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PubMed1996

Hemiballismus following closed head injury.

Movement disorders are relatively rare after closed head injury (CHI), but when present they can go unrecognized if clinicians are not aware of their occurrence. We are presenting a case of hemiballismus which was not recognized over 3 years and was labelled as malingering or as psychosomatic. The symptoms have responded significantly to pharmacological interventions. The SPECT scan of the brain showed the lesions in the subthalamic areas while MRI, CT scans of brain and EEGs were reported normal. It is concluded that one should be aware of the existence of movement disorders after mild to moderate CHI, and that SPECT scan of the brain should be considered if a patient is symptomatic and other neuroimaging studies prove 'normal'.

Brain↗
PubMed1998

Neuropsychological outcomes of traumatic brain injury and substance abuse in a New Zealand prison population.

Fifty subjects with a history of traumatic brain injury (TBI) and/or substance use, completed neuropsychological measures of short and long term verbal and visual memory, information processing, motor speed and co-ordination, executive functioning, and malingering. All subjects performed below norms on tests of verbal memory and verbal abstract thinking, but overall no differences were found due to either severity of TBI or level of substance use. Maori subjects obtained the lowest scores on tests of verbal ability, but also reported higher rates of TBI and substance use, which is presumed to account for this result. In conclusion, prison populations seem to have disproportionately high rates of TBI, recurrent TBI, and substance use, compared to the general population. Further, there are a group of individuals who have experienced both TBI and substance abuse, with associated impairments in verbal memory and learning, abstract thinking, and who report problems with general memory and socialization. These difficulties may affect functioning both in prison and following release.

Adult↗
PubMed1999

Recovery from mild head injury.

The subjective and objective sequelae accompanying mild head injury (MHI) are discussed in an attempt to clarify MHI's immediate and long-term consequences. Areas covered included epidemiology, classification, the post-concussive syndrome (PCS), malingering, extent of recovery, rehabilitation and guidelines for clinical practice. Special emphasis is placed on the poor relationship between subjective complaint and objective measures of impairment. Also discussed are some of the methodological problems in the MHI literature, including attempts to match MHI subjects and controls with respect to cognitive and emotional complaint and the possible confounding effects of practice. The evidence for long-lasting (i.e. more than 1 year), subtle neurobehavioral impairment after MHI indicates that additional research is required on MHI 1 year or more after injury.

Adolescent↗
PubMed2006

New instrumentation for automated tinnitus psychoacoustic assessment.

CONCLUSION: Although tinnitus is a major health problem, techniques to quantify its perceptual aspects are not standardized. This study represents a key step in our efforts to develop clinical methodology to accurately and reliably quantify the sensation of tinnitus, using a uniform method for obtaining a battery of tinnitus measures. OBJECTIVES: The purpose of this study was to evaluate the performance of the automated system, which was redesigned to reduce time of testing and to add new testing capabilities. The primary difference in function was the use of a 'knob' device that enabled patient control of auditory stimuli. The new tests included assessment of minimum masking level (MML) and residual inhibition (RI). MATERIALS AND METHODS: As with previous iterations of the system, a computer program ran all testing and subjects read instructions and provided responses via a computer touch-screen. Three separate studies were conducted. Study 1 evaluated within- and between-session test-retest response reliability of tinnitus loudness matches (LMs) and pitch matches (PMs). Study 2 was conducted to evaluate differences in LMs and PMs between subjects with and without tinnitus - to obtain pilot data to assist in the development of a test for 'tinnitus malingering.' Study 3 evaluated the system's capability of obtaining MMLs and RI as well as the between-session reliability of these measures. RESULTS: Study 1 documented that the new system could obtain LMs and PMs within approximately 20 min, while maintaining clinically acceptable reliability. Study 2 revealed characteristic differences in LM and PM test results for individuals who did not experience tinnitus. Study 3 documented the system's ability to obtain measures of MML and RI that were reliable across sessions.

Auditory Threshold↗
PubMed2005

Ecological validity of the WMS-III rarely missed index in personal injury litigation.

