ASSESSMENT
Etherton
10.1177/1073191105274859
et al. / RELIABLE DIGIT SPAN
Sensitivity and Specificity of Reliable Digit
Span in Malingered Pain-Related Disability
Joseph L. Etherton
Loyola University New Orleans and Jefferson Neurobehavioral Group
Kevin J. Bianchini
Kevin W. Greve
Matthew T. Heinly
University of New Orleans and Jefferson Neurobehavioral Group
The reliable digit span (RDS) performance of chronic pain patients with unambiguous spinal injuries and no evidence of exaggeration or response bias (n = 53) was compared to that
of chronic pain patients meeting criteria for definite malingered neurocognitive dysfunction
(n = 35), and a group of nonmalingering moderate-severe traumatic brain injury (TBI) patients (n = 69). The results demonstrated that scores of 7 or lower were associated with high
specificity (> .90) and sensitivity (up to .60) even when moderate to severe TBI are included.
Multiple studies have demonstrated that RDS scores of 7 or lower rarely occur in TBI and
pain patients who are not intentionally performing poorly on cognitive testing. This study
supports the use of the RDS in detecting response bias in neuropsychological patients complaining of pain as well as in the assessment of pain-related cognitive impairment in patients
whose primary complaint is pain.
Keywords: malingering; chronic pain; cognition; assessment; attention; back injury
Assessing the validity of patient performance on psychological and neuropsychological evaluations is important in cases involving incentive to manifest disability,
such as in workers’ compensation and personal injury litigation cases. A number of strategies have been developed
to detect malingering of cognitive and perceptual symptoms in neuropsychological evaluations, including specialized measures such as forced-choice symptom validity
tests (SVT; for a review of SVTs, see Bianchini, Mathias,
& Greve, 2001) and internal validity indicators derived
from standard clinical instruments (e.g., Millis, Putnam,
Adams, & Ricker, 1995; Mittenberg et al., 2001). Internal
validity indicators have drawn considerable research and
clinical interest because they (a) enhance the sensitivity of
the entire malingering battery without requiring extra administration time, (b) can provide information about the
validity of performance on specific tests (Mathias, Greve,
Bianchini, Houston, & Crouch, 2002; Meyers & Diep,
2000; Meyers & Volbrecht, 1998), and (c) may be less
susceptible to coaching than SVTs (Mathias et al., 2002).
Reliable digit span (RDS; Greiffenstein, Baker, &
Gola, 1994; Greiffenstein, Gola, & Baker, 1995) is an internal validity indicator derived from the digit span test, a
component of several commonly used clinical batteries,
for example, the Wechsler Adult Intelligence Scale–III
(WAIS-R; Wechsler, 1997a), the Wechsler Memory
Scale–III (WAIS-III; Wechsler, 1997b), the StanfordBinet (Thorndike, Hagen, & Sattler, 1986), and the
Neuropsychological Assessment Battery (Stern & White,
2003). RDS is based on the assumption that a person attempting to exaggerate or fabricate impairment will perform poorly on digit span because it looks like a test on
Requests for reprints should be sent to Kevin W. Greve, Ph.D., Department of Psychology, University of New Orleans-Lakefront,
New Orleans, LA 70148; telephone: 504-280-6185; fax: 504-280-6049; e-mail: kgreve@uno.edu.
Assessment, Volume 12, No. 2, June 2005 130-136
DOI: 10.1177/1073191105274859
© 2005 Sage Publications
Etherton et al. / RELIABLE DIGIT SPAN 131
which brain-injured patients might experience difficulty
(Meyers & Volbrecht, 1998; Owens, 1995), although digit
span is actually fairly well preserved even among patients
with brain dysfunction, including amnesia (Greiffenstein
et al., 1994).
RDS is calculated by summing the longest forward and
backward digit strings for which both trials were completed without error. Although there is some variability in
the literature, RDS scores of 7 or less have generally been
associated with specificity of greater than 90% in braininjured and healthy populations (e.g., Inman & Berry,
2002; Larrabee, 2003; Mathias et al., 2002; Meyers &
Volbrecht, 1998; Strauss et al., 2002). At this cutoff, sensitivity higher than 50% to both simulated and clinically diagnosed malingering has been reported (Larrabee, 2003;
Mathias et al., 2002; Strauss et al., 2002). Thus, RDS
scores at or below 7 are rarely or never seen in patients
with brain dysfunction, and such scores accordingly imply
poor effort, negative response bias, or both.
Although the relationship between low RDS scores and
negative response bias has been well documented, other
factors, such as affective disturbance, medication side effects, and pain, may have an impact on RDS performance.
The potential impact of pain is relevant because of the high
incidence of pain reported during evaluations with incentive. Neuropsychological patients frequently report pain
(Larrabee, 2003), and pain may be accompanied by cognitive complaints such as impaired memory or concentration, even in the absence of brain dysfunction (Iverson &
McCracken, 1997; Nicholson, Martelli, & Zasler, 2001).
Similarly, pain-related deficits have been demonstrated
for complex cognitive tasks (Eccleston, 1994, 1995).
Many chronic pain patients without brain dysfunction
undergo psychological assessment as part of disability
evaluations, and these evaluations have increasingly included SVTs and internal validity markers (Bianchini,
Etherton, & Greve, 2004; Gervais, Green, Allen, &
Iverson, 2001; Meyers & Diep, 2000; Tsushima &
Tsushima, 2001). Because pain is present in many patients
undergoing evaluations involving validity indicators, the
potential impact of pain on validity indicator performance
should be addressed to reduce the possibility of falsepositive errors.
Studies involving nonclinical college-age participants
have demonstrated that pain induced via cold-pressor procedure does not impair RDS scores (Etherton, Bianchini,
Ciota, & Greve, 2005) or performance on the Test of Memory Malingering (TOMM; Tombaugh, 1996; Etherton,
Bianchini, Greve, & Ciota, in press), even when pain levels were reported as severe. Etherton et al.’s (2005) RDS
simulator study results were consistent with findings in
clinical brain injury patients. However, it is possible that
the effects of chronic pain on performance may differ from
laboratory-induced pain in nontrivial ways such that the
results of simulator studies in college students may not
generalize to clinical pain patients. In other words, because of the nature of the pain and characteristics of the
persons experiencing it, clinical chronic pain may affect
performance on clinical validity indicators in ways not
observed in the context of laboratory-induced pain.
Accordingly, this study was conducted to evaluate the
potential impact of clinical pain on RDS performance to
clarify any potential limitations on the use of RDS in clinical evaluations of patients with pain. Specifically, in this
study the RDS performance of clinical patients with
chronic pain and unambiguous spinal injuries but without
evidence of symptom exaggeration or response bias was
compared to that of a group of chronic pain patients who
met published criteria for definite malingered
neurocognitive dysfunction (MND; Slick, Sherman, &
Iverson, 1999).
METHOD
Participants
The records of approximately 200 patients seen clinically for psychological pain evaluations in a southeastern
clinical psychology group practice were reviewed. These
patients were referred by physicians, workers’ compensation companies, and attorneys. Extensive medical records
reviewed in the context of these evaluations provided objective medical diagnostic test results as well as physicians’ clinical diagnoses and injury descriptions that
contributed to study group assignment into either malingering or nonmalingering groups or exclusion from the
study (see below for inclusion and exclusion criteria).
Most patients (all patients in the malingering group) had
financial incentive in the form of either a workers’ compensation claim or personal injury suit. The medical diagnoses of the patients in each of the two clinical pain groups
are reported in Table 1. Some patients received more than
one diagnosis. A group of nonmalingering patients with
moderate-severe TBI was also included for comparison
(see below).
