
ionitrtn,
49 50 49
A-5
-mrrpn-a*ttrda
I
pari etaVocci pital
I
ex vacuo dilatation of occipital
*in
.rut
in eft
Bilateral hom of left lateral ventricle' ischemic gliotic and lacunes gtngl¡t iárut white matter' ^r,o..o. in neriventricular
aPhasia, left MCA stroke'
parietal area Encephalomalacia in left with infarct of left supenor
consistent
MCA tenitory.
(631
MCA
49 50
A-6
within left stroke incoohalomalacia ion-ttuent aPhasia, left MCA portion of anteriol a sparing territory hemiparesis)' hypertresidual right
50
+o.cinn alcohol abLlS€.
t5e)
45 50
A-7
Fluent aPhasia, right Ponnne (residuai teft hemiparesis)' bacterial diabetes, aÜial fibrilla-
L=346 R=58$
50
(73)
ieningiüs,
tions, anemia.
A-8
50 50
R=7s L=4u''
MCA stroke Ñ-oJluent aPhasia, left
(54)
A-9
50 50
50
R=24s
(44)
A-10
50
seizure disfresiduaf right neglect)' abuse' alcohol order, hYPertension, arthritis. gout.
43 50
ePiderlnom¡a, left temPoral lobe (residual right moid cyst resection
50
verbal leaming/retenüon
WMS.R.
;;;*"
seizure disorder'
, colonglllYp& slaucoma,
hemianoPiaf
Most gr#'''|l*;ffJ
,
hom of vacuo dilatation of posterior
pañetal ano Encephalomalacia of left and L*potut lobes including anterior
fissure' inferiol asPect of SYIüan involves putamen' Left subcortical infarct pattiOus, andanterior limb of
otUus
:rntemal
irto
WMi.il
of left MUA' lnfarct in ústribution area periventricular MultiDle lacunes in left white matter. Calcification in dentate in Uasat ganglia' nuctei of cereUettum anO .enirl fnsa ilr rErr r¡r¡ve'e. I uysflc cavltY utttnrion into posterior fossa'
I *ittt
38
ntropnY of left Peduncle'
ffi I
ffi ;;;:Áiüsual leaming/reterrtion scores
for caretakers' week to proüde respite were in hospiul'for a
*
mafter capsule into the white all involves Broca's area' Lesion
periventricular oi ttt. ,ntt¡ot ?3 of the .-..t i*o -^ttor and most of the posterior'
50
t71)
,
ro.tiu.*
stroke' Fluent aPhasia, left MCA
{73)
A-11
lnfarct right Pontine area' parietal region Encephatmalacia in left Ex wiÜr old watershed infurct' r-+or¡r vent¡ielp- M¡ld atroDhy presenl
stroke Fluent aPhasia. left MCA homonomous tresidual right
L=50s
50
^.rio+al lnhP
Clinical Sample
Patient (age) A-12
TOMM Scores
1 2 Retain
48 50
50
t65)
Verbal
'
Medical History
Learning & Retention
RadiologY {CT/MRl}
Visual L=78s
Fluent aphasia' left MCA stroke.
R-<1r
hypertensi0n, atrial fibrillation'
lnfarct remote anterior left temporal and teft mid to posterior parietal lobes' l¡cunar infatcts in basal ganglia and deep
white matter. A-13
46 49
48
(6s)
Conduction aPhasia, left MCA stroke, occluded left intemal carotid
parietal Encephalomalacia involving left thalamus' lobe, left caudate. and left
artery hYPertension, hYPercholes-
Cavum sePtum Pellucidum.
