Simulation

Simulation (from Latin simulare - to feign). In medicine, S. refers to the presentation of a picture of pathological condition which the subject being examined is well aware they do not have; either the entire pathological form or only individual symptoms are simulated. S. must be distinguished from artificial diseases when the subject is actually ill or disabled (see Artifact, Self-mutilation), from aggravation (see), and from dissimulation (see); For the diagnosis of S., there are certain general rules, and the examination of such conditions requires appropriate conditions when the physician-expert works on themselves beforehand in order to improve their preparation for work as an expert and understanding of the tasks of the court. Specific types of S. Mental disorders. If detailed study of the case history data, peculiarities of the patient's behavior, a number of physical and mental symptoms, and the course of the illness in the subject being examined does not allow one to conclude the presence of one or another natural form of mental disorder, then the question arises of excluding S. For the correctness of conclusions, it should be kept in mind that during examination the following may be found: 1) S. in its pure form, 2) mental disorders in which patients additionally simulate for the purpose of aggravation, 3) diseases in which simulation is one of the characteristic, almost inseparable properties. In diagnosing malicious S. or aggravation, it is kept in mind that any symptom that can be imitated without particular difficulty for a shorter or longer time can be simulated (imbecility, hallucinations, illusions, delusional ideas, amnesia). Only what cannot be reproduced for a sufficiently long period is not simulated (the urge to move of patients in the stage of maximum excitement, prolonged insomnia, severe confusion and flow of ideas, catalepsy, organic symptoms inaccessible to artificial reproduction, etc.). Although the main basis for the diagnosis of S. is the erudition and clinical experience of the physician, there are also some general rules for excluding S. of mental disorder. When questioning a suspect of S., the method of rapid questions is very convenient in order not to give the subject in appropriate cases time to think about answers; in this case, various inconsistencies incompatible with the presented picture of mental illness are taken into account. According to Bischoff, with deliberate calculation, one can sometimes change the behavior of the simulator, drawing the attention of those present to the absence of one or another symptom supposedly characteristic of the disease, as if by the way: this can lead to the appearance of the missing symptom soon after; of course, cases of increased suggestibility in certain mental states (hysteria, catatonia, etc.) must be excluded. Simulators are not inclined to hide their mental illness, whereas mentally ill patients more often strive to hide it if possible given their mental state. The open discovery by the examiner that S. is not suspected leads to the fact that subjects with weak will or somewhat weak-minded begin to simulate to a greater extent or less carefully. The delusional ideas and hallucinations presented by simulators usually do not affect the general mood, nor do they lead to the appearance of one or another affects (Bischoff). The facial expression of subjects also represents a field for diagnostic research, and in order to distract the subject's attention, certain questions should be asked. The facial expressions of simulators seem to lack an sincere tone, as expressive facial expression as a whole is outside of volitional influences. According to Laurent, due to the close connection with mental experiences, the expression of the eyes has special significance. Based on the totality of behavior and symptoms, the simulator can give only a parody of illness, without presenting a complete clinical picture of such, or gives simultaneously incompatible symptoms. According to Eichwald, delusions are simulated relatively rarely, more often they are dissimulated, and if presented, they usually have the character of delusions of grandeur or persecution, however without the accompanying affective phenomena. In cases of presenting disorders of consciousness (orientation), it should be kept in mind that in truly ill patients, the criterion of time is usually, but not always, violated before the criterion of place, whereas a simulator may present ignorance of their location but gives correct answers to questions about time. According to Eichwald, favorite techniques among simulators were refusal of