PhD/PsyD confusing adult eval: malingering? Munchausen? weird trauma-related sequelae? so out of my lane

[singasongofjoy]

tl,dr: Adult client has trauma history, family history SMI/legal trouble, presents for ASD eval. EMR is excruciatingly long, discovered many inconsistencies and omissions even of recent events in client's inital interview, further digging makes me feel something is "off" / suspect; is client highly medical seeking even when unnecessary and what to do about that? Don't trust patient report, concerned about overutilization of healthcare and corresponding lack of sufficiently addressing mental health though client states they are attending weekly therapy. Plan to ask again re: consent to speak with therapist, try to get parent on video so can confirm is not client providing the info under pretense. But what else- WWYD? And what to make of CNT testing in general?

I'll be careful not to provide too many details, but gist of it is: I do IDD/ASD evaluations, a lot of adolescents and adults. I do not have any specific training in long-term sequelae of extended adverse circumstances/repeated trauma beyond the more obvious behavioral /cog overlaps with ASD in some cases/ages

Adult client comes in, reveals history of abuse at various times into adulthood, perfunctory care at best during childhood yet client managed to do well in school, in gifted program purportedly. Client also reports strong family history of ASD though upon further digging the validity of that is suspect either due to timelines in other records not lining up, diagnoses given without any ASD specfic testing or accounting for other factors, but that's not the point. Client's medical record is eons long. lots of diagnoses, lots of meds (psychiatric and other), lots of nonspecific symptoms complaints. In the month since interview there are about 30 entries to sift through covering probably about 6 appointments, 3 specialties plus PCP, ER, UC. Reading them there is so much inconsistency in what is reported to whom, and contradictory to some of the info shared w us during interview (these were jsut a few weeks apart) Also no comments about unusual behavior, interaction, etc. in the many ROS and MSEs.

Missed our appointment because, client says, was advised to go to ER by her PCP due to fever. However, notes from another specialty appt from earlier today indicates feels "better than in months". Deep dives down med record show HUGE things that were not mentioned during the interview including recent family legal troubles, violence; medications, previous diagnoses, different number of kids reported within the same year, fairly certain client completed measures meant to be completed by parent, says is in therapy but not part of what we can access in care everywhere on our platform so idk if that's true or not and plan to get consent for that, but.... the bulk of the sketchiness did not come to light until after the initial interview and received report from another (very recent) recent evaluation.

Client has more entries in EMR than I can recall ever seeing but also at least half client's care has been at places where we don't have access to the records/don't participate in "care everywhere" record sharing so I"m only seeing a fraction.. There are many "textbook" complaints (medical conditions were referred to as a "special interest" on client's hisotry form to us) Many inconsistencies in reporting over time when sifting through medical records, so I wondered initially about memory issues, ID?. Yet very recent neuropsych testing - the only full report we were able to get - shows average to above average IQ (all domains), memory (short and long term, verbal and visual)-- but this is all based on the CNT - Computerized Neuropsych Test, with which I'm wholly unfamiliar. No other standalone cog/memory tests administered it seems. This same measure noted emotional IQ as average (how is that tested??) How much stock should i put in that testing? No measures of malingering were given but the validity scales were valid, and I'm reasoning that while you can "fake" bad, you can't "fake" good so her abilities must be at least grossly intact, right? So assuming it's reasonable to conclude her memory isn't completely disorganized, why is her reporting so full of holes, inconsistent, etc.? Even for very recent events, which came up during the other interview? self-report measure for psychopathology was moderate to severe on everything, so basically useless. FWIW there are no indicators in any of the records / ROS /MSE that sound like ASD or mention the types of bx observed in interview. Client was seen by a colleague earlier this week (also telehealth, and focused on a different family member) and they said the same.

Here's my concern. client is in poor health presumably given the very high number of appointments, ER visits etc. Client states there are several children in the home and homeschools them (ranges K-12th grade) with a variety of reported DD/LDs. Home observed via telehealth by another colleague on a different day seen to be v. chaoticin general. I don't have any concrete reason to think the kids aren't sufficiently cared for; I haven't even met any of them. It just... something feels off about the big picture and it would be nice to have some sort of secondary assurance someone is checking in. Other than listing on hx form and one clarifying question from interviewer, no mention of the kids whatsoever during the rest of the 2 hr interview, several kids were supposedly home but didn't hear a peep from them the whole time which seems highly atypical IME. There is a partner but idk how present they are or really anything about them. As far as I can tell client's bx does not seem med-seeking and not like eval with me would help in that anyway. Possible history of starting an online fundraiser in the recent past for a diagnosis that i don't see in the med hx.

do (large AMCs) typically have teams that case-manage things like this where a patient has so many different diagnoses and visits? client msut have at least 2 interactions with healthcare a week, sometimes considerably more. I thought about reaching out to insurance (medicaid) in client's area to see what they might offer to this end and see if I could get client to buy into that, but this client recently moved to our area from another area of the state and they're managed by separate MCOs... worth it to follow up with new one to see what's available for such general types of situations (non-patient-specific)?

Game plan: f/u for consent to speak with therapist, prescribing provider of psych meds (psych NP?) which was not returned at initial ask; try to get parent on telehealth / video to ask questions about early childhood (video to confirm isn't patient). nonjudgmentally ask patient about any big life happenings/stressors that there wasn't time to mention during the initial interview, see if any of this comes up. But... what else?

I'm not even concerned about the question of ASD or not honestly. More like what else is this either with or without ASD and what kind of oversight of client's medical care could be facilitated to ensure best treatment / decrease chances of overutilization or adverse interaction (patient forgot to mention a few meds)? If nothing else the frequent ER visits over what are likely not true emergencies/emergent issues is painful to see. I just imagine this client going from provider to provider and maybe moving on when someone starts to 'catch on' but then again maybe I'm just pre-judging too harshly. Regardless most people aren't going to have the time/resources to go on such a deep dive as I/we (seeing this with another psychologist due to the complexity; frankly I've already spent way too much time on this one) and I'm concerned that consequently some other providers might not think to consider whether there's a more comprehensive overlay here to be addressed beyond whatever the presenting physical / somatic complaint is.. to give the benefit of the doubt to this client I'm hypothesizing maybe hyperfocus on health, somatic sx may be related to trauma, maybe even ASD- doesn't seem likely, but I'm always willing to be surprised.... and should be better addressed by good therapy (which is supposedly happening, but not sure if it is or of the quality). So.... WWYD in addition to the above? And is the CNT assessment worth anything?

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[WisNeuro]

I do not know what the CNT is. I sometimes see Computerized Neurocognitive Tests (CNT) used as an umbrella term in research to categorize things like CogState or CNS vital signs, but I have never heard of or seen a battery called the CNT.

 

[singasongofjoy]

I do not know what the CNT is. I sometimes see Computerized Neurocognitive Tests (CNT) used as an umbrella term in research to categorize things like CogState or CNS vital signs, but I have never heard of or seen a battery called the CNT.

I tried googling it and came to the same conclusion that it's just an umbrella term, yet I'm pretty sure I didn't see anything more specific in the report even though subscales, scores etc were reported - edit - nope, nothing more specific named in the report. Results include general mental ability index with subtests includign vocab, visual reasoning, emotional intelligence, math fluency for addition and multiplication and results in a VIMSAT score but not defined what VIMSAT means. I'm getting sucked too far down the rabbit hole on this case- time to put this file back in the drawer and move on to something more in my lane for the day!

 

[WisNeuro]

I tried googling it and came to the same conclusion that it's just an umbrella term, yet I'm pretty sure I didn't see anything more specific in the report even though subscales, scores etc were reported - edit - nope, nothing more specific named in the report. Results include general mental ability index with subtests includign vocab, visual reasoning, emotional intelligence, math fluency for addition and multiplication and results in a VIMSAT score but not defined what VIMSAT means. I'm getting sucked too far down the rabbit hole on this case- time to put this file back in the drawer and move on to something more in my lane for the day!

If "VimSat" is with the math fluency stuff, it may be a typo for "VisMat" or visual matching from the WJ sets. Either way, whoever wrote the report seems like a hack. The tests used should be generally laid out somewhere.

