Brain Injury, July 2005; 19(7): 539–543

REVIEW

The Rey 15-item memory test for malingering: A meta-analysis

L. REZNEK

University of Toronto, Toronto, Ontario, Canada

(Received 12 January 2004; accepted 12 July 2004)

Brain Inj Downloaded from informahealthcare.com by Northeastern University on 11/04/14

Abstract
Background: The Rey 15-Item Memory Test (RMT) is frequently used to detect malingering. Many objections to the test
have been raised. Nevertheless, the test is still widely used.
Objective: To provide a meta-analysis of the available studies using the RMT and provide an overall assessment of the
sensitivity and specificity of the test, based on the cumulative data.
Results: The results show that, excluding patients with mental retardation, the RMT has a low sensitivity but an excellent
specificity.
Conclusions: These results provide the basis for the ongoing use of the test, given that it is acceptable to miss some cases of
For personal use only.

malingering with such a screening test, but one does not want to have many false positives.

Keywords: Malingering, Rey

Introduction is very simple because of the redundancy among

There is growing evidence that there is an element
of malingering in many cases where patients are in
litigation and claiming brain damage. Binder and
Rohling [1] assess that 23% of all cases of closed
head injuries would not be professing disability
if financial compensation were eliminated. This is
an alarming statistic and suggests that financial
incentives play a significant role in these cases.
Interestingly, these authors show that those patients
who were less severely injured were more likely to seek
monetary compensation. What is urgently needed,
then, is a reliable test to detect such cases.
Rey [2] proposed such a test. The RMT is a quick,
easily administered test used to detect the malinger-
ing of memory impairment. The test consists of five
rows of three characters each on a card (A B C,
1 2 3, a b c, œ
i, I II III). Subjects are shown
the card for 10 seconds and told to study it carefully
in order to try to remember as many of the items as
they can. The RMT is presented to subjects as a very
difficult memory test consisting of having to remem-
ber as many as 15 different items. In fact, the test
items, and even patients with significant impairment
can perform the test without difficulty. However, it is
assumed that malingerers will not know this. Instead,
they will reason that, in order to register a result of
being memory impaired, they will have to recall
only a few items. Thus, patients with impairment
will do well on the test, while malingerers will do
poorly, enabling one to identify them.
Many guidelines have been presented in using this
test. Goldberg and Miller [3] examined the perfor-
mance of patients with severe psychiatric disorders
and patients with mental retardation. Based on
their finding that none of the patients with psychi-
atric disorder recalled fewer than nine items, these
investigators proposed a cut-off of less than nine
for identifying individuals exaggerating memory
impairment. Excluding the patients with mental
retardation, this gave the RMT a specificity of 100%.
Bernard and Fowler [4] examined the perfor-
mance of patients with brain damage (most of
whom had received a significant head injury) in com-
parison to normal controls. They confirmed that

