home site map our company review board contact us update profile
| 
| 
| 
| 
| |
| News & Information » News » Articles » Interviews » Ask the Expert » Submissions |
| » 800.242.5183» Email Us |
| Home | Articles | Article Details |
  |
||||||||||
 2/25/2008 Malingering Aphasia? Improbable, Not Impossible Gail V. Pashek, Ph.D., Department of Communication Sciences & Disorders, University of South Florida | |||||||||||
| Abstract “Functional” disorders have been estimated to represent approximately 4-5% of adult neurogenic caseloads. Although speech-language pathologists are trained to identify the presence of neurogenic impairments, they are less-prepared to assess the absence of organic impairment, as suspected in the case described in this report. The case of a 49-year-old African American woman with sudden onset of inability to speak or write is detailed. To the author’s knowledge, this patient presents a unique case of an attempt to malinger aphasia along with a “pseudoforeign” accent, possibly following a conversion disorder. Multiple medical evaluations failed to find unequivocal evidence of neurological disorder in the presence of several identifiable stroke risk factors. Following two months of persisting speech complaints, the patient was referred to a speech-language pathologist for evaluation by her primary physician. A process-approach to assessment from initial referral, review of available records, assessment methods, and results of the clinician’s attempts to modify the patient’s communication differences are described. Objective findings and information obtained in the consultation are discussed in light of diagnostic criteria that may be employed for distinguishing among neurogenic disorders, psychogenic disorders such as conversion disorder, and malingering. The need for additional preparation of aphasiologists in diagnosis and management of such atypical disorders is emphasized. Introduction Malingerers and individuals with psychogenic disorders often present with symptoms resembling those observed in neurogenic disorders. Whereas psychogenic disorders may be defined as conditions with a psychological rather than a physiological basis, malingering refers to conscious, deliberate attempts to falsify or exaggerate symptoms of a physical or psychological nature motivated by external incentives (e.g., avoiding unpleasant work or military duty; or achieving financial gain; Hales, Yudofsky, & Talbott, 1999). Such “functional” conditions have received minimal attention in the aphasiology literature except for a handful of notable reports (Baumgartner & Duffy, 1997; Duffy, 2005; Helm-Estabrooks & Hotz, 1998; Sapir & Aronson, 1985, 1987, 1990). With these exceptions (largely focused on the areas of voice and stuttering), there is currently limited clinical direction available for practitioners in the area of neurogenic language disorders seeking to differentially diagnose and manage these conditions. In general, it is fair to say that speech-language pathologists are generally trained to diagnose the presence, not the absence of neurological communication disorders. It may be argued that there remains a substantial need for additional education in this area, as noted by Butcher, Elias, and Raven (1993). Differential diagnosis of true neurologic disorders, psychogenic disorders, and malingering can be enigmatic. According to Dula and DeNaples (1995), the primary constellation of symptoms in psychogenic disorders may be difficult to distinguish from those of many neurogenic disorders. In addition, comorbidity of documented neurological disorders and psychogenic disorders is frequent – Marsden’s (1986) analysis suggests that neurological conditions may exist in up to 60% of patients with psychogenic diagnoses; Maldonado and Spiegel (2000) note that frequency of concurrent diagnoses of neurogenic disorder and conversion disorder has ranged from 20% to 70% across studies. To further complicate the differential diagnostic landscape, malingering of neurocognitive dysfunction is also common (Rogers, 1997), both in the presence of a true neurogenic disorder (Bianchini, Greve, & Love, 2003; Ricker, 2004), and in combination with a psychogenic disorder (e.g., Barnard, Birch, & Wildey, 1990). Duffy (2005) reports that psychogenic disorders were found in approximately 4.2% of patients with acquired speech-language disorders presenting at the Speech Pathology section at Mayo Clinic. Similarly, analysis of data reported by Lempert, Dieterich, Huppert, and Brandt (1990) suggests that 4% of individuals (17 of 405) eventually diagnosed with psychogenic disorders presented with speech, cognitive, or swallowing symptoms in their general medical sample. It is difficult to obtain figures on malingering, as malingerers present to a wide variety of health-related disciplines. Doubtless, a number successfully evade detection. Malingering is of concern in both hospitals and medical clinics treating neurogenic disorders, and patients attempting to malinger may present with speech, cognitive, language, and/or hearing