+a¡nlomin
A-14
31
Globalaphasia, left MCA strore,
41
hypertension. hypercholesterolemia
(55t
diabetes. hypothyroidism. Respite'
Encephalomalacia involüng left frontal' parietal, and temporal lobes extending
into watershed region of left occipital. lobe. Left basal ganglia and internal capsule involved"
A-15
45 49
Mixed a.phasia, right MCA fronto-
49
parietal stroke, mYocardial
(68)
rction, diabetes, hYPertension, renal transplant, comeal implants'
infu
Mild to moderate cortical atrophy' Lateral ventricles enlarged. lnfarct in right frontoparietal cortex extending into subcortical and deep white matter' Lacunes in bilateral thalami and basal ganglia, pons, and right cerebellum'
-
A-16
47 50
Global aphasia, left
50
MCMCA
stroke
(residual right hemi-sensory
(661
neglectl. hYPertension, carotid stenosis, PePtic ulcer disease,
Encephalomatacia in left frontoparietal area in ACA-MCA border zone distribu-
tion. Lacunes in caudate and subcortical
white matter bilaterallY-
asthma
N17
41 50
Mixed aphasia, left MCA stroke
50
(residual right hemiparesis), atrial fibdllation, coronary artery disease,
(651
nerinheral vascular disease.
A-18
46 50
Mixed aphasia, coronary artery
50
disease, hYPertension. diabetes, liver failure, chronic renal insuf-
172l
ficiency, anemia.
Encephalomalacia in distribution of left gyrus MCA involving superior and middle region of temPoral lobe. Lacunar infarction in left cerebellum and centrum semiovale.
A-19
47
L=26s
50
R:16s
(7el
Non-fluent aPhasia, left thalamic stroke, hYPertension, diabetes, C0PD. degenerative ioint disease,
prostate cancer. A-20
47 48
(75)
A-21
lTzl
48
50
50
Non-fluent aPhasia, left MCA stroke hypertension, glaucoma.
Mixed aPhasia, left MCA stroke (right hemiparesis), stenosis of left intemal caroüd artery, hypertension'
39
lnfarct in left parietal and temporal lobes. with ex vacuo dilatation of left lateral ventricles. Cerebral atrophy present lnfurction involving left MCA territory'
Patient
T0MM Scores
(age)
1 Z Retain
TBI-1
38 48
50
(3S)
Tiaumatic Brain lniurY (TBll Medical History Learning I Retentioni
Radiolosy {CT/MRU
Verbal
Visual
L:gs R:2,ó
L:90n
Closed head injury from MVA.
MRI and CT within nonnal limits. SPECT
R=12ú
L0C:none.
showed decreased Perfusion in left anterior frontal area and questionable decrease in left caudate nucleus'
TBI-2
50 50
Massive head wound due to gunshot resulüng in right frontal lobec-
s0
{52}
tomy, seizure disorder, Prostate cancer. C0PD.
LOC=38 days. TBI-3
49
50
(351
14ñ =30s
L=
L=48s
R
R= 1 2s
Closed head injuries, unconfirmed seizure disorder, depression, panic
Unremarkable.
attacks.
L0C:&5 TBI-4
49
1d L=37ñ R:<1d A=72d
L:
50
l24l
<
hours.
Extensive right temPoral lobe MVA w¡th right ePidural hematoma encephalomalacia with ex vacuo cranio' requiring and brain hemiation dilatation of right temporal horn. A left hemiParesis. tomy {residual smaller area of encephalomalacia occurs mild dysarthrial, seizures. in the peripheral right posterior parietal L0C=3 months. lobe. Cerebellar atrophy and Wallerian degeneration.
TBI.5
37 47
49
(30)
MVA with evacuation of subdural
Encephalomalacia in right ftonto-
hematoma. TriPlegic, seizure
temporoparietal region with ex vacuo dilatation of right lateral ventricle' Wallerian degeneration involves right
disorder, tracheostomY, fecal and urinary incontinence'
L0C:5
cerebral peduncle, pons and medulla' Old infarct in right basal ganglia. Ventricles
weeks.
considerably dilated for patient's age and could represent communicating hydrocephalus. TBI.6
47 50
50
{651
L:10ü* R:20il
L-ZZ'ú
Stab i¡vound to left orbit intracranial
R:3d
{left temporal lobe} left
eYe
blindness, dePression.
