Managing Symptom Exaggeration in Rehabilitation

Detecting and Managing Symptom
Exaggeration in ‘Brain’ Disorders
Dr Susan Shaw
Neuropsychologist PsyD
[email protected]
Most commonly seen in these ‘Brain’
 Mild Traumatic Brain Injury
 Post Concussion Syndrome
 Chronic Pain Syndromes
 Chronic Fatigue
 Depression / anxiety/PTSD / mental
 Disorders which are ‘high on symptoms
– low on signs’
Step 1. Is the progression consistent
with expectation?
 Some disorders improve with time,
while others get worse.
 In order to know if the disorder is
progressing in accordance with
expectations based on medical
literature, you need to know a little bit
about what those expectations are.
 Progressive Vs non-progressive
 CVA or Stroke – Usually acute event
followed by recovery
 Considered stable at about 18 months
post CVA
 Need to look at causes for CVA to
determine if the person at risk of
 Haemorrhagic or ischaemic?
Haemorrhagic or ischaemic
 Haemorrhagic usually has low risk for
repeat event if caused by a congenital
malformation or berry aneurysm, trauma to
 High blood pressure? – more likely to
happen again if cause not treated.
 Ischaemic can be due to cholesterol or
‘bubbles’ or ‘clots’. More likely to happen
again if cause not treated.
 Some tumours
 Dementias = Alzheimer’s Disease, Fronto-temporal
dementia, Picks Disease, Diffuse Lewy Body Disease.
 Vascular Dementia
 Multi Infarct Dementia
 Mental Health problems like depression – can
fluctuate in accordance with psychosocial stressors.
 Epilepsy can be caused by an acquired injury or can be
idiopathic. Not usually progressive if well managed
with medication.
General rule
 Illness / Disease is likely to be
 Acute injury like trauma, CVA is more
likely to recover to some extent and
then become stable. Give it at least 18
Detection of Symptom Exaggeration
– In the Office
 Step 1. – Is the course consistent with
 Step 2. – Refer for an assessment with a
suitably experienced neuropsychologist who
will administer psychometric measures to get
an objective measurement – not a psychiatrist
or a clinical psychologist who will rely on
‘intuition’ as they are wrong 50% of the time!
 Fairly easy for neuropsychologists in
cases of cognitive symptom
 Use psychometric measures with robust
statistical properties
 80 - 90% can be achieved by individuals
with severe TBI, advanced dementia and
intellectual disability.
 MTBI client achieving 60% is suspicious!
 Slick et al (1999) developed criteria for diagnosing
malingering with regard to cognitive and pain
 Key features are as follows:
 Inconsistency between reported symptoms and
those expected given the documented or reported
 Inconsistency between patterns of recovery and
those expected given the documented or reported
 Inconsistency between performances on cognitive
tests and those expected in the context of the
 Identifiable secondary gain
 Failure on tests of symptom validity.
Sensitivity = 0.542 Specificity = 1.00
 Laribee 2003 – atypical patterns of
performance on three measures used as
indicators of symptom validity = specificity of
Does not matter which measures are used
 Newer measures of Symptom Validity have
better statistical properties, so two
measures should suffice.
Robust Evidence
 If you find that the client meets the Slick
et al (1999) criteria for malingering
 The client fails three measures of
symptom validity (e.g.Laribee) …
I would argue that this is an extremely
strong indication that the test
performances were not a valid
reflection of the true abilities.
 Avoid confrontation and subsequent
defensive behaviour – worsens
 Give a ‘face saving way out’.
 Help significant others understand the
true nature of the problem where it fits
with ‘face saving’.
 Give incentive to ‘recover’
From the very start you can….
 Build a good foundation from which to
progress rehabilitation.
 Focus on ensuring the client knows
someone understands their condition –
generates confidence.
 Non-progressive - reassure client that
recovery is the most likely outcome
Recovery ‘unknown’ myth
 Clients often tell me the literature is very nonspecific about recovery timeframes, and noone knows why. ‘Dr Google’
 Not true.
 ‘Narrow’ literature search to be specific to the
client e.g. age, gender, health status, mental
health history, personality, coping
mechanisms, psychosocial supports.
 Reinforce notion that psychological factors
inhibit recovery.
Client expectations predict recovery
 Whittaker, R. Kemp, S. House, A.
