Malingering in the workers' compensation setting.

Friday, January 18, 2008 | 1

By Dr. Steven D. Feinberg

For many individuals that sustain an injury, there is a close correlation between subjective complaints and objective pathology. Since most physicians are trained in treating physical pathology, the outcome of treatment is usually satisfactory for all concerned.
For some patients, however, there appears to be a significant disparity between subjective complaints and objective findings.

The patient may present with various exaggerated pain behaviors, such as limping, moaning, groaning, and grimacing, while the physical examination and various tests may not reveal any obvious pathology. These individuals remain symptomatic longer, stay off work for prolonged periods of time (if they go back at all), and they tend to utilize a disproportionate share of
health care resources.

They are often labeled symptom magnifiers, elaborators, or exaggerators. We hear terms like hysteria, functional overlay, somatization, and chronic pain syndrome.
 
Some physicians do not understand or even recognize the disparity between subjective complaints and objective findings. The physician may take the patient at his or her word. If the patient says they cannot do certain activities, the physician acknowledges that they cannot do those activities. If the patient reports excruciating pain, the physician accepts that they must
have excruciating pain. If the patient claims to be wheelchair bound, then they must be confined to a wheelchair.

Many of these individuals are subjected to repeated and varied medical interventions, sometimes leading to untoward side effects and iatrogenic (physician created) complications. Physicians may become puzzled when their best effort seems to have corrected a physical abnormality, but the patient is not better or is even worse. In fact, the physician may get angry at the patient for not getting better and may blame the individual for not being motivated or for having a psychological problem to explain the lack of response to treatment.

Sometimes physicians continue to search for the "Holy Grail" to identify the  pain generator. After all, if it can be found, it can be fixed, can't it?

Perhaps there is another explanation.

Well-trained and experienced Pain Medicine physicians know that the extent of a patient's subjective complaints often have more to do with developmental, psychological, social, and cultural factors than with physical pathology. In fact, the seasoned pain specialist recognizes that there is risk of iatrogenic complications when the focus is on pathology without the realization that other non-physical factors may be playing a significant role in the clinical presentation.

Some patients who present with musculoskeletal pain complaints have underlying non-organic or behavioral problems that may not be immediately apparent. These non-organic causes of pain may be a deliberate deception (consciously aware) such as malingering in order to obtain secondary gain or factitious disorder in which the patient seeks to occupy the sick role. The causes may also be due to a process unknown to the patient (not consciously aware) such as with somatoform disorders.

Underlying causes of nonorganic back pain: Malingering
Malingering is defined as feigning or grossly exaggerating illness or disability to derive benefit, or secondary gain (e.g., to escape work, gain compensation or obtain drugs). By definition, a malingerer is a liar who is trying to cheat the system. If proven a malingerer, the individual may lose all workers' compensation benefits and also may face prosecution.

Risk factors for malingering include (a) ongoing litigation, (b) significant discrepancy between subjective disability and objective findings, (c) lack of cooperation with the evaluation and with treatment, and (d) the presence of antisocial personality disorder. The latter is marked by a history of unlawful behavior, aggressive behavior, deceitful behavior, consistent irresponsibility, and lack of remorse for wrongdoing. Fortunately, malingering is relatively rare.

Factitious Disorder
In factitious disorder, patients who want to occupy the sick role consciously fabricate symptoms to attract the attention of physicians. Factitious disorder is often confused with malingering. The patient with a factitious presentation not uncommonly agrees to unnecessary surgery and interventions, which the malingerer will not. The factitious patient is motivated by psychological needs, not external gain as in the case of the malingering patient. These unmet needs may include a need for attention, a desire to gain nurturance, or other intrapsychic issues.

The most severe and persistent form of factitious disorder is called Munchausen syndrome, after the fabled Baron von Munchausen, who spoke outrageous lies about his adventures. In Munchausen syndrome, the individual intentionally produces clinically convincing physical and laboratory signs of disease in order to obtain medical treatment. These individuals will inject themselves to produce swelling or infection, ingest agents to distort their laboratory findings, rub irritants on their skin to
produce rashes, or wear splints or braces unnecessarily. Over time, their medical records show extensive workups for convincing signs and symptoms, which change as the originally suspected disorder is on the verge of being ruled out.

These individuals need treatment for their underling psychiatric disorder, although affecting behavior change for this group is often quite difficult. This condition is infrequently seen in the injured worker population.

Somatoform Disorders
Somatoform disorders are a family of disorders that describe patients with complaints that may not have a physical cause. It is used to describe the variety of processes that lead patients to seek medical help for bodily symptoms that are misattributed to physical pathology.

