TOMM index

[ghost dog]

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Hey folks,

I was wondering if people could give me some feedback on the
Test of Memory Malingering (TOMM).

If a patient "fails" this test, is it considered valid to allow them to attempt a repeat ? I have seen this done.

In the scenario I have seen it used , the person invariably has a chronic pain complaint (and not a memory issue). What potential conclusions can be drawn from such a test?

What do you think of using the Structured Inventory of Malingered Symptomatology (SIMS) in the setting of a chronic pain / medico legal context?

 

[PsyDr]

Hell no.

That's like having a patient describe glove anathesia and then asking them for more valid symptoms. Especially when you are using a forced choice.

Why are you giving psychological measures?

 

[nitemagi]

I wouldn't allow a repeat. I would consider other measures like the Rey-2 for quick cognitive screening. What is it you think they're malingering? Pain? Unfortunately there's no good (validated) measures for malingering of pain that I'm aware of. The PHQ-15 is ok for multi-system physical complaints, but probably wouldn't be useful for the population you're seeing, who might be malingering a specific type of pain. The SIMS focuses on psychiatric pathology and is intended for forensic settings like NGRI evaluations.

What's wrong with the usual approach -- Documenting all inconsistencies in history, do urine drug checks to see that they're taking it opioids) and not diverting it, and set firm limits on refills. And do statewide checks from the DEA on prescribing of controlled substances.

 

[PsyDr]

Ahem

http://www.uth.tmc.edu/clinicalneuro/institute/2006/Larrabee/Larrabee 2003(2).pdf

 

[nitemagi]

Ahem

http://www.uth.tmc.edu/clinicalneuro/institute/2006/Larrabee/Larrabee 2003(2).pdf

That's validated in a forensic population with patients also thought to be malingering neurocog impairments. Are there papers supporting its validation in a primary care clinic or pain specialists office?

 

[PsyDr]

nitemagi,

Your initial statement is true. The OP specifically asked about use of psychological measures "in the setting of a chronic pain / medico legal context" and I confined myself to that arena to respond. In regards to your question: yes, there are other measures with such validation in those settings.

OP if you are administering psychological measures with this degree of understanding, especially in a medico-legal setting, you are opening yourself up to some legal difficulties. I would suggest you either get significantly more training or farm this stuff out.

 

[nitemagi]

nitemagi,

Your initial statement is true. The OP specifically asked about use of psychological measures "in the setting of a chronic pain / medico legal context" and I confined myself to that arena to respond. In regards to your question: yes, there are other measures with such validation in those settings.

OP if you are administering psychological measures with this degree of understanding, especially in a medico-legal setting, you are opening yourself up to some legal difficulties. I would suggest you either get significantly more training or farm this stuff out.

I think the OP was really asking does the measures give medicolegal protection, but I could be wrong.

 

[Therapist4Chnge]

If you are asking these types of questions, you probably shouldn't be using these assessments without a great deal more training/supervision with them.

 

[IAmAUser]

.

 

[ghost dog]

If you are asking these types of questions, you probably shouldn't be using these assessments without a great deal more training/supervision with them.

You misunderstand.

I don't perform these type of tests, I am looking for an explanation of their results, and what conclusions you can draw from them. I'm neither a psychiatrist or a psychologist.

Thank you.

 

[Therapist4Chnge]

You misunderstand.

I don't perform these type of tests, I am looking for an explanation of their results, and what conclusions you can draw from them. I'm neither a psychiatrist or a psychologist.

Thank you.

Ahh, okay. Please ignore my previous response.

The TOMM is an effort measure, so failure on the TOMM generally suggests sub-optimal effort. There are some special populations that have a chance of scoring poorly, though this is rare and the performance typically looks much different than someone who is malingering. Etherton et al. (2005) published a useful article about the use of the TOMM and pain's role in test performance.....pain ended up being a non-factor.

"Test of Memory Malingering Performance is unaffected by laboratory-induced pain: Implications for clinical use" by Joseph Etherton, Kevin Bianchini, Kevin Greve, Megan Ciota. Archives of Clinical Neuropsychology, May, 2005, vol. 20, #3, pages 375-384.

