MALINGERING

Published on 16/03/2015 by admin

Filed under Orthopaedics

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2585 times

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

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).

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

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

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

image

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

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

Anesthesia

Blindness Cerebellar lesions Consciousness Deafness Facial anesthesia Facial pain Seeligmuller sign General pain Lower back Olfactory nerve Anosmia testing Paresis Sciatica Stoicism Stoicism indexing Trigeminal nerve Anosmia testing

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).

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

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 Signs Tenderness Anatomic distribution 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.

GENERAL PROCEDURES

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 13-7 PSYCHOGENIC RHEUMATISM*

Symptoms and signs of psychogenic rheumatism are:

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.

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.

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).

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).

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).

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).

ORTHOPEDIC GAMUT 13-13 OSWESTRY-TYPE PAIN-DISABILITY QUESTIONNAIRE*

This questionnaire has been designed to give the examiner information about pain and how it affects your ability to manage in everyday life. Please circle, in each section, only one statement that most closely applies to you.

SENSORY DEFICIT QUALIFICATION AND QUANTIFICATION

Overview

The nervous system does not perceive external events directly. Instead, the brain receives an abstract picture that is a composite of nerve impulses that originate at the periphery. The transformation of external stimuli into conductible impulses is called transduction. Sensibility is the reception or encoding of external stimuli and the transmission of impulses along nerve fibers.

CUIGNET TEST

Assessment for Simulated Blindness

ORTHOPEDIC GAMUT 13-25 SUMMARY OF CLINICAL TESTS FOR FUNCTIONAL VISUAL LOSS

Adapted from Chen CS et al: Practical clinical approaches to functional visual loss, J Clin Neurosci 14(1):1-7, 2007.

Clinical tests Principle
Total Binocular Blindness
Observation Clue to true or simulated difficulties in visual tasks
Finger tip test Proprioceptive tasks and does not require
Signature test vision
Mirror test Convergence, miosis and accommodation reflex
Optokinetic test Optokinetic reflex of smooth pursuit
Pupil response Detection of afferent and efferent pathway
Menace reflex Shock value
Tearing reflex Tearing with bright light
Monocular Blindness
Pupil response Direct afferent visual pathway light testing
Fogging test Elicit better vision than claimed
Stereopsis testing Require binocular vision
Prism shift test Demonstrates binocular vision
Reduced Visual Acuity
Fogging test and stereoacuity As above
Reduced Visual Field
Visual field to confrontation, kinetic and static perimetry Physiological visual field characteristics

LIMB-DROPPING TEST (UPPER EXTREMITIES)

Assessment for Feigned Unconsciousness

ORTHOPEDIC GAMUT 13-32 GLASGOW COMA SCALE

Eye Opening
Spontaneous 4
To speech 3
To pain 2
None 1
Best Verbal Response
Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best Motor Response
Obeys commands 6
Localizes pain 5
Withdrawal (normal flexion) 4
Abnormal flexion (decorticate) 3
Extension (decerebrate) 2
None 1

SNELLEN TEST

Assessment for Feigned Color Blindness

In normal (trichromatic) vision, the eye can perceive three light primaries (red, blue, and green) and can mix these in suitable portions. Thus white or any color of the spectrum can be matched. Color blindness can result from a lessened capacity to match three primary colors. It can be dichromatic vision, in which only one pair of the primary colors is perceived, the two colors being complementary to each other. Most dichromats are red-green blind and confuse red, yellow, and green (Table 13-7).

TABLE 13-7 COMPARISON OF ACQUIRED AND CONGENITAL COLOR VISION DEFICIENCIES

Acquired Color Vision Defect Congenital Color Vision Defect
Onset after birth Onset at birth
Monocular differences in the type and severity of the defect occur frequently Both eyes are equally affected
Color alterations are frequently associated with other visual problems such as low acuity and reductions in the useful visual (except in rod monochromatism) or visual field The visual problems are specific to color perception; there are no problems with acuity field
The type and severity of the deficiency fluctuate throughout life The type and severity of the defect are the same
The type of defect might not be easy to classify; combined or nonspecific defects occur frequently The type of defect can be classified precisely
Predominantly either protan or deutan Predominantly tritan
Higher incidence in men Same incidence in both sexes

Adapted from Lillo JA, Moreira H, Charles S: Color blindness. In Encyclopedia of applied psychology, New York, 2004, Elsevier.

PARALYSIS QUALIFICATION AND QUANTIFICATION

Overview

Motion is a fundamental property of most animal life. The lowest multicellular animals possess rudimentary neuromuscular mechanisms. In higher forms, motion is based on the transmission of impulses from a receptor through an afferent neuron and ganglion cell to muscle. This same principle is found in the reflex arc of higher animals, including humans, in whom the anterior spinal cord has developed into a central regulating mechanism. This central regulating mechanism is involved in initiating and integrating movements.

Motor disturbances include weakness and paralysis, which may result from lesions of the voluntary motor pathways or of the muscles themselves. Impaired motor functioning may result from involvement of muscle, myoneural junction, peripheral nerve, or the central nervous system.

The types of paralysis or paresis are based on the location. Hemiplegia is a spastic or flaccid paralysis of one side of the body and extremities, limited by the median line sagittally. Monoplegia is a paralysis of one extremity only. Diplegia is a paralysis of any two corresponding extremities, both of which are usually lower extremities, but may be upper extremities. Paraplegia is a symmetric paralysis of both lower extremities. Quadriplegia, or tetraplegia, is a paralysis of all four extremities. Hemiplegia alternans (crossed paralysis) is a paralysis of one or more ipsilateral cranial nerves and contralateral paralysis of the arm and leg.

