ADHD malingering testing

[Scorcher31]

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Bringing back one of whoppers old posts:

"It's not uncommon for someone to fall in that unfortunate zone where they can look like they have everything when in fact they only have one disorder..

E.g. person has problems sleeping, is easily angered, abuses drugs, feels keyed up, has difficulty concentrating, has low self esteem which may or may not be related to years of poor academic performance. Just what the heck is that?"

Bipolar, Borderline, ADHD, Anxiety, Malingering? Please shake the magic 8 ball and ask again.

Adult patient gives ADHD sx and story, but no way to get any real collateral. Already tried on non stimulant. Patient already on a lot of other scheduled meds (not from me). I would really like to refer for neuropsych testing but no access. I have some reasons to be skeptical, but would like something more objective. Any reccomended tests I could do myself to try and weed out malingering from ADHD? Looking for clinical pearls, quasi validated written testing (hopefully free). I would love to use TOVA, but really can't do anything computerized until I have my own office.

 

[loveoforganic2]

Assuming it isn't malingering, couldn't it be useful to treat any one of the current problems with pharmacotherapy/psychotherapy and hope to break the cycle that appears to be going on? Is it necessary to get to the underlying etiology before doing a month trial of stimulant and seeing how things improve (or don't)?

 

[Scorcher31]

Assuming it isn't malingering, couldn't it be useful to treat any one of the current problems with pharmacotherapy/psychotherapy and hope to break the cycle that appears to be going on? Is it necessary to get to the underlying etiology before doing a month trial of stimulant and seeing how things improve (or don't)?

Thats exactly what Im trying to do. Treat somewhere else in the cycle and hope everything gets better. The etiology is very muddy and is even more complicated than whoppers description. My gut says if I give the person the stimulants they want everything will be "better". The question really is malingering vs ADHD. If I'm going to say no eventually, I'd like something quasi objective to present to the pt.

 

[vistaril]

Bringing back one of whoppers old posts:

"It's not uncommon for someone to fall in that unfortunate zone where they can look like they have everything when in fact they only have one disorder..

E.g. person has problems sleeping, is easily angered, abuses drugs, feels keyed up, has difficulty concentrating, has low self esteem which may or may not be related to years of poor academic performance. Just what the heck is that?"

Bipolar, Borderline, ADHD, Anxiety, Malingering? Please shake the magic 8 ball and ask again.

Adult patient gives ADHD sx and story, but no way to get any real collateral. Already tried on non stimulant. Patient already on a lot of other scheduled meds (not from me). I would really like to refer for neuropsych testing but no access. I have some reasons to be skeptical, but would like something more objective. Any reccomended tests I could do myself to try and weed out malingering from ADHD? Looking for clinical pearls, quasi validated written testing (hopefully free). I would love to use TOVA, but really can't do anything computerized until I have my own office.

good question, and it's something a lot of outpt psychiatrists in many settings deal with every week. I think it's important to ask yourself this question- suppose you do the NP testing or have some more objective method(which is questionable to begin with) to 'prove' they don't have adhd....then what? If you're going to tell the pt "well this test proves you don't have adhd and therefore you are not going to recieve a stimulant from me", what's the point? You just spent a lot of money to do something that you could have done anyways by just telling the pt before the NP testing or some other form of testing.....

When people ask questions like this, I think most of the time they are pretty sure the person doesn't have adult ADHD. So if the testing comes back which suggests adult ADHD, are you then going to believe that over your clinical judgement? I'm not familar with some of the more sophisticated testing that neuropsychologists use at the VA to malingering in disability claims, but I do know that for typical NP testing it is very easy for non-ADHD patients to look like they have adhd. It is also very possible for some very high functioning adhd patients to not fall into an adhd category.

But basically, what are are you hoping to gain from the test? If the testing comes back and says the pt doesn't have adhd, do you honestly think the patient is going to say "huh, that's a relief. Now we can try other medications that aren't stimulants"....of course not. He's going to do the exact same thing if you had saved the 500 bucks(or whatever) and just told him you don't believe he has adhd and aren't going to give him stimulants- go to someone else who will give him stimulants.

 

[Scorcher31]

good question, and it's something a lot of outpt psychiatrists in many settings deal with every week. I think it's important to ask yourself this question- suppose you do the NP testing or have some more objective method(which is questionable to begin with) to 'prove' they don't have adhd....then what? If you're going to tell the pt "well this test proves you don't have adhd and therefore you are not going to recieve a stimulant from me", what's the point? You just spent a lot of money to do something that you could have done anyways by just telling the pt before the NP testing or some other form of testing.....

When people ask questions like this, I think most of the time they are pretty sure the person doesn't have adult ADHD. So if the testing comes back which suggests adult ADHD, are you then going to believe that over your clinical judgement? I'm not familar with some of the more sophisticated testing that neuropsychologists use at the VA to malingering in disability claims, but I do know that for typical NP testing it is very easy for non-ADHD patients to look like they have adhd. It is also very possible for some very high functioning adhd patients to not fall into an adhd category.

