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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
Clinical Interview: J.R. was angry, irritable, and challenging throughout the interview and testing. He complained of balance problems, headache, blurred vision, and memory problems. He claimed to lack memory of the injury itself, for the week before the accident and for one month following. Inconsistent history reporting was evident. For example, he did not recall any details of his birthday the week before the fall. Yet, he remembered slipping on items another worker left on the ground just prior to the fall. He was noncompliant with medications, claiming Alprazolam (Xanax) caused memory problems and Amitryptilline (Elavil) 25 mg made him sleep from 11 A.M. to 2 P.M. the following day. When asked why he had a bandage on a forefinger, he claimed the finger was broken "with the bone coming through the skin," but that he had not consulted a physician. Other physical complaints were equally bizarre or over-elaborated. He held his head claiming severe headache, refusing to perform serial 7 subtractions. He denied problems with appetite, sleep, or energy, but complained of severe depression. He said that most of all, he just wanted to return to work.
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Social and Mental Health History: J.R. had a 15-year history of alcohol abuse, but admitted only occasional alcohol use in the last two years. He was married one year to his third wife, with an 8-month-old child. He paid child support to his first two wives. The couple admitted financial stress predating the accident. J.R. had been on the job less than three months at the time of the incident. This was his fourth Worker's Compensation claim. He told the insurance case manager that he was suing an examining doctor who injured his neck. His case manager reported that J.R.'s father was disabled most of his life following a Worker's Compensation injury. He denied a history of psychiatric difficulties.
Test Results: J.R.'s performance on the Rey Memory Tests was suspect since he obtained less than three rows (see Figures 3 and 4). The Mini Mental State Exam (MMSE) score of 26 was borderline for his age and education, atypical for mild TBI. He refused to attempt serial 7 subtractions, or the Gordon Diagnostic Systems distractibility subtest, angrily saying the flashing lights gave him a headache. He refused to complete the PDRT. The MMPI-2 was not administered since he resisted much shorter tests. Full Scale IQ was borderline at 79, with no significant discrepancy between Verbal and Performance IQ scores at 79 and 83. Nevertheless, most test scores were normal with the exception of scores on list learning, verbal fluency, and strength and coordination in the right hand. On the California Verbal Learning Test (CVLT), delayed recall was particularly low, one of 16 list items. Recognition memory was worse than expected for mild TBI, 11 words with five false positive errors. On the other hand, J.R.'s performance on the test lacked the common mild TBI subtle findings of repetition or intrusion errors. The Geriatric Depression Scale was in the range for severe depression despite the lack of vegetative findings for sleep, appetite, or energy.
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