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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
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
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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.
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