Traumatic brain injury when symptoms don't add up: conversion and malingering in the rehabilitation setting. (Traumatic Brain Injury).

There are occasions in rehabilitation when a person presents with symptoms that are inconsistent, exaggerated, do not fit with any known medical diagnosis, or are frankly unbelievable, leading the rehabilitation specialist to label the person as a malingerer. Often, however, people demonstrate symptoms of a psychological disorder that is not malingering - the rehabilitation specialist may actually be observing an unconscious psychological need to be "ill" in some way, i.e., a disorder that is conversion or conversion-like. In the literature, there are few articles discussing the presence of conversion in the rehabilitation setting (Speed, 1996; Teasell & Shapiro, 1994), and there is a dearth of literature that explores the difficulty of differentiating between conversion (and conversion-like disorders) and malingering.

This paper will focus on the special case of traumatic brain injury (TBI). The authors have found those persons with mild, moderate, and even severe TBIs occasionally present with symptoms that are in excess of or inconsistent with what would be expected for their diagnosis. In the case of mild traumatic brain injury, most people experience symptom resolution within one to three months (Dikmen, McLean, & Temkin, 1986; Gentilini, Nichelli, & Schoenhuber, 1989; Levin, Eisenberg, & Benton, 1989). However, 10% to 15% of people with mild TBIs continue to report persistent deficits and impairment after this three month time period (Alexander, 1995). Understandably, total symptom resolution is not expected in persons with moderate to severe TBIs. However, cognitive and functional gains are generally made in a more or less linear fashion over the course of months and years, barring significant medical problems.

There have been several reasons conjectured to account for the ongoing and at times excessive complaints of persons with TBI. Psychiatric problems are often thought to contribute to symptom exaggeration (Lishman, 1988). Just as often, persons with TBI are misjudged and accused of malingering. It is necessary to explore the conversion versus malingering differential as patients reporting "unbelievable" symptoms are often incorrectly perceived as malingering and not given the treatment they need. This paper serves to outline conversion, malingering, and related disorders, describe assessment tools used to make a differential diagnosis, delineate two pertinent case studies, and discuss treatment options for persons with TBI who are demonstrating and reporting symptom exaggeration.

Conversion

Conversion disorder falls under a class of disorders known as the somatoform disorders. The common feature of all somatoform disorders "is the presence of physical symptoms that suggest a general medical condition ... and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder" (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), 1994). Conversion disorder is the unconscious expression of what is thought to be psychological conflict through physical symptoms. The DSM-IV (1994) delineates diagnostic criteria for conversion disorder. Namely, the symptoms must cause significant distress or impairment in social, occupational, or other areas of functioning, the deficits presented must be motor or sensory, and the symptoms are not due to pain, sexual, or mental disorders (e.g., schizophrenia). In addition, medical diagnoses do not fully account for the symptoms, psychological conflicts and stressors precede the symptoms, and the symptoms are not intentionally produced.

The presence of a psychological conflict or stressor is a fine, but important, point. The patient may not fully acknowledge the significance of such a conflict or stressor or may deny that the conflict or stressor has affected him or her. Regardless, the role of the conflict/stressor is critical. The symptoms that arise from the conflict/stressor are symbolically related to unconscious drives. Symptoms are believed to allow partial expression of a forbidden wish or unacceptable need, disguising the wish so that the patient need not consciously confront it. For example, a single mother of three children under five years of age resented that her large extended family was not helping her more. She always felt that her family was not supportive, causing her to act independent and overly self-reliant throughout her childhood. She developed amnesia for her entire childhood and severe new learning deficits after a minor vehicle accident in which there was no loss of consciousness and no positive medical findings. The amnesia necessitated that her family intervene and subsequently she obtained the help she needed without having to acknowledge and express her anger and unmet dependency needs.

Epidemiology and Etiology

Prevalence rates of conversion disorder have ranged from as low as 11/100,000 to as high as 300/100,000 in the general population (DSM-IV, 1994; Ford & Folks, 1985). In medical centers, incidence rates have ranged from 5% to 20% (Zeigler, 1970). A number of predisposing factors may make people susceptible to developing a conversion disorder, including being female, adolescent psychopathology, pre-existing psychopathology, and history of serious medical illness (Barsky, 1989; DSM-IV, 1994).

