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PubMed1999

Factitious disorders.

Reports of factitious disorders, Munchausen's syndrome, and self-induced illness exist throughout medical history. In practice, disease simulation represents a spectrum of behaviors that range from relatively common and benign (e.g., pleading illness to avoid an unwanted social obligation) to rare and malignant forms (e.g., Munchausen's syndrome and factitious disorder by proxy). Factitious disorders are differentiated from malingering by the goal that motivates the individual's behavior. The only apparent goal in factitious illness is to gain the sick role; the goal in malingering is to gain rewards, such as compensation, or to avoid the unwanted, such as military service or jail. This article summarizes clinically relevant information on factitious disorders for primary care physicians.

Diagnosis, Differential↗
PubMed2003

Suboptimal performance on neuropsychological tests in patients with suspected chronic toxic encephalopathy.

Suboptimal performance during neuropsychological testing can seriously complicate assessment in behavioral neurotoxicology. We present data on the prevalence of suboptimal performance in a group of Dutch patients with suspected chronic toxic encephalopathy (CTE) after long-term occupational exposure to solvents. One hundred and forty-five subjects referred to one of two Dutch national assessment centers for CTE were administered the Amsterdam Short-Term Memory Test (ASTM) and the Test of Memory Malingering (TOMM), two tests specifically developed for the detection of suboptimal performance. For both tests, very cautious cut-off scores were chosen with a specificity of 99%. Results indicated that suboptimal performance appears to be a substantial problem in this group of patients with suspected CTE after long-term exposure to organic solvents. Only 54% of our subjects obtained normal scores on both tests of malingering, i.e. at or above cut-off score. The two tests seemed to measure the same concept in that nearly all the subjects with low TOMM scores also had low ASTM scores. However, a higher proportion of subjects scored below the cut-off on the ASTM than on the TOMM.

Adult↗
PubMed2002

Actual versus self-reported scholastic achievement of litigating postconcussion and severe closed head injury claimants.

Psychologists typically rely on patients' self-report of premorbid status in litigated settings. The authors examined the fidelity between self-reported and actual scholastic performance in litigating head injury claimants. The data indicated late postconcussion syndrome (LPCS) and severe closed head injury litigants retrospectively inflated scholastic performance to a greater degree than nonlitigating control groups. The LPCS group showed the highest magnitude of grade inflation, but discrepancy scores did not significantly correlate with a battery of malingering measures or with objective cerebral dysfunction. These findings support previous studies, which showed self-report is not a reliable basis for estimation of preinjury cognitive status. Retrospective inflation may represent a response shift bias shaped by an adversarial context rather than a form of malingering.

Adult↗
PubMed2002

Does the conscious exaggeration scale detect deception within patients with chronic pain alleged to have secondary gain?

OBJECTIVES: The illness behavior questionnaire (IBQ) is a test battery developed by Pilowsky to detect what he has termed abnormal illness behavior, which includes malingering. The IBQ has been widely utilized in patients with chronic pain (PWCP). Clayer developed a 21-item scale out of the IBQ, which he termed the conscious exaggeration (CE) scale. He proposed that the CE scale could detect conscious deception, i.e., malingering. The purpose of the present study is to test the CE scale in PWCP alleged to have secondary gain and thereby at greater risk for poor pain treatment outcome. It was postulated that the CE scale should generate scores in these groups significantly different from a comparison group and should predict treatment outcome in the secondary gain groups. DESIGN: A total of 96 PWCP completed the CE scale at admission and after completion of a 1-month pain facility treatment regimen. Other relevant pain variables, such as pain, depression, and anxiety, were measured and the data collected at admission and treatment completion. Work status was determined at 1, 3, 6, 12, 18, 24, and 30 months posttreatment. PWCP secondary gain subgroups (Workers' Compensation patients, patients in litigation, patients having a lawyer) were compared to the comparison group (no secondary gain factors) for treatment CE scale change scores. In order to control for the effects of pain, an analysis of covariance with pain level statistically removed was performed on admission and discharge CE scores utilizing the above patient subgroups. Pearson product correlations were utilized to determine the relationships between CE scores and psychological variables. Stepwise regression analyses were utilized to predict return to work with the CE scale score as a potential predictor. SETTING: Pain facility. PATIENTS: PWCP treated for 1 month in a pain facility. RESULTS: Overall, the analyses did not support the main hypothesis. For example, CE scale scores did not predict return to work. There was a significant degree of correlation between the variables of pain, depression, anxiety, and CE scale scores. CONCLUSIONS: PWCP characterized by the alleged secondary gain variables of Workers' compensation status, litigation, and having a lawyer did not differentially respond to the CE scale versus the comparison group. The CE scale, therefore, does not appear to be a valid instrument for identifying exaggeration in PWCP.

