Lying in neuropsychology.

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Neurophysiologie Clinique/Clinical Neurophysiology (2014) xxx, xxx—xxx 1

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Lying in neuropsychology

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Mensonge et neuropsychologie

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X. Seron

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Université catholique de Louvain, institut de psychologie, 70, avenue du Cor-de-Chasse, 1170 Bruxelles, Belgium

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Received 17 November 2013; accepted 12 April 2014

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KEYWORDS Neuropsychology; Malingering; Lying; Somatoform disorder; Symptoms Validity Test (SVT); Consciousness

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Summary The issue of lying occurs in neuropsychology especially when examinations are conducted in a forensic context. When a subject intentionally either presents non-existent deficits or exaggerates their severity to obtain financial or material compensation, this behaviour is termed malingering. Malingering is discussed in the general framework of lying in psychology, and the different procedures used by neuropsychologists to evidence a lack of collaboration at examination are briefly presented and discussed. When a lack of collaboration is observed, specific emphasis is placed on the difficulty in unambiguously establishing that this results from the patient’s voluntary decision. © 2014 Published by Elsevier Masson SAS.

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MOTS CLÉS

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Expertise neuropsychologique ; Simulation ; Mensonge ; Biais de réponse ; Trouble somatoforme ; Trouble cogniforme ; Symptoms validity tests

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Résumé La question du mensonge se pose en neuropsychologie surtout lorsque les examens sont conduits dans un cadre médicolégal. Lorsqu’un sujet présente intentionnellement des déficits inexistants ou lorsqu’il exagère leur gravité dans le but d’obtenir une compensation financière ou matérielle, on parle de simulation (malingering). Dans cet article, la simulation est discutée dans le cadre plus général des travaux en psychologie sur le mensonge. Les différentes procédures utilisées par les neuropsychologues pour établir une absence de collaboration sont brièvement présentées et discutées. Enfin, lorsqu’un manque de collaboration est établi, une attention particulière a été apportée à la question de savoir si cela résulte d’une décision volontaire et consciente du patient. © 2014 Publi´ e par Elsevier Masson SAS.

After a traumatic accident, when a person is physically and mentally disabled, it has become customary in forensic

E-mail address: [email protected]

medicine to conduct a neuropsychological examination to determine whether the patient presents a significant decrease of his/her cognitive abilities. The results of neuropsychological examination with other medical and psychosocial information will then be used to establish the

http://dx.doi.org/10.1016/j.neucli.2014.04.002 0987-7053/© 2014 Published by Elsevier Masson SAS.

Please cite this article in press as: Seron X. Lying in neuropsychology. Neurophysiologie Clinique/Clinical Neurophysiology NEUCLI 2439 1—15 (2014), http://dx.doi.org/10.1016/j.neucli.2014.04.002

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extent of the financial, social or medical assistance to which the patient may be entitled (for example, financial reward, compensated time away from work, relief from legal consequences or obtaining medications) [98,118]. The results of neuropsychological assessment can greatly influence the size of the claim and therefore insurance companies require that this examination produce a credible appraisal of cognitive deficits and of their consequences on the patient’s quality of life (economic and health status, but also psychological and emotional well-being). In the context of forensic evaluation, neuropsychologists have not only to evaluate the patient’s deficits but must also exclude the existence of cognitive or behavioural deficits due to any preexisting conditions such as dementia, learning disabilities, previous accident or psychiatric condition, unrelated to the accident. Among the alternative causes of the exhibited deficits, neuropsychologists have to consider the existence of poor cognitive performance due to insufficient cooperation or even malingering. Later in this article, we employ the term malingering in the classic psychiatric sense, which refers to ‘‘the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives’’. We will examine malingering in the broader context of research on lying in psychology and neurosciences. We will then consider the difficult question of the relationship between lying and hysterical or somatoform reactions.

The psychology of lying There is no simple definition of lying, but in a general way to lie is to make a believed-false statement to another person with the intention that the statement be believed to be true [109]. However, in forensic psychology, lying is not restricted to the production of false statements, since it includes not only verbal statements but also any form of behaviour with the intention to make others form false beliefs regarding health and cognitive conditions. This larger definition includes lying by omission and withholding information [41,185]. A critical point is that lying implies intentionality. The intent of a liar must be to deliver information that he/she does not believe to be true, in a way that is intended to convince the receiver that it is true. Therefore, if a subject delivers false information that he believes to be true, there is no intent to deceive and thus there is no lie [47]. Although in some contexts lying is a deviant behaviour, there is wide acknowledgment that lying is a very common and socially useful behaviour. Most lies are produced for psychological motives: to protect ourselves, to obtain social support, to exchange supportive emotion. For instance, in an extensive study, De Paulo and her collaborators asked college students and unselected subjects of the community to keep daily records for a week of the lies they told in social interactions [31]. Based on the strict definition of a lie as ‘‘intentionally trying to mislead someone’’ they observed that lying was an everyday behaviour. Participants in the community study, on average, told one lie every day; while participants in the college student study told two. One out of every five times that the community members interacted

with someone, they told a lie; for the college students, it was one out of every three times. Interestingly, there was no effect involving either the sex of the liars or that of their victims. Although the diary method used by the authors was carefully controlled, it is highly probable that more lies were produced, since participants must have forgotten to report some lies, may have decided not to reveal some of them or even may have not realized that they were lying. People lie most frequently about their feelings, their preferences, and their attitudes and opinions. Less often, they lie about their actions, plans, and whereabouts. Lies about achievements and failures are also commonplace [30]. Lie-telling behaviour appears early in development since it emerges in the pre-school and early primary school years (3—8 years) [170]. Lying in children is associated with the development of their conceptual moral understanding of lies, with executive functioning, and theory-of-mind understanding. Lying is thus a frequent and normal behaviour acquired soon in life, socially and functionally useful in several situations [169]. At a behavioural level, lying can be examined in two directions: the production of lies and the detection of lies, and an important difference has indeed been observed between the human ability to produce versus to detect lies.