A number of theories purport to explain the onset of conversion symptoms. One theory, based on a psychodynamic conceptualization of the symptoms, posits that the person derives primary gain by keeping the internal conflict out of conscious awareness. On the other hand, learning theory suggests that a person derives secondary gain by avoiding an activity or activities that are stressful or noxious and by gaining emotional or social support that may not otherwise be available.

Diagnosis

Conversion disorder is very difficult to diagnose. The rehabilitation specialist must invest energy, time, and financial resources to rule out a medical disorder prior to making a diagnosis of conversion. As discussed above, conversion disorders are diagnosed if a medical diagnosis does not fully account for the symptoms. Ergo, the patient may have an underlying, very real medical disorder and still demonstrate conversion symptoms. Diagnosing a psychiatric disorder, such as conversion, is complicated by the fallibility of medicine and diagnostic tests. One study found that of patients given the diagnosis of conversion, in 60% of those cases an "organic" cause for the symptoms was eventually found (Gould, Miller, Goldberg, & Benson, 1986).

Differentiating medical diagnoses from psychiatric diagnoses is further complicated because psychological factors are often associated with the onset of many medical disorders, e.g., depressive and anxiety symptoms. Also, secondary gain or external incentives are common with many medical disorders. For example, it is not uncommon for someone with a stroke or cerebral vascular accident to demonstrate depressive symptoms or histrionic features under the stress of the physical, functional, and psychosocial changes or losses that occur. Furthermore, symptoms associated with a TBI may include irritability, fatigue, and deficits in attention, memory, and executive functioning. Someone experiencing these problems after TBI may not be able to follow through on work or social obligations, and may need to rely on others for emotional, financial, and functional support--seemingly deriving secondary gain. While in this situation secondary gain appears obvious, in reality the reliance on others is a natural and perhaps appropriate result of losing one's independence.

Making the differential diagnosis between malingering and somatization type disorders, such as conversion, can be difficult. Conversion symptoms can be inconsistent and unbelievable, very similar to malingering. It is commonly believed that patients who are in pursuit of compensation frequently report symptoms with longer duration (Mittenberg, Diguilio, Perrin, & Bass, 1992). The authors of the current paper contend that duration of reported symptoms does not necessarily imply the secondary gain of compensation associated with malingering. It is possible that patients may employ an unconscious psychological process that also involves secondary gain, but of the nature that meets or modifies a psychological need, i.e., conversion or conversion-like disorder.

Finally, the critical difference between conversion disorder and malingering is intent. That is, is the person consciously and volitionally producing symptoms? Unfortunately, even the most precise tests cannot measure or determine whether someone is consciously or unconsciously motivated to report symptoms. In the case of TBI, expectancies for TBI symptoms commonly occur in normal populations, i.e., people who have not experienced a TBI can accurately describe common sequelae (Alves, Macciocchi, & Barth, 1993). Because TBI symptoms are commonly known and predictable, patients can relatively easily report symptoms. Patients who are at risk demographically for conversion disorder are more susceptible to developing conversion symptoms if they have some knowledge of a medical disorder. Similarly, patients who are intentionally feigning symptoms, as in the case of malingering, can more easily do so if the disorder has predictable symptoms.

Related Disorders

There are a number of DSM-IV diagnoses that must be considered in the differential between conversion and malingering. As noted above, conversion disorder is a subtype of the somatoform disorders, several of which can be confused with conversion disorder, including somatization disorder, undifferentiated somatoform disorder, pain disorder, hypochondriasis, and somatoform disorder not otherwise specified. A differential diagnosis must also be made between a somatoform disorder such as conversion, and a DSM-IV category of conditions known as Psychological Factors Affecting Medical Condition. Lastly, one must also consider Factitious Disorder in the differential. A full explanation of all related disorders is beyond the scope of this paper. See the DSM-IV for complete diagnostic criteria of related disorders.

Malingering

Malingering is the intentional production of medical or psychiatric symptoms to obtain an external incentive (DSM-IV, 1994). In the psychiatric literature, the incentive is known as secondary gain, and may consist of monetary or other gain, or avoidance of negative consequences. Because malingering is not a psychiatric or medical diagnosis, it was assigned a nondiagnostic DSM-IV V-code. Intent to defraud is difficult to prove to a certainty, so that many clinicians avoid labeling a person as a malingerer (Binder, 1992).