Journal Article↗
PubMed1997

Amsterdam Short-Term Memory test: a new procedure for the detection of feigned memory deficits.

The validity of two malingering tests, the newly developed Amsterdam Short-Term Memory (ASTM) test and the Distraction test (Baker, Hanley, Jackson, Kimmance, & Slade, 1993) was examined in a group of patients with closed-head injury (CHI), a normal control group, and a control group with instruction to feign memory deficits. Both control groups consisted of first-degree relatives of the patients. The ASTM test is a forced-choice verbal memory test, based on the technique of symptom validity testing. Stimulus material was chosen from category norms and chance level is not transparent. The CHI and normal control groups scored near ceiling on the ASTM test, whereas the feigned deficit group scored significantly worse. The ASTM test classified all subjects correctly. Contrary to expectation, the Distraction test appeared to be invalid. The score profiles of the CHI and feigning groups on conventional memory and concentration tests were indistinguishable from each other. Thus, the ASTM test may be very useful for the detection of malingering and other kinds of less than optimal performance. The test may readily be constructed in any language for which category norms are available.

Adult↗
PubMed2003

Differential brain activations during intentionally simulated and subjectively experienced paralysis.

INTRODUCTION: Distinguishing conversion disorder from malingering presents a significant challenge as the diagnosis ultimately depends on the patient's subjective report and the clinician's suspicion of an intention to deceive. Using hypnosis to manipulate the intentionality of movement inhibition in the same subjects, we used positron emission tomography (PET) to determine whether failure to move during intentionally simulated and subjectively experienced paralysis is mediated by different neural structures. METHODS: Using a within-subject design, 12 normal, hypnotised subjects were tested under two paralysis conditions during the same scanning session. Half of the scans were performed with the suggestion that the left leg was paralysed (subjectively experienced paralysis condition) and half with the leg normal but with the instruction that paralysis should be feigned (intentionally simulated paralysis condition). RESULTS: Relative increases in brain activation were seen in the right orbitofrontal cortex, right cerebellum, left thalamus, and left putamen during subjectively experienced paralysis compared to intentionally simulated paralysis, although a previously reported activation of the right anterior cingulate cortex was not seen. During intentionally simulated paralysis compared to subjectively experienced paralysis relative increases in brain activation were seen in the left ventrolateral prefrontal cortex, and a number of right posterior cortical structures. CONCLUSIONS: Our results suggest that subjectively experienced paralysis has a different neural basis to intentionally simulated paralysis. These findings have theoretical and clinical implications for malingering and related attempts to unravel the neuropsychological basis for conversion hysteria.

Journal Article↗
PubMed2000

Feigning combat-related posttraumatic stress disorder on the personality assessment inventory.

