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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To address the psychological and emotional issues contributing to H.B.'s decline in functioning, he continued to participate in both individual and group psychotherapy. Psychotherapy addressed his unmet dependency needs and focused on his strengths and abilities. Group psychotherapy focused on helping develop a more flexible interpersonal style, i.e., less demanding of and more appropriately assertive with others. Group psychotherapy also served to provide healthy models of recovery and coping for H.B. After four more months of treatment, he was discharged able to function independently, with less focus on his deficits, and adequate speech production. Tongue thrusting was virtually eliminated. A follow-up MMPI-2 was administered three months after the initial administration (see Figure 2).

[FIGURE 2 OMITTED]

A neuropsychological test battery was also administered to assess the patient's improved functioning. Full Scale IQ was 100 with Verbal and Performance IQ scores at 107 and 91. He demonstrated mild inconsistencies with some evidence of limited effort on easier tests, and more effort on difficult ones. For example, Digit Span was average, but Arithmetic was superior. Despite some inconsistencies, H.B.'s overall performance was consistent with moderate TBI, his acute care hospital diagnosis. Specifically, he demonstrated deficits in speed of processing, memory retrieval, planning, and organization.

Analysis: Although H.B. demonstrates some of the hallmarks of malingering, i.e., exaggerated deficits, inconsistent performance, history of psychological difficulty, recent severe psychosocial stress, secondary gain, the change in H.B.'s MMPI-2 profile clearly suggests that he improved. Improvement alone without resolution of legal or relationship issues strongly suggests that H.B.'s symptoms were not intentional or conscious, but instead were likely unconscious attempts to meet dependency needs, which surfaced under extreme distress. Validity indicators on the follow-up MMPI-2 were again within normal parameters: H.B. did not attempt to over-report or under-report symptoms. Analysis of his profile indicates an overall lowering of all clinical scales. H.B.'s new code-type was 3-8-5, suggesting mild to moderate histrionic traits with ongoing cognitive and sensory disturbances. Results of neuropsychological testing appeared to be a relatively accurate reflection of his cognitive strengths and weaknesses.

Case Study: Suspected Malingering

History of injury: J.R. was a right-handed 35-year-old man with a high school education. He had an unwitnessed fall on flat ground while working as a construction site plumber. He was found face down, got up, walked a few steps, and reportedly fainted. He regained consciousness with paramedics present. At the emergency room, a CT scan of the brain was negative, and he was diagnosed with a contusion and muscle strain. His wife picked him up three hours after the incident. Later that night, he became dazed and bumped into the walls. His wife took him back to the ER where another CT scan was negative. His wife noted childish behavior, bad temper, and cognitive "fuzziness" for a month following the accident.