Malingering is often associated with litigation or Worker's Compensation claims. There are numerous articles published on the incidence of malingering or likely malingering in persons with TBI. Many studies have found that persons in litigation or pursuing Worker's Compensation claims performed with less consistency on neuropsychological tests (Reitan & Wolfson, 1995; Reitan & Wolfson, 1996), performed with neuropsychological test score patterns that do not occur in nonlitigating persons with TBI (Reitan & Wolfson, 1992), or performed with questionable motivation (Fox, 1994; Schmand, Lindeboom, Schagen, Heijt, Koene, & Hamburger, 1998; Youngjohn, Burrows, & Erdal, 1995). In contrast, Ruff, Wylie, and Tennant (2000) found no differences between litigants and nonlitigants with TBI on neuropsychological test performance. Suhr, Tranel, Wefel, and Barrash (1997) argue that factors other than pending litigation contribute to poor or inconsistent performance. In addition, there is no evidence that TBI patients, as a group, intentionally feign or exaggerate deficits on neuropsychological testing more often than other diagnostic groups (Leininger & Kreutzer, 1992).

Epidemiology and Etiology

Because there are disincentives for the malingerer to reveal feigning a disability, the incidence is difficult to determine. Estimates range from 1% to 50%, depending on the setting and population (Grant & Alves, 1987; Resnick, 1988; Schretlen, 1988). However, most patients try to appear psychologically normal and to minimize their cognitive deficits (Pankratz, 1988), including those seeking compensation (Lezak, 1995). Some experts say the incidence of malingering is much less common than expected given the amount of attention focused on it in the literature (White & Proctor, 1992). Nevertheless, a Rand Corporation study found 35% to 42% of the medical costs claimed in motor vehicle accidents in 1993 involved staged or nonexistent accidents, or inflated claims (Carroll, Abrahamse, & Vaiana, 1995).

Antisocial traits, antisocial personality disorder, and substance abuse are associated with deception and can increase the chances of malingering (Miller, 1989, 1990). As a result, angry and challenging affect may be seen. The reported circumstances surrounding the precipitating accident may be vague or odd. Falls may be unwitnessed, or the patient may demonstrate intact abilities after the injury, which he subsequently "loses." Malingerers typically do not cooperate well during examination and treatment. Excessively detailed complaints, bizarre or unusual complaints, or claimed stress out of proportion to the precipitating agent are common. Responses may be excessively slow, as the malingerer tries to determine what response best suits each question. For example, a patient with severe documented orthopedic trauma tried to claim a brain injury as well. However, a basic question such as, "What color is the sky?" elicited the improbable answer, "Greenish-blue?" after a lengthy pause.

Diagnosis

There are a number of assessment tools used to explore psychological factors that contribute to symptom presentation. When the patient with a TBI presents with a complicated and confusing symptom picture, the authors suggest the following assessment strategy: clinical interview, collateral interview with significant other, interviews with staff working with patient (e.g., physical, occupational, and speech therapists), review of medical records, neuropsychological testing, MMPI-2, and appropriate tests of malingering.

The first step to assessing malingering is for the examiner to establish the severity of the initial injury using standard medical procedures and measures. For example, the Glasgow Coma Scale (GCS, Teasdale & Jennett, 1974), a measure of coma severity, is expected to be 13 to 15 in cases of mild TBI, 8 to 12 in cases of moderate TBI, and below 7 in cases of severe TBI. Loss of consciousness (LOC) must be less than 20 minutes in mild TBI (Rimel, Giordiani, Barth, 1981). LOC in a concussion may be present or absent without affecting symptom outcome. Mild TBI subjects complaining of symptoms one to 24 months post-injury who had brief LOC did not differ neuropsychologically from those without LOC (Leininger, Gramling, Farrell, Kreutzer, & Peck, 1990).

An accident history incompatible with the patient's report should be noted. However, some apparent discrepancies may be explained. For example, a person with a recorded GCS of 14 and ability to follow commands in the emergency room who claimed two days of coma may not be dissimulating if he or she is referring to post-traumatic amnesia (PTA). PTA estimates the amount of time after injury before day-to-day memory function can be documented (Rosenthal & Griffith, 1985). Retrograde amnesia (RA) refers to the period of memory loss preceding the TBI. Periods of PTA and RA spanning from weeks to years occur with severe TBI, but not with mild TBI. With complicated mild TBI in which there are CT scan findings, usually of a subdural hematoma or intracerebral contusion, results similar to moderate TBI can be expected (Williams, Levin, & Eisenberg, 1990).