Lie production On the production side, people differ greatly in their ability to lie convincingly. Although little empirical research has examined the influence of personality factors on the ability to lie, it has been shown that fantasy-prone people are better able to fabricate stories that are judged more emotional, more plausible and richer by independent judges using standardized credibility criteria [116]. It has also been observed that individuals with high emotional intelligence (EI) defined as the ability to perceive, process, manage, and regulate emotion [146] are more efficient in adopting deceptive facial expressions (i.e., simulated more convincing deceptive emotions and maintained these displays for longer durations), relative to low EI participants [134]. Further, Grieve [68] found that varying levels of personality traits (i.e., high self-monitoring, low sincerity) contributed to efficient emotional manipulation. Previous studies have also shown that psychopathic traits — specifically, high level of interpersonal manipulation — are related to shorter duration of unintended emotional ‘‘leakage’’ during deceptive facial expressions. In summary, psychopathic individuals are good liars because they don’t feel guilty or uncomfortable when lying; whereas subjects with high EI are potentially good liars because of their ability to control their emotion and a heightened ability to simulate emotional expressions [62,87,133]. However, the relationship between psychopathic individuals and lying efficacy is not always observed and in a recent study on a sample of prisoners, no relationship between higher level of psychopathic traits and feigned symptoms of major mental illness was observed [135]. Although it has been postulated that good liars will also be good at detecting liars, on the contrary, several older studies have shown that the ability to lie effectively is unrelated to the ability to detect the lies of others [28,192]. However, more recent studies indirectly raise some doubts about the absence of such link between lie production and


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detection. In a recent meta-analysis [42], Elfenbein and Eisenkraft indeed observed a positive but small correlation (of r = 0.19 on average) between posed emotional expression and emotion interpretation. Such a correlation is however rather low, and not present if one considers natural emotional expression. Furthermore, in a recent experimental study asking subjects to produce and to recognize facial emotions, these authors confirmed the presence of such a link since they found a medium-to-large positive correlation between emotion recognition accuracy and the accuracy of deliberately posing emotional expressions [43]. Although these researches do not directly concern deception, they suggest that good liars who are skilful in adopting false emotions could also be a little better in interpreting the emotions of others. Finally, some recent experimental studies also suggest that the ability to lie may be influenced by the by the frequency with which that person tells lies [177] and even that systematic practice may improve the liars’ ability [173].

Lie detection Although there are large variations in people’s ability to tell convincing lies, there is much less variability between individuals in their capacity for lie detection. In a seminal study, Ekman and O’Sullivan [39] compared the efficiency of subjects issued from a range of professions typically associated with lie detection (secret service agents, psychiatrists, judges, police officers and polygraph examiners) along with a cohort of college students at a lie detection task. Subjects were asked to decide if a woman on videotape was truthfully describing her emotion. They found that only secret service agents were significantly better than chance at accurately detecting liars. The judges, the polygraph examiners, and the psychiatrist were not very good and not different from the college students. This observation was recently confirmed in a large meta-analysis by Bond and DePaulo [8], looking at people’s ability to detect truth and lies, covering 206 research studies and 24,483 observers. In relevant studies, when subjects have to discriminate lies from truths, in real time and with no special aids or training, they obtain an average of 54% correct lie-truth judgments with a bias towards classifying individuals as truthful. Although people regularly imagine themselves better lie detectors than they are, their performance is only slightly better than chance [112,183]. Interestingly, the rates of lie detection vary little from study to study. While most studies suggest that lay people and professionals are equally poor at detecting deception, some researchers have proposed the existence of deception detection experts who can consistently and accurately detect deception [126]. This claim was however challenged and it has been argued that studies identifying human experts (‘wizards’) have significant methodological and statistical issues [9]. Furthermore, in a psychometric analysis of 247 samples, Bond and DePaulo [10] found that individual differences in detection were very small with a standard deviation (SD) in judgment ability of less than 1%. It has also been suggested that people with high emotional intelligence (EI) given their superior emotional skills and emotional knowledge should be better at detecting emotional lies [45,128]. This suggestion remains

3 however unverified and, in a recent study, it has instead been shown that a high EI is associated with impairment in evaluating sincerity. In fact, it seems that subjects with high EI are sensitive to all the emotional facial expressions and to their frequency and given that deceptive pleaders showed a somewhat greater range of emotional expressions than truth-tellers, they generated more sympathy from high EI individuals [2]. This poor detection capability is partially due to the fact that the cues used to detect lying are either not the right ones or are simply not predictive [30]; in fact, our stereotypes about the cues revealing a liar are often false. For example, observers think that liars are nervous and thus hesitating in their speech output, present an increasing speech rate, averted gaze and produce more body movements than truth tellers [183]. In fact, some studies showed that there was actually a decrease in these activities during lying. On the contrary, some cues are erroneously considered as not related to lying; for example, observers tend to consider that response length and self-referential speech are irrelevant, while some studies showed that liars take less time to respond to questions and tend to speak about themselves much less than when telling the truth [185]. Thus although there exists a large diversity in the human ability to lie, on the detection side differences are clearly less dispersed. Given the poor level of our ability to detect liars, psychologists developed two main directions of research: a classical approach considered that some emotional factors are associated with lying, whereas a more recent approach suggested that lying requires the intervention of additional executive processes.

Lying and emotion The potential role of emotional cues in lying detection was firstly suggested by Ekman [41], who proposed that lying is accompanied by specific emotional states: fear of being discovered, guilt at not being honest but a feeling of ‘‘duping delight’’ when successfully lying. As a consequence, it has been suggested that a useful strategy to discriminate liars from truth tellers may consist of identifying the emotional cues associated with the emotion that liars are experiencing. However, such a detection strategy is not so easy because liars develop emotional control strategies with the objective of either masking their actual emotion, presenting a neutral face or adopting a falsified expression corresponding to a different emotion. The interesting point is that the liar’s protective camouflage is considered not to be perfect because emotional expressions such as facial expressions, speech and other non-verbal behaviours are not completely under voluntary control. Liars are thus confronted with a conflict between the true emotion they are experiencing (but have to inhibit) and the faked emotion they are not experiencing (but have to illustrate in a convincing way). Given such a conflict, it was hypothesized a long time ago by Darwin (in 1872) [23] that when a subject tries to simulate a non-experienced emotion, first the configured pattern of the simulated emotion is far from perfect (it is suggested that some facial muscle actions related to the simulated emotion cannot be correctly realized) and second that extremely brief ‘‘flashes’’ of the true emotion appear


