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Re: Tests to determine exaggeration of symptoms or psychological overlay
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 6:47:00 AM
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JLS_PT_OCS
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From: USA
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Jon, it may be that no one in the rehab world is advocating a soft approach, I agree with you there.
I would say that just the way our system (here in the US anyway) is designed, it encourages this type of behavior. In effect, the laws and rules of our society make this type of thing a problem. I think Waddell hit it on the head when he brought up the incidence of work loss related to back pain in nurses in an african country (can't remember which one). There was not one lost work day on record for a large cohort. Simply, if they didn't work, they didn't get paid. Therefore, the incentive was not there.
I am not advocating we take that approach, but I think it illustrates how difficult it is to establish guidelines when the range of human reaction to pain and the social issues associated with work and compensation are so varied.
I agree with those who say that works such as Waddell's, Butler's, Hadler's, and others are very helpful in beginning to understand the scope and complexity of this issue. I remember in school sort of dreading all these psychosocial and pain physiology classes, thinking that they were a waste and people just need to get over things and move on. Boy, was I wrong. Those classes are some of the most important ones I had, and I dearly wish I had worked harder in them to learn more, knowing how instrumental they are in understanding things. Or beginning to understand things, anyway.
I wouldn't even know how to begin to do Vagus' job, and I'm glad that I'm not responsible for that part of the equation.
J
_____________________________
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 8:46:00 AM
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VagusX
Posts: 215
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From: Savannah, GA, USA
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Trust me everybody. I have been toiling over the whole disability system since I started. Most of the time I say "are you kidding me?, do they even set an eye on this guy before they send them over to me." I have 45 minutes to assess the person the best I can to gather as much evidence as possible for or against my "recommendation" on what this person is able and not able to do. I have been intructed by the system to not say that a person is "disabled" in my write up. I'm getting better at being up front but some of the time I can jsut not convey what I see during these exams.
I feel that running as many tests, taking a thorough subjective hx and gathering as much objective information as possible will assist the system in making the final decision. They like to hear my opinion on whether or not I feel a person is giving maximal effort, if I feel that this person has real problems or if I feel that person needs outside help. After the report leaves my office, I wish I knew more but it seams to disappear into obsurity. I have been told that they use my reports, but I know know that the claimant's get sent through a slew of other people like MD's, Shrinks, and then judges. Apparently most of the people that I see get denied. They are the questionable one's in the first place. I have been told directly by somebody at Social Security Adujudication Services that if the person is less than 55 y/o and they can put a sticker on a box then they probobly will not get disability.
I tend to have a little bit of both of the attitudes that Duffy explains. I think I teeter more to the side that exaggeraters as a plague not as something that needs to be nurtured and petted until they get exactly what they need to somehow return into the normal working world. Most people that come in, IMO, just don't want to work. Hopefully, when all is said and done with the disability process, they are denied and are forced to make changes in their lives to survive.
I recently came back from Costa Rica. I was a small town called Cabano in southwestern part of CR. I had one of my carry on bags stolen and I lost all of my medication. I needed to get a script from a MD to get my meds back because the pharmacy wouldn't just give them to me. I went around the corner to a MD office that was on top of a restaurant and waited for 15 minutes to see him without an appointment.
I went in and began to talk to him about what I did back in the US and he had questions about the healthcare system etc and then he went on to tell me about an accident he had while riding his bike. He said he got slammed by a passing motorcycle and was knocked off his bicycle. In the impact he gotten his left clavicle fractured. I asked if I could look at it and he took his shirt off. Well the clavicle was broken and overlapping. It happened 6 weeks previously and he was told by an ortho that he didn't need surgery. His range was good but he was very weak so I decided to draw him out some exercises. Told him about SC/AC mobs and scapular/RTC strength. We continued to talk and I brought up whether he was going to sue the guy that hit him. He sorta laughed and said "no, I let the guy that hit me leave the scene. I road my bike home with a broken clavicle and put myself in a sling." He said that he only took 2 days off from work and that was to travel to San Jose to see an orthopod.
Very interesting experience. He only charged me 5000 colones for the consultation ($10 dollars.) It was 10 of the best dollars that I have ever spent. What in the hell happened to the US. It justt cost me $200 plus a $40 dollar co-pay to see an MD for 10 minutes. Where is our society heading?
Thanks everybody for the great responses. I will be looking into some of the research posted, books and tests that people have put up.
Thank you
Daniel
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 9:17:00 AM
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Jon Newman
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From: Amherst, WI
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One of my favorite titles by Nortin Hadler is "If you have to prove you are ill, you can't get well"
Actually that's only part of the title but you get the picture.
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 9:57:00 AM
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VagusX
Posts: 215
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From: Savannah, GA, USA
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Some truth to that statement Jon. The problem comes in when the clinician is not educated on a particular problem/diagnosis and instead of looking into what that patient may have, they pon it off as made up. This is mostly referring to mental illness. Musculoskeletal problems that do not show objective differences from the normative values would most likely fit that phrase the best.
Dan
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 11:12:00 AM
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nari
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From: Australia
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Vagus and others
I agree, this is an area that I am not familiar with and frankly, do not want to be involved with.
