The MILD interview: evaluating complaints of memory loss.

Patients complaining of memory loss present a complex diagnostic challenge to the physician. The physician must evaluate the patient's mood disturbance, medical condition, lifestyle and drug use as potential contributors to memory loss. An interview strategy focused on these factors may help the physician identify patients who simply need information and reassurance, patients who may benefit from new or revised treatment plans and patients who should undergo more comprehensive assessment.

Soundness of treatment: a survey of psychologists' opinions.

A random sample of 300 psychologists listed in the National Register of Health Service Providers in Psychology were surveyed about the soundness of forms of mental health treatment and use of these treatments in practice. The 139 psychologists responding expressed greatest confidence in cognitive-behavioral therapy and antipsychotic medications. Approaches most in question as to soundness were primal therapy, neurolinguistic programming, bioenergetics, and aversive therapy. Factor analysis indicated widespread endorsement and use of multiple techniques within two broad camps of research-based "hard-edged" versus clinical wisdom/philosophy-based "soft-edged."

Habitually wandering patients.

BACKGROUND: Physicians are sometimes confronted with patients who gain admission to one hospital after another, sometimes referred to as "wandering patients." Little is known about the presenting symptoms of these patients, their use of hospital resources, or the costs of their medical care. We analyzed the demographic and clinical characteristics of wandering patients served by Department of Veterans Affairs medical centers (VAMCs). METHODS: For each patient they admit, all 159 hospitals in the Veterans Affairs medical system submit demographic and diagnostic information to a central data base at the Data Processing Center in Austin, Texas. We searched these records to identify patients who were admitted to four or more VAMCs within each year from fiscal year 1988 through 1992. Patients so identified in any one year were called "wanderers"; those identified in all five years were designated "habitual wanderers." RESULTS: We identified 1013 wanderers in 1988. The number gradually declined each year to 729 in 1993. In 1991 there were 810 wandering patients, who averaged about eight admissions per year and over 100 days of inpatient care; they accounted for about $26.5 million in costs for inpatient and outpatient care in that year. Only 35 patients wandered in all five years from 1988 through 1992. The most common discharge diagnoses of these 35 men were related to substance abuse (mostly alcoholism) and mental disorders. Their 2268 admissions and 7832 outpatient visits cost an estimated $6.5 million over the five-year period. CONCLUSIONS: Patients who are repeatedly admitted to different hospitals--wandering patients--accumulate high numbers of admissions, cause diagnostic confusion, and receive uncoordinated care. Because of the complexity of their disorders, such patients require case management on a regional or national basis.

Personality disorders in problematic medical patients.

To better understand problematic medical patients, the psychiatric diagnoses of 448 patients referred to a behavioral medicine clinic were examined. Forty-two percent met DSM-III-R personality disorder criteria. Analysis of the comorbidity of Axis I and Axis II diagnoses revealed a statistically significant co-occurrence between somatoform and personality disorders (P < 0.0001). Some of the difficulties in making a personality disorder diagnosis are reviewed, as are reasons why knowledge of personality disorder diagnoses is important to medical providers.

The identification and management of drug-seeking behavior in a medical center.

We describe the development of a quality assurance program that monitors prescription medication misuse in a medical setting. The program focuses on patient activities that influence physician prescribing of abusable medications. Seven defining criteria have been developed to judge the presence of drug seeking by patients. When appropriate, a drug-seeking label is attached to the patient's chart and the hospital computer information system. The warning informs the physician and protects the patient from excessive medications.

[A test of symptom validity in assessing functional symptoms]. / Test zur Symptomvalidität zur Einschätzung funktioneller Symptome.

Symptom Validity Testing was developed to evaluate complaints of sensory deficits. The assessment is based on the inability of patients to perceive a sensory signal. Subjects must guess the signal using the model of coin flipping (head or tail). The signals are presented randomized in an equal number of alternatives. A 50-percent hit-rate for enough trials is expected in a true sensory deficit. Deceptive patients are expected to perform a hit-rate below the probabilities of chance.

Neuropsychological evidence of a factitious memory complaint.

The authors describe a patient who complained of a severe memory loss. Information gathered from the history, interview, and testing suggested malingering. The patient was then assessed by a strategy called Symptom Validity Testing. Her score was statistically worse than chance, which provided compelling evidence that she was faking bad.

Cerebral dysfunction in the Munchausen syndrome.

Brain dysfunction has been noted Munchausen syndrome patients but rarely explored. We describe five Munchausen syndrome patients who all appeared intellectually intact because of their excellent verbal skills. However, formal neuropsychological assessment testing revealed deficits in conceptual organization, management of complex information, and judgement. We suggest that subtle but important neuropsychological impairment may contribute significantly to the aberrant behavior of Munchausen syndrome patients. Typical Munchausen behaviors such as irascibility, the desperate search for care, and pseudologia fantastica, may be understood as solutions to problems created by brain damage.

Magician accuses faith healers of hoax.

Discussions of faith healing have traditionally focused on the persuasiveness of the healer and the receptivity of the audience. Recently magician James Randi investigated popular American faith healers and accused them of deliberate fraud. The deceptions he identified are those used for many years by fraudulent mediums and psychics. This paper reviews the history of conflict between charlatans and magicians, providing a context for understanding the findings of Randi.

A new technique for the assessment and modification of feigned memory deficit.

The two-alternative forced-choice technique has been successful in the assessment of functional sensory deficits because it has the power to assess deception or exaggeration. This report describes how the procedure can be used for the assessment and modification of a memory complaint. Three case studies are presented. In two cases the supposed deficit was judged to be functional. In a third case a brain-injured patient "cheated" to obtain correct answers, suggesting that he was trying to hide a deficit and not attempting to obtain compensation.