by Paul C. McCormick, Jr., MD, and Jessica Simberlund, MD

Drs. McCormick and Simberlund are with the Department of Psychiatry at Weill Cornell Medicine and the New York-Presbyterian Hospital in New York, New York. Dr. Simberlund is also with Weill Cornell Medical College in New York, New York.

FUNDING: No funding was provided for this study.

DISCLOSURES: The author has no conflicts of interest relevant to the content of this article.

ABSTRACT: We present here the case of a 27-year-old man with schizoaffective disorder for roughly eight years who, seven years prior to presentation at our institution, suffered a severe traumatic brain injury (TBI) in a car accident. His course since that time has been marked by paranoid and guilty delusions, Cotard delusion (CD), which is the belief he is dead or does not exist, and scam susceptibility leading to the loss of nearly $200,000. He was hospitalized at our institution after his uncle called emergency medical services, concerned about the patient’s increasing disorganization and worsening delusions in the setting of medication nonadherence. In our inpatient unit, clozapine was titrated to its highest tolerable dose and, while reality testing appeared and his CD resolved, he remained acutely vulnerable to scams even while hospitalized. We review the existing literature on scam vulnerability, which heretofore has focused primarily on the elderly, and also TBI rehabilitation strategies in an attempt to better understand the underpinnings of this patient’s scam susceptibility and to construct a multidisciplinary approach to lessening his susceptibility to financial exploitation in the future.

KEYWORDS: Schizoaffective disorder, traumatic brain injury, financial exploitation, scams, scam susceptibility, gullibility, metacognitive strategy intervention, traumatic brain injury rehabilitation

Innov Clin Neurosci. 2020;17(4–6):41–44

Financial exploitation through scams cost the United States $1.42 billion in 2017, with the FBI receiving more than 300,000 complaints.1 It has been estimated that the true loss is even higher as a result of the fear and shame surrounding reporting, with testimony at a 2005 Senate hearing estimating $40 billion lost annually to telemarketing fraud and $30 billion lost to mail fraud and sweepstakes.2 Because of this tremendous economic impact, as well as the mental health burden on victims, research has expanded to better understand how and why certain people are more vulnerable than others to financial exploitation and scams.1–7 Most of this research has focused on the elderly. This is not surprising given that one in 18 nondemented, community-dwelling adults over the age of 50 years experiences some form of scam each year.8 Additionally, adults over the age of 65 years are estimated to hold approximately one-third of all wealth in the United States and have little time and opportunity to recoup losses.2,9,10 Research thus far has indicated that scam susceptibility is not just a behavioral result of loneliness but also might be a personality trait and have neuroanatomical correlates.1–3

The mentally ill are also recognized as being vulnerable to scams.11,12 Those with psychiatric illness rank finances and better money management skills among their most important goals.13 Yet most literature in the field focuses on patients without the capacity to manage their finances being assigned a Social Security Administration representative payee.14 Literature that delves more deeply focuses primarily on teaching financial axioms, which can be a challenge for some psychiatric patients to retain.11

There is also relatively little in the literature discussing financial vulnerability in those with traumatic brain injury (TBI), other than reporting TBI as a risk factor for dementia.15 This is despite the fact that TBI incidence has nearly doubled from 1999 to 2013, from 1.5 million cases to almost three million cases per year, although improved reporting contributed partly to this increase.16,17
     Here, we present a case of a young, schizoaffective male who suffered a TBI roughly a year after developing symptoms of schizoaffective disorder and whose course has been complicated by paranoid and guilty delusions; Cotard delusion (CD) (a relatively rare delusion in which the person believes they are dead or do not exist); and financial exploitation through a variety of Internet, telephone, video-messaging, mail, and in-person scams. This is the first case report of this type that we found in the literature. We then review the available literature on scam vulnerability and selected theories of TBI rehabilitation in an attempt to better understand the nature of scam vulnerability and to create strategies to lessen our patient’s risk of further exploitation.

Case Presentation

Mr. J (not his initial) is a single, unemployed, 27-year-old man who showed evidence of schizoaffective disorder in his mid-teens and suffered a severe TBI after a motor vehicle accident at the age of 20 years. He presented to our facility, an urban academic hospital, after his uncle called emergency services due to concern about Mr. J’s worsening paranoid and guilty delusions in the setting of nine months of medication nonadherence. Mr. J was admitted to the inpatient psychiatry service for further evaluation and treatment.

The psychiatry team learned that Mr. J experienced a depressive episode at the age of 16 years and a hypomanic episode at the age 17 years, and thereafter developed delusions at the age of 18 years about a religious sect monitoring him without concurrent affective symptoms. Mr. J briefly received outpatient medication management for his depressive episode, whereas his other symptoms did not prompt additional care. At 19 years of age, during his sophomore year of college, his academic course load increased. He began studying more and sleeping less. In this setting, his paranoid delusions intensified, and he began skipping classes and hiding in stairwells. This behavior prompted Mr. J’s father to retrieve Mr. J from school. On their drive home, Mr. J and his father were involved in a motor vehicle accident. Mr. J’s father died, and Mr. J was in a coma for 10 days, after which point, he required more than a month of extensive speech, occupational, and vestibular therapy.