The purpose of this study was to evaluate the clinical utility of the Rarely Missed Index (RMI) to detect cognitive exaggeration in 78 nonlitigant patients (i.e., Mixed Clinical group) and 158 personal injury litigants (i.e., 20 Suspected Exaggerators, 12 Borderline Exaggerators, 126 Genuine Responders). The base rate for probable malingered neurocognitive dysfunction in the litigant sample was 12.7%. The false positive error rate of the RMI in the Genuine Responder and Mixed Clinical group ranged from 5.4% to 8.6%. Positive RMI scores were found in 25% and 41.7% of the Suspected Exaggerator and Borderline Exaggerator groups respectively. The clinical utility of the RMI to identify Suspected Exaggerators versus individuals in the Genuine Responder and Mixed Clinical groups revealed low sensitivity (sensitivity = .25), very high specificity (range = .91 to .95), moderate positive predictive power (range = .50 to .71), and moderate to high negative predictive power (range = .68 to .83). These results do not support the use of the RMI as a reliable predictor of cognitive exaggeration.

Adult↗
PubMed2006

Noncredible psychiatric and cognitive symptoms in a workers' compensation "stress" claim sample.

Information is lacking regarding the prevalence of fraudulent psychiatric and cognitive symptoms in the "stress" claim workers' compensation population. Using various validity indices (Negative Impression Scale, the Malingering Index, and the Rogers Discriminant Function) of the Personality Assessment Inventory (PAI), between 9 and 29% of 233 workers' compensation "stress" claim litigants were identified as exhibiting noncredible psychiatric symptoms. In addition, 15% of the subjects were determined to have noncredible cognitive symptoms on the Dot Counting Test, although only 8% displayed suspect effort on the 15-Item Memorization Test, with 5% of subjects failing both cognitive effort tests. The percentage of positive identifications on both a PAI and cognitive credibility index ranged from only 2 to 4%. Further, correlations between PAI validity indices and cognitive effort scales were nonexistent to modest, indicating that the psychiatric and cognitive credibility indices are measuring different aspects of noncredible symptom production. It was predicted that the PAI profiles of the participants displaying suspect cognitive symptoms would be elevated on the Somatic Concerns, Antisocial, and/or Borderline scales; however, elevations (relative to subjects with credible cognitive performance) were instead noted on the Somatic Concerns, Depression, Anxiety, Anxiety-Related Disorders, and Schizophrenia scales.

Adult↗
PubMed2006

Known-groups cross-validation of the letter memory test in a compensation-seeking mixed neurologic sample.

Compensation-seeking neuropsychological evaluees were classified into Honest (HON; n = 37) or Probable Cognitive Feigning (PCF; n = 53) groups based on results from the Victoria Symptom Validity Test, the Test of Memory Malingering, and the Digit Span subtest of the Wechsler Adult Intelligence Scale--3rd ed. The groups were generally comparable on demographic, background, and injury severity characteristics, although HON TBI participants were significantly more likely to have a documented loss of consciousness, whereas PCF participants were significantly more likely to be currently on disability. PCF participants scored significantly lower on many neuropsychological test, particularly of memory, as well as higher on most MMPI-2 clinical scales. The PCF group also had significantly higher scores on multiple indices of feigning of psychiatric symptoms. Results from the Letter Memory Test (LMT) were significantly lower for the PCF group, and using the recommended cutting score, specificity was .984, whereas sensitivity was .640, suggesting adequate performance on cross-validation.

Adult↗
PubMed1998

Psychiatric diseases presenting as infectious diseases.

Although many psychiatric diseases have somatic manifestations, some focus on fears or delusions of infection. When a patient with a psychiatric basis for an apparent infection presents to an infectious disease physician, the physician may find the problem confusing, amusing, and ultimately frustrating until the psychiatric basis for disease is recognized. Some of these psychiatric disorders can be treated and controlled with medication and psychotherapy, although patients may resist psychiatric referral. This article reviews examples of psychiatric disorders in patients who present to the infectious disease physician, including factitious infection, malingering, obsessive compulsive disorder, phobias, veneroneuroses, somatization disorders, and delusional infection. The role that physicians play in amplifying these disorders is reviewed. Strategies for referral to psychiatric services are also discussed. Patients with a psychiatric disease are seen in infectious disease practices more commonly than physicians realize.

Adult↗
PubMed2004

Elevated serum S-100B protein as a predictor of failure to short-term return to work or activities after mild head injury.

