Malingering and the Expert Witness Psychologist (Devon/South West)

An overriding issue in psychology within a medico-legal arena is the issue of malingering. Malingering involves the exaggeration (fake bad) or underplay (fake good) of symptoms, either consciousely or unconsciousely for secondary gain (an ulterior motive). It differs from a number of other presentations, including somatization, health anxiety/hypocondriasis, and medically unexplained symptoms to name but a few. Psychologists should always bare the possibility of malingering in mind, especially during litigation because of monetary gains. The symptoms most commonly feigned include those associated with mild head injury, fibromyalgia, chronic fatigue syndrome, and chronic pain. Failure to detect actual cases of malingering imposes a substantial economic burden on the health care system, and false attribution of malingering imposes a substantial burden of suffering on a significant proportion of the patient population.
Diagnosis and detection

The DSM-IV-TR states that malingering is suspected if any combination of the following are observed:

1. Medicolegal context of presentation
2. Marked discrepancy between the person’s claimed stress of disability and the objective findings
3. Lack of cooperation during the diagnostic evaluation and in complying with prescribed treatment regimen
4. The presence of Antisocial Personality Disorder
However, these criteria have been found to be of little use in actually identifying individuals who are malingering.
Detection
Some features at presentation which are unusual in genuine cases include:
1. Dramatic or atypical presentation
2. Vague and inconsistent details, although possibly plausible on the surface
3. Long medical record with multiple admissions at various hospitals in different cities
4. Knowledge of textbook descriptions of illness
5. Admission circumstances that do not conform to an identifiable medical or mental disorder
6. An unusual grasp of medical terminology
7. Employment in a medically related field
8. Pseudologia fantastica (i.e., patients' uncontrollable lying characterized by the fantastic description of false events in their lives)
9. Presentation in the emergency department during times when obtaining old medical records is hampered or when experienced staff are less likely to be present (e.g., holidays, late Friday afternoons)
10. A patient who has few visitors despite giving a history of holding an important or prestigious job or a history that casts the patient in a heroic role
11. Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
12. Acceptance, with equanimity, of the discomfort and risk of surgery
13. Substance abuse, especially of prescribed analgesics and sedatives
14. Symptoms or behaviors only present when the patient knows he is being observed
15. Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
16. Reporting of wild psychological symptoms, and silly wrong answers on questionaires, not likely in patients with similar but real conditions.
17. Fluctuating clinical course, including rapid development of complications or a new pathology if the initial workup findings prove negative
18. Coinciding indigence or homelessness of the patient, with impending cold weather and a need for indoor lodgings.
19. Giving approximate answers to questions, usually occurring in factitious disorder with predominantly psychological signs and symptoms (see Ganser Syndrome)
20. Eagerly endorsing symptoms suggested by a clinician, but not mentioned by the patient, though they would have been prominent and obvious had they been real.
21. A test for factitious mental disorders presents symptoms which are extremely improbable. Endorsing these symptoms which almost never occur can raise doubt of the person's sincerity.

If a psychologist suspects malingering in a case of possible brain damage (i.e. caused by head trauma or stroke), they may look for a discrepancy between the patient's reported functions of daily living and their performance on neuropsychological tests. In theory, any neuropsychological test could be used in this way, depending on the context. No one test, administered by itself, can proffer a diagnosis of malingering, so a neuropsychological examination typically consists of a battery of tests. Two tests commonly used to determine malingering are:
• Minnesota Multiphasic Personality Inventory (MMPI) (see Validity scales)
• The Test of Memory Malingering (TOMM)
The psychiatrist or neuropsychologist may use these tests, and use the DSM-IV TR criteria while adding a "dimensional analysis" to assist in diagnosis and treatment. Dimensional analysis consists of learning the patient’s history, information about similar cases, and the context of the illness, which could help differentiate cases of malingering from factitious disorders. Tests are rarely conclusive but often need to be triangulated and weighed against other forms of information, including presentation and self reported symtpoms as mentioned before.

Private Neuropsychology Assessment in Devon, Somerset and Cornwall (South West)

Private Neuropsychology Assessment

Private neuropsychological assessment shares many similarities to the work done within the NHS. Private work is often conducted by an experienced psychologist to provide an expert assessment and report that outlines the nature and extent of any genuine cognitive impairment following a neurological event/insult. Often this is in cases of personal injury, but sometimes clinical negligence. Neurological events most relevant to legal work include various types of brain injury (severe/moderate/mild/open/closed/anoxic/diffuse/focal). In recent years post concussion syndrome has caused much debate within neuropsychology and related arenas, as to its validity and suitability for assessment and diagnosis. As the quality of assessments increases through time and experience, the professional concensus is one of better understanding and clearer identification of this syndrome.

More time is spent in private work assessing possible malingering, exaggeration or falsification of symptoms. Treatments are usually recommended following an assessment and report, but are usually carried out by another practioner. Individual psychologists or psychologist consortiums offer private services. Most of these psychologists will work within the NHS and conduct private work part-time or in their spare time. The South West, including Devon, Cornwall and Somerset is a huge geographical area with a restricted number of suitable psychologists available to conduct private neuropsychological assessments.

Demystifying Psychology in Neuro-Rehabilitation: Emotional Support

The following is a presentation to neuro-rehabilitation multi-disciplinary staff explaining the role of the clinical psychologist when supporting patients with emotional distress.

The Core Roles of a Clinical Psychologist
To work as part of the MDT
To conduct cognitive assessments and to make recommendations
To provide emotional support and psychological treatments to patients who require them…. This is the focus of this presentation.

Common Emotional Symptoms in Neuro-Rehabilitation
Anxiety
Panic
Depression and low mood
Low mood
Trauma
Stress

The Need for Addressing Emotional Symptoms
Primary reason is to address the ongoing personal distress of the patient.
However, emotional symptoms are also addressed because they are:
To the detriment of the rehab potential
Have a negative impact upon family and friends
Increase the risk of suicide/harm

What does emotional support really mean?
Different from full-on therapy
Patient needs to be onboard
Timing has to be right
Sometimes the goals is an improvement in mood, sometimes it preserves mood and ‘gets people through’ a difficult spell.

Other Key Factors of the Patient
Personal history
Personality before the event
Style that they were parented in/early experiences
Psychiatric history (previous mental illness)
Relevance of any neurological deficits
Triggers
Level of support from others
Level of personal resilience and coping style
Interests

A Psychologist Basic Tools: Listening Skills
To provide a safe/private place to talk
To clarify what they mean and to summarise
To listen and resist offering too much opinion or direction
To consider that some behaviours may be ‘attempted solutions’ to a problem
To guide the patient in discovering their own solutions

More Advanced Psychological Techniques
Formulation
Behavioural Experiments
Challenging negative thoughts
Relaxation
Identity work
Stress management
Assertiveness work
Empty chair work
Therapeutic letters

Exercise and Mental Health: An Overview

The following is presentation of an overview of exercise in mental health which I recently gave. Although not specifically, neuropsychologically based nor neuro-rehab specific, some of the content is relevant in working therapeutically within neuro-rehab settings.


Intro to Sedentary Lifestyles

 Society has become increase sedentary

 Work, travel, domestic, leisure activities

 Urbanisation

 Labour saving devices

 Changes to childhood

 All creating a diversion from the physical role we evolved to do



Footnote:

Exercise is the purposeful application of physical activity

Both concepts have application to the promotion of mental health and wellbeing and both have been researched



Plan for Presentation

So….

 We know generally we don’t get enough

 But we know its society’s fault!!

 We know its generally good for us

But…

 What are the mechanisms/how does it work?

 What are the specific psychological effects?

 How effective exactly is it?

 What about exercise and mental illness specifically?

 How much do we need for an effect?

 What are the current exercise dose recommendations?

 What should we do with exercise as clinicians?



Mechanisms

Bio

Serotonin (Barchas & Friedman, 1963)

Endorphine/opioid system (Harber & Sutton, 1984).

Blood circulation/Cerebral blood flow (Dishman, 1995; Martinsen, 1987).

Realignment of circadian rhythm/sleep (Buxton et al., 2003; Youngstedt, 2005)



Psycho

Anxiolytic and mood enhancing qualities (see latter slides)

Accumulative mood improvements (Baekeland, 1970; Conboy, 1994; Mondin et al., 1996)

Increased tolerance to stress (Salmon, 2001)

Increase in self-esteem (Folkins & Sime, 1981; Fox, 2000)

Flow (Csikszentmihaly, 1990)

Distraction (Daley, 2002)

Control of negative thoughts (Morgan, 1985; 1987)

Improved retrieval of positive thoughts (Clark et al., 1983)

Positive rumination (Feldman et al., 2006)

Skill mastery (Lepore, 1997; Mynors-Wallis et al., 2000)

Spiritual/developmental theories



Social

Behavioural Activation/engagement (Jacobsen et al., 1996)

Socialisation (NHS, 2001; Priest, 2007)

Social inclusion (Taylor et al. 1999; DHSE, 1999)

Value of the group more than its constituent parts?

Drug and alcohol avoidance?



The Key Psychological Effects of Exercise:

Anxiolytic Effects

 Low to moderate anxiety reducing effect (Long & van Stavel, 1995; McDonald & Hogdon, 1991; Petruzzello et al., 1991).

 Exercise has an immediate anxiety reducing effect

 Exercise training has been linked to trait measured reductions anxiety

 Exercise sessions can reduce physiological reactivity and enhance recovery from psychosocial stressors

 Main mechanism: it is believed that accumulative experiences of exercise protect people against physiological and cognitive stress and anxiety by reducing sympathoadrenal or pituitary-adrenal responses. Put another way, exercise presents an opportunity to habituate to similar symptoms to that of anxiety (Mills & Ward, 1986).



Antidepressant Effects

 There is large scale, controlled, cross sectional support for a causal link between exercise and decreased depression (Steptoe and Butler, 1997 and Stephens, 1988)

 Meta-analyses have estimated that Beck Depression Inventory (BDI) Scores decrease by between 0.3 and 1.3 of a standard deviation after exercise by controlled comparison (Craft & Landers, 1998; McDonald & Hogden, 1991; North et al., 1990; Lawlor & Hopker, 2001).

 RCT studies have suggested that physical activity can be as successful at treating depression as psychotherapy or medication for mild and moderate levels (Klein, 1985; Mental Health Foundation, 2004; NICE, 2003).

 Potential for treating comorbid depression (HIV, Dementia, CHF, cancer survivors, forensic)



Self-esteem

 Exercise can promote physical self-worth and body image for males and females

 The effect is strongest amongst children and middle-aged adults, and those with lowest self-esteem

 Support for aerobic and resistance (latter acting quicker) (Fox, 2000)



Cognitive Function

 Majority of cross sectional studies show that fit older adults display better cognitive task performance than less fit adults

 Particularly in attention demanding and rapid tasks

 Small improvement in cognitive functioning of older adults who experience improvement in fitness (Boutcher, 2000)

 Slight beneficial & protective (Broe et al. 1990) effect in AD and other dementias but not VaD (Laurin et al. 2005)

 Anecdotal evidence from physical training focus within non-physical sports (darts, snooker, golf)



Mental Illness

 Inconsistent and poorly controlled evidence (Faulkner, 2005)

 Significant impact upon negative symptoms

 Mixed findings with positive symptoms (Helmsey, 1995)

 Potential risks (esp. in mania (Moore 2010), eating disorders (Szasbo 2000) and poly-medication treated patients (Faulkner 2005



Exercise Routine

 Exercise dependence is extremely rare

 Mixed evidence to who benefits most: sedentary individuals with greater potential (Fasting & Gronningsaeter, 1986; Roth & Holmes, 1987; Simons & Birkimer, 1988; Williams & Lord, 1997) or more regular exercisers who value it higher (Steptoe et al. 1997)

 Some evidence has shown that interruption of exercise routine in athletes/seasoned exercisers can lead to physical symptoms, including somatic anxiety and feelings of inability to cope (Loumidis & Wells, 1998).

 Theories of stress may help explain this (Salmon, 2001 Gauvin & Szabo, 1992; Morris et al., 1990)



Single Dose Immediate Effect

 15 minutes is enough to instigate an increase in positive mood, activation and valence, along with an energising effect whilst walking and a calming effect whilst recovering after walking (Ekkekakis et al., 1999; Ekkekakis & Petruzello, 1999; Thayer, 1987).

 Approx. 65% of MHR but inter-individual difference in preference of intensity (Ekkekakis et al., 2005; Rocheleau et al., 2004).

