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PubMed1997

Factitious renal colic.

OBJECTIVES: We reviewed our experience with patients with factitious disorders who presented with renal colic to identify their common characteristics and to quantify the cost burden placed on the health care system as a result. METHODS: We retrospectively reviewed the medical records of two Philadelphia area hospitals from 1989 to 1995 to find patients with factitious disorders who presented with renal colic. A control group of patients with nephroureterolithiasis was also identified. RESULTS: We identified 12 patients who presented with renal colic and had a final diagnosis of Munchausen's syndrome or malingering. The incidence of factitious renal colic was 0.6%. Eighty-three percent of these 12 patients were men, had an average age of 32 years, and made a total of 18 hospital visits. Ninety-two percent claimed an intravenous contrast allergy, 25% claimed an allergy to a specific narcotic, and 39% of the hospital visits ended with the patient voluntarily discharged against medical advice. Thirty-three percent were treated elsewhere for similar complaints. Only the number of intravenous contrast allergies and the number of patients leaving against medical advice were statistically different from the control group. The total cost for all factitious visits was $52,452, with a mean cost per visit of $2914. The average bill of those patients who received retrograde pyelograms was $3046 greater than for those who did not. CONCLUSIONS: Factitious disorders should be considered when evaluating patients with an intravenous contrast allergy and renal colic. These patients are likely to leave against medical advice and place a significant cost burden on hospitals.

Adult↗
PubMed2003

Psychogenic seizures: clinical features and psychological analysis.

Approximately 25-30% of patients referred to epilepsy centers for refractory epilepsy are found to have nonepileptic seizures (NES). In many cases psychological assessments are performed to evaluate for underlying psychiatric disorders. The authors analyzed the clinical features of 23 patients with NES and correlated the features with underlying psychological status. Thirteen of the twenty-three patients (56.5%) had motor manifestations and 10 presented with limpness and unresponsiveness. There was no significant difference in the occurrence of depression, anxiety, posttraumatic stress disorder, or malingering between patients with limpness and those with motor manifestations. However, only patients with motor manifestations had a history of sexual and physical abuse. Those with limp and unresponsive presentations were less likely to have a history of sexual and/or physical abuse. This finding may help treating physicians to choose optimum psychiatric treatment for patients with NES. Additional studies are needed to clarify the association.

Adolescent↗
PubMed2002

Facial expression of pain: an evolutionary account.

This paper proposes that human expression of pain in the presence or absence of caregivers, and the detection of pain by observers, arises from evolved propensities. The function of pain is to demand attention and prioritise escape, recovery, and healing; where others can help achieve these goals, effective communication of pain is required. Evidence is reviewed of a distinct and specific facial expression of pain from infancy to old age, consistent across stimuli, and recognizable as pain by observers. Voluntary control over amplitude is incomplete, and observers can better detect pain that the individual attempts to suppress rather than amplify or simulate. In many clinical and experimental settings, the facial expression of pain is incorporated with verbal and nonverbal vocal activity, posture, and movement in an overall category of pain behaviour. This is assumed by clinicians to be under operant control of social contingencies such as sympathy, caregiving, and practical help; thus, strong facial expression is presumed to constitute and attempt to manipulate these contingencies by amplification of the normal expression. Operant formulations support skepticism about the presence or extent of pain, judgments of malingering, and sometimes the withholding of caregiving and help. To the extent that pain expression is influenced by environmental contingencies, however, "amplification" could equally plausibly constitute the release of suppression according to evolved contingent propensities that guide behaviour. Pain has been largely neglected in the evolutionary literature and the literature on expression of emotion, but an evolutionary account can generate improved assessment of pain and reactions to it.

Adaptation, Physiological↗
PubMed2003

Detecting color vision in a malingerer.

A patient describing himself as totally color blind was ordered by the judicial system to have his color vision investigated in order to establish his suitability for military service. Basic clinical (Farnsworth Panel D-15, Moreland and Rayleigh anomaloscope equations), electroretinographic (ERG) and psychophysical techniques (spectral sensitivities) were applied to determine the extent of his color discrimination performance and cone function. These standard procedures were complemented by a test for cone interaction (transient tritanopia) and by newly developed cone-isolating flicker large-field ERG recordings. The patient's data consistently indicate the function as well as the functional interaction of the middle-wavelength-sensitive (M-) and the short-wavelength-sensitive (S-) cones. But the function of the long-wavelength-sensitive (L-) cones was completely absent. Hence the patient was correctly demonstrated to be a protanope. This study establishes that standard classical procedures, in combination with newly developed and easy to apply psychophysical and ERG ones, which can be reliably used to assess true color discrimination performance, in difficult cases of malingering.