Mr. J was formally diagnosed with schizoaffective disorder after the accident; however, the pre-TBI history that we obtained from Mr. J and collateral was consistent with this diagnosis: he had experienced delusions for months without any attendant mood symptoms. Additionally, he had a genetic predisposition as his mother had been diagnosed with schizoaffective disorder. Mr. J was thereafter trialed on a variety of antipsychotics and mood stabilizers for treatment. Mr. J attempted to resume college courses but, due to reported “concentration problems,” he was not successful.

When Mr. J arrived at the inpatient psychiatry unit, he was polite and showing good behavioral control but guarded with darting eyes behind sunglasses, which he refused to remove. He told an incoherent story about various government agencies and a social media platform and its founder pursuing him for unknown reasons. He reported that he had caused the tractor-trailer to crash into his father’s vehicle, though he was not sure how, and believed that he had also died in the crash or that he was an impostor. Additionally, due to his guilt about the accident, he also believed he was guilty of many other crimes. He would often make statements such as “I may be dead or we are all dead…I have the guilt of the survivor maybe…how can I know what I’ve done? It’s safer just to do what they say.” The “they” that Mr. J frequently referred to were the creators of scams that would ask Mr. J for money. Mr. J’s uncle reports that Mr. J has spent $200,000 paying scammers and spent the majority of his time answering emails, calls, or texts related to these entities. This money primarily came from a large financial settlement as a result of the accident. Due to Mr. J’s paranoia and failure to follow-up, legal and financial guardianship had not been established. It was never made clear whether Mr. J had ever fallen victim to scams prior to the accident, but his uncle did not think so.

Mr. J did not demonstrate or endorse any affective symptoms on presentation, and he agreed to reinitiate his home medication, risperidone, which was titrated up to a daily dose of 6mg. On this dose, he became linear, less guarded, and was able to discuss his delusions at length, but he never exhibited reality testing.

Due to the lack of significant improvement on risperidone, the team switched to clozapine. We chose clozapine because Mr. J and his former psychiatrist confirmed previous efficacy but subsequent discontinuation due to nonadherence to blood draws. We learned from discussions with his former treater that multiple trials of long-acting injectable formulations of risperidone, including the maximum available dose, had failed to achieve any meaningful benefit. Additionally, Mr. J had a delusion that he could not afford injectables and did not wish to transition to one. He was, however, amenable to restarting clozapine. Clozapine was titrated to 200mg daily, at which point, side effects (i.e., tremor and tachycardia) made further increase intolerable. Over the course of two weeks, Mr. J’s delusions lessened. He no longer believed he was dead and could engage in reality testing pertaining to his paranoid delusions. In addition, the team began instructing Mr. J in techniques to think critically about the scams. While he was able to teach back and demonstrated good use of the techniques, after 10 or 15 minutes, he would pay the scammer. When questioned about the change, he stated, “well, I know it’s a scam, but I can’t be totally sure.” The scams he fell prey to were either ones in which famous people accused him of unnamed crimes and required money wired to them in order to buy their silence or romance scams in which he sent money to supposed women in other countries requesting financial support. He was contacted primarily through email but also was targeted with video calls and, at one point, a visitor to the unit attempted to obtain his college tuition from Mr. J, which he agreed to pay until the psychiatry team intervened. He subsequently required visitor and computer restriction.

Mr. J was paranoid of brain imaging and, given his stable presentation, there was no indication to pursue imaging over his objection. Neuropsychological testing showed normal intelligence with strengths in cognitive speed, verbal skills, and abstraction/problem-solving but deficits in executive function and attention and a moderate level of impairment in facial emotional recognition. Consequently, the team worked with Mr. J’s uncle to set up power of attorney and financial guardianship. Additionally, due to Mr. J’s isolation and loss to follow-up, he transitioned to a day program in his community with the ultimate goal of obtaining a job and, perhaps, finishing school.

Discussion

We present here a case of a young man with schizoaffective disorder who suffered a severe TBI after a motor vehicle accident seven years prior to presentation to our institution. Despite initial medication resistance, he achieved reality testing of his paranoid delusions and the resolution of his CD while on clozapine. Yet, despite these gains, the patient remained vulnerable to Internet scams, losing over $1,000 on the inpatient unit even after his delusions began to resolve and restrictions on his Internet use and visitors were placed.

