Word Memory Test profiles in two cases with surgical removal of the

left anterior hippocampus and parahippocampal gyrus.

Carone, D., Green, P. and Drane, D.

In Press, December, 2012, Applied Neuropsychology


One principle underlying the use of the Word Memory Test (WMT) as an effort test is that, with good effort, recognition scores above the cut-offs will be observed. However, in order to understand the limits of effort testing, it is necessary to study people known to have severe impairment and significant neuropathology involving memory structures. Goodrich-Hunsaker and Hopkins (2009) reported that three amnesic patients with bilateral hippocampal damage had severely impaired free recall of the WMT word list but passed the recognition subtests of the WMT, which are often called effort subtests. We tested two patients with surgical resections in the left anterior temporal region to treat chronic intractable epilepsy, both of whom suffered post-operative strokes. Patient A was a 15 year-old boy and Patient B was a 58 year-old woman. Despite destruction of the left anterior hippocampus and the parahippocampal gyrus and despite impairment of Free Recall, both cases passed the easy WMT effort subtests. These data reinforce previous findings that people with severe impairment of free recall will score much higher on the verbal recognition memory subtests than on the more difficult memory subtests. Even severe memory impairment and/or removal of hippocampal areas does not necessarily lead to failure on the easy WMT recognition subtests.

Keywords: effort; word memory test; left temporal lobe epilepsy; hippocampus;

1.        Dominic A. Carone, Ph.D., ABPP-CN, Neuropsychologist and Clinical Assistant Professor (PM&R & Psychiatry), SUNY Upstate Medical University, Syracuse, NY

2.        Paul Green, Ph.D., Private Practice, Edmonton, Alberta, Canada

3.        Daniel L. Drane, Ph.D., Assistant Professor of Neurology, Emory University School of Medicine, Atlanta, Georgia


Disclaimer:  Paul Green is the author of the Word Memory Test. Neither Dominic Carone nor Daniel Drane has any financial interest in the WMT or any other products of Greenís Publishing.


Traditionally, the hippocampus has been considered essential to episodic memory and the left hippocampus is usually thought of as the basis of verbal learning and memory. Thank you Brenda Milner and many others. In this paper, we report on two cases in whom the left anterior hippocampus was removed, as well as the parahippocampal gyrus. Both cases passed the WMT recognition memory subtests (IR and DR) but had impaired Free Recall. Clearly, recognition memory of this type is a very different animal from what we usually think of as memory (e.g. free recall of information). We might ask what part of the brain has to be removed to lead to failure of the WMT in people who are motivated to do well? The paper leads us to contrast those with hippocampal damage who pass the WMT with cases of mild TBI and a compensation incentive who fail it.   

Paul Green



Memory complaints and SVT failure are strongly linked in a study of over 3,400 compensation cases:

As various SVT scores decline, there is a corresponding major increase in scores on all scales of the Memory Complaints Inventory. This is best explained by the underlying dimension of symptom exaggeration. 




Conclusions: 1) When memory complaints are present, symptom exaggeration must be ruled out using objective tests and 2) Subjective memory complaints are uncorrelated with objective memory test scores, a fact which is well attested in many studies including the latter study.


A replication study using a different sample is already in press.


Misinterpreting WMT results: Willis et al (2012) recently reported the results of three cases on the WMT. Unfortunately, the authors misinterpreted and misrepresented the WMT.


The authors did not follow the simple and very explicit interpretive guidelines laid out in the Advanced Interpretation program. For example, the demented doctor, one of three cases, would automatically be classified by the AI program as a case where dementia must be ruled out before concluding poor effort. Yet they called it a false positive.


Interpreted correctly and according to the principles used by thousands of WMT users, the WMT in this case would have been very helpful in pointing directly to a possible diagnosis of dementia because almost no other condition could explain such results in a physician. They also misinterpreted the data on the other two cases.


Click this link for a more detailed critique.

MILITARY MEDICINE, 176, 12:1426, 2011

Here is an example of how the Advanced Interpretation program helps in the interpretation of scores from the WMT, MSVT, NV-MSVT or MCI. In this example, a woman was feigning dementia.