disorders. For example, differential diagnosis of malingering and mild head injury has recently been of particular interest in the neuropsychology literature. A recent survey of members of the American Board of Clinical Neuropsychologists revealed that 39% of patients reportedly complaining of mild head injury were diagnosed as probable malingerers (Mittenberg, Patton, Canyock, & Condit, 2002). Although Sapir and Aronson (1990) mention the possibility of a psychogenic disorder presenting with primary languagee symptoms, descriptions of difficult cases have been almost exclusively disorders of speech, specifically voice disorders, stuttering, mutism, or articulation problems. Porec and Porch (1977) investigated the extent to which sophisticated versus naïve speakers could emulate aphasic language-finding variable results across both groups. These investigators concluded that of all available evidence, patterns of performance across a major language battery (The Porch Index of Communicative Ability; Porch, 1967) were most revealing. In the present day healthcare environment, there is little time to complete a full aphasia battery; hence, one might ask whether other, more efficient forms of evaluation might be attempted. Shaibani and Sabbaugh (1998) state that individuals presenting signs of what they term “pseudoneurologic” conditions tax the healthcare economy by using medical resources at a much higher rate than that of individuals in the general population. Given this concern and the accelerating rate of requests for forensic evaluations of patients with neurological disorders (Larrabee, 2005), speech-language pathologists may be increasingly called upon to render professional opinions in cases in which neurological symptoms are claimed and/or observed. Thus, increased awareness of diagnostic criteria, characteristic signs and symptoms, and management strategies for these “pseudoneurologic” conditions are needed. Presented in Appendix A are diagnostic guidelines for common psychogenic disorders and malingering, as outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) of the American Psychiatric Association (APA, 1994), along with other characteristics of these disorders frequently reported in the literature germane to the case presented. The patient in this report described a constellation of symptoms initially suggesting both speech and language disorders similar to those observed in some patients with left hemisphere lesions. In addition, medical history was significant for age and ethnocultural risk factors for CVA. However, the patient’s overall profile also included a number of indistinct and atypical symptoms that caused examining clinicians to question a possible psychogenic disorder or malingering from the initiation of the evaluation. This illustrative report focuses on the process of evaluating the patient’s medical symptoms and interdisciplinary cooperation in evaluation of her symptoms. It is the author’s hope that this article will engender interest and discussion within the profession about similar interesting cases of patients presenting with atypical symptoms. Although optimally, evaluation and management of psychogenic disorders and malingering should be best addressed by psychiatrists and psychologists, it is important to note that individuals involved: (1) most often present to clinicians outside the mental health professionals, and/or (2) are most often at least initially reluctant or resistant to referral to a mental health professional. Case Study Information included in this report was obtained: (1) during a two-hour consultation with the patient and her husband and the author, a speech-language pathologist; (2) from medical records requested (with the patient’s permission) from the patient’s local hospital, primary care physician, and consulting neurologists; and (3) from a post-evaluation follow-up communication with the patient’s primary care physician and adult daughter. The Patient RS, a 49-year-old, right-handed African American female native of a rural area of a southeastern state, presented at the emergency room of a nearby small town hospital following an episode of sudden speech loss and inability to write while at work. Her medical history was significant for asthma, gastrointestinal reflux disease (GERD), and possible borderline hypertension. According to her primary care physician, RS presented on several occasions in the previous year with other vague complaints of gastrointestinal problems and TMJ disorder that were not consistent with medical findings. RS was a high school graduate, who had been a food service manager in a local school cafeteria for 22 years. RS was married to a man of Jamaican descent and had four grown children. Medical History Review Initial Presentation in the Emergency Room RS was described as alert and cooperative, all vital signs were reported to be within normal limits. No detail was provided on specific speech or language characteristics, although the physician’s notes included an impression of “dysarthria.” Emergency room (ER) evaluation