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on the face uncontrollably as ‘‘micro-expressions’’ (i.e. a full-face expression lasting 1/25th—1/5th of a second called ‘‘emotional leakage’’). Such facial expression inconsistencies and other non-verbal cues are indeed difficult to control and are scrutinized by experts and novices when judging a person’s veracity [40,183]. Although a priori promising this direction of research is faced with many difficulties. Several studies have indicated firstly that emotional cues are not so salient and secondly that naïve subjects, as well as experts, regularly attend to the wrong cues and, as a result, their judgments are surprisingly poor [131,132,184] despite high self-reported confidence in their assessments [29,88,179]. Given these limitations, some authors consider that this direction of research is not fruitful, but others continue to believe that the relationships between emotional cue and lies remain a pertinent domain of research. It has been suggested that the present poor success of emotional cues in lie detection is due to the fact that many experiments have concerned lies produced in low-stakes context (classical experimental studies with psychology students) whereas the control and simulation of emotion will be particularly difficult in high-stakes or high emotional contexts [127]. It has indeed been demonstrated in experiments manipulating the level of emotional intensity that more emotional leakage is observed in high intensity emotional contexts [134]. In this line of research in a recent and interesting study, Ten Brinke et al. [171] analysed videotaped facial actions of 52 individual emotionally pleading to the public for the return of a missing relative. Half of the subjects, however, were found to have murdered that person. The facial analysis focalized on muscle activations associated with the more emotionally loaded portion of the video during which the individual appealed to the (supposed) perpetrator to release the missing person, asked the missing person to make contact or asked the public to provide information. The authors postulated that genuinely distressed pleaders would be more likely to engage those muscles associated with true sadness relative to deceptive individuals and that deceptive individuals were less able to represent all the aspects of the sadness expression. Experienced judges blinded to veracity coded different facial action units. The result indicates that effectively, some of the targeted facial expressions under limited voluntary control are less well correctly activated in deceptive individuals. This research seems encouraging but one has to underline that the discrimination power of these analyses remains modest: the global correct classification score varied according to face action unit between 67.3% and 69.2%, and the identification of the deceivers between 50% and 57%. However, the presence of innate facial actions related to sadness was a reliable indicator of genuine feelings of distress and sincerity in this particular context. However, aside from research conducted in emotionally loaded situations, the difficulties with the emotional cues approach remains manifold because: • it has been observed that some liars have an excellent control of their emotion; • that the majority of lies produced in daily life are not associated with emotional feelings and; • that when the stakes are high, truth tellers can feel the same emotion as liars.

Honest people may indeed present signs of anxiety during interview when they are afraid of not being believed or may feel nervous because they are scrutinized by others. The fear of being falsely accused of simulating an illness or from having committed a crime may generate distress, anxiety or anger.

Lying and executive processes Given the relatively poor prediction that can be derived from emotional cues, another research approach considers that lying is a more complex activity than truth telling and thus requires the activation of some additional cognitive processes [182,192]. The importance of executive processes in lying is evident: all deceptions require the execution of a response that is incompatible with the truth. Executive processes are required for different purposes: to make the decision to deceive, to suppress the truth and to activate a lie. According to the context and the audience, this activity is quite complex and requires on line coordination of different mental processes in order to infer what others already know, to keep the false story straight, to monitor the reactions of the listener, and if necessary to adjust the lie to make it more believable [14,149]. These different activities require the intervention of working memory to construct the lie in association with some truth elements, response inhibition to prevent the intrusion of the truth response, and mental flexibility to switch between being honest and being deceptive [85,178]. The cognitive view of lie production is supported by a number of studies. Firstly, it has been observed that lying is accompanied with specific behaviours that are also observed when people are involved in complex and resource-demanding tasks [40,103], such as less hand and arm movements, reduced eye blinking and more pauses when speaking [30,102,162,176]. Secondly, in concealed information reaction time tasks, lying is associated with more errors and increased response latencies compared to truth telling, which suggests that it takes longer to formulate a deliberate false response than a truthful one [151,152]. Thirdly, in deception studies participants reported that lying is associated with a more important mental effort than truth telling [148]. In addition, brain activations associated with lying activate a large cerebral network also activated by executive tasks [18]. However, given that telling the truth may also require some complex cognitive processes (to retrieve relevant information from memory, to order the events, to produce a story) truth telling is also resource-demanding even if it constitute a less complex activity than lie telling. Furthermore, the view that lying is always more cognitively complex has been questioned by studies suggesting that in certain contexts lying might be not so cognitively demanding, especially when it emerges from extensive practice.[59,173]. To enhance the difference between truth telling and lying, some researchers have adopted a new general strategy that consists of using cognitive load-inducing techniques designed to elicit greater mental effort in liars than in truth tellers [180,188]. The central idea is that, given the difference of complexity between the two tasks, an increase in cognitive load will have a more devastating effect when subjects are lying than when they


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are telling the truth. The rationale underlying these studies is analogous to the one used in cognitive attention literature suggesting that information processing in the primary task is more difficult in dual task conditions than in single task conditions [183]. This approach was developed in mental chronometric studies as well as in interview studies. For example in a reaction time task when participants have to give a truth or a false response, Debey et al. [24] have shown that by modifying the rate of presentation of the stimuli, they modify the amount of resources required for goal maintenance which is more disturbing for lies than for truthful response production. In interview situations, different manipulations increasing the cognitive load appeared to be more disturbing for liars than for truth tellers. This has been observed in situations where the subjects were asked to tell the story events in reversed order, to respond quickly to unanticipated questions [180,189], to maintain eye contact with the examiner [181] or even, but with less success, to perform a concurrent task during the interview [130]. All these techniques seem promising and innovative but it is still too early to confirm their validity and to be sure that they are resistant to the countermeasures developed by clever liars [188].