Illness perceptions and outcome in mild
head injury: a longtitudional study.
Journal of Neurology, Neurosurgery and
Psychiatry. 2007; 78:644 – 6.
 Poor outcome predicted by expectation
of non-recovery, non-attribution of
symptoms to psychological factors and
being in receipt of health related
benefits at time of initial consultation.
In the Clinic
1. Ascertain Symptom Exaggeration Vs
another undiagnosed problem.
2. Determine reasons for Symptom
3. Do something about it – this is the
hardest part but is much easier if you
have done the first two steps well.
Intuition, absent, ‘harden up’ approach – not
What often happens
 1. Detection through ‘Intuition
 2. Ascertaining reasons for behaviour is absent
 3. Problem managed by confrontation and telling
the client to ‘harden up’.
 This approach does not work!
Case Example
35 year old male
 Transport business owner
 10 employees
 ‘Hard man’ – very ‘macho’
‘Hard’ on employees when they
made mistakes.
 High level athlete – determined.
 TBI rugby – LOC > 3 mins, nil retro, PTA
< 30 mins. Now 1 year post
 Wife RTW after 12 months maternity
 Wife developed depression
 Client irritable and unpleasant at home
and at work – exacerbated by fatigue.
 Client had to ‘step in’ at home when
wife unwell and care for children aged 1
and 3.
 Adamant that RTW was main goal
 Adamant that recovery period
‘unknown’ but possibly 2 years.
 No financial incentive for not RTW
 ‘Failure’ regarding GRTW – stalled.
 Referred to me
 ‘Failure’ on SV measures.
 Strong indicators of cognitive symptom
 WHY?
At Work
 Loss of confidence with regard to
ability to ‘dominate’ at work following
‘mistake’. Vulnerable
 Catastrophic thinking with regard to
 Feeling ‘vindicated’ or ‘Blameless’ if
‘mistake’ due to ‘brain damage’.
 Acceptable (not my fault) but also very
scary (future?)
At Home
 Resentful that wife ‘stealing thunder’ by
having a diagnosis of her own
 Resentful at having to ‘step in’ and help
out when wife unwell, as he was also
not feeling the best.
 Rapid deconditioning from inactivity –
concerns about ‘weakness’ in sporting
 Loss of confidence – catastrophic
 Shifting ‘blame’
 Significant physiological changes
? Opting out – ‘driven’ lifestyle –
stress – pressure to perform at
work, at home and sports field.
What to do?
Consider depression
 Find a ‘face saving’ way out
 Exercise programme - education
 Don’t back into a corner or he will
come out ‘fighting’ and symptoms
will be exaggerated.
 Wife could be ‘key’.
Neuropsychologist spoke about
models of memory to explain
‘mistake’ and reduce catastrophic
Psychologist met with OT to
discuss above issues – same page
Psychologist met with client to
‘touch’ on some of the above,
asking questions and letting client
‘work it out’ himself.
 OT reassured client that now a ‘change
in tactic’ was to take place.
 Shift focus from ‘fatigue management’
to confidence building and increased
physical strength and fitness
 OT reassured client that this ‘new’
approach works very well with clients
like him.
 OT reassured client that if TBI related sx
would resolve with this approach –
those which did not resolve unlikely to
be due to TBI
 Wife understood loss of confidence
issues and felt greater empathy for
him, rather than feeling resentful
and frustrated.
 Improved relationship led to
improved mood for both.
Wife more able to ‘pull her weight’
at home
Outcome ctd
 Wife ‘ignored’ complaints of fatigue
and headaches, irritable behaviour.
 Wife praised desirable behaviours
and rewarded with ‘extra’ time for
gym etc.
 Client increased fitness gradually
and focussed on an ‘event’.
 RTW took care of itself!
Main points
 ‘Set
the scene’ early on – reassure that
most likely outcome is recovery.
 ‘Counter’ claims of extended recovery
by recommending a more ‘narrow’
literature search.
 Introduce the importance of
psychological and personality factors
early on.
4 Easy Steps
1. Objective measurement of
symptom validity.
2. Determine reasons why
3. Give a ‘face saving’ way out
4. Give incentives to recover and
deterrent for non-recovery.
Don’t be confrontational!! It makes
symptoms worse.

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