Table Of ContentNeurological Malingering
http://taylorandfrancis.com
Neurological Malingering
Edited by
Alan R. Hirsch
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2018 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
International Standard Book Number-13: 978-1-4987-4246-7 (Hardback)
This book contains information obtained from authentic and highly regarded sources. Reasonable efforts
have been made to publish reliable data and information, but the author and publisher cannot assume
responsibility for the validity of all materials or the consequences of their use. The authors and publishers
have attempted to trace the copyright holders of all material reproduced in this publication and apologize
to copyright holders if permission to publish in this form has not been obtained. If any copyright material
has not been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, trans-
mitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter
invented, including photocopying, microfilming, and recording, or in any information storage or retrieval
system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright
.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood
Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and
registration for a variety of users. For organizations that have been granted a photocopy license by the
CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation without intent to infringe.
Library of Congress Cataloging‑in‑Publication Data
Names: Hirsch, Alan R. editor.
Title: Neurological malingering / [edited by] Alan R. Hirsch.
Description: Boca Raton : Taylor & Francis, 2018. | Includes bibliographical references
and index.
Identifiers: LCCN 2018001399 | ISBN 9781498742467 (hardback : alk. paper)
Subjects: | MESH: Malingering | Nervous System Diseases | Diagnostic Techniques,
Neurological
Classification: LCC RC346 | NLM W 783 | DDC 616.8--dc23
LC record available at https://lccn.loc.gov/2018001399
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents
Foreword ..................................................................................................................vii
Introduction ...............................................................................................................ix
Editor .....................................................................................................................xiii
Contributors .............................................................................................................xv
Chapter 1 Malingering: A Historical Perspective .................................................1
Pouyan Kheirkhah, MD
Chapter 2 Historical Indications of Malingering ..................................................7
Marissa A. Hirsch, BS
Chapter 3 Neurological Examination of Malingering ........................................19
Jose L. Henao, MD, Khurram A. Janjua, MD,
and Alan R. Hirsch, MD
Chapter 4 The Challenge of Detecting Malingering among Persons
with Lower Back Pain ........................................................................59
Richard Paul Bonfiglio, MD
Chapter 5 Malingering: A Physical Medicine Perspective .................................65
Jasmine M. Campbell, BA, Chevelle Winchester, BS,
Angela Rekhi, BSc, MD, Khurram A. Janjua, MD,
Anton N. Dietzen, DC, MD, and Alan R. Hirsch, MD
Chapter 6 Validity of Waddell’s Sign ..................................................................77
Jasir T. Nayati, AAS, CNMT and Ather M. Ali, MD
Chapter 7 The Electrodiagnostic Evaluation of Malingering .............................89
Roberto P. Segura, MD
Chapter 8 Toxicologic Malingering ....................................................................93
Jerrold B. Leikin, MD
v
vi Contents
Chapter 9 Pretending to Not Concentrate: Malingering Attention Deficit
Hyperactivity Disorder .......................................................................97
Angela Rekhi, BSc, MD, Jasmine M. Campbell, BA,
and Alan R. Hirsch, MD
Chapter 10 Detection and Management of Malingering to Obtain Narcotics ....109
Anum Wani, HBSc, Mariam Agha, HBSc,
and Alan R. Hirsch, MD
Chapter 11 Chemosensory Malingering .............................................................119
Alan R. Hirsch, MD
Chapter 12 Malingering in Geriatrics .................................................................185
Jason J. Gruss, MD
Chapter 13 Forensic Psychiatric Approach to the Detection of Malingered
Neuropsychiatric Symptoms ............................................................195
Carl M. Wahlstrom, Jr., MD
Chapter 14 Feigning ≠ Malingering: A Case Study ............................................205
Gregory DeClue, PhD, ABPP
Chapter 15 Malingering, Noncompliance, and Secondary Gain ........................217
Henry Phillip Gruss, JD and Valerie Gruss, PhD, APN, CNP-BC
Chapter 16 Physician Response to Neurological Malingering ...........................223
Kamran Hanif, MD and Alan R. Hirsch, MD
Index ......................................................................................................................229
Foreword
Sherlock Holmes had his fingerprints, neurologists have EMGs, nerve conduction
velocities, and PET scans. Being a neurologist in many ways is like being a detec-
tive. In search not of Professor Moriarty, but rather, of Charcot’s triad of neurologic
diseases: (1) is there neurologic disease; (2) if so, where is it localized; and (3) what is
the pathological process occurring? With malingering, the detective work is focused
on (1) is there the presence of true neurological disease? Understanding this one
step further, what is the motivation of such behavior? In this book, these questions
are explored from a myriad of perspectives—historical, diagnostic, legal, and even
from the perspective of the physicians’ countertransference and feelings towards the
malingering patient.
