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Tests to determine exaggeration of symptoms or psychological overlay
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Tests to determine exaggeration of symptoms or psycholo... - March 14, 2005 9:08:00 AM
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VagusX
Posts: 216
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From: Savannah, GA, USA
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Hello Everybody,
I do lots of Disability/Social Security Evaluations and I am intested in streamlining the examination process and trying to make it easier for the adjudicators to weed out the fakers, exagerattors, and psych cases.
I am currently using the Modified Oswestry, Innapropriate Pain Questionaire, Pain Drawing, and a pre and post VAS pain scale. I also throw in some non-physiological testing during the examination.
What are some recommendations on Pain Questionaires/Tests that are effective in pulling out the population that i listed above.
Thanks
Dan
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 10:50:00 AM
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jma
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From: NY
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Hello,
I am not too familiar with the specifics of pain tests that can sort out fakers, etc. I have heard of Gordon Waddell, who describes a series of tests that are designed for use as a simple and rapid screening exam to help indentify the patients who present with nonorganic, psychologist and social elements to their pain syndrome. However, this applies to those who complain of back pain.
This is the article:
Waddell G: Non-organic Physical Signs in Low Back pain. Spine 5: 117-125, Mar/Apr 1980
JMA
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 11:03:00 AM
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VagusX
Posts: 216
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Thanks for the response jMa
I am familiar with most of Wadell's non-organic testing.
I am already using Simulation of Axial loading, Simulation of Roation, Distraction SLR/Flip Test, Regional Disturbances such as cogwheeling, nonanatomic regional tenderness, overreaction, Hoover Sign, Lumbar flexion Test, my favorite Gordon toe Flexion Test (wiggling the hallux to increase back pain), patella shift test, and dorsiflexion/Plantarflexion test. A bunch of other one's exist.
I am more interested in paper tests that I can give to claimant's/patients during the intake.
Dan
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 11:11:00 AM
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jma
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Hello,
These tests came from one of my textbooks. Perhaps you have come across them but perhaps not all of them. Maybe one of them can help you.
1. McGill Pain Questionnaire (MPQ)
2. McGill Melzack Short Form
3. Multidimensional pain Inventory (MPI)
4. Pain disability index
5. Pain perception profile
6. Pain and Impairment Relationship Scale (PAIRS)
7. Symptom checklist 90 (SCL-90)
JMA
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 12:31:00 PM
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SJBird55
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I thought that Waddell or someone did not recommend the tests to be used to determine malingerers.
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 2:49:00 PM
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Brad_Stevens
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SJ you're spot on:
Main & Waddell (1998) have cautioned medical personnel about over-interpreting the significance of the presence of Waddell's signs:
"Isolated signs should not be over-interpreted. Multiple signs suggest that the patient does not have (only) a straight forward physical problem, but that psychological factors also need to be considered…Behavioural signs are not on their own a test of credibility or faking."
Main CJ & Waddell G (1998) Behavioral responses to examination. A reappraisal of the interpretation of "nonorganic signs". Spine 23(21):2367-71.
Waddell G, McCulloch JA, Kummel E, & Venner RM (1980) Nonorganic physical signs in low-back pain. Spine 5(2):117-25
Indeed Waddell's (and others) shift from these clinical signs to more valid measures of psychosocial factors as fear-avoidance beliefs could be interpreted as important.
Brad
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 4:06:00 PM
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VagusX
Posts: 216
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From: Savannah, GA, USA
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I am not trying to use these tests soley crucify malingerers. The Wadell test are used to determine the presence of psychological overlay, not to weed out malingerers specifically. I believe stronly that many people who test positive for the Wadell tests have a psychological problem and are not out the screw the system. I use the tests in my exams to assist the adjudicators in making an accurate decision on whether or not a person is disabled psychologically. I still run all my MMT/ROM, sensory, coordination, functional tests even though a person is frequently lethargic and complaining.
I do not run the Waddell tests on everybody, but if a 28 y/o female with an ingrown toenail (which i have actually received) walks into my room for a disability evaluation I am going to use every test in the book to show that either this person is a mental case or a malingerer. I like the tests. They assist more than saying I think that this person has some psychological overlay and leave it at that. Plus, deep down I think that she should be working. I can't help it.
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 4:30:00 PM
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nari
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Vagus
This is quite brutal thinking, in the light of pain physiology; if someone comes in with an ingrown toenail, and distressed, should they seriously be called mental or malingerer?
Do you think that people invent pain for the fun of it...not sure if there are too many true malingerers around, though some definitely milk the system.
Instead of being labelled as a mental case, maybe this person is simply showing a lack of coping skills and revealing a nasty social history.
We ALL have psychological "overlay" -it exists in everything we do and say and think. It is normal functioning.Using such a term is quite outdated;
I wonder what the definition of a malingerer is in the USA - how do we prove beyond doubt this person has no pain??
