Cogniform Disorder & Cogniform Condition

1. Cogniform Disorder & Cogniform Condition

2. Where to put "Excessive" Cognitive Symptoms? • Somatization: requires pain, GI, sexual, and pseudoneurologic symptoms • Undifferentiated somatoform: requires physical complaints • Conversion: requires deficits in voluntary motor or sensory functions • Pain Disorder: requires only excessive pain symptoms • Dissociative Amnesia: requires one specific type of cognitive problem, memory loss • Dissociative Fugue: requires memory loss plus travel away from home • Dissociative Identity Disorder: intended as a stand-in for multiple personality disorder

3. Malingering & Factitious Disorder • DSM-IV-TR features of Malingering • Intentional production of false or exaggerated symptoms, motivated by external incentives • Medicolegal context of presentation • Marked discrepancy between claimed disability and objective findings • Lack of cooperation during evaluation and treatment • Presence of antisocial personality • DSM-IV-TR criteria for Factitious Disorder • Intentional production or feigning of psychological signs or symptoms • Motivation is to assume the sick role • External incentives for the behavior are absent • With predominant psychological, physical, or combined signs

4. Slick, Sherman, & Iverson, 1999 • Malingered Neurocognitive Disorder requires assessment of two facets of presentation: presence or absence of external incentive, and presence or absence of objectively verifiable feigning • Levels of MND: • Definite Malingering: individuals with motive to feign and objective evidence of intentional poor performance (e.g., below-chance performance on forced-choice tests) • Probable Malingering: individuals with incentive to feign, but who did not perform below chance on forced-choice tests • Possible Malingering: individuals with incentive to "underperform" who provide discrepant results on self-report

5. Delis & Wetter, 2007 Problems with diagnosing "excessive cognitive symptoms" • Specificity of symptoms • Existing diagnostic entities that categorize "excessive" symptoms require specific symptom presentations (e.g., pain disorder) • "Cognitive"-specific entities (dissociative amnesia and fugue) are overly specific • Intentionality of symptoms • Malingering and Factitious Disorder require a determination that symptoms are produced intentionally • Other disorders, such as somatoform disorder, require non-intentional symptom production • It is impossible to make these determinations based on objective data • Determining external incentive • Presence of external incentive is often difficult to determine • External incentive may be "comorbid" with a sick role

6. Delis & Wetter, 2007 • Cogniform Disorder: • Cogniform Condition: excessive complaints that do not arise in "widespread areas of life"

7. Delis & Wetter, 2007 • Specify: • With evidence of interpersonal incentive (e.g., "sick role") • With evidence of external incentive (e.g., legal proceedings) • Not otherwise specified • Not intended as a diagnosis for: • The "worried well" (because they generally perform within normal limits for age) • Individuals with anxiety or mood disorder (because their complaints are consistent with their disorder)

8. Commentary • Larrabee, 2007 • Clarify cogniform disorder and condition as variants of somatoform disorder • Clarify that entities apply to "atypical," not just "excessive," presentations • Application to post-concussive syndrome • Mittenberg et al. (1992): selective attentional mechanism for non-intentional "production" of symptoms • Putnam & Millis (1994): related to characterologic "proneness" to misattribution of symptoms • Suhr & Gunstahd (2002): "diagnosis threat" serves as a maintenance factor; students with mTBI performed more poorly when examination was related to brain injury than when not

9. Commentary • Binder, 2007 • Delis & Wetter criteria are "a starting point for debate," not a final list • Problems: • Modifier "proposed" is often forgotten rather than tested (as with Slick et al. malingering levels) • Criteria are imperfect: e.g., "inconsistent pattern of results" criterion relies on assumption that multiple tests of the same construct are highly correlated, which they often are not • Only two of these imperfect criteria are required • Debate as to whether significantly below-chance performance is "proof" of malingering

10. Commentary • Boone, 2007 • Unclear whether forced-choice paradigms can be unequivocally used to detect malingering • Originally designed to detect conversion • Overlap between malingering and "conversion" as measured by forced-choice or personality tests (e.g., MMPI-2) • Subgroups of disorder entities presumably subsumed under cogniform label; e.g., distinction between "hypochondriacal" and converting patients • Delis & Wetter propose that malingering and adoption of a "sick role" can co-occur; however this obviates the usefulness of surveillance in determining malingering • Reduces the Slick et al. (1999) reliance on effort indicators for determining malingering