Why functional neurological disorder is not feigning or malingering.

Functional neurological disorder (FND) is one of the commonest reasons that people seek help from a neurologist and is for many people a lifelong cause of disability and impaired quality of life. Although the evidence base regarding FND pathophysiology, treatment and service development has grown substantially in recent years, a persistent ambivalence remains amongst health professionals and others as to the veracity of symptom reporting in those with FND and whether the symptoms are not, in the end, just the same as feigned symptoms or malingering. Here, we provide our perspective on the range of evidence available, which in our view provides a clear separation between FND and feigning and malingering. We hope this will provide a further important step forward in the clinical and academic approach to people with FND, leading to improved attitudes, knowledge, treatments, care pathways and outcomes.

Analysis of morphological measurements of the trigeminal nerve in the linac stereotactic radiosurgery simulation targeting the root entry zone in trigeminal neuralgia / Análisis de las mediciones morfológicas del nervio trigémino en la simulación de radiocirugía estereotáctica con LINAC considerando como blanco la zona de entrada de la raíz en neuralgia trigeminal

Purpose: To describe the anatomical measurements of the trigeminal nerve in patients with trigeminal neuralgia (TN) during Linac (linear accelerator)-based stereotactic radiosurgery (SRS) simulation, targeting the root entry zone (REZ), with a 30% isodose line tangential to the pons, using 4-mm and 6-mm collimators. Methods: In this retrospective study, 53 TN patients, who underwent Fiesta sequence scanning prior to any treatment modality, were assessed. Bilateral measurements were obtained from the cisternal segment of the trigeminal nerve, the trigeminal-pontine angle, and the lateral width of the pontine cistern on the Fiesta MRI sequence. Linac-based SRS simulations were estimated with a radiation dosage of 90Gy to 30% isodose line tangential to the pons, with both 4- and 6-mm collimators. Distances from the calculated targets to the pons and the Gasserian ganglion were measured for later analysis. The statistical analysis was performed comparing the affected side against the unaffected side. Results: Right trigeminal nerve was affected in 36 patients (67.9%), and left one in 17 (32.1%) patients. The mean length of the trigeminal nerve was 9.8mm (range: 4.6-16.8mm) on the affected side, and 10.5mm (range: 5.6-18.4mm) on the unaffected side (p=.02). The mean trigeminal-pontine angle was 12.5° (range: 5.4° to 19.5°) on the affected side, and 10.2° (range: 5.0° to 30.5°) on the unaffected side (p=.01). In the simulations, the distances from the estimated targets to the pons and the Gasserian ganglion were not statistically different between sides. The variation of target-pons and target-ganglion distances was statistically significant on the affected side with the change of collimators (p<.001). Conclusions: In this anatomical study, significant differences were identified in the length of the affected trigeminal nerve and trigeminal-pontine angle compared to the unaffected side in TN patients in Fiesta sequences prior to surgery or radiosurgery. Significant variation of the target location was found on the REZ between the 4- and 6-collimators during the Linac-based SRS simulations with the estimated radiation dosage of 90Gy and 30% isodose line tangential to the pons

Objetivo: Describir las mediciones anatómicas del nervio trigémino en pacientes con neuralgia del trigémino (NT) en la simulación para radiocirugía estereotáctica (SRS) con acelerador lineal (LINAC), utilizando como blanco la zona de entrada de la raíz (REZ), con una línea de isodosis del 30% tangencial al puente, usando colimadores de 4 y 6mm. Métodos: En este estudio retrospectivo, fueron evaluados 53 pacientes con NT con una secuencia FIESTA de RM previo a recibir alguna modalidad de tratamiento. Las mediciones obtenidas bilateralmente fueron la longitud de la porción cisternal del nervio trigémino, del ángulo trigémino-pontino y la anchura lateral de la cisterna pontina. Las simulaciones de SRS con LINAC fueron estimadas con una dosis de radiación de 90Gy a una línea de isodosis del 30% tangencial al puente, tanto con colimadores de 4 y 6mm. Las distancias desde los blancos calculados al puente y al ganglio de Gasser, bajo estos parámetros, fueron medidas. El análisis estadístico fue realizado comparando el lado afectado contra el lado no afectado. Resultados: El nervio trigémino derecho se encontró afectado en 36 pacientes (67,9%), y el izquierdo en 17 (32,1%) pacientes. La longitud media del nervio trigémino fue 9,8mm (rango: 4,6-16,8mm) en el lado afectado, y 10,5mm (rango: 5,6-18,4mm) en el lado no afectado, con una diferencia media estadísticamente significativa (p=0,02). El ángulo trigémino-pontino fue 12,5° (rango: 5,4-19,5°) en el lado afectado y 10,2° (rango: 5,0-30,5°) en el lado no afectado, con una diferencia media significativa (p=0,01). En las simulaciones, las distancias desde los blancos estimados al puente y al ganglio de Gasser no fueron significativamente diferentes entre ambos lados. La variación de las distancias blanco-puente y blanco-ganglio fue estadísticamente significativa en el lado afectado con el cambio de colimadores (p<0,001). Conclusiones: En este estudio anatómico, diferencias significativas fueron identificadas en la longitud del nervio trigémino y el ángulo trigémino-pontino en el lado afectado al compararse con el lado no afectado en pacientes con NT idiopática en secuencias FIESTA previo a cirugía o radiocirugía. Se observó variación en la localización del blanco sobre la REZ en las simulaciones de SRS con LINAC entre los colimadores de 4 y 6mm, con una dosis de radiación estimada de 90Gy y una línea de isodosis del 30% paralela al puente

