Functional Ophthalmic Disorders Ocular Malingering and Visual Hysteria Robert Enzenauer William Morris Thomas O’Donnell Jill Montrey 123 Functional Ophthalmic Disorders Robert Enzenauer (cid:129) William Morris Thomas O'Donnell (cid:129) Jill Montrey Functional Ophthalmic Disorders Ocular Malingering and Visual Hysteria Robert Enzenauer William Morris Department of Ophthalmology Department of Ophthalmology University of Colorado University of Tennessee Aurora , CO , USA Memphis , TN , USA Thomas O’Donnell Jill Montrey Department of Ophthalmology Medical Writer/Editor University of Tennessee Denver , CO , USA Memphis , TN , USA Videos to this book can be accessed at h ttp://www.springerimages.com/videos/978-3-319-08749-8 ISBN 978-3-319-08749-8 ISBN 978-3-319-08750-4 (eBook) DOI 10.1007/978-3-319-08750-4 Springer Cham Heidelberg New York Dordrecht London Library of Congress Control Number: 2014946609 © Springer International Publishing Switzerland 2014 T his work is subject to copyright. 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Violations are liable to prosecution under the respective Copyright Law. T he use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Introd uction Patients usually visit a healthcare provider because of specifi c signs or symptoms. In the general course of events, the provider: (cid:129) Conducts an examination and testing. (cid:129) Discovers an objective fi nding that explains the symptoms. (cid:129) Makes a diagnosis. (cid:129) Institutes appropriate treatment. (cid:129) Follows the patient over time, anticipating symptoms will improve. Less often—and more frustrating for all—the provider does n ot discover an objective fi nding that leads to a diagnosis of an organic illness that explains the symptoms. In such a case, providers adopt a policy of watchful waiting, tradition- ally known as the “tincture of time.” Time permits the symptoms of a minor malady to disappear. Time also allows for the development of an abnormal fi nding that eventually enables a diagnosis. H owever, in some cases, time convinces a provider to consider the diagnosis of a functional disorder. In a functional disorder, the patient has symptoms or signs of illness, but there is n o evidence of organic disease. The challenge is then to diagnose the type of functional disorder and prescribe the proper treatment and follow-up. The process is complicated because a functional disorder can overlay an organic illness and a small percentage of functional disorders ultimately are linked to an underlying medical etiology. T his treatise briefl y reviews the historical and contemporary thought on func- tional disorders in general, functional ophthalmic disorders in particular, and pro- vides a “how-to” manual on diagnostic testing for the different types of functional ophthalmic disorders. Aurora, CO Robert W. Enzenauer Memphis, TN William R. Morris Memphis, TN Thomas O’Donnell v Contents 1 Terminology of Functional Disorders ................................................... 1 1.1 Nomenclature ................................................................................... 1 1.2 Simple Classifi cation of Functional Disorders ................................ 2 1.3 Types of Conscious Functional Disorders (Traditional Malingering) ................................................................ 3 1.4 Types of Unconscious Functional Disorders (Traditional Hysteria) ....................................................................... 4 1.5 Ophthalmic Functional Disorders .................................................... 4 1.6 DSM-5 and MeSH Classifi cation of Functional Disorders .............. 5 1.7 Terminology in This Text ................................................................. 7 References ................................................................................................. 8 2 History of Functional Disorders ............................................................ 11 2.1 History of Hysteria ........................................................................... 11 2.2 History of Ocular Hysteria ............................................................... 16 2.3 History of Malingering .................................................................... 20 2.4 History of Visual Malingering ......................................................... 24 References ................................................................................................. 26 3 Hysterical Ocular Functional Disorders ............................................... 33 3.1 Defi nition and Overview .................................................................. 33 3.2 Epidemiology ................................................................................... 34 3.3 Natural History ................................................................................. 36 3.4 Risk Factors and Etiology ................................................................ 37 3.5 Signs and Symptoms ........................................................................ 39 3.5.1 Overview of Signs and Symptoms ....................................... 39 3.5.2 Visual Acuity ........................................................................ 41 3.5.3 Visual Fields ......................................................................... 42 3.5.4 Disturbances of Sensibility .................................................. 47 vii viii Contents 3.5.5 Disturbances of Light and Color .......................................... 47 3.5.6 Systemic Symptoms with Proclaimed Ocular Cause ........... 48 3.6 Treatment ......................................................................................... 48 References ................................................................................................. 50 4 Ocular Malingering ................................................................................ 55 4.1 Defi nition and Overview ................................................................. 56 4.2 Epidemiology of General Malingering ............................................ 56 4.3 Epidemiology of Ocular Malingering .............................................. 58 4.4 Natural History ................................................................................. 58 4.5 Risk Factors and Etiology ................................................................ 