 

[WisNeuro]

Found something that may relate

http://wapbowen.oss-cn-hongkong.aliyuncs.com/PubFiles/FPBS10035-20150629-152926-3502-40911.pdf?Expires=1623435199&OSSAccessKeyId=UVhDXw2HqaJ5Mj2n&Signature=5WgvIVoh6acVmgZfPDx57EosMCQ%3D

Still nothing I have seen used clinically in my entire training and career time.

 

[borne_before]

Personally, I'd just refer out to an adult neuropsychologist. I'd explain that it would be hard/impossible to diagnose autism based on the age of the patient. Furthermore, there may be low utility in a diagnosis (what's it gonna do, open up ABA for them).

The legal stuff, the inconsistencies, etc., all of that is above your pay grade.

This smells the patient has other uses for this report/diagnosis. I'd distance myself as fast as possible.

 

[AlmostaPhD]

I would agree that you should refer to someone for a more comprehensive eval (maybe neuropsych but also just general psych). If insurance is an issue is there a training clinic in the area that might be willing to see them? If there are recent records with avg/above avg IQ and no childhood hx of ASD sxs then it's unlikely to be ID/ASD and therefore not your jurisdiction. I also get your concern about the home environment but suspect you don't have enough info to do anything yet and depending on where you are wraparound-type services may be hard to get. Likely helpful, but there may not be anything for you to refer to.

Complex assessments are my jam so feel free to PM me if you want to talk specifics .

 

[ClinicalABA]

Even if you could somehow observe enough ASD symptoms, you're going to have a hard time establishing that they were present in early developmental period if you're not trusting of self report. I'd refer out to have the other stuff identified/ addressed first anyways, as that's more likely to lead to an effective treatment plan than an ASD dx, given client age and all the other issues you describe above.

Good on you for even doing ASD evals with adults. I top out at 4-5 years old, and typically like to stay in that 18-30 month range for a first time eval.

 

[futureapppsy2]

Personally, I'd just refer out to an adult neuropsychologist. I'd explain that it would be hard/impossible to diagnose autism based on the age of the patient. Furthermore, there may be low utility in a diagnosis (what's it gonna do, open up ABA for them).

The legal stuff, the inconsistencies, etc., all of that is above your pay grade.

This smells the patient has other uses for this report/diagnosis. I'd distance myself as fast as possible.

It is possible to dx adults and adolescents with ASD--parent report, sibling report, and/or childhood records can all help--and can be really useful for the patient and treatment team in terms of understanding the underlying pathology, needs, and experiences. I had one client who was a late adolescent and had a really complex psych history by the time she came to us (hx of ED, abusive relationships, a suicide attempt, etc). We did a very thorough diagnostic eval, ended up diagnosing her with ASD, and it really helped explain and frame her lifelong social/communication struggles for her, her family, and future clinicians and how they underlay the other issues that had developed.

That said, the case described in the OP sets off huge Cluster B red flags for me, especially given the trend I've seen in adult women to seek an ASD diagnosis in place of a Cluster B PD, because of stigma and the perceived acceptance from within the autistic community.

 

[PsyDr]

I wouldn't make it my problem. I would write the report, stating that memory is normal, and that there was no cognitive explanations for inconsistencies in self report. Then I would recommend a team conference, and educating the patient about the exact diagnoses. That creates an outline, which providers can use to interpret behavior.

 

[MCParent]

I wouldn't make it my problem. I would write the report, stating that memory is normal, and that there was no cognitive explanations for inconsistencies in self report. Then I would recommend a team conference, and educating the patient about the exact diagnoses. That creates an outline, which providers can use to interpret behavior.

This. We aren't PIs. Well, not that kind of PI.

 

[cara susanna]

I once had this truly awful testing referral that was a diagnostic clarification but also had this component of "is this patient lying?" Note that I'm not a forensic person. I kept writing things like, it is impossible for this writer (yes guys, third person ) to determine why there are inconsistencies in Veteran's self-report, but here is what the data indicates regarding diagnosis" etc. Sometimes people seem to think that testing means we can access a crystal ball, I swear.

