Forensic psychiatry lacks objective biological markers and relies on clinical methodologies inherently influenced by the evaluator's cultural background and cognitive biases. This case study, spanning 30 years of clinical and forensic assessments, highlights the challenges associated with achieving diagnostic consistency and objectivity in expert opinions. A 63-year-old man, first detained at 19 for attempted robbery and homicide, underwent multiple forensic psychiatric evaluations from 1989 to 2025. Initial assessments consistently found him not guilty by reason of insanity due to a schizophrenic disorder associated with mild intellectual disability. Recurrent diagnoses included schizophrenic syndrome, paranoid schizophrenia and delusional disorder. Expert reports for the defense and court-appointed evaluations supported this view. In 2022, significant discrepancies emerged: a collegial panel concluded that the subject was partially criminally responsible, while the Public Prosecutor's consultant proposed a dissociative disorder characterized by exaggerated symptoms, judging the subject fully criminally responsible; in contrast, the defense reaffirmed the opinion of not guilty by reason of insanity. In 2023, a new expert opinion found full criminal responsibility suggesting malingering. A further evaluation is currently ongoing (as of 2025). Over the years, a wide range of professionals applied differing methodologies with psychometric and neuroscientific tools introduced only in the most recent phase. This case illustrates how, lacking shared standards, forensic psychiatric assessments may remain vulnerable to methodological variability and individual bias. Divergent conclusions on criminal responsibility suggest standardized and multidisciplinary approaches could improve reliability and scientific rigor in forensic evaluations. However, these findings remain exploratory given the single-case nature of the report.

There are few performance-based tests assessing feigned severe psychopathology, and they tend to focus on specific diagnostic presentations. We explored how feigning impacts the Rorschach task, a typical performance test, with a preregistered meta-analysis of 21 studies (32 contrasts) comparing feigners of severe psychopathology (including experimental simulation and suspected malingering designs) to both nonclinical and clinical control groups. We investigated hypothesized Rorschach variables, controlling for the Number of Responses and adjusting for skewness when feasible. Compared with nonclinical controls, feigners simulate by increasing indicators of perception and thinking problems and exaggerating indicators of stress and distress; however, their task engagement remained similar. Relative to clinical controls, feigners provided less simplistic responses, displayed fewer thinking problems, similar perceptual difficulties, and exaggerated stress and distress indicators. We discuss three novel composites that may improve the detection of feigned severe psychopathology. These findings contribute to future research and clinical assessment in forensic contexts.

Recommended performance validity test (PVT) cutoffs may vary across examinee characteristics. This study evaluated Word Choice (WC) and Test of Memory Malingering Trial 1 (TOMM T1) cutoffs in a diverse clinical sample (41% Hispanic/Latino, 26% English/Spanish bilingual, education: 5-20 years). Logistic regressions examined predictors of performance using established cutoffs. Older age predicted reduced odds of WC valid performance. Higher education predicted increased odds of WC and TOMM T1 valid performance. Ethnicity and language were not statistically significant predictors. WC false positive rates were low (4.8%-6.5%) and did not differ by ethnicity or language. TOMM T1 false positives were higher in Hispanic/Latino and bilingual participants (13.5%-14.3%) compared to Non-Hispanic/Latino and monolingual participants (9%-10%); differences were nonsignificant. WC and TOMM T1 cutoffs appear appropriate for Hispanic/Latino and bilingual examinees, though caution is warranted given elevated TOMM T1 false positives and risk of misclassification in examinees with less education.

Forensic psychological injury evaluations often require an opinion on whether post-event symptoms are attributable to a specific accident, assault, workplace exposure, institutional event, or alleged abuse. Such opinions cannot rest on temporal sequence, clinical plausibility, or the presence of a trauma-related diagnosis alone. This conceptual analysis argues that defensible causal attribution requires coordination of three elements that are often handled separately: legal causation concepts, psychological causal reasoning, and validity assessment. The article distinguishes event occurrence, psychological injury, functional impairment, and imputability of injury to the event. It then discusses but-for causation, material contribution, proximate or legal causation in common-law settings, and the broader problem of imputability in civil-law contexts. The article further argues that performance validity tests, symptom validity tests, and broader response-validity analysis are not ancillary psychometric issues but conditions that shape the permissible strength of causal conclusions. A revised framework is proposed that distinguishes direct causation, material contributory causation, indirect causal pathways, and insufficient basis for attribution, while treating precipitating, exacerbating, accelerating, cumulative, and perpetuating effects as modifiers. The framework is positioned relative to prior work on psychological injury, malingering, and forensic evaluation, and is translated into a practical reporting sequence, a short vignette, and calibrated wording for expert reports.