Just curious.
nari
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 6:41:00 PM
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VagusX
Posts: 216
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From: Savannah, GA, USA
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And a person with a nasty social hx needs help. If I can somehow lead that person in the right direction by giving my insight into the situation then I am doing my job correctly.
At this point in my life I am convinced that I have a job that can change people's lives as well as improve society. I do it by seperating rational and irrational thought. I am rational in my thinking that letting people know that they CAN be functional in the state that they are currently at IS possible. They may need help but it is possible.
I am learning more and more about pain psychology all the time. I am becoming more sensitive to it and at the same time feel that I am better able to diagnose people with "psychological overlay" and able to determine those whom want to milk the system. I give everybody the benefit of the doubt. But I can become cynical quickly. I do not fully agree with the diasability system. I do what I can.
What would you suggest we use other than the word "overlay?" I would like to understand how you explain people that walk into your office that are "questionable." How do you handle it? Do you nurture them and bring them back to health in every case, or do you send them away in the same state that they came to you? How are you getting these people help that they need? This is not an attack. I would honestly like to know how others handle these patients.
As far as proving pain. You can't. But humans have an inate ability to sense pain. I beleive each one of us can see into the eyes of our patients and understand the pain that they are having. If I do not sense pain, or I sense exaggerated pain, high pain focus or whatever you would like to call it I will take the next step as to find out what else is needed for that patient. A sensed malingerer will receive one outcome and the psychological will receive another.
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 7:11:00 PM
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Dr.Wagner
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secondary gain is so ground into our lives, one would be naive to think there is no utility in Waddells tests. People will lie to your face if they have 1. something to hide 2. something to gain.(yes there are other reasons, but these are the two I frequently deal with) These same people will take you for a ride...they play a game.
I had a young man lie to my face two seperate times today. When I exposed his lie, he apologized. Why, he had something to hide (crack use). Point blank to my face he denied using. My examples are endless...I have no doubt what so ever I was lied to as a PT...today I am jaded that I sniff this stuff out much better.
Doubt is healthy.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 8:25:00 PM
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VagusX
Posts: 216
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From: Savannah, GA, USA
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I'm just curious Dr. Wagner. What do you do when a person like that tells you, or lies to you then tells you that he is using crack? I'm not going to ask you any specific details about his hx or anything but how did you handle the situation?
Dan
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 8:41:00 PM
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nari
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From: Australia
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Vagus
Thanks for your expanded thoughts.
Words like 'catastrophising'; 'loss of control'; 'acopia' come to mind when we are talking "psychological" issues. But pain is physiological, not psychological in my mind - and if they understand how their reactions are altering the pain state; if they understand that the pain they feel may not be necessary if they can tackle their negative thoughts, low self-esteem, belief that they are 'victims' of their own attitude and that their injury (if there is one) is healed... it is a start.
A comprehensive subjective history is the first stop - and when the yellow flags start flapping in the breeze, you can deal with the issues there, or if their depressive state is beyond a PT's abilities to handle - refer on.
In run of the mill patients, there may be few malingerers; they are more commonplace in pain clinics where objective findings simply do not match subjective, and there is often a secondary gain (along with $$$$$s) to be considered.
Careful about the word 'psychology'...the vast majority of patients with ongoing pain sit with the study of pain physiology.
Brain and body are not separate - they are one.
Good references are papers and texts by Louis Gifford, Lorimer Moseley, David Butler for a start.
Dr Wagner - I think the patients you see are in the front line; I do recognise that addicted persons want only one thing - quick fix, never mind the s--t, give the stuff to me....
And I do not envy you one bit!!!
nari
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Re: Tests to determine exaggeration of symptoms or psyc... - March 14, 2005 9:14:00 PM
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Randy Dixon
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Nari,
I don't know what kind of environment you work in, perhaps the Australian system doesn't encourage this behavior. I worked in Industrial Rehab., virtually everyone lied, virtually everyone exaggerated at one time or another. Many were outright cheats, but even those who had no reason to lie, did. The reasons are complicated. They might be feeling good that day, or maybe running actually felt good for them, but if they admitted it they were scared they wouldn't be believed that they were really injured. Many times when a worker is injured on the job the relationship between employer and employee becomes adversarial. This is unfortunate, and there is some movement towards reducing this. For example, it was, and often is, standard practice that when an employee is injured no one from the company communicates directly with them, don't ask then how they are doing, or make any admission about how the injury happened.
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 2:02:00 AM
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SJBird55
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Vagus, I think you do have to go about things the way you are. I know that when someone applies for disability, somewhere along the line my notes will be requested. I hope that when they are requested that someone really reads mine. Believe it or not, there are times that folks who are in so much pain and filing for disability because they can't do their "job" any longer lie like a rug.
I had one guy who was using a chainsaw and cutting up shrubbery, putting in a pasture fence... going out dancing.... painting walls.... and the crazy sucker was planning to murder his ex-wife's lover and use me as an alibi.... oh, but he had so much pain and he couldn't do anything. Yeah... I booted him out of the clinic. Looking in his eyes, there was no substantial physical pain.