food, grimacing, presentation of peculiar mannerisms, e.g. when drinking water, when lighting a cigarette, etc. It should be kept in mind that S. ceases in cases of absence of further reasons to continue S., e.g. when realizing the futility of simulation or when failing in the latter. In cases of indications in the case history of former mental illness and even when presenting certificates of previous stay in a medical institution for the mentally ill, the possibility of deliberate prior admission to such an institution for the purpose of obtaining documents regarding observed mental disorder should be kept in mind (this is called 'preventive simulation'). As already noted, S. is an integral sign in the picture of certain mental disorders and therefore in such states errors in diagnosis can be made; these include schizophrenia, hysterical psychoses, prison psychoses, puerilism, reactive psychoses, Ganser's symptom (see), etc. In diagnosing S., the so-called (according to Kretschmer) 'flight into illness' should also be kept in mind; this is one of the types of hysterical defensive reaction. In such cases, a hysterical subject, noticing that the presentation of a picture of one or another pathological condition turned out to be protective from the unpleasantness of the environment, begins in appropriate cases to again present the same pathological phenomena, and gradually even intensifies them for greater effect among those around. Subsequently, the presentation of these pathological conditions becomes automated. To exclude S. of imbecility, in addition to detecting corresponding defects in the mental sphere, the presence of physical defects and nervous consequences of brain diseases in the subject should also be established, in which imbecility is only part of the observed picture. Deformations of the skull, various deformities, abnormal conditions of the sexual organs, other signs of degeneration, paralyses, difference in reflexes of the two halves of the body, speech defects, physical signs of cretinism, mongolism, etc. should be taken into account. In addition, imbeciles sometimes suffer from epileptic and choreiform disorders, etc., which may be accompanied by mental inferiority. To exclude S. of 'pathological affect', the special physiological and mental signs should be kept in mind (see Affect). To exclude S. of epilepsy, the following are taken into account: 1. Case history data regarding the duration of seizures, peculiarities of falling and the course of seizures, information about precursors of seizures, about the time of onset and causes of the last, indications of the frequency of seizures, of their uniformity and periodicity, information about the profession of the subject during the presence of seizures. Information in these directions is often so unique and uncharacteristic of epilepsy that in connection with further data it can strongly reinforce the establishment of the unfoundedness of the statement about suffering from epilepsy. 2. When observing seizures, suspicious for S. according to Boisseau, falling without danger to health, absence of seizures when apparently there is no observation of the subject, and presence of seizures when non-medical observation, absence of aura, absence of a piercing initial cry in the presence of multiple cries or absence thereof; absence of initial pallor of the face and subsequent cyanosis; in S., convulsive manifestations are symmetrical, not predominantly on one side; they can be excessively intense and last longer than 1-2 minutes; in S., there is no initial arrest of breathing for 10-40 seconds and the hoarseness characteristic of this arrest is absent; in S., the pulse is rapid from physical exertion but not of weak filling; suspicious is biting the tongue not at the beginning of the seizure but only at the end, and not from one side but from both; in S., the eyes are closed and efforts to roll up and hold the cornea under the upper eyelid are observed; the pupils react to light at this time; sensitivity of the cornea is preserved; in a real seizure, sweating is observed only at the end of it, in S. it can also be at the beginning; there are no involuntary discharges of urine and especially feces. During the seizure, the subject's reactions to spraying the face with cold water, irritation with strong ammonia spirit brought to the nose should be taken into account. During examination, it should be kept in mind that the corneal reflex, reflexes from mucous membranes may be absent due to the use of appropriate means, e.g. cocaine, atropine; special research at the end of the seizure should lead to clarification of the question. 3.