Correspondence: L. Resnek, MD, University of Toronto-Sunnybrook and Women’s Health Sciences Centre, 2075 Bayview Ave., Toronto, Ontario MN4 3M5,
Canada. E-mail: ashaki.adonis@sw.ca
ISSN 0269–9052 print/ISSN 1362–301X online # 2005 Taylor & Francis Group Ltd
DOI: 10.1080/02699050400005242
 540 L. Reznek
using a cut-off of nine items was able to exclude the
vast majority of the cases with brain damage from
being classified as malingerers. A score of eight or
less was recommended in identifying individuals
exaggerating memory difficulties. Their results gave
the RMT a specificity of 94%.
Schretlen et al. [5] compared subjects who were
instructed to malinger amnesia with patients from
several clinical groups (for example, those with
brain damage, severe psychiatric disorders and
dementia). Using the cut-off of nine (recall of eight
or less items), these investigators found that the
RMT has a sensitivity of 12% and a specificity of
73%.
Lee et al. [6] tested the utility of the RMT using
Brain Inj Downloaded from informahealthcare.com by Northeastern University on 11/04/14
a group of patients with neurological disorders
(suffering from temporal lobe epilepsy). They
found that a cut-off of nine was too demanding for
this group of patients and generated an unacceptably
low specificity, identifying many of the patients
with neurological disorders as malingerers. They
proposed instead a cut-off of eight as a better
standard—scores of seven or less gave the RMT
a specificity of 96%. That is, it classified 96% of
For personal use only.
the non-malingerers correctly as non-malingerers.
Guilmette et al. [7] administered the RMT to a
group of non-litigating individuals with moderate-
to-severe brain damage, psychiatric in-patients with
depression and a group of normal subjects asked to
fake memory impairment. Using a cut-off of seven
or less items as suggested by the above study, 40%
of the group with brain damage and 20% of the
psychiatric in-patients with depression would have
been identified as malingerers. On the other hand,
the same cut-off gave the RMT a sensitivity of
only 5%.
Taylor et al. [8] challenged these latter findings.
They tested a group of patients with severe brain
injury and found that all of them were able to score
a perfect 15/15 on the RMT. This suggests that per-
haps a higher standard would be more appropriate
even for patients with severe brain damage. On
their results, a cut-off of nine gave the RMT
a specificity of 100%.
Arnett et al. [9] used the RMT to detect malinger-
ing in a group of patients with neurological disorder
and a group of subjects instructed to simulate
memory impairment. A cut-off of less than two com-
plete rows correct gave the RMT a sensitivity of 64%
and a specificity of 96%. However, the usual cut-off
of nine (that is, a score of eight or less items recalled)
gave the test a specificity of 100%, but a sensitivity
of 5%.
Hays et al. [10] examined the performance of
patients with psychiatric disorder on the RMT.
They found that IQ accounted for 37% of the
variance in scores. Those patients with psychiatric
disorder and a low IQ not uncommonly scored
below the cut-off score of nine previously suggested.
This demonstrated that, for those patients with
psychiatric disorder and mental retardation, the
RMT was not very specific and identifies many
non-malingerers as malingerers. This is consistent
with the original findings of Goldberg and Miller
[3]. Excluding those patients with psychiatric dis-
order and mental retardation (that is, who had an
IQ less than 70), the RMT had a specificity of 85%.
Simon [11] tested the RMT by comparing 14
diagnosed malingerers with 14 forensic in-patients
who had been acquitted by reason of insanity. He
found that a cut-off of nine was useful in identifying
86% of the malingerers. That is, remembering more
than eight items excluded 86% of the non-malinger-
ing group and included 86% of the malingering
group as malingerers.
Lee et al. [12] used the RMT to assess the cogni-
tive performance of 64 older patients with major
depression. They found that the cut-off of nine
gave the RMT a specificity of over 95%.
With all these results, some conflicting, there is a
need to provide guidelines for the use of the RMT.
The method adopted in this study was to pool all
these data and generate an overall assessment of
the sensitivity and specificity of the RMT.
Method
An Internet search for studies using the RMT was
undertaken. Studies were gathered that had exam-
ined the use of the RMT. Some studies had to be
discarded, as they did not provide sufficient informa-
tion on the way that individual subjects had scored,
so that their data could not be pooled. A total of 13
studies were gathered [3–15]. Their results were
pooled to generate the overall results.
Results
Assuming a cut-off of nine (that is, those scoring
eight or less are identified as malingering), 837 out of
983 patients who were not malingering were
identified as not malingering. This gives the RMT
a specificity of 85%. Using the same cut-off of nine,
70 out of 192 malingerers were identified as
malingerers. This gives the RMT a sensitivity of
36% (see Tables I and II).
Adopting a cut-off of eight (that is, those scoring
seven or less are identified as malingering), 853
out of 925 patients who were not malingering were
 Rey 15-item memory test 541

Table I. Specificity.

Ratio of Ratio of
not malingering not malingering
Study Subjects at cut-off <9 at cut-off <8

Goldberg and Miller [3] Subjects with psychiatric disorder 50/50 50/50
Goldberg and Miller [3] Subjects with mental retardation 10/16 ?
Bernard and Fowler [4] Normal subjects 16/16 16/16
Bernard and Fowler [4] Subjects with brain damage 18/18 18/18
Simon [11] Mentally ill forensic cases 12/14 ?
Taylor et al. [8] Subjects with severe brain damage 5/5 5/5
Schretlen et al. [5] Normal 80/80 80/80
Schretlen et al. [5] Subjects with brain injury 55/55 55/55
Schretlen et al. [5] Subjects with severe psychiatric disorder 40/40 40/40
Schretlen et al. [5] Subjects with mixed dementia 8/9 9/9
Schretlen et al. [5] Subjects with neuropsychiatric disorder 26/34 34/34
Schretlen et al. [5] Subjects with amnesia 8/10 10/10
Lee et al. [6] TLE 93/100 96/100
Brain Inj Downloaded from informahealthcare.com by Northeastern University on 11/04/14

Lee et al. [6] Subjects with neurological disorders 37/40 38/40

Lee et al. [6] Subjects with depression 61/64 64/64
Bernard [14] Controls 21/28 ?
Guilmette et al. [7] Subjects with brain damage 18/20 18/20
Guilmette et al. [7] Subjects with depression 11/20 12/20
Beetar and Williams [13] Normal 30/30 30/30
Hays et al. [10] Subjects with psychiatric 24/74 49/74
disorder w/IQ <70
Hays et al. [10] Subjects with psychiatric 180/226 195/226
disorder w/IQ <70
Arnett et al. [9] Subjects with neurological disorder 34/34 34/34
For personal use only.

