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Accuracy of the Modified Somatic
Perception Questionnaire and Pain
Disability Index in the Detection of
Malingered Pain-Related Disability in
Chronic Pain
Kevin J. Bianchinia, Luis E. Aguerrevereb, Brian J. Guiseac,
Jonathan S. Ordc, Joseph L. Ethertond, John E. Meyersef, R. Denis
Soignierg, Kevin W. Grevea, Kelly L. Curtish & Joy Buia
a Jefferson Neurobehavioral Group, Metairie, LA 70002, USA
b Department of Psychology, Stephen F. Austin University,
Nacogdoches, TX 75962, USA
c Department of Psychology, University of New Orleans, New
Orleans, LA 70148, USA
d Department of Psychology, Texas State University, San Marcos, TX
78666, USA
e Center for Neurosciences, Orthopedics and Spine, Dakota Dunes,
SD 57049, USA
f Meyers Neuropsychological Services, Mililani, HI 96789, USA
g Department of Psychology, Nicholls State University, Thibodaux,
LA 70310, USA
h Department of Psychology, High Point University, High Point, NC
27262, USA
Published online: 17 Dec 2014.
To cite this article: Kevin J. Bianchini, Luis E. Aguerrevere, Brian J. Guise, Jonathan S. Ord,
Joseph L. Etherton, John E. Meyers, R. Denis Soignier, Kevin W. Greve, Kelly L. Curtis & Joy Bui
(2014): Accuracy of the Modified Somatic Perception Questionnaire and Pain Disability Index in the
Detection of Malingered Pain-Related Disability in Chronic Pain, The Clinical Neuropsychologist, DOI:
10.1080/13854046.2014.986199
To link to this article: http://dx.doi.org/10.1080/13854046.2014.986199
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Downloaded by [Kelly Lynn Curtis] at 12:32 19 December 2014
Accuracy of the Modified Somatic Perception
Questionnaire and Pain Disability Index in the Detection of
Malingered Pain-Related Disability in Chronic Pain
Kevin J. Bianchini
1
, Luis E. Aguerrevere
2
, Brian J. Guise
1,3
,
Jonathan S. Ord
3
, Joseph L. Etherton
4
, John E. Meyers
5,6
,
R. Denis Soignier
7
, Kevin W. Greve
1
, Kelly L. Curtis
8
, and
Joy Bui
1
1
Jefferson Neurobehavioral Group, Metairie, LA 70002, USA
2
Department of Psychology, Stephen F. Austin University, Nacogdoches, TX 75962, USA
3
Department of Psychology, University of New Orleans, New Orleans, LA 70148, USA
4
Department of Psychology, Texas State University, San Marcos, TX 78666, USA
5
Center for Neurosciences, Orthopedics and Spine, Dakota Dunes, SD 57049, USA
6
Meyers Neuropsychological Services, Mililani, HI 96789, USA
7
Department of Psychology, Nicholls State University, Thibodaux, LA 70310, USA
8
Department of Psychology, High Point University, High Point, NC 27262, USA
The Modified Somatic Perception Questionnaire (MSPQ) and the Pain Disability Index (PDI)
are both popular clinical screening instruments in general orthopedic, rheumatologic, and
neurosurgical clinics and are useful for identifying pain patients whose physical symptom pre-
sentations and disability may be non-organic. Previous studies found both to accurately detect
malingered pain presentations; however, the generalizability of these results is not clear. This
study used a criterion groups validation design (retrospective cohort of patients with chronic
pain, n= 328) with a simulator group (college students, n= 98) to determine the accuracy of
the MSPQ and PDI in detecting Malingered Pain Related Disability. Patients were grouped
based on independent psychometric evidence of MPRD. Results showed that MSPQ and PDI
scores were not associated with objective medical pathology. However, they accurately differen-
tiated Not-MPRD from MPRD cases. Diagnostic statistics associated with a range of scores are
presented for application to individual cases. Data from this study can inform the clinical
management of chronic pain patients by screening for psychological overlay and malingering,
thus alerting clinicians to the possible presence of psychosocial obstacles to effective treatment
and triggering further psychological assessment and/or treatment.
Keywords: Pain Disability Index; Modified Somatic Perception Questionnaire; Chronic pain; Somatization;
Malingered pain-related disability; Criterion groups design; Symptom validity test; Response bias.
INTRODUCTION
Symptomatic and functional outcomes in spinal pain are not fully explained by
objectively demonstrated physical pathology (Boden, Davis, Dina, Patronas, & Wiesel,
1990; Boden, McCowin, et al., 1990) and psychosocial factors, including potential
financial compensation (Voorhies, Jiang, & Thomas, 2007) are known to complicate
Correspondence should be addressed to: Kelly L. Curtis, Ph.D., Department of Psychology, High Point
University, High Point, NC 27262, USA. E-mail: kcurtis0@highpoint.edu
(Received 3 April 2014; accepted 5 November 2014)
© 2014 Taylor & Francis
The Clinical Neuropsychologist, 2014
http://dx.doi.org/10.1080/13854046.2014.986199
Downloaded by [Kelly Lynn Curtis] at 12:32 19 December 2014
clinical pain management (Barnes, Smith, Gatchel, & Mayer, 1989; Block, Gatchel,
Deardorff, & Guyer, 2003; Bruns & Disorbio, 2009; Fishbain, Turner, Rosomoff, &
Rosomoff, 2001; Gatchel, 2004; Guo, Tanaka, Halperin, & Cameron, 1999; Harris,
Mulford, Solomon, van Gelder, & Young, 2005; Linton, 2000; Linton & Boersma,
2003). Painful injuries often occur in the context of legally compensable events
(Schofferman, Anderson, Hines, Smith, & White, 1992) and as many as a third of pain
patients seen for psychological evaluation in a compensable context can be diagnosed as
malingering (Greve, Ord, Bianchini, & Curtis, 2009; Mittenberg, Patton, Canyock, &
Condit, 2002). However, malingering is just one explanation for why exaggeration of
physical complaints may be present. It is likely that various forms of psychosocial
complication contribute to the misdirection of scarce healthcare resources, so their iden-
tification and detection is of considerable importance from both an economic and patient
care perspective (Bannwarth, 1999; Bianchini, Greve, & Glynn, 2005; Portenoy, 1996).
Unfortunately, clinical judgment is an unreliable method of identifying psychoso-
cial complication and malingering, so other means are necessary (Ekman, O’Sullivan,
& Frank, 1999; Faust, Hart, & Guilmette, 1988; Grevitt, Pande, O’Dowd, & Webb,
1998; Heaton, Smith, Lehman, & Vogt, 1978). A number of questionnaires have been
studied for their capacity to detect exaggerated and even malingered subjective, physi-
cal complaints; the most studied of these is the Minnesota Multiphasic Personality
Inventory-2nd edition (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer,
1989). The MMPI-2 is a particularly well-validated method of detecting symptom exag-
geration and psychological complication of physical symptoms (Block, Ohnmeiss,
Guyer, Rashbaum, & Hochschuler, 2001; Vendrig, Derksen, & de Mey, 1999). A num-
ber of MMPI-2 scales have also been developed and/or validated for the detection of
malingering (Ben-Porath, Greve, Bianchini, & Kaufman, 2009; Lees-Haley, Iverson,
Lange, Fox, & Allen, 2003; Rogers, Sewell, Martin, & Vitacco, 2003). Unfortunately, a
number of practical issues such as test length and proprietary scoring software limit the
feasibility of the MMPI-2 and similar questionnaires used in many medical settings.
