MALINGERING

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CHAPTER THIRTEEN MALINGERING

INTRODUCTION

In a framework for disability, the examining physician needs to understand the interaction between the disability and the factors affecting a return to work. In this model of interaction, a pathologic condition is the disturbance of normal bodily processes at the cellular level. Impairment is a specific loss of function. Functional limitation is the lack of ability to perform an action or activity. Disability is the inability to perform socially defined activities. Quality of life refers to the patient’s concept of total well-being. Risk or cofactors include biologic, environmental, lifestyle, and behavioral characteristics that are associated with musculoskeletal conditions. Whether people with specific physical limitations are disabled depends on their expectations, resources, and the demands of their physical environment.

Feigned illness, or malingering, is a sensitive medicolegal issue. Illness or injury that cannot be supported by medical fact confounds the physician’s diagnostic procedures and health care delivery; it also serves as an element of fraud in the third-party payer system. Patients participating in this behavior are a bane.

ORTHOPEDIC GAMUT 13-1 COMMONLY USED PROCEDURES IN DETERMINING EXISTENCE OF COGNITIVE MALINGERING

• Victoria Symptom Validity Test (VSVT): The VSVT is a computer-administered and computer-scored test. It includes a total of 48 items, presented in three blocks of 16 items each. During the study trial, a single five-digit study number is presented for 5 seconds in the center of the computer screen. This presentation is followed by the retention interval and then by the recognition trial, in which the target and a five-digit distractor are displayed. The respondents are asked to choose the number they saw in the study trial. The retention interval is 5 seconds in the first block, 10 seconds in the second, and 15 seconds in the third.

• Test of memory malingering (TOMM): The TOMM is an instrument designed to provide an assessment whether an individual is falsifying symptoms of memory impairment. It consists of 50 pictures of common objects that the subject must remember. After the presentation of the 50 pictures, the individual has to recognize which one is the correct picture between two alternatives. The TOMM consists of two learning trials and an optional retention trial and has good face validity as a test of learning and memory.

• The b test: The b test is a measure to identify malingering requiring recognition of overlearned information. This test is a letter recognition and discrimination task that consists of a 15-page stimulus booklet. The examinee is asked to circle all instances of the letter b that appear on each page, working as quickly as possible.

Not all patients who feign an illness are completely aware of their actions. Some patients embellish symptoms and physical signs as learned responses or traits, whereas others describe physical problems with hysterical emotional overlays. The latter group is influenced mostly by fear of the unknown. Depression bears a significant relationship to pain (Box 13-1).

BOX 13-1 SYMPTOMS OF DEPRESSION

Data from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, ed 3, revised, Washington DC, 1987, American Psychiatric Association. In White AH, Schofferman JA: Spine care, vol. 1-2, St. Louis, 1995, Mosby.

1. Depressed mood or irritable mood

2. Markedly diminished interest or pleasure in activities

3. Significant weight loss or weight gain when not dieting

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation—observable by others

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive or inappropriate guilt, which may be delusional

8. Diminished ability to think or concentrate; indecisiveness

9. Recurrent thoughts of death, recurrent suicidal ideation without a plan, a suicide attempt, or a specific plan for committing suicide

10. Lack of reactivity to usually pleasurable stimuli

11. Depression worse in the morning

12. Early morning awakening

ORTHOPEDIC GAMUT 13-2 DSM-IV ^* SYMPTOM SPECIFIC CATEGORIES IN EXCESSIVE COGNITIVE SYMPTOMS

A. Somatization disorder requires:

a. At least four pain symptoms

b. Two gastrointestinal symptoms

c. One sexual symptom

d. One pseudoneurologic symptom

B. Undifferentiated somatoform disorder requires one or more physical complaints, with no reference made to cognitive difficulties.

C. Conversion disorder requires one or more symptoms or deficits affecting voluntary motor or sensory function without mention of cognitive or memory difficulties.

D. Pain disorder requires only excessive pain symptoms.

E. Somatoform disorder NOS includes individuals with predominantly excessive cognitive symptoms.

F. Dissociative amnesia requires one specific type of cognitive problem, such as the inability to recall important personal information, usually of a traumatic or stressful nature.

