THE PAIN DETECTIVE: IS PAIN MALINGERING A VALID CONCEPT?

1. THE PAIN DETECTIVE: IS PAIN MALINGERING A VALID CONCEPT? George Mendelson MB BS, MD, FRANZCP, FFPMANZCA Department of Psychological Medicine, Monash University; Caulfield Pain Management and Research Centre, Melbourne, Australia Presented at Clinical and Legal Issues in Pain SIG Conference Stanford University, August 2002

2. “Pain is the disease most frequently assumed; and in proportion to the facility of assuming it, must be the vigilance of those whose duty it is to detect the fraud.” Elements of Medical Jurisprudence, Albany: Websters and Skinners, 1823. Theodric Romeyn Beck (1791-1855)

3. “willful, deliberate, and fraudulent feigning or exaggeration of the symptoms of illness or injury, done for the purpose of a consciously desired end.” Dorland’s Medical Dictionary

6. The words worried David and he became very much afraid of King Achish of Gath. So he concealed his good sense from them; he feigned madness for their benefit. He scratched marks on the doors of the gate and let his saliva run down his beard. 1 Samuel 21:13-14

11. “The intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.” (V65.2) DSM-IV-TR (2000)

12. Chapter XXI Factors influencing health status and contact with health services (Z00 - Z99) Z76.5 Malingerer [conscious simulation] Includes: persons feigning illness with obvious motivation ICD-10 (1992)

13. Indicators of allegedly malingered pain • weakness to manual testing not seen in other activities, i.e., heel toe walking • disablement is disproportionate to objective findings • pain does not follow organic pattern • endorsement of false symptom suggestions • cogwheel weakness • overreaction during examination Leavitt & Sweet, 1986

14. Approaches to the evaluation of allegedly malingered pain • questionnaires • clinical examination • facial expression • mechanical testing • differential spinal blocks • thermography • amytal or pentothal administration

15. Approaches to the evaluation of allegedly malingered pain Questionnaires - SCL-90 - Pain Patient Profile - MMPI-2

16. Approaches to the evaluation of allegedly malingered pain Clinical examination Waddell’s nonorganic signs - tenderness: superficial, nonanatomic - simulation: axial loading, rotation - distraction: straight leg raising - regional: weakness, sensory - overreaction

17. Approaches to the evaluation of allegedly malingered pain Facial expression - Poole & Craig, 1992

18. Approaches to the evaluation of allegedly malingered pain Mechanical testing - spinal dynamometry - Jamar dynamometer (grip strength)

19. Approaches to the evaluation of allegedly malingered pain Differential spinal blocks - Winnie & Collins, 1968

20. Approaches to the evaluation of allegedly malingered pain Thermography “There is no doubt in the mind of the Court, after hearing six days of medical testimony, that the beauty of a thermogram seems to lie in the eyes of the beholder and that its diagnostic value is not supported in any way by even one scientific study which conforms to scientifically accepted protocol.” Palma v State Farm Fire & Casualty Co., 489 So.2d 147

21. Approaches to the evaluation of allegedly malingered pain Amytal or pentothal administration - Shoichet, 1978 - Thomas & Aidinis, 1989

22. Approaches to the evaluation of allegedly malingered pain “It should also be noted that the assessment of ‘exaggeration; inappropriate responses; functional behaviour pattern; inappropriate pain response etc’ is a personal assessment…”

24. Nomogenic disorders in court (1) The only reported cases have been in Canada, predominantly in British Columbia Term has been used in reports by Bonnie Hayes and by Carol Solyom (co-authors of the 1993 study published in Spine), both in Dept of Psychology, UBC, Vancouver

25. Nomogenic disorders in court (2) “… for a psychologist’s report to be admissible it must, of course, be relevant to some matter directly in issue, not just a comment on the credibility or reliability of the plaintiff… The crux of the psychologist’s opinion at the end of a very long report… is that ‘the results of personality testing point to a nomogenic component to the complaints’ … because of the limits of her expertise, the opinion of the psychologist in her report about the validity of the plaintiff’s complaints being simply a comment on credibility or reliability, is inadmissible.” Klimchuk v Lebrun, Paris J, 1993 B.C.L.R. (2d) 360

26. Nomogenic disorders in court (3) “… it has, in my view, been decided that an opinion as to the existence of what psychologists refer to as a ‘nomogenic component of complaints’ is not admissible to prove that a plaintiff’s complaints are maintained by expectations of financial gain through litigation. If Dr. Hayes’ conclusion is inadmissible there is then no basis on which any part of her report can be admitted.” Kuhne v Minifie et al; Kuhne v I.C.B.C., Loo J, 2000 BCSC 1778

29. “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” IASP, 1975

30. “The reports of individuals may lack credibility for a variety of reasons... The reasons for this are multiple, including psychosis, severe depression, memory deficits secondary to brain injury, and a lack of cooperation. Other individuals provide detailed information, but the validity of the information is questionable.” AMA Guides, 5th edition, 2000

33. Legitimate role of the healthcare professional in the assessment of personal injury/disability claimants  Is there a diagnosable disorder/disease?  What is the aetiology of the condition?  What is the extent of impairment? - is it temporary or permanent?  Is the history consistent? - is it plausible?  Are findings on physical examination/MSE consistent/credible?  Has there been compliance with treatment and  recommendations?  Has there been cooperation and motivation during rehabilitation?

34. Conclusion The “ultimate issue” of veracity is for the court to determine. Pain is a subjective experience - there are no objective methods to determine the presence of chronic pain. The “gold standard” of malingering is a legal finding of fraud - psychologists and psychiatrists are not “lie detectors”.