I got rather carried away without sussing out the environment sufficiently. Thanks for expanding on that scene.
Nari
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 12:20:00 PM
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steve
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From: Canada
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Vagus,
Thanks for bringing up and expanding on this topic, it is one that is not often discussed in rehabilitation circles in such a frank manner. Having worked in this area it can be mentally and ethically draining and requires that you be very objective and thourough clinically. It sounds like you do all of this well.
I use the DRAM to evaluate mood, which has been correlated with potentially poor outcomes and will use a heart rate monitor to evaluate if there is a physiological change to effort exerted along with observation - ie. shaking, postural compensation etc. I also watch them perform functional tasks and compare this with their clinical examination and note discrepancies or lack of discrepancies. Of course, none of this can weed out if there is true intent to malinger or if a chronic pain scenario is occurring. A wise man once told me that the chronic pain patient is consistantly inconsistant in their presentation while the malingerer is inconsistant with their inconsistancies.
Steve
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Re: Tests to determine exaggeration of symptoms or psyc... - March 15, 2005 4:52:00 PM
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Dr.Wagner
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From: Indianapolis
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Vagus, you struck on two important topics...
First, what do I do when a patient lies, bold face lies... Well, as a Doc (vs when I was a PT) I now have a WHOLE lot more to look at, a much bigger picture, and a whole lot more to lose. When a patient sees me for back pain, in the acute care setting...I have a gigantic differential. So if the pain is exagerated, is this because of pathology or not? Do I need to search extensively for the pathology (medical pathology) or should I stick to muscular. Searching extensively can potentially be expensive (say kidney stones or AAA or mesenteric ischemia) or rather cheap, exertional "strain". So if a patient LIES to me, I get rather pissed, I don't want to waste my time and somebody's money. But I think I have a MUCH MUCH better trigger to tell if I am being lied to than I did as a PT. Why...because of the above, I have so much to lose and so much to consider. So if a patient is lying to me about "have you had discharge" or "have you been smoking crack" or "have you ever taken vicodin" or "so are you REALLY allergic to ibuprofen/toradol/naproxen/ultram/steroids/etc"...I generally know it and when the truth comes out, I let them know that 1. I am not the cops 2. don't lie to me again 3. their mistruths hide appropriate treatment plans
As for Costa Rica...EVERY doc would love to treat that way. But when the lawyers actively hunt for your head and insurance companies don't want to pay you...well then you find that you have to do something.
Perhaps if the CEO of Anthem didn't make 2 million a year.
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Moderator of Medical Complexity Forum
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Re: Tests to determine exaggeration of symptoms or psyc... - March 16, 2005 12:17:00 AM
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pablo w
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From: Canberra
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I've been following this with interest. I even started a reply and then canned it. A lot of interesting points, different points of view. I don't think it's that easy to solve. But based on what I have learned, all I can add is this: don't blame the patient. There are lots of reasons why people don't get better. I think that by assuming eceryone is a malingerer, we can do more harm than good. How many times have the patients who end up claiming for disability had rational, evidence-based treatment? Also keep in mind (as has been raised) that it's not just patients who potentially have something to gain from the process. Therapists, doctors, lawyers, the list goes on. It's easier to blame the patient than to question the system, our knowledge, etc.
Don't get me wrong, I'm not that naive that I think malingerers don't exist. But if someone seems to be exaggerating symptoms, for example, it might be because that is the most appropriate thing to do in that context. The doctor in Costa Rica does what is appropriate in his context. An injured worker who is treated from day one as if he were a malingerer is affected by the context as well. Exaggerating may actually be an appropriate behaviour. Think about it. You are in pain, and no-one believes you. How do you get attention so that you can get appropriate treatment? I think the environment/context has more to do with this than malicious intent.
Don't blame the patient if the system has failed.
OK, let me have it!
Pablo
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Re: Tests to determine exaggeration of symptoms or psyc... - March 16, 2005 1:46:00 AM
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SJBird55
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Pablo, I'm not really sensing anyone blaming the patient. The system here in the states has some problems that has created the potentiality for patients to not really be as they present to us at times. I think most of us, including Vagus, try to focus on not "rewarding" patients by giving in to their schemes of receiving monetary gain without substantial objective measures to justify why they should receive the money and why they should be deemed "disabled."
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Re: Tests to determine exaggeration of symptoms or psyc... - March 16, 2005 2:40:00 AM
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Jon Newman
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From: Amherst, WI
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Hi Pablo,
I think you make the point Hadler tends to make as demonstrated by the title I posted. If the system is set up such that you have to prove you are ill, people will adopt illness behavior in order to be right. And they may be right, but when their economic survival plan is on the line they amplify the behavior to make sure the point gets across. In so doing, the workers in that system are likely to say to themselves, "come on, give me a break".
Of course this could be seen as maladaptive but it is a form of adaptation nonetheless. It is "human nature".
What is amenable to change, "human nature" or the culture produced by a socio-bureaucratic system? I would answer that one is impossible and the other simply seems to approach that extreme.
How would people change the "system" in which they choose to work, in order to reduce this burden? I'll add, what part do we play in the system in which we work? I think Pablo, you are asking this as well.