G. Dissociative fugue requires one specific cognitive difficulty, such as the inability to recall some or all of one’s past. This difficulty must surface in the context of a sudden, unexpected travel away from home or one’s customary place of daily activities.

H. Dissociative identity disorder occurs in individuals with multiple personalities in which they exhibit an inability to recall important information about one or more personality states when they are in a different personality state.

I. Dissociative disorder NOS encompasses individuals with excessive cognitive complaints.

^* DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
NOS, Not otherwise specified.

ORTHOPEDIC GAMUT 13-3 PREDICTORS OF WORK INCAPACITY AND WORK LOSS BECAUSE OF DEPRESSION

1. Incoherent presentation of pain localization and stable symptoms

2. Inability to influence pain and function by movement or change of position

3. Relapse of a preexisting condition and lack of response in previous episodes

4. Work dissatisfaction

5. Problems of communicating realistic treatment goals

6. Poor self-perceived prognoses with unrealistically high perception of impairment

Two major categories of hysterical disorders are identified: patients with a fictitious illness, such as in malingering, and patients with Munchausen syndrome. Both types of patients are those with signs and symptoms that have no organic basis but who are not deliberately attempting to mislead the examiner.

Trivial physical trauma or disease is often at the root of a portrayed illness or injury. In many instances, by the time symptom embellishment is clinically recognized, the complaints are of such a magnitude that they are completely incongruous with the original illness or injury. A patient who originally experienced a minor, clinically documented upper respiratory infection now describes symptoms and subjective complaints that resemble those for histoplasmosis or black lung disease. Yet another patient may complain of total leg disability after a minor thigh contusion. Both patients have in common the total lack of clinical findings to support the complaints, and some type of secondary gain serves as a driving force behind the medical charade.

Individuals may feign physical symptoms to continue in a less-strenuous job at work, or they may do so to receive a parking space closer to their place of employment. These individuals may also fake symptoms to gain control over family members or fellow workers. The injured party may also allow others to do work the patient would ordinarily do.

The diagnosis of hysteria should be established based only on positive evidence. Even if the patient has an obvious hysterical disorder, a serious organic illness may still be present.

Conversion symptoms have a physiologic or pathologic substrate. A conversion disorder denotes a process in which a patient’s emotions become transformed into physical (motor or sensory) manifestations. These patients are asking for help but in an inappropriate way. Conversion symptoms often occur in mentally defective individuals or in adolescents as a way of coping (albeit inadequately) with the environment. Common presentations include blindness, deafness, paresis, sensory disturbances, ataxia, seizures, and unconsciousness.

Malingering is the conscious misrepresentation of thoughts, feelings, and facts, and it is a condition in which symptoms and signs associated with pain or dysfunction are either partially or entirely feigned for secondary gain. Most commonly, malingering occurs in the setting of the workplace, where workers’ compensation is an issue.

Labeling patients as hysterics, frauds, or malingerers is difficult. This task is rarely accomplished without reaping the wrath of the patient or substantial legal repercussions.

The actual percentage of patients who are malingerers is undetermined. However, estimates suggest that 2% of all patients seeking health care are malingering. Obviously, the ascertainment of the inaccuracy of a patient’s report of pain and disability is a difficult process, but the possibility of malingering should be raised in the mind of the treating physician when major discrepancies or inconsistencies appear in the patient’s medical situation. In this effort, outcome measures for the assessment of work capacity, work tolerance, dependable ability, and task demand are useful tools (Table 13-3).

TABLE 13-3 DISTINCTIONS AMONG WORK CAPACITY, WORK TOLERANCE, DEPENDABLE ABILITY, AND TASK DEMAND

From Demeter SL, Andersson GBJ, Smith GM: Disability evaluation, St Louis, 1996, Mosby.