yielded no deficits in motor or sensory functions, normal reflexes, and mental status. According to the ER physician, the patient was not taking any medications at the time of onset. The patient’s initial CT scan and lab work were within normal limits. RS was discharged to her home with a recommendation to follow-up with her family physician within 24 hours. Primary Care Physician—24-Hour Follow-Up Notes from the patient’s follow-up evaluation on the next day indicated that RS “is able to make sentences, and she knows what she wants to say,” but that “it is just tough for her to get it out.” It was unclear from this note whether the patient’s difficulty producing sentences was observed by the physician or whether this was the patient’s report. In this visit, RS was described as “awake, alert, and cooperative,” and her speech as “dysarthric.” No description of specific speech characteristics was given, and two months following this evaluation, the physician did not recall specific speech characteristics. The physician’s initial impression recorded was “possible CVA.” RS was referred to a local neurologist for further evaluation. Neurology Consultation—1st Week Post-Onset of the Problem The consulting neurologist ordered both an MRI and carotid ultrasound studies, forwarding copies of study outcomes, but no neurology consultation report to the author. According to the report, MRI T1 axial and sagittal images complemented by T2 axial images were interpreted as “unremarkable.” Real time and color flow imaging of the carotid and vertebral systems revealed “no significant stenosis…” and “no turbulence of flow or flow reversal.” The consultation report did not include speech or language detail other than the patient’s own report of her speech difficulty, but the overall impression of the neurologist was “depression with a possible hysterical reaction.” Following the initial neurological consultation, her primary care physician was consulted and the patient was placed on a daily dosage of 40 mg of Paxil. Primary Care Physician—One Month Follow-Up At a scheduled follow-up one month post-onset of speech difficulty, RS was still taking Paxil as recommended but voiced new complaints of dizziness & headache, along with continued speech difficulty. The physician reported that the patient “is quite upset and teary” but that she “is awake, alert, and cooperative. Speech is somewhat dysarthric [no detail was provided], but I can understand everything that she is saying.” The patient’s vital signs were once again within normal limits, with the exception of blood pressure, which was 120/70. The physician’s recommendation was for replacement of Paxil with 20 mg. of Celexa daily. Second Neurological Consultation The patient was then referred for a second opinion evaluation by a neurologist in a metropolitan area in her state. RS was interviewed, MRI scans were reviewed, and labs were repeated with results all judged to be within normal limits. A thyroid profile was also completed and judged to reflect normal functioning. Speech and mental status were reported to be “normal.” The consulting neurologist’s impression was one of “hysterical reaction related to depression.” The patient was placed on a lower dosage of Paxil and a psychiatric consultation was recommended. Primary Care Physician Follow-Up—Eight Weeks Post-Onset At RS’s eight-week follow-up appointment with her primary physician, it was learned that she had not followed through with the recommended psychiatric consultation and had discontinued Paxil independently. The patient stated that she wished to discuss her “speech” disturbance and reported she was “depressed.” The patient reportedly stated, “I have been unable to work for 45 days.” In this evaluation, RS’s husband stated that he and RS were willing to travel longer distances to larger metropolitan areas to treat her problem, if this was necessary. Following this session, the physician consulted with a neurologist at an academic medical institution who recommended referral for a speech-language evaluation with the author. Speech-Language Pathology Evaluation Interview and History Upon arrival for evaluation, the clinician handed RS a case history form to complete. RS then asked her spouse to complete the case history stating “I cannot write.” RS seemed circumspect in her approach to questions, at first volunteering little information beyond brief, direct answers to questions posed to her. RS asked the clinician whether she was a psychiatrist several times in the first few minutes of the interview. Following is a transcript of selected portions of the clinical interview: Clinician: “What prompted you to come here?”As evidenced in the transcript, RS was able to communicate in complete, grammatically intact sentences. Her oral expression contained elements of both African American vernacular English (AAVE) and southern rural Standard American English (SAE; Kortmann & Schneider, 2004). Speech was highly intelligible throughout the interview. Rate and volume appeared to be within normal limits, and pitch appeared to