L0C:2
weeks.
Large left hemisphere lesion involving most of temporal lobe-surface and
deep. Portions of hiPPocamPus and amygdala are involved. Additional lesions in areas 18 and 19 in occipital lobe and in superior parietal lobe.
TBI.7
49 50
50
l24l
TBI-8 (801
L=25ó
L=99t
CHI
R=16ü
R=99ü
seizure disorder. aPhasia.
with temPoral hematoma,
L0C:4
49 50 50
L: <'.ld R=<1r
Encephalomalacia involving left
temporoparietal region.
days.
disorder, fluent aPhasia|, hYPer-
Encephalomalacia in left parietotemporal lobe. lschemic changes in periventricular
tension, transurethral resection of
white matter.
MVA craniotomY (residual seizure
prostrate, mild dementia' LOC=3 weeks. Battery (tAMB-tist l¡amingl.
and Memory üonscorescamefromüreCVLTo¡theLeamingandMem0ryBattery(tAMB-U$Eamlngl.
WIIS.R.
i
'
WMS-B' dcores from the Logical Memory subtest of thé
40
Clinical Sample
Patient
TOMM Scores
Learning É Retention
(age)
1 2 Retain
Verbal
TBI-9
49 50
L=50ü R=63d
s0
(45)
Radiology (CT/MRl)
Medical History
Visual L=54s
CHI subarachnoid hemorrhage.
Resolution of previously observed
R:24ü
traumatic ePidural and subdural hematomasl, alcohol abuse (with-
subdural, epidural and subarachnoid hemorrhages.
drawal seizures!, spinal meningitis. LOC=7 davs.
TBt-l0
50 50
50
(73) TBt-11
47 50 47 50
L:60ú
Head trauma, hYPertension, degen'
Evidence of old shearing injury in posterior
R:51d
erative joint disease. L0C:none.
aspect of genu of corpus callosum.
1r R=<1r
L:63d
CHI (seizure disorder-status
B=19ü
epilepticus!, anoxic encephalopathy.
Old bifrontal contusions with resultant encephalomalacia, left greater than righl
l0C=5
Extensive cerebellar atroPhY.
L= <
50
(461
TBt-12
L:Zd 8=66
L=86ü* L:98ü
50
R=9s
(451
R:87ó
davs.
MVA (motorcYlel.
Encephalomalacia involving bilateral
LOC:10-14
temporal, right, frontal and left parietal lobes. These findings are consistent with
ffA=3
days.
months.
old trauma. TBr-13
46 49
L=<1r R=
50
(28)
TBl-14
48 50
50
46 50
50
l24l ru115 (37)
TBt-16
42 50
50
(251
TBt-l7
L:12ü
MVA.
R:Zd
L0C:20
L=2d* L=3d R=1r R:66 L=4ó* L:2li
R=gü B=48s L: <'.lr L=246 B= <1s R=14ü
davs.
Assault.
Mild enlargement of the 3d, lateral and 4r
IOC=4 weeks.
ventricles. Mild atrophy. No focal findings
"Banged head manY times.
LOC: none. Left and right frontotemporal junction contusions and inferior right frontal
MVA.
L0C:1 week.
contusion.
44 50
Encephalomalacia involving right MCA
48
tenitory and both PCA tenitories' left more than right. Evidence of Prior
(341
craniotomy. Smalt infarcts in left medulla
and left cerebellum. TBr-18
34 48
49
(33) TBt-19
s0 50
50
(s6l TBt-20
50 50
50
(411
TBt-21
M5050
l22l
drrration unklown.
L:g3d* L:29h R=66ñ R:5ú
Bomb explosion. L00:Positive.
L=gú*
Fell down flight of stairs-
L:98ü
duration unknown.
MVA.
R=99m 49
L:2"d
L:48ü
MVA.
R:48ü
[0C:nofl0.
50
R=106 L= ( 1r
L=76ü
Fall (45 feeü.