TABLE 13-1 MALINGERING CROSS-REFERENCE TABLE BY ASSESSMENT PROCEDURE

TABLE 13-2 MALINGERING, HYSTERIA, AND EMBELLISHMENT CROSS-REFERENCE TABLE BY SUSPECTED SYNDROME OR TISSUE

Anesthesia

Janet test

Midline tuning-fork test

Regional anesthesia testing

Blindness

Cuignet test

Marcus Gunn sign

Midline tuning-fork test

Snellen test

Cerebellar lesions

Coordination-disturbance testing

Position-sense testing

Romberg sign

Hemiplegic posturing

Simulated foot-drop testing

Consciousness

Limb-dropping test (upper extremities)

Stoicism indexing

Deafness

Gault test

Limb-dropping test (lower extremities)

Facial anesthesia

Facial anesthesia testing

Lombard test

Facial pain Seeligmuller sign General pain

Libman sign

Mannkopf sign

Marked part pain-suggestibility test

Related joint motion test

Lower back

Axial trunk-loading test

Trunk rotational test

Tripod test (bilateral leg-fluttering test)

Olfactory nerve Anosmia testing Paresis

Bilateral limb-dropping test (lower extremities)

Hemiplegic posturing

Hoover sign

Simulated foot-drop testing

Simulated forearm-and-wrist-weakness testing

Simulated grip-strength-loss testing

Sciatica

Flip sign

Plantar flexion test

Stoicism Stoicism indexing Trigeminal nerve Anosmia testing

ORTHOPEDIC GAMUT 13-4 THE FIVE Ds OF GLOBAL HEALTH STATUS

1. Death

2. Disability—upper or lower limb functional problems

3. Discomfort—physical or psychologic

4. Drug reactions—or other medical or surgical iatrogenic problems

5. Dollars—both direct and indirect costs

ORTHOPEDIC GAMUT 13-5 IMPORTANCE OF MALINGERING ASSESSMENT

Examiners should be concerned about whether treatment-seeking patients are malingering for several important reasons:

• Diagnosis and treatment planning

• Malingering needs to be ruled out before establishing a diagnosis.

• If the diagnosis is incorrect, the resulting treatment may be misguided.

• Threat to the therapeutic alliance with clinicians: Clinicians routinely working with traumatized populations that have high rates of suspected but undetected malingering often become suspicious of the motives of all patients.

• Economic impact

• In 1995, the total cost of insurance fraud in the United States was estimated to be .3 billion.

• Most of this cost was the result of health insurance fraud, including (but not limited to) the malingering of posttraumatic stress disorder.

• Threat to research databases: Researchers commonly recruit people studies from treatment-seeking populations.

OUTCOMES ASSESSMENTS

The health assessment questionnaire (HAQ) is a self-administered instrument that assesses discomfort and disability. It is used to measure outcome in many different neuromusculoskeletal diseases. Disease-specific instruments have been produced to help follow outcomes in several other neuromusculoskeletal diseases. This area includes a fibromyalgia impact questionnaire. The activity of inflammatory neuromusculoskeletal diseases can be assessed through serologic measures. Separate measures of both tender and swollen joints can be charted on a homunculus. A generic measure of anxiety and depression, such as the hospital anxiety and depression (HAD) scale, allows psychologic variables to be assessed independently from orthopedic disease-related outcomes. The EuroQuol® thermometer is one of the instruments that uses a simple visual technique to allow people to assess their own health status; the disease repercussion profile is another such resource (Box 13-2).

BOX 13-2 DISEASE IMPACT INDEX

From Carr AJ, Thompson PW: Towards a measure of patient-perceived handicap in rheumatoid arthritis, Br J Rheumatol 33:378, 1994.

Patients report severity of problems on a 0-to-10 scale in six dimensions:

• Functional activities

• Social activities

• Relationships

• Emotions

• Socioeconomic factors

• Body image

Armed with Borg pain scales, Oswestry disability indices, symptom magnification indexing, Dallas Pain Questionnaire, Waddell indexing (Table 13-4), and neuroorthopedic malingering tests, the physician is able to substantiate or refute the existence of malingering in any given case. These tests and indices are usually used in combination with the more traditional neuroorthopedic physical examinations. A singular positive finding or test does not indicate that the patient is magnifying or faking symptoms. Rather, the malingering diagnosis is based on the preponderance of positive malingering test findings and the absence of findings from traditional neuroorthopedic tests. Any positive findings must be further correlated with the medical history of the patient. The constellation of positive malingering tests, normal findings in traditional tests, and medical history discrepancies form the malingering diagnosis. Malingering and psychogenic rheumatism patients complain primarily of pain, sensory losses, or paralysis in any combination.