This study examined whether individuals who were instructed on the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) criteria for posttraumatic stress disorder (PTSD) could feign PTSD on the Personality Assessment Inventory (PAI; Morey, 1991). The study also investigated whether PAI indexes of symptom exaggeration, the Negative Impression Management (NIM) scale and the Malingering index, could identify individuals feigning PTSD. The diagnostic rule for PTSD (Morey, 1991, 1996) was applied to the profiles of a group of 23 veterans with combat-related PTSD and 23 male undergraduates instructed to malinger PTSD. Seventy percent of the student malingerers produced profiles that received diagnostic consideration for PTSD. The NIM cutting score (> or = 8) was highly effective in detecting simulation of PTSD but resulted in the misclassification of a large number of true PTSD cases. There were no significant differences in the overall efficiency of the test with various validity criteria. We discuss the implications of these findings for the use of the PAI in the diagnosis of combat-related PTSD.

Adult↗
PubMedDate not supplied

Clinical impedance audiometry.

This manuscript has attempted to briefly outline the most important areas of clinical impedance audiometry. The author has emphasized the use of impedance audiometry in differentiating different types of middle ear pathology and utilizing the stapedial reflex in the determination of malingering as well as an overall test of the normal function of the auditory nervous system from the inner ear to brain stem. Finally, the use of Eustachian tube function can also be utilized by the trained audiologist in determining whether or not there is Eustachian tube dysfunction. It is important to again emphasize that impedance audiometry is objective and does not involve the cooperation of the patient. Thus in the autistic child and in the child who is uncooperative, it is of particular help to the clinical otologist and audiologist. In patients who are malingering the stapedial reflex may assist in determining a valid response in routine autiometry. Finally, with special types of tests which have not been discussed in this manuscript, such as stapedial reflex decay, one may be able to determine the presence of an early acoustic neurinoma.

Acoustic Impedance Tests↗
PubMed2000

[Reliability of electrogustatory threshold--electrogustometry using CNV].

CNV (contingent negative variation), an event-related potential, is induced when an oncoming imperative stimulus (S2) is anticipated after recognition of a warning stimulus (S1). With this in mind, we assessed the usefulness of electrogustometry using CNV as an objective gustatory test with an electric gustatory stimulus as a warning stimulus, S1. A gustatory test was performed on a total of 100 sides of the tongue in 50 subjects. Excluding no response cases on 5 sides in 5 subjects, the CNV threshold was successfully determined on 95 sides in 50 subjects. When the CNV threshold values obtained and the conventionally measured subjective threshold values were compared, a very high correlation was demonstrated between the two thresholds, with a correlation coefficient of 0.961. To assess the reliability of the CNV threshold, three additional measurements on 5 sides in 5 subjects with normal subjective threshold values were performed on different days, and the CNV threshold value variation among the three measurements in all 5 subjects never exceeded 13 microA. Separately, subjective threshold and CNV threshold values were compared in 4 patients with facial palsy (hence with gustatory abnormality) who consented to a follow-up examination. The difference between the subjective threshold and CNV threshold values in all 4 patients never exceeded 10 microA. These findings demonstrate that the reliability of the CNV threshold is satisfactory. Next, a gustatory imitation experiment was performed to assess the usefulness of electrogustometry using CNV as a means of detecting gustatory abnormality malingering. The experiment was performed on a total of 6 subjects: 3 physicians with knowledge of CNV (knowledge group) and 3 others with no knowledge of CNV (no-knowledge group). The differences between the imitated threshold and the subjective threshold values in all of these subjects never exceeded 10 microA, and the difference between imitated threshold and CNV threshold values never exceeded 13 microA. Comparison between the knowledge group and the no-knowledge groups showed that the imitated threshold values were very close to the subjective threshold and CNV threshold values. Based on the above results, it was concluded that gustometry using CNV is useful and can serve well as a method of objective evaluation of gustatory sensation. The results also suggested that it will be useful in diagnosing malingering.

Adolescent↗
PubMedDate not supplied

The importance of illness behavior in disability management.