 

[WisNeuro]

I once had this truly awful testing referral that was a diagnostic clarification but also had this component of "is this patient lying?" Note that I'm not a forensic person. I kept writing things like, it is impossible for this writer (yes guys, third person ) to determine why there are inconsistencies in Veteran's self-report, but here is what the data indicates regarding diagnosis" etc. Sometimes people seem to think that testing means we can access a crystal ball, I swear.

I'd get those now and then in hospital settings. I cancel those, and then contact the referral source to have them resubmit asking only clinical questions. I'd rather not have that in the documentation in case of patient advocate/board complaint.

 

[cara susanna]

I'd get those now and then in hospital settings. I cancel those, and then contact the referral source to have them resubmit asking only clinical questions. I'd rather not have that in the documentation in case of patient advocate/board complaint.

That is an excellent idea. I don't manage consults here, unfortunately. I did put in VERY explicit language at the top clarifying that this was not a forensic eval and intended only for treatment purposes.

 

[mdwpsyd]

I once had this truly awful testing referral that was a diagnostic clarification but also had this component of "is this patient lying?" Note that I'm not a forensic person. I kept writing things like, it is impossible for this writer (yes guys, third person ) to determine why there are inconsistencies in Veteran's self-report, but here is what the data indicates regarding diagnosis" etc. Sometimes people seem to think that testing means we can access a crystal ball, I swear.

I agree: "Is this patient lying?" is not a a good referral question.

On the other hand, the following referral questions would be reasonable: Are there indications that this patient might be exaggerating or feigning symptoms? If so, what might be their motivation(s)?

Here is a hypothetical example. I'll pretend I'm a VA clinical psychologist who receives a referral from the PTSD treatment team that asks the above questions about a 72-year-old Vietnam veteran who is has a 50% disability rating for PTSD and recently filed a claim for an increased disability rating.

I explain to the veteran that the psych eval is intended to help his doctors provide the best treatment for him, i.e., it is for treatment planning purposes. Assessment procedures include:

• Review all available medical, psych, and military records, and try to obtain records not currently available (if applicable).
• Unstructured interview regarding developmental, military, social, psychological, legal, educational, and medical history (and to establish rapport, ask mental status exam questions, review informed consent, etc.).
• Structured diagnostic interviews, e.g., MINI (Mini-international neuropsychiatric interview) + CAPS-5.
• Interview significant other(s) (with veteran's approval).
• Administer psychological instruments, e.g., MMPI (2, RF, or 3) or PAI, MENT (Morel Emotional Numbing Test), MoCA, SIMS, Word Memory Test, IOP-29, TOMM.

Assuming the veteran is reasonably cooperative, e.g., does not just respond randomly to multiscale inventory items, I would most likely be able to answer the referral questions in a manner that would help the treatment team and the veteran.

I realize that's a lot of psychological tests, which might not be feasible. But including SVTs and PVTs is important based on the research, plus most people with PTSD (or who are claiming they have PTSD) report cognitive problems.

Trying to answer those referral questions, and conducting a psychological evaluation as I describe above, are reasonable expectations for a non-forensic clinical psychologist.

 

[beginner2011]

I agree: ...

Love this. Thanks for spelling out what can be reasonably expected in terms of a comprehensive psychological evaluation for a referral like this. Coming from a program where assessment training was not prioritized or well integrated into the curriculum or most practica, it's helpful to have this example laid out by an expert.

This is the kind of content that keeps bringing me back to the forum.

 

[cara susanna]

I agree: "Is this patient lying?" is not a a good referral question.

On the other hand, the following referral questions would be reasonable: Are there indications that this patient might be exaggerating or feigning symptoms? If so, what might be their motivation(s)?

Here is a hypothetical example. I'll pretend I'm a VA clinical psychologist who receives a referral from the PTSD treatment team that asks the above questions about a 72-year-old Vietnam veteran who is has a 50% disability rating for PTSD and recently filed a claim for an increased disability rating.