As mentioned earlier, susceptibility to scams is a costly public health and economic scourge. A central tenet of scam susceptibility involves the theory of gullibility.1 As defined by Teunnise, et al gullibility is an individual’s propensity to accept a false premise in the presence of untrustworthiness clues. At times, all individuals experience gullibility because there are a variety of external factors that can affect this propensity such as fatigue, cognitive load, and emotional state. Indeed, a report is referenced in which people primed to be happy were more likely to make errors in detecting deceptive communications.18 However, a chronic inability to detect untrustworthiness, as in the case of our patient, points toward low social intelligence being the cause of gullibility. Social intelligence is a complicated, multifaceted construct that draws from both behavioral components (e.g., “people skills”) and cognitive components (e.g., mentalizing or perspective-taking).19 Taking into account our patient’s neuropsychological testing showing impairment in facial emotional recognition, it is perhaps not surprising that our patient repeatedly struggled to understand the perspectives of others. Indeed, other patients with deficits in facial emotional recognition seem to show impaired mentalizing even in situations without visual interaction.20–22 When asked why famous billionaires might have wanted a few hundred dollars from our patient in order to stay silent on unnamed crimes, Mr. J could not answer. “I don’t know…I’m not sure what they’re thinking.” Other research has shown that, even with intact cognitive skills, motivations and wishes might hamper the ability to think critically. For instance, a desire for love might cloud the judgment of a usually critical person when involved in a romance scam.4 Our patient, already suffering from diminished mentalization abilities, lamented his loneliness and would admit at times that he worried “the emails and messages would stop if I don’t answer all these people, whoever they are.” This wish for social connection likely further contributed to his scam susceptibility.

Research out of the Rush Memory and Aging Project suggests that, beyond psychological constructs, scam vulnerability might have neuroanatomical correlates.2,3 A subset of patients within the study (327 participants, 78.9 percent female, mean age: 81.55 years) answered a scam susceptibility self-report measure and underwent magnetic resonance imaging. Adjusting for age, education, sex, and cognitive function revealed an inverse association between scam susceptibility and gray matter volume in the right parahippocampal/hippocampal/fusiform, right hippocampal, and right medial temporal regions.2 Medial temporal lobe structures have been implicated in prospective memory-processing, which has increasingly been associated with decision-making.23–26

Future thinking helps to inhibit the tendency of humans to discount the value of future rewards for more immediate, smaller rewards. Future thinking has been attributed to the functional coupling of medial temporal lobe structures and the anterior cingulate cortex, which guides voluntary choices coming from frontal lobe networks based on the history of past actions and their outcomes. The accurate representation of past events and their outcomes has been attributed specifically to the medial temporal lobe.23,26 A study from the same group looking at white matter differences found that a high level of scam susceptibility was correlated with lower white-matter integrity in right hemisphere temporal and parietal regions—a complement to the gray matter findings of 2015.3 Essentially, a breakdown in this network might decrease the ability of a person to accurately assess the negative consequences of a potential scam, particularly based on past learning and experience. While these studies were conducted in an elderly population, it is worth noting that these differences were seen even after adjusting for cognition. Additionally, our patient suffered from a severe TBI and chronic mental illness, which can both cause damage similar to that seen during aging and degeneration.

Given that our patient’s symptoms could not be easily attributed to either his TBI or his psychotic illness and that further increases of clozapine were intolerable, we explored various adjunctive treatments for TBI. Therapy for TBI is comprehensive and multidimensional. Increasing research has been performed on patients with TBI and subsequent social communication difficulty and there has been a shift toward focusing on context-sensitive treatment rather than impairment-focused therapy27,28—i.e., focusing on improving the ability to complete activities of daily living rather than attempting to improve scores on working memory or cognitive flexibility tests. These interventions are almost always done with some measure of group activity. In our patient’s case, the daily activity to work toward would be navigating the Internet safely, with our hope that his social abilities and “people skills” could be enhanced in an outpatient day program.

There has been rising interest in metacognitive strategy intervention (MSI). Metacognition means thinking about thinking. In MSI, patients are trained to break up complicated tasks into smaller ones and to monitor themselves as they go about completing these tasks.29 A pilot study from Australia using MSI showed promising results as a proof of concept.30 For our patient, the potential to break up the complex task of navigating the Internet and messaging sites into manageable pieces could leverage his residual cognitive strengths. His computer restriction allowed 30 minutes of closely supervised computer use/coaching with a member of the team who helped him organize his Internet usage into smaller pieces in order to achieve his goals (e.g., reading the news and talking to his uncle).

Our case report highlights how practitioners must continually assess their patients’ functioning outside of traditional domains. The patient here, after initiating rehabilitation and clozapine, could be quite linear and even reality test. However, he continued to lose money to scammers despite good control of his delusions. Research into scam susceptibility has revealed a number of interesting findings related to pathogenesis and demonstrate that it is not just a behavior born out of circumstances but, likely, a trait with neuroanatomical correlates made worse by aging, injury, or mental illness. TBI rehabilitation research has opened a number of promising avenues with regard to possible risk mitigation including a focus on context-sensitive treatment as well as meta-cognitive strategies. Our patient’s treatment going forward will need to encompass not just medication but also extensive rehabilitation, with tenets learned from TBI recovery research.

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