It should be noted that volitional underperformance is not the only explanation for performance validity test failure. In addition, poor performance validity has been shown to be related to cognitive performance in postacute TBI patients seen in outpatient rehabilitation settings ( Donders & Boonstra, 2007 Locke, Smigielski, Powell, & Stevens, 2008). Studies show that decreased performance on neuropsycho-logical measures is associated with larger financial compensation ( Bianchini, Curtis, & Greve, 2006 Binder & Rohling, 1996).
Financial compensation has been shown to play a large role in probable response bias issues ( Binder & Rohling, 1996 Cook, 1972 Miller, 1961 Paniak et al., 2002 Reynolds, Paniak, Toller-Lobe, & Nagy, 2003). Many traumatic brain injuries (TBIs) are caused by motor vehicle accidents, on the job injuries, or other situations that may lead to lawsuits and the potential for compensation ( Donders & Boonstra, 2007 Locke et al., 2008). There are many reasons why patients might want to appear more impaired than they actually are, most commonly to avoid a variety of social, financial, or personal consequences ( Lezak, Howieson, & Loring, 2004). It may also reflect an external incentive to demonstrate diminished performance. Reduced effort may be due to the patient not being invested in the outcome of the testing. For the purposes of this article, we will define effort as the intensity with which one tries to perform to one's best ability on neuropsychological tests. Patients may not always be exerting maximal effort on tasks, however, and poor effort greatly affects neuropsychological performance ( Iverson, 2005). Neuropsychological evaluations are often useful for uncovering cognitive and behavioral deficits that may not appear in functional images of the brain or in neurological exams.
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