Malingering

This is not a medical or psychiatric diagnosis. It refers to willful production of a physical or psychological symptom with the intent of deceiving others and gaining some privileges. The difference from factitious disorder is that here the malingerer is after material gain or escape from punishment. Usually this occurs in forensic settings (when some public figure is arrested!) and in prisoners. The doctor has to examine the patient at different times to check for consistency if the symptoms. If the symptoms are changing in an inconsistent manner it is conclusive proof. The patient’s behavior has to be observed when he is unaware of this. A person with limping may be found to walk normally when alone in his room. Subjective complaint like insomnia may be reported to get hypnotic drugs. Here also observation is important.
It is not correct to ill-treat or insult a malingerer. He has no valid reason to be in the hospital. But he may be having other difficulties. After ensuring that this is ‘genuine’ malingering, the doctor has to report this to concerned authorities. He has to be handled by appropriate social, legal or government agencies.

Usual situations for MUPS

1) Physical illness in the early stages. It takes time for a disease to manifest its pathognomonic signs. Before this the sufferer may have sub threshold symptoms without any objective evidence. Hence it is mandatory that the patients’ symptoms are treated as real and adequate evaluation is done.

2) Subjective exaggeration of mild discomforts by a person who has excessive traits of anxiety or depression.

3) Anxiety and Depressive disorders

4) Somatoform disorders.
i. Somatization disorder.
ii. Conversion disorder.
iii. Persistent pain disorder.
iv. Hypochondriasis.
v. Factitious disorders

5) Malingering.

Each of these are unique situations. They need diferent skills and approaches. In most situations close collaborationb between the treating doctor and mental health professional is needed for proper evaluation and management.

Some underlying concepts..

There is wide variation in our ability to perceive sensations. This is important in our ability to perceive pain and other sensations arising from within our body. Some people are able to perceive peristalsis and other internal movements at a very low threshold. Ability to endure pain also shows wide variation. It also depends on our subjective mental state and contextual factors (e.g.: being lonely in a strange hospital or being surrounded by one’s close kith and kin).

Illness behavior: A person’s belief about presence or absence of illness in him. It can be abnormal when an ill person denies having illness or a healthy person misperceives himself as ill.

Sick Role: It is the privilege given by the society to a person found to be sick by appropriate specialists. The sick person is temporarily exempted from work and other responsibilities. In turn he is expected to subject himself to medical examinations and comply with treatments prescribed. When he is declared as relieved he is expected to abandon sick role and return back.
Clinical picture
14 symptoms are the cause of 50% of medical attendance in general practice. Only 10 to 15% of these are found to be having an organic basis over a period of one year follow up. The rest of them continue to seek medical help without benefit. They sometimes frustrate and irritate the doctors and give rise to arguments. They are a potential source for legal battles. A lot of money is squandered by them and they are at risk of iatrogenic complications from medical investigations and surgical procedures.

The common symptoms are
1) Abdominal pain.
2) Headache.
3) Chest pain / tightness in chest
4) Palpitations
5) Breathing difficulty
6) Low back ache.
7) Vague aches and pains / fibromyalgia.
8) Dyspepsia
9) Dizziness / tinnitus.
10) Vaginal discharge
11) Pelvic pain / premenstrual syndrome.
12) Alterations in bowel habits.
13) Fatigue
14) Sleep disturbance.

Symptoms are usually of prolonged duration with a waxing and waning course. Multiple consultations including specialist work ups would have drawn a blank.

Medically Unexplained Physical symptoms (MUPS)

Patients commonly present to doctors with symptoms or complaints. Complaints are usually of pain and alterations in structure or function of body organs or regions. Doctors are like Sherlock Holmes. Their aim is find out what is wrong with the patient. This exercise is based on the data he is able to collect by history (accurate description of the difficulty including its location, factors associated with onset and termination, duration, nature or quality, other accompanying symptoms etc) and physical examination (aimed to uncover objective evidence to support the symptom – findings like swelling, warmth, restriction of movements or altered sounds during heart beats, breathing etc).

Usually the doctor rules out serious conditions by the above methods, makes an informed guess (provisional diagnosis) about the likely cause of the symptom and prescribes treatment like drugs, dietary changes or other advice. He may order additional tests to confirm or rule out other causative conditions. All this looks fairly simple and straight forward.

Sometimes the doctor senses that the patients’ complaints and objective evidence (obtained by physical examination or tests) do not match. Some patients do not show concern even when they are told that they have serious diseases. Others are not relieved by such pronunciations by the doctor and appear unconvinced, tense and worried.

Both these situations need special attention. Many of the patients who fail to get relief from modern medicine later seek help in alternative systems of medicine as there is no conflict between them and experts in these fields. Practitioners of alternate systems have a very ill defined concept about basic anatomy, physiology and pathology. They are not worried about the mismatch between subjective report and objective evidence like experts in modern medicine. They are in a primitive state (or post modern state with contextual interpretation of reality) and happily listen to long narration of bizarre symptoms uncritically.
The emotional relief obtained from this ventilation may be partly responsible for the therapeutic gains obtained. Some who fail to get relief even from them, flock to faith healers or quacks and demigods out of desperation.

