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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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Clinical Picture: Outpatient treatment in a comprehensive Brain Injury Program consisted of individual speech, occupational, and psychotherapy, as well as group cognitive therapy, adjustment group, and community re-entry group. The outpatient staff initially saw H.B. make good progress. After a few weeks in outpatient therapy, his girlfriend complained that H.B. was too dependent on her. She was encouraged to set limits with him as he was capable of completing many if not all complex activities of daily living. Soon though she left the home, and then finally the relationship. During the dissolution of the relationship, H.B.'s performance on cognitive tests and tasks declined. In fact, as time went on his deficits became more "severe". He also developed slurred speech, with prominent tongue protrusion. Medical workup did not reveal physiological or medical explanations for the change in his performance. He was prescribed Effexor by his physiatrist for self-reported depressive symptoms. Interpersonally, he cooperated in group but clearly demonstrated passive-aggressive, narcissistic, and histrionic personality traits. A few members on staff strongly suspected malingering, i.e., that H.B. was intentionally producing cognitive deficits in order to gain attention and support. Despite the staff's conviction, there were clear predisposing factors, which could have contributed to development of a conversion disorder; i.e., an unintentional or unconscious production of symptoms. These factors included Axis I and possible Axis II psychopathology, major life stressors, knowledge of TBI and related deficits. However, in the conversion versus malingering argument, H.B. also demonstrated what are thought to be typical malingering behaviors: inconsistent performance, engaging in a lawsuit, and avoiding work and other responsibilities. H.B. was administered the MMPI-2 (see Figure 1) to begin assessing the psychological and emotional factors which could have been affecting his rehabilitation progress. A neuropsychological test battery was not administered due to the patient's severely and profoundly impaired performance on all cognitive tests administered during speech therapy. It was clear that neuropsychological testing would have also shown severe deficits in all areas of cognitive functioning.

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[FIGURE 1 OMITTED]

Analysis: Analysis of the MMPI-2 administered did not reveal any over or under-reporting of concerns. He was not necessarily trying to put himself in an overly positive light. Validity indicators suggested a valid profile. His code-type, 1-3-8, was interpreted with his TBI deficits in mind. Typically, 1-3-8 profiles are viewed as schizophrenic. In this case, the elevation on scale 8 can be explained in part by deficits reported by many patients with TBI. The 1-3 elevation suggests classic conversion symptoms.

Treatment: The staff was encouraged to begin suggesting to H.B. that he should improve over time, regardless of his complaints that he was severely impaired. As difficult as it was, the staff was encouraged to remain supportive and nonreactive to his apparent symptom exaggeration. To address his progressive speech problem he was put on a behavioral program. To reduce the likelihood that H.B. would interpret the intervention as "psychological", the speech therapist introduced the plan to him. To "correct" the tongue protrusion he was instructed to speak with clenched teeth for five days. Reminders were given. He was given a pseudo-scientific explanation for the intervention and told that for his particular disorder, five days of teeth clenching was the therapy and cure. It was suggested to him that if his speech did not improve, there must be some "other" nonmedical explanation for his speech problem. In addition, if he slipped back into maladaptive speech production, he was instructed by staff and his peers to clench his teeth. Within two weeks, tongue protrusion decreased and H.B.'s speech production improved dramatically.

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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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