59 4.6 Signs and Symptoms ........................................................................ 60 4.6.1 General Malingering Signs and Symptoms ......................... 60 4.6.2 Overview of Ocular Malingering Signs and Symptoms ...... 60 4.7 Treatment ......................................................................................... 66 References ................................................................................................. 67 5 Differentiating Ocular Functional Disorders: Hysteria Versus Malingering ................................................................. 71 5.1 Is There a Need to Differentiate Type of “Ocular Functional Disorder”? .................................................... 71 5.1.1 The Rationale for Limiting Diagnosis to Ocular Functional Disorder ............................................. 72 5.1.2 The Rationale for Distinguishing the Type of Ocular Functional Disorder ............................................. 73 5.2 Differentiation of Malingering from Hysteria ................................. 74 5.3 The Role or Need for Referral to Ophthalmic Specialists ............... 76 5.4 The Role or Need for Referral to Psychiatry ................................... 76 References ................................................................................................. 78 6 Overview of the Clinician–Patient Interaction ..................................... 81 6.1 The Clinician’s Conduct .................................................................. 81 6.1.1 Preparation ........................................................................... 81 6.1.2 Attitude ................................................................................ 82 6.1.3 Therapeutic Encounter ......................................................... 82 6.1.4 Minimize Patient Exaggeration ............................................ 82 6.1.5 Interview Style ..................................................................... 83 6.1.6 Obtaining Evidence .............................................................. 83 6.1.7 How to Talk to Patients About Their Diagnosis ................... 83 6.2 The Patient’s Conduct ...................................................................... 84 6.2.1 Affect ................................................................................... 84 6.2.2 General Behavior ................................................................. 84 6.3 The Medical Report ......................................................................... 85 6.4 Testimony/Medicolegal Issues ......................................................... 86 References ................................................................................................. 86 Contents ix 7 Techniques and Tests for Functional Ophthalmic Disorders .............. 89 7.1 General Overview ............................................................................ 89 7.2 Principles Used in Examination ....................................................... 90 7.3 Video Illustration of Tests ................................................................ 91 7.4 Suggested Order of Tests ................................................................. 92 7.4.1 Testing for Functional Binocular Blindness ........................ 92 7.4.2 Testing for Functional Monocular Blindness ....................... 93 7.5 Testing for Functional Binocular Decreased Vision ........................ 93 7.5.1 Testing for Functional Monocular Decreased Vision ........... 94 References ................................................................................................. 94 8 Testing for Functional Total Blindness .................................................. 95 8.1 Tests Based on Normal Physiology/Fixation Refl exes .................... 95 8.1.1 Pupillary Responses ............................................................. 95 8.1.2 Optokinetic Nystagmus Test ................................................ 96 8.1.3 Mirror Test ........................................................................... 96 8.1.4 The Threat Reaction or Menace Refl ex ............................... 98 8.1.5 Sudden Strong Focal Illumination ....................................... 99 8.1.6 The Head-Rotation: Doll’s Eyes (Oculovestibular Nystagmus)............................................... 99 8.2 Tests Based on Subjective Examiner Perception ............................. 99 8.2.1 Avoidance of Obstacles ........................................................ 99 8.2.2 Signature Writing ................................................................. 100 8.2.3 The Shock or Startle Card Test ............................................ 100 8.2.4 Making Sudden Ridiculous Facial Expressions ................... 100 8.2.5 The Schmidt-Rimpler Test ................................................... 101 8.3 Tests Based on Prisms ...................................................................... 102 8.3.1 General Principles of Prism Tests ........................................ 102 8.3.2 Objective Fixation Test with Six-Diopter Base Out Prism .................................................................... 105 8.4 Tests Based on Electrophysiology ................................................... 106 8.4.1 Electroencephalography ....................................................... 106 8.4.2 Visual Evoked Potential ....................................................... 106 8.4.3 Psychogalvanic Refl ex ......................................................... 107 References ................................................................................................. 107 9 Tests for Simulation of Monocular Blindness ....................................... 111 9.1 Tests Based on Normal Physiologic Refl exes .................................. 112 9.1.1 Tests Based on Induced Diplopia with Prism Manipulation 112 9.1.2 Manually Induced and Physiologic Diplopia ....................... 118 9.2 Tests Based on Subjective Examiner Perception ............................. 119 9.2.1 Observation .......................................................................... 119 9.2.2 Patient Response to Simple Offi ce Techniques Mainly Based on Refractive and Sensory Trickery.............. 119