Nonmalingering clinical pain sample. Patients were included in this group if their medical records demonstrated
objective clinical abnormalities of the spine as indicated
by computerized tomography, magnetic resonance imaging, X ray, myelography, electromyography studies, or
surgery. They were excluded from this group if there was
any psychometric evidence of symptom exaggeration or
response bias or if there were physician reports of
nonphysiological findings or inconsistencies. Patients
132
ASSESSMENT
TABLE 1
Diagnoses for Nonmalingering
and Malingering Groups
Diagnosis/Symptom Report
Nonmalingering
Paina
Vertebral disc herniation/rupture (any level)
Neck or back strain or sprain
Spinal stenosis
Other back pain or injury (any level)
Sacroiliac joint dysfunction
Degenerative disc disease
Vertebral fracture
Facet pain/hypertrophy
Low back pain unspecified
Spondylolysis
Degenerative joint
Radiculopathy
Sciatica
Neuropathy/neuropathic pain
Nerve impingement syndrome
Failed back syndrome
Fibromyalgia
Myofascial pain
Complex regional pain syndrome
Reflex sympathetic dystrophy
18
8
3
21
1
2
2
1
1
4
0
5
1
1
2
2
0
0
0
1
Definite
Malingering
b
Pain
3
9
0
23
0
1
0
2
1
1
1
7
0
1
2
0
1
3
1
1
NOTE: Some patients received more than one diagnosis.
a. Nonmalingering clinical pain group.
b. Definite malingered neurocognitive dysfunction clinical pain group.
were excluded if any of the following were present: scores
below published clinical cutoffs on any forced choice SVT
(Portland Digit Recognition Test [PDRT], Binder, 1993;
TOMM, Tombaugh, 1996]); T scores above 85 on MMPI2 F and/or Fb scales (Greve et al., 2004); or Fake Bad Scale
[FBS], Lees-Haley, English, & Glenn, 1991) raw scores
above 24 for men and above 26 for women (Larrabee,
1998). Of the cases reviewed, 53 patients (34 men and 19
women: age, M = 43.25, SD = 11.57) met criteria for inclusion. Of these 53 patients, 42 met criteria for a workers’
compensation claim, 3 for a personal injury claim, 3 were
referred in the context of a disability evaluation and 1 by
vocational rehabilitation, the remaining 4 had no incentive
and were referred by their physicians.
Definite MND clinical pain patients. Thirty-five clinical pain patients (23 men and 12 women, age M = 42.57,
SD = 8.38) met the Slick et al. (1999) criteria for MND by
virtue of a statistically below-chance performance on a
forced-choice SVT. Typically, they failed either the PDRT
or the TOMM. However, several patients failed a tactile
SVT (Greve, Bianchini, & Ameduri, 2003). The interpretation of a below-chance result as definitive evidence of intentional exaggeration of cognitive deficits even in the
context of objective pathology has become well established in the neuropsychological literature (e.g.,
Bianchini, Greve, & Love, 2003). Of these 35 patients, 32
were seen for a workers’ compensation claim, 2 for a personal injury claim, and 1 was referred for a disability evaluation. Patients with evidence of symptom or deficit
exaggeration who did not meet the Slick et al. (1999)
criteria for definite MND were excluded from study.
TBI sample. For comparison purposes, 69 patients (52
men and 17 women: age, M = 34.59, SD = 15.42; education, M = 12.22, SD = 2.73; time since injury in years, M =
1.38, SD = 2.34) with documented moderate to severe TBI
and no evidence of poor effort, suspect behavior, or malingering were included. These patients had documented evidence of acute neurological pathology indicating an injury
that was worse than a mild TBI as defined by the Mild
Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American
Congress of Rehabilitation Medicine (1993). Specifically,
they were considered to have suffered a moderate to severe
TBI if they met any of the following criteria: (a)
posttraumatic amnesia greater than 24 hours, (b) an initial
Glasgow Coma Scale < 13, and (c) loss of consciousness >
30 minutes and/or positive neuroradiological findings
(e.g., skull fracture, hemorrhage, hematoma) or focal
neurological signs. Of the 69 patients, 39 were seen in a
compensation-seeking context, and these patients were included in the sample only if they met the same exclusion
criteria as the nonmalingering pain group. All of the patients without incentive were referred by physicians. Of
the patients with incentive, referral source was as follows:
physician, 14; case manager, 13; and attorney, 12. These
patients had been previously selected for a separate study
of RDS in TBI (Heinly, Greve, Love, Brennan, &
Bianchini, 2004).