 Salmon (2001) suggests one way exercise may improve mood is that each single dose has an accumulative effect, increasing the likelihood of triggering positive cognitive appraisals, behaviours and social interactions.



Exercise Guidance

 Recommendations vary slightly according to different sources but most agree that greatest improvement to anxiety, depression and mood is caused by rhythmic, aerobic exercises, that use large muscle groups, such as walking, jogging, swimming, and cycling, of moderate and low intensity (between 50% and 75% of Vo2 max heart rate), conducted for 15 to 30 minutes and performed a minimum of three times a week in programs of 10-weeks or longer (Guszkowska, 2004; NICE 2003).

 Exercise in this format is safe but initially aversive enough to present a challenge, whilst also remaining controllable and offering a sense of achievement on completion (Salmon, 2001).



Questions for the clinician?

 How to we best get across the message?

 How far do we push the message?

 Is it our role?

 How do we integrate exercise interventions into our therapeutic work?

 How do we ensure longevity to the interventions?

 How do we incorporate exercise into relapse prevention?

 Should we and do we practice what we preach?

The Neuropsychology and Psychiatric Consequences of Anabolic-Androgenic Steroid Abuse (AAS)

AAS refers to the specific use of steriods to increase protein synthesis within cells, which results in the buildup of cellular tissue (anabolism), especially in muscles. More commmonly it is not athletes who seek this effect but recreational body builders. A number of key events in the evolution of this social concern are documented within Kanayama et al. (2008):

Psychiatric effects

In addition to several detrimental physiological consequences*, evidence points to several significant detrimental psychiatric effects of AAS:

1 Increased likelihood of aggression/violence


2 Increased likelihood of mania


3 Increased likelihood of psychosis and paranoia


4 Increased likelihood of mood disorder and depressive illness


5 AAS dependence


6 Increased progression to other illicit drug use

See http://en.wikipedia.org/wiki/Anabolic_steroid

And

http://www.archido.de/index.php?option=com_docman&task=doc_view&gid=2732

* Increased likelihood of hypertension, elavated cholesterol, heart problems, sexual dysfunction, testicular atrophy and infertility.



Neuropsychological Effects

Unfortunately no controlled studies have looked at long term neuropsychological effects of AAS; and this is partly down to the fact that the phenomena is relatively recent with participants at the very most, only passing into middel age now, and that participants are essentially hard to identify and recruit. However, some research has been conducted with animals into the neurophysiological mechanism of AAS. In an animal study male rats developed a conditioned place preference to testosterone injections into the nucleus accumbens, an effect blocked by dopamine antagonists, which suggests that androgen reinforcement is mediated by the brain. Moreover, testosterone appears to act through the mesolimbic dopamine system, a common substrate for drugs of abuse. Nonetheless, androgen reinforcement is not comparable to that of cocaine, nicotine or heroin. Instead, testosterone resembles other mild reinforcers, such as caffeine, or benzodiazepines. The potential for androgen addiction remains to be determined.

The neuropsychological effects of AAS present an urgent opprtunity for clinical research.

The Mental Capacity Act and the Deprivation of Liberty Safeguards

Mental capacity is an issue in neuropsychology/neuro-rehabilitation when a clients family and the clinical team providing care and treatment are trying to arrange what is in the best interests of the client, because the client may lack the mental function and capacity to make an informed decision. In 2005 a specific act, The Mental Capacity Act (2005) was created, in order to clear up a number of issues:
1. The assessment of a person's capacity and acts by carers and people working with those who lack capacity
2. The provisions whereby people can plan ahead for a time when they may lack capacity
3. Important safeguards
1 The Act makes it clear that any assessment of a person’s capacity must be ‘decision specific’. This means that:

• The assessment of capacity must be about the particular decision that has to be made at a particular time and is not about a range of decisions
• If someone cannot make complex decisions, this does not mean that he/she cannot make simple decisions
• You cannot decide that someone lacks capacity based upon his/her age, appearance, condition or behaviour
• People who have capacity have the right to make poor judgements/decisions- this is not a basis for lacking capacity.
People lacking capacity will include those with dementia, learning disability, mental health problems, brain damage, toxic confusional state and physical injury or illness. The mental incapacity may be permanent or temporary.

