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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
An accident history incompatible with the patient's report should be noted. However, some apparent discrepancies may be explained. For example, a person with a recorded GCS of 14 and ability to follow commands in the emergency room who claimed two days of coma may not be dissimulating if he or she is referring to post-traumatic amnesia (PTA). PTA estimates the amount of time after injury before day-to-day memory function can be documented (Rosenthal & Griffith, 1985). Retrograde amnesia (RA) refers to the period of memory loss preceding the TBI. Periods of PTA and RA spanning from weeks to years occur with severe TBI, but not with mild TBI. With complicated mild TBI in which there are CT scan findings, usually of a subdural hematoma or intracerebral contusion, results similar to moderate TBI can be expected (Williams, Levin, & Eisenberg, 1990).
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Neuropsychologists cannot accurately identify malingering using neuropsychological tests alone (Faust, Hart, Guilmette, & Arkes, 1988), except perhaps in obvious cases (Trueblood & Binder, 1997). Having said that, some test patterns are suggestive of dissimulating. Obvious malingering may be seen when feigning subjects believe a test is more difficult (Slick, Hopp, Strauss, & Spellacy, 1996). Frequently, better performance on more difficult tests and poor performance on much easier tests may be interpreted as an attempt at malingering while also attempting to preserve ego. A case in point is that old over-learned information is preserved in most persons with TBI. One patient with an unwitnessed fall from a truck claimed he did not know what the numbers one or two were, presumably because his memory was impaired. He continued to deny knowledge of the numbers one and two even after adding them to obtain three. Of course, such widespread memory loss does not occur with traumatic brain injury patients who have intact attention, as this patient did.
In addition to exaggerated or inconsistent findings, possible malingerers tend to over-endorse symptoms. They may report having every symptom about which they are questioned. More intelligent or psychopathic individuals may have researched appropriate responses. However, they will lack the subtle findings associated with the disorder. For example, intrusion and repetition errors are common on list-learning tasks with mild TBI, a sign of diminished self-monitoring. Malingerers may have no more of these errors than non-brain injured individuals.
Many attempts were made to adapt neuropsychological measures to detect malingering during the course of a standard battery of tests. Malingering indices were developed for simple reaction time (Strauss, Spellacy, Hunter, & Berry, 1994), Digit Span (Iverson & Franzen, 1994), and for the Paced Auditory Serial Addition Test (Strauss et al., 1994). Common memory tests were adapted to assess malingering, such as the Wechsler Memory Scale-Revised (Bernard, Houston, & Natoli, 1993; Mittenberg, Azrin, Millsaps, & Heilbronner, 1993), the Recognition Memory Test (Iverson & Franzen, 1994; Millis, 1992, 1994), and the Rey Auditory Verbal Learning Test (Bernard, 1991; Bernard et al., 1993; Binder, Villanueva, Howieson, & Moore, 1993). To date, none of these adaptations is either thoroughly cross validated or widely used.
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