H=34s
L0G:10
50 50
50
49 50
R=53d
L=33d R=53d
50
(401
TBt-26
Hit by streetcar. L00:Positive,
L:97s
49 50
50 50
L=80ó*
MVA.
45
(381
TBt-25
LOC:approx 24 hours'
L=70ó L:96ü R=50s R:91d L:576* L=76ü R=61r fi=72nt
37 41
l22l TBr-24
R=21*
L0C:none.
(471
TBr-23
Hit by car while on bike.
R=10s
R=22nd R=64ü
(35) TBI-22
L=25ü* L=6s
R=gs
L0C:3
ffA:S ffA=S
weeks.
Mild to moderate atrophY.
days
months.
Unremarkable.
PTA:L0C+5 monthsMultiple blows, boxing class.
Unremarkable.
LOC:none. Subarachnoid hemonhage in right
l0C:30
minutes
hemisphere. Unremarkable.
days.
Left occipital skull fracture. Right posterior superior temporal lobe contusion
with possible uncal hemiation41
TOMM-Test of Memory
Patient {age} TBt-27
TOMM Scores
1 2 Retain
50 50
50
(361
Medical History
Learning & Retention Verbal Visual
L:34n R:13ü
L:94s
Fell off horse.
R:94ú
LOC
= positive, duration unknown.
Radiology (CT/MRl)
Extensive traumat¡c cerebral damage in
left inferior frontal lobe and anterior portion of left temporal lobe. Subacute subdural hematoma in left posterior
temporal, occipital, and parietal regions. TBt-28
50 50
50
(58t TBt-29
50 50
50
(3e) TBI-30
43 50
4t
(43)
tBt-31
47 50
50
(751
rut-32
50 50
50
{58) TBt-33
€4948
(371
TBt-34 f
50 50
50
191
TBt-35
50
45
(21 I
TBI-36
L:10ü
R:6ú
L:99ü
Fall [14 feet].
Fractures through both anterior, lateral,
B=99s
L0C:none.
and medial wall of maxillary sinus.
MVA (motorcylel.
Unremarkable.
8m L:90h H:8s R:90s L:3d L=48ü R:2d R:1s L:1
6ü R:Ss L:1
TBl-37
L0C:"brief".
L:3d L:88ó R:8s R=94ü L= <1s L:48s B:7ó R:14ü L:31$ L:85ú R:12ñ R=16ü L:33d L=37ü
MVA, craniotomy. skull fracture.
R:62"d
L0C=none.
r¡! ilt n;
* il tr
LOC=10 hours. MVA.
LOC:8 weeks.
MVA.
lndustrial accident, skull fracture.
LOC:6 months.
42 50
50
L:(18t
lndustrial accident.
50 50
50
Right frontal hematoma and possible
MVA.
L=62"d
contusion to frontal poles.
R:86ü
40 48
50
(351
L:66ü H:14ú
Right cerebral hematoma. Right frontal
craniotomy and bifiontal lobectomy.
R:9ü
l24l TBt-39
L0c=positive, duration unknown. Fall on wet floor.
M49
{361
TBr-38
MVA, epilepsy.
R:96ü
(401
L:98ú
MVA, craniectomY, grand mal
Encephalomalacia involving right occipital
B=96s
seizure, occipital skull fracture.
and parietal lobes. Generalized atrophy in
L0C-2
cerebral and cerebellar hemispheres
weeks.
bilaterally. TBt-40
39 44
47
(41I
L=<1r L=(1tt R= <1s R=
MVA, left frontoParietal subdural
Focal areas of encephalomalacia within
hematoma. right homonYmous
the subfrontal regions, frontal and
hemianopsia, right hemiParesis.
temporal lobes.
LOC=3 months. TBI-41
50 50
50
{541
TBt-42
42 48
48
{401
TBt-43
37 48
L:18ü R:8ü
L:88s
MVA.
R:7s
L0C:none.
lf
L=99ú
MVA.
R=lz{'
L0C=none.
L=
R:gs
MVA.