All studies All subjects 837/983 ¼ 85% 853/925 ¼ 92%

All studies All subjects except subjects with 803/893 ¼ 90% 804/851 ¼ 95%
mental retardation

Table II. Sensitivity.

Ratio of Ratio of
not malingering not malingering
Study Subjects at cut-off <9 at cut-off <8

Simon [11] Malingerers 12/14 ?

Schretlen et al. [5] Suspected fakes 6/7 4/7
Schretlen et al. [5] Fake amnesia 0/47 0/47
Lee et al. [6] Subjects with neurological 6/16 6/16
disorder in litigation
Bernard [14] Malingerers 43/58 ?
Guilmette et al. [7] Normals malingering 3/20 1/20
Beetar and Williams [13] Normals malingering 0/30 0/30
All studies All subjects 70/192 ¼ 36% 11/120 ¼ 9%

identified as such. This gives the RMT an enhanced
specificity of 92%. Using the same cut-off of seven or
less items recalled, 11 out of 120 malingerers were
identified as such. This gives the RMT a sensitivity
of 9% (see Tables I and II).
Excluding those patients with mental retardation
and using the cut-off of nine, 803 out of 893 patients
who were not malingering were identified as such.
This gives the RMT a specificity of 90%. If those
patients with mental retardation are excluded and
the cut-off of eight used, 804 out of 851 patients
who were not malingering were identified as such.
This gives the RMT a specificity of over 95% (see
Tables I and II).
Discussion
The specificity of a test is defined as the capacity
of that test to identify only those patients that the
test is designed to identify. Specificity is calculated
by finding the ratio of true negatives to the sum of
the true negatives and the false positives [16]. That
 542 L. Reznek
is, specificity ¼ true negatives/true negatives þ false
positives. A test with 100% specificity implies that no
one without the condition is identified as having that
condition. A test that is highly specific has very few
false positives—that is, people identified as having
the condition who, in fact, do not have it.
The sensitivity of a test is defined as the capacity of
that test to identify patients that the test is designed
to identify. Sensitivity is calculated by finding the
ratio of true positives to the sum of the true positives
and the false negatives [16]. That is, sensitivity ¼ true
positives/true positives þ false negatives. A test with
100% sensitivity is one that is able to classify all of
the patients with the condition as having that condi-
tion. A test that is highly sensitive has very few false
Brain Inj Downloaded from informahealthcare.com by Northeastern University on 11/04/14
negatives—that is, people who have the condition
who are not identified as having it.
Clearly, the sensitivity of a test and the specificity
of a test are competing virtues. That is to say, a test
that is highly sensitive in that it captures all those
who have the condition is likely to achieve this at
the expense of specificity—that is, it is likely to also
identify some patients who do not have the condition
as having it. By setting the standard very low (to
exclude false negatives), it is likely that patients
For personal use only.
who do not have the condition will get identified as
having it. On the other hand, a test that is highly
specific and ensures that no one who does not have
the condition is identified as having it, will likely
not be very sensitive. By setting the standard very
high (to exclude false positives), it is likely to miss
many patients who do, in fact, have the condition.
This is exactly the case with the RMT. If the cut-
off is set low, then one is likely to miss many patients
who are in fact malingering. On the other hand, the
good thing about setting a low cut-off score is that
there will be very few false positives. If the cut-off
is set high, then one may be able to identify many
malingerers. However, one is likely to identify
many patients who are not malingering as
malingerers. How should the cut-off be selected?
Should it be set low, to exclude false positives? Or
should it be set high, to exclude false negatives?
To answer this question, one must turn to ethics.
The cost of misidentifying a non-malingerer as a
malingerer is greater than the cost of missing a
malingerer by incorrectly classifying him as a non-
malingerer. This is why the justice system presumes
innocence and requires the law to prove guilt
beyond reasonable doubt. This high legal standard
is there to exclude the worst option—that of convict-
ing an innocent person. For the same reason, then,
a test should be chosen that minimizes the chance
of classifying a non-malingerer as malingering.
Therefore, one should aim to exclude false positives
and choose a cut-off that generates a high specificity
at the cost of a high sensitivity.
If one is going to use a test to arrive at a damning
assessment (of malingering), one wants most of all to
have the test highly specific. It is worth letting a
number of malingerers escape detection and having
a test of low sensitivity in favour of being sure that
when someone is identified as malingering it is very
unlikely that he is not. For this reason, when using
the RMT, one should use it only with those who
do not have mental retardation and set the cut-off
at seven correct items, giving a specificity of greater
than 95%. While this gives the RMT a very low
sensitivity (of only 10%), this is a trade-off worth
making.
This meta-analysis is limited in that it only exam-
ined studies where the raw data is available or could
be inferred from the papers. It is also limited in that it
only examined the quantitative response to the
RMT. Other studies looking at the qualitative differ-
ences in the results were not explored. Larger studies
are needed using multiple measures of malingering
to further evaluate the use to the RMT.
It must also be stressed that malingering is a clin-
ical judgement and cannot be made on the basis of a
single test result alone. Other factors such as the pre-
sence of financial incentives, marked discrepancy
between subjective complaints and the objective clin-
ical presentation, inconsistencies, bizarre and unphy-
siological symptoms not normally encountered in
neurologic and psychiatric practice and the use of
other tests to elicit malingering of cognitive deficits,
such as the Test of Memory Malingering [17],
should be taken into account. All these factors
should be used to arrive at a clinical judgement
of malingering. However, in the end, malingering
can only be confirmed with 100% confidence if the
person either confesses to it or is observed not to
be disabled, even though he claims he is.
Acknowledgements
I would like to thank Professor Anthony Feinstein for
his helpful review of the earlier draft.
References
1. Binder LM, Rohling ML. Money matters: A meta-analytic
review of the effects of financial incentives on recovery after
closed-head injury. American Journal of Psychiatry
1996;153:7–10.
2. Rey A. The Clinical Examination in Psychology. Paris:
University Press of France; 1964.
3. Goldberg JO, Miller HR. Performance of psychiatric
in-patients and intellectually deficient individuals on a task
that assesses the validity of memory complaints. Journal of
Clinical Psychology 1986;42:793–95.
4. Bernard LC, Fowler W. Assessing the validity of memory
complaints: Performance of brain-damaged and normal indi-
viduals on Rey’s task to detect malingering. Journal of Clinical
Psychology 1990;46:434–36.