The Modified Somatic Perception Questionnaire (MSPQ; Main, 1983) and the
Pain Disability Index (PDI; Pollard, 1984) are both popular clinical screening instru-
ments in general orthopedic, rheumatologic, and neurosurgical clinics. The MSPQ reli-
ably and validly measures heightened somatic and autonomic awareness (Main, 1983).
The PDI reliably measures self-assessed functional ability in seven areas: occupational,
home/family, recreational, social, sexual, activities of daily living, and life support
(Gronblad et al., 1993; Tait, Chibnall, & Krause, 1990; Tait, Pollard, Margolis, Duckro,
& Krause, 1987). Similar to the MMPI, both are useful for identifying patients whose
physical symptom presentations and disability are influenced by non-organic factors
(Petrak, Hardt, Kappis, Nickel, & Tiber Egle, 2003; Sikorski, Stampfer, Cole, &
Wheatley, 1996). For instance, Brasseux, Greve, Gianoli, Soileau, and Bianchini (2008)
found a positive correlation between MSPQ scores and aphysiologic (i.e., non-organic)
computerized dynamic posturography sway patterns in a sample of 115 patients with
complaints of vestibular dysfunction and hearing impairment. Within the context of
pain, Larrabee (2003) found both the MSPQ and PDI to accurately detect malingered
pain presentations in preliminary research; however the generalizability of these results
is not clear. Specifically, Larrabee’s study only used a small number of probable malin-
gerers who were compared to the normative groups of both tests, the members of which
were poorly described in terms of physical injuries and legal status.
2 KEVIN J. BIANCHINI ET AL.
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The present study replicates Larrabee (2003) in assessing the accuracy of the
MSPQ and PDI in detecting malingered pain related disability and extends it in several
ways. First, data were collected from a large group of clinical pain patients referred for
a psychological evaluation whose injuries and medical status were well characterized.
Second, malingering status was defined using well-validated indicators of negative per-
formance validity and symptom exaggeration applied within the criteria for Malingered
Pain-Related Disability (MPRD; Bianchini et al., 2005). Third, data from college under-
graduates (simulators and honest responders) addressed convergent validity. Finally,
diagnostic accuracy data for a range of scores are reported.
METHOD
Participants
Institutional Review Board approval at all relevant institutions was obtained for
this study and all data were collected in accordance with relevant guidelines.
Clinical pain patients. Clinic cases were obtained from the records of a series
of 772 referrals for psychological pain evaluation at a clinical psychology practice in
the Southeastern United States from 1998 through 2003. Referral sources included phy-
sicians, workers compensation companies, and attorneys. Medical diagnostic test
results, physicians’clinical diagnoses, and injury descriptions were obtained from medi-
cal records. Inclusion criteria were (1) referral for persisting pain-related complaints
regardless of their nature or etiology; and (2) completion of the MSPQ and/or PDI.
Exclusion criteria were (1) age > 59; (2) time since injury of < 6 months or > 15 years;
(3) moderate or more severe traumatic brain injury; and (4) formal education < 9 years.
There were 23 no-incentive pain patients provided by the sixth author (JEM).
The final clinical sample was 328 (305 with incentive, 23 without incentive). The
sample was 39.6 months post injury (SD = 28.8) and 43.3 (SD = 12.0) years of age
with 12.1 (SD = 2.2) years of education. At the time of the interview they rated
their pain at 6.3 (SD = 2.1) out of a maximum of 10. The sample was 65.1% male
and 67.1% Caucasian (African-American = 30.5%; Hispanic = .9%; other or not
indicated = 1.5%). Of the full sample, 93.0% had external incentive (workers com-
pensation claims, 68.9%; personal injury law suit, 22.0%; other, 9.1%). Over half
(50.3%) were represented by an attorney, although less than a quarter (22.3%) were
attorney-referred. The remainder were referred by clinicians (usually medical doctors;
18.3%) or case managers / adjusters (46.6%). Table 1provides information about the
sample’s injury-related characteristics.
Healthy controls. Students from a southern United States university completed
the MSPQ (n= 62) and/or PDI (n= 21) in standard fashion for course credit. A second
group of students (Simulators; n= 36) from a different southern United States
university were asked to respond to the MSPQ and PDI items while feigning pain-
related impairment (see Methods Attachment 1/Appendix Afor simulator scenario/
instructions). At the end of their participation, Simulators described their method of
MSPQ AND PDI IN CHRONIC PAIN 3
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feigning and they would have been excluded had they not followed instructions. None
was excluded.
Procedure
All patients completed the Pain Disability Index (PDI; Pollard, 1984), and the
Modified Somatic Perception Questionnaire (MSPQ; Main, 1983) as part of a formal
psychological pain evaluation which included the Wechsler Adult Intelligence Scale-III
(WAIS-III; Wechsler, 1997), the California Verbal Learning Test (CVLT; CVLT-1:
58.8%; CVLT-2: 32.9%; Delis, Kramer, Kaplan, & Ober, 1987,2000). The Minnesota
Multiphasic Personality Inventory-2 was completed by 100% of the cases (MMPI-2;
Butcher et al., 1989), 89% of the sample completed the Portland Digit Recognition Test
(PDRT; Binder, 1993), 91.5% completed the Test of Memory Malingering (TOMM;
Tombaugh, 1996) and 87.2% completed the Word Memory Test (WMT; Green, 2005;
Green, Allen, & Astner, 1996). All procedures were administered in standard fashion
by experienced psychometricians.
Malingering classification. The patient malingering status was determined
through application of the criteria for MPRD (Bianchini et al., 2005) as it has been
applied in a number of previously published studies (Greve, Ord, et al., 2009; Greve
Table 1. Injury / symptom characteristics of entire chronic pain
sample (n = 305)
n%
Primary back/spine injury 243 74.1
Head injury in accident 35 10.7
Pain symptoms / area of body
Head 104 31.7
Spine 267 81.4
Chest / abdomen 11 3.4
Upper extremity 135 41.2
Lower extremity 191 58.2
Spine Findings
any spine findings 205 62.5
degenerative disc/spine 124 37.8
herniated nucleus pulposus 21 6.4
disc bulge/protrusion 154 47.0
neural impingement 17 5.2
Spinal Surgery
discectomy / fusion 78 23.8
decompression/laminectomy 38 11.6
Other pain diagnoses
Complex regional pain syndrome 11 3.4
Fibromyalgia 3 0.9
Myofascial pain syndrome 9 2.7
Note that an individual patient may be positive in more than
one category so the sum of percentages may be greater than
100.
4 KEVIN J. BIANCHINI ET AL.
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et al., 2010; Greve, Etherton, Ord, Bianchini, & Curtis, 2009) (see Methods Attachment
2 / Appendix Bfor details). Relative to response bias or malingering, each psychomet-
ric score was classified as negative, ambiguous, or positive. Using all available informa-
tion (psychometric and clinical findings), each patient was placed into one of the
following seven groups:
(1) No incentive (n= 23, 7.0%).
(2) Negative on all indicators (n= 32, 9.8%).
(3) A single ambiguous psychometric finding, no inconsistencies (n= 19, 5.8%).
(4) One ambiguous psychometric finding, no positive psychometric findings or one
inconsistency (n= 37, 11.3%).