Neuropsychologists cannot accurately identify malingering using neuropsychological tests alone (Faust, Hart, Guilmette, & Arkes, 1988), except perhaps in obvious cases (Trueblood & Binder, 1997). Having said that, some test patterns are suggestive of dissimulating. Obvious malingering may be seen when feigning subjects believe a test is more difficult (Slick, Hopp, Strauss, & Spellacy, 1996). Frequently, better performance on more difficult tests and poor performance on much easier tests may be interpreted as an attempt at malingering while also attempting to preserve ego. A case in point is that old over-learned information is preserved in most persons with TBI. One patient with an unwitnessed fall from a truck claimed he did not know what the numbers one or two were, presumably because his memory was impaired. He continued to deny knowledge of the numbers one and two even after adding them to obtain three. Of course, such widespread memory loss does not occur with traumatic brain injury patients who have intact attention, as this patient did.

In addition to exaggerated or inconsistent findings, possible malingerers tend to over-endorse symptoms. They may report having every symptom about which they are questioned. More intelligent or psychopathic individuals may have researched appropriate responses. However, they will lack the subtle findings associated with the disorder. For example, intrusion and repetition errors are common on list-learning tasks with mild TBI, a sign of diminished self-monitoring. Malingerers may have no more of these errors than non-brain injured individuals.

Many attempts were made to adapt neuropsychological measures to detect malingering during the course of a standard battery of tests. Malingering indices were developed for simple reaction time (Strauss, Spellacy, Hunter, & Berry, 1994), Digit Span (Iverson & Franzen, 1994), and for the Paced Auditory Serial Addition Test (Strauss et al., 1994). Common memory tests were adapted to assess malingering, such as the Wechsler Memory Scale-Revised (Bernard, Houston, & Natoli, 1993; Mittenberg, Azrin, Millsaps, & Heilbronner, 1993), the Recognition Memory Test (Iverson & Franzen, 1994; Millis, 1992, 1994), and the Rey Auditory Verbal Learning Test (Bernard, 1991; Bernard et al., 1993; Binder, Villanueva, Howieson, & Moore, 1993). To date, none of these adaptations is either thoroughly cross validated or widely used.

Psychology Tests Used to Detect Malingering

The MMPI and its successor, the MMPI-2, are the most common tests administered to detect malingering. The Psychopathic Deviate Scale (Scale 4), a measure of antisocial traits, may be elevated in some malingering individuals. However, it frequently is not. The Infrequency scale (F), Back Infrequency scale (Fb), Infrequency-Psychopathology scale, and the Dissimulation scale-2 (D-sub(s2)), are scales that are typically analyzed in persons presenting with exaggerated complaints. Although these scales can differentiate between personal injury litigants and controls, the scales were not able to differentiate litigants and clinical, nonlitigants. The Fake Bad Scale (FBS) was able to differentiate between litigants and clinical, non-litigants (Tsushima & Tsushima, 2001). Regarding MMPI/MMPI-2 clinical scales, Boone and Lu (1999) found that the 1-3/3-1 (Hypochondriasis and Depression) code types showed evidence of non-credible cognitive performance on malingering and neuropsychological tests. Some sophisticated feigners of malingering produce valid MMPI-2 profiles, while the most unsophisticated feigners produce suspicious profiles (Slick, et al., 1996). One neuropsychological test expert, Lezak (1995) contends that no "Malingering Profile" exists on the MMPI or MMPI-2.

The Structured Interview of Reported Symptoms (SIRS; Rogers, 1986, 1992) was developed for psychiatric patients. Its primary scales include compendiums of rare, improbable and absurd symptoms, as well as blatant versus subtle symptoms. The supplementary scales include a direct appraisal of honesty as well as subscales for defensive symptoms, overly specified symptoms, and symptom inconsistency, which can be helpful in interviewing a suspected malingerer.