RDS
The RDS score is derived from the digit span subtest of
the WAIS-R or WAIS-III and is determined by summing
the longest forward and backward digit strings for which
both trials were completed without error. Thus, if a participant correctly repeated both five-digit strings forward and
both three-digit strings backwards but failed to correctly
repeat both of the longer digit strings, the RDS score
would be 8.
Pain Rating
Pain ratings were recorded during the interview portion
of the psychological pain evaluation for most clinical pain
patients using an 11-point numerical scale (0 = no pain,
10 = the worst imaginable pain). Such scales are commonly used in both clinical and research settings (Gracely,
1989; Gracely, McGrath, & Dunbar, 1978; Peckerman et
Etherton et al. / RELIABLE DIGIT SPAN 133
TABLE 2
Results of the Group Analysis of Reliable Digit Span Scores
Group
M
SD
Range
n
Nonmalingering Pain
Definite Malingering Pain
Nonmalingering TBI
F
p<
2
10.51a
2.28
7-17
53
7.20b
2.95
0-13
35
10.23a
2.25
6-16
69
23.04
.001
.23
df = 2, 154
NOTE: Row means with same subscript letter did not differ significantly at alpha < .05.
al., 1991). Typically, ratings were collected for current,
worst, and least pain. Full pain rating data were not available for all patients.
RESULTS
The clinical nonmalingering and malingering groups
did not differ in their mean pain ratings (nonmalingering
group: current pain, M = 6.82, SD = 1.50; least pain, M =
4.85, SD = 1.93; and worst pain, M = 9.36, SD = .93; clinical malingering group: current pain, M = 6.70, SD = 2.14;
least pain, M = 4.78, SD = 1.96; worst pain, M = 9.26, SD =
1.58). There was no correlation between pain rating and
RDS performance: current pain, r(74) = –.08, p = .49; least
pain, r(58) = –.05, p = .73; worst pain, r(64) = –.10, p = .45.
There were no significant gender effects for RDS, and age
was not correlated with RDS performance. Significant
group effects were observed in that the malingering pain
group scored significantly lower than both the
nonmalingering pain group and the TBI group, which did
not differ from each other (see Table 2 for details). It is
worth noting that the means for the two nonmalingering
clinical groups in this study were almost identical to those
of the control and cold pressor groups reported by
Etherton et al. (2005). Moreover, the clinical malingering
group scored almost identically to Etherton et al.’s
simulator group.
Table 3 provides sensitivity and specificity data for the
current clinical patients as well as those participants from
Etherton et al.’s (2005) simulator study. As can be seen,
scores of 6 and lower are associated with perfect specificity in the clinical pain patients (one TBI patient had a 6),
whereas sensitivity predictably declines with more extreme scores. For scores with perfect specificity, positive
predictive power (+PP) is 1.00 regardless of sensitivity
and base rate, which means that one can be confident that
such a performance reflects intentionally poor effort. Table 4 presents sensitivity, specificity, and positive predictive power for a range of hypothetical base rates. Table 4a
bases the calculation of +PP on specificity derived only
from the nonmalingering pain patients. The calculation of
+PP presented in Table 4b uses specificity based on the
combined nonmalingering pain and TBI samples. As can
be seen in Table 4, scores as high as 8 may be considered
suspicious for malingering at higher base rate levels (i.e., >
.30). At base rates likely to be encountered in real world
settings (i.e., approximately ≥ 30%; Mittenberg, Patton,
Canyock, & Condit, 2002) scores of 7 should clearly raise
suspicion of malingering, whereas scores of 6 and lower
can be fairly confidently interpreted as evidence of malingering.
