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PubMed2006

Olfactory dysfunction and its measurement in the clinic and workplace.

OBJECTIVES: To provide an overview of practical means for quantitatively assessing the sense of smell in both the clinic and workplace. To address basic measurement issues, including those of test sensitivity, specificity, and reliability. To describe and discuss factors that influence olfactory function, including airborne toxins commonly found in industrial settings. METHODS: Selective review and discussion. RESULTS: A number of well-validated practical threshold and suprathreshold tests are available for assessing smell function. The reliability, sensitivity, and specificity of such techniques vary, being influenced by such factors as test length and type. Numerous subject factors, including age, sex, health, medications, and exposure to environmental toxins, particularly heavy metals, influence the ability to smell. CONCLUSIONS: Modern advances in technology, in conjunction with better occupational medicine practices, now make it possible to reliably monitor and limit occupational exposures to hazardous chemicals and their potential adverse influences on the sense of smell. Quantitative olfactory testing is critical to establish the presence or absence of such adverse influences, as well as to (a) detect malingering, (b) establish disability compensation, and (c) monitor function over time.

Air Pollutants, Occupational↗
PubMed2005

Sleep-related violence.

Most violent behaviors arise from wakefulness. It is important to realize that violent behaviors that may have forensic science implications can arise from the sleep period. By virtue of the fact that these behaviors arise from sleep, they are executed without conscious awareness, and, therefore, without culpability. The most common underlying conditions arising from sleep are disorders of arousal (sleepwalking and sleep terrors), the rapid eye movement sleep behavior disorder, and nocturnal seizures. In addition, there are a number of psychiatric conditions (dissociative disorders, malingering, and Munchausen syndrome by proxy) that actually arise from periods of wakefulness occurring during the sleep period. The clinical and medico-legal evaluation of such cases is outlined, and should be performed by a multidisciplinary team of experienced sleep medicine practitioners.

Humans↗
PubMed2000

Is fibromyalgia a distinct clinical syndrome?

The validity of the fibromyalgia syndrome (FMS) as a distinct clinical entity has been challenged for several reasons. Many skeptics express concern about the subjective nature of chronic pain, the subjectivity of the tender point (TeP) examination, the lack of a gold standard laboratory test, and the absence of a clear pathogenic mechanism by which to define FMS. Another expressed concern has been the relative nature of the pain-distress relationship in the rheumatology clinic. The apparently continuous relationship between TePs and somatic distress across a variety of clinical disorders is said to argue against FMS as a separate clinical disorder. The most aggressive challenges of the FMS concept have been from legal defenses of insurance carriers motivated by economic concerns. Other forms of critique have presented as psychiatric dogma, uninformed posturing, suspicion of malingering, ignorance of nociceptive physiology, and occasionally have resulted from honest misunderstanding. It is not likely that a few paragraphs of data and logic will cause an unbeliever to change an ingrained opinion. Therefore, this review describes the clinical manifestations of FMS, responds to some of the theoretic arguments against it, and discusses some possible pathophysiologic mechanisms by which FMS may develop and persist as a unique syndrome.

Autonomic Nervous System↗
PubMed2001

Somatization Disorder.

There are many new developments regarding somatization disorder, which is among the most difficult and cumbersome of the psychiatric disorders encountered in neurology practice. Diagnostic criteria have been revised to facilitate clinical care and research. The differential diagnosis includes neurologic disorders (eg, multiple sclerosis, epilepsy), systemic medical disorders, and other psychiatric disorders (eg, mood and anxiety disorders, conversion disorder, malingering, and factitious disorder). Many patients have one or more of these illnesses comorbid with somatization disorder. Finally, somatization disorder demands creative biopsychosocial treatment planning by the neurologist, psychiatrist, and other health professionals.

Journal Article↗
PubMed2006

Diagnosis and management of functional visual deficits.

Patients with functional or nonorganic visual disturbances are often seen in general ophthalmology practice and then referred to neurology and/or neuro-ophthalmology. The diagnosis of functional vision loss requires comprehensive examinations and diagnostic testing to eliminate possible organic entities. Inconsistencies between examinations may be key to the functional/nonorganic nature. These cases represent some of the most time-consuming diagnoses that an ophthalmologist sees. These patients may be malingering or may have already seen multiple physicians. The more sophisticated patients may go online to learn about an entity that they are trying to mimic. Large amounts of time and money may be spent on diagnostic workups that are thought necessary to prove that there is nothing organic involved. Occasionally there are legal elements of the vision loss, such as minor trauma, in which case the history is key; the complaints tend to resolve when the legal issues are resolved. Another issue to consider is whether someone claiming to be blind is trying to qualify for workmen's compensation or disability.