be appropriate. Overall breath support appeared adequate for speech tasks. However, inconsistently, speech was produced in a “staccato like” manner, with equal stress across syllables. No syllable reductions or unusual intonation were noted. Throughout the interview, the patient’s spouse generally did not offer any information, even when asked questions directly. He generally echoed his wife’s responses or deferred to his wife to respond. Oral Structure/Function Examination Nonverbal oral motor tasks were assessed prior to formal speech evaluation tasks. No abnormalities in posture or respiratory movements were apparent on informal examination of the patient at rest. No asymmetries or abnormal movements of the articulators were observed in an oral peripheral examination or when the patient was at rest. Tongue and jaw strength to resistance were judged to be within normal limits. Gag reflex (elicited with some protest from the patient) appeared normal and a volitional cough was elicited. No slowness of the articulators was noted in alternating movements (e.g., jaw opening and closing, pucker-smile combinations, tongue lateralization, and elevation). Motor Speech Screening In motor speech tasks, alternating motion rates were produced in a slow, measured fashion (seven repetitions each of /pʌ/, /tʌ/, /kʌ/, in five seconds). Of interest, the patient also was able to repeat seven sequences of /pʌtʌkʌ/, in 5 seconds in the same rhythm used for repetition of individual syllables. All syllables were accurately and clearly articulated with no sign of weakness, struggle, or groping. No pitch changes or irregular rate were noted. In contrast to RS’s slow rate of articulation in the syllable repetitions, rate of speech for a five-minute sample of conversational speech was 154 words per minute which was judged to be within normal limits. The patient was able to sustain phonation of /α/ for a maximum of five seconds without loss of volume or pitch changes; when she was urged to try to sustain phonation for longer periods of time, she stated,. “I can’t.” Limited Language Evaluation Selected subtests of the Boston Diagnostic Aphasia Examination (BDAE; Goodglass & Kaplan, 1983) were administered to screen language abilities. Auditory comprehension for single words and commands appeared within normal limits, with the patient performing between the 75th and 90th percentile for comprehension of oral and written texts and repetition of high probability sentences. Of particular interest are observations that RS was able to orally read sentences better than words, and that she was more accurate in repetition of Low-Probability than High-Probability sentences. Also, RS’s errors in oral word and sentence reading were of a bizarre nature (e.g., “treeangle” for “triangle,” “broon” for broom). The patient did not attempt to correct her errors and was unsuccessful in modifying her errors given visual and auditory cues by the examiner. On the Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983), RS achieved a score of 54/60, reflecting performance within one standard deviation of the mean for the patient’s age and level of education. When the patient was asked to name some of her friends with her husband present, she became teary and stated, “I don’t know any of them” and refused to attempt the task. RS initially refused to write a description of the Cookie Theft Picture, stating again that she was unable to write. However, she verbally described the picture. With coaxing to write her oral response to the picture, she then wrote, “There is a family of three. Mother is washing dishes, and the children are busy with the cookie jar,” but refused to write more. No abnormalities in her ability to form letters or spell words were observed. RS’s writing ability, in the face of her stated inability to write, did not seem to surprise her. When asked to sing “Happy Birthday,” RS stated she could no longer sing. She was able to recite words to the song, again with inconsistent staccato-like phrases, but did not include melody. As the patient had previously mentioned that her problems might have been caused by a stroke, the clinician casually offered that many individuals with strokes and speech difficulty could sing, and were often better at singing than speaking. Following this comment, RS was able to first sing in unison with the clinician, and then to continue singing independently as the clinician quickly faded support. RS did not seem surprised at her newfound singing ability and was unresponsive to the clinician’s praise for her success. Attempted Intervention Duffy (2005) and Baumgartner (1999) stress the importance of attempting symptomatic therapy in the assessment session for atypical cases in which psychogenic disorders might be suspected, noting that reversal of symptoms may rule out a neurologic cause and confirm a psychogenic diagnosis. Although RS reported vague symptoms of deficits that appeared to distress her, only minor prosodic difficulties were noted and significant abnormalities in communication were not apparent. Intervention