Forensic assessment of somatoform and functional neurological disorders 2024 Datta and Blum

[Andy]

Abstract

Functional neurological disorders (FND) and somatization are common in clinical practice and medicolegal settings. These conditions are frequently disabling and, if arising following an accident, may lead to claims for legal compensation or occupational disability (such as social security disability insurance). However, distinguishing FND and somatization from symptoms that are intentionally produced (i.e., malingered or factitious) may pose a major forensic psychiatric challenge. In this article, we describe how somatoform disorders and FND lie along a spectrum of abnormal illness-related behaviors, including factitious disorder, compensation neurosis, and malingering. We provide a systematic approach to the forensic assessment of FND and conclude by describing common litigation scenarios in which FND may be at issue. Forensic testimony may play an important role in the resolution of such cases.

Paywall, https://onlinelibrary.wiley.com/doi/10.1002/bsl.2651

 

[NelliePledge]

Ugh. Can’t bring myself to click this link. @dave30th may be interested?

 

[rvallee]

Almost annoyed that I can't read it, because wow are the so many layers of wrong. Starting with the word forensic, which is the investigation of a crime. And of course the fact that most forensic "science" has been revealed to be pseudoscience of almost zero validity. Their wild claims of being able to tell the difference are just as absurd as the old lie of 'lie detectors'. They may as well be judges who claim to be able to tell when a witness lies, that's basically the same thing.

They speak of distinguishing (interesting that they don't use differentiating) FND and "somatization" (which obviously means they are the same thing) from symptoms that are intentionally produced, but of course there is no such things as symptoms that are intentionally produced, especially as they mean here factitious. There are only symptoms that can be factitiously reported, but obviously not produced. Are they factitious, or not? If they're internally produced, they can't be factitious. Of course they must mean factitiously reported here, but since the belief system is 'disordered' internal conversion of symptoms out of distress, or whatever, and of course they can't tell the difference in any case, then that's all a big bag of made-up junk, and it's not the patients making it up.

It's odd that they speak of compensation only in the case of accidents, when that's not the only case. But of course if this is driven by insurers, and you can bet that it is, then of course they'll frame it that way. The authors declare no conflict of interest. Right. I bet they feel that way. Just like the MDs who shilled for the tobacco industry. Some of them actually believed it sincerely. I'm sure to their grave. Their large grave with a big expensive tombstone, bought with blood money.

And of course they can't really help but slip the mask, and place factitious disorder on the spectrum of FND/somatization, which literally all means the same thing: I, MD, cannot confirm your symptoms as part of a diagnosis that I, and my peers in general, accept as valid. So as usual, this is diagnosis based on the beliefs of the MD, not anything to do with what is happening to the patients.

But of course they'll still pretend that factitious disorder, which is just a fancy shmancy term for fraud, being part of the spectrum of FND doesn't mean that FND is factitious. No, of course not. They're not calling you a prostitute, they're merely saying that you take money in exchange for sex with strangers. Totally different.

It's really scary how deep and absurd this is. There is not even anything else close to it in any other profession. The closest would actually be forensic science, in criminology, and that was widely accepted as being iffy soft science at best, now mostly debunked, although quite a few lives have been ruined by assertions otherwise.

 

[SNT Gatchaman]

A few quotes —

Clinical Context

Although structural magnetic resonance imaging is normal in individuals with FND (unless the person is affected by another medical condition), other neuroimaging techniques have revealed brain changes in these individuals.

Participants with functional movement disorders show an abnormal reduction in the activation of the right temporoparietal junction, a structure known to play a role in the perception of self‐agency—that is, the ability to attribute one's own actions to oneself. These findings could partly explain why individuals perceive functional neurological symptoms to be involuntary or outside their conscious control. However, whether these findings reflect a cause of functional symptoms or a consequence of chronic illness remains unclear.

Related behaviors

Somatization is the tendency to experience and communicate psychological distress via bodily symptoms.

Functional somatic syndromes include irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and persistent post‐concussive syndrome. Individuals with FND may have one of these conditions or a more diffuse somatoform disorder, which should be identified and diagnosed.

In practice, malingering, somatization, conversion, factitious disorder, and compensation neurosis overlap significantly. Factitious disorder does not preclude external incentives for behavior. This is seen, for example, in the phenomenon of “Munchausen by Internet,” in which patients solicit money, gifts, and sympathy for their factitious illnesses via online forums

Approach to the forensic evaluation

In addition, the examiner should evaluate for the presence of associated features that commonly accompany FND, such as headaches, fatigue, and memory problems (“brain fog”). In many cases, depression, panic disorder, generalized anxiety disorder, post‐traumatic stress disorder, and personality disorders (such as borderline, dependent, histrionic, and narcissistic personality) may accompany FND. As previously noted, FND may be part of a broader diathesis to somatization, including symptoms of persistent postconcussive syndrome, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, chronic pelvic pain, and tension headaches. Others still may have a distorted perception of their illness, believing that their symptoms were caused by toxic mold exposure, chronic Lyme disease, or electromagnetic or multiple chemical sensitivities.

Predisposing factors for FND include a history of emotional, physical, and sexual abuse, as well as neglect. Additionally, the examiner should identify if the examinee had any close contacts or relatives with neurological or other serious medical symptoms that may have provided an “illness model.” Alexithymia—the inability to identify and describe emotions—is common in those who develop FND; examinees may describe an early aversive environment in which they avoided experiencing strong emotions. There may be other family members with somatoform symptoms or who work in healthcare professions.

Precipitating factors may include [...] Consistent with psychological models of FND, the development of functional symptoms may provide an “escape” from these stressors. In a recent systematic review family problems, relationship problems, and work‐related stressors were found to be the most common life events preceding FND. Work‐related events may be particularly relevant to workers' compensation, as well as harassment and discrimination claims. To identify stressful life events, forensic evaluators may utilize a structured interview approach, such as the Life Events Checklist for DSM‐5 Interview Version, to enhance the probability of identifying potentially relevant life events.

Perpetuating factors include a refusal to accept that one's symptoms have a functional etiology, reinforcement from well‐meaning loved ones, escape from an aversive work environment, and ongoing disability payments or litigation.

Psychological testing

Neuropsychological testing may be indicated for claimants presenting with cognitive symptoms. The California Verbal Learning Test and the Test of Memory Malingering both contain indicators of insufficient effort; repeated failures on these measures are generally inconsistent with FND.

Personal injury litigation

The prognosis for FND is generally considered poor. Although treating clinicians often emphasize that FND is a treatable condition that can and does improve, even without treatment, the literature suggests a lack of improvement in symptom burden during follow‐up, along with low rates of employment and poor quality of life.

Medical malpractice

Approximately 4% of patients diagnosed with FND are later found to have an organic disease that adequately explains their original symptoms. When a misdiagnosis of FND leads to a delay in treatment, especially in emergency settings, it may result in litigation.