A largely unrecognized feature of the Spanish Inquisition (1478-1834) was the mandatory medical evaluation of all defendants, generating a vast archive of clinical documentation that remains almost entirely unexplored by historians of neurology. The institutional need to distinguish genuine illness from malingering and demonic affliction prompted physicians to evaluate neurologic conditions including convulsions, palsy, and behavioral changes. Drawing on published scholarship and targeted searches of the Spanish national archives, we identified over 80 cases related to neurology and neuropsychiatric content. In this article, we analyze 7 of them, for illustrative purposes, involving convulsions (termed aferecía or gota coral), palsy and paralysis (perlesía), and miscellaneous brain pathology (leso de la cabeza, cerebro débil y flaco), documented between 1562 and 1700. These records reveal a tripartite diagnostic framework (physician, surgeon, and exorcist) that evolved over 2 centuries and often favored naturalistic medical explanations. Cases analyzed include the convulsive episodes of King Carlos II, whose symptoms the Suprema (the supreme governing body of the Inquisition) ruled to be natural disease rather than bewitchment, and the case of Fray Mateo de la Puebla, who was absolved on neurologic grounds after his behavioral changes were attributed to acquired CNS disease. The Inquisition archives merit further investigation as a potential source for the history of clinical neurology in the early modern period.

Malingering-traditionally defined as the intentional production of false or exaggerated symptoms for external gain-has long been treated as a unitary construct. Yet patients who feign illness do so for widely divergent reasons, from seeking material necessities to avoiding legal accountability. This paper critiques the limitations of "malingering" as a clinical category and proposes a motivation-based taxonomy of feigned symptoms: Resource-Driven Symptom Expression (RDSE), Accountability-Avoidant Symptom Expression (AASE), Care Access Symptom Expression (CASE), and Socially Motivated Symptom Expression (SMSE). By reframing feigned presentations through motive rather than symptomatology, clinicians can bring an individualized, ethical and just approach to a significant clinical challenge.

The etiology of eye malformations is complex and includes environmental and genetic factors. Identifying the etiology of an eye malformation is very important for the counseling and management of these patients. This case report illustrates the complexity in diagnosing apparently isolated ophthalmic anomalies, and the power of genetic evaluation in establishing the prognosis.

Objective: To evaluate rates of below cutoff performance (fail rates) for the Test of Memory Malingering Trial 1 (TOMM-1) and Reliable Digit Span (RDS) in a culturally and linguistically diverse community-based cognitive aging cohort. Methods: Cognitively and functionally normal adults from the Health and Aging Brain Study-Health Disparities (HABS-HD) cohort in the Dallas-Fort Worth area, free of major neurological, psychiatric, or cardiovascular conditions, were included. Fail rates were examined for TOMM-1 (≤41, ≤40) and RDS (≤6, ≤5) cutoffs, including combined thresholds, across demographic subgroups. Relative importance of sociodemographic variables was tested via regression. Results: In the normative sample, overall fail rates were higher for RDS (3.1-11.6%) than TOMM-1 (2.1-2.9%), with combined cutoffs yielding <1%. Higher fail rates occurred primarily among less educated (<12 years) and Spanish-speaking participants, with the highest among Spanish speakers on RDS (46.7%). Acceptable false-positive rates for the TOMM-1 (≤5.9%) and combined (≤3.2%) TOMM-1 and RDS were demonstrated across all evaluated groups. Language and education explained most variance in RDS scores (14.9%, 10.3%, respectively), while education and age explained most variance in TOMM-1 scores (2.3%, 1.4%, respectively). Demographic effects were more influential on RDS than on TOMM-1. Conclusions: Performance validity outcomes vary across community adults without external incentives, influenced by education and language.

