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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
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).
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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).
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