There are several subtypes of Somatoform Disorders. Somatization disorder, for example, involves a variety of physiologic symptoms, such as pain, G.I. disturbance, sexual symptoms, and pseudoneurological symptoms (such as paralysis, weakness, blindness, etc.). There must be symptoms in each of these areas to meet the criteria for diagnosis and the symptoms cannot be fully explained by the medical work-up. Somatization “Disorder” is different from a patient who uses somatization as a “defense mechanism.” In the latter, the term is used more broadly to characterize patients who tend to develop physical symptoms to manifest emotional distress. That is, all patients with a Somatoform Disorder of some type employ somatization
as a defense. However, they may or may not meet the exact criteria for the more specific Somatization Disorder.

Another very common subtype of Somatoform problems is called Pain Disorder. For this problem, the criteria are relatively loose. Pain must be the predominant focus. There often is some form of physical etiology, but psychological factors must play a role in the onset, severity, exacerbation, or maintenance of the pain.

A Somatoform diagnosis does not mean there is no physical pathology or illness but that these behavioral symptoms can coexist with, mask, and facilitate real illness. While there may or may not be an underlying physical cause, the patient's symptoms and physical incapacity are out of proportion to the underlying physical condition. Although somatizing patients
usually have a psychologically-based problem, they rarely seek the help of a mental health professional. Rather, they seek care through the medical setting, where physicians often have serious difficulty recognizing and understanding them. Ineffective and sometimes harmful medical care can result.
 
Somatization may follow a relatively trivial injury after which the individual suffers ongoing and increasing symptoms. No matter what the physician does, the patient seems to get worse. Somatizing patients often become increasingly passive and dependent, and they may assume a victim role. A careful history usually reveals that in one way or another, these individuals
were emotionally short-changed during their childhood.

Alternately, somatizing patients may have been differentially reinforced for their behavior. That is, they may have been sent the message that it’s okay to be physically ill, but not okay to be “depressed” or “anxious.” Over time, family members, friends, and even physicians can inadvertently reinforce this belief.

An individual's perception of disease and disability is often fueled by factors having little to do with true physical pathology. In a society of entitlements, some people expect another individual or entity to take care of them. Illness, for some, becomes a way of life, with fulfillment obtained by time out from perceived unpleasant activities (i.e., work), while increased attention is gained from significant others who often assume a care-taking role. These patients typically use medical services in maladaptive and highly inefficient ways. They often obtain care from multiple medical providers and change doctors often. They reward doctors who provide excessive and unnecessary invasive and passive treatment approaches. They fire doctors who confront them about secondary gain and emotional issues.

These patients are convinced they are physically ill and deny the possible role of psychosocial factors. They resist psychiatric referral and in general are difficult to treat.

Contributing Factors
Although almost anyone can somatize under stress, certain individuals are prone to somatization. Research has shown that factors that contribute to somatization range from biological to psychological to social and to culture areas. These can make a patient particularly vulnerable to somatic complaints.

Factors that have been found to contribute to somatization can be  recognized and described by:

• Abuse or emotional deprivation in childhood
• Adult acute personal turmoil often involving abandonment and/or increased responsibilities
• Societal roles
• Learned behavior
• Secondary gain
• Cultural factors
• Seeking redress for a perceived wrong
• Personality factors (particularly histrionic, narcissistic, and borderline personality traits)

Somatization is essentially a disorder of appraisal. Some patients more readily ascribe illness to bodily sensations. These patients can also have a greater awareness and heightened perception of bodily states. This can result in more intense emotions that can increase somatic symptoms in these patients. In our society, we hold patients accountable for psychological distress, but not for physical distress. These physical symptoms can become a source of power for those who have no power in their workplace, family, or society. For some individuals being sick can solve more problems than it creates. Patients can temporarily escape from other role responsibilities (work, household chores, etc.) during the time they are sick.

Somatization may also be a learned behavior pattern that is maintained through social reinforcement. Patients who are sick receive attention and can get their needs met this way. Family members may become overly solicitous and care-taking. They do more and more, while the “disabled” member does less and less. Independence and functioning erode. Over time,
behavioral patterns of disability become as strong as cement.

Cultural factors also play an important role in somatization. Somatic symptoms can be used by patients to convey a message that they are having troubles in various areas of their lives. These symptoms may be used in the patient's culture as a way to communicate or a way to receive help and attention. Complaints such as sadness, loneliness or anxiety may not be taken seriously, whereas complaints of stomach pains or headaches are looked at very seriously. In some Latino cultures, men are not supposed to show weakness. In some Asian cultures, women are not supposed to show assertiveness. Whenever cultural rules or mores cut off legitimate expression of feelings, somatization becomes an avenue for communication or release of feeling states.

