For many individuals that sustain an injury, there is a close correlation between subjective complaints and objective pathology. Since most physicians are trained in treating physical pathology, the outcome of treatment is usually satisfactory for all concerned.
For some patients, however, there appears to be a significant disparity between subjective complaints and objective findings. The patient may present with various exaggerated pain behaviors, such as limping, moaning, groaning, and grimacing, while the physical examination and various tests may not reveal any obvious pathology. These individuals remain symptomatic longer, stay off work for prolonged periods of time (if they go back at all), and they tend to utilize a disproportionate share of health care resources. They are often labeled symptom magnifiers, elaborators, or exaggerators. We hear terms like hysteria, functional overlay, somatization, and chronic pain syndrome.
Some patients who present with musculoskeletal pain complaints have underlying non-organic or behavioral problems that may not be immediately apparent. These non-organic causes of pain may be a deliberate deception (consciously aware) such as malingering in order to obtain secondary gain or factitious disorder in which the patient seeks to occupy the sick role. The causes may also be due to a process unknown to the patient (not consciously aware) such as with somatoform disorders.
Table 1. Underlying causes of nonorganic back pain
Malingering is defined as feigning or grossly exaggerating illness or disability to derive benefit, or secondary gain. Risk factors for malingering include (a) ongoing litigation, (b) significant discrepancy between subjective disability and objective findings, (c) lack of cooperation with the evaluation and with treatment, and (d) the presence of antisocial personality disorder. The latter is marked by a history of unlawful behavior, aggressive behavior, deceitful behavior, consistent irresponsibility, and lack of remorse for wrongdoings.
In factitious disorder, patients who want to occupy the sick role consciously fabricate symptoms to attract the attention of physicians. Factitious disorder is often confused with malingering. The patient with a factitious presentation not uncommonly agrees to unnecessary surgery and interventions, which the malingerer will not. The factitious patient is motivated by psychological needs, not external gain as in the case of the malingering patient. These unmet needs may include a need for attention, a desire to gain nurturance, or other intrapsychic issues.
The most severe and persistent form of factitious disorder is called Munchausen syndrome, after the fabled Baron von Munchausen, who spoke outrageous lies about his adventures. In Munchausen syndrome, the individual intentionally produces clinically convincing physical and laboratory signs of disease in order to obtain medical treatment. These individuals will inject themselves to produce swelling or infection, ingest agents to distort their laboratory findings, rub irritants on their skin to produce rashes, or wear splints or braces unnecessarily. Over time, their medical records show extensive workups for convincing signs and symptoms, which change as the originally suspected disorder is on the verge of being ruled out.
Somatoform disorders are a family of disorders that describe patients with complaints that may not have a physical cause. There are several subtypes of Somatoform Disorders. Somatization Disorder, for example, involves a variety of physiologic symptoms, such as pain, G.I. disturbance, sexual symptoms, and pseudo-neurological symptoms (such as paralysis, weakness, blindness, etc.). There must be symptoms in each of these areas to meet the criteria for diagnosis and the symptoms cannot be fully explained by the medical work-up. Somatization “Disorder” is different from a patient who uses somatization as a “defense mechanism.” In the latter, the term is used more broadly to characterize patients who tend to develop physical symptoms to manifest emotional distress. That is, all patients with a Somatoform Disorder of some type employ somatization as a defense. However, they may or may not meet the exact criteria for the more specific Somatization Disorder.
Another very common subtype of Somatoform problem is called Pain Disorder. For this problem, the criteria are relatively loose. Pain must be the predominant focus. There often is some form of physical etiology, but psychological factors must play a role in the onset, severity, exacerbation, or maintenance of the pain.
A Somatoform diagnosis does not mean there is no physical pathology or illness but that these behavioral symptoms can coexist with, mask, and facilitate real illness. While there may or may not be an underlying physical cause, the patient’s symptoms and physical incapacity are out of proportion to the underlying physical condition. Although somatizing patients usually have a psychologically-based problem, they rarely seek the help of a mental health professional. Rather, they seek care through the medical setting, where physicians often have serious difficulty recognizing and understanding them. Ineffective and sometimes harmful medical care can result.
Somatization may follow a relatively trivial injury after which the individual suffers ongoing and increasing symptoms. No matter what the physician does, the patient seems to get worse. Somatizing patients often become increasingly passive and dependent, and they may assume a victim role. A careful history usually reveals that in one way or another these individuals were emotionally short-changed during their childhood.
Alternately, somatizing patients may have been differentially reinforced for their behavior. That is, they may have been sent the message that it’s okay to be physically ill, but not okay to be “depressed” or “anxious.” Over time, family members, friends, and even physicians can inadvertently reinforce this belief.
An individual’s perception of disease and disability is often fueled by factors having little to do with true physical pathology. In a society of entitlements, some people expect another individual or entity to take care of them. Illness, for some, becomes a way of life, with fulfillment obtained by time out from perceived unpleasant activities (i.e., work), while increased attention is gained from significant others who often assume a care-taking role.
These patients typically use medical services in maladaptive and highly inefficient ways. They often obtain care from multiple medical providers and change doctors often. They reward doctors who provide excessive and unnecessary invasive and passive treatment approaches. They fire doctors who confront them about secondary gain and emotional issues. These patients are convinced they are physically ill and deny the possible role of psychosocial factors. They resist psychiatric referral and in general are difficult to treat.
