Review Question - QID 216701

This patient presents with witnessed convulsions that did not have an electrographic seizure correlate on video EEG, demands for an external benefit (paid time off work), and an acute worsening of symptoms when denied the external benefit, making malingering the most likely cause.

In malingering, patients intentionally fake symptoms to deceive physicians for an external benefit, such as worker’s compensation, avoiding criminal responsibility, or obtaining drugs. The key differentiating feature of malingering from factitious disorder is the presence of an external benefit or reward. In factitious disorder, patients also intentionally fake symptoms but do so for an internal reward (i.e., assuming the sick role). The key differentiating feature of malingering and factitious disorders from somatic symptom disorder is intentionality; patients with somatic symptom disorder typically have physical symptoms that cause significant distress but are unintentionally produced.

Bass and Halligan discuss the challenges and nuances of diagnosing factitious disorders and malingering. They emphasize the importance of a comprehensive and team-based approach in the diagnosis and management of these disorders. Alsaadi and Marquez review the presentation of psychogenic non-epileptic seizure disorder as well as its treatment, including psychiatric care. Bowman and Markand discuss the epidemiology of pseudoseizures, including the high correlation with adult and child trauma.

Incorrect Answers:
Answer 1: Alcohol withdrawal seizure would be unlikely in this patient given that her last drink was 4 weeks ago. Alcohol withdrawal seizures usually present within 48 hours of the last drink in patients with alcohol use disorder.

Answer 2: Epilepsy can present with generalized convulsions but seizures would be unlikely in this patient who has normal brain activity on EEG during a witnessed episode. Additionally, patients with epilepsy typically have postictal symptoms, such as weakness and/or aphasia.

Answer 3: Factitious disorder would also present with intentionally falsified symptoms, but there cannot be the presence of external benefit or reward. This patient is seeking external benefit in the form of paid medical leave from work.

Answer 5: Psychogenic non-epileptic seizure disorder would also present with normal brain activity on EEG during a witnessed episode, but is typically non-intentional. While patients with this disorder may ask for time off work because their symptoms are real, external gain is not a central tenet of this condition. For example, an acute worsening of symptoms after an external benefit is denied would not be typical. Malingering is more likely in this patient who is aggressively seeking external benefit.

Bullet Summary:
Malingering occurs when patients intentionally falsify symptoms to deceive physicians for external benefit or reward.