A DETAILED OUTLINE FOR QUALIFIED MEDICAL EXAMINERS: Detection and Assessment of Malingering in Chronic Pain Patients January 1, 2016 General Fall-Winter 2015-16: The Spine, Marin Medicine Magazine Anish Shah, MD, and Alex Kettner, PsyD According to several research studies, malingering, often referred to as symptom fabrication, may occur in a striking 20–40% of patients presenting with chronic pain. Symptom fabrication is defined as a condition where an individual intentionally exaggerates physical or psychological symptoms for external incentives such as obtaining financial compensation or medication, avoiding work or military duty, or eluding criminal prosecution.1–4 Although it has been proposed that symptom fabrication typically occurs in the hope of potential financial gain, statistics show that this is not usually the result. Studies have indicated that 82% of disabled people living in the U.S. have greater financial difficulties than when they were working, financial status remained about the same for 17%, and only 1.5% experienced financial gain.2,5 The reasons proposed for some patients assuming a “sick role” include:1–3 Weighing the cost/benefit of malingering. Not recognizing a better alternative. Wanting to avoid work-related stress. Dissatisfaction with a current position. Trying to obtain medication. Trying to receive the medical coverage that often accompanies disability benefits. Two 1990 nationwide surveys of Americans showed that 20% believed that fabricating symptoms for workers’ compensation claims was acceptable.6, 7 Moreover, a 2002 survey involving 144 neuropsychologists across the U.S. and Canada who performed medical-legal evaluations reported that 33.5% of injured patients with chronic pain engaged in symptom fabrication.1 This suggests that workers’ compensation claims can sometimes prompt symptom fabrication, whether for financial incentive or as an unintended result of medical-legal complexities. Due to the fairly high incidence of symptom fabrication among disability claimants, distinguishing patients who are fabricating or exaggerating symptoms from those who are truly chronic pain sufferers is a significant challenge for clinicians. This may be due to the complex and time-consuming nature of such assessments and/or clinicians’ concerns about the potential legal liabilities of a misclassification or the stigmatization it may cause a patient. Clinicians face additional obstacles because the doctor-patient relationship cannot be upheld in such cases. The assessment is based primarily on self-reported data, and the patient’s credibility may be brought into question, which can often lead to an exaggeration of reported symptoms. Obstacles like these raise the question as to how clinicians who serve as qualified medical evaluators (QMEs) in such cases can effectively perform objective evaluations. For years, self-reports have been the most widely used way of assessing chronic pain.8 To date, however, a reliable and accurate method of detecting symptom fabrication in self-reports is not available. To address this issue, a novel assessment was recently developed that involved measuring temperature and pain-sensation thresholds in healthy people under two conditions: one that encouraged honest reporting and one that encouraged feigning pain. The results can be used as a standard against which the scores of individuals reporting pain can be compared. It is possible that this approach may help clinicians better detect malingering.8 According to the DSM-IV-TR, patients who are suspected of fabricating symptoms typically display the following behavioral and emotional patterns:4 Symptoms presented in a medicolegal manner. Marked discrepancies between reported symptoms or disability and clinical findings. Failure to cooperate during evaluation or to comply with the prescribed treatment regimen. Symptoms associated with antisocial personality disorder. Combining observed patterns like these with the results of the recently developed assessment approach mentioned above may prove to be an effective means of detecting chronic pain malingering. Conversely, criteria that clinicians can consider when evaluating patients exhibiting true chronic pain include: Information that the patient has received intensive treatment for the injury. Objective corroboration of the reported symptoms and the diagnostic evaluation. Evidence that the patient has suffered obvious and significant personal and financial losses. Presence of self-defeating behavior. Symptom fabrication must also be differentiated from conditions such as undetected or underestimated physical illnesses, somatoform disorders (e.g., pain, somatization, hypochondriasis, conversion), and factitious disorders that present predominantly physical symptoms. When a clinician is evaluating a potential symptom fabrication case, the diagnosis is based mainly on whether other factors that may contribute to the patient’s condition can be excluded. One critical factor that must be ruled out is an undetected or underestimated physical illness that may be responsible for the symptoms, disability and impairment presented. Similarly, the clinician must exclude somatoform disorders associated with symptoms of a psychological etiology that are not fabricated or exaggerated. Conversion disorder, also classified under the somatoform category, generally results in actual physical symptoms such as voluntary or sensory deficits attributed to psychological and neurological factors.4 Hypochondriasis, although somewhat psychological in nature, is based on a patient’s misrepresentation of one or more actual symptoms,4 thereby excluding this condition too from symptom fabrication. In contrast to undetected or underestimated physical illnesses and somatoform