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Neurocare president is Philadelphia and Delaware valley neurologist, psychiatrist, psychopharmacologist, neuropsychiatrist, and psychotherapist Robert I. Winer, M.D., a medical doctor specialist in neurology, psychiatry, psychopharmacology, psychotherapy. Dr. Winer's psychotherapy is Jungian-oriented (using the approach of psychiatrist Carl Jung ) making use of dreams (dream interpretation) to work with the unconscious. In his psychotherapy practice he performs therapy, psychotherapy, analysis, and psychoanalysis.

Dr. Winer is the president of the C.G. Center of Philadelphia. He is also the president of the Winer Foundation which has been doing humanitarian and medical education in Ethiopia since 1994.

Neurocare 2801 S. Island Ave, Suite 14 Philadelphia, PA 19153 Phone: 215-365-0277 Fax: 215-365-4394

Introduction

In the medical-legal arena, medical specialists, physical therapists, and psychiatrists are called upon to assess and / or give an opinion as to the whether a patient's complaints or efforts are principally organically, psychiatrically, or pain-based. Oftentimes, a further differentiation is required: Is the clinical presentation the result of conscious feigning (malingering)?

Various clinical tests have been designed to specifically assess the so-called "truthfulness" of a patient's pain or the "actuality" of the degree of effort they put forth which amounts to a so-called "objective" measure or assessment of the "validity" of the degree of organic impairment. In my opinion, the results of these so-called "validity" test has been disappointing, and worse yet, sometimes misleading. When such a thing takes place, it is my sense that the health care provider who is assessing the condition has a limited knowledge base and lack the clinical breadth to understand properly the scope of the clinical problem that is encountered. Another important contributing factor is the one-sided conception that the "problem" is either in the mind or the body or neither (malingering). Bowing to the need for clear diagnostic criteria most modern medical practitioners might be called "splitters" -- the problem or condition is physical ("organic") or emotional / mental ("functional"). Of course there are important advancements in health care that have resulted from this splitting of the problem, however it seems to me impossible to unlink body and psyche. Such an irrevocable linkage has been repeatedly proven scientifically and experimentally. We all know of the psychic distress that results from a bodily illness, but few accept that for all of recorded history, all of humanity accepts that, at one time or another, psychic distress results in bodily disturbance. Every society knows of the physical symptoms of an emotional "stomach ache." Every society knows that anger changes the circulation of the blood to the face, making it red, as in he was "hot with anger." Depth psychology has clearly understood such things since the beginning of the nineteenth century, making a clear disnction between emotions and feelings. Therefore, an emotion is defined as a feeling-tone accompanied by bodily activation, the most common being tears (activation of the tear ducts) or laughter (involuntary innervation of the glottal and diaphragmatic musculature). For more on this, see my writings on the four functions of sensing, intuition, thinking, and feeling.

Malingering

A diagnois of malingering means that the examiner is convinced that a patient manifests false or grossly exaggerated physical and/or psychological symptoms and / or signs. The symptoms are presumed to be under voluntary control and are said to be feigned or embellished because of a conscious desire to achieve or maintain some financial or addictionally-driven gain or to avoid some unpleasant consequences (work, conscription to militiary service, imprisonment, drug withdrawal).

I place a high burden of responsibility on the examiner in regard to diagnosing malingering. In my opinion, it should not be considered unless there is surveillance which unequivocably shows that the symptoms are feigned / embellished and that the gain or avoidance is clearly discernible from the circumstances of the patient, such that it could be understood easily by an average person.

If such criteria were used in all cases of "proven" malingering then one would could reasonably expect prompt resolution of the signs and symptoms once the cash award takes place or if the need for feigning ceases. I have been surprised at how often this is not the case in many patients who have been suspected as malingers by experts. When the clinical symptomatology remains consistent for a long period of time, despite the completion of a medical-legal settlement, one must seriously consider that either there was not malingering in the first place or that an additional diagnosis or condition is present. Dr. C.G. Jung pointed out just such a situation as early as 1903 in reporting the simultaneous existence of conversion hysteria in patients who committed crimes which required them to deceive others by assuming a false persona (1).