Lying in neuropsychology Regarding lying in neuropsychological evaluation in the forensic context, the situation is quite different since lying does not only refer to the telling of a false story, although this could occur during the history taking. More frequently, lying refers to the creation of non-existent cognitive deficits or to the exaggeration of mild deficits usually in order to obtain a financial or material compensation. The issue of lying is more critical when the traumatic event does not result in visible brain lesions. Indeed, when there is no identified brain lesion such as in many case of mild head injury or whiplash, the unique source of information for the physician relies on the patient’s subjective experiences and reports and on his/her results at psychological tests. All of these elements are under the patient’s control and cannot be confirmed by brain imagery or neurophysiological data. Given the absence of biological indicators attesting to the existence of an actual brain damage or dysfunction due to the accident, the veracity of the patient’s complaints is regularly brought into question. This suspicious attitude was illustrated in French-speaking regions by the use of the label ‘‘le syndrome subjectif des traumatisés crâniens’’ (traumatic brain injury (TBI) subjective syndrome) to characterize post-concussion syndromes and that hopefully has been progressively abandoned thanks to progress in neuropsychology and brain imagery. However, even when the brain damage is severe and cognitive disorders are clearly present, the question of the patient’s collaboration is raised since in that case the possibility of lying concerns not the invention of deficits but an exaggeration of their severity. Given the current economic climate in the United States and European countries, the existence of excessive symptomatology involving cognitive complaints, such as memory, concentration, and other mental problems, has been the focus of considerable research and debates. In the past 10 years, more than 500 studies have been published

5 in peer-reviewed neuropsychological reviews that address this problem (see [78,79,98,168]). The strategies developed by neuropsychologists to identify excessive symptoms are many: in a major direction following the approach initially developed in Switzerland by André Rey, neuropsychologists have developed new instruments specifically designed to assess the validity of cognitive disorders [138]; the socalled Symptoms Validity Tests (SVT) [7,11,50,64,77,172]. Presently, SVT fall into three main categories: firstly, tasks seeming sufficiently complex to measure a cognitive ability (more often memory functioning) but that are in fact so simple that even patients with severe neuropsychological deficits perform the task at a quasi perfect level; secondly, tests that follow a forced-choice paradigm, which can be evaluated for worse than chance level performance based on the normal approximation to the binomial distribution; and thirdly, self-reporting instruments that measure overendorsement of symptoms.

The self-reporting instruments The use of questionnaires containing items referring to atypical and bizarre symptoms have mainly been used in clinical psychology and psychiatry to identify subjects suspected to complaint exaggeration. Some classical test such as the Minnesota Multiphasic Personality Inventory (MMPI; [74]) and its successor (the MMPI-2: [36]; the MMPI 2RF; [5]) were constructed by integrating validity scales to identify potential misrepresentation of symptoms (both psychiatric and somatic) (i.e., [51]). The recent MMPI-2-RF contains different validity scales: the symptom validity scale (FBS-r) designed to assess non-credible somatic and neurocognitive complaints; the infrequent somatic responses scale (Fs), which contains complaints that were infrequently endorsed; and the response bias scale (RBS; [56]) measuring symptom exaggeration associated with poor performance on cognitive symptom validity tests (SVTs). The different MMPI validity scales have provided some interesting results in the detection of non-credible somatic or psychiatric symptoms in medico-legal settings (for a review, see [150]). However, in the two studies published to date, the validity scales of the MMPI were not able to effectively differentiate somatic malingers from somatoform disordered patients [150,165]. Aside from these classical instruments, some questionnaires have also been specifically constructed to detect malingering. The Structured Inventory of Malingered Symptomatology (SIMS) [156] is one of the best known (but see also the SIRS, [142]). The SIMS is composed of 75 questions covering a wide range of disorders usually invented by malingers, but rarely found in true pathological conditions. It is composed of different sub-scales designed to detect malingering for five different conditions: low intelligence, affective disorders, neurologic impairment, psychosis, and amnestic disorders. The rationale underlying its construction is that feigners will endorse substantially more often than genuine patients the atypical and bizarre items. The SIMS has proved to be able to accurately discriminate between control subjects simulating different pathological conditions [37,124]. It is also relatively resistant to symptom and test coaching of subjects asked to feign a traumatic brain accident [81,82,84] and heterogeneous


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psychiatric conditions [115]. However, one study has reported low sensitivity [141] and there exists some overlap between SIMS and self-reported psychopathology such as depression [115]. Finally, SIMS has been successful for the detection of a feigned symptomatology in a single-case study of a patient presenting a Ganser-like syndrome [114] but was less effective in distinguishing factitious and hysterical pathology from malingered conditions [140]. Another important tool also frequently used is the SIRS (structured interview of reported symptoms). The SIRS is time consuming but is well-validated in the forensic literature for discriminating psychiatric patients from normal controls; however, it might not distinguish psychiatric patients from malingers [38]. To date, use of such questionnaires alone presents some limitations in terms of the data obtained; they have so far been infrequently used with patients presenting somatoform or dissociative disorders; and in rare cases when they have been used, have not been very successful. The main difficulty results from the fact that somatoform disorders and malingering are not dissociable on the basis of the reported symptoms but only through the presumed underlying motivation.

Underperformance at tests Given the limitations of the self-report approaches, neuropsychologists generally consider that the best evidence for malingering results either from a very low performance at an easy test or from a pattern of false responses below chance at a Forced Choice Test. The observation of a ‘negative response bias’ is indeed considered by many experts to be ‘‘closest to an evidentiary ‘gold standard’ for malingering’’ [155]. Over the last thirty years, several SVTs mostly utilizing the forced-choice procedure have been published [12,98]. It is beyond the scope of the present article to present these tests and discuss their respective limits and virtues. The best known and most frequently used in English-speaking countries are: the TOMM (Test of Malingered Memory) [58,67,172]; the Rey 15-item test [139]; the WMT [68]; the Victoria Symptom Validity Test [154] and in Dutch- and German-speaking countries the ASTM (Amsterdam short-term memory test) [148].1 Broad agreement among neuropsychologists also exists that the evidence for lack of effort is stronger when examiner have used more than one SVT, and that a single indication of insufficient effort within a large battery of tests cannot be considered as an evidence of wrong collaboration since it could simply indicate a transient attentional or motivational problem that might not lead to the general conclusion that all the testing is invalid. Moreover, a set of criteria must be met in the selection, use and interpretation of SVT; these criteria include: • sensitivity and selectivity; • face validity; • measurement of relevant dimensions in relation to the complaint;

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Some of these tests have been standardized for French-speaking countries; this is the case for the TOMM and the ASTM for example).

