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Performance validity test failure in clinical populations—a systematic review
  1. Laura McWhirter,
  2. Craig W Ritchie,
  3. Jon Stone,
  4. Alan Carson
  1. Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Laura McWhirter, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH8 9YL, UK; laura.mcwhirter{at}


Performance validity tests (PVTs) are widely used in attempts to quantify effort and/or detect negative response bias during neuropsychological testing. However, it can be challenging to interpret the meaning of poor PVT performance in a clinical context. Compensation-seeking populations predominate in the PVT literature. We aimed to establish base rates of PVT failure in clinical populations without known external motivation to underperform. We searched MEDLINE, EMBASE and PsycINFO for studies reporting PVT failure rates in adults with defined clinical diagnoses, excluding studies of active or veteran military personnel, forensic populations or studies of participants known to be litigating or seeking disability benefits. Results were summarised by diagnostic group and implications discussed. Our review identified 69 studies, and 45 different PVTs or indices, in clinical populations with intellectual disability, degenerative brain disease, brain injury, psychiatric disorders, functional disorders and epilepsy. Various pass/fail cut-off scores were described. PVT failure was common in all clinical groups described, with failure rates for some groups and tests exceeding 25%. PVT failure is common across a range of clinical conditions, even in the absence of obvious incentive to underperform. Failure rates are no higher in functional disorders than in other clinical conditions. As PVT failure indicates invalidity of other attempted neuropsychological tests, the finding of frequent and unexpected failure in a range of clinical conditions raises important questions about the degree of objectivity afforded to neuropsychological tests in clinical practice and research.

  • neuropsychiatry
  • neuropsychology
  • cognition

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  • Contributors LM performed the literature search, data extraction and collation and writing. AC, JS and CWR contributed equally to the study design, and to subsequent review and revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests LM is funded by a University of Edinburgh Clinical Research Fellowship funded philanthropically by Baillie Gifford. LM provides independent medical testimony in court cases regarding patients with functional disorders. AC is a director of a limited personal services company that provides independent medical testimony in Court Cases on a range of neuropsychiatric topics on a 50% pursuer 50% defender basis, is an associate editor of the Journal of Neurology Neurosurgery and Psychiatry, and is the treasurer of the International Functional Neurological Disorder Society. JS reports personal fees from UptoDate, outside the submitted work, runs a self help website for patients with functional neurological symptoms ( which is free and has no advertising, provides independent medical testimony in personal injury and negligence cases regarding patients with functional disorders, and is secretary of the International Functional Neurological Disorder Society. Professor JS is a Chief Scientists Office NHS Research Scotland Career Researcher. CWR declares no conflicts of interest.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.