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 17, 2005 1:07:00 PM
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pablo w
Posts: 88
Joined: November 13, 2002
From: Canberra
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Thanks Nari for this link:
Clin J Pain • Volume 20, Number 6, November/December 2004
Malingering Pain in the Medicolegal Context
[Special Topic Series: Pain Deception and Malingering]
Abstract: Malingering—the willful, deliberate, and fraudulent
feigning or exaggeration of illness—was originally described as a
means of avoiding military service. In present-day clinical practice,
malingering may occur in circumstances where the person wishes to
avoid legal responsibility or in situations where compensation or
some other benefit might be obtained. In law, the term malingering is
used in relation to persons to whom military regulations apply; in
other situations, malingering is regarded as fraud and may lead to
charges of perjury or criminal fraud. Assertions that an individual is
malingering are particularly common in clinical settings where the
complaint is of a subjective nature and is not accompanied by objectively
demonstrable organic abnormalities. This may occur in relation
to complaints of pain in situations where the person is entitled
to receive pain-contingent compensation or is suing for damages. In
this article, we will review the literature on pain and malingering
and discuss attempts that have been made to develop methods
and guidelines for the detection of malingered pain. There are, however,
no valid clinical methods of assessment of possible malingering
of pain. In our view, the ultimate issue of the veracity of the
plaintiff is for the Court to decide, and epithets such as “malingerer”
have no place in reports prepared for legal purposes by health care
professionals.
Check if the link works:
http://gateway.ut.ovid.com/gw2/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=00002508-200411000-00007&NEWS=N&CSC=Y&CHANNEL=PubMed
Pablo
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Re: Tests to determine exaggeration of symptoms or psyc... - March 17, 2005 1:26:00 PM
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pablo w
Posts: 88
Joined: November 13, 2002
From: Canberra
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Some more, from the same issue. The whole issue is worth a look if you have access:
Is There a Relationship Between Nonorganic Physical Findings
(Waddell Signs) and Secondary Gain/Malingering?
David A. Fishbain, MD, FAPA,*†‡§ R. B. Cutler, PhD,*§ H. L. Rosomoff, MD, DMedSc, FAAPM,†‡§
and R. Steele Rosomoff, BSN, MBA†‡§
Abstract: This is a structured evidence based review of all available
studies addressing the concept of nonorganic findings (Waddell
signs) and their potential relationship to secondary gain and malingering.
The objective of this review is to determine what evidence, if
any, exists for a relationship between Waddell signs and secondary
gain and malingering.
Waddell signs are a group of 8 physical findings divided into 5
categories, the presence of which has been alleged at times to indicate
the presence of secondary gain and malingering. A computer and
manual literature search produced 16 studies relating to Waddell
signs and secondary gain or malingering. These references were reviewed
in detail, sorted, and placed into tabular form according to
topic areas, which historically have been linked with the alleged possibility
of secondary gain and malingering: 1) Waddell sign correlation
with worker compensation and medicolegal status; 2) Waddell
sign improvement with treatment; 3) Waddell sign correlation with
Minnesota Multiphasic Personality Inventory validity scores; and 4)
Waddell sign correlation with physician dishonesty perception. Each
report in each topic area was categorized for scientific quality according
to guidelines developed by the Agency for Health Care Policy and
Research. The strength and consistency of this evidence in each subject
area was then also categorized according to Agency for Health
Care Policy and Research guidelines. Conclusions of this review were
based on these results. There was inconsistent evidence that Waddell
signs were not associated with worker’s compensation and medicolegal
status; there was consistent evidence that Waddell signs improved
with treatment; there was consistent evidence that Waddell signs
were not associated with invalid paper-pencil test; and there was inconsistent
evidence that Waddell signs were not associated with physician
perception of effort exaggeration. Overall, 75% of these reports reported
no association between Waddell signs and the 4 possible methods
of identifying patients with secondary gain and/or malingering.
Based on the above results, it was concluded that there was little
evidence for the claims of an association between Waddell signs and
secondary gain and malingering. The preponderance of the evidence
points to the opposite: no association.
Key Words: nonorganic physical signs, Waddell signs, nondermatomal
sensory abnormalities, malingering, chronic pain, secondary gain
(Clin J Pain 2004;20:399–408)
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Re: Tests to determine exaggeration of symptoms or psyc... - March 17, 2005 3:45:00 PM
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Jon Newman
Posts: 1707
Joined: April 24, 2004
From: Amherst, WI
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Some interesting commentary along these lines can also be found in the following references
Spine 30(2), Jan 15 2005, pp 265-268
This is a letter written by Lynton Giles, a DC, PhD.
Another reference can be found is Spine 29(13), July 1 2004, p 1392
This is an editorial by Centeno, Christopher J. MD; Elkins, Whitney L; Freeman, Michael
People interested in the subject may find the book Telling Lies by Paul Ekman worth a read.
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 17, 2005 4:49:00 PM
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pablo w
Posts: 88
Joined: November 13, 2002
From: Canberra
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Thanks Jon,
I'll chase those up. I have some of Ekman's work, but not Telling Lies.
Pablo
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