Abnormal illness behaviors, ranging from non-deliberate distortion to intentional deception, are associated with clinical phenomena that lie along a continuum from unconscious symptom exaggeration to psychiatric disorders and malingering. Failure to recognize abnormal illness behavior leads to inappropriate treatment and erroneous estimates of impairment or disability. This review is divided into three sections. First, basic terms are defined, including dissimulation, distortion, deception, misattribution, false imputation, and malingering. Second, syndromes characterized by abnormal illness behavior are described, including somatization, somatoform disorders, factitious disorders, and symptom magnification. Third, methods for detecting deception are illustrated, including maximum voluntary effort assessment, objective personality inventories, and symptom validity testing.

Disability Evaluation↗
PubMed2003

A practical method for the evaluation of symptom exaggeration in minor head trauma among civil litigants.

Forensic psychiatrists and psychologists are often called on to provide opinions and render testimony in which minor head trauma accompanied by persistent somatic, cognitive, and/or emotional symptoms is alleged. The frequency of persistent symptoms following such minor head injury is generally low. The forensic clinician therefore must differentiate between subtle brain dysfunction, symptom amplification, psychogenic-based causes for the presence of cognitive and other deficits, or frank malingering. The purpose of this article is twofold: first, to review critical issues related to the assessment of malingering and symptom exaggeration in mild head injury cases; and second, to offer a practical model for the assessment of amplified neuropsychological and psychiatric deficits in civil litigants in cases of minor head trauma.

Craniocerebral Trauma↗
PubMed2001

Detection of inadequate effort on neuropsychological testing: a meta-analytic review of selected procedures.

Thirty-two studies of commonly researched neuropsychological malingering tests were meta-analytically reviewed to evaluate their effectiveness in discriminating between honest responders and dissimulators. Overall, studies using the Digit Memory Test (DMT), Portland Digit Recognition Test (PDRT), 15-Item Test, 21-Item Test, and the Dot Counting Test had average effect sizes indicating that dissimulators obtain scores that are approximately 1.1 standard deviations below those of honest responders. The DMT separated the means of groups of honest and dissimulating responders by approximately 2 standard deviations, whereas the 21-Item Test and the PDRT separated the groups by nearly 1.5 and 1.25 standard deviations, respectively. The 15-Item Test and the Dot Counting Test were less effective, separating group means by approximately 3/4 of a standard deviation. Although the DMT, PDRT, 15-, and 21-Item Tests all demonstrated very high specificity rates, at the level of individual classification, the DMT had the highest sensitivity and overall hit-rate parameters. The PDRT and 15-Item Test demonstrated moderate sensitivity, whereas the 21-Item Test demonstrated poor sensitivity. The less than perfect sensitivities of all the measures included in this review argue against their use in isolation as malingering screening devices.

Journal Article↗
PubMed2000

The use of significant others to enhance the detection of malingerers from traumatically brain-injured patients.

Cognitive and neurobehavioral symptoms are common following traumatic brain injuries (TBIs). Because malingerers are likely to complain of such symptoms and perform poorly on neuropsychological tests, clinicians may have considerable difficulty distinguishing malingerers from TBI patients. In this study, we compared the subjective complaints of malingerers to TBI patients and then compared both groups to the problems observed by their respective significant others. We tested the assumption whether significant others could add one more piece to the challenging puzzle of diagnosing malingering. Our results demonstrated that the malingerers complained of more problems than patients who had sustained moderate or severe TBI. However, the significant others of the malingerers observed fewer cognitive, emotional-behavioral, and total problems than did the significant others of patients with severe, moderate, and even mild TBI. These findings suggest that the detection of malingering can be enhanced by interviews with significant others.

Journal Article↗
PubMed2000

The effects of two motivational manipulations on the neuropsychological performance of mildly head-injured college students.

