Why study malingering in the area of whiplash?

The relevance of considering malingering in the clinical assessment of a person with any injuries or complaints arises from the co-occurrence of two necessary factors:

Symptoms of whiplash associated disorders (WAD) clearly meet these two fundamental criteria, since:

In the case of whiplash-associated injuries, it is now well established that even low-impact MVCs may result in a range of physical and psychological complaints.^1–3 The most common complaints after whiplash are of increased pain and decreased range of neck movement, but a range of other symptoms may develop, including sensorimotor deficits, psychological and psychiatric sequelae (e.g. anxiety about driving, post-traumatic stress disorder and depression) and a broad spectrum of cognitive complaints, including reduced memory function and attentional problems. While the development of chronic pain is well documented after whiplash, the possible psychological consequences of MVCs are related to the severity of the accident.⁴ In the case of whiplash injury, a serious impact is not a prerequisite and so reactive psychological disorders, such as post-traumatic stress disorder (PTSD), are not commonly associated with whiplash per se, but with the subjective psychological impact of the accident in which the whiplash injury occurred.

The precise extent and nature of whiplash-associated cognitive complaints is also controversial. The controversy regarding the presence of cognitive complaints arises from the question—can a whiplash injury cause brain damage without direct trauma to the head? There is a proposed mechanism by which acceleration–deceleration forces may cause ‘neuronal shearing’ and there is evidence confirming the presence of generalised cognitive impairment after whiplash, but there is no compelling evidence that the forces exerted in a whiplash injury are sufficient to cause damage to the brain. The evidence that neuropsychological function is compromised may have alternative explanations, such as the impact of chronic pain, the effects of medication or the influence of psychological disorders, such as reactive depression and PTSD in more serious accidents.⁵ Studies that adequately examine these competing explanations have yet to be carried out.

For the reasons outlined above, the current discussion will focus on malingering of pain symptoms, as there is incontrovertible evidence that chronic pain can occur after whiplash injury. It is inconceivable that all chronic pain claimants after whiplash are malingerers, so the challenge for clinicians is to differentiate genuine chronic pain from malingered chronic pain.

While the relationship between whiplash and cognitive impairment is still unclear, a good deal of the methodological advancement in the identification of malingering has been in the domain of cognitive impairment. This chapter considers some of the advances in the identification of malingered cognitive impairment, as these methodologies have implications for the identification of malingered pain.

It is important from the outset to clarify that, although there is a perception among healthcare professionals that malingering is a common occurrence in those claiming compensation for pain,⁶ there is little evidence to support this view. The history of doubt and scepticism about symptom veracity when compensation is a factor has perhaps been immortalised in the phrase ‘compensation neurosis’, coined by Rigler,⁷ who noted the high level of disability among injured railway workers, and the concept of ‘accident neurosis’ defined by Miller⁸—a ‘a state of mind, born out of fear, kept alive by avarice, stimulated by lawyers and cured by a verdict’.

Although perhaps less extreme views are held at present, there is a persisting belief by some that compensation and disability are intimately related.^9–11 However, a meta-analysis suggests that malingering may actually only be present in between 1.25% and 10.4% of people with chronic pain, although this conclusion is based on very limited evidence.⁶ Indeed, the explicit fabrication of symptoms in the absence of a genuine injury is rare. Furthermore, it may be argued that all clinical complaints should be treated equally. We know from extensive clinical and research experience that a multitude of variables may individually or in combination influence:

All of these trajectories occur in a range of health conditions. The presence of a medicolegal context on top adds another layer of complexity but is not the sole determinant of a claimed chronic pain problem. Indeed, considering all of these contributing factors, it could be argued that inconsistency in pain onset, presentation and course is perhaps the norm. This is not a new observation—Hackett¹² eloquently identified many of the intra-individual factors that influence pain experience. More recently, it has been noted that the current definition of chronic pain from the International Association for the Study of Pain (IASP)¹³ uses a reference standard of ‘normal’ pain, but argued that that there is no agreement, either statistical or empirical, about what constitutes ‘normal’ pain.¹⁴ From the perspective that variability in pain experience is, in fact, normal, it may be further argued that the efforts of clinicians should be focused on assisting people to recover functioning to the greatest extent possible, rather than seeking to apply labels such as malingering.

Having made the argument that variability in pain is the norm, there can be little doubt that some deliberate symptom fabrication and deception does occur, and many clinicians are required to provide reports for legal purposes and/or to provide an opinion about the veracity of the claimant. This chapter aims to outline the state of our knowledge to assist the clinician in arriving at an informed opinion about claimant veracity—or whether it is even possible to complete that task.

What is meant by ‘malingering’?

Within the Diagnostic and Statistical Manual of Mental Disorders (DSM),¹⁵ malingering is classified as a condition that may be a focus of clinical attention. According to the DSM, malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives, such as avoiding military duty, avoiding work, obtaining financial compensation, evading prosecution or obtaining drugs. The DSM specifies that malingering should be strongly suspected if there is any combination of a medicolegal context, marked discrepancy between the person’s claimed disability and the objective findings, lack of cooperation with assessment and treatment, and the presence of antisocial personality disorder. The International Classification of Diseases (ICD)¹⁶ categorises malingering in the Z codes—factors influencing health status and contact with health services (Z00–Z99)—and defines malingering (conscious simulation) simply as ‘person feigning illness (with obvious motivation)’.

Neither of these definitions is very useful for diagnostic purposes, since they merely describe the behaviour of malingering without any practical guidance on decision-making in relation to the presence or absence of the characteristics proposed to be important. More useful conceptualisations recognise that malingering is a complex phenomenon with many ‘shades of grey’ in terms of the extent to which symptoms are actually produced de novo (i.e. symptoms arising in the absence of injury), exaggerated where they actually exist or reported in the absence of any genuine symptoms. The DSM and ICD definitions also fail to recognise the role of combined external incentives and internal psychological processes, and the extent to which compensation systems may act to encourage prolonged symptom reporting and disability.