TABLE 13-4 NONORGANIC PHYSICAL SIGNS INDICATING ILLNESS BEHAVIOR

	Physical Disease/Normal Illness Behavior	Abnormal Illness Behavior
Symptoms
Pain	Anatomic distribution	Whole leg pain Tailbone pain

Numbness Dermatomal Whole leg numbness Weakness Myotomal Whole leg giving way Time pattern Varies with time and activity Never free of pain Response to treatment Variable benefit

Intolerance of treatments

Emergency admissions to hospital

Signs Tenderness Anatomic distribution

Superficial

Widespread nonanatomic

Axial loading No lumbar pain Lumbar pain Simulated rotation No lumbar pain Lumbar pain Straight-leg-raising Limited on distraction Improves with distraction Sensory Dermatomal Regional Motor Myotomal Regional, jerky, giving way

From Waddell G, et al: Symptoms and signs: physical disease or illness behavior? Br Med J 289:739, 1984, British Medical Association.

CLINICAL PEARL

Standardized instruments are often used in survey research. Many of these instruments are devised in clinic settings where trained health care professionals complete health assessments. However, prohibitive cost and relative ease make participant-assessed outcome measures a more feasible approach to obtain constructs describing functional and mental health outcomes. With these more-convenient measures of health increasingly used as primary outcomes in epidemiologic studies, selecting an appropriate assessment tool involves careful review of the many standard survey instruments available. The Millennium Cohort, the largest cohort study ever undertaken by the U.S. Department of Defense, was launched in 2001 to gather health outcome information along with occupational and environmental exposures employing a longitudinal approach. In the first panel of enrollment, more than 77,000 participants joined the 22-year-long study, filling out either a mailed survey or an identical Web-based survey.

GENERAL PROCEDURES

General Patient Observation

Consensus has been reached among physicians that malingering is readily detected with appropriate medical and psychologic tests. Most patients who have remained conscious during an injury can give an adequate description of what happened. A malingerer is vague and on guard while describing the incidents of an injury or accident. However, some patients who also remain conscious at the time of injury are not as observant as others are, and these patients will be somewhat vague.

A malingerer often appears quarrelsome, nervous, and ill at ease. General observation of the patient before and after the physical examination may reveal that the patient is fully capable of movements or activities that were claimed to be impossible in the physical examination. The examiner should note how the patient enters and behaves in the reception room. It is helpful if a nonprofessional staff person takes the patient’s history and engages the claimant in conversation.

Detailed History

Occasionally, the physician is asked to distinguish fraud or exaggeration from organic injury. As should be apparent by now, this task is not an easy one. An examination, when deception or exaggeration is suspected, should be completed with a strictly impartial attitude on the part of the examiner. The patient must be accorded all the tact and courtesy that is ordinarily extended to any other patient. If the physician-patient rapport is compromised, confidence is destroyed, and questions and tests, which are constructed to evoke sincerity on the part of the patient, become unreliable.

In many instances, the patient grudgingly gives the history. The malingering patient may remark, “I’ve told this to the last doctor, and I don’t see any reason to repeat it.”

The patient may also deny permission to review previous X-ray findings or case histories, stating that only the attorney can grant such permission. The genuine patient will not usually hesitate to furnish all patient information or permissions in this regard.

Malingerers will give an involved and long history, most of which is often discovered to be false. When the patient’s history, actions, and examination findings suggest that symptoms are exaggerated, one of the duties of the physician to make the examination so complete that no question will remain as to the actual extent of any organic disease or injury.

Psychogenic Rheumatism Profile

Patients with psychiatric disorders may develop pain as part of the symptoms associated with mental illness. Patients with pain may also develop psychiatric disorders as part of the symptoms associated with the physical illness. Pain associated with neurosis is more common than pain associated with schizophrenia or endogenous depression.