In case of delay in the onset of a seizure, the presence of a post-epileptic state is established; since convulsive phenomena in epilepsy usually occur to a greater degree on one side of the body, subsequent phenomena of sensory depression and some paralysis are also observed on the corresponding side; the presence of decreased and rapid exhaustion of tendon reflexes predominantly on one side, the presence of the Babinski reflex or its remnants are also means of subsequent control of the recently experienced epileptic seizure. In the depth of the conjunctiva after a real seizure, hemorrhages can be found, and in the state of the eyes sometimes nystagmus; if the latter was present before, it is intensified. After a real epileptic seizure, in addition to the dullness and confusion that persist for some time, there is also a complete lack of memory of the phenomena during the seizure; the simulator cannot maintain amnesia for long and gradually gives himself away. It is interesting to compare the features of a series of seizures based on anamnesis, references, and results of observation in a medical institution. The simulator most often gives each new seizure in a somewhat different form than the seizures presented earlier; in a real epileptic, seizures after being placed in a medical institution should generally become less frequent compared to what is noted in the anamnesis, whereas in a simulator trying to quickly convince of the presence of seizures and the severity of his suffering, seizures in the hospital setting become more frequent; the clear intervals between seizures turn out to be unequal in this case. Real epileptics are often intolerant of alcohol. In diagnosis, it is necessary to keep in mind epileptic mental equivalents and forms of minor epilepsy (petit mal - see Epilepsy). In a hysterical seizure, to exclude S., it should be kept in mind that during a real seizure the pulse is sharply increased - to such a degree of frequency that when lying down, it never reaches this level merely due to physical exertion. Outside of seizures, it is necessary to take into account the presence of hysterical stigmata and constitution. In anesthesia and hyperesthesia, first of all, one must consider how typical the presented sensory disorders (peripheral, radicular, regional) are in accordance with the essence of the complaints presented. In neuritis or other diseases, other symptoms must fit into the corresponding clinical picture. In particular, anesthesia and hypesthesia are accompanied by a decrease in protective skin "reflexes in the corresponding areas with sudden pricks. According to Goldscheider and Freund, if one simultaneously pricks an anesthetized area and touches at least a finger to a healthy area and then ask "what was done", the actually sick person will answer that he was touched in such and such a place, whereas the simulator will be at a loss, because according to psycho-physiological laws, having perceived the pain from the prick, he simultaneously cannot notice the relatively weak irritation of the touch and therefore will answer "nothing" to the question, noticing only the prick in the supposedly anesthetized area; at this point, the subject cannot indicate the pain without contradicting his own complaints. When applying sudden, disorderly repeated pricks, sometimes in anesthetized areas, sometimes in healthy ones, the subject is asked to answer "yes" to each painful irritation, doing so quickly enough (not giving time for a choice reaction); in this case, the simulator often will react positively to pricks in areas claimed to be anesthetized, contradicting himself. An attempt to make the correct choice quickly will lead the simulator to extreme fatigue and in any case to errors. It is useful to consider the stability of the localization of anesthesias by changing the positions of the corresponding areas (position on the back - on the stomach, crossing of the arms in front - behind, etc.). When examining hyperesthesia - consider the uniqueness of complaints about painful experiences, the reasons for this, changes in the general state of health in connection with actually frequent pains. When evoking painful experiences - the face becomes hyperemic or pale, the frequency of breathing and pulse changes, on the corresponding side of the body the pupil may dilate during pain; when irritating hyperesthetic areas of the skin, protective reflexes here are strengthened. Tremors. To exclude S. of tremors, it is necessary to consider their correspondence in the totality of properties to actually pathological tremors known in clinical practice, and changes in the picture in connection with attracting attention; however, the latter does not directly prove S., but only indicates the possibility of psychogenic influences. There is no doubt about tremors accompanied by contractions of groups of muscles or muscle fibers, which we cannot voluntarily contract. Paralyzes and pareses. When evaluating atrophies, it is kept in mind that a difference in circumference of both arms and lower legs of 0.5-1 cm, of thighs - of 1-2 cm with symmetrical measurements is sometimes possible even in healthy individuals. If there are no clinical data supporting the validity of the subject's complaints, if hysterical paralysis or paresis is excluded, then one proceeds to the diagnosis of S. For this, the