was attempted to decrease the prosodic “staccato-like” differences in her utterances using (1) a continuous phonation fluency strategy, and (2) practicing correct stress placement in a list of common multisyllabic words. RS was accurate on 2 of 20 attempts to achieve continuous phonation in three- to four-word sentences. In some of these attempts, phonation became less continuous. RS could not seem to imitate correct stress placement on any of the words presented, including her own name, although she was observed giving her name with a normal stress pattern on two other occasions in the evaluation session. Clinician Communication with Other Family Members Following the initial testing and prior to testing, the patient’s husband was ushered to a waiting area by the author. When he was asked how her speech had changed, his responses continued to be vague; however, he did offer the following comment: “You know I can understand her just fine. Last week I told her she was talking normally one night and she got real mad at me and told me not to tell the doctor [speech-language pathologist].” In a post-evaluation telephone interview, one of the patient’s daughters echoed her mother’s complaints but said her mother’s speech had always been understandable to her. When the daughter was questioned about her mother’s written language ability, she said that her ability to form letters, words, and sentences did not appear very different from that before her the onset of the problem. She stated she could read her writing “but it was very light.” Post-Testing Interview with Patient Alone Following testing, when RS appeared to be more comfortable with the examiner, an additional interview was conducted in which the clinician probed for more information. First, the examiner asked whether RS wished to return to work and what her plans were for the future. RS responded that as it was almost the end of the school year, she did not plan to go back, stating “I’ll collect my long-term disability and we’ll see after the summer.” She volunteered that she enjoyed being at home and she would return to work “only with a lawyer.” Second, the clinician asked whether she had ever known anyone who had experienced a stroke, as she had mentioned stroke earlier in the evaluation and seemed familiar with some stroke symptoms. RS replied that she had taken a friend to speech therapy for several months after the friend had sustained a stroke with right-sided weakness and “speech problems.” When asked about the nature of the speech problems, RS stated that her friend had trouble “saying her words.” Finally, the clinician asked whether RS was interested in additional sessions to work on her speech. RS replied that she did not think that speech therapy would help her with her speech disorder, and she had just decided that she would “have to learn to live with it.” Diagnosis It became clear to the clinician that the patient was, indeed, attempting to malinger a rather unusual disorder at the time of the evaluation and doing so rather unsuccessfully. The major confirmatory evidence was the husband’s report that his wife had asked him not to be truthful in the upcoming interview with the clinician. Supporting information came from the patient’s voluntary statements about monetary benefits of remaining “disabled,” lack of compliance with medical recommendations, the vague nature and atypicality of her “symptoms” and reluctance to directly address them, as well as her suggestibility to emulating signs of stroke. Finally, additional support for the diagnosis came from the patient’s affirmative response to the clinician’s question as to whether she had ever known anyone who had experienced a stroke and speech problems. Thus, it was most important, as a clinical strategy, to interview this family member privately, as he appeared reluctant to say anything in front of her. Additional clinical strategies useful in reviewing this case were careful evaluation of available medical records for inconsistencies and lack of compliance with medical recommendations, evaluating possible sources of secondary gain, achieving modifications of the “disorder” in the clinical session consistent with the patient’s conception of stroke behavior, and investigating how the individual might have become aware of the disorder she was attempting to malinger. Outcome Following evaluation, the author contacted RS’s primary care physician and told him that it was her opinion that neither the patient’s reported symptoms nor observed behaviors at the time of consultation appeared to be consistent with dysarthria, apraxia, or aphasia commonly seen in neurogenic disorders, and that the patient did not desire speech therapy. Both conversion disorder and malingering were discussed as possible classifications, and information about the patient’s comments about her disability was reviewed. The author stated that she felt the patient could still benefit from evaluation by a mental health professional given her continuing signs of depression, and suggested that referral to a psychologist