• existence of sufficient normative data among subject controls and in real simulators; • resistance to faking or coaching; • ease of use and of interpretation [72]. Besides SVT, some patterns of performance have also been considered as cues for insufficient effort such as atypical performances on standard ability tests [26,80,99,120,121] or observation of test—retest profile inconsistencies [78,79]. In addition to the analysis of the patient’s performance on testing, an ensemble of guidelines and criteria were developed for diagnosing suboptimal effort and malingering on neuropsychological testing. These include inconsistencies between: self-reported history with medical documented history; self-reported symptoms and behavioural information or known patterns of brain functions; neuropsychological test scores and medically documented severity of the injury; or neuropsychological test scores and behavioural presentation [15,66,155]. Moreover, it is important to note that the use of effort tests should be part of any neuropsychological assessment whatever the objective of the evaluation. A consensus indeed exists to consider that effort is a superordinate factor in cognitive or neuropsychological testing. As rightly pointed out by Kemp et al. [89]: ‘‘Scores on all standard cognitive tests will underestimate a subject’s true ability if the test effort is insufficient’’. A valid evaluation of the cognitive ability of a subject is indeed necessary to understand brain-behaviour relationship, to support a diagnosis or to plan a revalidation. Using these methods and guidelines, neuropsychologists still do not agree about the frequency of individuals exhibiting excessive or exaggerated cognitive symptoms in medico-legal evaluations. Some suggest that few patients are malingering while others find it clearly very frequent and the mean frequency of occurrence oscillates according to the studies between 20% and 40% [15,49,65,66,99,119,122,141,143]. Whatever the actual distribution of malingering in the patient population, it is now generally accepted that cognitive validity testing is an important part of the neuropsychological assessment process, and for a clinician to decide not to use effort tests and embedded validity indicators requires a solid justification, especially within a forensic context [15]. However, the use of SVT is not a panacea and some important questions remain unsolved. Firstly, although Symptom Validity Testing procedures were originally developed to detect malingering of sensory deficits [129] and short-term memory disorders [6] most of the existing SVT concern episodic memory function, whereas patients with moderate or severe traumatic injury frequently complain of difficulties in several other cognitive domains such as attention, perception, motor function and problem solving. Therefore, a need exists for measures of malingering regarding perception, motor dysfunction, problem solving and also chronic pain, chronic fatigue and even post-traumatic stress disorder (PTSD) [98]. Secondly, some authors take a more nuanced look at lower random scores [12]. One of the difficulties with cutoff scores based on chance is their lack of sensitivity. Subtle simulators quickly understand that a plausible performance must be above the level of chance. This is the well-known problem of the too ‘‘transparent’’ nature of the majority of


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SVTs. A major flaw in several SVTs is indeed their simplicity, and it is likely that only naive subjects would be misled by the falsely difficult nature of this type of test. In most cases, even if deliberately trying to boost difficulty level, patient performance will not be so low that it drops below chance [44]. It is this type of observation that led Dodrill [34] to remark that if, occasionally, we can establish that a lack of effort took place, it is virtually impossible to establish that it did not happen. However, this pessimistic evaluation was not entirely confirmed in two subsequent studies by Merckelbach et al. who showed that respectively 40% [113] and 59% of the participants (psychology students) [83] scored below chance level at an SVT procedure when asked to simulate a feigned amnesia. Thirdly, the appropriate use of SVT does not depend only on their specificity and selectivity levels, but also on the actual base rate of simulators in the population of patients consulting at a given location [61,144]. If the rate of malingers is low, the use of some SVT can lead to more errors than their non-diagnostic use. This variable is more troublesome as the rate of malingers is a priori unknown and varies according to context. Fourthly, and more importantly the presence of evident biases of responses at one or several SVT does not clarify the underlying causes for these biases; more specifically it does not permit to conclude as to the existence of ‘‘malingering’’. Neuropsychologists have to examine whether this lack of effort or any other inconsistencies in the patient’s performance cannot be accounted for by psychiatric, neurological, or developmental factors. The question is not simple because no clear clinical categories exist to include patients that present unexplained cognitive symptoms, in the sense of symptoms that cannot be derived from an organic lesion. However, the DSM IV includes two categories for symptoms that cannot be related to an identified organic basis: somatoform disorders and dissociative disorders, but none of these categories correspond to what is frequently observed in neuropsychology. The somatoform and the dissociative disorders relate to internal sensorimotor or organic disorders or target highly specific and relatively rare forms of cognitive problems (such as dissociative amnesia or psychogenic non-epileptic seizures [PNES]). These diagnostic categories also fail to include the classical and frequent exaggeration of symptoms encountered in conventional neuropsychological testing. For instance, the memory impairments met in neuropsychology rarely take the form of a true dissociative amnesia, in which it is autobiographical memory that is severely impaired. In neuropsychology, memory disorders are more diverse and more often concern anterograde memory functioning.

Awareness of the disorders The absence of any ‘‘ready-made’’ psychopathological category paves the way for an unambiguous interpretation: ‘‘failure at one or several SVT is evidence of malingering’’. We believe that even if this statement is based on strong arguments, it is important to remain critical and to adopt a position that allows this notion to be questioned. The concept of malingering in forensic psychology is in fact grounded on the implicit idea that subjects oscillate

7 between two distinct and opposite roles: ‘‘the honest man’’ who ‘‘tells the truth’’ and ‘‘the cheater’’ who ‘‘lies’’. Such a dichotomous approach is however too simplistic. As Drob et al. rightly pointed out, the notion of malingering relies in part on the assumption of a rational willing subject [36]. It postulates a subject perfectly aware of his disorder, who voluntarily decides either to present his functioning in the most objective way or to simulate a non-existent disorder, and who is able to mobilize his cognitive resources in perfect accordance with his decision. However, these three dimensions: • awareness of the disorder; • choice between truth versus lies and; • production of the corresponding behaviour are complex and not so easy to identify and to categorize. Regarding self-awareness, an extensive literature in neuropsychology suggests that patients can be unaware of their disorders and in some case may even develop an active denial. Anosognosia for one’s own disease or deficit is observed in relation to many different kinds of pathological conditions, ranging from denial of mental disease, such as dementia, to unawareness of neurological and cognitive deficits following focal brain damage. In these latter cases, patients may be unaware of their language, attention, executive or memory disorders [136]. Besides anosognosia, there are also instances in which subjects intentionally minimize or deny their symptoms. Some patients may wish to negate the presence of some deficits when they are afraid about a decision that could have direct implications for their autonomy (i.e., capacity to drive or to use money). Denial is also a form of symptom invalidity but actually there is no instrument in neuropsychology for the detection of denial or minimization of signs or symptoms (on the other hand, for psychiatric patients, see the self-report scale of Cima et al. [19]). At the opposite end of the self-awareness continuum, especially anxious patients or those with hypochondriac personality may on the contrary present a hyper-arousal and an amplification of their disorders without any explicit intention to deceive. Poor effort at neuropsychological tests was indeed more frequently observed in patients with a history of psychiatric problems [123] and a relation between poor effort and type-D personality tendencies has recently been observed [166]. Emotional variables like anxiety, fatigue or depression can affect the patient’s performance at SVT. These emotional disorders that are common in cases of mild traumatic brain injury may provoke decreased effort level [55,137,166], and their influence has been observed even with patients not involved in litigation. Furthermore, one has to also consider that patients with damage to their limbic system or prefrontal area may be diminished in their motivational capacity [22,167] and present a more or less pervasive apathy that may result in a performance below their residual competence.