Case Study: Suspected Malingering with Ultimate Conversion Diagnosis

History of injury: The first case study involves a 39-year-old man (H.B.) who sustained a moderate TBI in a motor vehicle accident. H.B. was a passenger traveling to his job, when the car he was in was hit head-on. H.B. lost consciousness at the scene. CT scan on admission and on follow-up three days post injury revealed a large amount of intraventricular hemorrhage. Upon admission to acute rehabilitation almost two weeks after his accident, he was confused, restless, distractible, and logorrheic. He was also mildly anomic, but speech was generally fluent. At discharge from inpatient treatment two weeks later, he was oriented in all spheres and had mild to moderate deficits in memory. His thoughts were generally organized and he could independently complete all simple activities of daily living. He was discharged to his home with his girlfriend and began treatment in an outpatient brain injury program.

Social and Mental Health History: H.B.'s medical history was unremarkable. With regard to mental health history, he reported a depressive episode after the death of his mother. He self-medicated with alcohol, but never received treatment for depression or alcohol abuse. Prior to the accident, he was a moderate social drinker. H.B.'s work and relationship history was somewhat complex. He had numerous careers and jobs throughout his adulthood. At one point he studied ballet, but most of his jobs were unskilled or semi-skilled. He attended college, but did not complete any course of study. He had a history of close, and sometimes chaotic social relationships. Most recently, he lived with his girlfriend of eight months. Apparently, they became seriously involved after two weeks of dating. During his outpatient treatment, the girlfriend revealed she was dissatisfied in the relationship prior to the accident. He had a relatively unremarkable legal history, but admitted to nonpayment of taxes for five years. This was a source of conflict in his relationship with the girlfriend. H.B. also noted that he was intent on suing the driver of the car that caused the accident.

Clinical Picture: Outpatient treatment in a comprehensive Brain Injury Program consisted of individual speech, occupational, and psychotherapy, as well as group cognitive therapy, adjustment group, and community re-entry group. The outpatient staff initially saw H.B. make good progress. After a few weeks in outpatient therapy, his girlfriend complained that H.B. was too dependent on her. She was encouraged to set limits with him as he was capable of completing many if not all complex activities of daily living. Soon though she left the home, and then finally the relationship. During the dissolution of the relationship, H.B.'s performance on cognitive tests and tasks declined. In fact, as time went on his deficits became more "severe". He also developed slurred speech, with prominent tongue protrusion. Medical workup did not reveal physiological or medical explanations for the change in his performance. He was prescribed Effexor by his physiatrist for self-reported depressive symptoms. Interpersonally, he cooperated in group but clearly demonstrated passive-aggressive, narcissistic, and histrionic personality traits. A few members on staff strongly suspected malingering, i.e., that H.B. was intentionally producing cognitive deficits in order to gain attention and support. Despite the staff's conviction, there were clear predisposing factors, which could have contributed to development of a conversion disorder; i.e., an unintentional or unconscious production of symptoms. These factors included Axis I and possible Axis II psychopathology, major life stressors, knowledge of TBI and related deficits. However, in the conversion versus malingering argument, H.B. also demonstrated what are thought to be typical malingering behaviors: inconsistent performance, engaging in a lawsuit, and avoiding work and other responsibilities. H.B. was administered the MMPI-2 (see Figure 1) to begin assessing the psychological and emotional factors which could have been affecting his rehabilitation progress. A neuropsychological test battery was not administered due to the patient's severely and profoundly impaired performance on all cognitive tests administered during speech therapy. It was clear that neuropsychological testing would have also shown severe deficits in all areas of cognitive functioning.

[FIGURE 1 OMITTED]

Analysis: Analysis of the MMPI-2 administered did not reveal any over or under-reporting of concerns. He was not necessarily trying to put himself in an overly positive light. Validity indicators suggested a valid profile. His code-type, 1-3-8, was interpreted with his TBI deficits in mind. Typically, 1-3-8 profiles are viewed as schizophrenic. In this case, the elevation on scale 8 can be explained in part by deficits reported by many patients with TBI. The 1-3 elevation suggests classic conversion symptoms.