Journal Article↗
PubMed1983

Ocular motility testing in the evaluation of visual hallucinations.

Distinguishing organic visual hallucinations from those caused by hysteria or malingering is important but difficult. We found that ocular motility testing is helpful in making the distinction in some patients who allege that their hallucinations move. A 9-year-old girl thought to have organic hallucinations, possibly caused by an occipital lobe neoplasm, was unable to generate smooth pursuit movements when she attempted to follow the movements of the hallucinations. Instead, she executed a series of small downward saccades. Her hallucinations were presumably stress-induced. Conversely, a 62-year-old man with hypertension, arteriosclerotic heart disease, and depression, whose hallucinations were thought to be hysterical, was able to execute smooth pursuit movements when he attempted to follow the hallucinations. Detection of a previously unrecognized visual field defect helped to establish that the hallucinations were organic. Thus, patients with moving organic hallucinations may produce smooth pursuit movements when attempting to follow the hallucinations, but patients with feigned or hysterical hallucinations, who lack a fixation target, are likely to execute a series of saccades.

Brain Ischemia↗
PubMed1979

The Munchausen spectrum: borderline character features.

In this paper the author presents a continuum of disease simulation that ranges from hysteria to malingering, with a range of relative unawareness to awareness of producing such deception. Focus is on the particular group of patients who consciously and repeatedly simulate disease. The frequency and form of such disease mimicry vary within such a group. A continuum in terms of frequency ranges from occasional adventures to the simulation of disease as the center of a person's life. Two groups of patients designated as exhibiting Munchausen Syndrome are defined within this continuum: (a) those who work (mostly as nurses or in other medical professions) and (b) those called "hospital hobos" --the more prototypical Munchausen patient. The author takes a somewhat different approach to Munchausen Syndrome in that it is viewed as a subgroup of the borderline character. Further, the often found exhortation for psychiatric treatment of Munchausen patients is reexamined, and caution regarding such zeal and its potential negative effects is registered.

Adult↗
PubMed1990

Doctors and the state: lessons from the Biko case.

The death of the well-known black leader, Steve Biko, in detention in South Africa in 1977 has continued to generate debate in the international medical literature. The three doctors who examined him during his terminal illness made a diagnosis of malingering in spite of overwhelming evidence suggesting that he had suffered extensive traumatic brain injury while in detention. The inquest into his death provided a rare insight into the manner in which state doctors function in relation to the police of a repressive regime. This article documents the relevant testimony from the inquest and explores the reasons for the doctor's mismanagement of Biko. It is suggested that failures in the doctors' judgement were a result of complex influences including the effects of their own social conditioning, the risk of habituation by state doctors to degrading prison conditions, the inroads that Apartheid has made into medical practice, the possibility of reprisal if state doctors oppose the wishes of the police, and, more speculatively, the possibility that the doctors' obedience and passivity were exploited by the Security Police who wished to absolve themselves from responsibility of Biko's injuries. Most importantly, it is argued that the repeated failure of the major medical organizations in South Africa to provide clear guidance and leadership to state-employed doctors increases the risk that individual doctors will continue to succumb to hierarchical pressures to condone acts of state-sanctioned violence against detainees.

Dissent and Disputes↗
PubMed1994

Susto and the career path of the victim of an industrial accident: a sociological case study.