Doctors of modern medicine need to rethink why they are helpless or driven to desperation by such patients. We need to be tuned in to the cues of emotional distress voiced by the patients, and hone up our skills as counselors and emotional healers.

World Mental Health Day 2008 at Kozhikode (Calicut)

My earlier post on the same program on 11th October gives the details of the program. The last photos show Drawing competiton ans Quiz program on Mental Health conducted for school student as part of the WMH Day.

More on delusions ---Form and content.

Another distinction made by psychiatrists is between 'form' and 'content' of the symptom. A person believes that neighbors are plotting to harm or kill him. He may have some reasons for this, as there were some disputes between them and his family over boundary of the plot or something else. But of all the family, only this person believes that there is a plot against him. The other family members might say "It is true that we are not on good terms with them. But that was because our father had a case against them in the court over the boundary. Now that is over, but we are not very cordial to them. Our children play and talk with each other. We do not see any reason why they should conspire to harm or kill us. They are ordinary people without such malicious intent". Now what can the psychiatrist do. He looks at the form and the content.

Content is explainable (explaining and understandability are term used in phenomenological psychology) from the antecedent event of previous conflict. It means that you can reasonably explain the circumstances and the logic behind the belief. But the form (the false unshakable belief, which is not shared by his family members - that is a delusion) is not understandable (understandability is the ability to empathize with him based on the person's situation). Why does he believe so, when even his father (who filed the case) does not believe so ? This is how the belief is labelled as a delusion. Presence of a delusion is conclusive proof of a psychotic illness. Now this is done by looking at other parameters. The person may get one of the psychotic diagnosis - Delusions (paranoid)psychosis, paranoid schizophrenia, or mood disorder (either mania or depression) with psychotic features.
There are two aspects in analyzing any symptom. The Dynamic psychology, which explains the content of the symptom - Why this person is showing this particular symptom now ?. This is based on psychological theories - psychoanalysis or others.
The other is the phenomenological school. The task of Phenomenology is to describe any phenomena that is manifesting in a person's mind by making him to describe it in as much detail and accuracy as possible. This helps to explain the belief baesd on cause and effect logic. Ability to understand and empathize will help to form the therapeutic alliance. In the case of delusions, explanation may be possible based on antecedents, but the form, that is, how a man could be convinced of a patenlty false ideas is not understandable.

Freud and psychoanalysts stressed on the dynamic line of thinking. Emil Kraepelin (the father of psychiatric classification) stressed on accurate description and labelling of the symptom. It was Karl Jaspers (psychiatrist who later turned a philosopher) who highlighted the importance of the use of Phenomenology (a branch of existential philosophy) in Psychiatry.
The dynamic approaches were very popular as everybody wanted an explanation for the errant behavior. But this approach met with only limited success as a therapeutic tool. Later most of the underlying psychological theories used to explain behaviors fell into the category of pseudoscience, as empirical evidence for support was lacking. The current classification systems (both DSM - IV TR and ICD - 10) give more emphasis to accurate descriptions of symptoms. This is why their manuals become a list of symptoms. Used sensibly, this helps to increase objective agreement between different clinicians seeing the same patient. But superficial approaches can do more harm than good.
One more issue is the role of insight. A person with a delusion does not have the insight that his belief is false, or that it does not hold up on objective scrutiny. This is why Esquirol (is it not him ?) remarked "Delusions are the hallmark of insanity". Hence presence of a delusion merits the diagnosis of psychosis (Insight is lost in psychosis, contrary to neurosis). So Sashi's fond hope that a person with a delusion will voluntarily seek treatment does not happen usually. On the contrary they turn hostile to anybody who attempts to correct their belief. Yesterday I Happened to see a lady send by the CJM court Thalassey, who was abusing even the accompanying police constables alleging that they are also a party to the big conspiracy against her.

On Delusions....

It is indeed heartening to follow the discussions on the basis of psychiatric diagnosis, and the relationship between creativity and mental illnesses. Let me go into a little more details on delusions. A delusion is defined as a false and unshakable belief that is not explainable by the persona's socio cultural factors. It can be explained
1) False belief - the belief in question can be shown to be false by objective methods or verification by others.
2) Unshakable - The person refuses to accept any proof contrary to his belief and holds on to it.
3) Not explained by socio cultural factors - This criterion may have been added for social or political reasons than based on science. The most difficult issue at that time may have been 'how to keep religious belief out of the domain of psychopathology'. Without this criterion it will be difficult to do this. Cultural beliefs (for example, a local belief that God resides on top of a nearby mountain) may have to be labelled as psychopathology.

Richard Dawkins explains why he chose the title of his book as 'The God delusion'. He admits that delusion is a technical word used by psychiatrists, but justifies his title seeing no reason not to call belief in God as a delusion. We need not discuss this further. What I am trying to convey is that psychiatric diagnosis have a social/ political/ cultural angle to it and safeguards should be there to prevent abuse of psychiatry by totalitarian regimes.