(5) >= one positive psychometric finding or >= one inconsistency but did not meet
full malingering criteria (n= 112, 34.1%).
(6) Met criteria for probable malingering (n= 90, 27.4%).
(7) Met criteria for definite malingering (n= 15, 4.6%).
For the purpose of some analyses, patients in groups 2 and 3 were combined into
a single Incentive-Only group (n= 51, 15.6%). The group 4 cases were referred to as
Indeterminate while groups 5, 6, and 7 were called Possible, Probable, and Definite,
respectively. To specifically examine the diagnostic accuracy of the questionnaires, the
Probable and Definite MPRD groups were combined into a single MPRD group
(n= 105, 32.0%) and compared to the single Not MPRD group made up of the
No-Incentive and Incentive-Only groups (n= 74, 22.6%). The Indeterminate and
Possible groups were not included in classification accuracy analyses because their
status could not be determined with a reasonable degree of certainty.
RESULTS
Sample characteristics
Table 2presents characteristics of the pain patients as a function of malingering
group membership. There were no differences for age; however, the No-Incentive cases
were significantly longer post injury than the other clinical patients. There was no
meaningful relationship between malingering status and education, nor was education
correlated with MSPQ (r=–.05) or PDI (r=–.11). The No-Incentive and Incentive-
Only groups reported significantly less “current”subjective pain. A similar pattern was
observed for “best”pain rating. No significant group differences were observed for
“worst”pain ratings. Table 3presents the medico-legal characteristic of the sample by
group membership. Among those patients with incentive, slightly more than half the
cases were known to be represented by an attorney, most had been referred by a doctor
or case manager/adjuster, and a large majority were seen in the context of a workers
compensation claim.
Table 4presents the injury and symptom characteristics for each group of pain
patients. Most of the patients were seen for a primary complaint of back pain, although
objective pathology of the spine or spinal cord was absent in most cases. One-quarter
to one-third of cases had undergone some form of spine surgery. Comorbid pain syn-
dromes (e.g., fibromyalgia, complex regional pain syndrome) were rare. Although not
MSPQ AND PDI IN CHRONIC PAIN 5
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Table 2. Demographic and some injury-related characteristics of the chronic pain sample as a function of malingering status
No-Inc Inc-Only Indeterm. Poss MPRD Prob MPRD Def MPRD
M (sd) M (sd) M (sd) M (sd) M (sd) M (sd) F p = eta
2
Age 47.1 (15.5)
a
39.9 (9.6)
ab
41.9 (10.3)
ab
43.8 (9.0)
ab
44.2 (8.6)
ab
42.2 (8.8)
b
2.4 0.04 0.03
Education 12.5 (1.7) 12.8 (2.4) 12.6 (2.1) 11.8 (2.3) 11.8 (2.0) 11.9 (2.5) 2.2 0.05 0.03
TSI
1
20.4 (23.7) 32.9 (21.2) 32.5 (31.1) 43.1 (30.2) 43.3 (29.9) 40.4 (23.5) 2.3 0.05 0.04
Current 5.1 (2.3)
a
5.2 (2.1)
a
6.7 (2.2)
b
6.7 (2.0)
b
6.8 (2.0)
b
6.8 (2.4)
b
5.8 ≤.001 0.08
Best 3.2 (1.9)
a
3.6 (2.1)
ab
5.4 (2.5)
c
4.8 (2.4)
bc
5.0 (2.2)
bc
6.1 (2.5)
c
6.3 ≤.001 0.10
Worst 8.8 (1.5) 9.0 (1.9) 9.2 (1.5) 9.2 (1.5) 9.4 (1.3) 9.6 (0.7) 1.2 0.34 0.02
abc
Row means with the same letter are not significantly different at alpha < .05.
1
Only 1 in 10 No-Incentive patients had data for months post-injury.
TSI = time since injury; Inc = Incentive; Indeterm = Indeterminate; Poss = Possible; Prob = Probable; Def = Definite; MPRD = Malingered Pain Related Disability;
Current, Best, & Worst corresponds to pain levels.
6 KEVIN J. BIANCHINI ET AL.
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Table 3. Medico-legal characteristics of the chronic pain sample as a function of malingering status
No-Inc Inc-Only Indeterm Poss MPRD Prob MPRD Def MPRD
Status of legal representation
No attorney 100 49.0 51.4 41.1 52.2 13.3
Represented by attorney 0 51.0 48.6 58.9 46.7 86.7
Attorney status unknown 0 0.0 0.0 0.0 1.1 0.0
Referral source:
doctor 100 23.5 16.2 19.6 17.8 26.7
case manager / adjuster 0 45.1 62.2 50.9 50.0 33.3
attorney 0 29.5 21.6 27.7 29.1 40.0
Claim type:
workers compensation –68.6 89.2 75.0 72.2 60.0
personal injury –29.4 10.8 24.1 22.2 40.0
disability –0.0 0.0 0.0 1.1 0.0
The number represents the percentage of patients in each group meeting the medico-legal characteristic;
Def = definite; Inc Only = incentive present but not malingering; Indeterm. = malingering status is indetermi-
nate; MPRD = Malingered Pain-Related Disability; Poss = possible; No Inc = no incentive; Prob = probable.
Table 4. Percentage of injury/symptom characteristics of the chronic pain sample as a function of
malingering status
No-Inc Inc-Only Indeterm Poss MPRD Prob MPRD Def MPRD
Primary back/spine injury 70 71 73 78 77 53
Head injury in accident 0 0 11 11 13 7
Pain symptoms/area of body
head 0 29 30 35 38 33
spine 65 71 84 83 84 73
chest / abdomen 26 4 3 2 6 7
upper extremity 57 37 51 40 36 33
lower extremity 48 49 62 62 61 87
Spine findings
any spine findings 57 65 68 63 63 47
degenerative disc/spine 48 31 46 36 39 33
herniated nucleus pulposus 17 4 8 4 7 7
disc bulge/protrusion 22 51 57 51 46 27
neural impingement 9 51 3 4 8 0
Spinal surgery
discectomy / fusion 26 25 19 27 20 25
decompression/laminectomy 9 14 8 14 8 17
Other pain diagnoses
complex regional pain
syndrome
04 0 1 8 7
fibromyalgia 0 0 0 2 1 0
myofascial pain syndrome 0 0 0 3 6 7
1
Value represents the percentage of patients within a group with the indicated presentation, symptom,
finding, or procedure. Note that an individual patient can be positive in more than one category so the sum of
percentages in a particular category may be greater than 100.
MSPQ AND PDI IN CHRONIC PAIN 7
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presented in this table, almost all the patients were being treated with a variety of
medications, many had undergone injections, and most had received physical therapy.
Malingering group analyses
Questionnaire scores were submitted to an Analysis of Variance (ANOVA). A
significant group effect was seen for MSPQ, F(7, 418) = 30.05, p< .001, eta
2
= .34,
and PDI, F(7, 362) = 40.8, p< .001, eta
2
= .44 (see Table 5).
For the MSPQ, post-hoc testing (Tukey’s b) demonstrated that the Probable
MPRD, Definite MPRD, and Simulator groups did not differ significantly from each
other. The Indeterminate and Possible did not differ from each other, nor did they differ
from the Probable MPRD and Simulator group. The Incentive-Only group did not differ
significantly from the No incentive group. Healthy controls scored lower than all other
groups but not significantly lower than the No-Incentive group.