DISCUSSION
This study sought to examine the sensitivity and specificity of RDS in clinical patients with chronic pain. The results demonstrated that scores of 7 or lower were
associated with high specificity (> .90 at 7, 1.00 at scores <
7) and excellent (between .37 and .60) sensitivity in the detection of cognitive malingering in clinical patients with
pain. Even moderate to severe TBI scores of 6 or lower
were associated with a specificity of .99. These results are
consistent with the findings of Etherton et al. (2005) based
on their laboratory-induced pain study and with multiple
reports of the performance of patients with TBI (e.g.,
Inman & Berry, 2002; Larrabee, 2003; Mathias et al.,
2002; Meyers & Volbrecht, 1998; Strauss et al., 2002). It is
worth mentioning that in all studies except Etherton et al.
(2005), digit span was administered as part of the WAIS so
it is possible that these results may not generalize to the administration of digit span in isolation. However, the
Etherton et al. data, which are presented in Table 3, are
generally consistent with those of this and other studies. In
summary, multiple studies have demonstrated that RDS
scores below 7 rarely occur in TBI and pain patients who
are not intentionally performing poorly on cognitive
testing and that scores of 7 should at least raise suspicions
about malingering.
134
ASSESSMENT
TABLE 3
Cumulative Percentages of Patients With Scores at or Below the Indicated RDS Score
Current Study
n
Etherton, Bianchini, Ciota, and Greve, (2005)
Nonmalingering
Pain
Definite
MND Pain
Nonmalingering
M/S TBI
Control
Simulator
Cold Pain
53
35
69
20
20
20
—
—
—
—
—
—
0
8
17
40
55
68
83
91
94
96
98
100
3
3
6
9
14
26
37
60
74
80
86
89
94
100
—
—
—
—
—
—
—
—
—
0
1
9
25
42
59
75
81
90
96
99
100
—
—
—
—
—
—
—
—
0
25
35
55
65
85
90
95
95
100
—
5
5
10
20
25
35
40
65
80
90
100
—
—
—
—
—
—
—
—
—
—
—
—
—
0
0
15
40
55
75
90
100
—
—
—
—
RDS
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
NOTE: MND = malingered neurocognitive dysfunction; TBI = traumatic brain injury. Groups: Nonmalingering pain = nonmalingering clinical pain group;
definite MND Pain = definite malingered MND clinical pain group; nonmalingering M/S TBI = nonmalingering moderate-severe TBI group. The tabled
value is the percentage of patients performing below or worse than the given score. For nonmalingering patients, this is the false-positive error rate (reciprocal of Specificity); for malingering patients (including simulators), this is the Sensitivity rate.
TABLE 4
Specificity, Sensitivity, and Positive Predictive Power for Different Reliable
Digit Span (RDS) Scores and Hypothetical Base Rates of Malingering
Positive Predictive Power for Hypothetical Base Rates
RDS
Specificity
Sensitivity
.10
Pain patients only
8
83
74
.33
95% CI
70-92
57-88
.17-.55
7
92
60
.45
95% CI
82-98
42-76
.21-.81
6
100
37
1.00
95% CI
93-∞
21-55
.25-∞
5
100
26
1.00
95% CI
—
19-50
—
4
100
14
1.00
95% CI
—
5-30
—
Nonmalingering traumatic brain injury patients included in calculating specificity
8
79
74
.28
95% CI
70-86
57-88
.17-.41
7
92
60
.45
95% CI
85-96
42-76
.24-.68
6
99
37
.80
95% CI
96-99
21-55
.37-.86
5
100
26
1.00
95% CI
97-inf
19-50
.41-∞
4
100
14
1.00
95% CI
—
5-30
—
.20
.30
.40
.50
.52
.32-.73
.65
.37-.90
1.00
.43-∞
1.00
—
1.00
—
.65
.45-.83
.76
.50-.94
1.00
.56-∞
1.00
—
1.00
—
.74
.56-.88
.83
.61-.96
1.00
.67-∞
1.00
—
1.00
—
.81
.66-.92
.88
.70-.97
1.00
.75-∞
1.00
—
1.00
—
.47
.32-.61
.65
.41-.83
.90
.57-.93
1.00
.61-∞
1.00
—
.60
.45-.73
.76
.55-.89
.94
.69-.96
1.00
.73-∞
1.00
—
.70
.56-.81
.83
.65-.93
.96
.78-.97
1.00
.81-∞
1.00
—
.78
.66-.86
.88
.74-.95
.97
.84-.98
1.00
.86-∞
1.00
—
NOTE: CI = confidence interval. These values are undefined because of the necessity to divide by 0.