48
L0C:none.
lz4l TBt-44
45 50
50
tzzl IBt-45 {66}
47 50
50
8s 8:6ü L=
1
I
LOC:3 weeks.
L=98ú
R--34d'
il
L:56ú
MVA.
R=25m
LOC=5 days.
L=76ü
MVA.
fl=38q
LOC=3 weeks.
42
iir:liir¡ i rji. ,.
iiiiütr,,,,, i' .J
;-,-* 't'
-,
I
Dementia Patient
(agel
tlr
: T&#fd Scores ,I 2Retain 15 49
48
Learning & Retention
Verbal
Visual
L: 3d
L=90á
R=(1r R=
m¡
Medical History
Radiolosy (CT/MRl)
Alzheimer's disease, ríght parietal
Bilateral lacunes in basal ganglia.
meningioma, hypertension, diabetes, coronary artery disease. myocardial infurction; angioplasty.
D-2
42 49
50
D-3
48 50
50
45 50
50
(73)
l!4
|
-qt
I
B:15ü
(65)
R:81n
L:ln L=9ü R:
(721
:eaó
R=<1'!
Vascular dementia, demenüa
Cerebellar atrophy, cavum septum.
pugfistica.
pellucidum. \fVhite matter changes in periventricular,frontal lobe area.
Alzheimer'S disease.
Etiology of dementia unknown.
Hyperintensity in left parietotemporal
migraine headaches, AVM gait
lobe suggestive of a venous angioma
dísturbance, atypícal chest pain,
with old hemonhage, atrophy of left cere-
hiatal hemia. malaria. Respite.t
bral peduncle, and temporal lobe atrophy slightly more prominent on the left side.
D-5
42 46
48
{6sl
0-6
31 44
48
L:<1* L:10ü R:
Vascular dementid, coronary artery
L:(ls
Alzheímer's dísease. hypertensíon.
R: <1s
(761
D-7
L:<1r
disease, myocardial infurction.
41 45
49
L=,lgü
R=1*
(67)
Central and cortical atrophy. l¡cunes in pons bilaterally.
Mild to moderate generalízed central and cortical atrophy.
L= < 1r
Alcohol dementia, seizure disordel
Moderate generalized cerebral atrophy,
R=<1$
hypertension, skin.cancer.
gliotic changes in periventricular white matter. Encephalomalacia' in right frontal lobe consistent with contusion.
D-8
46 48
49
(711
L:27Á R:1 0ü
l=42na
Multiple etiology for dementia. CNS
Encephalomalacia in ACA/MCA border
R:36ü
hypoxia, seizure disorder, alcohol abuse, coronary artery disease,
zone. lnfarct in area served by right MCA penetrating vessels. Central and cortical
pacemaker.
atrophy. Lacunar infarcts in centrum semiovale. basal ganglia, intemal capsule. and pons. Moderate cerebellar atrophy.
D-9
37M42
(821
L: <1ü L: < 1r R:<1$ R=<1r
Alzheimer's disease or vascular dementía, coronary artery disease.
Marked central and cortiial atrophy. Moderate cerebellar atrophy. lschemic gliotic changes in periventricular white matter and left thalamus.
D-l 0
37 45
47
(85)
L:<1$ L:<1r R:
Alzheimer's disease, alcohol abuse,
Moderate cerebral cortical and centnl
paranoid ideation, peptic ulcer.
atrophy. Bilateral subfrontal and right frontopárietal encephalomalacia. 0ld
L=25s
Vascular deméntia. right, fronto-
subarachnoid hemonhage. D-1
1
50 s0
50
R=4s
(571
L=48ü R=27ü
parietal subdural hematoma. hyper-
tension. duodental ulcer.
D-l2 f8:!t
35 43
32
L=
Alzheimels disease, coronary artery Atrophy of temporal lobe, particularly the disease, degenerative joint disease, hippocampus and superior temporal lumbar stenosis. gyrus: Bilateral enlargement of temporal horns of lateral ventricles, left greater than right.