Treatment: The staff was encouraged to begin suggesting to H.B. that he should improve over time, regardless of his complaints that he was severely impaired. As difficult as it was, the staff was encouraged to remain supportive and nonreactive to his apparent symptom exaggeration. To address his progressive speech problem he was put on a behavioral program. To reduce the likelihood that H.B. would interpret the intervention as "psychological", the speech therapist introduced the plan to him. To "correct" the tongue protrusion he was instructed to speak with clenched teeth for five days. Reminders were given. He was given a pseudo-scientific explanation for the intervention and told that for his particular disorder, five days of teeth clenching was the therapy and cure. It was suggested to him that if his speech did not improve, there must be some "other" nonmedical explanation for his speech problem. In addition, if he slipped back into maladaptive speech production, he was instructed by staff and his peers to clench his teeth. Within two weeks, tongue protrusion decreased and H.B.'s speech production improved dramatically.

To address the psychological and emotional issues contributing to H.B.'s decline in functioning, he continued to participate in both individual and group psychotherapy. Psychotherapy addressed his unmet dependency needs and focused on his strengths and abilities. Group psychotherapy focused on helping develop a more flexible interpersonal style, i.e., less demanding of and more appropriately assertive with others. Group psychotherapy also served to provide healthy models of recovery and coping for H.B. After four more months of treatment, he was discharged able to function independently, with less focus on his deficits, and adequate speech production. Tongue thrusting was virtually eliminated. A follow-up MMPI-2 was administered three months after the initial administration (see Figure 2).

[FIGURE 2 OMITTED]

A neuropsychological test battery was also administered to assess the patient's improved functioning. Full Scale IQ was 100 with Verbal and Performance IQ scores at 107 and 91. He demonstrated mild inconsistencies with some evidence of limited effort on easier tests, and more effort on difficult ones. For example, Digit Span was average, but Arithmetic was superior. Despite some inconsistencies, H.B.'s overall performance was consistent with moderate TBI, his acute care hospital diagnosis. Specifically, he demonstrated deficits in speed of processing, memory retrieval, planning, and organization.

Analysis: Although H.B. demonstrates some of the hallmarks of malingering, i.e., exaggerated deficits, inconsistent performance, history of psychological difficulty, recent severe psychosocial stress, secondary gain, the change in H.B.'s MMPI-2 profile clearly suggests that he improved. Improvement alone without resolution of legal or relationship issues strongly suggests that H.B.'s symptoms were not intentional or conscious, but instead were likely unconscious attempts to meet dependency needs, which surfaced under extreme distress. Validity indicators on the follow-up MMPI-2 were again within normal parameters: H.B. did not attempt to over-report or under-report symptoms. Analysis of his profile indicates an overall lowering of all clinical scales. H.B.'s new code-type was 3-8-5, suggesting mild to moderate histrionic traits with ongoing cognitive and sensory disturbances. Results of neuropsychological testing appeared to be a relatively accurate reflection of his cognitive strengths and weaknesses.

Case Study: Suspected Malingering

History of injury: J.R. was a right-handed 35-year-old man with a high school education. He had an unwitnessed fall on flat ground while working as a construction site plumber. He was found face down, got up, walked a few steps, and reportedly fainted. He regained consciousness with paramedics present. At the emergency room, a CT scan of the brain was negative, and he was diagnosed with a contusion and muscle strain. His wife picked him up three hours after the incident. Later that night, he became dazed and bumped into the walls. His wife took him back to the ER where another CT scan was negative. His wife noted childish behavior, bad temper, and cognitive "fuzziness" for a month following the accident.

Clinical Interview: J.R. was angry, irritable, and challenging throughout the interview and testing. He complained of balance problems, headache, blurred vision, and memory problems. He claimed to lack memory of the injury itself, for the week before the accident and for one month following. Inconsistent history reporting was evident. For example, he did not recall any details of his birthday the week before the fall. Yet, he remembered slipping on items another worker left on the ground just prior to the fall. He was noncompliant with medications, claiming Alprazolam (Xanax) caused memory problems and Amitryptilline (Elavil) 25 mg made him sleep from 11 A.M. to 2 P.M. the following day. When asked why he had a bandage on a forefinger, he claimed the finger was broken "with the bone coming through the skin," but that he had not consulted a physician. Other physical complaints were equally bizarre or over-elaborated. He held his head claiming severe headache, refusing to perform serial 7 subtractions. He denied problems with appetite, sleep, or energy, but complained of severe depression. He said that most of all, he just wanted to return to work.