Malingering in the Psychiatric Emergency Department: Prevalence, Predictors, and Outcomes.

OBJECTIVE: Malingering is commonly encountered in the psychiatric emergency department, yet little is known about its prevalence, objectives, or effect on patient management. This study analyzed characteristics of malingering and patient disposition in a 24/7-staffed comprehensive psychiatric emergency program (CPEP) and created predictive models to understand malingering and its effect on physician decision making. METHODS: Attending psychiatrists completed questionnaires after comprehensive assessments of 405 patients presenting to the CPEP during the 1-month study, recording suspicion of malingering, symptoms malingered, associated secondary gains, demographic characteristics, and initial disposition decision. Analyses examined characteristics associated with degree of malingering suspicion and disposition. RESULTS: Malingering was suspected among one-third of patients, and 20% were strongly or definitely suspected of malingering. High suspicion was associated with malingering of multiple symptoms and was likely to result in immediate discharge. Lower suspicion was associated with being held for further observation. Among patients for whom suspicion of malingering was high, malingering was most frequent for suicidal ideation (58%) and depression (39%); malingering was often used to seek hospital admission (54%) and to stay in the CPEP (35%); malingering was sometimes used to seek multiple secondary gains (25%); and malingering often involved multiple symptoms (44%). Patients for whom suspicion was high had an admission rate of 4%. Among patients suspected of malingering, three variables each independently increased the likelihood of hospital admission: seeking social work or housing services, seeking admission, and malingering of suicidal ideation. CONCLUSIONS: Malingering was prevalent in the psychiatric emergency department, and suspicion of malingering was associated with disposition differences. Disposition was significantly influenced by both suspicion of malingering and the gains sought by patients.

The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation.

OBJECTIVE: The therapeutic discharge of patients assessed as misrepresenting suicidal ideation, though in the best interests of the patient, physician, and health care system, is an inherently risk-assuming action. The rationale and conduct of the therapeutic discharge has been written on previously. Here, we propose a method of documenting the therapeutic discharge in a way that is useful and teachable. METHOD: After describing some other types of note-writing that can be needed in the care of deceptive patients, we describe an approach to each of the major sections of an initial consultation/encounter note as it applies to the therapeutic discharge. RESULTS: Each note section is handled slightly differently than ordinarily. The history of present illness follows the sequence, rather than the re-organization of the information obtained. The past medical history requires and reflects a more granular chart review than is usually warranted. The mental status exam is less cross-sectional than usual. The assessment and plan incorporates several components that reflect a reasoning process specific to the therapeutic discharge. CONCLUSION: While labor-intensive, the documentation approach advocated for and exemplified here reaffirms aspects of one's identity as a physician, ensures responsible execution of a risk-involving decision, and potentially simplifies subsequent patient encounters.

Simulador gastrointestinal dinámico (simgi): una herramienta potencialmente útil en nutrición clínica / The dynamic gastrointestinal simulator (simgi): a useful tool for clinical nutrition