Background/Objectives: Uterine fibroids are one of the most prevalent forms of benign tumors in women and may substantially impair quality of life due to heavy menstrual bleeding, pelvic pain, and pressure-related symptoms. Transvaginal radiofrequency ablation (TV-RFA) has emerged as a promising minimally invasive, uterus-sparing treatment approach. However, there exists a paucity of data regarding the early vascular response evaluated through quantitative Doppler parameters. This study aimed to assess the short-term clinical outcomes and ultrasound effectiveness of TV-RFA in treating symptomatic uterine fibroids, with particular emphasis on early vascular and morphological response. Methods: This retrospective study included 38 women who presented with symptomatic uterine fibroids and underwent TV-RFA between July 2024 and December 2025. Inclusion criteria were as follows: (1) presence of up to three intramural fibroids (FIGO types 3-6) and (2) maximum diameter of fibroids: ≤6 cm. Patients were assessed at baseline and at 1- and 3-month follow-up visits. Ultrasound evaluation included the measurement of fibroid dimensions and volume as well as quantitative Doppler parameters (Pixels Power, Ratio, and CM[2] Power Index). Clinical outcomes were assessed based on the intensity and duration of menstrual bleeding. Statistical analysis was performed using nonparametric tests with significance set at p < 0.05. Results: Significant reductions in fibroid dimensions and volume were observed at both follow-up time points, with the greatest effect at 3 months (p < 0.001). Doppler analysis demonstrated a marked decrease in vascularization parameters, particularly CM[2] Power Index and Pixels Power (p < 0.001), suggesting an early vascular response to treatment. Clinically, the proportion of patients experiencing heavy menstrual bleeding considerably reduced, accompanied by a significant shortening of bleeding duration (p < 0.001). No major complications requiring surgical intervention were reported. Conclusions: TV-RFA was associated with significant short-term reductions in fibroid vascularization, fibroid volume, and bleeding-related symptoms in this cohort of women with symptomatic uterine fibroids. Quantitative Doppler parameters may serve as valuable early markers of treatment response; however, further studies with larger cohorts and a longer follow-up duration are warranted.

Binomial probabilities are used to interpret below chance performance on forced-choice validity tests, but this does not account for variance inherent in true random responding. This study examined random responding on Trial 1 of the Test of Memory Malingering (TOMM) using a novel experimental condition. Fifty-five undergraduates completed TOMM Trial 1 under sham instructions to induce random guessing. Total scores and item-level responses were tested against exact binomial probability assumptions. Mean Trial 1 performance was 25.96/50 (SD = 3.38, range = 17-33), significantly above nominal chance, t(54) = 2.12, p = .039. A 95% probability range would be 19-33/50, with the theoretical exact range being 18-32/50. Twelve TOMM 1 items deviated significantly from .50 after correction. Sham random responding on TOMM Trial 1 closely approximated the binomial model at the total-score level, with only small item-level departures from .50 producing a slight, clinically trivial upward shift in the mean. These data empirically support the continued use of binomial-based total-score interpretation for below-chance responding, while indicating that item-level probabilities are not perfectly uniform.

Visual acuity (VA) assessment traditionally relies on patient cooperation, which can be unreliable in pediatric cases, cognitive impairment, or suspected malingering. While the visual evoked potential (VEP) provides an objective alternative, it primarily reflects the integrity of the early visual pathways and may overestimate VA in conditions like amblyopia. This concise review explores the P300 event-related potential as a promising cognitively-driven tool for objective VA estimation. A literature search was conducted to identify studies utilizing the P300-a marker of high-level cognitive processing and conscious perception-for VA estimation. Additional literature was included to provide a broader context. Unlike the VEP, which depends on physical stimulus characteristics, the P300 is elicited during conscious stimulus categorization, typically using an oddball paradigm. Therefore, P300-based VA estimation can utilize standard clinical optotypes, such as Landolt Cs, allowing for a more direct comparison with gold-standard psychophysical testing. For instance, P300-based VA mirrors psychophysical deficits in amblyopia better than VEP-based methods. The P300 serves as a valuable objective complement to traditional visual electrophysiology, bridging the gap between physiological stimulus processing and conscious perception. While challenges such as recording duration still need to be resolved, the ability to use custom-tailored stimuli offers significant potential for forensic evaluations and complex clinical cases in ophthalmology.