Role of metacognition Apart from these emotional and personality variables, metacognition constitutes another factor that may


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intervene in patient performance. Metacognition refers to the knowledge that subjects have regarding their own cognition and that of others as cognitive beings. It comprises implicit and explicit knowledge about the person him/herself and their relations with various cognitive tasks and strategies [46]. Meta-knowledge can be segregated into different domains according to cognitive functions such as memory or thinking, resulting in ‘‘meta-memory’’, ‘‘meta-attention’’ knowledge and so on [124]. Metacognition presents not only a cognitive dimension, but also an emotional aspect related to the perception that subjects have of their capabilities, given the complexity of the task and their past experience in dealing with similar tasks. Patients may have poor performance and may apply little effort to the test because they are a priori convinced they will fail. These false representations may furthermore be activated by a variety of events, including reading about general effects of brain lesions, hearing about the case of an acquaintance, illness-related media reports, as well as contradictory and dispersed information on the Internet. Such beliefs may have an impact on symptom self-perception and as a result the person may become increasingly anxious and hypervigilant for any sensations or signs that could be indicative of the disorder [121]. Bodily sensations and small cognitive failures or slips are then filtered through a confirmatory bias that exaggerates any evidence of illness. Actually, the rare studies examining the role of cognitive self-assessment in mild traumatic injury have regularly found a correlation between poor self-assessment and some psychiatric dimensions such as depression, PTSD and anxiety but a poor correlation with cognitive performance at neuropsychological evaluation [160]. However, at present too little is known about how much these factors, that have little to do with intention to deceive, contribute to the effort level during neuropsychological performance of brain damaged patients.

Testing in context Another important point is that a cognitive evaluation is carried out in a specific social context that may exert an influence on the patient’s performance and attitude. It has for example been observed in elderly people without dementia, that when aged subjects are categorized as ‘‘young subjects’’ before performing a neuropsychological test they perform better than when they are categorized as ‘‘old subjects’’. Thus, a simple categorization based on age induced by the examiner and emphasizing the role of age in cognitive performance had a direct impact on cognitive performance [73]. To our knowledge, no studies exist that consider the effect on the patient’s performance of the examiner’s expectations regarding the percentage of patients likely to be liars. It has however been observed, in other clinical contexts, that psychologists are not immune to erroneous attribution of causality and are influenced by the classic attitude trying to confirm their hypothesis rather than trying to refute it. It is thus not absurd to suggest that examiners definitively convinced that patients presenting long lasting disorders after a mild traumatic injury or a whiplash are in fact malingering, might examine their patients with a suspicious attitude. Experimental research has shown that examiners may influence participants via

non-verbal behaviour [145]. Even if these potential biases can be diminished via standardization of testing instructions and procedures [147], the occurrence of discrete gestures, differences in facial expression, or variations in intonation cannot be ruled out. For example, gender differences have been found in smiling [94] and non-verbal communication styles [70,164]. Expressive, supporting non-verbal behaviour could motivate the patient striving for best performance. Conversely, it seems possible that non-verbal communication can be distracting and irritate the test taker. Thus, even, if examiners try to be neutral, part of their preconceptions may unconsciously influence some aspects of their behaviour. If they feel this suspicion, patients may become anxious or angry not being believed and may increase the salience of their symptoms to make them more credible. Thus, even if most neuropsychologists do their job with a neutral and fair attitude according to the ethical recommendations of the American Psychiatric Association (APA) it is at least plausible that some aspects of their private conviction may have an effect on the patient’s performance. It is astonishing that the very great majority of researches in forensic neuropsychology are devoted to the patient’s behaviour as if the examiner’s behaviour (verbal and non-verbal) has no influence on the evaluation process. It must be emphasized that the neuropsychological examination is a social interaction whose results cannot be summarized and interpreted only through the patient’s performance at the tests.

From the patient’s side Considered from the patient’s perspective, the situation of expertise is somewhat paradoxical since to behave perfectly at tests is at the risk of being self-punitive. In the context of litigation, a neuropsychological evaluation requires the patient to perform at the evaluation with the maximum effort in order to produce the best performance! However the better patient’s performance, the lower the possible compensation! As a result, even if such patients do not consciously make a decision to deceive, they also have no imperative reason to do their best. On the contrary, if their self-appraisal of the difficulties they encountered in daily life situations conduct them to think that actually they have some cognitive deficits they will be oriented towards protecting their interests. So, even if a patient does not intend to deceive, he also has no interest to do his best. More precisely, when patients have the feeling that the brain accident has actually reduced their cognitive efficiency and when they have the complementary feeling that insurance companies are trying to avoid or to diminish any compensation, they may develop a conscious or unconscious protection strategy that may conduct them to exaggerate their deficits. In summary, in the context of litigation, a lot of reasons can be evoked to explain an unexpectedly poor performance at a neuropsychological evaluation that cannot simply be explained by ‘‘malingering’’.

