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PubMed2004

Clinical application of the multifocal visual evoked potential.

BACKGROUND: Measures of visual function thresholds such as visual acuity and visual fields are generally dependent on subjective responses and assume maintenance of fixation, attention and motivation. In the young, elderly, cognitively impaired or malingering populations, such measures may be inaccurate or difficult to obtain. The Visual Evoked Response Imaging System (VERIS) has been claimed to give more objective topographic recordings of retinal and cortical function. This paper aims to explore the adequacy of this technique in four unusual, unrelated, clinically difficult cases. METHODS: Multifocal visual evoked potentials (mfVEPs) recorded on the VERIS System 3.01 are used to assess visual function in four cases with contradictory clinical findings or unreliable subjective responses. RESULTS: Patient 1 had sustained a head injury and had normal ocular and pupil examination but light perception in the right eye and 6/5 acuity in the left. Multifocal VEPs showed a marked depression of the right visual field with little macular response. Patient 2 had sustained a head injury, had a left field hemianopia, possible macular sparing and loss of much of the right field, reduced but variable visual acuities, good near vision and normal ocular fundi. Multifocal VEPs showed a severe depression in both visual fields (L more than R) with little macular response. Patient 3 had a left optic nerve meningioma and experienced great difficulty with visual field assessment. mfVEPs showed a bilateral depression in the superior field particularly the left field, with a larger deficit in the left eye. Patient 4 had unexplained visual acuity and peripheral field deficits. mfVEP results were inconclusive in this case. DISCUSSION: Where there is difficulty performing traditional techniques or conflicting clinical findings, mfVEPs may provide additional objective information to aid in the assessment of patients.

Adult↗
PubMed1999

Critical perimetry - functioning methods.

Visual field defects without any organic correlate require critical control to avoid inadequate management of psychogenic defects. Which methods are promising to detect psychogenic visual field defects? Twenty ophthalmologically trained volunteers motivated to pretend a concentric visual field loss were tested by manual perimetry with centripetal and centrifugal movement of the stimulus, by evoking saccadic eye movements towards a stimulus outside the subjectively claimed visual field and by observation of the volunteers' strategy searching a stimulus beyond the subjectively claimed borders. Malingering could be proven in 16 persons. The most favourable procedure is to evoke eye movements towards a peripheral stimulus. These movements yield information about the visual field outside the subjectively stated limits.

Adult↗
PubMed1981

Psychogenic retention of urine.

Psychogenic retention of urine (PRU) may manifest itself in different clinical forms which mimic a genuine organic disturbance. Three clinical examples are presented in which PRU appears as: (1) malingering; (2) an upper motor lesion inducing spastic closure of the bladder neck, and (3) an alteration of the sensory input, closely resembling sensory neuron damage. The urologist becomes involved in the treatment of these patients by the natural expression of the symptoms. The underlying psychogenic factor does not become evident until urodynamic investigations and often specific therapeutic steps have been undertaken. The urologic treatment sometimes appears helpful because the patients do not realise or refuse to accept the idea of a psychogenic cause and expect relief from the urologist. The latter should withdraw his involvement as soon as an organic cause has been excluded.

Adult↗
PubMed1990

Münchhausen syndrome: psychopathology and management.

A case report on a patient with Münchhausen syndrome is presented and the psychopathological features are compared to other reports in the literature. Diagnosis and differential diagnosis are discussed with regard to other somatoform disorders such as conversion disorder and somatization disorder as well as to malingering and cenesthesic schizophrenia. The management of Münchhausen syndrome is aggravated by the low compliance in these patients, who expose themselves to serious complications of unnecessary medical and surgical procedures. Early diagnosis could to a considerable extent exclude these iatrogenic risks. We recommend that patients presenting the psychopathological features of a Münchhausen syndrome should be conservatively observed and an attempt to clarify both the medical and the psychiatric diagnosis should be made before any invasive procedure is undertaken.

Adult↗
PubMed1985

False patients/real patients: a spectrum of disease presentation.

