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Industry: Email Alert RSS FeedTraumatic 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
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).
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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.
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