ORTHOPEDIC GAMUT 13-6 REASONS FOR PSYCHOLOGIC ILLNESS THAT CAUSE THE APPEARANCE OR EXACERBATION OF PAIN

1. Anxiety

2. Psychiatric hallucination

3. Increased tension in the muscles, with associated inadequate circulation and the accumulation of metabolic byproducts (lactic acid)

4. Hysteria with conversion reactions

ORTHOPEDIC GAMUT 13-7 PSYCHOGENIC RHEUMATISM^*

Symptoms and signs of psychogenic rheumatism are:

1. Dramatic urgency for an appointment that is not justified by the severity of the disease

2. A list (in writing) of complaints so long and detailed that no fact is left out

3. Multiple test results, including electrocardiogram, electromyelogram, electroencephalogram, barium enema, upper gastrointestinal series, computed tomography scans, myelograms, and magnetic resonance imaging, with no positive findings

4. Patient demands to review the laboratory data first to determine the cause of the symptoms; patient highlights any minor abnormalities

5. Preoccupation with future disability from minor physical changes

6. Persons who accompany the patient may be entirely separated from the patient’s condition or intensely supportive; the companion may be highlighting every abnormality, often using the pronoun we during the description of tests or treatments

7. Inability of the patient to relax during the examination (Boxes 13-3 and 13-4)

8. Marked theatrical responses to questions concerning pain

9. The patient often holds onto the physician during the examination, as a gesture of seeking support

BOX 13-4 DSM-III-R ^* CRITERION FOR ANXIETY

300.02 Generalized anxiety disorder—unrealistic or excessive anxiety and worry more days than not

Other anxiety disorders

Panic disorder

300.21 with agoraphobia or

300.01 without agoraphobia

300.22 Agoraphobia without history of panic disorder

300.23 Social phobia

300.29 Obsessive compulsive disorder

300.89 Posttraumatic stress disorder

300.00 Anxiety disorder not otherwise specified

^* DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders, third edition, revised.

ORTHOPEDIC GAMUT 13-8 COMBINED EMORY AND ELLARD INCONSISTENCY PROFILES^*

Data from Ellard J: Psychological reaction to compensable injury, Med J Australia 2:349-55, 1970; and Brena SF, Chapman SL: Pain and Iitigation: textbook of pain, London, 1984, Churchill Livingstone.

1. Discrepancies become apparent between a patient’s complaints of terrible pain and an attitude of calmness and well-being.

2. A complete work-up for organic disease by two or more physicians is negative.

3. The patient makes dramatized complaints that are vague or have global implications. “It just hurts,” or “I hurt bad.” This statement may be further attested by malingering hand signals.

4. The patient exaggerates a trivial pathologic condition (e.g., a mild strain, muscular cramp, contusion) and embellishes it with medical terms learned from previous contact with physicians. “My back spasms paralyze my legs.”

5. The patient overemphasizes gait or posture abnormalities that develop suddenly, persist, and cannot be substantiated objectively. For example, the patient complains of a limp that is not confirmed by a specific pattern of wear on old shoes; or the patient reports daily use of a cane or back brace, but these items show little wear.

6. The patient resists evaluation or rehabilitation when the stated goal of therapy is a return to gainful employment.

7. The patient exhibits a lack of motivation to learn new coping skills, despite verbal reports of compliance with treatment. For instance, the patient will show no increase in back motion despite claims of completing range-of-motion exercise daily.

8. The patient misses appointments for objective studies that measure function, motion, or vocational capabilities.

9. The patient has an unconventional response to treatment, such as reports of increased symptoms after therapy that follows no anatomic or physiologic pattern. For example, the patient may respond to tranquilizers as if they are stimulants and vice versa.

10. The patient shows resistance to treatment procedures, especially in the presence of intense complaints of pain.

11. Psychologic or emotional disturbances are absent (Box 13-5).

12. Psychologic tests are inconsistent and without clinical presentations. For example, the Minnesota Multiphasic Personality Index profile indicates a psychotic disorder, but no clinical signs of psychosis are present (Box 13-6).

13. Discrepancies arise between reports by the patient and spouse or other close relatives.

14. Personal and occupational history appears unstable.

15. The patient’s personal history reflects a character disorder that might include drug or alcohol abuse, criminal or compulsive behavior, erratic personal relationships, and violence.