This paper presents a synthesis of varying frameworks and value systems in which all patients are viewed by clinicians. A gradient of behaviors is arrayed which places disease simulation (Munchausen syndrome, malingering) at one end of a spectrum, with the other end anchored by 'real' disease. Between these two polarized opposites are placed the patients with 'psychological' origins to somatic presentations. These patients often called 'crocks' are somewhat different from those patients who present with disease simulation. Such patients are often referred to as 'crooks' in that they are absolutely false in their presentation and aware of such deception. The advantage of this particular schema is that it presents a gradient of behavior instead of isolated categorization. As such it is much more easily understood and used by clinicians and it presents the 'normal' and 'abnormal' within a single conceptual gradient instead of discreet categories.

Adult↗
PubMed1985

Posttraumatic stress disorder: a thirty-year delay in a World War II veteran.

Some clinicians doubt the validity of a diagnosis of delayed posttraumatic stress disorder for Vietnam veterans. Precombat psychopathology, drug abuse, factitious symptoms, and malingering in pursuit of disability compensation are cited as alternative explanations for the syndrome. The authors discuss the case of a much decorated World War II veteran whose symptoms of posttraumatic stress disorder first occurred more than 30 years after combat. They consider the alternative explanations for his symptoms to be inadequate.

Combat Disorders↗
PubMedDate not supplied

Factitious disorders: reformulating the DSM-IV criteria.

The author criticizes and reformulates the DSM-IV criteria in a clinically and nosologically sensitive way. Criterion A, the intentional production of physical or psychological signs or symptoms, emphasizes symptoms and cannot accommodate pseudologia fantastica, voluntary false confessions, and impersonations. Criterion B, the motivation is to assume the "sick role," has no empirical content and fulfills no diagnostic function. The two criteria need reformulating in terms of lies and self-harm, respectively. Criterion C causes misdiagnosis by pushing factitious disorders into the somatoform and malingering categories and should be abandoned. The author discusses the implications for the etiology of conversion disorders and the classification of factitious disorders.

Diagnostic and Statistical Manual of Mental Disord↗
PubMed1984

Factitious posttraumatic stress disorder: the veteran who never got to Vietnam.

The historical uniqueness of the Vietnam War produced an unusually high rate of psychiatric dysfunction among veterans, particularly in the form of posttraumatic stress disorder (PTSD). Now, in the wake of unprecedented media coverage of PTSD and the growth of veteran outreach centers documenting and publicizing the difficulties of some veterans, a heretofore unrecognized variant of PTSD-factitious PTSD--has arisen. The authors present seven cases of factitious PTSD, a classic example of clinical deception found among veterans who were never in combat and, in some cases, were never in Vietnam. The authors discuss the etiologies of the disorder and the underlying psychopathology, which suggests either factitious syndromes, such as Munchausen's, or malingering. They conclude with recommendations for diagnosis and treatment.

Adult↗
PubMed1989

Motor phenomena in benzodiazepine withdrawal.

Chronic use of benzodiazepines, the most widely prescribed of all psychotropic medicines, may lead to severe symptoms of withdrawal when the drugs are discontinued. The authors describe two cases of benzodiazepine withdrawal accompanied by unusual muscle activity. The neurologic mechanism for the motor abnormalities appears to be marked disinhibition of subcortical motor areas normally inhibited by gamma-aminobutyric acid. The motor phenomena may persist long after the more common signs of withdrawal have resolved and, if unrecognized, can lead to such misdiagnoses as drug seeking, conversion, hysteria, or malingering.

Aged↗
PubMed1994

Olfactory mucosa of patients with olfactory disturbance following head trauma.

The olfactory mucosa in 7 patients with olfactory disturbance following head trauma were sampled for biopsy with special biopsy forceps and examined by immunohistochemical staining with anti-neuron-specific enolase (NSE) and S-100 protein (S-100) antibodies. The residual olfactory receptor cells and nerve bundles were counted, and the degree of degeneration was determined. In 5 patients, olfactory receptor cells that reacted with anti-NSE antiserum remained, although the number varied with the patient, and in 2 patients the receptor cells disappeared. In the lamina propria, the S-100-immunoreactive olfactory nerves were retained in 6 patients. The outcome was poor in all cases regardless of the number of residual receptor cells and nerve bundles. These results indicate that the degree of impairment of the peripheral olfactory region after head trauma differs from case to case, and that even if the receptor cells and nerve bundles remain, it is difficult to improve the condition, although some cases of malingering may be contained.

