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(March, 2007 Note: Most of my articles on temperament, dreams, psychology, etc. are now hosted at www.neurocareusa.com. Go there for the latest version of articles. However, the links to old versions are still functional.)

Malingering and Conversion Reactions (2002)
by Robert I. Winer, M.D.

Introduction

In the medical-legal arena, medical specialists, physical therapists, and psychiatrists are often called upon to make an assessment that renders an opinion as to the whether a patient's complaints or efforts are organically, psychiatrically, or pain-based. In particular, the psychiatric side of this equation often is the decision of whether the clinical presentation is the result of conscious feigning, what is called "malingering." Various clinical tests have been designed to assess the so-called "truthfulness" of a patient's pain or the "actuality" of the degree of effort they put forth which may be termed the "validity" for organicity of the test.

It is my sense that the main difficulty is that the majority of practitioners making these decisions have too small a knowledge base and lack the clinical breadth to understand properly the scope of the clinical material that one may encounter. I In particular, it seems to me that the main problem is the one-sided conception that a problem is either in the mind or the body. Modern medicine has become filled with splitters -- those who for the sake of making clear diagnostic criteria have arbitrarily decided that some conditions are physical (or use the term organic) while others are mental (also called functional). Of course there is truth to this, however, clinicians must face the fact that the body and psyche are irrevocably linked. This has been repeatedly proven scientifically and experimentally. The plain fact is that all of humanity manifests, at one time or another, psychic disturbances in bodily form. A example is the physical symptoms of an emotional "stomach ache." Depth psychology understands emotions as a feeling-tone accompanied by bodily activation, the most common being tears or laughter. For more on this, see my writings on the four functions of sensing, intuition, thinking, and feeling.

Malingering

Malingering is diagnosed when the examiner is convinced that a patient manifests false or grossly exaggerated physical and/or psychological symptoms and / or signs. The symptoms are presumed to be under voluntary control and are said to be feigned or embellished because of a conscious desire to achieve or maintain some financial or addictionally-driven gain or to avoid some unpleasant consequences (work, conscription to militiary service, imprisonment, drug withdrawal).

To diagnose malingering, it is also assumed that the examiner either knows with certainty that both the symptoms are feigned / embellished (via surveillance) and that the gain or avoidance is clearly discernible given the circumstances of the patient.

If malingering were the correct diagnosis in a medical legal case (which is the type of judgment that most experts practicing in this field are asked to make), then one could expect prompt resolution of the signs and symptoms once the cash award takes place or if the need for feigning ceases. I t is surprising how this is not the case in many patients who have been suspected as malingers by experts. When the clinical symptomatology remains consistent for a long period of time, despite the completion of a medical-legal settlement, one must seriously consider another diagnosis.

Often times, non-psychiatric physicians note an alleged disparity between certain physical signs, such as gait or movements, during their physical examination. They use this as "evidence" of malingering or "symptom embellishment" (a particular irksome phrase which is as vague and subjective as it sounds). Sometimes an examiner will say that movements appeared different when "the patient believed they were not being observed." Then this alleged "disparity" is cited as "evidence" of malingering, without any attempt to make an empirical explanation of the phenomenon. Of course, malingering is one possibility and it should be considered. However, most of the time, the physician involved (here I am talking about a neurologist, orthopedic surgeon, or physiatrist) has little or even no professional training in psychiatry / psychology other than their own experience as a clinican in their fireld. Specifically, in all patient-doctor contacts there is a distinct psychodynamic which has nuances depending upon whether the encounter is part of a regular patient-doctor relationship, IME, or some other relationship-contract. Typically these so-called discrepancies are characterized by verbiage such as this:

"The observed inconsistencies in her behavior inside and outside the clinic suggests that she may have more strength then the patient is willing to admit. She did not seem to be cooperating fully in the examination."

Other alleged signs of disparity take place in conditions of cognitive dysfunction. Here's another excerpt from a physician note:

"The patient was lucid in some responses despite her complaint of confusion. This points to symptom magnification."

Discussion

Do disparities in examination in different environments establish the diagnosis of malingering? The answer is emphatically no. However if these observations are accurate observations, they do provide important diagnostic information. These "so-called" discrepitancies, if viewed from a psychological point of view, are evidence of psychological factors being operational.

Conversion disorder

The diagnosis of conversion disorder demands a clear temporal link to a traumatic event or a trigger to activate the psychiatric response to a previous traumatic event. The examiner must also find these events or triggers to be of a sufficient severity at the time of the onset of symptoms or signs to be the causal factors.

Somatization disorder

Somazation disorder can sometimes be an attractive diagnosis in medical-legal cases suspected of malingering. In regard to symptom complex, one must perform a careful checklist to see if a patient meets the DSM-IV criteria for this diagnosis and that the symptoms are of a sufficient severity to significantly alter life style.

Hypochondrical features may also be part of the clinical picture in patients suscepted of malingering. In hypochondriasis, patients have an unrealistic interpretation of their physical complaints, along with a pre-occupation with their perception of being ill.

Some suspected malingerers also have features of schizotypical behavior such as social isolation, odd speech, inadequate rapport in face-to-face interaction due to constricted affect and compulsive/narcissistic features such as perfectionism and preoccupation with details, fixation on her bodily complaint and drawing of attention to themselves in the outside world and in the clinical doctor/patient relationship.