Protein S-100B is an established serum marker of primary and secondary brain damage and stroke. A group of patients after mild head injury (MHI) develop post-concussion symptoms that interfere with the ability in the short-term to return to work or undertake certain activities. The aim of this study was to examine the correlation of serum S-100B with short-term outcome after MHI. We studied 100 subjects who were referred to the Emergency Department (ED) after a MHI. All subjects had a GCS of 15 either with or without loss of consciousness (LOC) and/or post-traumatic amnesia (PTA). Serum S-100B was collected within 3 h from the injury and a value of > or = 0.15 microg/L was considered as abnormal. Subjects with other injuries, including scalp or cervical spine, were excluded, as well as those with alcohol/narcotic drug consumption or history of serious physical/mental illness. An independent observer measured the return to work/activities within one week. Thirty-two (32%) subjects had elevated S-100B. The failure to return to work/activities was significantly correlated with elevated S-100B: subjects with increased S-100B had a failure rate of 37.5% versus 4.9% of those with normal values (p = 0.0001). In MHI, the elevated S-100B seemed to correlate with an unfavorable short-term outcome. This might be useful in (1) selecting patients who need closer observation, hospitalization, and further investigations (such as CT scan or MRI), and (2) the prognosis of genuine post-concussion symptoms, that interfere with return to work or activities, versus other causes such as premorbid personality, labyrinthine dysfunction, whiplash syndrome, postinjury stress, occupational injury, litigation, and malingering.

Activities of Daily Living↗
PubMedDate not supplied

Exaggerated pain behavior: by what standard?

This paper provides a philosophical, historical, and clinical analysis of exaggerated pain behavior, focusing on the nature of the standards used to judge behavior as exaggerated. Malingering is understood as a special case of exaggerated pain behavior. Drawing upon the work of philosopher Ludwig Wittgenstein and psychiatrist-anthropologist Horacio Fabrega, I argue that these standards are primarily moral rather than scientific in nature. Pain behavior is not validated by matching public pain behavior with private pain experience. If this pain experience is truly private, it is not available to scientific investigation. Rather, pain behavior is judged as appropriate or exaggerated through complex assessments of the function of this behavior in its social context. As human social contexts have become more complex through history, so have the accommodations made for sick and disabled members of the group. Criteria for legitimate entry to the sick role have evolved with society, with only modern industrial society placing heavy emphasis on tissue damage demonstrated on medical tests. The highly variable relation between clinical pain and tissue damage, as well as the common problem of medically unexplained physical symptoms in primary care, pose serious challenges to this strategy of illness behavior validation. It will remain necessary to triage suffering presented to health care providers into that which should be addressed in the medical setting and that which is better addressed elsewhere. But we need to discard pseudoscientific reliance on medical tests and develop new standards that are openly acknowledged to be moral and social in nature.

Activities of Daily Living↗
PubMed1994

Disease, disorder, or deception? Latah as habit in a Malay extended family.

Thirty-seven cases of latah are examined within the author's Malay extended family (N = 115). Based on ethnographic data collected and a literature review, cases are readily divisible into two broad categories: habitual (N = 33) and performance (N = 4). The first form represents an infrequent, culturally conditioned habit that is occasionally used as a learned coping strategy in the form of a cathartic stress response to sudden startle with limited secondary benefits (i.e., exhibiting brief verbal obscenity with impunity). In this sense, it is identical to Western swearing. Performers are engaged in conscious, ritualized social gain through the purported exploitation of a neurophysiological potential. The latter process is essentially irrelevant, akin to sneezing or yawning. It is concluded that latah is a social construction of Western-trained universalist scientists. The concept of malingering and fraud in anthropology is critically discussed.

Adaptation, Psychological↗
PubMed1976

Covert anticoagulant ingestion: study of 25 patients and review of world literature.

Twenty-five patients with covert ingestion of oral anticoagulant drugs were studied. Most of the patients were women who were either connected with the medical profession or were previously treated with antigoagulants. The most common findings were ecchymoses, hematuria, and a markedly prolonged prothrombin time. The anticoagulant drug was identified in the plasma of all 25 patients. Most patients responded promptly to administration of vitamin K1. The most common motives were malingering and suicide. The world literature was reviewed for covert ingestion of oral anticoagulant drugs and 48 other cases were found. The correct diagnosis is important to focus the physician's attention on the psychiatric rather than the somatic aspects of the disorder.

Adult↗
PubMed2005

Detection of feigned tactile sensory loss using a forced-choice test of tactile discrimination and other measures of tactile sensation.

OBJECTIVE: Intentional exaggeration of disability is a risk in work injuries but is hard to reliably detect clinically. This study examined the accuracy of tactile sensory threshold and forced-choice discrimination measures in detecting feigned sensory loss. METHODS: Participants (n = 80) were randomly assigned to one of four sensory loss groups: (1) none; (2) partial; (3) full; or (4) feigned. Sensory data were collected for the upper extremities. RESULTS: Tactile thresholds greater than 0.5 g, discriminability less than 0.50, or forced-choice scores less than 90% were associated with a very low probability of false-positive errors. CONCLUSIONS: Below-chance scores are definitive evidence that the sensory loss is intentionally feigned. Scores beyond cut-offs should raise the clinician's suspicion of malingering if there is no physical basis for sensory loss.