Etherton et al. / RELIABLE DIGIT SPAN 135
It is important to note that for these findings to be clinically useful, it is not necessary to identify a best or recommended cut point. Clinically, the relevant question is as
follows: What does this score tell me about my patient?
Therefore, one need only take the patient’s RDS score and
determine the appropriate +PP by reference to Table 4;
+PP describes the empirical likelihood (with confidence
intervals) that the observed score was produced by someone who is malingering. We have no specific recommendations as to what level of probability is acceptable for
concluding that that negative response bias is present, but
one could argue that the legal standard of “more probable
than not” would be satisfied by a +PP of .51 or greater.
Reference to Table 4 shows that this standard would be
met by scores of 7 or lower at base rates of 30% or higher
and scores of 8 at base rates of 40% or higher. At the same
time, the data from a single test, whatever the +PP, should
not be used in isolation and, instead, must be considered in
the context of a diagnostic system such as that of Slick et
al. (1999).
Eccleston (1994) demonstrated that chronic pain
patients were impaired only on more complex attentiondemanding tasks; those tasks that required fewer
attentional resources were unaffected even when reported
pain levels were high. Moreover, digit span, from which
RDS scores are derived, is a task for which performance is
often preserved even in individuals known to have significant neurologically mediated memory deficits (e.g., moderate-severe TBI; Langeluddecke & Lucas, 2003). Thus, it
is reasonable to conclude that RDS is an index of effort,
not cognitive ability or capacity, even in patients with
chronic pain. Moreover, poor RDS performance cannot
reasonably be attributed to the secondary effects of pain
such as fatigue, mood disorder, and medication effects because it is unlikely that these would be differentially prevalent among our definite malingerers compared to the
nonmalingering pain and TBI patients. Accordingly, clinicians may be more confident in concluding that scores of 7
or lower reflect intentionally poor effort and possibly malingering.
Ultimately, a diagnosis of malingering requires the
careful review and integration of a range of information.
Internal validity indicators such as the RDS are important
sources of evidence regarding the presence of response
bias. This study complements earlier work on laboratoryinduced pain (Etherton et al., 2005, in press) by addressing
the potential influence of clinical pain on RDS performance and also provides data on the performance of
nonmalingering patients with moderate-severe TBI. Thus,
the current study supports the use of the RDS in detecting
response bias in neuropsychological patients complaining
of pain as well as in the assessment of pain-related
cognitive impairment in patients whose primary
complaint is pain.
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Joseph L. Etherton is an assistant professor at Loyola University New Orleans and a licensed clinical psychologist. His research interests include psychosocial factors in pain and the
assessment of pain-related malingering.
Kevin J. Bianchini, Ph.D., is a licensed clinical neuropsychologist in private practice in New Orleans. His current research interests include pain-related disability, malingering, and
toxic exposure.
Kevin W. Greve, Ph.D., is a professor of psychology at the University of New Orleans and in private practice as a clinical
neuropsychologist in the New Orleans area. His current research
interests include executive functions and the psychosocial factors that influence outcome in brain injury and chronic pain.
Matthew T. Heinly, M.S., is a doctoral student in applied
biopsychology at the University of New Orleans, Louisiana. His
current research interests include cognitive neuropsychology,
brain trauma, and malingering.