Pain Signal Misinterpretation and Relation to Fear
Some individuals do not understand the cause and meaning of their pain. They may interpret the pain signal as implying some sinister pathology or believe that nothing can be done to bring relief. Imagine the relatively uneducated patient with a back sprain who is discovered to have a spondylolysis on x-ray. This finding of a lumbar pars interarticularis "fracture" may have been present since childhood and may be of no clinical significance, yet the patient may report thereafter the presence of a
"fractured" spine and the inability to do anything out of fear.

The meaning that people make of their symptoms contributes greatly to disability. The patient’s interpretation, or appraisal, of their symptoms should be ascertained and gently corrected during every medical evaluation.

Waddell Behavioral Signs

A clinical assessment usually begins with history taking and records review and continues with a physical examination. In the assessment of low back pain, the patient's response to the physical examination is particularly important. In 1980, Dr. Gordon Waddell and associates drew attention to non-organic signs in back pain and attempted to integrate them into modern concepts of pain and illness behavior. They published a standardized assessment of behavioral (non-organic) responses to examination.

Waddell grouped eight signs into five types. These five types, or categories of signs, are tenderness, simulation, distraction, regional disturbances, and overreaction. The presence of three or more of these signs is considered a positive finding and is associated with other clinical measures of illness behavior and psychological distress – suggesting the patient does not have a
straightforward medical problem.

• Tenderness: Superficial and non-anatomic skin discomfort on palpation. Tenderness related to physical disease is usually
localized. Physical back pain does not make the skin tender to light touch.

• Simulation: Axial loading or simulated rotation with report of low back pain. Pressure on the top of the head (axial loading) of a standing patient should not cause low back pain. When the shoulders and pelvis are rotated in unison (simulated rotation), the structures in the back are not stressed. If the patient reports back pain with this maneuver, the test is considered positive for a non-organic source of the patient's complaints.

• Distraction: In the standard straight-leg raise test, the patient is recumbent and aware of the test being performed. In contrast, a distracted straight-leg raise test is performed anytime the hip is flexed with the knee straight. The distracted straight-leg raise test can be done by examining the foot with the patient seated with one knee extended. Another example of a distraction test would be when the patient uses the injured limb when distracted.

• Regional Disturbances: Sensory change or weakness. Any widespread or global numbness that involves an entire extremity (stocking - glove) or side of the body and does not follow expected neurologic patterns is suspect. Regional, sudden or uneven weakness (cogwheeling, giving way, breakaway) is a non-organic, behavioral sign.

• Overreaction: The patient may be hypersensitive to light touch at one point during examination but later give no response to touching of the same area. This is a positive sign of overreaction, as evidenced by a disproportionate grimace, tremor, exaggerated verbalizations, sweating, or collapse. Other behavioral signs include inappropriate sighing, guarding,
bracing, and rubbing; insistence on standing or changing position; and questionable use of walking aids or equipment.

The original purpose of the Waddell behavioral signs was to:
1. Aid clinical assessment by separation of the organic and non-organic elements of the presentation.

2. Direct appropriate resources toward the physical pathology.

3. Identify illness behavior.

4. Reduce or eliminate unnecessary procedures, diagnostic studies, and therapies.

In his article, Waddell cautioned the use of the behavioral signs in the following situations:

1. Multiple false positives were found in the elderly patients and it was recommended that such patients should be fully
evaluated.

2. Behavioral signs can occur in the presence of organic pathology. The presence of these behavioral signs does not
contradict organic findings.

Since Waddell published his article, multiple studies have independently validated his findings and have shown correlation between behavioral signs, level of disability, and physical and psychological factors. However, over the last twenty years Waddell behavioral signs have been misinterpreted and misused both clinically and medical-legally. Behavioral responses to
examination provide useful clinical information, but need to be interpreted with care and understanding. Multiple behavioral signs suggest that the patient does not have a straightforward physical problem and that psychological factors need to be considered. Patients who present with multiple behavioral signs require management of their physical pathology, as well as close attention and management of the psychological aspects of their illness. Behavioral signs offer only a psychological "red flag" and not a complete psychological assessment. Behavioral signs on their own are not a test of credibility or validity.

Differential Diagnosis

The most important step in the diagnostic process is the exclusion of significant underlying physical disease. Physicians are not omnipotent and many disease states are difficult to detect in the early stages, so great care is needed to rule out (within a reasonable degree) a diagnosable and treatable physical problem. Even if somatization or exaggeration is present, it behooves the physician to carefully watch for any symptoms or signs of underlying, previously unrecognized organic disease.