5. Schretlen D, Brandt J, Krafft L, Van Gorp W. Some
caveats in using the Rey 15-item memory test to detect
malingered amnesia. Psychological Assessment 1991;3:
667–72.
6. Lee GP, Loring DW, Martin RC. Rey’s 15-item visual
memory test for the detection of malingering: Normative
observations on patients with neurological disorders.
Psychological Assessment 1992;4:43–6.
7. Guilmette TJ, Hart KJ, Guiliano AJ, Leininger BE. Detecting
simulated memory impairment: Comparison of the Rey
fifteen-item test and the Hiscock forced-choice procedure.
Clinical Neuropsychologist 1994;8:283–94.
8. Taylor LA, Kreutzer JS, West DD. Evaluation of malingering
cut-off scores for the Rey 15-item test: A brain injury case
series. Brain Injury 2003;17:295–308.
9. Arnett PA, Hammeke TA, Schwartz L. Quantitative and
qualitative performance on Rey’s 15-item test in neurological
patients and sissimulators. Clinical Neuropsychologist
Brain Inj Downloaded from informahealthcare.com by Northeastern University on 11/04/14
1995;9:17–26.
10. Hays JR, Emmons J, Lawson KA. Psychiatric norms for the
Rey 15-item visual memory test. Perceptual and Motor Skills
1993;76:1331–34.
For personal use only.
Rey 15-item memory test 543
11. Simon MJ. The use of the Rey memory test to assess
malingering in criminal defendants. Journal of Clinical
Psychology 1994;50:914–17.
12. Lee A, Boone KB, Lesser I, Wohl M, Wilkins S, Parks C.
Performance of older depressed patients on two cognitive
malingering tests: False positive rates for the Rey 15-item
memorization and dot counting tests. Clinical
Neuropsychologist 2000;14:305–8.
13. Beetar JT, Williams JM. Malingering response styles on the
memory assessment scales and symptom validity tests.
Archives of Clinical Neuropsychology 1994;10:52–72.
14. Bernard LC. Prospects for faking believable memory deficits
on neuropsychological tests and the use of incentives in
simulation research. Journal of Clinical and Experimental
Neuropsychology 1990;12:715–28.
15. Hays JR, Emmons J, Stallings G. Dementia and mental
retardation markers on the Rey 15-item visual memory test.
Psychological Reports 2000;86:179–82.
16. Tombaugh T. Test of Memory Malingering. New York:
MHS; 1996.
17. Altman DG. Practical Statistics for Medical Research.
London: Chapman & Hall; 1991.