Abstract
"Functional" disorders have been estimated to represent approximately 4-5% of adult neurogenic caseloads. Although speech-language pathologists are trained to identify the presence of neurogenic impairments, they are less-prepared to assess the absence of organic impairment, as suspected in the case described in this report. The case of a 49-year-old African American woman with sudden onset of inability to speak or write is detailed. To the author's knowledge, this patient presents a unique case of an attempt to malinger aphasia along with a "pseudoforeign" accent, possibly following a conversion disorder. Multiple medical evaluations failed to find unequivocal evidence of neurological disorder in the presence of several identifiable stroke risk factors. Following two months of persisting speech complaints, the patient was referred to a speech-language pathologist for evaluation by her primary physician. A process-approach to assessment from initial referral, review of available records, assessment methods, and results of the clinician's attempts to modify the patient's communication differences are described. Objective findings and information obtained in the consultation are discussed in light of diagnostic criteria that may be employed for distinguishing among neurogenic disorders, psychogenic disorders such as conversion disorder, and malingering. The need for additional preparation of aphasiologists in diagnosis and management of such atypical disorders is emphasized.
Introduction
Malingerers and individuals with psychogenic disorders often present with symptoms resembling those observed in neurogenic disorders. Whereas psychogenic disorders may be defined as conditions with a psychological rather than a physiological basis, malingering refers to conscious, deliberate attempts to falsify or exaggerate symptoms of a physical or psychological nature motivated by external incentives (e.g., avoiding unpleasant work or military duty; or achieving financial gain; Hales, Yudofsky, & Talbott, 1999). Such "functional" conditions have received minimal attention in the aphasiology literature except for a handful of notable reports (Baumgartner & Duffy, 1997; Duffy, 2005; Helm-Estabrooks & Hotz, 1998; Sapir & Aronson, 1985, 1987, 1990). With these exceptions (largely focused on the areas of voice and stuttering), there is currently limited clinical direction available for practitioners in the area of neurogenic language disorders seeking to differentially diagnose and manage these conditions. In general, it is fair to say that speech-language pathologists are generally trained to diagnose the presence, not the absence of neurological communication disorders. It may be argued that there remains a substantial need for additional education in this area, as noted by Butcher, Elias, and Raven (1993).
Differential diagnosis of true neurologic disorders, psychogenic disorders, and malingering can be enigmatic. According to Dula and DeNaples (1995), the primary constellation of symptoms in psychogenic disorders may be difficult to distinguish from those of many neurogenic disorders. In addition, comorbidity of documented neurological disorders and psychogenic disorders is frequent - Marsden's (1986) analysis suggests that neurological conditions may exist in up to 60% of patients with psychogenic diagnoses; Maldonado and Spiegel (2000) note that frequency of concurrent diagnoses of neurogenic disorder and conversion disorder has ranged from 20% to 70% across studies. To further complicate the differential diagnostic landscape, malingering of neurocognitive dysfunction is also common (Rogers, 1997), both in the presence of a true neurogenic disorder (Bianchini, Greve, & Love, 2003; Ricker, 2004), and in combination with a psychogenic disorder (e.g., Barnard, Birch, & Wildey, 1990).
Duffy (2005) reports that psychogenic disorders were found in approximately 4.2% of patients with acquired speech-language disorders presenting at the Speech Pathology section at Mayo Clinic. Similarly, analysis of data reported by Lempert, Dieterich, Huppert, and Brandt (1990) suggests that 4% of individuals (17 of 405) eventually diagnosed with psychogenic disorders presented with speech, cognitive, or swallowing symptoms in their general medical sample. It is difficult to obtain figures on malingering, as malingerers present to a wide variety of health-related disciplines. Doubtless, a number successfully evade detection. Malingering is of concern in both hospitals and medical clinics treating neurogenic disorders, and patients attempting to malinger may present with speech, cognitive, language, and/or hearing disorders. For example, differential diagnosis of malingering and mild head injury has recently been of particular interest in the neuropsychology literature. A recent survey of members of the American Board of Clinical Neuropsychologists revealed that 39% of patients reportedly complaining of mild head injury were diagnosed as probable malingerers (Mittenberg, Patton, Canyock, & Condit, 2002).