BOX 13-5 MOOD DISORDERS—DSM-III-R ^* CLASSIFICATIONS

Bipolar Disorders

296.6x Mixed—both manic and depressed features

296.4x Manic

296.5x Depressed

301.13 Cyclothymia

296.70 Bipolar disorder not otherwise specified

Depressive Disorders—Major Depression

296.6x Single episode

296.3x Recurrent

300.40 Dysthymia

^* DSM-III-R, Diagnostic and Statistical Manual of Mental Disorders, third edition, revised.
Fifth digit (x) allows coding of current state of disorder: 1 = mild; 2 = moderate; 3 = severe, without psychotic features; 4 = with psychotic features; 5 = in partial remission; 6 = in full remission; 0 = unspecified

BOX 13-6 DESCRIPTION OF MMPI-2 ^*

From White AH, Schofferman JA: Spine care, vol 1-2, St Louis, 1995, Mosby.

L, F, and K are validity scales.

L is called the lie scale and measures willingness to admit minor social faults. It gives information about social conformity, self-image and self-insight, and denial.

F refers to infrequency and consists of items that are socially unacceptable or have disturbing content. Persons scoring on the low end of this scale are usually conventional and unassuming. Those with elevations are admitting to severe emotional distress or psychopathologic condition or both. Very high scores suggest an invalid profile.

K refers to correction, and the items measure personal resources required to cope with life. Low scores suggest exaggeration of problems or severe emotional distress. Higher scores can result when patients are very confident and in charge or when they are being defensive in their efforts to present themselves as adequate and in control when in fact their lives are in disarray.

Scales 1 through 10 are the basic clinical scales of the MMPI-2. The information is presented using T scores. A T score of 50 is average; T scores over 65 are in the abnormal range.

Scale 1 is also known as the Hypochondriasis (HS) scale. This scale consists of items that concern bodily functioning. Many of the items are vague in their content. Persons scoring low on this scale do not have or are denying that they have any physical complaints. Those whose scores are elevated have many physical complaints and concerns. If scores are above 65, physical complaints are often the major focus of the person’s life.

Scale 2 is known as the Depression (D) scale. It consists of items that measure subjective depression, psychomotor slowing and immobilization, physical complaints, mental dullness, and brooding. High scores indicate the presence of depression, and low scores indicate persons whose affective functioning is within normal limits.

Scale 3 is known as Hysteria (Hy). It consists of items that indicate whether the individual tends to avoid emotional and social unpleasantness. Those that do may then experience their emotions and stress as somatic complaints. High scorers will often deny psychologic problems and look for concrete solutions to their problems.

Scale 4 is known as psychopathic deviate (Pd). Eight items refer to authority conflicts, and the rest of the items deal with family conflicts, denial of social and dependency needs, social alienation, and self-integration. High scorers are often angry, impulsive, in conflict with authority figures in their lives, and are feeling isolated and despondent. High scorers who are not psychopathic are often undergoing stressful transitions in their lives.

Scale 5 is known as Masculinity-Femininity (Mf). Scores on this reflect traditional versus nontraditional masculine or feminine interests and beliefs, conflicts about sexuality, and interests in aesthetics. Low scores for women suggest feelings of helplessness and dependency, whereas low scores for men suggest an action-oriented macho approach to life. High-scoring men often hold interests in activities usually considered as feminine and may be experiencing insecurity, helplessness, and conflicts of sexuality. High-scoring women report interest in traditional male patterns and are often seen as unfriendly, dominating, and aggressive.

Scale 6 is known as Paranoia (Pa). In addition to paranoia and externalization of blame, this scale contains items related to hypersensitivity, subjectivity, naiveté, righteousness, and denial of hostility and distrust. Very high scorers are outright paranoid and may have a thought disorder, whereas low scorers may be insensitive to others and unaware of others’ motives. They may also be denying the presence of paranoid thoughts.

Scale 7 is known as Psychasthenia (Pt). Items center on the presence of worries, brooding, and rumination. High scorers are seen as anxious and insecure, and may be indecisive. If scores are very high, the individual may be compulsive and agitated with feelings of guilt and fear disrupting everyday functioning.

Scale 8 is known as Schizophrenia (Sc). High scorers are having difficulty with their thinking and feelings. They often feel out of control and unable to take positive action in their own behalf. Extremely high scores are suggestive of severe situational stress. More moderate elevations are seen in those with thought disorders with difficulties in logic concentration and judgment common.

Scale 9 is known as Hypomania (Ma). This scale provides information about motivation, physical and emotional activity levels, confidence in social situations, and feelings of self-importance. High scorers are restless, agitated, emotionally labile and may have racing thoughts. They may also have difficulty delaying gratification and can be impulsive. Manic features appear as scores elevate.

