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The Influence of Affective State and Time Since Injury on Test Effort in Patients With Mild Traumatic Brain Injury

Authors:
  • Burlington Psychological and Counselling Services

Abstract

The examination of test effort is an integral part of neuropsychological evaluation, as the validity of assessment findings is compromised if a patient fails to put forth an effortful performance. The Test of Memory Malingering (TOMM), a forced-choice technique for the detection of poor effort, is widely utilized and has been shown to be sensitive to incomplete effort in patients with mild traumatic brain injury (mTBI). Affective state and time since injury have remained largely unexamined as potential factors influencing TOMM performance. The results of this novel study suggest that the relationship between TOMM performance and scores on neuropsychological test measures may change as a function of time since injury. Indeed, suboptimal TOMM performance appears to be associated with poor performance across a wider spread of cognitive domains at 24 months post-injury compared to 6 months post-injury. Depression might influence effort level differentially in persons with mTBI compared to non-brain injured participants. This finding is significant because it suggests that care must be taken, in that depressed persons with TBI, in particular, are putting forth inadequate effort during cognitive assessment.
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Research funded by the Ryerson New Faculty SRC Development Fund, ORS, Ryerson University,
and the Canadian Institutes of Health Research (CIHR).
Acknowledgements
Greve, K. W., Ord, J., Curtis, K. L., Bianchini, K, J., Brennan, A. (2008). Detecting malingering in traumatic brain injury
and chronic pain: A comparison of three forced-choice symptom validity tests. Clinical Neuropsychologist, 22,
896-918.
References
Influence of Affective State on the TOMM
Factorial ANOVA revealed that the mTBI patients performed worse on the TOMM and showed elevated levels of anxiety and depression
at 6-months post-injury compared to controls.
Further analyses indicated that suboptimal TOMM performers tested at 24 months post-injury also reported significantly greater levels of
depression as measured by the BDI-II than optimal TOMM performers.
Suboptimal TOMM performers did not report statistically greater depression than optimal performers at 6-months post-injury. Therefore,
time since injury appears to alter the relationship between depression and scores on the TOMM.
Influence of Time Since Injury on Cognitive Functioning
Analyses revealed that suboptimal TOMM performers received lower scores on neurocognitive measures, in general.
There were more varied and greater differences in cognitive test performance between optimal and suboptimal TOMM performers at 24
months post-injury compared to the groups at 6 months post-injury.
Introduction
Participants
Archival data from 102 (47 females and 55 males) participants
were included in this cross-sectional study.
Group 1 (Controls):
Thirty-three non-brain injured, healthy people from the
general population.
Groups 2 and 3
A total of 69 traumatic brain injured patients, with a GCS =
13-15 (i.e., mild brain injury (mTBI)). Patients were referred
for a neuropsychological evaluation and assessed at 6-
months (Group 1) or 24-months (Group 2) post injury.
Psychological Measures
Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI-
II).
Neurocognitive Measures
Test of Memory Malingering (TOMM); Wechsler Abbreviated Scale of
Intelligence (WASI); Trail-Making Task A (TMT-A) and B (TMT-B);
Wechsler Memory Scale, Third Edition (WMS-III) – Logical Memory
subtest; Wide Range Achievement Test, Third Edition (WRAT-3);
Controlled Oral Word Association Test (COWAT); and, California
Verbal Learning Test, Second Edition (CVLT-II).
Method
Earlier in the course of injury, mTBI patients show poorer TOMM
performance and elevated psychological problems as evidenced
by increased depression and anxiety symptom severity.
Our results are contrary to those found in previous studies
examining the effect of mood, specifically depression, on TOMM
performance in certain populations.
Limitations of the current study indicate that future studies should
examine whether the relationship between TOMM performance
and depression observed in the current study holds true when:
Diagnosed with depression via interview rather than BDI-II
Examined in samples of strictly compensation seeking or
non-compensation seeking mTBI patients.
As expected, we found that mTBI patients who performed
suboptimally on the TOMM also received lower scores on
measures of cognitive functioning.
There were more varied and greater differences in cognitive test
performance between optimal and suboptimal TOMM performers
at 24 months post-injury compared to the groups at 6 months
post-injury.
Suboptimal performers exhibited possible deficits in the domains
of attention and verbal memory at 6 months post-injury.
Suboptimal performers at 24 months post-injury exhibited possible
deficits in the domains of general intellectual functioning and
executive functioning in addition to difficulty with attention and
verbal memory.
This finding is significant because it suggests that greater time
since injury is associated with poorer test performance across a
wider range of cognitive domains in persons who perform
suboptimally on the TOMM.
Discussion
The results of this novel study suggest that the relationship
between TOMM performance and scores on neuropsychological
test measures may change as a function of time since injury:
Suboptimal TOMM performance appears to be associated
with poor performance across a wider spread of cognitive
domains at 24 months post-injury compared to 6 months
post-injury.
Depression might influence effort level differentially in persons
with mTBI compared to non-brain injured participants. This finding
is significant because it suggests that care must be taken, in that
depressed persons with TBI, in particular, are putting forth
inadequate effort during cognitive assessment.
Conclusions
The examination of test effort is an integral part of
neuropsychological evaluation, as the validity of assessment
findings is compromised if a patient fails to put forth an effortful
performance.
The Test of Memory Malingering (TOMM), a forced-choice
technique for the detection of poor effort, is widely utilized and has
been shown to be sensitive to incomplete effort in patients with
mild traumatic brain injury (mTBI) (Greve et al., 2008).
Affective state and time since injury have remained largely
unexamined as potential factors influencing TOMM performance.
Results
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Figure 1. Mean scores for neuropsychological measures
administered at 6-months post-injury, grouped by optimal versus
suboptimal effort on the TOMM.
Figure 2. Mean scores for neuropsychological measures
administered at 24-months post-injury, grouped by optimal
versus suboptimal effort on the TOMM.
Goals
To determine the extent to which the TOMM is influenced by
depression and anxiety, as well as time since injury, in mTBI
patients.
To examine the effect of time since injury on general
neurocognitive performance, particularly amongst suboptimal
TOMM performers.
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Table 1. Group differences on neurocognitive measures.
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