Key Principles

There are five important things to think about:

1. Start off by thinking that everyone can make their own decisions.
2. Give a person the support he/she needs to make decisions before concluding that he/she cannot make his/her own decisions.
3. Nobody should be stopped from making a decision just because others may think it is unwise or eccentric.
4. Anything done for, or on behalf of, a person without capacity must be in his/her “best interests” - a decision which is arrived at by working through a checklist.
5. When anything is done or decided for a person without capacity, it must be the least restrictive of his/her basic rights and freedoms.

What does the Act do?

• It aims to clarify a number of legal uncertainties.
• It reforms and updates the current law where decisions need to be made on behalf of others, incorporating good practice into statute and introducing a process.
• It sets out a single test for assessing capacity which is a ‘decision specific test’ (covering emergency decisions; day to day decisions and significant, but not urgent, decisions – including where there are a series of minor decisions which together become significant).
• It covers a wide range of decisions, on personal welfare (including health care) as well as financial matters and substitute decision-making by attorneys or court appointed ‘deputies’. It also clarifies the position where no such formal process has been adopted.
• It includes new rules to govern research involving people who lack capacity and provides for new independent mental capacity advocates to represent and provide support to such people in relation to certain decisions.
• It provides recourse, where necessary and at the appropriate level, to a court with power to deal with all personal welfare (including health care) and financial decisions on behalf of adults who are lacking capacity.
• It replaces the current Court of Protection with a new Court of Protection which has more comprehensive powers.

What does the act mean?

It puts in place a code of practice to give guidance about the legislation. The code must be followed by those working in a professional capacity (e.g. doctors and social workers).

The Act offers appropriate protection for carers (both family members and unpaid carers), as well as health and social care professionals, to those who act in the reasonable belief that they are doing so in the person’s ‘best interests’ when the principles of the Act are followed.


2. The Act sets out provisions whereby people can plan ahead for a time when they may lack capacity

• Lasting Powers of Attorney (LPA)

the Act allows a person to appoint an Attorney to act on their behalf if they should lose capacity in the future. More information on Lasting Powers of Attorney is available.

• Advance decisions to refuse treatment

the Act makes it possible to make an advance decision to refuse treatment should they lack capacity in the future. The Act sets out clear safeguards for the making and application of advance decisions. Further guidance and explanation of advance decisions can found, in Chapter 9 of the Code of Practice.

3. The Act creates important safeguards

• A new Court of Protection

the new Court will have the power to make declarations about whether someone lacks capacity, make orders, or appoint Deputies to act and make decisions on behalf of someone who lacks capacity. More information on the Court of Protection and Deputies is available.

• A new Public Guardian

the Act creates a new public official called the Public Guardian. The Public Guardian will have several duties under the Act including registering Lasting Power of Attorney's (LPA's) and Deputies. The Public Guardian will be supported in his role by a new office called the Office of the Public Guardian (OPG). More information on the Public Guardian and OPG is available.

• Independent Mental Capacity Advocate (IMCA)

an IMCA is someone appointed to support a person who lacks capacity but has no one to speak for them, such as family or friends. They will only become involved when decisions about serious medical treatment or a change in the person's accommodation where it is provided by the NHS or a local authority. More information on the IMCA's can be found on the Department of Health website.

• Research involving people who lack capacity

the Act sets out clear guidelines for research involving people who lack capacity. The research must be approved by an appropriate body, who will also ensure that the research is safe and relates to the person's condition. They must also ensure that the research would not be as effective if they use people who have mental capacity. More information on research and its regulations can be found on the Department of Health website.

• New criminal offence

the Act introduces 2 new criminal offences of ill treatment and wilful neglect of a person who lacks capacity. A person found

The Mental Capacity Act Deprivation of Liberty Safeguard was introduced to specifically protect the freedom of people who cannot make decisions over their treatment and care because of a lack of mental capacity.

The Mental Capacity Act Deprivation of Liberty Safeguards is a new law, which came into force on 1st April 2009.

The safeguards are in response to the 2004 European Court of Human Rights judgement involving an autistic man who lacked the capacity to consent who was kept at Bournewood Hospital by doctors against the wishes of his carers. The court found that he had been deprived of his liberty unlawfully, and the Department of Health committed to introducing new legislation to close the 'Bournewood gap'.