Lying and intentionality The last and most important difficulty with malingering lies in its definition, which implies an intentional decision to


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deceive and it is for this reason that we have associated malingering with lying. Intentionality alone however does not suffice to define malingering unambiguously, since factitious disorders (FD) also imply the voluntary production of symptoms. Typically, the difference between malingering and factitious disorder is the patient’s supposed goal: in malingering the expected benefit is to obtain a material or a financial compensation, while in factitious disorders the objective is some type of internal reward associated with playing out the sick role. Factitious disorder is however not a very clear diagnostic entity. There exist some case reports of patients presenting chronic and persistent abnormal illness behaviour, who perform dangerous manipulations of their own physical condition to simulate or create disease or injury, and whose medical deceptions are often accompanied by a form of mythomania. However, this latter group who receive the label of ‘‘Munchausen syndrome’’ represent only a very small minority of FD patients. The majority of patients with a FD diagnosis are often indistinguishable from persons with somatization disorder, conversion disorder, pain disorder and other somatoform disorders [71]. Furthermore, there is no reason that a patient cannot pursue both goals at once: to occupy a patient’s role and to obtain some material benefits. Malingering has also to be distinguished from somatoform disorder and the criterion proposed here is intentionality; it is indeed proposed that malingering subjects intentionally deceive the examiner while the somatoform patient presents an abnormal behaviour created unconsciously. The critical dimension is here the ‘‘intention’’. The challenge is thus: are we presently capable of distinguishing with perfect scientific rigour between voluntarily and involuntarily produced excessive symptoms? Some authors such as Delis and Wetter [27] consider that no scientific procedure exists that is able to establish the existence of intentionality except the rare cases where the patient made a confession or where a reliable third party may provide some evidence for deception. However despite this limitation, they admit that a negative response bias in a forced-choice SVT constitutes evidence in favour of malingering. The rationale is the following: a below chance performance (i.e., the incorrect answer is significantly more often selected than the correct one) indicates strategic avoidance of correct answers and, therefore, intact memory of the pertinent event. They are joined in this position by the majority of experts in forensic neuropsychology [48,100,117] and by the American Academy of Clinical Neuropsychology (see the Consensus Conference Statement on the Neuropsychological Assessment of Effort, Response Bias, and Malingering, [75]). Thus, although these authors consider that several psychological conditions may influence patient performance, they also consider that there is no empirical evidence that psychological problems may foster SVT failure. In a recent and very well-documented article, Merten and Merckelbach [117] suggested that using these ill-defined psychological conditions as contributing factors led in fact to a circular position: ‘‘to clarify the nature of the atypical symptoms, SVT are administered and a ‘negative response’ bias is found which is explained away by the atypical symptoms’’ (pp. 132). While I can agree with this theoretical remark, these authors in turn also use a self-fulfilling prophecy that can be summarized as follows: if in a clinical or a

9 control population a subject demonstrates a ‘negative response bias’ on SVT, then there is malingering. Given that negative response biases have been observed in fibromyalgia and whiplash [13,122], in patients with PNES [21,35,76,156] and also in patients with neurologically unexplained symptoms [57,60,89], the hypothetical conclusion will be that these poorly defined syndromes contain in fact a lot of malingering subjects. Such a point of view seems reinforced by some cases published in the literature in which patients have been initially considered as presenting somatoform disorders but who have later admitted to lying or have been discovered to be lying. For instance, in 3 cases of psychogenic amnesia reported by Markowitsch, signs of malingering were observed in one case of psychogenic retrograde amnesia [89]. Some other cases of functional amnesia later admitted faking their deficit [4,86,191]. One cannot however generalize on the basis of such rare cases and it must be remembered that malingering involves the intentional production of invalid answers in order to obtain economic or financial compensation. There are however regular observations of insufficient effort on SVT with subjects not examined in a medico-legal context. This is especially the case with patients presenting PNES, who are not in a litigation context. One has thus to consider that invalid responding at effort tests may be in some cases part of somatoform disorder, since failure in those tests is frequently observed in these populations. It remains however important to examine why some patients perform normally on SVT while others do not [35]. This requires consideration, besides the the role of volition, the possible influence of factors such as fatigue, pain, stressors, low intellectual level or side effects of medication. Another strong argument advanced by Merten and Merchelbach against the idea that a response bias can be obtained involuntarily on SVT by some psychiatric patients, is that the tentative ‘‘psychological explanation’’ used to account for the negative response bias was not theoretically motivated and thus had never been translated into a empirically testable functional model. However, the fact that there is currently no convincing evidence that some psychological conditions may be responsible for a negative response bias, does not indicate that such a possibility has to be discarded. The simplicity argument used by Merten and Merckelbach is not the most convincing when they suggest: ‘‘Given the current knowledge base, SVT failure should be interpreted as uncooperativeness. Such an interpretation is dictated by lex parsimoniae or Occam’s razor: among competing scientific explanations, the one should be preferred that makes the fewest assumptions. The assumption that unconscious psychopathology causes failure in cognitive SVTs is not only more complex than that of uncooperativeness, but it resorts to additional and, more importantly, untestable conjectures (i.e., the idea that there is a causal link between genuine psychopathology and negative response bias)’’ (pp. 132) [117]. However, in cognitive neurosciences, there is no guarantee that the simplest explanation or model would be the best one and it is not because the many alternative interpretations have at present the status of untestable conjectures that they are false! There is a risk that the exigency of simplicity was not only motivated by scientific criteria, but also by obedience to pragmatic requirements with the desire to show that psychologists are capable with their instruments


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to establish unequivocally the validity of the patients’ performance.