Nari, if I'm understanding Vagus correctly, Vagus has a primary role in assessing to determine if disability is potentially granted to the person. If he fell for every sob story and believed everything he heard.... geesh, tax dollars supporting every person that couldn't function normally. I don't think Vagus has a role in treating anyone, just determining if disability requirements are met and recommending what the person needs.
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 2:44:00 AM
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Jon Newman
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When one tells a lie, what pretense are they trying to uphold? This should be easy, just think of the last lie you told...it likely wasn't long ago.
What environmental conditions need to exist for someone not to lie. This should be easy also. What were the conditions that promted you to lie most recently and under what conditions would have told the truth?
Often to our detriment, we are in a position in which to judge people.
Vagus judges who is worthy of being reimbursed for leading a disabled life. It's part of his job description.
Dr. Wagner judges who is worthy of narcotics. It's part of his job description.
Judging is a legitimate aspect of your job descriptions and not just some unintended consequence. What would you folks like to see happen to make your decisions easier?
I don't think a test is going to do it.
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 4:41:00 AM
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Diane
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I thought this link might belong here:
[URL=http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6X03-4FNP84W-C&_coverDate=02%2F01%2F2005&_alid=256705719&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=7203&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=e766277cd62c74e2287af6be391dbe7a]Reflections on the Ethical Dimensions of Outcomes Research[/URL]
This one is just plain interesting, sort of the opposite of what lots of PTs assume..
[URL=http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8V-4FPDXJD-G&_coverDate=01%2F01%2F2005&_alid=256703946&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5096&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=2ec0fc8ab099838823205321872f246c]low back pain and alexithymia[/URL]
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 5:02:00 AM
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PTupdate.com
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There are basically two lines of thinking in this post, and they really fall along the lines our society thinks about many things.
There are many who see persons exaggerating symptoms and malingering as a plague, and an issue that needs to be dealt with directly. Others recognize the behavior, and feel there are more deep roots to the problem.
If someone is symptom magnifying, faking, or whatever, the behavior is wrong...period. I don't care what their deeper reasons are, the behavior is wrong. I don't care if they don't like their dog, hated their mother when young, or just don't want to work any more. Call me cold, but I think what we see and read every day indicates that too soft of an approach leads to abuse.
A recent study in Spine journal notes how countries with very very limited payout for auto claims (thus the removal of secondary gain) have almost no claims for disability and minimal utilization after MVA.
Our country, on the other hand, rewards people with a cash settlement based on an average of 3x medical expenses (after some greasy attorney takes his handful). I have been floored at some of the requests for SS Disability I have recieved over the years, and my first thought is usually "that goof can work like the rest of us"
In my 14 years of practice, I have NEVER once had a case where there were signs/symptoms of symptom magnification without some form of secondary gain. Those times where I felt something fishy was going on, but did not have the info up front (yes they fell, but it was at a restaurant and the plan on suing, etc), I have always ended up in the long run getting the answer.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 5:28:00 AM
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january
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Diane,
Your second link exists in full free text access. (click on the tittle of the journal and access it thru the "sample online").
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 6:06:00 AM
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JLS_PT_OCS
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I would agree with John D in that the problem is as much about how our society and our medical system treats people than it is how an individual copes with a problem.
I think we can all agree on the extremes of this spectrum: ie #1 calling everyone with yellow flags or secondary gain issues worthless layabouts and #2 giving everyone who complains of pain all the treatment and money they want.
Clearly, the issue for us is deciding where someone fits along that line and how best to address their rehabilitation needs. Or in Vagus' case (no envy for you here, buddy), determining whether benefits are paid.
We need to strike the right balance between sympathy and care for those in pain and respect for fairness for those who must pay for such care.
Certainly there is significant epidemiological evidence that points to no issues with secondary gain or with claims when there is no opportunity to make money. Low back pain is rife with this type of research, and Waddell's Back Pain Revolution book chronicles and cites those well.
However, we all do know that there are definitely some cognitive-behavioral, yellow flag type issues out there that complicate the picture. We use the Fear Avoidance Behavior Questionnaire with many of these patients (low back pain only), and I find it helpful in sorting out who can be treated and streeted relatively quickly, and who needs a more CBT type of intensive intervention.
I think our goal here should be to, as Vagus asked, identify those folks who have those types of issues as early as possible so they can get optimal treatment. So far given current evidence, optimal treatment seems to be a multidisciplinary strategy involving both rehab and CBT type stuff, either by PT or by professional counselors.
Perhaps if those types of issues are found, perhaps Vagus can recommend a reeval for disability benefits after a 6-8 month period of such intensive multidisciplinary treatment? I don't know if that's an option for him, but I would think it would be an appropriate recommendation.
In the meantime, I recommend the FABQ.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 6:34:00 AM
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Jon Newman
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Duffy,
I don't see anyone advocating a soft approach.
I would encourage all to read virtually anything written by Nortin Hadler for more on the subject. I think he has some excellent insights.
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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