Sample case on AI 



Symptom validity test performance in U.S. veterans referred for evaluation of mild TBI.

Armistead-Jehle P.

Department of Mental Health, Department of Veterans Affairs, Pacific Island Health Care System, Honolulu, Hawaii, USA.

The current study examined Medical Symptom Validity Test (MSVT) performance in U.S. veterans referred for evaluation of mild traumatic brain injury (TBI) after scoring positive on the Veterans Health Administration (VHA) TBI screening measures. Fifty-eight percent of the sample scored below the MSVT cut scores on subtests more sensitive to effort than to neurological insult. There were no differences among those who did and those who did not pass the MSVT as a function of gender, age, education, ethnicity, previous posttraumatic stress disorder or substance use disorder diagnoses, or Personality Assessment Inventory validity scales designed to measure negative impression management. Those who were service connected and previously diagnosed with a depressive condition failed the measure at a higher rate than those who were not. These results are discussed in relation to the specific nature of VA patient populations.

PMID: 20146122 [PubMed - in process]

Appl Neuropsychol. 2010 Jan;17(1):52-9.



Children with severe TBI easily pass the MSVT but adults with mild TBI fail: How can that be?

Carone, D. (2008) Children with moderate/severe brain damage/dysfunction outperform adults with mild to no brain damage on the Medical Symptom Validity Test. Brain Injury, 22, 12, 960-971. 


Primary objective: This study sought independent confirmation that the English computerized Medical Symptom Validity Test can be easily passed by children with moderate-to-severe brain injury/dysfunction (e.g. traumatic brain injury, stroke) and/or developmental disabilities. In addition, it was hypothesized that a higher percentage of such children would pass the MSVT compared to adults with mild traumatic brain injury or head injury (MTBI/HI) and would rate the task as easier.

Methods: Thirty-eight children and 67 adults were administered the MSVT during an outpatient neuropsychological evaluation.

Results: Two children (5%) failed the MSVT, whereas 14 (21%) of adults failed. Children performed significantly better on the MSVT and rated it as significantly easier compared to adults who failed the MSVT. There were no such differences when children were compared to adults who passed the MSVT.

Conclusions: Findings independently validate the use of the MSVT with children and demonstrate symptom exaggeration in a sub-set of adult MTBI/HI patients.

Keywords: Effort testing, validity testing, mild traumatic brain injury, children, malingering



Brain Inj. 2009 Aug;23(9):741-50.

Examining false positives on the Word Memory Test in adults with mild traumatic brain injury.

Green P, Flaro L, Courtney J.

PRIMARY OBJECTIVE: Many adults with mild traumatic brain injury (MTBI) fail effort tests, indicating poor effort and invalid test results. However, two studies have suggested a high rate of false positives on the Word Memory Test (WMT) in adults with MTBI. This study examines the question of false positives in adults with MTBI who failed the effort subtests of the WMT. RESEARCH DESIGN: A modified and shortened version of the WMT, the Medical Symptom Validity Test (MSVT) was given to adults with MTBI, some of whom failed the WMT. It was also given to samples of schoolchildren in grades two and above, to several hundred children with developmental disabilities and to healthy adults. OUTCOMES AND RESULTS: Failures on the MSVT were far more frequent in adults with MTBI than in second grade children or in children with developmental disabilities. Adults with MTBI who failed the WMT scored much lower on the MSVT effort subtests than children with a mean FSIQ of 63 and much lower than children with impaired memory. CONCLUSIONS: Comparison with developmentally disabled children on the MSVT suggests that the adults with MTBI who failed the WMT were not making an effort to do well on either the WMT or the MSVT. Their results were invalid. False positives on the WMT in adults with mild TBI are very rare.



How do we know that the TOMM has many false negatives for poor effort? One study shows that many people fail the Nonverbal MSVT but they pass TOMM. The study shows that such cases are false negatives for the TOMM. Here is the abstract.



Accuracy of medical assessments of impairment:

A physician associated with AMA guides to rating impairment says that doctors' assessments of impairment are invariably inaccurate:  DISCUSSIONS/RECENT_PAPERS_2010/doctors_inaccurate_rating_disability.pdf

For one thing, most do not employ objective measures of symptom exaggeration.