But basically, what are are you hoping to gain from the test? If the testing comes back and says the pt doesn't have adhd, do you honestly think the patient is going to say "huh, that's a relief. Now we can try other medications that aren't stimulants"....of course not. He's going to do the exact same thing if you had saved the 500 bucks(or whatever) and just told him you don't believe he has adhd and aren't going to give him stimulants- go to someone else who will give him stimulants.

Thats a good point Vistaril and to be honest I have to think it over. I can't send this person for neuropsych testing anyways. I was looking for something I can do on my own in a regular 30 minute visit. Maybe something forsenics people know of like the TOVA, but minus the computer. Because I'm a resident I don't charge differently for scales and testing if I do it on my own. It just takes up their appointment time. Generally when I tell someone Im more than happy to keep treating you, but Im not going to be able to give you "x" medication they still continue to see me. It's an artifact of the one clinic I'm at. In a cash only private practice the patient would probably be gone.

I'm leaning toward malingering but it's like 70/30. I think if I had one or two tests that take into account fake score ranges for malingering or what not I may at least reconsider stimulant use. If I had more evidence for malingering, the pt would without a doubt get my "Im happy to see you but, but your not getting X and here is why speech". Either way though, I have to think it over some more and obviously my statements above are simplified. I appreciate the feedback from you guys.

 

[vistaril]

Thats a good point Vistaril and to be honest I have to think it over. I can't send this person for neuropsych testing anyways. I was looking for something I can do on my own in a regular 30 minute visit. Maybe something forsenics people know of like the TOVA, but minus the computer. Because I'm a resident I don't charge differently for scales and testing if I do it on my own. It just takes up their appointment time. Generally when I tell someone Im more than happy to keep treating you, but Im not going to be able to give you "x" medication they still continue to see me. It's an artifact of the one clinic I'm at. In a cash only private practice the patient would probably be gone.

I'm leaning toward malingering but it's like 70/30. I think if I had one or two tests that take into account fake score ranges for malingering or what not I may reconsider stimulant use. If I had more evidence for malingering, he would without a doubt get my "Im happy to see you but, but your not getting X and here is why speech".

well yeah if you really feel that such testing would help you get a better sense of whether the pt has ADHD or not, I suppose it may be worthwhile.

In general, I just have little use for ordering a test just to be able to defend to the patient a clinical decision I want to make. I just do what I want to do. in your explanation above it seems to be there is more to it than that though.

the larger issue, of course, is just what the heck is adult ADHD, how common is it really, and most importantly what sort of inattiveness spectrum exists in general. Evaluating all these 26 year olds who come into clinic seeking stimulants for adhd as if we are trying to evaluate them for sickle cell disease or something is absurd.....I'm not neccessarily saying it's wrong or right. I just find the idea of deciding whether to give a young adult a stimulant based on the question 'does he have adhd' as if it is a yes/no answer to be silly and not real.

 

[Scorcher31]

the larger issue, of course, is just what the heck is adult ADHD, how common is it really, and most importantly what sort of inattiveness spectrum exists in general. Evaluating all these 26 year olds who come into clinic seeking stimulants for adhd as if we are trying to evaluate them for sickle cell disease or something is absurd.....I'm not neccessarily saying it's wrong or right. I just find the idea of deciding whether to give a young adult a stimulant based on the question 'does he have adhd' as if it is a yes/no answer to be silly and not real.

Well said!

 

[nitemagi]

I stray a little from the pack.

I don't treat ADHD with primary approach of stimulants. Mostly because I work with such a high addiction population that it's usually not a good idea. Plus the lack of good history most of the time.

1. Rule out secondary causes of inattention -- conditions that may look like ADHD but aren't. Namely anxiety (GAD, PTSD, etc), depression, dissociative conditions. Treat those and see what sx's are left.

2. Consider the possibility of just conditioned inattention . Are they able to try other approaches (CBT, etc). With this is also the natural avoidance of painful or difficult experiences, including doing work. Many come in not wanting to work on that which they're not interested in. In which case the approach may be to focus on their motivation, not attention.

3. Once worked through on all that, if having sufficient records, then start with a non-stimulant (WBT, strattera).

90% of the people that come into my office for attention problems have 3 other conditions (drugs, alcohol, depression, dissociative states, etc), that once treated they never even bring up wanting anything for ADHD again.

And I tell them up front that if they have a history of drug use, stimulants are not an option. Though I do distinguish different subtypes of drug dependence (based on some work by Barry Everitt). I'm not sure I buy that stimulants in ADHD kids prevent drug use later in life, as so much of the ADHD literature is pharma skewed and funded, and I frankly question everything that comes out of Biedermann's lab. In the end, in my population the risks outweigh the benefits of using stimulants with most patients.

 

[vistaril]

I stray a little from the pack.