disorders, factitious disorders are characterized by physical signs and symptoms that are intentionally exaggerated or, in some cases, fabricated in order to assume or maintain the “sick role.”4 Symptoms may include self-reported pain from a nonexistent or self-inflicted condition and/or the exacerbation of a pre-existing medical condition. However, if external incentives such as financial gain or the avoidance of legal prosecution are absent in patients who present with factitious disorders, it would appear that malingering can be excluded as the cause of these disorders. Clinicians must also consider how social and cultural factors may influence the presentation of illness-related behavior since research shows that sociocultural factors can affect the way patients display symptoms.9,10 For instance, pain-related behavior is dramatic in some cultures and stoic in others. So a perceived exacerbation of symptoms should not automatically be deemed a sign of symptom fabrication without applying additional differential diagnostic criteria, e.g., cultural criteria. In order to circumvent some of the obstacles that clinicians face as QMEs, California and some other states use the Frye standard to help clinicians select the appropriate symptom fabrication assessment methods and tools. Furthermore, a QME’s testimony must meet the Frye standard to be admissible as evidence in civil, criminal, disability and workers’ compensation cases. Meeting the Frye standard may guide a judge’s decision regarding the validity of the expert’s testimony. According to the Frye standard, an expert’s testimony should be based on reasoning and a methodology that is generally accepted within the relevant scientific community, using the following criteria:11,12 Is the witness qualified to be an expert? Is the underlying scientific premise generally accepted? Is the evidence that has been presented based on a testable theory or on a technique that is falsifiable and refutable? Has the scientific evidence been sufficiently tested and accepted by the relevant scientific community? Has the theory or technique been subjected to peer review? Is there a known error rate for the assessment? Based on these criteria, if a QME uses an assessment that does not have supportive evidence from peer-reviewed studies or methods, a Frye challenge may arise—although the standard of evidence in California is reasonable medical probability. Nonetheless, a challenge limits the type of assessment tools that a QME can choose. This limit may serve as a guide toward the best choice. Back pain is a common chronic condition that may motivate some sufferers to engage in symptom fabrication or exaggeration. Back pain may arise in the bones, muscles, ligaments, tendons and nerves in different parts of the back. It may be classified as acute pain that lasts six weeks or less; periodic or frequent pain that persists up to three months; or chronic pain that lasts more than three months. A number of diseases or injuries may result in back pain. Low back pain is the most commonly reported type, resulting in millions of annual emergency room visits. According to the American Physical Therapy Association (APTA), more than 60% of Americans have experienced debilitating low back pain at some point in their lives, though middle and upper back pain are also frequently reported.13 Clinical comparisons of patients with chronic back pain have shown that those seeking compensation often report significantly higher levels of pain, disability, psychological problems, unemployment and time off work than patients not seeking compensation.14 The amount of time spent seeing doctors for medical reports and lawyers appears to rise in parallel with apparent symptom fabrication, as does awareness that a longer recovery could result in a larger financial settlement.15 Therefore, in many cases of chronic back pain, the effects of the back injury, the psychological disturbances, and the quest for financial compensation often elicit symptom fabrication. Through careful observation and examination, QMEs can distinguish true pain patients from those engaging in fabrication. A complete physical and medical assessment for chronic pain fabrication should adhere to the following guidelines: Physical examination relevant to the reported chronic pain. Patient self-report. Structured interview that focuses on variables indicative of possible symptom fabrication. Review of medical records and diagnostic tests. If psychological symptoms need to be evaluated, a psychological QME should screen for them in a comprehensive evaluation. This should include a clinical interview, a mental status examination, behavioral observations, standardized psychological tests and, if possible, third-party information. Obtaining information that contradicts—or supports—the examinee’s version of events is probably the most accurate means of detecting exaggeration, fabrication or denial—or their absence—and may be the only viable evidence in the case of examinees who sabotage interview and testing efforts.16 The following commonly used psychological tests are helpful in detecting symptom fabrication, symptom exaggeration and testing effort. Minnesota Multiphasic Personality Inventory-2 (MMPI-2)—The validity scales (L, F and K) can be used to help identify individuals motivated to exaggerate or fabricate psychological symptomology. Rey 15-Item Memory Test (Rey-15)—This is used to detect feigned memory impairment. Test of Memory Malingering (TOMM)—This forced-choice measure is used to detect malingered memory impairment. Validity Indicator Profile (VIP)—This is used to assess testing effort. Victoria Symptom Validity Test (VSVT)—This forced-choice measure is used to detect exaggerated or feigned cognitive impairment. The