As for sub-optimal effort....I'd look for secondary gain factors (litigation, compensation, attention, etc).

 

[whopper]

A problem in giving a patient a second try at a test is it begs the question that doing it over again can invalidate the results.

E.g. if a patient takes a conventional multiple choice test, fails, it, and takes it again, they will likely get a better score because they would've remembered at least some of the questions.

A problem with the TOMM is people want to see if the person is malingering memory problems or not, but there are sometimes results that are the product of something other than these 2 possible outcomes.

Another problem, and I'm encountering this from time-to-time on a forensic unit filled with people that coach each other, is if we nail one guy as malingering with a test, that bozo sometimes tells the other people on the unit what we did. E.g. I had a guy who I was convinced was malingering, but whenever I did an M-FAST, the score was in a grey zone. The more I looked into it, the more I suspected that he was coached by other patients to not fall into the trick of pretending to have symptoms that were too bogus. Turned out my theory was correct. Now when my treatment team does malingering testing we try to do it quickly before the newer patients can form alliances with the antisocial ones that'll coach them.

 

[ghost dog]

A problem in giving a patient a second try at a test is it begs the question that doing it over again can invalidate the results.

E.g. if a patient takes a conventional multiple choice test, fails, it, and takes it again, they will likely get a better score because they would've remembered at least some of the questions.

A problem with the TOMM is people want to see if the person is malingering memory problems or not, but there are sometimes results that are the product of something other than these 2 possible outcomes.

Another problem, and I'm encountering this from time-to-time on a forensic unit filled with people that coach each other, is if we nail one guy as malingering with a test, that bozo sometimes tells the other people on the unit what we did. E.g. I had a guy who I was convinced was malingering, but whenever I did an M-FAST, the score was in a grey zone. The more I looked into it, the more I suspected that he was coached by other patients to not fall into the trick of pretending to have symptoms that were too bogus. Turned out my theory was correct. Now when my treatment team does malingering testing we try to do it quickly before the newer patients can form alliances with the antisocial ones that'll coach them.

I have a hard time wrapping my brain around the TOMM:

1. It seems that this test is evaluating a person's effort and not cognition.

2. So, if a patient fails this test, and thus the conclusion is possibly that they are providing a suboptimal effort - this test is a surrogate measure for malingering in general ?

Is this is a reasonable conclusion to make ?

I will say that in MVA related disability cases, it is rare for the claimant funded psychologist to perform the TOMM. The insurer paid psychologist will perform this test all the time, in addition to the SIMS.

 

[whopper]

1. It seems that this test is evaluating a person's effort and not cognition.

2. So, if a patient fails this test, and thus the conclusion is possibly that they are providing a suboptimal effort - this test is a surrogate measure for malingering in general ?

Is this is a reasonable conclusion to make ?

All of the above points are reasonable IMHO.

An issue with the TOMM as with any malingering test is that sometimes the end score will strongly suggest with good mathematical likelihood that the person is malingering or strongly suggest they are not malingering. In other results, it can yield grey area results.

If it's strongly one way or the other, there's good clinical data to support the test results, well viola, this is usually simple. In grey area results, then this becomes more difficult.

Your experience that some people use testing more often than others, well I've noticed that too. From personal experience, and this is unfortunate, it's the hired-guns that tend to simply give something based on clinical observation, and as I've written before. I've seen some forensic psychiatrists that I strongly believed already convinced themselves of the conclusion, the one that favors his boss-the hiring lawyer, and watch the evaluee and try to mold his testimony of the evaluee's presentation into something that'll support the conclusion, without trying to honestly figure out what was really going on. While this in highly unethical, money has a way of allowing some people to open their minds to it, even ones at namebrand institutions.

So it's no surprise that one side tends to use psychological testing more often than another side.

The big problem I've experienced when doing evaluations is what do you do when you get a grey area result, and the case is extremely serious...e.g. a feloney where the defendant can go to prison for decades, and you're not convinced either way? These are cases where I lose sleep.