Clin Neuropsychol. 2010 Feb 23:1-13. [Epub ahead of print]

The base rate of suboptimal effort in a pediatric mild TBI sample: Performance on the Medical Symptom Validity Test.

Kirkwood MW, Kirk JW.

Department of Physical Medicine & Rehabilitation, University of Colorado Denver and The Children's Hospital, Aurora, CO, USA.

Performance on the Medical Symptom Validity Test (MSVT) was examined in 193 consecutively referred patients aged 8 through 17 years who had sustained a mild traumatic brain injury. A total of 33 participants failed to meet actuarial criteria for valid effort on the MSVT. After accounting for possible false positives and false negatives, the base rate of suboptimal effort in this clinical sample was 17%. Only one MSVT failure was thought to be influenced by litigation. The present results suggest that a sizable minority of children is capable of putting forth suboptimal effort during neuropsychological exam, even when external incentives are not readily apparent. The MSVT appears to have good potential value as an objective measure for detecting symptom invalidity in school-age youth.



High Specificity of the Medical Symptom Validity Test in

Patients with Very Severe Memory Impairment

Ankush Singhala, Paul Greenb,*, Kunle Ashayea, Kuttalingam Shankara and David Gilla

a Department of Psychiatry, Lister Hospital, Stevenage, UK
b Private Practice in Clinical Neuropsychology, Edmonton, Alberta, Canada

The above paper is now available online to NAN members.  

 Q) Why does it matter that analysis of the MSVT and NV-MSVT profiles very rarely misclassifies advanced dementia patients as poor effort?

 A)  Because these are the most cognitively impaired people we can test.  False positives on an SVT occur if someone tries their best and actually cannot pass. Advanced dementia patients are more likely than anyone else to be false positives on SVTs. If they very rarely produce false positives, it is not plausible that people with lesser impairment will be false positives (e.g. Mild TBI adults).

Note: In this approach the term false positive does not refer to being wrongly classified as a malingerer. It means that the results indicate poor effort and unreliable test data, when the data are actually valid and a result of best effort. This is an important distinction. It is not advisable to say that a poor effort profile on MSVT or NV-MSVT means the person is malingering. We should be meticulous and not infringe on the right of judge and jury to decide intent. It is more conservative and scientifically valid to conclude that results appear reliable or that they appear unreliable due to poor effort.

Archives of Clinical Neuropsychology 2009 24(8):721-728




On page 456 of the Archives of Clinical Neuropsychology conference abstracts (vol 24, issue 5, August 2009), there is a study by Davis, Ramos, Sherer, Bertram and Wall (2009). 

They looked at the sensitivity of the TOMM and WMT to malingering in two groups, who were naive or coached simulators.

-   Sensitivity for the TOMM was a mean of 48% (59% for naive and 38% for coached simulators).

-   Sensitivity for the WMT was 71% for both naive and coached simulators.

-   Both the TOMM and WMT had 100% specificity in a control group making a good effort (using only pass/fail easy subtests).

Conclusion: The WMT was more sensitive to poor effort than the TOMM, especially in simulators who had been coached. They were equally specific in controls.



On page 487 of the Archives of Clinical Neuropsychology conference abstracts (vol 24, issue 5, August, 2009), there is a study of the relative sensitivity and specificity of embedded effort measures versus stand alone SVTs like the TOMM, Rey-15, VSVT and WMT. The authors are Miele, Lynch and McCaffrey (2009)

Conclusion: In litigating patients, the data on embedded symptom validity indices do not support their use at the exclusion of free standing SVTs.



William A. Lindstrom, Jr., Jennifer H. Lindstrom, Chris Coleman, Jason Nelson & Noel Gregg. The Diagnostic Accuracy of Symptom Validity Tests when Used with Postsecondary Students with Learning Disabilities: A Preliminary Investigation.

Archives of Clinical Neuropsychology  in press but available online (October 2009)

Conclusion: This independent study shows that the WMT is more sensitive to poor effort than the TOMM in people asked to simulate impairment.