Dentro de la microbiota humana, el tracto gastrointestinal alberga el ecosistema más complejo y abundante del cuerpo humano, siendo el colon donde se encuentra la concentración más alta de microorganismos (1012 cél/g). La microbiota intestinal desempeña funciones metabólicas, tróficas y de protección que son de gran importancia para el hospedador. Durante las últimas décadas, son numerosos los estudios que han tratado de aportar evidencias científicas acerca de los factores que, a través de cambios en la composición de la microbiota intestinal, influyen en la salud humana. Sin embargo, esta aproximación está cambiando, y son cada vez más los expertos que apuestan por evaluar cambios a nivel de funcionalidad de la microbiota. Si aplicamos este enfoque dual al papel desempeñado por la dieta, resulta obvia la necesidad de disponer de modelos dinámicos de simulación gastrointestinal, como es el simgi, que permitan evaluar las transformaciones que sufren los alimentos y/o ingredientes alimentarios durante el tránsito por el tracto gastrointestinal, así como para determinar los posibles cambios en la composición y funcionalidad de la microbiota intestinal derivados de la ingesta de alimentos. Los estudios llevados a cabo hasta el momento con el simgi constatan sus potenciales aplicaciones en el área de los alimentos como paso previo a su aplicación en nutrición clínica, para prevenir y/o tratar enfermedades asociadas a disbiosis intestinal, así como trastornos metabólicos. Asimismo, esta revisión recoge posibles perspectivas de utilización del simgi en la investigación clínica relativa a enfermedades vinculadas con disfunciones de la microbiota intestinal (AU)

The human gastrointestinal tract harbours the most complex and abundant community of the human body, the colon being where the highest microbial concentration is found (1012 cell/g). The intestinal microbiota exerts metabolic, trophic and protective functions which are important in the maintenance of the host health. Over recent decades, numerous studies have attempted to provide scientific evidence about the environmental factors that can impact on human health through the modulation of the intestinal microbiota composition. However, this approach is changing, and a new focus on assessing changes at functional level is being developed. If we apply this dual approach to the role played by the diet, it is obvious the need of dynamic gastrointestinal simulation models such as simgi, that allow to evaluate the transformations undergone by food and/or food ingredients during their transit through the gastrointestinal tract, as well as to determine potential changes in the composition and functionality of the intestinal microbiota after food ingestion. So far the studies using the simgi have confirmed its potential applications in the area of food as a prior step to its application in clinical nutrition to prevent and/or treat diseases associated with intestinal dysbiosis and metabolic disorders. Likewise, this review includes feasible perspectives of the use of simgi in clinical research concerning to diseases related to the intestinal microbiota (AU)

[Factitious disorders]. / Artifizielle Störungen.

Patients with factitious disorders intentionally fabricate, exaggerate or feign physical and/or psychiatric symptoms for various open and covert psychological reasons. There are many issues regarding the diagnostic state and classification of factitious disorders. Both the categorical differentiation of and clinical continuum ranging from somatoform/dissociative disorders to malingering are being controversially debated. Epidemiological studies on the frequency of factitious disorder meet basic methodological difficulties. Reported rates of prevalence and incidence in the professional literature most probably have to be considered underestimations. Illness deception and self-harm as core features of the abnormal illness behaviour in factitious disorder may refer to various highly adverse and traumatic experiences during early development in a subgroup of patients. Chronic courses of illness prevail; however, there are also episodic variants.

General practitioners' approach to malingering in basic military training centres.

OBJECTIVES: Malingering can be defined as the abuse of the right to benefit from the health services. In this study, the frequency of the malingering cases in Basic Military Training Centres (BMTCs) and the behaviours and the attitudes of the military physicians towards the recruits who are suspected malingerers were described. METHOD: A total of 17 general practitioners in nine different BMTCs in different regions of Turkey constitute the universe of this descriptive study. In the questionnaire, there were a total of 30 questions about the descriptive characteristics of the participants and their attitudes and behaviours towards malingering. Informed consent form and a questionnaire were applied through the intranet via participants' emails. In the study, 15 physicians were reached with a response rate of 88.2%. RESULTS: All of the physicians suspected malingering in some of the soldiers who were examined. A total of 80% of the physicians (n=12) suspected malingering in at least 10% of the patients they examined. Only 13.3% of the physicians (n=2) had officially diagnosed a case of malingering in the last training period. All of the participants stated that they did not report the official decision for every soldier suspected of malingering. Instead of reporting official decision for malingering, the military physicians apply alternative procedures for suspected malingerers. CONCLUSIONS: In countries where the military service is compulsory, prevalence of malingering is estimated to be higher (approximately 5-25%). The problem of malingering is often underestimated due to the fact it is usually overlooked. Malingering remains a problem for the entire military healthcare system, due to the difficulties in exact diagnosis. Therefore, it can be useful to take some practical administrative measures for the soldiers who are prone to malingering, in order to discourage the behaviour.

Self-Inflicted Lesions in Dermatology: A Management and TherapeuticApproach - A Position Paper From the European Society for Derma-tology and Psychiatry.