Other psychiatric conditions should also be considered, such as a depressive  disorder or anxiety disorder. Somatization does not rule out the existence of other psychiatric phenomena. Secondary gain issues need to be considered and factored into the equation to better understand the patient's presentation. Lastly, while uncommon, malingering and fraud must be considered as
well.
 
Management & Treatment

Optimally, each patient should be informed of their diagnosis, the expected course and duration of treatment, and their prognosis. This information helps to give the patient a sense of control over their condition, to avoid the assumption of the chronically sick role, and the ability to gauge their return to work plans.

It is also important to assess the patient's perception of the cause, meaning, and impact of the pain. If the patient believes that the cause is tissue damage, which means that activity will result in the progression of an illness, it will be difficult to get the individual to engage in a functionally oriented physical rehabilitation program. Treatment must be preceded by a cognitive shift, such that the patient no longer sees the illness as progressive and sinister. If movement, despite pain, is perceived as “safe,” then rehabilitation can ensue.
 
Adding a functionally-oriented physical rehabilitation pain management program can prove effective not only in reactivating the patient, but also by way of giving the individual a medical or non-psychiatric reason for getting better. Even with Somatoform Disorders with little or no medical contribution, physical rehabilitation provides a “face-saving” means for the
patient to get well.

Many patients do not believe they have a psychological problem and may feel that their physician is not taking them seriously.

Preparing patients for psychological referral is an important and artful step. Adopting an educational approach is preferred as it is non-accusatory and integrative. Especially in the absence of significant physical findings, the physician should educate the patient about the mind-body connection and explain the role that negative emotions play in symptom production, symptom perception, and illness behavior.

It is important to legitimize the patient’s symptoms. In an empathic manner, the physician should make a referral to a psychologist and/or psychiatrist, explaining that by addressing their emotional state, they will feel better psychologically and this will also help them heal and learn symptom-management techniques.

In addition, psychotropic medications are particularly helpful when the physical complaints are a manifestation of underlying depression or anxiety, and research has shown that antidepressant medication can have an analgesic effect as well.

Psychological treatment approaches used to treat somatization include cognitive-behavioral treatment, relaxation training, and psychotherapy (both group and family). Patients with somatoform tendencies often feel a strong need to have their pain validated. They have experienced test after test, often without positive finding of organic disease, despite knowing that
“something is definitely wrong." A useful technique is to inform them that they do in fact have a real medical problem – one that is related to their autonomic nervous system and that it is not “all in their head."

The physician can take the role of educator, explaining that the symptoms  are due to a disorder of the autonomic nervous system, which can be present despite “normal” diagnostic tests. After gaining confidence with the patient, an effort is made to identify psychosocial stressors that worsen the patient’s pain complaint and draw a link between these stressors and the disordered autonomic nervous system. Efforts can then be directed toward reducing or eliminating these stressors.

Psychotherapy that includes the family can assist the patient with managing chronic pain since significant others may inadvertently (or in some cases purposefully) support and maintain the patient's pain/illness behavior at home. Family members may also hold the same beliefs and attitudes toward disease. By working with the entire family “system,” psychotherapists can
provide education and model effective responses to illness behavior for the family.
 
The goals of treatment are to assist patients in (a) improving their function while managing their pain, (b) recognizing their underlying feelings and needs, (c) decreasing utilization of medical resources, and (d) improving productivity, such as work/school attendance. It is also important to keep the patient in one medical practice to discourage "doctor shopping" and
unnecessary tests/procedures and iatrogenic complications.

Summary

Patients occasionally present with complaints that far exceed the objective pathology. For some, physical symptoms serve as a focus for getting attention and remuneration, as well as a means to avoid personal and work responsibilities. For others, physical symptoms can be an expression of psychosocial or emotional conflict. Health care practitioners treating these
individuals may focus on the complaints, assume a correlation between findings on tests and procedures with the level of symptoms, and go forward with a variety of treatments while psychological, social and cultural factors may significantly (or in some cases solely) contribute to the patient's presentation. This type of approach unfortunately reinforces dysfunction and disability, and may result in iatrogenic complications.

The proper treatment for these individuals is to start by recognizing that non-physical factors can play a role in their presentation. Once recognized, appropriate treatment is then directed toward integrating both psychological and physical rehabilitation approaches. Treatment involves assisting the individual and family members in shifting beliefs away from viewing the pain of discomfort as sinister and damaging. Vigorous physical reactivation combined with educational and cognitive-behavioral approaches offer the patient the best chance for reasserting physical and emotional functionality and returning to gainful employment.

Dr. Feinberg is an associate clinical professor at the Stanford University School of Medicine. He is a member of the American Board of Pain Medicine, American Board of Electrodiagnostic Medicine, American Board of Physical Medicine & Rehabilitation
and serves as a qualified medical evaluator.