The Effects of Repeat Testing, Malingering, and Traumatic Brain Injury on Computerized Measures of Visuospatial Memory Span

David L Woods, John M Wyma, Timothy J Herron, E W Yund, David L Woods, John M Wyma, Timothy J Herron, E W Yund

Abstract

Spatial span tests (SSTs) such as the Corsi Block Test (CBT) and the SST of the Wechsler Memory Scale are widely used to assess deficits in spatial working memory. We conducted three experiments to evaluate the test-retest reliability and clinical sensitivity of a new computerized spatial span test (C-SST) that incorporates psychophysical methods to improve the precision of spatial span measurement. In Experiment 1, we analyzed C-SST test-retest reliability in 49 participants who underwent three test sessions at weekly intervals. Intraclass correlation coefficients (ICC) were higher for a psychophysically derived mean span (MnS) metric (0.83) than for the maximal span and total correct metrics used in traditional spatial-span tests. Response times (ReTs) also showed high ICCs (0.93) that correlated negatively with MnS scores and correlated positively with response-time latencies from other tests of processing speed. Learning effects were insignificant. Experiment 2 examined the performance of Experiment 1 participants when instructed to feign symptoms of traumatic brain injury (TBI): 57% showed abnormal MnS z-scores. A MnS z-score cutoff of 3.0 correctly classified 36% of simulated malingerers and 91% of the subgroup of 11 control participants with abnormal spans. Malingerers also made more substitution errors than control participants with abnormal spans (sensitivity = 43%, specificity = 91%). In addition, malingerers showed no evidence of ReT slowing, in contrast to significant abnormalities seen on other malingered tests of processing speed. As a result, differences between ReT z-scores and z-scores on other processing speed tests showed very high sensitivity and specificity in distinguishing malingering and control participants with either normal or abnormal spans. Experiment 3 examined C-SST performance in a group of patients with predominantly mild TBI: neither MnS nor ReT z-scores showed significant group-level abnormalities. The C-SST improves the reliability and sensitivity of spatial span testing, can accurately detect malingering, and shows that visuospatial working memory is largely preserved in patients with predominantly mild TBI.

Keywords: computer; concussion; digit span; feigning; head injury; reaction time; reliability.

Figures

FIGURE 1
FIGURE 1
A computerized spatial span test (C-SST) sequence of length five. The square sequence was shown to participants using the cursor (a small white square), which moved from square to square over 977 ms intervals. Each square flashed green as it was selected (bottom right). When the sequence had been shown, the “Done” button illuminated (bottom center). The participant’s task was to select the squares in the correct order using the mouse. The dashed line has been included to illustrate the cursor displacements, but was not visible to participants. Participants clicked “Done” when their selection was complete.
FIGURE 2
FIGURE 2
Mean spatial span (MnS) of participants as a function of age. For control participants in the normative dataset (Norm.), participants in Experiment 1a (Reps), malingering participants (Mal, Experiment 2), and mild and severe TBI (mTBI and sTBI) patients (Experiment 3).
FIGURE 3
FIGURE 3
Mean response times (ReTs) as a function of age. ReTs were averaged over different list positions. See Figure 2 for group membership specifications.
FIGURE 4
FIGURE 4
Mean span (MnS) and log-transformed ReT z-scores. The z-scores were corrected for the contributions of age and computer-use using multiple regression values from the normative data. Vertical and horizontal red lines show p < 0.05 abnormality thresholds. See Figure 2 for group membership specifications.
FIGURE 5
FIGURE 5
Percentage of errors of different types made by participants of different groups. Oms, omissions; Adds, additions; Subs, substitutions; Trans, transpositions; Perms, permutations. Error bars show standard errors. See Figure 2 for group membership specifications.
FIGURE 6
FIGURE 6
Differences in ReT z-scores on the C-SST and two processing speed tests in malingering and control conditions. Ordinate: Differences between ReT z-scores and z-scores on the Trail Making Test, part A (TrAz). Abscissa: Differences between Log ReT z-scores and Simple Reaction Time z-scores (SRTz). Horizontal and vertical red lines show the upper limits (p < 0.05) of the difference distribution in the normative control group of 187 participants (Norm). See Figure 2 for group membership specifications.

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