These safeguards provide protection for a very vulnerable group of people who are cared for in hospitals or in care homes registered under the Care Standards Act 2000, in circumstances that deprive them of their liberty, and who are unable to consent (but who are not detained under the Mental Health Act 1983).

The safeguards are designed to protect the interests of an extremely vulnerable group of service users and to:

• ensure people can be given the care they need in the least restrictive regimes

• prevent arbitrary decisions that deprive vulnerable people of their liberty

• provide safeguards for vulnerable people

• provide them with rights of challenge against unlawful detention

• avoid unnecessary bureaucracy

What is a Deprivation of Liberty?

Deprivation of liberty has no clear definition. Many people in hospitals and care homes may have their liberty restricted but not all will be deprived of their liberty. The following factors need to be considered:

• Whether professionals have complete and effective control over assessment, care, treatment, contacts, movement and residence

• Whether the person will be under constant supervision and control and not free to leave

• Whether restraint is used including sedation

• Whether the person would be prevented from leaving if they attempted to do so

• Whether a request from carers for the person to be discharged into their care is likely to be agreed

• Whether the person can maintain social contacts

• Whether the person has choice about their life within the home or hospital

Who do the Deprivation of Liberty Safeguards apply to?

The safeguards apply to anyone:

• aged 18 and over

• who suffers from a mental disorder or disability of the mind – such as dementia or a profound learning disability

• who lacks the capacity to give informed consent to the arrangements made for their care and / or treatment and

• for whom deprivation of liberty (within the meaning of Article 5 of the ECHR) is considered after an independent assessment to be necessary in their best interests to protect them from harm

What are the authorities' duties under the Safeguards?

Hospitals and Care Homes (these are called Managing Authorities) have a duty to:

• provide care and treatment in ways that do not deprive a person of their liberty, or if this is impossible;

• apply to the Supervisory Body for authorisation of the deprivation of liberty.

The Council and the Primary Care Trust (these are called Supervisory Bodies) have a duty to:

• assess any person for whom the Managing Authorities request a deprivation of liberty;

• authorise a deprivation if it is necessary and in the best interests of a person to whom the Safeguards apply;

• set any necessary conditions to make sure the person's care/treatment meets their needs in their best interests;

• set a timescale for how long a deprivation can last;

• keep records of who is being deprived of their liberty.

What should I do if I feel a person is being deprived of their liberty?

Discuss the issue with the hospital or care home. They may be able to change a person's care or treatment to make sure the person is not being deprived of their liberty, or may be able to explain why a person is not actually deprived of their liberty.

Request that the Supervisory Body reviews the person to see whether they are being deprived of their liberty. This request can be by telephone, fax or email. There are standard letters available to use.

Wernicke’s Aphasia

Wernicke’s aphasia (AKA fluent aphasia/receptive aphasia) is characterised by inappropriate words and the inability to understand spoken language. Speech is preserved with normal rhythm, but language content is incorrect. This may vary from the insertion of a few incorrect or nonexistent words to a profuse outpouring of jargon. Grammar, syntax, rate, intonation and stress are normal. Substitutions of one word for another (paraphasias, e.g. “telephone” for “television”) are common. Comprehension and repetition are poor.

It is often a result of damage to Wernicke’s area, a left laterised focal area in 97% of people (including the majority of left handers). The major deficit of Wernicke’s aphasia can be understood as an inability synchronising objects and ideas with the words that signify them. Patients who recover from Wernicke’s aphasia report that, while aphasic, they found the speech of others to be unintelligible and, despite being cognizant of that fact that they were speaking, they could neither stop themselves nor understand their own words. Contrast this to Broca’s aphasia which is typified by non-fluent speech lacking in grammer.

An example of Broca’s aphasia:
“I am a sig… no… man… uh…., well,…again.”

(These words were emitted slowly and with great effort. The sounds were not clearly articulated and each syllable was uttered harshly, explosively and in a throaty voice. Moreover, Broca’s aphasia is often accompanied by right hemiparesis).

An example of Wernicke’s aphasia:
“Ive done a lot well, I impose a lot, while, on the other hand, you know what I mean, I have to run around, look it over, ?trebbin? and all that sort of stuff”.”