This is a case study of the processes involved in attaining the status of 'victim' after an industrial accident. In this case a migrant working in the manufacturing industry becomes increasingly 'disabled' and seeks legitimation as a 'victim' who is 'worthy' of financial compensation. The institutional processes involved are the industrial, medical and legal systems. Chronic pain is a condition that often defies an unambiguous diagnosis. Most chronic pain victims are therefore constantly seeking legitimation for their condition as physicians attempt to uncover the aetiology of the pain. Most chronic pain victims also fail to fulfil the expectation of getting well as soon as possible. Physicians can, at best, only give a prognosis that is little better than an 'educated guess'. The conditional nature of the legitimacy gives the chronic pain victims only limited legitimacy for their sick role and this often results in physicians seeking psychological or moral explanations for what began as a relatively simple physical problem. Psychological or psychiatric diagnoses are considerably weaker metaphorically than physiological diagnoses and tend to infer the strong possibility of the victim contributing to her/his condition as a result of hypochondriacal or psychosomatic 'tendencies' or, even worse, 'malingering'. The migrant client can exacerbate this situation through an earnest desire to (over)conform to norms by going along with whatever is recommended by people who hold superior status by virtue of their knowledge and power ('posicíon'). Among some Latin American countries 'over-compliance' has been recognised a socio-medical condition and is termed 'susto'. In the workers' compensation context the shift to overconformity ('susto') results from the uncertainty about receiving (legitimate) acknowledgement and compensation. The desire is to ensure, as far as possible, that a certainty of outcome is achieved (i.e. a return to work or adequate compensation). In other words, concurrent practises within the system (medical-social-legal) produces what it tries to eliminate--the seemingly unjustifiable/illegitimate internalising of the role of victim intent on receiving compensation. 'Susto' is therefore an adaptive response to normative ambiguity and uncertainty about future outcomes. Under conditions of worsening health (physical and mental), and the pressure to continue treatment, the best "solution" for the victim appears to be to "pull the victim out of the medical system", to de-socialise her/him from semi-institutionalisation, and to use social and informal support structures to build up on the victim's independence, self-esteem, personal integrity and sense of control of her/his own life.

Accidents, Occupational↗
PubMed2005

Anti-apoptotic role of BARF1 in gastric cancer cells.

Epstein-Barr virus (EBV) infection has been implicated in the carcinogenesis of several types of human cancer, including gastric cancer. In contrast to two other EBV-related malingancies, nasopharyngeal carcinoma and Hodgkins Lympomain which the latent membrane protein (LMP)-1 is often detected, in gastric cancer, BARF1, one of the early EBV genes, is frequently expressed in EBV-positive specimens. This indicates that expression of BARF1 may play a positive role in the development of gastric cancer. The aim of this study was to investigate the effect of BARF1 expression in gastric cancer cells. First, a retroviral vector containing the full length BARF1 gene was transfected into an EBV negative gastric cancer cell line, BGC823, and stable transfectants expressing ectopic BARF1 were generated. Microarray analysis was then performed and gene expression profiles were analysed and compared between the cells expressing ectopic BARF1 and the vector control. In addition, the effect of BARF1 on gastric cancer cell proliferation and apoptosis was investigated by MTT assay, DAPI staining, flow cytometry as well as Western blotting. We found that expression of BARF1 in gastric cancer cells led to significant alterations of gene expression, especially genes related to proliferation and apoptosis. In addition, the BARF1 expressing cells were more resistant to apoptosis induced by a commonly used anticancer drug, taxol. This chemo-protective effect of BARF1 was associated with increased Bcl-2 and Bax ratio and decreased expression of cleaved PARP, but not alterations in cell proliferation. Our results suggest that BARF1 expression in gastric cancer cells may provide a protective role against apoptosis through an increased Bcl-2 to Bax ratio, thus promoting cancer cell survival.

Antineoplastic Agents, Phytogenic↗
PubMedDate not supplied

Peritraumatic dissociation as a predictor of post-traumatic stress disorder: a critical review.

In psychiatric literature, dissociative reactions at the time of a traumatic event (i.e., peritraumatic dissociation) are considered to be risk factors for the development of post-traumatic stress disorder (PTSD). In this article, we critically review research concerned with the link between peritraumatic dissociation and PTSD. Our main point is that studies in this area heavily rely on retrospective reports of dissociative reactions during the trauma. We argue that this methodology has important limitations since people in general and PTSD patients in particular find it difficult to give accurate descriptions of past emotional states. Restrictive factors that play a role in this context have to do with forgetting, attribution, and malingering.

Dissociative Disorders↗
PubMed2006

Can we solve the mysteries of the National Vietnam Veterans Readjustment Study?