The classification of self-inflicted skin lesions proposed by the European Society for Dermatology and Psychiatry (ESDaP) group generated questions with regard to specific treatments that could be recommended for such cases. The therapeutic guidelines in the current paper integrate new psychotherapies and psychotropic drugs without forgetting the most important relational characteristics required for dealing with people with these disorders. The management of self-inflicted skin lesions necessitates empathy and a doctor-patient relationship based on trust and confidence. Cognitive behavioural therapy and/or psychodynamic and psychoanalytic psychotherapy (alone, or combined with the careful use of psychotropic drugs) seem to achieve the best results in the most difficult cases. Relatively new therapeutic techniques, such as habit reversal and mentalization-based psychotherapy, may be beneficial in the treatment of skin picking syndromes.

Identifying and Managing Malingering and Factitious Disorder in the Military.

Malingering is the intentional fabrication of medical symptoms for the purpose of external gain. Along similar lines as malingering, factitious disorder is the intentional creation or exaggeration of symptoms, but without intent for a concrete benefit. The incidence of malingering and factitious disorder in the military is unclear, but likely under reported for a variety of reasons. One should be aware of potential red flags suggesting malingering or factitious disorder and consider further evaluation to look for these conditions. A deliberate and intentional management plan is ideal in these cases. Furthermore, a multi-disciplinary team approach, a non-judgmental environment, and the use of direct but dignity sparing techniques will likely be most "successful" when confronting the patient with malingering or factitious disorder.

Escenarios de simulación clínica creados por alumnos de medicina: descripción de la experiencia de 2 años / Clinical simulation scenarios designed by medical students: The description of a two-year experience

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Sexsomnia: sleep sex research and its legal implications.

"Sleep sex," also known as sexsomnia, is a sleep disorder characterized by sexual behaviors committed while asleep. There has recently been increased interest in sexsomnia due to controversies arising in legal trials that have been widely publicized in the social and public media. This article attempts to marshal the current information about sexsomnia from the forensic literature and provides an overview of sexsomnia including common features, precipitating factors, prevalence rates, diagnostic procedures, and treatment. As sexsomnia represents a condition in which sexual acts are committed without awareness or intention, this paper also reviews the development of sexsomnia as a legal defense and summarizes Canadian case law on the topic. It provides an overview of the hurdles presented to defense attorneys attempting to utilize the defense and examines popular public notions surrounding the legitimacy of sexsomnia and the possibility of malingering. We conclude that sexsomnia is a legitimate sleep disorder for which case law now exists to support its use in legal defenses based on automatism. The question of whether it is an example of "sane" or "insane" automatism remains to be determined by the courts. Regardless of whether or not sexsomnia is determined to be a mental disorder by the courts, it is now a recognized and well-described sleep disorder that can be safely treated and managed by knowledgeable clinicians.

Factitious disorders and malingering: challenges for clinical assessment and management.

Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.

Malingering psychosis: guidelines for assessment and management.

PURPOSE: The purposes of this paper are to (a) identify theoretical underpinnings of malingering, (b) to discuss interview and intervention techniques based on pertinent literature, and (c) to offer an organized mnemonic to help clinicians easily identify possible malingered psychosis presentations. CONCLUSION: Detecting the malingering of psychotic symptoms is a challenging task for Advanced Practice Psychiatric Nurses. Diagnosing a patient of malingering requires caution on the clinician's part. PRACTICE IMPLICATIONS: A thorough understanding of potential signs of malingering vs. genuine psychosis is needed as well as knowledge of legal ramifications.

Self-inflicted burns in soldiers.

BACKGROUND: Self-inflicted burns are a multidisciplinary medical challenge. In contrast to the more common motive of attempted suicide in self-infliction of a burn, usually of a serious degree, a second motive is malingering. Motivation of this nature has been exhibited among Israeli soldiers who inflict on themselves low- to moderate-degree burns to obtain dismissal from mandatory military service. The purpose of our study is to investigate and define this phenomenon. METHODS: A retrospective analysis was performed on a population of 75 soldiers admitted to our Medical Center during the year 2010 with the diagnosis of any sort of burn. We set up a database including all relevant information about the burns including date and time of occurrence, cause, body location, depth of burn injury, area and shape of burn, etiology, and prescribed treatment. RESULTS: The summer was found to be the season with the highest incidence of burns. As far as the day of the week was influential, we found that the greater percentage of burns occurred at the beginning of the week. Most of the burns involved a minor surface area on the dorsal aspect of the foot. Scalding with hot water was the most common cause of burn. Eighty-one percent of the burns were atypical, being well demarcated.Most of the burn cases happened at home with no witnesses to the event. Sixty-one percent of the patients were not admitted to the hospital and were conservatively treated. CONCLUSIONS: Israeli soldiers tend to inflict burns on themselves for ulterior motives. Such burns are almost always minor with a small trauma area and sharp demarcations, and hence can be differentiated from other self-inflicted burns described in the literature. We found that most of the burns occur when the soldiers are on vacation at home. This is probably because the privacy allows them to carry out their act undisturbed. It is important to raise the awareness of attending physicians to the characteristics of these burns. Such patients should be evaluated by medical teams including mental health professionals to help them psychologically and to eliminate this unfortunate problem.