Social and Mental Health History: J.R. had a 15-year history of alcohol abuse, but admitted only occasional alcohol use in the last two years. He was married one year to his third wife, with an 8-month-old child. He paid child support to his first two wives. The couple admitted financial stress predating the accident. J.R. had been on the job less than three months at the time of the incident. This was his fourth Worker's Compensation claim. He told the insurance case manager that he was suing an examining doctor who injured his neck. His case manager reported that J.R.'s father was disabled most of his life following a Worker's Compensation injury. He denied a history of psychiatric difficulties.

Test Results: J.R.'s performance on the Rey Memory Tests was suspect since he obtained less than three rows (see Figures 3 and 4). The Mini Mental State Exam (MMSE) score of 26 was borderline for his age and education, atypical for mild TBI. He refused to attempt serial 7 subtractions, or the Gordon Diagnostic Systems distractibility subtest, angrily saying the flashing lights gave him a headache. He refused to complete the PDRT. The MMPI-2 was not administered since he resisted much shorter tests. Full Scale IQ was borderline at 79, with no significant discrepancy between Verbal and Performance IQ scores at 79 and 83. Nevertheless, most test scores were normal with the exception of scores on list learning, verbal fluency, and strength and coordination in the right hand. On the California Verbal Learning Test (CVLT), delayed recall was particularly low, one of 16 list items. Recognition memory was worse than expected for mild TBI, 11 words with five false positive errors. On the other hand, J.R.'s performance on the test lacked the common mild TBI subtle findings of repetition or intrusion errors. The Geriatric Depression Scale was in the range for severe depression despite the lack of vegetative findings for sleep, appetite, or energy.

[FIGURES 3-4 OMITTED]

Analysis: The inconsistent history, over-elaborate complaints, and test findings strongly suggested malingering. The couple was told there was no cognitive reason that he could not return to work. They immediately said his balance was too poor to work on construction sites, as he would have to stick his head down in holes or go up ladders. He did not seem pleased when other alternatives to working construction were suggested, despite the claim that he only wanted to return to work.

Treatment: As noted previously, setting limits is the primary treatment for suspected malingerers.

Discussion

Treatment considerations will focus on conversion disorder, as the only treatment for obvious malingering is limit setting. Conversion disorder should be conceptualized as a real and treatable problem. There is potentially much overlap between somatoform disorders such as conversion disorder and malingering. Both diagnoses may be associated with inconsistent and seemingly exaggerated performances, secondary gain, various psychopathologies, and stressful life events. The single most important difference between the two diagnoses is whether or not the patient is unintentionally or unconsciously producing the symptoms (somatoform or conversion disorder) versus intentionally or consciously producing the symptoms (malingering).

The patient with a TBI, mild or moderate, may be especially vulnerable to being diagnosed with malingering or intentional feigning of symptoms. This vulnerability may stem from the variable and the sometimes inconsistent nature of TBI sequelae, the appearance of secondary gain such as law suits or family attention, and the difficulty coping that some patients have after TBI due to the subtle, but significant changes in how they think and function. In addition, patients with TBI are frequently misjudged by the public due to the misperceptions that the public has about brain injury and recovery. These misperceptions about recovery may be strongly influenced by the media, e.g., the seemingly complete recoveries that football players make after sustaining multiple concussions. The entertainment industry also fuels the misperceptions regarding TBI recovery as can be seen by the complete recoveries that actors make after coma. As a result of these misperceptions, many people expect the patient who has sustained a concussion or TBI to make a full recovery and when the patient continues to report symptoms, they are seen as poor copers, exaggerators, or at worst malingerers.

It is clear that neuropsychological testing alone is not sufficient to differentiate between conversion disorder and malingering. Persons with TBI who are in litigation may over-endorse symptoms or under-perform on neuropsychological tests, but these facts by themselves, do not indicate malingering. Specifically, poor motivation and inconsistent performance on tests does not equal malingering. Other factors such as concomitant depression and anxiety or premorbid psychiatric problems, may account for "the inexplicable." It is essential that a person's performance on neuropsychological tests be interpreted within the context of an adequate history via record review and a thorough clinical interview (Iverson & Binder, 2000; Klonoff & Lamb, 1998). The record review and clinical interview process (the writers of this paper also recommend multiple clinical interviews and observation of rehabilitation therapies) will help determine where the conscious versus unconscious line in drawn.