L"rñffi,¡u*-r 'üsuatBaüer {LAM&{ist Leaming}. *r" ror t'r Beproduction subtest sf $e
Leaming (Q and Beter¡tion {B} scores are expressed as percentiles. Most veóal leaming/retention scores carr fror ü'r ÑLTor tttr wh€n üese wBfB not aailable' scores from the Logical Memor subtest of the W\4S-R we¡e used; All üsual leam¡ng/retention srorur
wMs-8
¡ Bespite--Patient
were in hosp'rtal for a week to pmvide respite for caretakers.
TOMM-Test of Memory Malingering
Patient (agel
T0MM Scores Retain
1 2
48 50
D-l3
L:gs B:3d
50
(621
35 45
D-14
(1s R=<1d
L=
45
t77l
L=42nd
R=10ü
Radiology (CT/MHl)
Medical History
Learning & Retention Verbal Visual
Alzheimer's disease, TlAs, hYPertension, panic attacks, chronic back
Moderate frontoparietal and temporal atrophy.
nain
L=
R=<1d
Etiology of dementia unknown' peptic ulcet alcohol abuse. anemia.
l¡cune in left cerebellum. Cerebellar atrophy.
disease, benign Prostatic
37 45
D-l5
L=ltó R=
43
(66)
L=3d
R:9ü
Vascular dementia, left occiPital' stroke {residual right homonymous hemianopia), diabetes, hypertension
Left PCA infarct. Extensive encephalomalacia within left occipital lobe' Lacunes
in left extemal capsule. thalamus. and putamen, and in right caudate. internal capsule. and Putame¡'
D-l6
44 49
L=(ld L=<1r R=<1r B=<1d
48
(74)
Vascular dementia, alcohol abuse'
alcoholic hepatitus, hypertension' peripheral vascular disease, gangrene with
D-'17
Untestable-severe
D-l8
Untestable-severe
D-1
I
47 50
{78}
D-20
32
L=42nr R=22nn
40
R:<1ú
R-<18t
(6sl
(ltt L=72nd B=<1s R:49ú
D-22
L:<1ú
D-21
49 50
50
36
50
3648M 38 47
46
34 33
35
(56) D-25
greater Extensive cortical atrophy, right Vascular dementia, r¡ght hemlspnere right than left. Encephalomalacia in frontal stroke, left hemisphere stroke frontoparietal lobe. Extensive bilateral hypertension. pure red cell dyplasia' posterior hom Periventricular c0ronary vascular disease' Respite' ieukomalacia, right greater than left'
vascular dementia' hypenenslon' diabetes, dePression, alcohol nrostate cancer.
L=14ü
Alzheimer's. disease, hypertension'
Lacunar infarcts in corpus callosum, centrum semiovale and basal ganglia'
Generalized cerebral atrophy' lnfarct
within right cerebellum.
(ld R=4ó L: < 1r L=lnt R:(1f fl=(1d
Alzheimer's disease.
L=4s
Alzheimer's disease, alcohol abuse'
R=
t6sl D-24
L=
Bifrontal subdural fluid collections reflecting hygromas or chronic subdural hematomas.
CanCgf.
'hilce
t73l D-23
.=.-
Etiology of demenüa unknown, diabetes, bYPass coronary surgery'
,,t^arc ¡nviptV nrostate
L=Bü L-.lo
(801
fros|lite
Moderate cerebellar and cerebral atrophy'
em entia (Alzheimer's).
L:32nd R=30ú
50
Ventricles are markedly dilated proportional to degree of cortical atropy'
(71)
p: ¿1¡t
L=66ü R=17ü
L:<1d L=(1o R:
Unremarkable.
Moderate cerebral cortical and central atrnnhv-
Vascular dementia, left PCA stroke' loss' right cataract surgery. hearing
gastric ulcer, C0PD.