For the PDI, Probable and Definite MPRD did not differ, nor did the No-Incen-
tive and Incentive-Only groups. The Indeterminate, Possible, and Simulators did not
differ from each other, nor did Possible differ from the Probable MPRD. Healthy
controls scored lower than all other groups but were not significantly different from the
No-Incentive group.
These data demonstrate a dose–response relationship, in that greater the amount
and magnitude of malingering findings as represented by group membership the higher
are the MSPQ or PDI scores. Since the groups did not differ in terms of objective injury
characteristics, higher scores cannot be attributed to more physical pathology.
Moreover, patients clinically determined to be malingering scored equal to or worse
than persons instructed to fake pain-related impairment.
Receiver operating characteristics (ROC) analysis
An ROC analysis provides a way of demonstrating how well a test variable differ-
entiates two groups by plotting sensitivity and specificity at all score levels. Three ROC
analyses were conducted.
First, the No-Incentive group was compared to the Incentive-Only group. The
area under the curve (AUC) for MSPQ score was .69 (p= .008; standard error = .06;
95% CI: .56 to .82) and for PDI score was .63 (p= .08; standard error = .08; 95% CI:
.49 to .78). At the individual level, the MSPQ significantly differentiates between pain
patients with and without external incentive but the PDI does not.
Second, the two MPRD groups (Probable and Definite) were combined and
compared to the Simulators. For the MSPQ, the AUC was .56 (p= .27; standard error
= .58; 95% CI: .45 to .68) and for the PDI it was .70 (p<. 001; standard error = .05;
95% CI: .60 to .79). Malingerers and Simulators perform similarly on the MSPQ.
However, Simulators judged themselves less disabled than clinical malingerers.
The final analysis determined how well the two questionnaires differentiated malin-
gering from non-malingering patients. For this analysis, the combined clinical Not-
MPRD group was compared to the combined clinical MPRD group. For MSPQ the AUC
was .67 (p< .001; standard error = .03; 95% CI: .75 to .87). The AUC for PDI was .77
(p< .001; standard error = .04; 95% CI: .69 to .84). This analysis further demonstrates
that the MSPQ and PDI accurately differentiate Not-MPRD from MPRD cases.
8 KEVIN J. BIANCHINI ET AL.
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Table 5. Descriptive statistics for MSPQ and PDI scores as a function of malingering status and results of analyses of variance
Controls No Inc Inc Only Indeterm. Poss MPRD Prob MPRD Def MPRD Sim
M (sd) M (sd) M (sd) M (sd) M (sd) M (sd) M (sd) M (sd) F
1
eta
2
MSPQ 3.2 (2.9)
a
5.9 (4.0)
ab
9.1 (5.0)
bc
11.9 (6.9)
cd
13.4 (6.4)
d
15.5 (7.5)
de
17.8 (6.6)
e
14.1 (7.5)
de
30.1 0.34
PDI 5.4 (7.1)
a
35.4 (11.2)
b
42 (13.7)
bc
49.9 (15.6)
cd
51.5 (11.5)
cd
52.7 (12.3)
d
54.1 (17.9)
d
46.3 (11.9)
cd
40.7 0.44
abcde
Row means with the same letter are not significantly different at alpha < .05.
1
Fratios for all variables are significant at alpha < .001
M = mean; sd = standard deviation; MSPQ = Modified Somatic Perception Questionnaire; PDI = Pain Disability Index; Inc = incentive; Indeterm = indeterminate; Poss =
possible; Prob = Probable; Def = definite; Sim = simulators; MPRD = Malingered Pain-Related Disability.
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Classification accuracy
The ROC analysis can demonstrate overall classification accuracy of diagnostic
tests but not test accuracy at specific cut scores. The choice of cut scores can have an
important influence on the resulting type of classification error. Table 6presents the
False Positive (FP) error rates, Sensitivity, Likelihood Ratio (LR), and Positive Predic-
tive Power (+PP) for a range of MSPQ and PDI cutoffs (Heilbronner, Sweet, Morgan,
Larrabee, & Millis, 2009). With this table the clinician can determine the probability
that a given score is due to intentional exaggeration of pain-related disability. The data
in this table demonstrate that the MSPQ is more effective at differentiating malingerers
from non-malingerers than the PDI.
MSPQ scores of 17 and higher (FP = 5%; Sensitivity = 39%; LR = 7.8, 95% C.I.
= 3.3 to 17.7; +PP = .81, 95% C.I. = .63 to .93) and PDI scores of 62 or higher
(FP = 3%; Sensitivity = 24%; LR = 8.0, 95% C.I. = 2.4 to 19.9; +PP = .81, 95% C.I. =
.54 to .93) are a strong indication that symptoms and disability are being deliberately
exaggerated. MSPQ scores of 13 and higher (FP = 12%; Sensitivity = 61%; LR = 5.1,
95% C.I. = 2.9 to 8.5; +PP = .73, 95% C.I. = .59 to .84) and PDI scores of 57 or
higher (FP = 11%; Sensitivity = 54%; LR = 4.9, 95% C.I. = 2.7 to 8.4; +PP = .73, 95%
C.I. = .57 to .84) are acceptable indicators of malingering. Lower scores do not
effectively differentiate malingering from non-malingering pain patients.
DISCUSSION
This study examined the classification accuracy of the MSPQ and PDI in detect-
ing malingered pain-related disability in a clinical sample of chronic pain patients seen
for psychological evaluation. This study extends the work of Larrabee (2003) by using
a large clinical sample whose physical pathology is well documented, improving gener-
alizability. MSPQ and PDI scores are not elevated to extreme levels by objective physi-
cal pathology (see Table 4showing that objective spine findings and surgery did not
differ across different pain groups; these groups differed only as a function of their
malingering status—see Table 5). They rise to higher levels as a function of increased
external evidence of MPRD. At higher scores, both of these instruments accurately
detect MPRD.
This study provides additional convergent evidence to that found by Larrabee
(2003) as well as a recent study conducted by Crighton, Wygant, Applegate, Umlauf,
and Granacher (2014) showing that extreme scores reflect intentional exaggeration—the
mean scores of the malingering groups in each of these studies are compellingly similar
for both the MSPQ and PDI. The MSPQ and PDI both have the capacity to differentiate
malingering patients from non-malingering patients with a high degree of accuracy,
although the MSPQ is more effective overall. The larger, more well-defined sample in
this study allows for the use of these two instruments as indicators in a comprehensive
diagnostic system for malingering (Bianchini et al., 2005) even in pain patients with
significant objective pathology and/or patients who have undergone surgery.