I don't treat ADHD with primary approach of stimulants. Mostly because I work with such a high addiction population that it's usually not a good idea. Plus the lack of good history most of the time.

1. Rule out secondary causes of inattention -- conditions that may look like ADHD but aren't. Namely anxiety (GAD, PTSD, etc), depression, dissociative conditions. Treat those and see what sx's are left.

2. Consider the possibility of just conditioned inattention . Are they able to try other approaches (CBT, etc). With this is also the natural avoidance of painful or difficult experiences, including doing work. Many come in not wanting to work on that which they're not interested in. In which case the approach may be to focus on their motivation, not attention.

3. Once worked through on all that, if having sufficient records, then start with a non-stimulant (WBT, strattera).

90% of the people that come into my office for attention problems have 3 other conditions (drugs, alcohol, depression, dissociative states, etc), that once treated they never even bring up wanting anything for ADHD again.

And I tell them up front that if they have a history of drug use, stimulants are not an option. Though I do distinguish different subtypes of drug dependence (based on some work by Barry Everitt). I'm not sure I buy that stimulants in ADHD kids prevent drug use later in life, as so much of the ADHD literature is pharma skewed and funded, and I frankly question everything that comes out of Biedermann's lab. In the end, in my population the risks outweigh the benefits of using stimulants with most patients.

what's the payer source for this particular outpt population you are referring to?

If I take community mental health position, I could see myself almost *never* using stimulants. If the patients don't like it they are free to pay out of pocket for another provider.

 

[Therapist4Chnge]

Adult patient gives ADHD sx and story, but no way to get any real collateral. Already tried on non stimulant. Patient already on a lot of other scheduled meds (not from me). I would really like to refer for neuropsych testing but no access. I have some reasons to be skeptical, but would like something more objective. Any reccomended tests I could do myself to try and weed out malingering from ADHD? Looking for clinical pearls, quasi validated written testing (hopefully free). I would love to use TOVA, but really can't do anything computerized until I have my own office.

Not ethically nor effectively.

When people ask questions like this, I think most of the time they are pretty sure the person doesn't have adult ADHD. So if the testing comes back which suggests adult ADHD, are you then going to believe that over your clinical judgement? I'm not familar with some of the more sophisticated testing that neuropsychologists use at the VA to malingering in disability claims, but I do know that for typical NP testing it is very easy for non-ADHD patients to look like they have adhd. It is also very possible for some very high functioning adhd patients to not fall into an adhd category.

So you trust your clinical judgment over psychometric testing, but aren't as familiar with psychometric testing, yet know that it is easy to fake ADHD when using psychometric testing?

 

[vistaril]

Not ethically nor effectively.



So you trust your clinical judgment over psychometric testing, but aren't as familiar with psychometric testing, yet know that it is easy to fake ADHD when using psychometric testing?

I'm sorta familar with the psychometric testing that I would have access to, or one could reasonably obtain in the community. I am certainly not an expert on the matter.

But ADHD is a clinical diagnosis.

 

[AcronymAllergy]

One thing I'll mention--even if a psychological or neuropsychological evaluation indicates that there's symptom exaggeration and/or questionable effort, that doesn't mean the patient doesn't have ADHD. After all, it's quite possible to have the disorder, yet exaggerate to the point that the examiner can't draw any definitive conclusions from the data other than that the person is exaggerating (although the practitioner should likely be willing to offer their informed opinion on the matter).

Vistaril makes a good point, though, that neuropsych testing isn't going to diagnose ADHD, as it's a clinical diagnosis (although there's research to indicate that practitioners are in fact relatively horrible at detecting poor effort/symptom exaggeration via clinical judgment alone). What it can do is a) allow the practitioner enough time with the patient to gather a thorough interview along with compiling information from multiple sources, and b) potentially indicate the location and severity of any cognitive deficits that do exist, which can be used to help inform treatment.

Nitemagi makes an excellent point, though--ruling out other conditions that can mimic and/or cause attention problems/ADHD is crucial, particularly when those conditions are more common (the current estimates for the prevalence of ADHD in adults typically indicate 4-5%, with some level of symptoms persisting from childhood into adulthood in anywhere from 30-70% of individuals).

 

[BobA]

Well said!

I think ADHD does exist, and some people benefit from stimulants. However, there's also research that shows stimulants help in some cognitive domains while impairing others (some social) domains.

I'll admit this is unconventional, but I think some cases of what we call adult ADHD are really part of an exercise deficiency syndrome brought on by modern living. We evolved to get massive amounts of exercise compared to how live now, and probably suffer now from our lack of exercise now.

 

[forenspsych]

What if there was a quick, $5 test you could do in your office, perhaps from a computer or iPad, to identify people who are exaggerating? No such a test exists at present, at least not with decent sensitivity. But if there was one, would you use it? And what would you do with it if there is a fail? What would be an acceptable false positive rate?

 

[hamstergang]

exercise deficiency syndrome

😱 Doctor, is that serious? Isn't there something you could do to help save me?