their condition or providing falsities about their described symptoms and their clinical and neuropsychological exam are considered not to be ill. Well, many times, if the key issues of focus are finding ways to trap the patient and determining whether they are really ill, clinicians can miss important facts about the patient’s illness. The fields of neuropsychology and neurology spend a considerable amount of time looking for inconsistencies within a level or sub-dimensions of test conditions. In this context, the clinician neuropsychologists and sometimes the neurologists perform different tests to evaluate the same function.
As an example, say, we carry out a test assessing short-term memory using more than one test measure. Assuming that the condition is legitimate, the results of short-term memory should be similar to two or more tests. While these measures can be taken to determine the legitimacy of a condition, caution should be maintained in interpreting the results as conditions such as pain, fatigue, anxiety, emotional instability, and fear, and yes, a secondary gain can influence consistency when different neuropsychological tests are administered for the same function.
I know a neuropsychologist (let’s call him Dr. Silva) who performs two different memory tests, each of which evaluates the same memory function, i.e., short-term memory. If there is a more than 40% deviation from the scores on the different tests of short-term memory, the neuropsychologist immediately assumes that the patient is malingering or exaggerating their symptoms. Neuropsychologists clearly carry out various tests before they can draw those conclusions.
(Case # 3)
I was hired by a plaintiff’s attorney to testify about the validity of the neuropsychological tests from the neuropsychologist, Dr. Silva. The attorney wanted me to testify regarding the legitimacy of the symptoms of a patient (Mr. Dalbert) who suffered a cerebral concussion. Neuropsychological tests performed by Dr. Silva determined that there was an inconsistency between the two neuropsychological tests of short-term memory with an over 40% difference between the results of the two. As a result, Dr. Silva declared in his conclusion that the patient was malingering. What was not evident to Dr. Silva was that Mr. Dalbert was a diabetic and had taken a dose of insulin in the morning before coming to take the tests. In addition, Mr. Dalbert was so nervous about the neuropsychological tests that he did not eat his breakfast before taking the test. Upon questioning the patient about the conditions surrounding the occasion when he took the second short-term memory neuropsychological test, the patient indicated that he was feeling very bad during the test. It was fortunate that the patient was very meticulous about checking his blood sugar; he provided us with his log of blood sugar levels. He had a finger-stick blood sugar test performed shortly after taking his insulin, and that was 2 hours before taking the second part of the neuropsychological test. He then did a follow-up blood sugar finger-stick test when he completed the second neuropsychological test because he was feeling lousy. My medical scribe who was reviewing his blood sugar log found that the patient was running low blood sugar. The results of his blood sugar before he completed the second neuropsychological test was 42 with normal being between 60–100 range, whereas the one performed 2 hours before the first neuropsychological test showed normal results. Months after seeing this patient, I was providing legal testimony in a deposition as to the legitimacy of the neuropsychological test performed on Mr. Dalbert. I was able to point out that a blood sugar of 42 would significantly compromise the patient’s cognitive function and affect his performance on memory test. I later received a call from the neuropsychologist administering the test. In that phone conversation, he made a declaration that he had learned an important lesson from this experience and pledged to be more cautious in interpreting the inconsistencies on neuropsychological testing, as many factors including low blood sugar could influence the results.
The history of cerebral concussion and more recently the history of the development of the chronic traumatic encephalopathy (CTE) diagnosis has faced significant controversy over the years. Until recently, the definitions of concussion required that there be a loss of consciousness, and we now know that this is not a necessity. Due to the applications of this loss of consciousness standard for research and other clinical evaluation tools, concussions have been largely underreported and underdiagnosed over the years.
Like the case of the tobacco industry which for years denied the link between smoking and lung cancer, the world has finally understood the link between the effects of repeated hits to the head during sporting activities, such as football, and concussion (Stieg 2014, Gardner 2015, Washington 2016).
This issue of the denial of the existence of a concussion has come with a price tag close to $1 billion in a court settlement for the National Football League (NFL). We now know that concussion is also linked to CTE despite the major denials over the years (Stieg 2014, Gardner 2014).
(Case # 4)
I once saw a patient, Alfonzo Grant, who was involved in a workers’ compensation situation where he genuinely fell off a roof while working as a roofer. I saw him approximately 10 years after the injury. After spending 2 hours listening to his litany of symptoms, I had a list of over 42 complaints. If you are a physician, you must have had the experience of such an encounter with a patient, having to sit through all the gory details and the plethora of complaints. Patients must understand that doctors are humans too; we can get impatient. My favorite manner of dealing with such patients is asking them to rank in order what bothers them the most. I finally asked Mr. Grant to tell me the one thing that bothered him the most. The patient answered, “My wife does not believe or understand the problems that I am having, and she expects me to do things that I cannot do.” Getting to really know this patient after several visits and meeting and understanding his wife’s perspective, I soon realized that the patient did have real symptoms, which were proved through clinical exams. Most of his complaints were rooted in the fact that his wife gave him little attention and made it a rule in the house that if he did not perform certain tasks, she would not allow him certain privileges. These included not receiving an allowance, having sexual intercourse, and not being permitted to drive his car. The patient soon realized that being sick at least got him sex because his wife paid more attention to him when he complained of feeling sick. Given that the patient was in a workers’ compensation situation, he had been seen by a neuropsychologist on the request of the insurance company. The neuropsychologist noted that he had various inconsistencies on the neuropsychological test, like what was noted the case of Mr. Dalbert. Various neurologists who saw Alfonzo had similar conclusions. Therefore, he was diagnosed as “malingering”. With this diagnosis given by his neuropsychologist, Alfonzo was forced to go back to work under the threat of his workers’ compensation financial benefits provided by the insurance carrier being cut off. The patient had important “drivers” that made him continue the sick role, and in my opinion, he utilized them well. Clearly, the clinicians came to this patient with a lot of biases and failed to understand the drivers of his pain, emotional state, and physical limitations. It took me some time spent with the patient’s attorneys, the workers’ compensation carrier, the patient, his wife, and employer to address the issue. At the end of the day, everyone agreed that the patient had a real condition and had suffered a real injury. The patient had regressed to a stage earlier than his stated age, causing him to emulate immature and childish coping behavior driven by his emotional needs. Today, the patient is working as a productive individual providing for his family. Saving this patient involved bringing all the parties together to eliminate the biases that we all have. Having put aside our biases, we were able to develop a treatment plan that made sense while addressing the patient’s situation. This patient had a real problem that was easily treated with medications and input from another neuropsychologist skilled in the management of such situations. We must realize that many patients who are considered to be malingering or exaggerating their symptoms do so but sometimes actually have real conditions. We, as clinicians, do a disservice when we fail to look for the real conditions that can be treated and introduce our personal biases because we believe that the patient has been untruthful in their symptoms or exaggerate their clinical exam situation for various reasons. It takes special skills as a clinician to distinguish fact from fiction and to even talk to patients and their families when such situations of malingering exist. If at the end of such a discussion, you have a satisfied patient