degree of calluses on the limbs in connection with work is taken into account; with complex movements, the presence of function in the muscles claimed to be paralyzed is established by unobtrusive observation; in tests for passive movements, the activity of the corresponding muscles is excluded, changes in the positions of the hands or legs from artificially created positions after losing support in these positions are taken into account, etc. Real contractures occur in the presence of scars, lesions of bones and joints of the corresponding areas, from shortening of muscles whose antagonists were previously paralyzed, from abnormal muscular tension, in some diseases of the brain and spinal cord; on the basis of reflex contracture and in hysterical states. Simulative contractures are not constant and not long-lasting, the muscles involved are hard and show fibrillary twitchings. In real contractures that allow movement within certain limits, such movements are painless, whereas the simulator presents all movements as painful. Chloroforming only helps to differentiate between contractures of peripheral (local) origin from contractures of central voluntary or involuntary character. In hysterical contractures, there is significant and prolonged persistence of hardness in other stigmata of hysteria. In doubtful cases, tests for fatigue of the corresponding muscles are useful. According to Nadezhdin, in actively tensed muscles (for simulating contractures), when listening to the muscles with a stethoscope, a sharp increase in normal muscle noise is observed, which is no different from such contraction of symmetrical healthy muscles. - With the sign of Romberg: the real "Romberg" and in hysterical states sometimes "pseudo-Romberg" are checked by diverting attention; for this (according to Schuster), when starting to examine, for example, painful sensitivity of various areas or pupillary reactions to light, the subject is asked to close his eyes, having previously given the corresponding position of the legs unnoticed. The real "Romberg" or "pseudo-Romberg" should manifest itself under these conditions. In sciatica, attention is paid to the correspondence of painful points to the anatomical course of the nerve and its branches. To control the presence of the Lasègue symptom, it is recommended to obtain a statement from the subject about pain if he, standing, extends the healthy leg forward or abducts the affected leg to the side. In the test for combined flexion on the side with the diseased nerve, a greater lifting of the knee should be observed. The Lasègue symptom should be considered negative if adduction and inward rotation of the flexed thigh of the examined leg are painless; however, if adduction and inward rotation are painful, and abduction "Lasègue" is negative, then suffering of the sacral roots may be suspected. According to Akopdzhants, when asked to stand on tiptoes, the heel of the leg affected by sciatica is often found to be higher. One must take into account the absence or decrease of the Achilles reflex on the corresponding leg, the change in position of the gluteal fold, the contours and muscles of the affected leg, the position of the spine. Neuralgias - consider the locations of painful points, where possible, an increase in skin reflexes near and corresponding to the painful area, an increase in local excitability to faradic current, and the above-mentioned objective signs of pain. Percussive dullness in the apices of the lungs: errors are possible due to technical incorrectness of percussion, when not taking into account the elevation of one shoulder, incorrect posture, incorrect position of the head, with local tension or increased development of muscles (right- and left-handedness), with scoliosis, kyphosis, changes in the clavicle or first ribs, with the presence of additional ribs, with enlargement of the corresponding lymph glands, with the presence of lipomas or parts of a developed retrosternal goiter in the subclavian areas. In a sitting patient when bending the head, the diseased apex percussively descends, the healthy one rises; the same thing happens during inspiration, and the sound noticeably clarifies upward, which does not happen with actual apical involvement.

Elevation of thermometer readings is produced either by rubbing the reservoir with mercury or by imperceptibly placing the thermometer's reservoir in the anus; the latter gives an increase of 0.5-1° in 1/2-1 minute; from the anus the thermometer can subsequently be imperceptibly moved back to the armpit. Temperature rises after vigorous walking, after work of muscles near the place of temperature measurement, from artificial hyperemia of the armpit areas due to rubbing with alcohol, salt water, etc. Temperature rises briefly in neurotics in connection with excitement. Tubercle bacilli in sputum: in doubtful cases, the subject should be asked to rinse their mouth and then, to produce sputum, to cough in the presence of a doctor. -Elevation of gastric juice acidity for the purpose of S: before pumping out the gastric juice, various amounts of hydrochloric acid can be taken, which is recognized by the sharp fluctuation in acidity of the juice upon repeated examinations. -C oncealed intestinal bleeding: as is known, a positive Gregersen reaction is only conclusive after a meat-free diet. For S. of