Adult↗
PubMed2003

MMPI-2 F scale elevations in adult victims of child sexual abuse.

The present study assessed whether the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) F scale elevations may reflect genuine trauma-related distress and/or psychopathology, rather than malingering, in a clinical sample of adult child sexual abuse (CSA) victims. Eighty-eight women seeking outpatient treatment for CSA after-effects participated. Self-report measures of dissociation, posttraumatic stress, depression, and family environment individually correlated significantly with F, and collectively accounted for 40% of its variance. Dissociation was the strongest predictor. Findings suggest that high F elevations may reflect genuine problem areas often found among CSA victims, rather than symptom overreporting.

Adolescent↗
PubMed2003

Detection of nonorganic visual loss with a new optotype chart in simulated malingerers.

BACKGROUND: We tested a new distance and pocket optotype chart for detection of nonorganic symmetrically decreased vision in simulated malingerers. The new optotype used in the charts is based on a subjective contour formed by a misalignment of two line segments. The minimum angle of resolution of this optotype is independent of its size. Subjects claiming to see only the larger optotypes are suspected of malingering. SUBJECTS AND METHODS: 90 normal subjects were asked to simulate symmetrically decreased vision. 60 of these subjects were tested with a distance chart and 30 with a pocket chart. The distance chart was always presented at a fixed distance of 5 m. The pocket chart was moved towards the malingerer until the largest optotype was clearly legible. RESULTS: With the distance chart, 62 % (37/60) of all simulated patients claimed to recognize only the larger optotypes, 33 % (20/60) claimed not to recognize any optotype size, and 5 % (3/60) were able to read all optotype sizes. With the pocket chart, 84 % (25/30) of all simulated patients claimed to recognize only the larger optotypes, 3 % (1/30) claimed not to recognize any optotype size, and 13 % (4/30) were able to read all optotype sizes. The difference between the two distributions of behavior was statistically significant (chi-square statistic, P < 0.005). CONCLUSIONS: Movement of the chart towards the subject (pocket chart) was better at detecting nonorganic visual loss than using a fixed distance (distance chart). Therefore, we suggest to use the pocket chart for the detection of nonorganic disease.

Chi-Square Distribution↗
PubMed2003

Using the TOMM for evaluating children's effort to perform optimally on neuropsychological measures.

Suboptimal effort is a threat to the validity of neuropsychological evaluations. Numerous papers have been devoted to this subject and a large number of measures have been developed in an attempt to detect suboptimal effort. To date, however, the clinical literature has focused almost exclusively on identifying suboptimal effort in adults, whereas suboptimal effort among children has not been addressed thoroughly in the clinical neuropsychological literature. The present study investigated whether or not already established effort measures could be used with children. The Test of Memory Malingering (TOMM) and the Rey-15-item test were administered to 128 children in two sites, the USA and Cyprus. The results indicated that the TOMM has the potential to be used as a measure for identifying children who do not put forth maximal effort during neuropsychological evaluations. In contrast, the Rey-15-item test does not appear to be a promising measure of effort for use with children, especially younger children.

Child↗
PubMed1999

P300 as an index of recognition in a standard and difficult match-to-sample test: a model of amnesia in normal adults.

Earlier research has supported the use of a P300 (P3)-based procedure to detect simulated amnesia. In the present experiment, an attempt was made to model the behavior and event-related potentials (ERPs) that amnestic patients might demonstrate with relatively easy recognition memory tests, by increasing the difficulty of a match-to-sample recognition memory test taken by 18 memory-unimpaired undergraduates. None of the participants in the modeled amnesic condition were classified as having intact recognition memory as the result of P3-based intra-individual tests (specificity = 100%). The results support the utility of a P3 procedure for the detection of malingering by demonstrating the procedure to be a valid measure of impaired recognition with this model of amnesia.

Adult↗
PubMed2001

Symptom validity testing: a critical review.

This paper provides a comprehensive review of the published literature on symptom validity tests (SVT) and, with the accompanying tables, serves as a reference to assist in their selection, interpretation, and defense. Because malingering is inherently an applied problem that frequently arises in a medico-legal context, the use of SVTs must meet certain standards. Thus, a number of methodological and theoretical weaknesses of SVT research which limit the use of SVTs as clinical tools and sources of evidence are highlighted. These criticisms incorporate recommendations which must be addressed if conclusions based on SVT data are to meet the increasingly rigorous standards for the admissibility of scientific evidence.

Brain Injury, Chronic↗
PubMed2001

Efficacy of the full and abbreviated forms of the Portland Digit Recognition Test: vulnerability to coaching.