The negative response bias: a definitive argument? In fine, the critical question remains open: is it possible to produce a response bias unintentionally at a multiple-choice test? At first sight, this seems unlikely and intuition suggests that systematic selection of negative items requires some conscious processing of information. This position is consistent with the classic view considering that unconscious processes are limited to very simple, reflexive behaviour [101]. However, this view has been challenged; indeed the distinction between conscious versus unconscious control is a current matter of debate and an overwhelming amount of research has shown that many cognitive processes can in fact occur without consciousness. It has been shown that unconscious primes can reach a high semantic processing level [174] and may be influenced by several top-down modulations [32]. Regarding the SVT procedure, the critical point is however to scan the upper border of unconscious processes to examine if they can modulate some strategic behaviour (to plan, to initiate, to adapt to conflict). This question is at the centre of several recent studies suggesting that some executive processes can indeed involve or be triggered by unconscious processing, with consequent effects upon on-going behaviours. For instance, Capa et al. have demonstrated that updating, which is considered as an important function of executive control, can also be driven by unconscious reward cues [17]. It has also been observed that conflict detection [3] and even conflict adaptation [33] may occur without awareness, and that some top-down processes can be strategically tuned by unconscious stimuli [175]. However, we must be cautious that research on awareness faces many methodological problems and in the majority of the experiments one cannot completely pretend that other ‘‘indirect’’ consciousness-mediated explanations cannot be offered in place of unconscious control effects [93]. This area of research, still in its early stages, surely requires further investigations to provide a coherent vision. It is also evident that none of these data can be considered as directly relevant to the question of awareness in the multiple-choice procedure used in most SVT. However, this new domain of research suggests that unconscious processes are more sophisticated than has been classically postulated, and as a result the assertion that a negative response bias cannot result from a non-deliberate decision may be questioned and submitted to more empirical investigations. Another question that is frequently raised but not sufficiently empirically examined is the categorical versus continuous separation between conscious and unconscious processes (see for example for contrasting point of views Dehaene and Naccache [25] versus Cleeremans [20]). Several authors confronted with patients or with subjects during hypnosis suggest that the distinction is not ‘‘all or nothing’’. Some authors have even suggested that a patient may progressively pass from one state to another beginning by faking a disorder but being progressively convinced that he actually has it, and thus that hysteria and malingering may gradually and imperceptibly supersede one another

X. Seron [69,90]! The distinction between simple lying and somatoform disorder not only requires that researchers elaborate more rigorous tests able to identify malingering subjects; it also requires a more precise understanding of the mechanisms linking dissociative and somatoform disorders to psychological stress or trauma. One must also acknowledge the possibility of the existence of an overlap in functional amnesia between ‘‘true’’ and ‘‘feigned’’ amnesia and, as suggested by Spiegel et al. [161] that ‘‘In cases where the dissociative amnesia involves distress over current life conflicts or indiscretions, there may be a mixture of dissociative and factitious/malingered elements that make for a difficult differential diagnosis’’. However, when extensive testing reveals multiple invalid performances, even in the context of genuine psychopathology, there is an increased probability that malingering is present.

Neuroimaging If at the behavioural level, it remains difficult to distinguish somatoform disorders from true malingering, one may wonder whether functional neuroimaging can help us. Several functional neuroimaging studies on lying have recently emerged in the field of cognitive neuroscience [95,97]. While the polygraph technique was used to gather the physiological activity associated with the state of stress or guilt that may be associated with lying, methods of neuroimaging attempt to identify brain activity that underlies the production of a lie. The objective is to obtain a ‘‘brain signature’’ of lying. As we have seen in a previous section, the production of a lie indeed requires a set of specific mental processes (inhibition of the truth, invention of a story or complaints, control of emotional reactivity) that may correspond to specific brain activations. Briefly stated, neuroimaging studies have shown that lying results in more widespread brain activations than truthful responding. These activations mainly concern the prefrontal cortex including the orbito-frontal/ventrolateral prefrontal cortex [96,105,106,108,125,157,158] and dorsolateral prefrontal cortex [1,53,92,95,96,105,106,108,125,157] but also the anterior cingulate cortex [1,53,95], the thalamus [91]; the temporal and parietal lobes [91,95] the caudate [105,125] and insula [91,95]. In fact, no particular brain region is specifically activated by the production of lies; the brain areas involved are those used in the mental processes underlying the lie and which concern inhibition, monitoring, decision making and emotional control. A major problem with neuroimaging studies is that people are lying because they are instructed to do so, while in natural situations, the subjects themselves decide to lie. Furthermore in many studies, subjects are asked not only to lie but are also instructed about the content of the lie and the moment that it is expected to occur. Some authors consider that these limitations are too important and ‘‘do not in fact investigate deception but, at best, some of the complex executive functions indirectly associated with the phenomenon’’ (pp. 48, [153]). The challenges and risks of lying are also very different. In neuroimaging research, the subjects are not involved in deception associated with important or vital outcomes. The situation is clearly less risky, less emotional than that experienced in


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medico-legal situations. Furthermore, the subjects enrolled in neuroimaging studies (students or colleagues of the lab) are generally not representative of subjects that neuropsychologists or jurists try to identify in medico-legal situations. Finally, and even more critically for the issue of malingering, very few experiments have involved situations in which lying refers to the exaggeration of cognitive impairment (but see [105,107]). It is thus premature at present to expect much help from neuroimaging studies. However, this field is rapidly growing and new directions of research are in development aiming to better recreate naturalistic situations. For instance, by looking at deception in relation to psychopathic traits [52], by examining lying in a paradigm with a social component [1]; by designing FRMI paradigm in which subjects chose when to lie [159] or even to compare the brain activation associated with either a somatoform motor paralysis versus a feigned motor disorder [11,187]; and by trying to identify the brain disorders that underlie the somatoform disorders [110,163,186]. Recent researches also compared detection of lying when subjects were trained to elaborate countermeasures [54] and also compare the brain activations related to unintentional memory errors with those associated with feigned memory impairment [104]. Although surely promising these advances do not presently permit to apply these methods to real-world situations. Moreover, we must be cautious in the use of any indicator of deception because of the inverse inference problem. The fact that no brain area, known to be exclusively activated by lie production, is activated when subjects are asked to lying does not ensure the inverse relationship: the observation of an activation in these brain areas network does not necessarily mean that a lie is going on. There is even a lot of evidence to the contrary since most of these areas are activated in a large variety of executive and attention demanding tasks. In summary, neuropsychologists have undoubtedly developed powerful and effective tools to identify patients that do not mobilize a sufficient effort at the SVT. Possible interpretations for this lack of effort remain however largely open. The question of intentionality is at present not fully resolved especially concerning patients with presenting dissociative or conversion disorders. Part of future progress will depend on several different developments including more detailed analysis of cognitive and emotional mechanisms in patients with psychiatric conditions, whose symptoms are close to those present in brain damaged patients. Better understanding of the role of unconscious processes in strategic behaviour is also needed, not only in control subjects but also in subjects with unexplained medical symptoms or in subjects presenting altered states of consciousness. More empirical data must also be collected regarding the specificity and the sensibility of the SVT in the population of persons with neuropsychological complaints outside a forensic context and in the population with somatoform and/or dissociative disorders.

Disclosure of interest The authors have not supplied their declaration of conflict of interest.

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