At times, health care practitioners with insufficient psychological knowledge or skill note in their physical examination an alleged disparity between certain physical signs, for example in the gait or in limb movement, tone, or strength, as compared to so-called "normal" walking or limb function. Such differences from "normal" are proclaimed as "evidence" of malingering or a phrase invented in the late twentieth century, "symptom embellishment" (in my opinion a a vague and subjective characterization). Sometimes an examiner will note that movements appear different when "the patient believed they were not being observed." Then this alleged "disparity" is cited as "evidence" of malingering, without the examiner attempting to make an empirical explanation of the phenomenon. Typically these so-called discrepancies are characterized by verbiage such as this:

"The observed inconsistencies in her behavior inside and outside the clinic suggests that she may have more strength then the patient is willing to admit. She did not seem to be cooperating fully in the examination."

Other alleged signs of disparity take place in conditions of cognitive dysfunction. Here's another excerpt from a physician note:

"The patient was lucid in some responses despite her complaint of confusion. This points to symptom magnification."

Of course, in such a case, malingering is a possibility and it should be seriously considered. However, all patient-doctor / health care practitioner contacts have there own distinct psychodynamic which in part reflects the nature of the encounter. Is the encounter between patient and practitioner part of a typical patient-doctor relationship, an Independent Medical Examination (IME), or some other relationship-contract. Do such disparities in examination in different environments establish the diagnosis of malingering? The answer is emphatically no. However if these observations are accurate (reflecting empirical observation) they do provide important diagnostic information. In my opinion, these "so-called" discrepitancies, if viewed from a psychological point of view, are evidence that other psychological factors are occurring such as: persona behavior, desire to please, splitting, compartmentalization, and somatoform disorder.

According to the DSM-IV (APA Diagnostic Classification, the Somatoform Disorders are:

Body Dysmorphic Disorder | Conversion Disorder | Hypochondriasis | Pain Disorder | Somatization Disorder | Undifferentiated Somatoform Disorder | and Somatoform Disorder NOS (not otherwise specified).  

According to the DSM-IV, the diagnosis of conversion disorder requires the presence of one or more symptoms or deficits affecting voluntary motor or sensory function that appear to be neurological in origin and also that there be preceeding psychological factors which either initiate or exacerbate the symptom or deficit. The diagnosis infers an unconscious reaction; thus it usually excludes factitious disorder or malingering. The clear temporal link refers to a traumatic event or as a trigger to a previous traumatic event which are inferred to be of sufficient severity to be the activating factors of the psychic bodily response.

Hypochondrical features may also be part of the clinical picture in patients suscepted of malingering. In hypochondriasis, patients have an unrealistic interpretation of their physical complaints, along with a preoccupation with their perception of being ill.

Somazation disorder refers to an illness with symptoms relating to multiple body systems: multiple sites of pain; gastrointestinal symptoms such as nausea, bloating, vomiting, diarrhea, or intolerance of several different foods; sexual symptoms; neurological such as impaired coordination, balance, strength, difficulty swallowing, loss of sensation, visual problems, seizures, or cognitive dysfunction. The symptoms should be of a sufficient severity to significantly alter life style.

Some suspected malingerers also have features of schizotypical behavior such as social isolation, odd speech, inadequate rapport in face-to-face interaction due to constricted affect and compulsive/narcissistic features such as perfectionism and preoccupation with details, fixation on her bodily complaint and drawing of attention to themselves in the outside world and in the clinical doctor/patient relationship.

1. Jung, C.G. (1957). "On Simulated Insanity." In R.F.C. Hull (Trans.), The Collected Works of C.G. Jung (Vol. 1, pp. 159-187). Princeton, NJ: Princeton University Press. (Original work published in 1903.)