Conceptually, malingering is reflected in scores that are higher than those typi-
cally seen in the non-malingering clinical patients, even those whose symptoms are
magnified by psychological factors (e.g., somatization). Scores will reflect a hierarchy
of exaggeration etiologies. Low scores likely reflect neither the influence of somatiza-
10 KEVIN J. BIANCHINI ET AL.
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Table 6. Cumulative percentages of patients and simulators with scores at or below the indicated raw score on the MSPQ and PDI
MSPQ PDI
No Inc Inc Only All All No Inc Inc Only All All
>Score Not MPRD MPRD LR +PP Sim >Score Not MPRD MPRD LR +PP Sim
30 4 3 70 1
29 6 3 69 0 0 1 –1
28 9 3 68 2 1 5 5 0.73
27 10 6 67 2 1 8 8 0.81
26 11 3 66 4 3 9 3 0.62 0
25 16 11 65 4 3 13 4.3 0.7 3
24 16 14 64 4 3 20 6.7 0.78 3
23 0 0 19 –1 17 63 4 3 22 7.3 0.8 6
22 4 3 23 7.7 0.81 17 62 4 3 24 8 0.81 6
21 4 3 26 8.7 0.82 22 61 8 6 28 4.7 0.72 6
20 6 4 30 7.5 0.8 22 60 10 7 38 5.4 0.75 6
19 6 4 33 8.3 0.83 28 59 13 10 38 3.8 0.67 8
18 6 4 35 8.8 0.82 36 58 14 11 46 4.2 0.69 8
17 0 8 5 39 7.8 0.81 47 57 14 11 54 4.9 0.73 17
16 5 14 11 48 4.4 0.7 50 56 20 14 54 3.9 0.68 19
15 5 14 11 55 5 0.73 50 55 0 20 14 56 4 0.68 25
14 5 16 12 61 5.1 0.73 50 50 18 32 29 73 2.5 0.58 39
13 11 22 18 70 3.9 0.68 53 45 41 48 44 83 1.8 0.45 69
12 11 28 22 75 3.4 0.65 56 40 41 66 59 87 1.5 0.44 81
11 16 31 26 79 3 0.62 58 30 59 82 74 93 1.3 0.4 92
10 16 41 32 82 2.6 0.58 64 20 92 87 91 97 1.1 0.36 94
5 68 82 76 93 1.2 0.4 94 10 100 97 99 99 1 0.35 97
0 100 100 100 100 1 –100 0 100 100 100 100 1 –100
LR = likelihood ratio; MPRD = Malingered Pain-Related Disability; MSPQ = Modified Somatic Pain Questionnaire; +PP = predictive power of a positive test assuming a
baserate of 35%; PDI = Pain Disability Index.
LR and PP+ come from the comparison of the All Not MPRD and All MPRD groups; it does not include the Simulators.
MSPQ AND PDI IN CHRONIC PAIN 11
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tion nor malingering. Within the next highest score range will be patients whose exag-
geration is due to either or both somatization and malingering. However, since scores in
this range may reflect exaggeration due to multiple influences, they are not specific
enough to be a reliable indication of intentional exaggeration. At the highest score
levels, symptoms are exaggerated to a degree that is rarely seen except in persons who
are known to be malingering.
This type of stratification can be demonstrated using existing MSPQ and PDI
data. Larrabee (2003) found an MSPQ score of >= 10 to be associated with 10% FP
rate, while in our psychologically referred chronic pain sample that same score was
associated with an FP rate = 32%. For the PDI, error rates were also higher using the
Larrabee cutoffs but the differences were less striking For example, Larrabee’s 10% FP
PDI cutoff of >= 55 was associated with an FP rate of 14% in the present sample.
The present sample likely had a higher degree of psychosocial complication (i.e.,
psychologically referred, external incentive) than the general chronic pain samples in
which the MSPQ and PDI were originally normed and from which Larrabee derived his
FP estimates. Therefore scores between Larrabee’s 10% FP cutoffs and the approxi-
mately 10% FP cutoffs derived from the present sample likely reflect the influence of
other psychosocial factors, either alone or with malingering. More research is needed
on the clinical correlates of MSPQ < 10 and PDI < 55.
Study limitations
There are limitations to this investigation. One limitation is that the current sample
may not be representative of all pain patients. This sample was composed of patients
with chronic pain (patients who have not recovered 6 months after the injury), a type of
pain episode that has been linked to emotional distress (Gatchel, Polatin, & Mayer,
1995; Gatchel, Bernstein, Stowell, & Pransky, 2008). Thus, the cutoffs related to this
study might not generalize to patients with acute or recurrent pain conditions. This study
did not specifically examine factors that impact these scales at the clinical level—below
scores associated with malingering. Finally, it is also important to note that because of
Table 7. Clinical application of findings from the MSPQ and PDI
Score level Interpretation Response
MSPQ >= 17 Malingering likely involved in patient’s
presentation
1
Refer for comprehensive psychological
evaluation and/or functional capacity
evaluation
PDI >= 62
MSPQ 10 - 16 Somatization and/or malingering may be
present but cannot be reliably differentiated
at lower score ranges
Psychological factors may interfere with
physical interventions, consider
comprehensive psychological evaluation
PDI 55 - 61
MSPQ < 10 Psychosocial complication likely minimal Psychological consultation not indicated
2
PDI < 55
1
Malingering diagnosis should not be made on the basis of questionnaire findings alone.
2
If surgical pain interventions (including spinal cord stimulator or intrathecal morphine pump) are being
considered, then patient should be referred for a pre-procedures psychological screen regardless of MSPQ or
PDI results.
12 KEVIN J. BIANCHINI ET AL.
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the conservative nature of the current paper’s methodology, there is a possibility that
some malingerers will go undetected at lower scores (i.e., there will be false negatives).
CONCLUSIONS
The data from this study can be used to inform the clinical management of
chronic pain patients (see Table 7). Absent other clinical evidence of psychological
complication, low PDI and MSPQ scores reflect minimal psychosocial complication
that ought not to interfere with clinical pain management and rehabilitation. Higher
scores indicate at least the possibility of psychological complication. While high scores
reflect an increased probability of malingering, they are insufficient for a diagnosis of
MPRD no matter how extreme (Bianchini et al., 2005; Heilbronner et al., 2009). The
data included in this paper allow for the use of these two measures in a comprehensive
diagnostic system for examining malingering in pain patients similar to the ones
described here (Bianchini et al., 2005).
AUTHOR NOTE
Data reported in this paper were presented at the 6th Annual Conference &
Workshops of the American Academy of Clinical Neuropsychology (June, 2008;
Boston, Massachusetts).
REFERENCES
Bannwarth, B. (1999). Risk–benefit assessment of opioids in chronic noncancer pain. Drug
Safety: An International Journal of Medical Toxicology and Drug Experience, 21, 283–296.
Barnes, D., Smith, D., Gatchel, R., & Mayer, T. (1989). Psychosocioeconomic predictors of treat-
ment success/failure in chronic low-back pain patients. Spine, 14, 427–430.
Ben-Porath, Y. S., Greve, K. W., Bianchini, K. J., & Kaufmann, P. M. (2009). The MMPI-2
symptom validity scale (FBS) is an empirically validated measure of overreporting in per-
sonal injury litigants and claimants: Reply to Butcher et al. (2008). Psychological Injury and
Law, 2,62–85. doi:10.1007/s12207-009-9037-4
Bianchini, K. J., Greve, K. W., & Glynn, G. (2005). On the diagnosis of malingered pain-related
disability: Lessons from cognitive malingering research. The Spine Journal: Official Journal
of the North American Spine Society, 5, 404–417.
Binder, L. M. (1993). Portland Digit Recognition Test manual (2nd ed.). Portland, OR: Author.
Block, A. R., Gatchel, R. J., Deardorff, W. W., & Guyer, R. D. (2003). The psychology of spine
surgery. Washington, DC: American Psychological Association. doi:10.1037/10613-000
Block, A., Ohnmeiss, D., Guyer, R., Rashbaum, R., & Hochschuler, S. (2001). The use of presur-
gical psychological screening to predict the outcome of spine surgery. The Spine Journal:
Official Journal of the North American Spine Society, 1, 274–282.