Valoración del daño corporal en personas afectadas de secuelas neurológicas / Assessment of damage in affected persons with neurological sequelae

Objetivo: Mostrar un nuevo sistema para simular la recuperación inicial de las funciones de la extremidad superior los primeros días después del ictus y simular la recuperación funcional de los pacientes bajo los programas de rehabilitación. Pacientes y metodología: Seleccionamos 29 pacientes en los primeros cuatro días después de padecer un ictus, valorados a los tres y siete días y uno, tres y seis meses, recogiendo tipo de ictus, clasificación (escala de Oxford), déficit neurológico (escala de NIHSS), medidas de discapacidad, valoración de la función motora de la extremidad superior (escala de Fugl-Meyer), tono muscular y balance muscular de la extremidad superior. Resultados: Los pacientes que presentaron un tono muscular disminuido tuvieron más dificultad en mejorar el control motor de las articulaciones de la extremidad superior. Los pacientes TACI presentaron mayor déficit neurológico, mientras que los tipos de ictus POCI y LACI tenían una función motora mejor con mayor independencia para el desarrollo de sus actividades de la vida diaria. Conclusión: La simulación virtual del brazo y la mano en pacientes afectados por un ictus proporciona a los médicos y fisioterapeutas una nueva herramienta que permite simular la evolución de los déficits en algunos pacientes (AU)

Objective: To show a new system in order to simulate the initial recovery of the functions of the upper extremity the first days after a stroke and to simulate the functional recovery of patients under the rehabilitation programs. Patients and methods: We selected 29 patients in their first four days after suffering a stroke. They were evaluated at three and seven days as well as at one, three and six months, and data was collected on types of stroke classification (Oxford scale), neurological deficit (NIHSS scale), disability measures, assessment of motor function of the upper extremity (Fugl-Meyer scale), muscle tone and balance of the upper extremity. Results: The patients with low muscle tone had a harder time improving Motor control of the upper extremity joints. TACI patients showed a higher neurological prevalence, whereas those patients with kind of strokes LACI and POCI had a better motor function more independently for the development of their activities of daily living. Conclusion: The virtual simulation of arms and hands in patients with a stroke provides doctors and physiotherapists a new tool to simulate the evolution of deficits in some patients (AU)

Protocolo para la detección de la simulación del dolor en la práctica clínica: estudio de casos / A Protocol for detection of malingered pain symptomatology in clinical practice: case studies

Se propone un protocolo para la detección de la simulación de dolor en la práctica clínica de tipo multimétodo, multisistema y multidisciplinar que busca, mediante las diferentes pruebas aportadas desde los ámbitos de la medicina y la psicología, encontrar las inconsistencias que nos presenta el paciente. De las diferentes pruebas y los distintos profesionales se obtienen los datos convergentes que nos llevan al diagnóstico de simulación (AU)

A multi-method, multi-system and interdisciplinary protocol for the detection of malingered pain symptomatology in clinical practice is addressed. This protocol is mainly based on the patient´s clinical behaviors inconsistencies, by taking into account evidence from different knowledge of medicine and psychology. From the different tests and different professionals, convergent data were obtained for the diagnosis of malingering (AU)

[Mental disorders--malingering].

This article reviews diagnostic and therapeutic perspectives of mental disorders malingering. Three explanatory models are presented: the pathogenic model, the criminological model, and the adaptational model. Methodological and specific issues are discussed, as well as an updated literature survey of psychological tests found to be useful in detecting malingering. The tests include objective personality questionnaires, especially the Minnesota Multiphasic Personality Inventory (MMPI). Using MMPI as a single tool may be misleading, as the malingerer learns to avoid detection. By adding the Symptom Validity Test (SVT) to MMPI, the problem can be resolved. Therapeutically, the effect of using a criminological model by DSM on malingerer's treatment is tested, and the contribution of the other models is also discussed. It seems that using a dichotomy approach to malingering is misleading. Instead, seeing malingering as a 2-way continual axis spectrum (conscious vs. unconscious; external vs. internal motivation) makes it possible to treat many patients who otherwise would be considered as untreatable and/or not in need of treatment.