The National Vietnam Veterans Readjustment Study (NVVRS) researchers reported that 30.9% of all men who served in that conflict developed posttraumatic stress disorder (PTSD) even though only about 15% had been assigned to combat units. Scholars, mainly historians, have questioned the accuracy of the PTSD prevalence rate. The purpose of this article is to evaluate the merits of several hypotheses adduced to explain the high apparent PTSD prevalence in the NVVRS. Empirical and conceptual analysis suggests that malingering is unlikely to account for many cases. Also, deployment to Vietnam in the absence of exposure to classic traumatic stressors is likewise unlikely to account for many cases. There are three plausible explanations for the high prevalence rate of PTSD in the NVVRS. First, DSM-III-R PTSD criteria, used in the NVVRS, did not require that symptoms produce impairment. Accordingly, some PTSD-positive cases may actually have been leading productive lives, despite occasional nightmares, or other stress responses. Second, some men assigned to non-combat duty (e.g., medics) may have been exposed to PTSD-inducing stressors. Third, some respondents may have invoked the Vietnam-PTSD narrative to make sense of postwar psychological difficulties having diverse causes unrelated to their military service. These three factors likely contribute to the high PTSD prevalence rate in the NVVRS.

Diagnosis, Differential↗
PubMed2006

Practical clinical approaches to functional visual loss.

Functional visual loss (FVL) refers to subnormal vision or altered visual fields where no underlying pathology of the visual system can be found. It may be seen in a continuum from frank malingering to hysteria. FVL may first present to the general practitioner or physician and the financial burden of evaluation and potential disability-related claims may be substantial. Diagnosis relies on a high index of suspicion and demonstration with a few simple tests that the patient has better vision than alleged. The aim of this review is to provide a practical approach to examination of patients with suspected functional visual loss. An accurate and early diagnosis of FVL starts with a high index of suspicion. Only a few of the tests need to be learned well, performed smoothly and confidently. These clinical tests obviate the need to perform expensive imaging such as magnetic resonance imaging and if used in the correct setting have the potential to reduce further the cost of diagnosis. Management requires an understanding approach and confrontation is seldom helpful. It is important to stress to the patient that FVL has a good prognosis, thereby providing "a way out" and giving the patient the opportunity to recover.

Blindness↗
PubMed2004

Are living beings in the state of self-organized criticality? A new interpretation of data on work incapacity due to low back pain.

Using data published elsewhere I demonstrate in this paper that the frequency distribution of the duration of work incapacity from low back pain follows a power law. Power laws are not common in medicine and the question arises why we can find one here. The peculiarity of the data considered here is that they embrace not only the passive reaction but also the whole spectrum of possible active responses of a living being to a disturbance. For the duration of sick leave due to low back pain is not only influenced by the defect a person is affected by, but even more dependent on how he or she copes with it. Coping comprises a broad range of possibilities from denial of the disability to its aggravation, from therapy to malingering. In contrast to the scientific ideal none of these faculties has been excluded in the data used here. They concern the whole living being. Power laws are typical for systems in the state of self-organized criticality. The system involved in the case of low back pain is the whole living human being with all its possibilities to react and to respond. Thus, my findings support empirically the hypothesis that living beings are in the state of self-organized criticality.

Data Interpretation, Statistical↗
PubMed2005

Manganese exposure: neuropsychological and neurological symptoms and effects in welders.

Manganese exposure reportedly may have an adverse effect on CNS function and mood. Sixty-two welders with clinical histories of exposure to manganese were compared to 46 matched regional controls chosen at random from a telephone directory. The following tests were given: Wechsler Adult Intelligence Scale (WAIS-III), Wechsler Memory Scale (WMS-III), Boston Naming, WRAT-3, Cancellation H, Trail Making Tests A and B, Auditory Consonant Trigrams, Stroop, Rey-Osterreith, Animal Naming, Controlled Oral Word Association (COWAT), Test of Memory Malingering, Rey 15-item, Fingertapping, Grooved Pegboard, Dynamometer, Visual Attention Test, Lanthony d-15 Color Vision, Vistech Contrast Sensitivity, and Schirmer strips. The controls were administered a shorter battery of tests and the Rey-Osterreith, Animal Naming and some of the subtests of the WAIS-III, WMS-III were not administered. Mood tests, given to both groups, included the Symptom Checklist-40, Symptom Checklist-90-R, Profile of Mood Scale, Beck Depression Inventory II, and Beck Anxiety Inventory. Forty-seven welders and 42 controls were retained for statistical analysis after appropriate exclusions. Results showed a high rate of symptom prevalence and pronounced deficits in motor skills, visuomotor tracking speed and information processing, working memory, verbal skills (COWAT), delayed memory, and visuospatial skills. Neurological examinations compared to neuropsychological test results suggest that neuropsychologists obtain significantly more mood symptoms overall. Odds ratios indicate highly elevated risk for neuropsychological and neurological symptomatology of manganism. Mood disturbances including anxiety, depression, confusion, and impaired vision showed very high odds ratios. Neurological exams and neuropsychological tests exhibit complementarity and differences, though neuropsychological methods may be more sensitive in detecting early signs of manganism. The present study corroborates the findings of our previous study in another group of welders.

