The factitious/malingering continuum and its burden on public health costs: a review and experience in an Italian neurology setting

Cry for help as a root cause of poor symptom validity: A critical note

When patients fail symptom validity tests (SVTs) and/or performance validity tests (PVTs), their self-reported symptoms and test profiles are unreliable and cannot be taken for granted. There are many well-established causes of poor symptom validity and malingering is only of them. Some authors have proposed that a cry for help may underlie poor symptom validity. In this commentary, we argue that cry for help is a (1) metaphorical concept that is (2) difficult to operationalize and, at present, (3) impossible to falsify. We conclude that clinicians or forensic experts should not invoke cry for help as an explanation for poor symptom validity. To encourage conceptual clarity, we propose a tentative framework for explaining poor symptom validity.

Al Ghazali's Concept of Diseases of the Spiritual Heart and its Significance to the DSM-5-TR Diagnosis

The intertwined relationship between religion and mental health has been accounted for since the earliest recorded history. This study aimed to explore the relationship between the concept of diseases of the spiritual heart (DOTSH) from the Islamic-Sufi perspective and the medical-psychiatric concept of mental disorder. We examined two essential documents as our primary data sources: (1) Al Ghazali's Ihya Ulumuddin (Revivals of Religion Sciences) Volume III entitled the Quarter of the Destructive and (2) The Diagnostic and Statistical Manual, Fifth Version, Text Revision (DSM-5-TR). We employed a document analysis of the qualitative method by applying six steps of data analysis. We reviewed the English version of Al Ghazali's book to identified DOTSH. In this stage, we found six DOTSH categories which comprised of 40 DOTSH. Then, we searched the correspondence of DOTSH's categories to the DSM-5-TR criteria for mental disorders. We found that all DOTSH categories correspond to DSM-5-TR diagnostics criteria, diagnostic features or diagnostic associated features. We concluded that spiritual heart diseases not only present as symptoms but also can be regarded as mental disorder preconditions that require preventive intervention.

[Functional neurological disorders and forensic medicine: Clinical and practical characteristics]

Functional neurological disorders (FND) have long been a challenge for medicine, both on clinical and psychodynamic point of view. The medico-legal issue is often relegated to the background in medicine, and FND patients also suffer from such neglected topic. Nonetheless, despite the difficulty to properly diagnose FND and the numerous associated organic and/or psychiatric comorbidities, FND patients report a significant level of deficiency and a high alteration of quality of life when compared to other well-recognized chronic disorders such as Parkinson's disease or epilepsy. Whether it is for the estimation of a personal injury, a prejudice, after-effects following a medical accident or certain legal contexts requiring the elimination of a factitious disorder or a simulation, the uncertainty and imprecision in the medico-legal assessment can imply notable consequences on the patient. In this article, we propose to define the different medico-legal contexts in which FND can occur that of the legal expert, that of the consulting physician, that of the so-called recourse physician and finally that of the attending physician who can provide detailed medical files to the patient in order to help him/her in his/her procedures. We then explain how to use standardized objective evaluation tools validated by the learned societies and how to encourage multidisciplinary cross-evaluation. Finally, we specify how to differentiate FND from historically FND-associated disorders (factitious and simulated disorders), through the clinical criteria, considering the difficulties linked to the uncertainty in the clinical examination of these disorders in a medico-legal context. In addition to the rigorous completion of expertise missions, we aim to reduce two damaging consequences characterizing FND: diagnostic delay and the patients' suffering through stigma.

Functional Neurologic Disorders, disorders to be managed by neurologists, or are neurologists wandering in a dangerous field with inadequate resources?

In recent years, some neurologists reconsidered their approach to Medically Unexplained Symptoms and proposed Functional Neurologic Disorders (FND) as a new entity, claiming that neurology could offer alternative treatment options to the psychotherapies provided in psychiatry settings. FNDs, for this purpose, should include only the disorders listed as Conversion from the Somatic Symptom and Related Disorders (SSRD) group. The present review analyzes the rationale of this position and challenges the arguments provided for its support. The review also discusses the systematization of these disorders as provided by public health systems. It outlines risks stemming from economic support and public funding uncertainty, given their negligible epidemiological dimensions resulting from the parcellation of SSRD. The review underlines the unresolved issue of Factitious Disorders, which are in the same SSRD category of the international classification but are, nonetheless, overlooked by the theoretical proponents of the FND entity. Comorbidity with other psychiatric disorders is also analyzed. We propose a model that supports the continuum between different SSRD conditions, including Factitious Disorders. The model is based on the emergence of feigned death reflex and deception from frontal lobe dysfunction. Finally, the paper summarizes the wealth of historical psychiatric and psychodynamic approaches and critical reviews. The study also puts in context the categorization and interpretation efforts provided by the most eminent researchers of the past century.

Functional neurological disorder and somatic symptom disorder in Parkinson's disease

The occurrence of Functional Neurological Disorder (FND) and Somatic Symptom Disorder (SSD) in PD was not commonly accepted until recently, despite some evidence that emerged in the pre and early L-Dopa era. More recently, the recognition of FND and SSD were noted to be relevant for the management of PD. FND and SSD appear early in the course of PD, often preceding motor symptoms, may interfere with treatment outcomes, often acquire psychotic features during progression, and are mixed with and often concealed by the progressive cognitive decline. We review the related features from the range of the available reports and discuss theoretical models conceived to explain the potential pathophysiological background of these disorders. Finally, we suggest that FND and SSD should be included among the non-motor symptoms of PD and be considered a prodromal feature in a subset of patients. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna.