Cogniform Disorder &

Cogniform Condition

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

Malingering & Factitious Disorder

• DSM-IV-TR features of Malingering

• Intentional production of false or exaggerated symptoms, motivated by external incentives

1. Medicolegal context of presentation

2. Marked discrepancy between claimed disability and objective findings

3. Lack of cooperation during evaluation and treatment

4. Presence of antisocial personality

• DSM-IV-TR criteria for Factitious Disorder

A. Intentional production or feigning of psychological signs or symptoms

B. Motivation is to assume the sick role

C. External incentives for the behavior are absent

1. With predominant psychological, physical, or combined signs

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

Delis & Wetter, 2007Problems 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

Delis & Wetter, 2007• Cogniform Disorder:

• Cogniform Condition: excessive complaints that do not arise in "widespread areas of life"

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)

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

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

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