Adult↗
PubMed1989

Psychiatric evidence: a study of psychological issues.

This article discusses the nature of psychiatric evidence in Icelandic criminal proceedings and presents findings from an investigation of the role of amnesia, malingering and overcontrolled hostility among different types of offenders. Amnesia was most common in homicide cases, and was almost invariably associated with alcohol intoxication. An unexpectedly high rate of overcontrolled hostility was found among sex offenders, which may have important theoretical and clinical implications. The results indicate that deliberate faking of an intellectual deficit on psychometric tests occurs rarely in a forensic context.

Adolescent↗
PubMed1989

Laypersons' knowledge about the sequelae of minor head injury and whiplash.

Even minor head injuries can result in the post traumatic syndrome, a symptom complex that includes physical discomfort and sleep, sexual, affective, and memory disturbance. Little is known about the layperson's knowledge of the syndrome but this may influence judgements about malingering and attitudes towards victims of minor head injury. Descriptions of rear-end automobile accidents were presented to two groups. One group (n = 22) rated the likelihood of a variety of physical, affective, cognitive, and distractor (never or rarely reported by trauma victims) symptoms. A second group (n = 21) judged the speed necessary to cause each of the symptoms. The results indicated that highly exaggerated speeds were thought necessary to produce even the most common physical symptoms. Moreover, cognitive symptoms were thought to be no more likely than were distractor symptoms. In contrast, the knowledge about physical symptoms, the effects of loss of consciousness and whiplash versus direct head injuries was consistent with what is known from research literature.

Adult↗
PubMed1978

Hysteria split asunder.

The authors present the proposed DSM-III classification of the traditional hysterical disorders, i.e., disorders that suggest physical illness but in which psychological factors are judged to be of importance. The use of the DSM-III inclusion and exclusion criteria--physical mechanism explains the symptoms, symptoms are linked to psychological factors, symptom initiation is under voluntary control, and there is an obvious recognizable environmental goal--are discussed in the differential diagnosis of somatoform disorder, factitious disorder, malingering, psychological factors affecting physical condition, and undiagnosed physical illness.

Conversion Disorder↗
PubMedDate not supplied

Definition, diagnosis, and forensic implications of postconcussional syndrome.

Injuries from blows to the head often are manifested only as subjective complaints. Postconcussional syndrome thus can be feigned for financial or psychological gain. The authors review the pathology of brain trauma, symptoms of postconcussional syndrome, and criteria for diagnosis. In addition to somatic deficits, psychological and cognitive problems are common. The likelihood and severity of postconcussional syndrome are greater for women. Malingering may be suspected in cases involving litigation, and tests to detect it are available. Treatment for postconcussional syndrome depends on the specific symptoms. Pharmacotherapies may be helpful, but care should be used in prescribing drugs that could produce deleterious CNS effects.

Brain Concussion↗
PubMed1994

Factors complicating cost containment in the treatment of suicidal patients.

OBJECTIVE: The treatment of suicidal patients contributes to escalating mental health expenditures. Fiscal realities necessitate that cost-containment measures be implemented wherever possible. The authors reviewed the literature to delineate factors that impede cost containment for the treatment of suicidal patients and to outline strategies for controlling costs while improving the quality of care. METHODS: Psychological Abstracts and MEDLINE databases were reviewed. Retrieval and analysis focused on literature published between 1982 and 1992. RESULTS AND CONCLUSIONS: Five factors unique to the treatment of suicidal patients that impede cost containment were identified: the lack of a specific and cost-effective screening method to determine true risk of suicide, the high number of parasuicidal and malingering patients, revolving-door admissions of involuntary patients who become noncompliant with treatment after discharge, the adverse clinical consequences of further increases in existing discriminatory mental health benefits, and the medicolegal liability incurred in treating suicidal patients. The low frequency of completed suicides in relation to attempts and reported ideation indicates that most inpatients labeled suicidal are hospitalized unnecessarily. Thus inpatient treatment should be reserved for patients who make attempts of high lethality and patients with suicidal ideation who are at high risk because of other factors. Ideally, suicidal patients should be committed not to an inpatient facility but to a treatment network in which they can move appropriately between inpatient, day hospital, and outpatient care.

Cost Control↗