Last updated: Wed, Jul 31, 2024
Malingering means a conscious attempt to appear ill when the individual knows that this isn't true. A review of 68 different studies concluded that malingering might be present in 1.25-10.4% of chronic pain patients. Since the studies were generally of poor quality, the review concluded that the percentages aren't reliable. It also concluded that malingering cannot be reliably identified by facial expression, questionnaire, sensory testing, clinical examination, Jamar dynamometer, [or] isokinetic testing.
1 Further, it concluded, no conclusions can be drawn from these data. As yet, there is no reliable method for detecting malingering within CPPs, although isokinetic testing shows promise. Claims by professionals that such a determination can be made should be viewed with caution.
2
"Secondary gain" was originally conceived of by Sigmund Freud, the father of introspective psychology. It referred to advantages received by a patient as a result of illness, and was thought of as either subconscious or incidental to the illness. Some who are healthy believe that there are advantages related to illness, including avoidance of work, sympathy, ability to avoid unpleasant life roles, and the financial rewards of illness. Those who are ill tend to a different view. Over time, Freud's original concept has often faded into the background, and "secondary gain" is sometimes used to mean simply the financial rewards that may accrue to the ill and injured, whether conscious or subconsciously appreciated. (The Disability System.)
There is evidence that the existence of "secondary gains" influences the behavior of patients, sometimes in conscious ways. For example, veterans are apparently influenced by Veterans Administration compensation policies in how they report symptoms related to PTSD. Patients in countries with different compensation schemes perform differently in tests of their functional abilities. In Denmark, patients who have obtained disability pensions tend to use the health care system less than patients who haven't received disability pensions.3
Patients with open workers' comp claims have been the subject of many studies.
A 1989 study compared 150 patients with "compensable" injuries (accidental injuries and job-related injuries) with another 150 with non-compensable injuries, one to four years after the patients were first treated. The groups were matched as to age and severity of injury. The compensable patients had greater pain and more disability, more psychological disturbance, longer unemployment, and more time off work. Settlement of the claims did not result in less-severe illness. The authors concluded that [t]hese results demonstrate that the payment of compensation delays recovery from low-back injury.
4
A 2001 study reviewed 11 original studies, again looking at the impacts of compensation on recovery. This study concluded that compensation, lawyers, and higher pain all predicted longer time to recover and poorer recovery. The study also noted a paucity of high-quality data on the subject.
5
Neither of these studies, both cited in Melzack and Wall's Textbook of Pain, is of terribly high quality and both are susceptible of alternative explanations. However, the idea that compensation and litigation impede healing is well-established and widely accepted in the pain treatment community.