I would like to thank the many who selflessly gave of their time and effort to allow
this book to come to fruition. First and foremost is Denise Fahey, without whose
relentless assistance in editing, organizing, and commitment this work would have
remained an unrealized idea. Also, kudos to Randy Brehm of CRC Press for her
continued support, understanding, and encouragement. Thanks to all the authors for
their efforts and time devoted to this project.
Lastly, a special thank you to my family, who patiently put up with me during the
endless hours spent on this project.
Alan R. Hirsch, MD
vii
http://taylorandfrancis.com
Introduction
As a practicing neurologist on a quotidian, or at least a hebdomadal basis, patients
with disorders are presented which defy diagnosis and whose complaints challenge
physiological explanation. Occasionally, these ultimately turn out to be common
diseases manifesting with unusual presentations, such as stroke-induced Capgras
syndrome (with misinterpretation of familiar faces as strangers) or multiple scle-
rosis manifesting with paroxysmal unilateral phantosmias, with hallucinated odors
confined to one nostril. The struggle the clinician faces, is delineating when such
bizarre presentations are in fact a rarely seen symptom of a common disease, a truly
rare disease, a functional disorder, or a conscious attempt to appear ill for second-
ary gain.
As a medical student, we learn of Waddell’s sign, paradoxical inhibition of unaf-
fected unilateral rapid alternating movements when tested bilaterally, astasia-abasia,
but of few other signs indicating malingering. It is the aim of this book to help fur-
ther the diagnostic ability to determine, detect, and diagnose malingering.
Beyond the how-to make the diagnosis, the impact of making such an emotionally-
laden diagnosis affects both the patient and the physician. Observing the rule
“primum non nocere” (first do no harm), one is reticent to make the diagnosis of
malingering. The diagnosis of malingering in medicine is the equivalent to Nathaniel
Hawthorne’s scarlet ‘A’ branded onto the medical records rather than embroidered
on the bodice. This diagnosis of malingering acts to destroy the physician–patient
relationship. Based on trust, this relationship assumes that the patients will attempt
to be truthful in their presentation with the physician. In the physician–patient rela-
tionship the goals are, if not identical, at least parallel to work together to treat dis-
ease and alleviate suffering. With malingering, the goals have diverged—the aim
of the malingerer is to fool the physician. The ramification of the diagnosis impacts
negatively on myriad aspects of not only the patient–physician dyad, but also the
patient’s life. With this diagnosis, the patient is likely to be rejected in claims for
workmen’s compensation, disability, or monetary reward in litigation. In the era of
electronic medical records, the diagnosis is likely to follow the patient as he or she
approaches other physicians for care. This may lead treaters to be skeptical of the
patient’s complaints, with a bias against the patient even at the start of their relation-
ship, possibly rejecting them altogether as a patient. One would anticipate that the
diagnosis would similarly negatively affect a patient’s ability to obtain health insur-
ance and, if the medical records became public, seek a higher-level job, as well as
dim their chances of successfully being elected to public office. Hence, it is much
more important to correctly diagnose malingering, since a false-positive diagnosis
could ruin the patient’s life. Beyond the cost to society, a false-negative diagnosis
of no malingering when malingering is actually present may subject the patient to
inappropriate and dangerous diagnostic testing and treatment. It can also add cost to
society or businesses. Thus, the importance of correctly diagnosing malingering in
those who malinger cannot be overemphasized.
ix