Acute inlarct with¡n the left PCA distribution in occipital lobe. Encephalomalacia within left anterior temporal lobe. Diffuse cerebral atrophy with ex
vacuo dilatation of ventricles. lschemic gliosis within periventricular deep white matter.
D-26
50 49
48
-L:<1$ ,-R:<'o
t71)
L:l8ü
n=(l'r
of dementra unloown' | ftiotogy I
,
*r:H'n*[,flii,1lll;
Bespite' I cholesterolemia'
AA
-l#
Mild generalized cerebral, cortical and central atrophY.
Patient (age)
39
D-?7
L= I !,**
43
f,=t?'
(64)
46
D-28
(661
26
D-29
29
(701
D-30
42
eCt
l* lgF .{=
L=
47
Radiolosy (ct/MRl)
Medical History
Swes
& fiemr$m 'i [ram&4 $r¡¡d W 1 2 Fetain
T0Mtrt
&il ,
of demer*ia un*nown,
bhod pressure.
A[lreirnef'S úsease.
l I
Aüñdmer's disease, hypertension'
|
tgnia,
dePression.
Significant generalized cerebral, cortical, Vasa¡br dementia, sÍoke, multiPle gait distur- and central atrophy. Multiple small old IlAs, akineüc syndrome,
49
(7sl
bance, udnary inconünence,
lacunar infarcts in bilateral basal gangfa,
dnbetel
centrum semiolale. pons and left cerebellum. Bilateral oid frontal contu-
Hespite.
sions.
33
D-31
Alzheimels disease, hyPertension,
38
polio. Respite.
(741
D-32 D-33
Unable
to complete the sample trial because of seveqqgrnentiajlljg!¡loüreni1
s0 50
50
{75}
L=
Vascular dementia, multiple strokes.
Encephalomalacia in left frontal lobe, left
TlAs, seizure disorder, deep vein thrombosis, prostate cancer, gout.
occipital lobe and left and right parietal lobes. Generalized cerebral cortical, central and cerebellar atrophy. lnfarcts involving cerebellum and left thalamus.
D-34
M4749
{e0}
D-35
48 48
L=<1r L:<1* R:<1s R:<1r
Alzheimer's disease, glaucoma. Respite. Vascular dementia, multiple strokes,
49
(681
Central and cortical atrophy.
Mult¡ple lacunes in bilateral cerebellum,
diabetes, hypertension, Bells palsy.
left pons. bilateral thalami, basal ganglia,
Bespite.
intemal capsule, and centrum semiovale. Old hemonhage in left caudate. Left
frontal arachnoid cyst. D-36 (81
42 48
47
L:
l
R:<1d
Etiology of dementia unknown, right MCA stroke {residual left hemipare-
sis
I
left hemineglect|, hyper-
Multiple lesions in left cerebellum, left pons. right temporal-occipital area, right extemal capsule, right parietal-occipital
tension, alcohol abuse, degenerative area, and left frontal area deep to internal joint disease. Respite. capsule. Marked cerebral and cerebellar atrophy, particularly in left parietal lobes. D-37
47 50
49
174l D-38
29
D-39
31
41
t64l
l' il t: €i
,
D-40
fl
Í:' F.,
f
F
I
{82}
L:14s
Alzheimels disease, hypertension,
R=]6ü
PISD, colon cancer.
<1s R:
L=3d
L:<1i B:
L:9ú
L=
37
(761 t:..
L:7ü* B:4t
R:4s Alzheimer's disease, hypertension.
Lacunar infarct in left putamen.
49 50
50
L=<1* g=<1r
L--18ü R=14ü
Vascular dementia, peripheral vas-
Mild generalized atrophy. Scattered focal
cular disease, right central retinal
areas within deep white matter showing
artery occlusion w¡th r¡ght eye blind- possible ischemic or gliotic change. ness. endarterectomy, lung cancer.
li É
li,,
í, f, B
t,
Í $.
Diffuse cortical atrophy. Mild periventricular ischemic gliotic changes.
R:3d
I
t I
Unremarkable.
45