might be less threatening to the patient than referral to a psychiatrist. In a subsequent appointment with RS, the primary care physician reportedly firmly, but politely, told the patient that her symptoms did not support medical documentation of a disability. In addition, he recommended that the patient see a local psychologist specifically to treat the patient’s depression. In a follow-up communication with RS’s primary care physician one week later, the author learned that the patient had returned to work at her new location for the remainder of the school year. It is unknown whether the patient followed-up on the psychological referral. The patient was subsequently lost to additional follow-up attempts. Summary and Discussion Although RS clearly was malingering at the time of evaluation, the incomplete detail describing the patient’s initial speech characteristics at onset and the apparent rapid improvement in her communication skills within 24 hours make it difficult to determine whether the patient may have had an actual neurological event and/or conversion disorder, or whether all symptoms had been malingered from the onset. First, the possibility of a true neurological disorder cannot be ruled out, given the patient’s risk factors for stroke. A mild or transient neurological disorder might not be evidenced in structural brain scans. Without a previous baseline of RS’s language abilities, the patient’s reported word-finding problems and mild observed comprehension deficits could be interpreted as resembling language deficits commonly seen in mildly aphasic individuals. However, RS’s bizarre performance on oral and reading tasks do not fit a typical aphasic profile. RS’s complaint that her speech made her sound like she “was from Jamaica” might be consistent with diagnosis of “foreign accent syndrome” (also known as “pseudoforeign accent” [Duffy, 2005]), a disorder that has been observed occasionally in individuals with neurological damage. Foreign accent syndrome is a disorder that has been said to exist mainly in the listener’s ear and is reportedly rare. Although is unlikely that symptoms of this disorder would be known to individuals outside professions interested in neurogenic communication disorders, the patient’s husband was from Jamaica and the characteristics of speech in Jamaican culture were not unknown to her. The patient’s equalization of stress across words and syllables in multisyllabic words, plus her tendency to shorten vowels in conversational speech could cause her speech to be perceived as being similar rhythm to that of native Jamaican speakers. Again, it appears that the disorder was more severe at onset than at the time of the speech-language evaluation. Of interest to this consideration are the recent report of Simon, Vogelman, and Conforth (2001) of a case of foreign accent syndrome in which the patient’s speech was perceived as sounding “Jamaican.” Diagnosis of an initial conversion disorder also cannot be ruled out. RS demonstrated signs of depression, commonly found in conversion disorders. In addition, other characteristics were present that might point to conversion disorder, including a history of somatization, vagueness of complaints, inconsistency of symptoms, responsiveness to suggestion, as well as the sudden onset of symptoms during an incident that was clearly traumatic for RS. Pseudoforeign accent has been observed in psychogenic disorders. Verhoeven, Marien, Engelborghs, D’Haanen, & DeDeyn (2005) report a case of foreign accent speech in conversion disorder. Although conversion disorder and malingering are mutually exclusive diagnostic categories in DSM-IV, an initial conversion disorder with subsiding symptoms with subsequent malingering is entirely possible. According to Celani (1976), secondary gains are common in conversion disorder and may serve to maintain original symptoms as well as encourage new or worsening symptoms. In an investigation of the predictive value of specific psychiatric criteria, Raskin, Talbott, and Meyerson (1966) found that secondary gains were present in 86% of patients diagnosed with conversion disorder. Finally, the possible comorbidity of a transient or mild neurological event and conversion disorder cannot be discarded as yet another possibility in this case, as epidemiological studies reveal that conversion disorders are more prevalent in individuals with true neurological disorders than in the general population. Although as noted by Baumgartner (1999) diagnosis of psychopathology is not within the scope of speech-language pathology, the speech-language pathologist needs to be knowledgeable about characteristics of both psychogenic disorders and malingering to clearly communicate suspicions of these disorders with other professionals involved, and to develop effective and efficient management plans. It may be tempting for an inexperienced clinician to dismiss or confront a patient who appears to have a “pseudoneurologic disorder;” experienced clinicians advocate taking a more compassionate and concerned approach, especially