concealed bleeding, blood can be suctioned from the gums, which is why a positive Gregersen test should be noted that supervision of the gums was maintained. -P rotein in urine is simulated by adding therapeutic serums, etc., to corresponding portions of urine. -S ugar in urine is simulated by adding glucose to portions of urine before examination. Sometimes a glucose solution can be introduced into the urethra or even into the bladder, which is why in doubtful cases before obtaining test portions of urine, the bladder should be washed with a warm boric solution. -C rick in the neck-preliminarily exclude diseases of the vertebrae, ligaments, muscles, presence of scars, tumors, neuritis. In S., we are dealing with contraction of the neck muscles that tilt the head from both sides, which is determined by palpation; with actual local suffering or muscle spasms, the changes are unilateral and only where they should be according to the nature of the disease. To detect variability of symptoms, tests for fatigue can be used with the head and body in various positions. The methods for excluding S. of contractures described above should also be kept in mind. For actual scoliosis, the following is characteristic: 1) compensatory curvature of the spine in other sections, 2) rotation of the spine around its longitudinal axis, 3) presence¹ folds in the skin, mainly below the armpit line on the concave side of the trunk. -L ordosis and kyphosis. Suspecting S., after excluding natural diseases, observe the state of the subject's spine during sleep, as well as its state if the subject is suddenly awakened; observe the spine in cases of sudden pricking of the lumbar area with a pin, especially when the subject is lying undressed on a sufficiently hard support. According to Nadezhdin, the detection of general tension in all muscles of the trunk and even limbs during examination of only spinal functions is also suspicious for S. In S., pictures of congenital kyphosis can be observed in the persistence of symptoms presented when the subject is lying horizontally on a table, and due to the inability to maintain the spine in an incorrect position for long, there almost immediately appears progressive pulse acceleration, other signs of fatigue, and finally the spine straightens. Nocturnal enuresis can be simulated during conscription or by young servicemen. For diagnosis, the following are important: 1) Anamnesis data-recording them in the content as presented. The information is sometimes so peculiar that it immediately arouses suspicion of S.; for example, many simulators, when asked why they did not report nocturnal enuresis during conscription, say that they entered the army to be treated. Indications of irregularity of enuresis are suspicious ('a month sometimes doesn't happen, but sometimes several times a week or in a night'). This is caused by the fact that depending on the conditions of testing, some enuretics sometimes change their behavior and even stop presenting enuresis and therefore try in advance to justify sudden changes in the picture of the disease. Information about heredity and personal characteristics of the subject indicating a neuropathic constitution should be taken into account. Indications of certain acute prolonged infections (e.g., typhoids) or other diseases leading to degeneration of muscles, including the bladder muscles, are specially considered; in such conditions, as well as as a result of great overstretching, temporary enuresis is possible. 2) The severity and multiplicity of a series of signs of underdevelopment or improper development (including the presence of a sacral cleft, which in healthy people, as a variation of structure, occurs in 12% and more of cases). 3) The state of the neuropsychic sphere. 4) Results of special urological examination of the urethra, bladder, and related organs. 5) Average daily amounts of urine per day for a series of days of testing and number of urges to urinate each day in order to assess the degree and constancy of the average physiological capacity of the bladder. 6) Verification of the physiological capacity of the bladder by introducing through a catheter into it, with the subject's eyes closed and lying down, a warm 2% boric solution until the objective detection of an irresistible urge to urinate. 7) The completeness of urine collection is verified by multiplying the last two digits of the specific gravity in the presented daily amounts of urine by the daily amount of urine for that day in cm³; with correct collection, the figures obtained for a series of days should differ little from each other. The above provides a basis for a conclusion based on the totality of data. When concluding, keep in mind that, according to Nadezhdin, there are no specific symptoms characteristic only of enuresis, since the latter is the result of a series of different causes; however, actual enuresis is usually accompanied by certain deviations in the state of the urinary excretory organs, deficiencies or abnormalities of physical development, as well as neuropsychic inadequacy. In adults, according to Nadezhdin, actual enuresis is a rarity, since even among severe psychopaths, by adulthood, nocturnal enuresis was found in only 2.8% of cases. An adult subject, properly physically and mentally developed, of satisfactory health has no grounds to be