The present study compared the efficacy of the abbreviated and the full scale PDRT in simulated malingerers and effortful controls. A total of 80 undergraduates were randomly assigned to normal effort, naïve simulators, informed simulators, and simulators with information and warning about malingering detection groups. Comparison shows abbreviated forms are superior to the full scale PDRT at detecting malingerers. The conservative abbreviated form detected 80% of the Naïve and Informed malingerers and 35% of the Warned. Warned Simulators were overall better at avoiding detection than Naïve or Informed Simulators.

Adolescent↗
PubMed2001

Validation of the computerized assessment of response bias in litigating patients with head injuries.

The detection of malingering in neuropsychological assessment requires valid measures of incomplete effort. The Computerized Assessment of Response Bias (CARB) is a digit-recognition procedure designed to detect poor effort during a neuropsychological evaluation. We examined the CARB performance of a consecutive series of litigating patients (N = 119) with a full range of head-injury severity, from trivial to severe. Patients with trivial or mild head injuries performed more poorly than did patients with frank brain injuries. Specifically, patients with moderate to severe traumatic brain injuries obtained higher total scores and demonstrated briefer response latencies than did patients with trivial or mild head injuries.

Adult↗
PubMed2002

Validity indicators within the Wisconsin Card Sorting Test: application of new and previously researched multivariate procedures in multiple traumatic brain injury samples.

The Wisconsin Card Sorting Test (WCST) is a popular neuropsychological measure of executive dysfunction that has been researched with regard to invalid performances, a subset of which in a forensic context could be associated with malingering. In the first of three studies, WCST multivariate approaches identified in prior research (Bernard, McGrath, & Houston, 1996; Suhr & Boyer, 1999), as well as newly created variables, were used to differentiate 33 chronic traumatic brain injury (TBI) patients with good effort and 27 patients with probable insufficient effort (IE). Newly created variables that were derived logically based upon hypotheses regarding strategies that might be employed by malingerers were not effective in differentiating TBI and IE groups. Application of previously researched validity indicators based upon commonly used WCST variables, individually, and within new logistic regression findings were reasonably effective in differentiating TBI and IE groups. In order to determine whether results would vary in different TBI samples, these validity indicators were examined in Study 2 with 75 moderate and severe, acute TBI rehabilitation patients whose posttraumatic amnesia had just resolved. Statistically significant differences were present between the IE group of Study 1 and the rehabilitation patient group of Study 2 on failures to maintain set, number of trials to achieve first correct category, and number of categories completed. All these measures were performed more poorly by the IE group. However, previously used multivariate approaches and the logistic regression analysis developed in Study 1 ranged widely in the degree to which Study 2's more acute rehabilitation patients were correctly classified. Specifically, the discriminant function of Bernard and colleagues correctly classified 73% and the Suhr and Boyer logistic regression correctly classified 75% of the Study 2 participants. The Study 1 logistic regression classified 97% of the Study 2 participants correctly. In Study 3, 130 mild to severe TBI patients in the VA system were studied. The Study 1 IE group performed significantly worse than the more acute and more severe VA TBI group on all 10 common WCST variables of interest. Application of the three multivariate procedures resulted in good to excellent classification rates: Suhr and Boyer logistic regression 85%, Bernard et al. discriminant function 85%, and Study 1 logistic regression 99%. The aggregate discussion of the three studies focuses on apparent differences in samples associated with varying degrees of success in identifying TBI patients. Application of these validity indicators in forensic situations should consider that some of these multivariate approaches possess possible classification limitations associated with chronicity and severity of the reported TBI. Only the Study 1 logistic regression demonstrated improved classification rates with the more acute and severe patients of Study 2 and Study 3. As with all validity indicators, use of any WCST IE criteria in isolation would not be appropriate.

Adult↗
PubMed2003

The Memory Assessment Scales in the detection of incomplete effort in mild head injury.

Despite differences in the constructs measured, the Memory Assessment Scales (MAS) remain an alternative to the Wechsler Memory Scales (WMS) as a broad-band instrument for assessing multiple aspects of attention and memory. Although a number of studies have examined indices of the WMS as indicators of malingering, few studies have similarly investigated the MAS. In this study, we examined the degree to which the MAS was effective in detecting incomplete effort in a clinical sample of patients referred for neuropsychological evaluation after mild head injury. Included in the sample were 21 financially compensable (FC) participants with alleged mild head injury and 21 participants who were not involved in litigation and suffered more serious head injuries. Examination of the four MAS domain indices indicated that Short-Term Memory was most useful at identifying incomplete effort. We also examined subscales of the MAS. Consistent with previous findings, brief tests such as Verbal and Visual Span had high rates of diagnostic sensitivity and specificity. Although tests based on a forced-choice recognition paradigm (e.g., Immediate and Delayed Visual Recognition) predicted group membership above chance levels, they failed to significantly add to prediction above Verbal and Visual Span subtests.

