Applied Neuropsychology: Adult ISSN: 2327-9095 (Print) 2327-9109 (Online) Journal homepage: http://www.tandfonline.com/loi/hapn21 Exaggerating Psychopathology Produces Residual Effects That Are Resistant to Corrective Feedback: An Experimental Demonstration Harald Merckelbach , Brechje Dandachi-FitzGerald , Peter van Mulken , Rudolf Ponds & Elly Niesten To cite this article: Harald Merckelbach , Brechje Dandachi-FitzGerald , Peter van Mulken , Rudolf Ponds & Elly Niesten (2015) Exaggerating Psychopathology Produces Residual Effects That Are Resistant to Corrective Feedback: An Experimental Demonstration, Applied Neuropsychology: Adult, 22:1, 16-22, DOI: 10.1080/23279095.2013.816850 To link to this article: http://dx.doi.org/10.1080/23279095.2013.816850 Published online: 12 Nov 2013. Submit your article to this journal Article views: 89 View related articles View Crossmark data Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hapn21 Download by: [University of Maastricht] Date: 04 May 2016, At: 03:06 APPLIED NEUROPSYCHOLOGY: ADULT, 22: 16–22, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 2327-9095 print=2327-9109 online DOI: 10.1080/23279095.2013.816850 Exaggerating Psychopathology Produces Residual Effects That Are Resistant to Corrective Feedback: An Experimental Demonstration Harald Merckelbach Forensic Psychology Section, Maastricht University, Maastricht, The Netherlands Brechje Dandachi-FitzGerald School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands Peter van Mulken Forensic Psychology Section, Maastricht University, Maastricht, The Netherlands Rudolf Ponds School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands Elly Niesten Forensic Psychology Section, Maastricht University, Maastricht, The Netherlands We explored the effects of feedback on symptom reporting. Two experimental groups (n ¼ 15 each) were given a scenario with the option to exaggerate symptoms. Compared with a control condition (n ¼ 15), both groups scored significantly higher on the Struc- tured Inventory of Malingered Symptomatology. Next, one group was confronted in a sympathetic way about their symptom validity test failure, whereas the other group was confronted in a neutral manner. Both groups subsequently completed the Brief Symp- tom Inventory (BSI). BSI scores of both feedback groups remained significantly higher Downloaded by [University of Maastricht] at 03:06 04 May 2016 than those of control participants. Participants who had been provided with sympath- etic feedback or neutral feedback did not differ in their BSI scores. Even participants who indicated during the exit interview that they had given up symptom exaggeration attained significantly higher BSI scores than those of controls, indicating that exagger- ation has residual effects that are resistant to corrective feedback. We discuss cognitive dissonance as a model for understanding the residual effects of symptom exaggeration. Key words: cognitive dissonance, feedback, psychopathology, residual effects, symptom validity Are there effective ways to reduce deliberate symptom exaggeration in neuropsychological settings? This is a Address correspondence to Harald Merckelbach, Forensic relevant question because there now exists abundant Psychology Section, Maastricht University, P.O. Box 616, 6200 MD, evidence that when examinees fail on tests flagging Maastricht, The Netherlands. E-mail: H.Merckelbach@maastricht university.nl symptom exaggeration, their other neuropsychological SYMPTOM EXAGGERATION AND CORRECTIVE FEEDBACK 17 data become largely noninterpretable (e.g., Dandachi- ultimately make the examinee more skillful in evading FitzGerald, Ponds, Peters, & Merckelbach, 2011; Fox, detection on subsequent symptom validity tests (e.g., 2011; Kirkwood, Yeates, Randolph, & Kirk, 2012). Bush, 2009). Decreasing the potential for symptom exaggeration Both deterrence theory (King & Sullivan, 2009) and may involve two stages: pretest instructions given to the cautious feedback approach seem to assume that the examinee and corrective feedback once an examinee potential malingerers have control over their symptom has failed a symptom validity test. There is, however, lit- reporting and that providing them with warning or feed- tle consensus about the effectiveness of attempts to back information will motivate them to normalize their decrease symptom exaggeration. Some authors contend scores. On the other hand, and as already noted, the that warnings and corrective feedback should not be empirical literature suggests that the corrective effects given at all as they may make malingerers more sophis- of warnings do not produce complete normalization. ticated in misrepresenting their