I explain to the veteran that the psych eval is intended to help his doctors provide the best treatment for him, i.e., it is for treatment planning purposes. Assessment procedures include:

• Review all available medical, psych, and military records, and try to obtain records not currently available (if applicable).
• Unstructured interview regarding developmental, military, social, psychological, legal, educational, and medical history (and to establish rapport, ask mental status exam questions, review informed consent, etc.).
• Structured diagnostic interviews, e.g., MINI (Mini-international neuropsychiatric interview) + CAPS-5.
• Interview significant other(s) (with veteran's approval).
• Administer psychological instruments, e.g., MMPI (2, RF, or 3) or PAI, MENT (Morel Emotional Numbing Test), MoCA, SIMS, Word Memory Test, IOP-29, TOMM.

Assuming the veteran is reasonably cooperative, e.g., does not just respond randomly to multiscale inventory items, I would most likely be able to answer the referral questions in a manner that would help the treatment team and the veteran.

I realize that's a lot of psychological tests, which might not be feasible. But including SVTs and PVTs is important based on the research, plus most people with PTSD (or who are claiming they have PTSD) report cognitive problems.

Trying to answer those referral questions, and conducting a psychological evaluation as I describe above, are reasonable expectations for a non-forensic clinical psychologist.

I agree that is a question any psychologist can assess (although that comprehensive of an assessment is likely not feasible for most VA psychologists given our time constraints). However, this question was not just about malingering but also "patient's story does not add up, did the trauma happen?" I administered the SIRS to assess for the former.

 

[Fan_of_Meehl]

I agree: "Is this patient lying?" is not a a good referral question.

On the other hand, the following referral questions would be reasonable: Are there indications that this patient might be exaggerating or feigning symptoms? If so, what might be their motivation(s)?

Here is a hypothetical example. I'll pretend I'm a VA clinical psychologist who receives a referral from the PTSD treatment team that asks the above questions about a 72-year-old Vietnam veteran who is has a 50% disability rating for PTSD and recently filed a claim for an increased disability rating.

I explain to the veteran that the psych eval is intended to help his doctors provide the best treatment for him, i.e., it is for treatment planning purposes. Assessment procedures include:

• Review all available medical, psych, and military records, and try to obtain records not currently available (if applicable).
• Unstructured interview regarding developmental, military, social, psychological, legal, educational, and medical history (and to establish rapport, ask mental status exam questions, review informed consent, etc.).
• Structured diagnostic interviews, e.g., MINI (Mini-international neuropsychiatric interview) + CAPS-5.
• Interview significant other(s) (with veteran's approval).
• Administer psychological instruments, e.g., MMPI (2, RF, or 3) or PAI, MENT (Morel Emotional Numbing Test), MoCA, SIMS, Word Memory Test, IOP-29, TOMM.

Assuming the veteran is reasonably cooperative, e.g., does not just respond randomly to multiscale inventory items, I would most likely be able to answer the referral questions in a manner that would help the treatment team and the veteran.

I realize that's a lot of psychological tests, which might not be feasible. But including SVTs and PVTs is important based on the research, plus most people with PTSD (or who are claiming they have PTSD) report cognitive problems.

Trying to answer those referral questions, and conducting a psychological evaluation as I describe above, are reasonable expectations for a non-forensic clinical psychologist.

This is awesome. May I also say that trying to take someone with a presumed dx of PTSD through a trial of cognitive processing therapy is a pretty definitive 'testing' procedure regarding the validity of their PTSD dx as well.

If you've ever had the excruciating misfortune of trying to drag/limp a patient malingering PTSD through THAT protocol...you know what I'm talking about.

Earlier in my VA career when I was fresh out of CPT training and freshly threatened with the fire-and-brimstone exhortations to get every PTSD patient into an EBP protocol ASAP, I had several such experiences.

Nowadays, if I'm at all dubious about the dx, it's easy to engineer a few behavioral/motivational compliance tests to likely prevent a repeat of that experience. If a veteran can't/won't cooperate with an in-session ABC worksheet or 'forgets' repeatedly to visit the VA PTSD decision aid website to learn more about PTSD treatment options then they're pretty unlikely to comply with the demands of a CPT protocol.