It is critical that the healthcare professional working in rehabilitation not assume that the TBI patient is intentionally or consciously producing symptoms, i.e., malingering: doing so would impede the needed treatment that the patient with TBI deserves. The rehabilitation specialist, who suspects possible conversion or conversion-like disorder, should refer the patient to a qualified mental health professional without necessarily discharging the patient from medically based treatment. Keeping the patient in a medical setting, treated by an interdisciplinary team, can be an ideal situation. When treating the patient who is over-focused on his or her symptoms, the rehabilitation specialist should not convey that the patient's symptoms are psychologically based. Doing so will encourage resistance and symptom exacerbation (Speed, 1996).

After determining that a medical diagnosis cannot fully explain the TBI symptoms, a mental health professional should assess the patient with appropriate psychological and neuropsychological tests. Next, a behavioral approach to treatment should be taken with the adjunct of psychotherapy. The goal of such a program should be to help the patient unlearn a maladaptive response, and learn more appropriate ways of dealing with the environment (Trieschmann, Stolov, & Montgomery, 1970). After a program is established, the patient should be given a pseudo-scientific explanation for his/her disorder. It should be implied that if there is no improvement after the specified course of treatment, the disorder could not be medically based (Teasell & Shapiro, 1994).

For the patient with a TBI, treatment should focus on setting hierarchical goals and providing cognitive related interventions. It is important to give positive reinforcement for improved function and "punish" signs of dysfunction (Speed, 1996). Dysfunction or maladaptive behaviors may be punished by systematic ignoring, removal of a special activity such as an outing, or returning to work on a lower level goal. This strategy is especially useful in group treatment settings. The treatment team should remain positive and patient and keep in mind that most people with conversion disorder improve eventually. TBI, regardless of severity, is a complex diagnosis affecting all aspects of a person's life. The person with a TBI is usually under a severe level of distress considering cognitive changes, physical changes, or both; relationship changes; work changes; and financial changes. Given the stressors with which the person with a TBI may have to deal, he or she may indeed exhibit psychological or emotional symptoms that complicate the picture. At the very least, persons who present with complicated presentations should be given the benefit of the doubt and, therefore, the benefit of rehabilitation treatment.

Table 1
[Tests of Malingering]

Table 1: Tests of Malingering

Name of Test           Author(s)           Description

CVLT-II (Forced        Delis, Kramer,      Forced Choice Recognition
Choice Recognition     Kaplan, & Ober,     of words on learned list
Subtest)               2000                versus novel unrelated
                                           words - > 1 error suggests
                                           poor motivation.

Dot Counting Test      Rey, 1941           Counting grouped dots
(DCT)                  Lezak, 1983         versus counting ungrouped
                                           dots -- counting grouped
                                           dots should take less time.

Rey Malingering Test   Rey, 1958           15 items presented in 5
(RMT)                                      groups of 3 -- subject
                                           should be able to draw at
                                           least 3 rows.

Symptom Validity       Pankratz, Fausti    Forced choice -- subject
Test (SVT)             & Peed, 1975        should score at least 50%
                       Pankratz, 1988

b Test                 Boone, 2000         15-page booklet of b's,
                                           q's, d's, etc. Cut-off
                                           scores for time, omissions
                                           and commissions.

Portland Digit         Binder & Willis,    Forced choice recognition
Recognition Test       1991                of digits -- subject should
(PDRT)                 Binder, 1993        score at least 50%.

Test of Memory         Rees & Tombaugh,    Forced Choice recognition
Malingering (TOMM)     1996                of 50 line
                                           drawings -- subject should
                                           score at least 50%.

Victoria Symptom       Slick, Hopp, &      Computerized version of
Validity Test          Strauss, 1992,      PDRT -- reaction time also
                       1995                measured. Results
                                           classified as malingered,
                                           questionable, or valid.

Validity Indicator     Frederick, 1997     Assesses consistency of
Profile (VIP)                              effort over time -- results
                                           indicate 1 of 4 response
                                           styles: compliant,
                                           careless, irrelevant, or
                                           malingered.

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Patricia Rogers Babin, Ph.D., Charlotte Institute of Rehabilitation 1100 Blythe Blvd., Charlotte, NC 28203