 

[Therapist4Chnge]

I have a hard time wrapping my brain around the TOMM:

1. It seems that this test is evaluating a person's effort and not cognition.

That is the exact purpose for the TOMM. There are very few exceptions where a congitive issue or other condition would confound the data. It is one of the most well researched effort assessments, so most special populations have been covered. You never use just one measure, but the data can go a long way in supporting a conclusion of sub-optimal effort.

I will say that in MVA related disability cases, it is rare for the claimant funded psychologist to perform the TOMM. The insurer paid psychologist will perform this test all the time, in addition to the SIMS.

It depends on the claiments reported problems, the referral question, etc.

 

[PsyDr]

If this person is neither a psychiatrist nor a psychologist, then posters should not be discussing test matters with him/her in order to maintain test security.

Come on guys.

 

[ghost dog]

If this person is neither a psychiatrist nor a psychologist, then posters should not be discussing test matters with him/her in order to maintain test security.

Come on guys.

I am a chronic pain physician. If you had bothered to conduct a fulsome review of this thread, it would have become apparent that I am a doctor / health care professional.

You might want to think before engaging your fingers. The only conceivable way that I can foresee of ``cheating`` on a test such as this would be as whopper has stated.

BTW, the TOMM is discussed on wikipedia and can be accessed for public consumption by typing it into a little known search engine known as ``google``. I am asking questions here as I would like some clinical feedback from the experts.

This is the second annoying comment on this thread. 😡

 

[IT514]

I'm trying to be vague here, but if I'm giving too much info, someone send me a PM.

I'm not comfortable using some effort measures due to the way that they move statistically with general intellectual ability. When you add in chronic pain AND low general cognitive ability, then I'm really uncomfortable. Others may disagree, the lit certainly allows for that, but as in every other domain, there is a big difference in how someone with an IQ of 70 malingers vs how someone with an IQ of 100 malingers. I'm not saying that this wipes out all the other grey areas, but certainly is a factor when talking about this measure.

 

[whopper]

Agree with all the above and I'm not pointing fingers. In general, and some psychological tests even request this be done on their directions, the suggestion is to not discuss these tests in detail in forums that the public can access because it'll teach people how to beat the test.

While some may argue that from a consumer knowledge standpoint, they have a right to learn how these things work, in effect it's pretty much giving them the answer key to one of the few methods that can be objectively used to determine if the person is malingering or not.

Hence the request above to not discuss this in much detail.

I'm not comfortable using some effort measures due to the way that they move statistically with general intellectual ability.

This issue is addressed in several psychological tests. If you read the TOMM directions, it'll give you insight into these matters. Another issue is that psychological tests, while they can be very effective, aren't the end all be all of testing. I had, for example, a guy who did a TOVA (a test for ADHD) for me and the test suggested he was malingering. I didn't think he was because he never asked me for a medication of potential abuse, didn't want to be on one, and I asked him to take it because I suspected he had it. After deeper discussion, he told me he didn't know what he was doing in some parts of the test and just reacted...and that could've set up a false positive for malingering.

Clinical observation needs to be used in conjunction with testing. Does the person have a motive to malinger? What would they gain? Do they have signs that are not consistent with symptoms? Are their symptoms atypical? The big benefit testing offers is it's objective, but it's not the end all be all.

 

[erg923]

I have a hard time wrapping my brain around the TOMM:

1. It seems that this test is evaluating a person's effort and not cognition.

2. So, if a patient fails this test, and thus the conclusion is possibly that they are providing a suboptimal effort - this test is a surrogate measure for malingering in general ?

Is this is a reasonable conclusion to make ?

I will say that in MVA related disability cases, it is rare for the claimant funded psychologist to perform the TOMM. The insurer paid psychologist will perform this test all the time, in addition to the SIMS.

All this (including the tests sensitivity and specificity) is clearly spelled out in the test manual. However, as others have mentioned the use and sale of psychological tests is highly restricted. Mostly to psychologists.

I am not sure why you would want to repeat the admistration. Was the person concious during the test... If so, obviously, the learning has taken place (even if it was poor the first time) and thus the test is no longer valid. If I were to play lawyer here, I would probably accuse you of being a little less than impartial...and likely advocating for the patient or pushing an agenda if you readministered this test. From the sound of it, this is NOT your role in this case.