Adolescent↗
PubMedDate not supplied

Thermography in posttraumatic pain.

Posttraumatic pain is often associated with complex disturbances of the sympathetic nervous system which also controls microcirculation of the skin. Circulatory skin changes are in turn reflected by altered superficial thermal emission, which can be reliably imaged by thermography. Examples of classic thermographic patterns associated with commonly occurring injuries and detected along cutaneous distributions of peripheral nerves or spinal root dermatomes are presented. Thermographic abnormalities may also occur in ondermatomal distributions to involve an entire hand, foot, or extremity as observed in reflex sympathetic dystrophy. Such thermographic findings often appear before skin or roentgenographic changes become manifest and lead to earlier diagnosis. Prompt and more effective treatment, particularly in reflex sympathetic dystrophy, may thereby be initiated so that full blown, difficult to manage, chronic disability may be averted. The diagnosis of malingering may also be strengthened or suspected if thermographic studies together with other examinations are normal.

Adolescent↗
PubMed1979

The limits of Munchausen's syndrome.

The authors review the literature on Munchausen's syndrome and speculate about possible underlying psychological mechanisms. The proposed DSM III classification of factitious illnesses suggests a continuum from hysteria on one end of the spectrum to malingering on the other. Two case studies are presented which represent variants of this syndrome. Both patients were given a sodium amytal interview, a procedure not previously reported in the Munchausen's literature. The procedure was helpful in eliciting a more accurate history and a clearer sense of the underlying dynamics. Some suggestions for further research are made.

Adult↗
PubMed2001

Dizziness and headache: a common association in children and adolescents.

Vertigo has long been recognized by the clinician as a frequent accompanying symptom of the adult migraine syndrome. This association has not been so readily identified in the pediatric population, and, as a consequence, children undergo unnecessary evaluations. We reviewed the charts of all children and adolescents referred for vestibular function testing to the Balance Center at the Barrow Neurological Institute between July 1994 and July 2000 (N = 31). Items analyzed included age, gender, symptoms that prompted the referral, test outcomes, family medical history, and final diagnosis. The most common justification for vestibular testing referral was the combination of dizziness and headache. Other less common reasons were "passing out" episodes, poor balance, and blurred vision. Normal test results were obtained from 70% of patients (n = 22). The most common abnormal test outcome was unilateral vestibular dysfunction (n = 5). Bilateral peripheral vestibular dysfunction was present in three patients. One patient had central vestibular dysfunction. The final diagnoses were vestibular migraine (n = 11), benign paroxysmal vertigo of childhood (n = 6), anxiety attacks (n = 3), Meniere's disease (n = 2), idiopathic sudden-onset sensorineural hearing loss (n = 1), vertigo not otherwise specified (n = 1), familial vertigo/ataxia syndrome (n = 1), and malingering (n = 1); in five patients, no definitive diagnosis was established. The stereotypical patient with vestibular migraine was a teenage female with repeated episodes of headache and dizziness, a past history of carsickness, a family history of migraine, and a normal neurologic examination. Patients who fit this profile are likely to have migrainous vertigo. Consequently, a trial of prophylactic migraine medication should be considered for both diagnostic and therapeutic purposes. Brain imaging and other tests are appropriate for patients whose symptoms deviate from this profile.

Adolescent↗
PubMed1994

The Effect of Somatoform Disorder and Paranoid Psychotic Role-Related Dissimulations as a Response Set on the MMPI-2

Two hundred thirty-seven undergraduate students were assigned to three instructional groups: somatoform disorder, paranoid psychotic, and general "fake-bad," and a standard test-retest control group in order to investigate the impact of specifically defined, role-related dissimulations on responding to the MMPI-2. It was found that each instructional group differed from the control group on a majority of MMPI-2 clinical and validity scales. Although the group that simulated the somatoform disorder differed from the simulated paranoid psychotic and general fake-bad groups, the simulated paranoid psychotic and general fake-bad groups did not differ from each other. An examination of various cutting scores suggests that validity indices used with the MMPI (i.e., F, F-K) are also useful with the MMPI-2. Overall, the F scale seems to be the most effective validity index. Implications for future MMPI-2 and malingering research are discussed.