Recently, much research has focused on the development and utilization of various motivational assessment techniques designed to identify malingered neuropsychological test performance. Other findings have suggested a strong link between the motivation of the subject and the degree to which the neuropsychological test results validly represent the individual's true level of functioning. However, the majority of the empirical work in this area has focused on only one end of the motivational spectrum, decreased motivation. In order to obtain a more complete assessment of the relationship between motivation and neuropsychological of test results, the present study involved an evaluation of the effects of motivational differences on test performance across three levels of motivation: high, low, and standard in 75 head-injured college students. Results supported past research showing significant decreases in test performance by participants given individual financial incentives (25.00 US dollars) to perform poorly. Additionally, the sensitivity of several malingering tests to this response set was supported. However, no reliable differences were found on neuropsychological or motivational tests between the group given financial incentives (25.00 US dollars) to perform well and the standard instruction group.

Journal Article↗
PubMed1998

Discriminant function analysis of malingerers' and neurological headache patients' self-reports of neuropsychological symptoms.

Interpretation of a patient's neuropsychological examination involves the determination of the role motivational and psychiatric factors may have played. The ability to detect malingering becomes crucial, particularly when the examination occurs as a result of litigation. Moreover, falsely identifying a performance as distorted has serious consequences for the patient. The present study was conducted to replicate previous research that discriminated between malingered and nonmalingered responses to a neuropsychological self-report inventory. An overall hit rate of 84% for malingerers and neurologic headache patients demonstrated replication of the inventory's ability to identify malingerers. Of those predicted to be malingerers, 27% were false positives indicating the need to use this inventory in conjunction with other neuropsychological measures.

Journal Article↗
PubMed2004

[Psychogenic disorders: concepts, terminology and classification].

The neurological interest on functional or psychogenic disorders (mental or physical disturbances with no organic basis, generally unleashed by stressful situations) has been receiving increasingly more interest over the last few years. In this article we review concepts, terms and classifications of these disorders, very different over time and among different authors. Psychogenic disorders are divided into: a) dissociation (with memory, consciousness and self-identity impairment), and b) disturbances with somatizations, divided into somatoform (unconscious), factitious (voluntary search for patient's role) and malingering (searching for material gain). Special emphasis is placed on conversion or hysteria, included in somatoform disorders. New findings in functional neuroimaging are analyzed. These new data suggest an important role of unconscious and involuntary inhibition in loss of volition (similar to hypnosis and different from malingering). Normal activity in certain brain areas (motor or sensory cortex) is blocked by other areas related to emotional integration (anterior cingular and orbitofrontal cortex). The neurologist's role is important to achieve an early diagnosis of psychogenic disturbances, particularly conversive ones. This means the use of fewer economic resources and better prognosis for the patient.

Dissociative Disorders↗
PubMed1979

Functional overlay: an illegitimate diagnosis?

Functional overlay is not a recognized psychiatric diagnosis. Evaluating functional overlay and differentiating between this concept and organic conditions is important in medicolegal areas in which financial values are placed on pain and disability. Functional overlay is not malingering: the former is based on preconscious or unconscious mechanisms, the latter is consciously induced. In considering psychologic reactions to pain and disability, a gradient of simulation, malingering, symptom exaggeration, overvaluation, functional overlay and hysteria is useful. The dynamics of overlay are a combination of anxiety from body-image distortion and depression from decreased efficiency of the body, as well as the resulting psychosocial disruption in a patient's life.

Body Image↗
PubMed1983

Hysterical conversion reactions: some patient characteristics and treatment team reactions.

Paralysis due to an hysterical conversion reaction may require an active rehabilitation program to prevent complications such as contractures and adhesions. The delivery of this care can create an emotional burden on the rehabilitation staff due to their awareness of the psychiatric etiology of this condition. Good patient care may be undermined by the thought that the patient is malingering. This paper explores features of hysteria--its relation to emotional stress, absence of organic pathology and symbolism--and contrasts it to malingering. The impact of this condition on the treatment staff is explored with two case studies. An understanding of hysteria could make the delivery of proper care to these troubled patients less stressful.

Adolescent↗