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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

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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.

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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).

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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

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