Boden, S., Davis, D., Dina, T., Patronas, N., & Wiesel, S. (1990). Abnormal magnetic-resonance
scans of the lumbar spine in asymptomatic subjects. A prospective investigation. The Jour-
nal of Bone and Joint Surgery, 72, 403–408.
MSPQ AND PDI IN CHRONIC PAIN 13
Downloaded by [Kelly Lynn Curtis] at 12:32 19 December 2014
Boden, S., McCowin, P., Davis, D., Dina, T., Mark, A., & Wiesel, S. (1990). Abnormal mag-
netic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investi-
gation. The Journal of Bone and Joint Surgery, 72, 1178–1184.
Brasseux, R., Greve, K. W., Gianoli, G. J., Soileau, J. S., & Bianchini, K. J. (2008). The relation-
ship between the Modified Somatic Perception Questionnaire and dynamic platform
posturography. Otology & Neurotology, 29, 359–362.
Bruns, D., & Disorbio, J. (2009). Assessment of biopsychosocial risk factors for medical treat-
ment: A collaborative approach. Journal of Clinical Psychology in Medical Settings, 16,
127–147. doi:10.1007/s10880-009-9148-9
Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). MMPI-2:
Manual for administration and scoring. Minneapolis, MN: University of Minnesota Press.
Crighton, A. H., Wygant, D. B., Applegate, K. C., Umlauf, R. L., & Granacher, R. P. (2014).
Can brief measures effectively screen for pain and somatic malingering? Examination of the
Modified Somatic Perception Questionnaire and Pain Disability Index. The Spine Journal,
14, 2042–2050. doi: 10.1016/j.spinee.2014.04.012
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (1987). California Verbal Learning Test:
Adult version manual. San Antonio, TX: Psychological Corporation.
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (2000). California Verbal Learning Test-2:
Adult version manual. San Antonio, TX: Psychological Corporation.
Ekman, P., O’Sullivan, M., & Frank, M. G. (1999). A few can catch a liar. Psychological Science,
10, 263–266. doi:10.1111/1467-9280.00147
Faust, D., Hart, K. J., & Guilmette, T. J. (1988). Pediatric malingering: The capacity of children
to fake believable deficits on neuropsychological testing. Journal of Consulting and Clinical
Psychology, 56, 578–582. doi:10.1037/0022-006X.56.4.578
Fishbain, D., Turner, D., Rosomoff, H., & Rosomoff, R. (2001). Millon behavioral health inven-
tory scores of patients with chronic pain associated with myofascial pain syndrome. Pain
Medicine, 2, 328–335.
Gatchel, R. (2004). Psychosocial factors that can influence the self-assessment of function. Jour-
nal of Occupational Rehabilitation, 14, 197–206.
Gatchel, R., Polatin, P., & Mayer, T. (1995). The dominant role of psychosocial risk factors in the
development of chronic low back pain disability. Spine, 20, 2702–2709.
Gatchel, R. J., Bernstein, D., Stowell, A. W., & Pransky, G. (2008). Psychosocial differences
between high-risk acute vs. chronic low back pain patients. Pain Practice, 8,91–97.
doi:10.1111/j.1533-2500.2008.00176.x
Green, P. (2005). Green’s Word Memory Test for Window’s: User’s manual. Edmonton, Canada:
Green’s Publishing Inc.
Green, P., Allen, L. M., & Astner, K. (1996). The Word Memory Test: A user’s guide to the oral
and computer-administered forms, US Version 1.1. Durham, NC: CogniSyst.
Greve, K. W., Bianchini, K. J., Etherton, J. L., Meyers, J., Curtis, K., & Ord, J. (2010). The
Reliable Digit Span test in chronic pain: Classification accuracy in detecting malingered
pain-related disability. The Clinical Neuropsychologist, 24, 137–152. doi:10.1080/
13854040902927546
Greve, K. W., Etherton, J., Ord, J., Bianchini, K. J., & Curtis, K. (2009). Detecting malingered
pain-related disability: Classification accuracy of the test of memory malingering. The Clini-
cal Neuropsychologist, 23, 1250–1271. doi:10.1080/13854040902828272
Greve, K. W., Ord, J., Bianchini, K. J., & Curtis, K. (2009). Prevalence of malingering in patients
with chronic pain referred for psychologic evaluation in a medico-legal context. Archives of
Physical Medicine and Rehabilitation, 90, 1117–1126. doi:10.1016/j.apmr.2009.01.018
Grevitt, M., Pande, K., O’Dowd, J., & Webb, J. (1998). Do first impressions count? A compari-
son of subjective and psychologic assessment of spinal patients. European Spine Journal:
14 KEVIN J. BIANCHINI ET AL.
Downloaded by [Kelly Lynn Curtis] at 12:32 19 December 2014
Official Publication of the European Spine Society, the European Spinal Deformity Society,
and the European Section of the Cervical Spine Research Society, 7, 218–223.
Grönblad, M., Hupli, M., Wennerstrand, P., Järvinen, E., Lukinmaa, A., Kouri, J., & Karaharju,
E. (1993). Intercorrelation and test–retest reliability of the Pain Disability Index (PDI) and
the Oswestry Disability Questionnaire (ODQ) and their correlation with pain intensity in low
back pain patients. The Clinical Journal of Pain, 9, 189–195.
Guo, H., Tanaka, S., Halperin, W., & Cameron, L. (1999). Back pain prevalence in US industry
and estimates of lost workdays. American Journal of Public Health, 89, 1029–1035.
Harris, I., Mulford, J., Solomon, M., van Gelder, J., & Young, J. (2005). Association between
compensation status and outcome after surgery: A meta-analysis. JAMA: The Journal of the
American Medical Association, 293, 1644–1652.
Heaton, R. K., Smith, H. H., Lehman, R. A., & Vogt, A. T. (1978). Prospects for faking believ-
able deficits on neuropsychological testing. Journal of Consulting and Clinical Psychology,
46, 892–900. doi:10.1037/0022-006X.46.5.892
Heilbronner, R. L., Sweet, J. J., Morgan, J. E., Larrabee, G. J., & Millis, S. R. (2009). American
Academy of Clinical Neuropsychology consensus conference statement on the neuropsycho-
logical assessment of effort, response bias, and malingering. The Clinical Neuropsychologist,
23, 1093–1129. doi:10.1080/13854040903155063
Larrabee, G. (2003). Exaggerated pain report in litigants with malingered neurocognitive dysfunc-
tion. The Clinical Neuropsychologist, 17, 395–401.
Lees-Haley, P. R., Iverson, G. L., Lange, R. T., Fox, D. D., & Allen, L. (2003). Malingering in
forensic neuropsychology: Daubert and the MMPI-2. Journal of Forensic Neuropsychology,
3, 167–203. doi:10.1300/J151v03n01_01
Linton, S. (2000). A review of psychological risk factors in back and neck pain. Spine, 25, 1148–
1156.
Linton, S., & Boersma, K. (2003). Early identification of patients at risk of developing a persis-
tent back problem: The predictive validity of the Orebro Musculoskeletal Pain Questionnaire.
The Clinical Journal of Pain, 19,80–86.
Main, C. (1983). The Modified Somatic Perception Questionnaire (MSPQ). Journal of Psychoso-
matic Research, 27, 503–514.
Mittenberg, W., Patton, C., Canyock, E., & Condit, D. (2002). Base rates of malingering and
symptom exaggeration. Journal of Clinical And Experimental Neuropsychology, 24, 1094–
1102.