Scale 10 is known as Social Introversion (Si). This scale provides information about social interests, interpersonal skills, self-consciousness, and feelings of alienation from self or others. High scorers are often depressed. They withdraw from social interactions and feel shy and insecure. Low scorers are usually socially extroverted and outgoing.

^* MMPI-2, Minnesota Multiphasic Personality Inventory, second edition.

CLINICAL PEARL

In distinguishing psychogenic rheumatism from primary fibromyalgia, the patients with primary fibromyalgia are usually women, 25 to 40 years of age, who complain of diffuse musculoskeletal aches, pains or stiffness associated with tiredness, anxiety, poor sleep, headaches, irritable bowel syndrome, subjective swelling in the articular and periarticular areas, and numbness. Physical examination reveals the presence of multiple tender points at specific sites and the absence of joint swelling. Symptoms are influenced by weather and activities, as well as by time of day (worse in the morning and the evening). In contrast, symptoms of psychogenic rheumatism have little fluctuation, if any, and are modulated by emotional rather than physical factors. Psychogenic rheumatism produces diffuse tenderness rather than tender points at specific sites.

Special Hand Signals by the Patient

How a patient uses the hands to describe the area of pain is useful in determining the validity of the complaints. At first, malingering patients take care not to touch the area they claim experiences pain. Because the complaint is a sham, touching of the part abets the lie. The examiner often inadvertently aids this process by physically touching the area of complaint before the patient has. The patient now only has to agree with the frustrated examiner concerning the exact location of the pain (Fig. 13-1).

FIG. 13-1 At first, the malingering patient takes care to avoid touching the area of claimed pain.

The psychogenic rheumatic patient uses the whole hand to paint the area of involvement with pain. Because this type of patient perceives the lesion abnormally, the distribution is painted to cover a whole body part. This pain crosses more than one dermatome boundary, and this patient’s discomfort is real. The discomfort may have origin in an organic lesion, but because of learned responses or fear, the patient rubs the whole part with the hand to indicate its extent. Careful questioning and guidance will help this patient better define the most focal trigger areas (Fig. 13-2).

FIG. 13-2 The hysteric patient, or the patient with psychogenic rheumatism, paints the area of complaint with the whole hand. The discomfort is real, but the borders of the complaint exceed the known anatomic distributions.

Patients with organic, pain-producing lesions are concerned that the source of the pain might be missed. When directed to point to the pain, this type of patient will touch the part with one or two fingers, which is representative of a more focal appreciation of the discomfort. In severe expression of the symptoms, this patient also may place the examiner’s hand on the exact location of the pain. These patients do not want to risk having the source missed and not treated (Fig. 13-3).

FIG. 13-3 Patients experiencing organic pain for the first time are concerned that the lesion will be missed. This patient will touch the part, precisely locating it with one or two fingers. The patient may also hold the examiner’s finger on the spot of worst complaint.

PAIN QUALIFICATION AND QUANTIFICATION

Overview

Pain disrupts the life of the individual in terms of relationships with others, self-esteem, ability to complete tasks of daily living and to work, and ability to function as a member of the community. Disability is strongly correlated with attitude to illness; these considerations underlie the importance of assessing patients’ beliefs regarding the nature and prognosis of their pain (Table 13-5).

TABLE 13-5 ACTIVITIES OF DAILY LIVING AND VISUAL ANALOG QUESTIONNAIRE

ORTHOPEDIC GAMUT 13-9 RELAY STATIONS

Three main relay stations for sensory stimuli from the periphery to the sensory cortex include:

1. The peripheral sensory nervous system, with its cell station in the spinal ganglia

2. The pathways and centers in the spinal cord and medulla

3. The sensory centers of the diencephalon, especially the thalamus

ORTHOPEDIC GAMUT 13-10 PAIN-RATING SCALES

ORTHOPEDIC GAMUT 13-11 CLINICAL FEATURES OF BURNING MOUTH SYNDROME

Adapted from Patton LL et al: Management of burning mouth syndrome: systematic review and management recommendations, Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 103(suppl 1):S39.e1-S39.e13, 2007.