Adult↗
PubMed1999

Detecting the faking of amnesia: a comparison of the effectiveness of three different techniques for distinguishing simulators from patients with amnesia.

This paper compared the effectiveness of three different procedures that have been put forward as possible ways of distinguishing patients with genuine memory problems from those who are attempting to simulate amnesia. The performance of 20 patients with amnesia was compared with the performance of 20 normal control individuals and 20 normal individuals who had been asked to simulate amnesia on the distraction/no distraction test (Baker, Hanley, Kimmance, & Slade, 1993), the coin-in-the-hand test (Kapur, 1994) and word fragment completion (Horton, Smith, Barghout, & Connolly, 1992). The distraction/no distraction test and the coin-in-the-hand test both proved successful in distinguishing patients with amnesia from simulators (p < .01). Excellent performance by virtually all patients with amnesia coupled with chance or below chance performance by 19/20 simulators on the coin-in-the-hand test was particularly striking. Consistent with the results of Horton et al. ( 1992), the word fragment completion test successfully discriminated between the performance of simulators and controls (p < .01). However, the fragment completion test proved incapable of distinguishing between the performance of patients with amnesia and simulators (p > .05). It is argued that there may be problems inherent in the use of tests designed to investigate implicit memory in attempts to detect malingering.

Adult↗
PubMed2003

Ganser symptoms in a case of frontal-temporal lobe dementia: is there a common neural substrate?

Neuropsychological testing was completed in a patient who showed cognitive decline of mental functions, unusual answers to questions, and other characteristics of what has typically been described in the literature as the "Ganser Syndrome." Clear evidence of malingering on a memory test seemed to confirm that this patient was exaggerating deficits for psychiatric reasons or secondary gain, yet the patient showed evidence of mild organic impairment on MRI and continued to deteriorate in cognitive functions and basic self-care. Although an initial SPECT scan had suggested a pattern inconsistent with dementia, a second scan showed frontal-temporal perfusion deficits. Based on this scan and the clinical picture of progressive deterioration, a diagnosis of frontal-temporal lobe dementia was made. This case illustrates that the seemingly deliberate selection of incorrect responses may occur in the early stages of an organic dementia, and that a diagnosis of frontal-temporal lobe dementia should be considered in cases where symptoms appear to be psychiatric or nonorganic. The case further raises the question of whether the reported symptoms of Ganser Syndrome may be accounted for by frontal-temporal lobe dysfunction, since there appears to be some overlap between symptoms of Ganser Syndrome and frontal-temporal lobe dementia. It is also important to note that many reported cases of Ganser Syndrome had a history of head injury.

Dementia↗
PubMed1983

Factitious illness. Dramatic deceit versus reality.

Patients with factitious illness present a particular challenge. Because they may be clever in their deception, they may be difficult to recognize as the fabricators of their apparent medical problem(s). Findings vary from relatively simple problems such as fever to more complex and often dramatic complaints of bleeding and pain. Differential diagnosis should include other, often more easily managed disorders such as somatoform disorders, malingering, antisocial personality, and schizophrenia. Because no definitive treatment exists, patients often consult many physicians, often in diverse geographical locations.

Diagnosis, Differential↗
PubMed1986

Functional somatic disorders. Key diagnostic features.

In diagnosis of functional somatic disorders, it is important to remember that the patient has no control over symptoms in somatization disorder, conversion disorder, psychogenic pain, and hypochondriasis. In addition, the environmental goals are recognizable only with careful history taking. Although voluntary symptom production is involved in both factitious disorder and malingering, environmental goals in the latter disorder are much more obvious. Depression can be an accompanying feature of all of these disorders; however, it is most closely linked with psychogenic pain. Atypical or masked depression should be included in differential diagnosis in elderly patients with somatic complaints. Referral to a consultation-liaison psychiatrist can help in evaluation and diagnosis of a somatic disorder. Joint consultation is the most effective way to plan treatment for this difficult group of patients.

Adult↗
PubMed1987

Neuropsychological evidence of a factitious memory complaint.

The authors describe a patient who complained of a severe memory loss. Information gathered from the history, interview, and testing suggested malingering. The patient was then assessed by a strategy called Symptom Validity Testing. Her score was statistically worse than chance, which provided compelling evidence that she was faking bad.

Amnesia↗