Resnick¹⁷ identified several types of malingering. He stated that pure malingering is the feigning of disease when it does not exist at all. Partial malingering is the conscious exaggeration of existing symptoms or the fraudulent allegation that prior genuine symptoms are still present. False imputation refers to the claimant ascribing actual symptoms to a cause consciously recognised by the patient as having no relationship to the symptoms. These distinctions have strong face validity in terms of the clinical presentation of patients following MVCs and, logically and intuitively, partial malingering or symptom magnification are likely to be the most prevalent forms of malingering using Resnick’s framework. Main¹⁸ argues that clinicians have a role in identifying symptom exaggeration (partial malingering) but that decisions about deception (pure malingering) should be the responsibility of the judicial system.

Rogers^{19, 20} has proposed an explanatory model of malingering. He suggested that malingering may occur for one of three reasons, because malingering persons are:

The mentally disordered or pathogenic model proposes that malingering occurs because of a mental disorder. There is little evidence to support such a model except in selected psychiatric conditions, such as factitious disorder. The criminological model, on which the DSM criteria are arguably based, is rejected by Rogers as it assumes that malingering is perpetrated by a ‘bad person, in bad circumstances, who is behaving badly’ (p 8).²⁰ Given that many ‘good’ people regularly malinger (e.g. to take a day off work or to avoid a social event), the argument that malingerers are inherently bad people does not stand up to scrutiny in everyday life.

The adaptational model proposes that malingering is an adaptive response to adversarial circumstances in which the individual has a substantial personal investment. This argument is philosophically interesting as it implies that malingering is, in a sense, a product of our litigious society in many cases. Anecdotally, it fits with the author’s own experience in medicolegal contexts—patients frequently describe being sent for assessments to antagonistic, disbelieving and sceptical health professionals where the patient feels pressured to ‘prove’ that their complaints are genuine and, in so doing, may well engage in abnormal illness behaviours with exaggerated disability. This presentation merely serves to reinforce the view of the sceptical assessor that the patient is malingering.

A fascinating study examined the number of claims for whiplash injury in a Canadian province after changing from a system of tort to a no-fault insurance system.²¹ The authors found that the number of whiplash claims fell by almost 30% and the claims were resolved, on average, some 200 days earlier. Longer time to completion was associated with higher initial pain intensity and depression in the claimant but also with non-patient factors, such as engaging the services of a lawyer or seeing health practitioners who were more likely to offer active interventions, perhaps ‘validating’ the illness perception. They concluded that the type of insurance system profoundly affects the frequency and duration of whiplash claims. However, it is argued that most people filing insurance claims are not malingerers—rather, their behaviour reflects a complex interaction between biological factors, psychological reactions and appraisals, social forces, legal influences and financial incentives.²²

Approaches to detection of malingering

Lanyon²³ has outlined a number of models for describing and understanding malingering and other forms of deception, from which methodologies for detecting malingering can be derived. According to Lanyon, traditional approaches to the detection of malingering have been based on a ‘global-signs-of-lying’ model, which assumes that certain universal, physiologically mediated signs correlate with attempts to deceive. Examples of detection strategies based on this model include the polygraph test and voice stress analysis. Lanyon described the basic characteristics of this model as follows:

Clearly, the model assumes that lying will produce psychophysiological arousal, which can be measured. An implicit assumption, therefore, is that lying is an emotion-producing activity. Another implicit assumption is that the physiological arousal observed on measurement is directly attributable to the lying. However, there is extensive evidence that physiological measures such as polygraphy are unreliable, and that results are open to multiple interpretations.^{24, 25}

Two other models identified by Lanyon are accuracy of knowledge (including lack of uncommon knowledge, erroneous stereotypes and over-endorsement) and personal influence Accuracy of knowledge refers to the assumption that successful deception requires the deceiver to have accurate knowledge of the target condition. This knowledge has two aspects: factual content and personal behaviour. Persons who are successful at deceiving know the facts about the target condition and also behave like a person who has the target characteristics. This leads directly to an assessment approach for detecting deception, that is, the assessment of a person’s level of relevant knowledge of the target condition that the person is attempting to simulate. This is, therefore, a cognitive (knowledge-based) model of deception rather than an affective or autonomic model of deception. Successful detection is based on the identification of those characteristics about which the person’s knowledge is most likely to be inaccurate.

Lanyon further delineated the accuracy of knowledge model into three subareas, as outlined below.

However, a significant weakness of malingering research has been the challenge of determining an appropriate ‘gold standard’ measure against which to evaluate the utility of diagnostic tests. In diagnostic testing, the gold standard would be another established test that accurately identifies a group with, and without, the condition under study (known-groups design). The problem in malingering research is that confirmed malingerers are exceedingly rare. This drawback has been addressed through the use of simulation designs, where a group responds to a test ‘as if’ they had the condition under study. However, there are several problems with this design; for example, the extent to which a simulation adequately reflects the reality of a clinical situation and the extent to which a simulation design can reflect the magnitude of the incentive in the malingering group.

Differential diagnosis of psychological disorders where symptom production or magnification is a feature

Some of the DSM disorders that may resemble malingering because of the unexplained symptom patterns have been identified.²⁶ These are briefly outlined below.

Related posts:

Epidemiology of whiplash associated disorders Potential role of stress systems in the pathogenesis of whiplash associated disorders Future directions Case descriptions Neuromuscular dysfunction in whiplash associated disorders The evidence for pathoanatomical lesions

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