 

[PsyDr]

I am a chronic pain physician. If you had bothered to conduct a fulsome review of this thread, it would have become apparent that I am a doctor / health care professional.

You might want to think before engaging your fingers. The only conceivable way that I can foresee of ``cheating`` on a test such as this would be as whopper has stated.

BTW, the TOMM is discussed on wikipedia and can be accessed for public consumption by typing it into a little known search engine known as ``google``. I am asking questions here as I would like some clinical feedback from the experts.

This is the second annoying comment on this thread. 😡

Here is how I engaged my brain in this matter:

-SDN does not require an ounce of proof for anything. You can say you are whatever and there are no validation procedures. I could say I am a unicorn who creates cinnamon rolls. This is not proof. This is self report. Nothing you stated in this thread indicated you were a physician, other than your self reported status as "attending". In reality, you could be a disability analyst, physician, attorney, litigant, etc. There is no telling.

I am sorry if this it is an insult that I stick with the ethics and legal obligations all test purchasers engage in when using/buying these tests. I am also sorry, that it is annoying to you that i do not trust the self report of a complete stranger who has provided no proof. Since this forum is accessible by this "google" you speak of, explaining exactly how this test works would be in violation of the legal/ethical obligations people engage in when using this test.

There are very real ways to cheat on this test. It is interesting that you would first request information about this test and then tell me how it is impossible to cheat on these tests.

 

[whopper]

My fellowship PD was in certain situations where he was convinced the person being evaluated was told how to beat a specific test because the guy's lawyer likely coached him and was able to obtain the materials for the test.

Limitation of the testing material lowers the odds that people being given the test will know how to beat it but unfortunately, just as there are hired guns in psychology and psychiatry, expect one rotten apple to be in with the bunch.

I was reviewing a case on the news, and while I did not professionally evaluate the case, the psychologist offering an NGRI defense is so blatantly giving testimony that if you're in the mental health profession, you'd know they are BS. I'm sure he'd be the same type of guy that'd be willing to teach someone how to beat a psychological test.

 

[DebDynamite]

Here is how I engaged my brain in this matter:

-SDN does not require an ounce of proof for anything. You can say you are whatever and there are no validation procedures. I could say I am a unicorn who creates cinnamon rolls. This is not proof. This is self report. Nothing you stated in this thread indicated you were a physician, other than your self reported status as "attending". In reality, you could be a disability analyst, physician, attorney, litigant, etc. There is no telling.

I am sorry if this it is an insult that I stick with the ethics and legal obligations all test purchasers engage in when using/buying these tests. I am also sorry, that it is annoying to you that i do not trust the self report of a complete stranger who has provided no proof. Since this forum is accessible by this "google" you speak of, explaining exactly how this test works would be in violation of the legal/ethical obligations people engage in when using this test.

There are very real ways to cheat on this test. It is interesting that you would first request information about this test and then tell me how it is impossible to cheat on these tests.

From my search of ghost dog's posts:- ghost dog has been posting on SDN since late 2008 (at least) and consistently posts on topics related to FM and pain management. I didn't read anything in this thread at all insinuating a request to spill the beans on the TOMM. Search took about one minute. Just. Sayin'.

 

[PETRAN]

I thought that this was about Theory Of Mind (but slightly stuttering). Like some awesome new index that measures how much theory of mind you have. Disappointed

 

[ghost dog]

All this (including the tests sensitivity and specificity) is clearly spelled out in the test manual. However, as others have mentioned the use and sale of psychological tests is highly restricted. Mostly to psychologists.

I am not sure why you would want to repeat the admistration. Was the person concious during the test... If so, obviously, the learning has taken place (even if it was poor the first time) and thus the test is no longer valid. If I were to play lawyer here, I would probably accuse you of being a little less than impartial...and likely advocating for the patient or pushing an agenda if you readministered this test. From the sound of it, this is NOT your role in this case.

you appear to have a reading disability, as I have previously
indicated I do not perform these tests.