A D E TA I L E D O U T L I N E F O R Q U A L I F I E D M E D I C A L E X A M I N E R S
Detection and Assessment of Malingering in Chronic Pain Patients Anish Shah, MD, and Alex Kettner, PsyD
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ccording 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
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).
Marin Medicine
• 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.
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or 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 bet ween reported symptoms or disability and clinical findings. • Failure to cooperate during evaluation or to comply with the prescribed treatment regimen. Fall/Winter 2015–16 25