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

Journal of Rehabilitation,  April-June, 2002  by Patricia Rogers Babin,  Patricia Gross

• E-mail
• Print
• Link

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).