Petrak, F., Hardt, J., Kappis, B., Nickel, R., & Tiber Egle, U. (2003). Determinants of health-
related quality of life in patients with persistent somatoform pain disorder. European Journal
of Pain, 7, 463–471.
Pollard, C. (1984). Preliminary validity study of the Pain Disability Index. Perceptual and Motor
Skills,59, 974. doi: 10.2466/pms.1984.59.3.974
Portenoy, R. (1996). Adjuvant analgesic agents. Hematology/Oncology Clinics of North America,
10, 103–119.
Rogers, R., Sewell, K., Martin, M., & Vitacco, M. (2003). Detection of feigned mental disorders:
A meta-analysis of the MMPI-2 and malingering. Assessment, 10, 160–177.
Schofferman, J., Anderson, D., Hines, R., Smith, G., & White, A. (1992). Childhood psychologi-
cal trauma correlates with unsuccessful lumbar spine surgery. Spine, 17(6 Suppl), S138–
S144.
Sikorski, J., Stampfer, H., Cole, R., & Wheatley, A. (1996). Psychological aspects of chronic low
back pain. The Australian and New Zealand Journal of Surgery, 66, 294–297.
Tait, R., Chibnall, J., & Krause, S. (1990). The Pain Disability Index: Psychometric properties.
Pain, 40, 171–182.
MSPQ AND PDI IN CHRONIC PAIN 15
Downloaded by [Kelly Lynn Curtis] at 12:32 19 December 2014
Tait, R., Pollard, C., Margolis, R., Duckro, P., & Krause, S. (1987). The Pain Disability Index:
Psychometric and validity data. Archives of Physical Medicine and Rehabilitation, 68, 438–
441.
Tombaugh, T. (1996). Test of Memory Malingering manual. New York: MultiHealth Systems.
Vendrig, A. A., Derksen, J. L., & de Mey, H. R. (1999). Utility of selected MMPI-2 scales in the
outcome prediction for patients with chronic back pain. Psychological Assessment, 11,
381–385. doi:10.1037/1040-3590.11.3.381
Voorhies, R., Jiang, X., & Thomas, N. (2007). Predicting outcome in the surgical treatment of
lumbar radiculopathy using the Pain Drawing Score, McGill Short Form Pain Questionnaire,
and risk factors including psychosocial issues and axial joint pain. The Spine Journal:
Official Journal of the North American Spine Society, 7, 516–524.
Wechsler, D. A. (1997). Wechsler Adult Intelligence Scale-III. New York, NY: Psychological
Corporation.
APPENDIX A
Simulator instructions
Imagine that you have been in an accident and suffered an injury to your neck, shoulder
and back. Initially you experienced sustained pain but now you are mostly healed, you have no
significant pain, and you are experiencing no further significant problems due to the injury.
Because you had an injury and some pain you have decided to file a lawsuit and you stand to
gain a very large financial settlement if you can convince the court that you are disabled. In your
lawsuit you are claiming that the injury has continued to cause pain and that this pain is causing
you significant impairment (even though the injury actually healed and the pain went away). You
claim that pain-related impairment makes you unable to perform college level schoolwork so that
your future employment opportunities are limited. You have been sent to a psychologist to evalu-
ate your claim of impairment and are now about to take a test for that purpose. Your task is to
perform on that test as if you were experiencing severe, persistent, chronic pain. However, you
must fake your impairment in a way that is believable because if your faking is detected, your
lawsuit will be thrown out of court and you will get nothing.
APPENDIX B
Malingering classification method
Determination of malingering status was based on the criteria for the diagnosis of MPRD
(Bianchini, Greve, & Glynn, 2005). Classification relied on performance on psychometric indica-
tors and examination of available records. The operationalization of the MPRD criteria results in
a given score being considered positive, negative, or indeterminate (neither clearly positive nor
negative). Therefore, the system results in patients being classified into one of four groups: (1)
Not MPRD; (2) Possible MPRD (some findings but insufficient for a higher level diagnosis); (3)
Probable MPRD; (4) Definite MPRD. Definite MPRD is defined by the presence of a significantly
below-chance finding on a forced-choice SVT or a compelling inconsistency. Probable MPRD is
defined in terms of two or more psychometric findings consistent with malingering or two or
more qualitative inconsistencies along with one or more psychometric findings.
Cases who had psychometric findings or two or more qualitative inconsistencies but who
did not meet these criteria where considered Possible MPRD. Because at least two qualitative
inconsistencies are required to reach at least the Possible designation, patients with only one
inconsistency are not clearly classifiable. Thus, the cases who do not meet criteria for an MPRD
16 KEVIN J. BIANCHINI ET AL.
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diagnosis were further divided into three groups: (1) those with no positive psychometric findings
or inconsistencies; (2) those with no more than one ambiguous psychometric finding and no
inconsistencies; (3) those with two or more ambiguous psychometric findings and/or only one
inconsistency.
Psychometric indicators. The cutoffs for the indicators used for MPRD classification were
based on examination of classification accuracy data derived from published criterion groups vali-
dation (known-groups) traumatic brain injury studies and in consideration of the general literature
on specific indicators. In all cases, the cutting scores are based on the performance of patients
seen for neuropsychological evaluation for claims of brain injury and the samples included
patients with objectively documented brain pathology.
Table B1 presents the data on the classification accuracy of the selected cutoffs for each
indicator. Also reported in Table B1 is Positive Predictive Power (+PP) for the weakest value
considered positive for each variable and Negative Predictive Power (–PP) for the weakest vari-
able values considered negative. The predictive values were derived using a hypothetical malin-
gering baserate of 35% (Mittenberg, Patton, Canyock, & Condit, 2002). +PP and –PP provide a
concrete index of confidence that a patient is malingering or not malingering, respectively. Appli-
cation of this system results in each score being classified as (1) a negative indication of response
bias or malingering; (2) an ambiguous indication of response bias or malingering; or (3) a posi-
tive indication of response bias or malingering.
Significantly below-chance performance. A statistically significantly below-chance
result on a forced-choice SVT is definitive evidence of intentional exaggeration of cognitive defi-
cits (Bianchini, Mathias, & Greve, 2001; Frederick & Speed, 2007). This has been recognized in
both published systems for diagnosing malingering (Bianchini et al., 2005; Slick, Sherman, &
Iverson, 1999). A below-chance result “is not a random or chance occurrence but represents a
purposive distortion by the examinee”(Reynolds, 1998; p. 272; emphasis added). In this study,
below-chance results were possible on the PDRT, TOMM, and/or WMT. For the TOMM, a score
of 17/50 or less on Trial 2 or Retention was considered significantly below chance (below the
lower bound of the 95% confidence interval around a score of 25/50). For the PDRT, scores of
11/36 on Easy or Hard, or 27/72 on Total were considered significantly below chance. For the
WMT, below chance was 13/40 on Immediate or Delayed Recognition. In summary, any score
that was significantly below chance was sufficient to place the examinee in the Definite MPRD
category.
Qualitative inconsistencies. Four kinds of inconsistencies were considered as part of
the MPRD classification: (1) non-organic or functional findings on physical examination
(exclusive of Functional Capacity Evaluation [FCE]); (2) an inconsistency between the patient’s
behavior during examination and their behavior when they do not believe they are being
observed; (3) inconsistencies between the patient’s subjective report of symptoms or history and
their documented history; and (4) evidence of submaximal effort, symptom magnification, or non-
organic/function findings on a formal FCE. Multiple inconsistencies are required to contribute to
a diagnosis of MPRD to account for their qualitative nature. The one exception is in the case of
“compelling inconsistencies”(Bianchini et al., 2005).