Although almost anyone can somatize under stress, certain individuals are prone to somatization. Factors that have been found to contribute to somatization can be recognized and described by: Abuse or emotional deprivation in childhood, Adult acute personal turmoil often involving abandonment and/or increased responsibilities, Societal roles, Learned behavior, Secondary gain, Cultural factors, Seeking redress for a perceived wrong, Personality factors (particularly histrionic, narcissistic, and borderline personality traits).
Cultural factors also play an important role in somatization. Somatic symptoms can be used by patients to convey a message that they are having troubles in various areas of their lives. These symptoms may be used in the patient’s culture as a way to communicate or a way to receive help and attention. Complaints such as sadness, loneliness or anxiety may not be taken seriously, whereas complaints of stomach pains or headaches are looked at very seriously. In some Latino cultures, men are not supposed to show weakness. In some Asian cultures, women are not supposed to show assertiveness. Whenever cultural rules or mores cut off legitimate expression of feelings, somatization becomes an avenue for communication or release of feeling states.
Pain Signal Misinterpretation and Relation to Fear
Some individuals do not understand the cause and meaning of their pain. They may interpret the pain signal as implying some sinister pathology or believe that nothing can be done to bring relief. Imagine the relatively uneducated patient with a back sprain who is discovered to have a spondylolysis on x-ray. This finding of a lumbar pars interarticularis “fracture” may have been present since childhood and may be of no clinical significance, yet the patient may report thereafter the presence of a “fractured” spine and perceive the inability to do anything out of fear.
The meaning that people make of their symptoms contributes greatly to disability. The patient’s interpretation, or appraisal, of their symptoms should be ascertained and distortions gently corrected during every medical evaluation.
Waddell Behavioral Signs
A clinical assessment usually begins with history taking, records review and continues with a physical examination. In the assessment of low back pain, the patient’s response to the physical examination is particularly important. In 1980, Dr. Gordon Waddell and associates drew attention to non-organic signs in back pain and attempted to integrate them into modern concepts of pain and illness behavior. They published a standardized assessment of behavioral (non-organic) responses to examination.
Waddell grouped eight signs into five types. These five types, or categories of signs, are tenderness, simulation, distraction, regional disturbances, and overreaction. The presence of three or more of these signs is considered a positive finding and is associated with other clinical measures of illness behavior and psychological distress – suggesting the patient does not have a straightforward medical problem.
Tenderness: Superficial and non-anatomic skin discomfort on palpation. Tenderness related to physical disease is usually localized. Physical back pain does not make the skin tender to light touch.
- Simulation: Axial loading or simulated rotation with report of low back pain. Pressure on the top of the head (axial loading) of a standing patient should not cause low back pain. When the shoulders and pelvis are rotated in unison (simulated rotation), the structures in the back are not stressed. If the patient reports back pain with this maneuver, the test is considered positive for a non-organic source of the patient’s complaints.
- Distraction: In the standard straight-leg raise test, the patient is recumbent and aware of the test being performed. In contrast, a distracted straight-leg raise test is performed anytime the hip is flexed with the knee straight. The distracted straight-leg raise test can be done by examining the foot with the patient seated with one knee extended. Another example of a distraction test would be when the patient uses the injured limb when distracted.
- Regional Disturbances: Sensory change or weakness. Any widespread or global numbness that involves an entire extremity (stocking – glove) or side of the body and does not follow expected neurologic patterns is suspect. Regional, sudden or uneven weakness (cogwheeling, giving way, breakaway) is a non-organic, behavioral sign.
- Overreaction: The patient may be hypersensitive to light touch at one point during examination but later give no response to touching of the same area. This is a positive sign of overreaction, as evidenced by a disproportionate grimace, tremor, exaggerated verbalizations, sweating, or collapse. Other behavioral signs include inappropriate sighing, guarding, bracing, and rubbing; insistence on standing or changing position; and questionable use of walking aids or equipment.
The original purpose of the Waddell behavioral signs was to:
- Aid clinical assessment by separation of the organic and non-organic elements of the presentation.
- Direct appropriate resources toward the physical pathology.
- Identify illness behavior.
- Reduce or eliminate unnecessary procedures, diagnostic studies, and therapies.
In his article, Waddell cautioned the use of the behavioral signs in the following situations:
- Multiple false positives were found in the elderly patients and it was recommended that such patients should be fully evaluated.
- Behavioral signs can occur in the presence of organic pathology. The presence of these behavioral signs does not contradict organic findings.
Since Waddell published his article, multiple studies have independently validated his findings and have shown correlation between behavioral signs, level of disability, and physical and psychological factors. However, over the last twenty years Waddell behavioral signs have been misinterpreted and misused both clinically and medical-legally. Behavioral responses to examination provide useful clinical information, but need to be interpreted with care and understanding. Multiple behavioral signs suggest that the patient does not have a straightforward physical problem and that psychological factors need to be considered. Patients who present with multiple behavioral signs require management of their physical pathology, as well as close attention and management of the psychological aspects of their illness. Behavioral signs offer only a psychological “red-flag” and not a complete psychological assessment. Behavioral signs on their own are not a test of credibility or validity.
The most important step in the diagnostic process is the exclusion of significant underlying physical disease. Physicians are not omnipotent and many disease states are difficult to detect in the early stages, so great care is needed to rule out (within a reasonable degree) a diagnosable and treatable physical problem. Even if somatization or exaggeration is present, it behooves the physician to carefully watch for any symptoms or signs of underlying, previously unrecognized organic disease.
Other psychiatric conditions should also be considered, such as a depressive disorder or anxiety disorder. Somatization does not rule out the existence of other psychiatric phenomena. Secondary gain issues need to be considered and factored into the equation to better understand the patient’s presentation. Lastly, while uncommon, malingering and fraud must be considered as well.