“What’s in a name?” —William Shakespeare. Romeo and Juliet , Act 2, scene 2, lines 1–2 “Then you should say what you mean” —Lewis Carroll. Alice’s Adventures in Wonderland

A colleague once made the witty observation that he has never met a referring doctor he didn’t like. We can readily endorse this sentiment since for many of us referrals are our life blood. But among the referred patients is a group who present special difficulties. These are the patients whose visual symptoms the referring ophthalmologist suspects (or even knows) are on a psychological or sociopathic basis. Many clinicians are frustrated by, and even feel hostile to, these patients because they do not appear to share with the physician the goal of eliminating the symptoms.

Their evaluation and management is difficult enough, but there is also the additional problem of selecting the best diagnostic term in each case. Many designations have been used and many clinicians consider them to be generic terms, unaware that they may have specific implications in law and psychiatry. Their casual use can have unintended consequences. For example, in the Commonwealth of Massachusetts “malingerers” would be denied workers’ compensation and would not be accepted on the rolls of the Commission for the Blind. “Hysterics,” however, may receive compensation for their illness and would be eligible to be registered with the Commission for the Blind. The requirement that we select billing codes listed in standard diagnostic manuals has brought the issue of nomenclature into sharp focus. I hope to convince readers to carefully consider the terms that they use and to show that ophthalmologists and neuro-ophthalmologists lack the training necessary to employ the specific diagnoses currently available in the diagnostic manuals.

“Organic” is a term used in psychology to designate a disorder “caused by neurochemical, neuroendocrinologic, structural, or other impairment or change.” It would be fair to say that this is the definition that is generally used by clinicians to classify patients as having an organic or a nonorganic disorder. The existence of competing schools of dynamic psychiatry and biological psychiatry reflected this duality. For many years the former was in ascendancy, but the situation has changed. Advances in the neural sciences are lessening the grip of Freudian orthodoxy and psychodynamics. Single-photon-emission computed tomography (SPECT) and other functional brain imaging techniques have identified loci of activation in patients with certain conversion symptoms and signs. There is even promise that functional brain imaging might distinguish between feigned and unfeigned symptoms and thus help to identify malingerers. Surprisingly, there have been few published investigations of patients with hysterical blindness. A fuller discussion of these developments in imaging is beyond the scope of this editorial and interested readers should peruse Ron’s editorial in Brain and the review by Vuilleumier.

This brief summary should not leave the impression that the results of functional imaging investigations prove that the clinical syndromes under consideration result from the abnormalities that are observed. It is also well to acknowledge the limitations of functional imaging. First, different laboratories have shown different alterations in the same disorder. Second, these studies involved small numbers of subjects. The implications of these investigations localizing brain function and dysfunction remain controversial; critics have even derided them as a “high-tech crystal ball” and “post-modern phrenology.”

Nevertheless, in the final analysis there is no brain-mind duality. Kandel has stated that “The basis of the new intellectual framework for psychiatry is that all mental processes are biological, and therefore any alteration in those processes is necessarily organic.” However, interactions with extracorporeal (nonorganic) phenomena appear to play a role in some disorders. Kendler has pointed out that psychiatric disorders are complex and multifactorial and favors the concept of explanatory dualism. In any case, until science has identified the structural or functional brain defects that are responsible for the visual disorders discussed in this essay, I feel justified in using the terms “organic” and “nonorganic.” A review of the various terms is in order.

“Hysterical blindness,” perhaps the diagnosis most often applied to patients with medically unexplained visual loss, is no longer included in DSM-IV. Patients who would have been placed in that category are subsumed under “Conversion disorder” (diagnostic code 300.11). How appropriate is this diagnosis? DSM-IV, 4th edition, tabulates the criteria for the diagnosis of conversion disorder. One criterion is that “Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.” We are not psychiatrists, and evidence of “conflicts and other stressors” will only infrequently be elicited by an ophthalmologist or neuro-ophthalmologist. The DSM-IV concedes that “Because psychological factors are so ubiquitously present in general medical conditions, it can be difficult to establish whether a specific psychological factor is etiologically related to the symptom or deficit.” Another criterion is that the “symptom or deficit is not intentionally produced or feigned.” You may suspect that the patient is feigning but, short of an outright confession (which must occur rarely), you can never be certain. All things considered, ophthalmologists and neuro-ophthalmologists are ill-equipped to use code 300.11.

“Factitious” is a designation (DSM-IV 300.19) that some physicians use. DSM-IV reserves this diagnosis for individuals who, motivated by a “psychological need, intentionally [italics mine] produce symptoms or signs in order to assume the sick role. The patient is not motivated by such external incentives as monetary gain.” Again, one must decide that the patient is intentionally producing the symptoms and signs and that the patient has a psychological need to manifest the symptoms. It seems inappropriate for a non-psychiatrist to make that diagnosis, and since the term “factitious” has a specific meaning rather than being a generic descriptor of nonorganic disease, it should be avoided. In any case it would be well to recognize that a patient may be consciously feigning visual impairment and yet not be a malingerer.

“Malingering” (DSM-IV V65.2) is a diagnosis that is apt to be applied when a patient has an obvious external incentive to appear ill and is feigning symptoms and signs. Here we are faced with 2 difficult tasks. The first is to identify an external incentive. The second is to determine if the patient is feigning. To complicate matters, there is expert opinion that patients with “factitious” disorders (see above) and patients who are “malingering” share so many characteristics that these may not be distinct entities. Furthermore, in presumed malingerers there may be psychological factors even if external incentives are present. The DSM-IV acknowledges that “the determination that a symptom is not intentionally produced or feigned can be difficult.” How then can we be expected to determine that a patient is malingering?

Several of the other designations that we sometimes use are not represented in either of the manuals. “Fictitious” is such a term. It means “created, taken, or assumed for the sake of concealment; not genuine; false.” Thus “fictitious” would imply that the patient has consciously assumed the sick role for purposes of concealment. This term, while less specific than “factitious” or “malingering,” would require that the clinician determine that the patient is feigning and also identify what it is that the patient is trying to conceal. Another term is “Psychogenic.” That implies that there is underlying psychopathology that is sometimes but not always present and that we are not trained to independently diagnose. “Nonphysiologic” is too inexact since all disease is nonphysiologic. If it is nonphysiologic it’s a disease! “Functional” is widely employed to designate nonorganic disorders. However, it is a term that should be eschewed, since the patients in question are, if anything, dys functional.

There are also nonpsychiatric diagnoses available in ICD-9-CM 2009 that might serve. These include: Subjective visual disturbance, unspecified (368.1); Unspecified visual disturbance (368.9); Sudden visual loss (368.11); Visual field defect, unspecified (368.4); and Generalized contraction or constriction (368.45). However, without a modifier they fall short, since none of them indicates that the disorder is nonorganic.

While not ideal, “nonorganic” seems to me to be the best available modifier that can be used with the terms listed in the last paragraph. This would convey that there is no evident organic basis for the symptoms or signs but does not imply more than an ophthalmologist or neuro-ophthalmologist is capable of determining. In any case, we should not venture to apply the diagnoses available in the standard diagnostic manuals because we are not qualified to make definitive psychiatric diagnoses. However, we are qualified to determine what a disorder is not , and “nonorganic” is a designation that, in my opinion, best fits the bill.