considered suffering from enuresis. Careful comparison of symptoms will reveal simulation. Shortening of a leg is simulated by artificial oblique position of the pelvis through active contraction of the lumbar-sacral muscles on the corresponding side. When measuring, the length of the legs is the same. In the knee-elbow position with elbows and knees aligned, the length will appear the same to the eye; the same will happen in the supine position with knees bent at a right angle and legs brought together. -In habitual dislocation, S. can manifest in the shoulder joints after preliminary forced pulling of the joint and subsequent training of the muscles rotating the head of the humerus and elevating the scapula. With indications of frequently recurring dislocations, take into account predisposing factors, for example, fracture of the bony protrusion that prevents dislocation, destruction or underdevelopment to some degree of the joint ends, strong relaxation of the capsule and ligaments, which is possible after former large hemorrhages or effusions, as well as ruptures. Take into account atrophic changes in the joint-strengthening muscles on the basis of inactivity or paralysis. On X-ray, the condition of the joint ends and traces of former hemorrhages and effusions are determined. S. of hearing disorders-see Deafness. Stuttering. For excluding S., the most interesting symptoms are those that cannot be reproduced intentionally. Thus, actual stuttering is accompanied, for example, by tic-like twitchings in the facial muscles, fibrillary contractions in the area of the neck and large pectoral muscles, spasm of the diaphragm, etc.; speech delay from actual stuttering is accompanied by a clear increase in pulse to some degree; to detect the increase in pulse, compare the state of the pulse in a sitting subject* in moments of silence and when presenting a delay in pronunciation. In false stuttering, the pulse does not change in frequency. In whispered speech, actual stuttering either does not manifest or sharply weakens. -A phonia- exclude laryngitis, organic and hysterical paralysis of the vocal cords. In feigned aphonia, the larynx with normal mucous membrane and vocal cords closes sufficiently. A simulator may refuse to whistle when asked. Pretenders who are 'whisperers' sometimes speak loudly at night in sleep, which can be noted through the duty personnel or by questioning neighboring patients. According to Nadezhdin, for S. the presence of a resonant cough is characteristic, for example when asked to cough or when the larynx is irritated, but without the stigmata of hysteria present. Ptosis. An actual patient holds their head as when looking upward; with true ptosis, if the paralyzed eyelid is raised without the help of fingers, then the frontal muscle contracts.

Since paralysis of the muscle that raises the eyelid, separately from paralysis of other muscles innervated by the oculomotor nerve, is rare, to detect S. (simulation) the subject's lowered eyelid is raised and they are asked, without raising their face, to look upward; at this time, the upward movement of the eyeball is noted, which should not occur in true paralysis. In case of sudden awakening, the simulator will open their eyes wide, whereas in paralysis the eyelid will remain lowered.--Nystagmus and strabismus can be simulated only in certain directions of gaze, and there is no completeness of symptoms that occur in diseases. In case of complaints about the inability to turn the eyes in any direction in the absence of objective data for this, or in case of complaints about supposedly constant squinting of both eyes in one direction, according to Nadezhdin, it is recommended to subject such subjects to rotation in the corresponding direction in a Barany chair; after this, nystagmus may appear in the direction where movement was previously claimed to be impossible.-Constriction of the visual field-for the diagnosis of S. (simulation), the approximate coincidence of responses to certain colors in repeated examinations (physiologically, each color has its own visual field) and the degree of coincidence of results with different orders of the same meridians are taken into account.-Simulation of chicken blindness-to exclude anemia, scurvy, intoxications; take into account the behavior of the subject left to themselves at night or in the evening; when examined in a semi-dark room, the simulator may refuse to perform actions that everyone can then perform in the dark. The results of repeated photometric examinations (constancy of data) can also be taken into account. In patients with hemeralopia, there may be dystrophic disorders on the eyelids.-S. (simulation) of unilateral or bilateral blindness, see Blindness.-S. (simulation) in decreased visual acuity is established by the results of repeated examinations at different distances, with different fonts, by placing flat, convex or concave glasses in front of one or the other eye, taking into account the correctness of the responses.-Dissimulation of color perception disorders: in the case of inability to distinguish red and green colors, distinction can however be made based on the intensity of the gray tone observed by the color-blind person-red is darker; therefore, slowness in matching, increased attention of the subject in the color perception test are suspicious of dissimulation.