neuropsychological def- In what seems to be the only empirical study on the icits (Youngjohn, Lees-Haley, & Binder, 1999; see also effects of feedback, Suchy, Chelune, Franchow, and Greiffenstein, 2009). Other authors advocate the so- Thorgusen (2012) found that providing patients who called deterrence theory (Sullivan & Richer, 2002), failed a symptom validity test with corrective feedback which posits that warnings may reduce the probability led to improved performance on readministered cogni- of symptom over-reporting because they encourage tive tasks. But again, this improvement did not take potential malingerers to undertake a cost–benefit analy- the form of a complete normalization of scores. sis of symptom distortion. Thus, it appears that malingerers continue to report Empirical studies addressing warnings and how they above-average symptom levels even when they have impact symptom over-reporting suggest that their ben- been warned before testing (King & Sullivan, 2009) or eficial effects are, at best, limited. For example, in an have been provided with feedback during testing (Suchy experimental study, King and Sullivan (2009) found that et al., 2012). This phenomenon fits well with the obser- warned malingerers instructed to simulate believable vation that malingering produces residual effects. psychological impairment had lower depression scores Merckelbach, Jelicic, and Pieters (2011; Study 1) instruc- compared with unwarned malingerers, yet they reported ted undergraduates to exaggerate symptoms on the higher depression levels than those of control parti- Structured Inventory of Malingered Symptomatology cipants. Employing a similar design, Sullivan and Richer (SIMS; Widows & Smith, 2005). The SIMS is a widely (2002) observed that warned malingerers had an used self-report instrument in forensic neuropsychology intermediate position between controls and unwarned that addresses atypical symptoms and experiences. Indi- malingerers with regard to their self-reported psycho- viduals who first over-reported symptoms but later— pathology, suggesting that warnings have corrective after 1 hr—were explicitly instructed to report honestly, potential but do not lead to complete normalization continued to endorse more symptoms at retest com- (see also Etherton & Axelrod, 2013; Gorny & Merten, pared with honest controls. Cognitive dissonance theory 2005). provides a framework for understanding such residual While the neuropsychological literature on the effects effects (Bayer, 1985; Merckelbach & Merten, 2012). This of warnings prior to test taking is limited, studies on cor- theory posits that people strive for consistency in their rective feedback during or after test taking are almost beliefs and behaviors. Thus, whenever the self-definition completely absent. Based on clinical experience, some of being an honest and healthy person is challenged by Downloaded by [University of Maastricht] at 03:06 04 May 2016 authors have formulated tentative desiderata about deliberate over-reporting of symptoms, an aversive state how to provide examinees who engage in symptom is likely to occur. This state has motivational properties exaggeration with feedback (e.g., Bush, 2009; Martelli, that may lead to an act of self-deception. That is to say, Nicholson, Zasler, & Bender, 2012; McMillan et al., the person will attempt to resolve cognitive dissonance, 2009). A recurrent theme in this literature is that neu- typically by changing her beliefs (‘‘I really suffer from ropsychologists should avoid an accusatory tone and symptom X’’). This way, people may come to believe that corrective feedback should be grounded in a non- their inflated symptom reports. confrontational attitude toward the examinee. Authors In the current study, we focused on the effects of agree that other factors than just malingering might feedback rather than on the effect of prospective underlie symptom exaggeration (e.g., the wish to be warnings. More specifically, and with the cognitive dis- taken seriously, difficulties in staying motivated during sonance theory in mind, we wanted to explore whether testing) and that neuropsychologists may not have suf- providing experimental malingerers with feedback ficient information to determine the precise cause of would produce normalization of their subsequent symptom exaggeration. Hence, a cautious approach is symptom reports. We compared two types of feedback: recommended. Another consideration is that feedback sympathetic confrontation, in which the examinee is that stipulates failure on the part of the examinee may told that (s)he failed a test without mentioning that this 18 MERCKELBACH ET AL. indicates malingering; and neutral