"Functional" disorders have been estimated to represent approximately 4-5% of adult neurogenic caseloads. Although speech-language pathologists are trained to identify the presence of neurogenic impairments, they are less-prepared to assess the absence of organic impairment, as suspected in the case described in this report. The case of a 49-year-old African American woman with sudden onset of inability to speak or write is detailed. To the author's knowledge, this patient presents a unique case of an attempt to malinger aphasia along with a "pseudoforeign" accent, possibly following a conversion disorder. Multiple medical evaluations failed to find unequivocal evidence of neurological disorder in the presence of several identifiable stroke risk factors. Following two months of persisting speech complaints, the patient was referred to a speech-language pathologist for evaluation by her primary physician. A process-approach to assessment from initial referral, review of available records, assessment methods, and results of the clinician's attempts to modify the patient's communication differences are described. Objective findings and information obtained in the consultation are discussed in light of diagnostic criteria that may be employed for distinguishing among neurogenic disorders, psychogenic disorders such as conversion disorder, and malingering. The need for additional preparation of aphasiologists in diagnosis and management of such atypical disorders is emphasized.
Introduction
Malingerers and individuals with psychogenic disorders often present with symptoms resembling those observed in neurogenic disorders. Whereas psychogenic disorders may be defined as conditions with a psychological rather than a physiological basis, malingering refers to conscious, deliberate attempts to falsify or exaggerate symptoms of a physical or psychological nature motivated by external incentives (e.g., avoiding unpleasant work or military duty; or achieving financial gain; Hales, Yudofsky, & Talbott, 1999). Such "functional" conditions have received minimal attention in the aphasiology literature except for a handful of notable reports (Baumgartner & Duffy, 1997; Duffy, 2005; Helm-Estabrooks & Hotz, 1998; Sapir & Aronson, 1985, 1987, 1990). With these exceptions (largely focused on the areas of voice and stuttering), there is currently limited clinical direction available for practitioners in the area of neurogenic language disorders seeking to differentially diagnose and manage these conditions. In general, it is fair to say that speech-language pathologists are generally trained to diagnose the presence, not the absence of neurological communication disorders. It may be argued that there remains a substantial need for additional education in this area, as noted by Butcher, Elias, and Raven (1993).
Differential diagnosis of true neurologic disorders, psychogenic disorders, and malingering can be enigmatic. According to Dula and DeNaples (1995), the primary constellation of symptoms in psychogenic disorders may be difficult to distinguish from those of many neurogenic disorders. In addition, comorbidity of documented neurological disorders and psychogenic disorders is frequent - Marsden's (1986) analysis suggests that neurological conditions may exist in up to 60% of patients with psychogenic diagnoses; Maldonado and Spiegel (2000) note that frequency of concurrent diagnoses of neurogenic disorder and conversion disorder has ranged from 20% to 70% across studies. To further complicate the differential diagnostic landscape, malingering of neurocognitive dysfunction is also common (Rogers, 1997), both in the presence of a true neurogenic disorder (Bianchini, Greve, & Love, 2003; Ricker, 2004), and in combination with a psychogenic disorder (e.g., Barnard, Birch, & Wildey, 1990).
Duffy (2005) reports that psychogenic disorders were found in approximately 4.2% of patients with acquired speech-language disorders presenting at the Speech Pathology section at Mayo Clinic. Similarly, analysis of data reported by Lempert, Dieterich, Huppert, and Brandt (1990) suggests that 4% of individuals (17 of 405) eventually diagnosed with psychogenic disorders presented with speech, cognitive, or swallowing symptoms in their general medical sample. It is difficult to obtain figures on malingering, as malingerers present to a wide variety of health-related disciplines. Doubtless, a number successfully evade detection. Malingering is of concern in both hospitals and medical clinics treating neurogenic disorders, and patients attempting to malinger may present with speech, cognitive, language, and/or hearing disorders. For example, differential diagnosis of malingering and mild head injury has recently been of particular interest in the neuropsychology literature. A recent survey of members of the American Board of Clinical Neuropsychologists revealed that 39% of patients reportedly complaining of mild head injury were diagnosed as probable malingerers (Mittenberg, Patton, Canyock, & Condit, 2002).