Journal Article↗
PubMed2005

Establishing the (extra)ordinary in chronic widespread pain.

Sufferers of chronic illness face delegitimation of their condition and threats to their identities. One way of establishing the legitimacy of their position is for sufferers of chronic illness to emphasize the 'ordinary' in their accounts. Sufferers of conditions which are chronic, invisible and contested, such as chronic widespread pain, have the same, and possibly greater, need to legitimize their condition and refute allegations of 'malingering' or psychological instability. The article uses interviews with women with chronic widespread pain to illustrate the ways in which the invisible, subjective and everyday nature of chronic pain leads to sufferers experiencing delegitimation of their condition. It suggests that the accounts of women suffering from chronic widespread pain are constructed to portray a positive identity in the face of this experience, particularly through the emphasis on the 'extraordinary'.

Aged↗
PubMed1996

Feigning psychopathology among adolescent offenders: validation of the SIRS, MMPI-A, and SIMS.

Clinical decision rules for the assessment of feigning and related response styles have not been systematically investigated in adolescent populations. For instance, evaluations of feigning on the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) involve cutting scores extrapolated from adult studies with the MMPI/MMPI-2. Such extrapolations are unwarranted because (a) adolescents perform differently than adults on MMPI/MMPI-2 validity scales and (b) the MMPI-A validity and clinical scales are substantively different than the MMPI/MMPI-2. Given the dearth of adolescent data, this study examined the clinical usefulness of three measures in the assessment of feigning: MMPI-A, Structured Interview of Reported Symptoms (SIRS), and Screening Index of Malingered Symptoms (SIMS). Employing a within-subjects analogue study on 53 dually diagnosed adolescent offenders, we found that commonly used MMPI-A scales (F, F1, and F2) were ineffective, but that F-K > 20 appeared promising. For the SIRS, classification of feigning based on adult criteria yielded moderate positive predictive poser and superb negative predictive power. As a screen, the SIMS proved to be moderately effective in identifying feigned protocols. Finally, two-stage discriminant analysis offered initial support of the incremental validity of a combined SIRS and MMPI-A evaluation of adolescent feigning.

Adolescent↗
PubMed1998

Development and preliminary validation of a forced-choice test of response bias for posttraumatic stress disorder.

This article describes the development and preliminary validation of the Morel Emotional Numbing Test for PTSD (MENT), a forced-choice test for detecting response bias in assessments for posttraumatic stress disorder (PTSD). The differences in MENT error rates among four groups of military veterans applying for monetary compensation for combat-related PTSD and two groups of hospitalized military veterans were investigated (N = 102): (a) disability claimants with veritable self-presentations, who were diagnosed with PTSD; (b) disability claimants with veritable self-presentations, who were not diagnosed with PTSD; (c) older disability claimants (age 63 or older) with veritable self-presentations; (d) disability claimants with suspect self-presentations; (e) chemical-dependent inpatients; and (f) schizophrenic inpatients. Veritable versus suspect grouping among disability claimants was determined by examining MMPI-2 F-K dissimulation index scores. The results indicated that the suspect group produced more errors on the MENT than the credible groups or the hospitalized patient groups (p < .0001). Clinical decision rules were used to evaluate the relative effectiveness of the MENT to identify malingering in the claimant groups. The overall efficiency or hit rate on the MENT was 95.6%.

Adult↗
PubMed1999

Testimony based on the Millon Clinical Multiaxial Inventory: review, commentary, and guidelines.

Test results from the MCMI have been ruled admissible in court for a variety of clinical and forensic issues. This article addresses MCMI issues such as the test's applicability and admissibility of test results in forensic evaluations, test administration, test scoring, malingering and deception, prediction and diagnosis of behavior, reliability, validity, operating characteristics and diagnostic efficiency statistics, and use of computer-assisted interpretation of test results for forensic presentation. Recommendations are suggested for dealing with each of these issues in a forensic context.

Diagnosis, Computer-Assisted↗