A“compelling inconsistency”occurs when the difference in the way a patient presents when
being evaluated compared to when they are not aware of being evaluated is so inconsistent that it is
not reasonable to believe the patient is not purposely controlling the difference (Bianchini et al.,
MSPQ AND PDI IN CHRONIC PAIN 17
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Table B1. Classification criteria for psychometric variables
Indicator Negative –PP Ambiguous Positive +PP
Reference for
Cutoff
Test of Memory Malingering
Trial 2 50–49 0.82 48–45 44–0 0.85 Greve,
Bianchini, &
Doane, 2006
Retention 50–49 0.83 48–45 44–0 0.91
Portland Digit Recognition Test
Easy 36–28 0.86 27–23 22–0 0.97 Greve &
Bianchini, 2006
Hard 36–23 0.86 22–17 17–0 0.93
Total 72–50 0.88 49–45 44–0 0.95
Word Memory Test
IR 100–80 0.83 78.5–72.5* 70–0 0.86 Greve
et al.,
2008
DR 100–80 0.83 78.5–72.5* 70–0 0.85
CNS1 100–75 0.83 72.5–57.5* 55–0 0.88
Wechsler Adult Intelligence Scale
RDS 17–8 0.87 7 6–0 0.86 Etherton
et al.,
2005
DS 19–8 0.85 7–54–1 1.00 Heinly
et al.,
2005
WMI 150–81 0.88 80–76 75–50 0.86 Greve
et al.,
2009
PSI 150–76 0.84 75–71 70–54 0.89 Etherton
et al.,
2006
California Verbal Learning Test
Rec Hits 16–12 0.82 11–10 9–0 0.91 Curtis
et al.,
2006
Minnesota Multiphasic Personality Inventory
F30–65 0.82 66–80 81–120 0.8 Greve
et al.,
2006
Fb 30–65 0.8 66–85 86–120 0.88
Fp 30–65 0.73 66–80 81–120 0.83
FBS 0–24 0.84 25–27 28–43 0.82
Citations in this table refer to the studies providing cutoffs. In general, WMT research has not focused on
malingering, but rather “invalidity”or “poor effort,”both of which can be caused by factors other than malin-
gering. The alternative cutoffs from the Greve et al. 2008 study are specific to malingering and are based on a
much larger sample size than the one used for the current paper.
*The WMT scores are recorded in increments of 2.5% so scores between 80 and 78.5 and between 72.5
and 70 are not possible. –PP = Negative Predictive Power, the minimum probability that a negative score was
produced by a non-malingering case assuming a malingering base rate of .35; +PP = Positive Predictive
Power, the minimum probability that a positive score was produced by a .malingering case assuming a malin-
gering base rate of .35; IR = immediate recall trial from the Word Memory Test; DR = delayed recall trial
from the Word Memory Test; CN1 = consistency of recall between IR and DR from the Word Memory Test;
RDS = Reliable Digit Span; DS = Digit Span scales score; WMI = Working Memory Index; PSI = Processing
Speed Index; Rec Hits = Recognition Hits from the California Verbal Learning Test; F = Infrequency scale;
Fb = Infrequency (back); Fp = Infrequency (psychopathology); FBS = Symptom Validity Scale.
18 KEVIN J. BIANCHINI ET AL.
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2005). Patients coded as having inconsistencies were examined in detail and the first and fifth
authors (KJB, KWG) had to agree that the inconsistency was compelling as defined above. If there
was no agreement, then the inconsistency was considered a normal qualitative inconsistency and
treated as described in the preceding paragraph. Three patients (n= 3) had compelling inconsisten-
cies and were classified as Definite MPRD.
REFERENCES FOR TABLE B1
Bianchini, K. J., Greve, K. W., & Glynn, G. (2005). On the diagnosis of malingered pain-related
disability: Lessons from cognitive malingering research. The Spine Journal: Official Journal
of the North American Spine Society, 5, 404–417.
Bianchini, K. J., Mathias, C. W., & Greve, K. W. (2001). Symptom validity testing: A critical
review. The Clinical Neuropsychologist, 15,19–45.
Curtis, K., Greve, K. W., Bianchini, K. J., & Brennan, A. (2006). California verbal learning test
indicators of Malingered Neurocognitive Dysfunction: Sensitivity and specificity in traumatic
brain injury. Assessment, 13,46–61.
Etherton, J., Bianchini, K. J., Ciota, M., & Greve, K. W. (2005). Reliable digit span is unaffected
by laboratory-induced pain: Implications for clinical use.Assessment, 12, 101–106.
Etherton, J., Bianchini, K. J., Heinly, M., & Greve, K. W. (2006). Pain, malingering, and
performance on the WAIS-III Processing Speed Index. Journal of Clinical and Experimental
Neuropsychology, 28, 1218–1237.
Frederick, R. I. & Speed, F. M. (2007). On the interpretation of below-chance responding in
forced-choice tests. Assessment, 14,3–11.
Greve, K. W., & Bianchini, K. J. (2006). Classification accuracy of the Portland Digit
Recognition Test in traumatic brain injury: Results of a known-groups analysis. The Clinical
Neuropsychologist, 20, 816–830.
Greve, K. W., Bianchini, K. J., & Doane, B. M. (2006). Classification accuracy of the test of
memory malingering in traumatic brain injury: Results of a known-groups analysis. Journal of
Clinical and Experimental Neuropsychology, 28, 1176–1190.
Greve, K. W., Bianchini, K. J., Love, J., Brennan, A., & Heinly, M. (2006). Sensitivity and
specificity of MMPI-2 validity scales and indicators to malingered neurocognitive dysfunction
in traumatic brain injury. The Clinical Neuropsychologist, 20, 491–512.
Greve, K. W., Etherton, J. L., Ord, J., Bianchini, K. J., & Curtis, K. (2009). Detecting malingered
pain-related disability: Classification accuracy of the test of memory malingering. The Clinical
Neuropsychologist, 23, 1250–1271. doi:10.1080/13854040902828272
Greve, K. W., Ord, J., Curtis, K., Bianchini, K. J., & Brennan, A. (2008). Detecting malingering
in traumatic brain injury and chronic pain: A comparison of three forced-choice symptom
validity tests. The Clinical Neuropsychologist, 22, 896–918. doi:10.1080/13854040701565208
Heinly, M., Greve, K. W., Bianchini, K. J., Love, J., & Brennan, A. (2005). WAIS digit span-based
indicators of malingered neurocognitive dysfunction: Classification accuracy in traumatic brain
injury. Assessment, 12, 429–444.
Mittenberg, W., Patton, C., Canyock, E., & Condit, D. (2002). Base rates of malingering and
symptom exaggeration. Journal of Clinical and Experimental Neuropsychology, 24,1094–1102.
Reynolds, C. R. (1998). Common sense, clinicians, and actuarialism in the detection of
malingering during head injury litigation. In C. R. Reynolds (Ed.), Detection of malingering
during head injury litigation (pp. 261–286). New York, NY: Plenum Press.
Slick, D., Sherman, E., & Iverson, G. (1999). Diagnostic criteria for malingered
neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical
Neuropsychologist, 13, 545–561.
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