1) In the following study by Booksh et al., the WMT performs better than clinical judgment in classifying students asked to simulate ADHD;

2) Poor effort has a greater effect on Connors' CPT than does ADHD;

3) Clinical judgment has high false positive rate, whereas WMT has a zero false positive rate;

4) the Fifteen Item Test displays zero sensitivity (It is impossible to get worse sensitivity than that!).

Booksh, R., Pella, R., Singh & Gouvier, W. (in press) Ability of College Students to Simulate ADHD on Objective Measures of Attention. Journal of Attention Disorders.

 For pre-print, email 



Brigham Young University researchers offer strong support for the WMT as a combined test of effort and verbal memory:

Three cases described as having bilateral hippocampal damage and amnesia all passed the easy subtests of the WMT.

However, they all had profound impairment of verbal memory on the WMT memory subtests.

See this abstract:-  DISCUSSIONS/WMT_in_bilateral_hippocampal_lesions_&_amnesia.doc



Children with severe TBI easily pass but adults with mild TBI fail: How can that be?

Carone, D. Children with moderate/severe brain damage/dysfunction outperform adults with mild to no brain damage on the Medical Symptom Validity Test. Brain Injury, 2008; 22, 12, 960-971. 



German study independently shows 100% specificity for the Nonverbal-MSVT in dementia and 98.5% in whole neurological group, using profile analysis:




Low false positive rate on MSVT in dementia because of profile analysis. Note that MSVT data do not just yield 'pass' or 'fail' but that there is a specific "dementia profile", which is unlike that from simulators.  Also see "Result Interpretation" on the bar at the left on this web page.

Characterization of the Medical Symptom Validity Test in evaluation of clinically referred memory disorders clinic patients

Laura L.S. Howe, Ashton M. Anderson, David A.S. Kaufman, Bonnie C. Sachs and David W. Loring
Available online 24 July 2007.


We prospectively evaluated performance of 63 referrals to a memory disorders clinic who received the Medical Symptom Validity Test (MSVT) as part of their standard neuropsychological evaluation. The patients were grouped based on independent medical diagnoses and presence or absence of a potential financial incentive to under-perform. Twenty-seven patients (42.9%) scored below cutoffs on the MSVT symptom validity indices. Two individuals in the potential financial incentive group showed clear signs of invalid responding (18.2%). Twenty-two of the remaining 25 patients who failed the symptom validity indices corresponded to the dementia profile. Three individuals did not correspond to the dementia profile but are thought to have performed validly representing a 4.8% false positive rate. When considering all MSVT indices, the base rate of invalid responding in the potential financial incentive to under-perform group increased to 27.3%. Combining all groups our base rate of invalid responding was 4.8%. Specific performances are presented.


Shell shock: WWI film footage of victims of shell shock.


Effort in children: See the abstract in this paper on effort in children: WMT/Effort_in_Children_2006.pdf

H.M. has now left us but hear him here:-


To hear H.M., click this link and then choose "LISTEN".

 (Photo taken in St. Maarten Heineken Regatta, March 2008)


DO YOU USE THE FBS & RBS together?
If so, see Roger Gervais, P. Lees-Haley & Y. Ben Porath's poster on jointly using FBS and RBS to get better prediction of cognitive symptom exaggeration.  For the poster click links.   

2007 handout GERVAIS
2007 poster NAN GERVAIS
NAN 2007 Handout
NAN 2007 Handout

In the graph, bars show percent failing SVTs. Bar 2 is "High FBS/Low RBS" and bar 4 is"High FBS/High RBS". Note the difference in SVT failures in these two groups.  The first group is "Low FBS/Low RBS" and the fourth group is "High FBS/High RBS". 

Note on copyright: As the inventor, first author and main researcher of the WMT, MSVT, NV-MSVT & MCI, Dr. Green is the legally registered owner of copyright of the WMT, MSVT, NV-MSVT & MCI internationally. Legitimate copies of the CDs and test manuals and the licenses to use the WMT, MSVT, NV-MSVT or MCI in any format are sold only by Green's Publishing.