Modified Somatic Perception Questionnaire (MSPQ) and Pain Disability Index (PDI) are also useful in helping clinicians identify chronic pain patients whose physical symptoms may be non-organic. Both these assessments have been shown to effectively detect malingering by accurately differentiating between pain-related disability where malingering is present or absent. Furthermore, the MSPQ and PDI can indicate the need for clinical treatment of chronic pain by assessing a potential psychological overlay along with malingering. This alerts clinicians to psychological issues that may hinder effective treatment as well as whether additional psychological testing may be necessary.17 Research also indicates that instruments such as the MMPI-2 Restructured Scale 1 (RC1) are effective at detecting malingering in chronic pain patients who are motivated by external incentives (e.g., disability benefits) as well as those who have no external incentive to exaggerate symptoms.18 Similarly, the Lees-Haley Fake Bad Scale (FBS) and the Henry-Heilbronner Index (HHI), which are often used to identify non-credible symptoms in disability claimants and personal injury litigants, have been shown to be efficient in revealing exaggeration of illness-related behavior.18 Tests such as the Portland Digit Recognition Test (PDRT) and the Test of Memory Malingering (TOMM) often fail to detect malingering when administered separately, but demonstrate superior efficiency when used in combination.19 These findings indicate that it is good practice to combine several tests to help differentiate between malingering and non-malingering chronic pain patients. Previous research supports this practice; it has been suggested that the administration of numerous neuropsychological tests, up to nine in certain cases, has been shown to correctly identify nonlitigating and litigating patients.20 More specifically, failing any two of these tests indicates that a patient is displaying motivational issues. Administering several tests is thus an optimal means of clearly identifying—or ruling out—malingering. In summary, health care professionals who have taken on the role of independent medical examiner (IME) or qualified medical evaluator (QME) in symptom fabrication cases should focus the evaluation on searching for the presence or absence of compelling inconsistencies in the self-reported, medical and neuropsychological data obtained from several tests, in conjunction with reviewing potential motivations or circumstances that may explain illness behavior. QMEs and IMEs who are aware of, have access to and are able to administer optimal medical and neuropsychological symptom fabrication evaluations that follow the Frye standard are best prepared to meet this challenge. Dr. Shah is a psychiatrist with offices in Santa Rosa, Novato and San Rafael. Dr. Kettner is a clinical psychologist in Petaluma. Both are qualified medical evaluators (QMEs). Emails: ashah@siyanclinical.com ; drkettner@gmail.com References 1. Mittenberg W, et al, “Base rates of malingering and symptom exaggeration,” J Clin Exp Neuropsychol, 24:1094-1102 (2002). 2. Aronoff GM, et al, “Evaluating malingering in contested injury or illness,” Pain Prac, 7:178-204 (2007). 3. Greve KW, et al, “Prevalence of malingering in patients with chronic pain referred for psychologic evaluation in a medico-legal context,” Arch Phys Med Rehabil, 90:1117-1126 (2009). 4. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, APA (2000). 5. Nagi SZ, et al, “Disability behavior, income change, and motivation to work,” Ind Labor Rel Review, 25:223-233 (1972). 6. Insurance Research Council, “Survey of public attitudes on auto safety issues,” IRC (1990). 7. Insurance Research Council, “Survey of public attitudes on the use of attorneys in auto insurance claims, ” IRC (1993). 8. Kucyi A, et al, “Distinguishing feigned from sincere performance in psychological pain testing,” J Pain, 2015, in press. 9. Coyne CA, et al, “Social and cultural factors influencing health in southern West Virginia,” Prev Chronic Dis, 3:A124 (2006). 10. Dusseldorp E, et al, “Cultural, social and intrapersonal factors associated with co-occurring health-related behaviours,” Psychol Health, 29:598-611 (2014). 11. DC Circuit Court, “Frye v. United States,” (1923); retrieved from http://www.law.ufl.edu/_pdf/faculty/little/topic8.pdf. 12. Seventh Circuit Court, “Cella v. United States,” (1993); retrieved from https://casetext.com/case/cella-v-us?page=424. 13. American Physical Therapy Association, “Low back pain by the numbers,” APTA (2014). 14. Greennough, CG, Drummond, PD, “Effect of compensation on emotional state and disability in chronic back pain,” Pain, 48:125-130 (1992). 15. Jayson MI, “Trauma, back pain, malingering, and compensation,” BMJ, 305:7-8 (1992). 16. Melton, GB, et al, Psychological Evaluations for the Courts, 3rd ed, Guilford Press (2007). 17. Bianchini KJ, et al, “Accuracy of the Modified Somatic Perception Questionnaire and Pain Disability Index in the detection of malingered pain-related disability in chronic pain,” Clin Neuropsychol, 28:1376-1394 (2014). 18. Henry GK, et al, “Comparison of the Lees-Haley Fake Bad Scale, Henry-Heilbronner Index, and restructured clinical scale 1 in identifying noncredible symptom reporting,” Clin Neuropsychol, 22: 919-929 (2008). 19. Greve KW, et al, “Detecting malingering in traumatic brain injury and chronic pain: A comparison of three forced-choice symptom validity tests,” Clin Neuropsychol, 22: 896-918 (2008). 20. Meyers JE, et al, “A validation of multiple malingering detection methods in a large clinical sample,” Arch Clin Neuropsychol, 18:261-276 (2003). << IT REALLY WORKS: Percutaneous Vertebral Augmentation PUBLIC HEALTH UPDATE: Marin County Opioid Prescribing Guidelines >>