with patients presenting signs of a possible conversion disorders (Duffy, 1998, 2005; Shaibani & Sabbaugh, 1998). In conversion disorder, Shaibani and Sabbaugh note that patients may unconsciously exhibit symptoms in what may be the only way they feel is acceptable in terms of the context of their situation and culture. Duffy (1998) suggested strategies for conducting symptomatic therapy without confronting the disorder directly, such as using physical contact, encouragement and praise for effort, with a stated optimism for the patient’s recovery. Although Duffy notes that such treatment alone may resolve the problem, it is important to recognize that symptoms of conversion disorders often recur and may continue to do so until underlying psychological issues are addressed (Maldonado & Spiegel, 2000). A speech-language pathologist can offer nonjudgmental validation of the patient’s complaints, and reinforce the notion that the patient has a problem for which there is appropriate therapy. In addition, the clinician should support the patient in seeking appropriate help from a mental health professional. Conjoint therapy with a psychologist or other professional may be especially helpful for some patients with conversion disorder (Baumgartner, 1999; Maldonado & Spiegel, 2000). Although more evidence-based reports are needed, support for the effectiveness of several psychological and psychiatric approaches, such as cognitive/behavioral therapies (e.g., Campo & Negrini, 2000; Mooney & Gurrister, 2004), pharmacotherapy (e.g., Wald, Taylor, & Scamvougeras, 2004), and hypnosis (Moene, Spinhoven, Hoogduin, Kees, & van Dyck, 2003), or some combination of these therapies (e.g., Moene, Spinhoven, Hoogduin, & van Dyck, 2002), have recently received attention. Despite the fairly obvious attempts to malinger of some patients, sophisticated methods of detecting malingering have been increasingly reported, particularly in neuropsychological tests for individuals with mild head injuries, a population in which differential diagnosis may be particularly difficult. Although not employed commonly in clinical practice, evoked potentials have been employed successfully in distinguishing between conversion disorder and malingering (e.g., Lorenz, Kunz, & Bromm, 1998). There has recently been proliferation of tests and assessment strategies designed to address malingering in the neuropsychological literature that may be useful in developing methods of assessment applicable to speech, language, and cognitive tests employed by speech-language pathologists. In contrast, there is almost no literature on appropriate management of individuals suspected of malingering. Anger at the suspicion that a patient may attempt to “dupe” an examiner can be a natural initial response to a patient’s lack of effort or atypical test performance. However, clinicians should keep in mind that individuals, such as RS, can have complex motivations for their behavior. Snyder (1998) notes that malingering may reflect an individual’s lack of moral maturity or maladaptive defenses to perceived threats. Similarly, Rogers (1997) characterizes malingering as adaptive behavior to attain a specific objective. Snyder suggests that malingerers may benefit from cognitive therapies advocating such strategies as modeling of problem-solving techniques, role-playing, and other approaches designed to help individuals cope and develop appropriate responsibility. Individuals, such as RS, with atypical disorders provide speech-language pathologists with a reminder that patients are much more complex than their communication symptoms and syndromes. They also provide opportunities to collaborate with professionals in mental health in efforts to better understand brain-behavior and mind-body relationships. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Barnard, N. A. S., Birch, J., & Wildey, H. (1990). Concurrent visual conversion reaction and simulated color vision defects in a 12 year-old child. Ophthalmic and Physiological Optics, 4, 391-393. Baumgartner, J. M. (1999). Psychogenic stuttering. In R. F. Curlee (Ed.), Stuttering and related disorders of fluency. New York: Thieme. Baumgartner, J. M., & Duffy, J. R. (1997). Psychogenic stuttering in adults with and without neurologic disease. Journal of Medical Speech-Language Pathology, 5, 75-95. Bianchini, K. J., Greve, K. W., & Love, J. M. (2003). Definite malingered neurocognitive dysfunction in moderate/severe traumatic brain injury. The Clinical Neuropsychologist, 17(4), 574-580. Butcher, P., Elias, A., & Raven, R. (1993). Psychogenic voice disorders and cognitive-behaviour therapy. San Diego: Singular Publishing. Campo, J. V., & Negrini, B. J. (2000) Case study: Negative reinforcement and behavioral management of conversion disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 39(6), 787-790. Celani, D. (1976). An interpersonal approach to hysteria. American Journal of Psychiatry, 133, 1414-1418. Duffy, J. R. (2005). Motor speech disorders: Substrates, differential diagnosis and management (2nd ed.). St. Louis, MO: Mosby. Duffy, J. R. (1998, November). Psychogenic speech disorders in people with possible neurologic disease. Paper presented at the annual meeting of the Academy of Neurological Communication Disorders and Sciences, San Antonio, TX. Dula, D. J., & DeNaples, L. (1995). Emergency department presentation of patients with conversion disorder. Academic Emergency Medicine 2(2), 120-123. Goodglass, H., & Kaplan, E. (1983). The assessment of aphasia and related disorders (2nd ed.). Philadelphia, PA: Lea & Febiger. Guggenheim, F. G., & Smith, G. R. (1995). Somatoform disorders. In H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry: Vol. 2 (6th ed.). Hales, R. E., Yudofsky, S. C. & Talbott, J. A. (1999). Textbook of psychiatry (3rd ed.). Washington, D.C.: American Psychiatric Press. Helm-Estabrooks, N., & Hotz, G. (1998). Sudden onset of "stuttering" in an adult: Neurogenic or psychogenic? Seminars in Speech & Language, 19(1), 23-29. Kaplan, E., Goodglass, H., & Weintraub, S. (1983). The Boston Naming Test. Philadelphia, PA: Lea and Febiger. Kortmann, B., & Schneider, E. W. (2004). A handbook of varieties of English: A multimedia reference tool. Berlin: Walter de Gruyter. Larrabee, G. J. (2005). Forensic psychology. New York: Oxford University Press. Lempert, T., Dieterich, M., Huppert, D., & Brandt, T. (1990). Psychogenic disorders in neurology: Frequency and clinical spectrum. Acta Neurologica Scandanavica, 82, 335-340. Lorenz, J., Kunze, K., & Bromm, B. (1998). Differentiation of conversive sensory loss and malingering by P300 in a modified oddball task. Neuroreport, 9(2), 187-191. Maldonado, J. R. & Spiegel, D. (2000). Conversion disorder. In K. A. Phillips (Ed.), Somatoform and factitious disorders. Review of Psychiatry (pp. 95-128). Washington, D. C.: American Psychiatric Publishers. Marsden, C. D. (1986). Hysteria: A neurologist’s view. Psychological Medicine, 16, 277-88. Mittenberg, W., Patton, C., Canyock, E. M., & Condit, D. C. (2002). Rates of malingering and symptom exaggeration. Journal of Clinical & Experimental Neuropsychology. 24(8), 1094-1102. Moene, F. C., Spinhoven, P., Hoogduin, K. A., Kees, A. L., & van Dyck, R. (2003). A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type. International Journal of Clinical & Experimental Hypnosis, 51(1), 29-50. Moene, F. C., Spinhoven, P., Hoogduin, K. A. L., & van Dyck, R. (2002). A randomized controlled clinical trial of the additional effects of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type. Psychotherapy & Psychosomatics, 71(2), 66-76. Mooney, G., & Gurrister, T. (2004). Behavioral treatment of psychogenic deafness: A case report. Psychology, 49(3), 268-271. Porec, J. P., & Porch, B. E. (1977). The behavioral characteristics of “simulated” aphasia. In R. H. Brookshire (Ed.), Clinical Aphasiology Conference Proceedings (pp. 297-301). Minneapolis, MN: BRK Publishers. Porch, B. E. (1967). Porch Index of Communicative Ability. Palo Alto: Consulting Psychologist Press. Raskin, M., Talbott, J. A., & Meyerson, A. T. (1966). Diagnosis of conversion reactions: Predictive value of psychiatric criteria. Journal of the American Medical Association, 197, 530-534. Ricker, J. H. (2004). Differential diagnosis in adult neuropsychological assessment. New York: Springer Publishing. Robins, L. N., & Rogier, D. (1991). Psychiatric disorders in America: the epidemiologic catchment study. New York: Free Press. Rogers, R. (1997). Clinical assessment of malingering and deception (2nd ed.) . New York: Guilford Press. Sapir, S., & Aronson, A. R. (1990). The relationship between psychopathology and speech and language in neurological patients. Journal of Speech and Hearing Disorders, 55(3) , 503-509. Sapir, S., & Aronson, A. R. (1987). Coexisting psychogenic & neurogenic dysphonia: A source of diagnostic confusion. British Journal of Disordered Communication, 22, 73. Sapir, S., & Aronson, A. R. (1985). Aphonia after closed head injury: Etiologic considerations. British Journal of Disordered Communication, 20, 289. Shaibani, A., & Sabbaugh, M. N. (1998). Pseudoneurologic syndromes: Recognition and diagnosis. American Family Physician, 57(10), 2485-2494. Simon, J. M., Vogelman, L. H., & Conforth, R. (2001, November). Foreign accent syndrome: An innovative approach to treatment. Paper presented at the annual convention of the American Speech-Language-Hearing Association, New Orleans, LA. Snyder, D. (Ed.). (1998). Wanting to talk: Case studies in communication disorders. London: Whurr Publishers. Verhoeven, J., Marien, P., Engelborghs, S., D’Haanen, H., & DeDeyn, P. (2005). A foreign speech accent in a case of conversion disorder. Behavioural Neurology, 16, (4) , 225-232. Wald, J., Taylor, S., & Scamvougeras, A. (2004). Cognitive behavioural and neuropsychiatric treatment of post-traumatic conversion disorder: A case study. Cognitive Behaviour Therapy, 33(1) , 12-20. Wool, C. A., & Barsky, A. J. (1994). Do women somatize more than men? Gender differences in somatization. Psychosomatics, 35, 445-452.  Click Here to View Appendix A (PDF) | |||||||||||
|
|||||||||||