Adult↗
PubMed2006

Using self-report measures in neurobehavioural toxicology: can they be trusted?

Questionnaires are one of the most common methodologies used in research on neurobehavioural effects in occupational and environmental health, most commonly for gathering information on demographic characteristics, psychological or neurological symptoms, mood state, or exposure to hazards. Questionnaires are self-report measures, so by definition are subjective, although their degree of subjectivity depends on the phenomenon they are measuring. For some phenomena questionnaires are used because they are convenient but the information can be obtained from other sources. For other phenomena questionnaire or self-report is the only way of obtaining the information, for example, feelings and experiences, mood or emotions. Questionnaires are essential tools in psychological and neurobehavioural research as they can tap into aspects of nervous system function that cannot be readily measured in other ways. Despite the obvious need for self-report measures, there are a number of serious issues that threaten their validity as effective indicators of neurobehavioural function. This paper considers the implications of some of the major problems with self-report measures, focusing particularly on current approaches to measurement of symptoms and mood. It includes issues relating to validity of measures such as demand characteristics, malingering and under or over reporting, individual differences and problems of language and question style. It also includes issues relating to the interpretation of self-report measures, the relationship between self-report and performance measures, whether they reflect primary or secondary effects and whether they can be used as diagnostic criteria for neurobehavioural functional effects of occupational or environmental exposure. The paper looks at some of the current approaches to overcoming these problems including using interviews and observational methods and improving psychometric qualities of these measures. Self-report measures are important tools in our arsenal of measures of the neurobehavioural effects of occupational and environmental exposure, but they need to be used with care.

Affect↗
PubMed2005

Neural correlates of feigned memory impairment.

While initial neuroimaging studies have provisionally identified activation in the prefrontal (including the anterior cingulate) and parietal regions during lying, the robustness of this neuroanatomical pattern of activation across forms of stimuli, genders, and mother tongues remains to be demonstrated. In this paper we report the results of three studies designed to test the reproducibility of the brain activation previously observed during feigned memory impairment. A total of twenty-nine right-handed participants, divided into three cohorts, participated in three different studies of feigned memory impairment. Findings indicate that bilateral activation of prefrontal and parietal regions was invariant across stimulus types, genders, and mother tongues, suggesting the general importance of these regions during malingering and possibly deception in general. In conjunction with earlier imaging findings, these three studies suggest that the prefrontal parietal network provides a robust neuroanatomical foundation upon which future dissimulation research may build.

Adult↗
PubMed2004

Effects of head injury on olfaction and taste.

Traumatic events such as motor vehicle accidents, falls, or assaults can lead to dysfunction in olfaction or gustation. Mechanisms of posttraumatic olfactory dysfunction include direct injury to the sinonasal tract or olfactory epithelium, shearing effect on olfactory fibers at the cribriform plate, or brain contusion or intraparenchymal hemorrhage. Posttraumatic gustatory dysfunction is rare, but may occur as a result of direct injury to the tongue, injury to cranial nerves VII or IX, or brain contusion or hemorrhage. Evaluation of head-injured patients presenting with olfactory or gustatory complaints should include a thorough history, including assessment for pre-and posttraumatic chemosensory dysfunction and potential mechanisms of injury, complete head and neck examination including nasal endoscopy and cranial nerve testing, and focused radiographic imaging, usually CT of the sinuses and skull base. Formal olfactory and gustatory testing may be performed using various techniques, although in cases potentially involving litigation, methodologies able to detect malingering should be used. Treatable causes of chemosensory disturbance, most notably conductive olfactory losses caused by chronic rhinosinusitis or nasal obstruction, should be ruled out. In the event of neurosensory deficits, recovery may occur up to 12 to 18 months after the traumatic event. All patients should be counseled regarding the risks of their chemosensory deficits, and given suggestions for appropriate compensatory strategies.

Brain↗