Distractibility and variability are especially common in psychogenic tremor (80% of cases) and commonly coexist with entrainment and coactivation signs (Table 13-8).

TABLE 13-8 CLINICAL CHARACTERISTICS OF PSYCHOGENIC MOVEMENT DISORDERS

Mode of onset

Clinical signs

Adapted from Hinson VK, Haren WB: Psychogenic movement disorders, Lancet Neurol 5(8):695-700, 2006.

BILATERAL LIMB-DROPPING TEST (LOWER EXTREMITIES)

Assessment for Feigned Paresis of Lower Extremity

ORTHOPEDIC GAMUT 13-40 THE BARTHEL INDEX

Full credit is not given for an activity if the patient needs even minimal help/supervision. A score of 0 is given when the patient cannot meet the criteria as defined.

Patient Name: ___________________________

Rater Name: ___________________________

Date: ___________________________

Activity Score
Feeding  
0 = unable  
5 = needs help cutting, spreading butter, etc., or requires modified diet  
10 = independent _______
Bathing  
0 = dependent  
5 = independent (or in shower) _______
Grooming  
0 = needs to help with personal care  
5 = independent face/hair/teeth/shaving (implements provided) _______
Dressing  
0 = dependent  
5 = needs help but can do about half unaided  
10 = independent (including buttons, zips, laces, etc.) _______
Bowels  
0 = incontinent (or needs to be given enemas)  
5 = occasional accident  
10 = continent _______
Bladder  
0 = incontinent, or catheterized and unable to manage alone  
5 = occasional accident  
10 = continent _______
Toilet Use  
0 = dependent  
5 = needs some help, but can do something alone  
10 = independent (on and off, dressing, wiping) _______
Transfers (bed to chair and back)  
0 = unable help (one or two people, physical), can sit  
10 = minor help (verbal or physical)  
15 = independent _________
Mobility (on level surfaces)  
0 = immobile or < 50 yards  
5 = wheelchair independent, including corners, > 50 yards  
10 = walks with help of one person (verbal or physical) > 50 yards  
15 = independent (but may use any aid; for example, stick) > 50 yards _________
Stairs  
0 = unable  
5 = needs help (verbal, physical, carrying aid)  
10 = independent _________
Total (0–100) SCORE_______

The advantage of the BI is its simplicity. It is useful in evaluating a patient’s state of independence before treatment, patient progress undergoing treatment, and patient status when reaching maximum benefit. The total score is not as significant or meaningful as the breakdown into individual items, because these indicate where the deficiencies are.

HEMIPLEGIC POSTURING

Assessment for Nonorganic Hemiplegia

ORTHOPEDIC GAMUT 13-41 HEMIPLEGIC MOVEMENT PATTERNS IN CHILDREN WITH CEREBRAL PALSY

Movement Patterns for the Task of Rising from a Supine Position to a Standing Position Segmental Score
I. Upper Limb Categories
a. Push and reach to bilateral push 1
b. Push and reach to asymmetric push 2
c. Symmetric push 3
d. Symmetric reach 4
e. Push and reach followed by pushing on one leg 5
f. Push and reach to bilateral push followed by pushing on leg 6
II. Axial Categories
a. Full rotation with abdomen down 1
b. Full rotation with abdomen up 2
c. Partial rotation 3
d. Forward with rotation 4
e. Symmetric 5
III. Lower Limb Categories
a. Pike 1
b. Pike jump to squat 2
c. Kneel 3
d. Jump to squat 4
e. Half-kneel 5
f. Asymmetric wide based squat 6
g. Narrow based symmetric squat 7

HOOVER SIGN

Assessment for Feigned Leg Paresis

Neurologic loss is usually described as a sensory or motor deficit. The sensory loss may produce hypoesthesia, paresthesia, or hyperesthesia and may produce pain or numbness over a specific area. The motor deficits may be described as a weakness, as stiffness, or, more commonly, as difficulty in walking far, running, or jumping. If outright paralysis is present, the onset may have been sudden or insidious (Table 13-9). The paralysis may be flaccid or spastic. Flaccidity is associated with lower motor neuron disorders and spasticity with upper motor neuron disorders. The examiner must determine whether the symptoms have increased or decreased and to what degree the patient is disabled. The examiner must also determine whether a loss of sphincter control of the bladder and rectum has occurred.

TABLE 13-9 COMMON CAUSES OF HYPOKALEMIC PARALYSIS

Potassium Deficit
Group 1
Hypochloremic metabolic alkalosis

Group 2 Hyperchloremic metabolic acidosis and low NH4+ excretion

Group 3 Hyperchloremic metabolic acidosis and high NH4+ excretion

Intracellular potassium shift Group 4 Normal acid–base balance

NH4+ Ammonium.

From Pompeo A et al: Thyrotoxic hypokalemic periodic paralysis: an overlooked pathology in Western countries, Eur J Intern Med 18(5):380–390, 2007.

PROCEDURE

TABLE 13-10 CAUSES OF UNILATERAL FOOT DROP AND BILATERAL FOOT DROP

I. Unilateral foot drop

II. Bilateral foot drop

(Adapted from Katirji B, Michael JA, Robert BD: Causes of unilateral foot drop and bilateral foot drop. In: Encyclopedia of the neurological sciences, New York, 2003, Academic Press.)

Share this: