The Role of a Psychiatric Assessor in Personal Injury Claims
Abstract
This paper is concerned with the language of psychiatry,
words, symbols, behaviour and their meaning. It concerns the interpretation
of phenomena in a vexed social and political context. It asks if somatization
can be distinguished from injury, and how it is to be dealt with in the medico-legal
setting.
The application of the concept of somatization to the psychiatric
assessment of personal injury claims, uncomplicated by elements of traumatic
neurosis, reveals a tendency towards certain behavioural clusters.
Profiles of five categories of disorder are reported: first,
the person who has been injured and has developed a neurotic illness with
somatization, (commonly called "functional overlay"); second, the
physically injured, uncomplicated by emotional factors; third, the malingerer,
fourth: the person with a paranoid attitude and fifth, the conversion hysteric.
These profiles are the product of investigation into the nature and duration
of physical symptoms, psychosocial background, interpersonal relationships
and psychological symptom profile.
Introduction
The following words all refer to the experience and communication
of distress as somatic symptoms: neurosis, hysteria, functional overlay, illness
behaviour, abnormal illness behaviour, ideogenic illness, psychogenic illness,
functional disorder, stress induced disorder, hypochondriasis and somatization.
Some of these expressions are explicitly antipathetic, some marginally hostile,
others, empathic or seemingly ambivalent. Like all psychiatric terminology,
they are inherently value-laden and potentially judgemental.
Somatization
Several definitions of the phenomenom of somatization have
been advanced. The first use of the term is attributed to Stekel, early this
century.[1] Katon et al.[2] define
it as "an idiom of distress in which patients with psycho social and
emotional problems articulate their distress articulate their distress primarily
through physical symptomatology", while Kleinman and Kleinman[3]
define it as "an expression of personal and social distress in an idiom
of bodily complaints with medical help-seeking."
Gould's[4] Medical Dictionary, in
contradistinction from the non dynamic and more value free formulation of
these more recent researchers, suggests "a psychoneurotic displacement
of emotional conflicts onto muscles and sensory apparatus innervated by the
voluntary nervous system, in distinction to psychosomatic reaction in which
displacement occurs onto organs and viscera innervated by the autonomic system,
conversion."
It remains pejorative to say that some one suffers from
hysteria, no matter how nicely it is done. Words, not so value laden, are
needed to allow the average person to ask him or herself what problem it is
that he or she could be somatizing.
"To somatize" is both a transitive and active
verb. To encourage its use in this context could be the first step in assisting
the patient to own, or to take responsibility for the process. "Being
hysterical," or worse, "suffering from hysteria" are both passive
states, consistent with the passive role of a patient being managed within
the medical model, rather than with understanding what is going on within
a broader psychosocial framework.
What is to be done about both acute and chronic somatization
is still largely unexplored territory. A good beginning would be made if the
language were to be made accessable to the community at large and to the medical
profession. While there are diagnostic categories for reactive anxiety and
depression, (adjustment disorders), there is no category of 'adjustment disorder
with somatization", a problem which accounts for the single most common
consultation in general medicine.[5] Physical
treatments and patent medicines do not seem to be theoretically sound and
their unreliable action suggests a placebo response at best.
Conversion hysteria is most frequently diagnosed in women,
and somatization in men. There seems little to warrant this beyond historical
tradition. Overt emotionality ranges from apparent indifference to disability
to virtual panic focussed on imminent death.[6]
Conversion hysteria represents the dysfunctional resolution of conflict, perhaps
any one of the many conflicts that women have between their duties and their
obligations. Acute somatization is encountered with fatigue, depression and
anxiety and these could relate to traditional male responsibilities; it is
considered that somatization more usual in pre-modern and traditional societies;
its opposite, psychologisation, is a product of an individualistic society.
Furthermore, groups tend to somatize and individuals psychologize.[7]
Malingering
The term "malingering" originated in the French
military and referred to the fabrication of illness for the purpose of avoiding
duty. Malingering, in its original meaning, was what is now called factitious
disorder.[8] However, factitious disorder in DSM IV
is so defined that there is no clinical language to describe the behaviour
of the actor in his natural habitat outside the casualty room. In his community
he puts about, say, that he is suffering from terminal cancer or he presents
in the compensation stream with an un-united fracture and interference is
suspected.
Invalid claims
Other invalid claims include the exaggeration of pain or
distress, the exaggeration of incapacity from a symptom and continued reporting
of old symptoms as if they were still there. Some people present with the
attitude that they are entitled to be compensated because of what has befallen
them, rather than because they are hurt. This presentation bears the ungainly
name of "attitudinal pathosis."[9]
The most common form of defensible claim encountered in
my office involves a conflict about the attribution of symptoms. These might
be generated by an old or a non compensable problem and blamed on something
that might attract compensation. Symptoms of emotional origin as occur in
neurotic disorder are attributed to a traumatic origin. Some claimants are
mistaken, others are poorly advised and a number are trying to deceive.
The sample
In the normal course of events, only a small number of people
would develop a limp at the prospect of being paid fifty thousand dollars
for it. Most people recover from injury in the normal course of events. The
population proceeding towards litigation, consists of fewer than ten percent
of those who have been hurt.
Initially we are tempted to believe that it is the most
seriously injured who do not recover. Experience soon teaches that some people
with broken spines do go to work in wheelchairs while others, with no discernible
pathology, cannot make a cup of tea or chop the vegetables.
The prevalence of emotional difficulties among this latter
group suggests that concurrent psychological distress could be the sine
qua non predisposing factor for prolonging disability.
Typically, members of this group seem to share the idea that they have been
injured, and ideas are the stuff that neuroses are made of.
Assessment of Claims
The injured person can be differentiated from the person
who mistakenly believes himself to be injured. Psychiatrists occasionally
find malingerers, but when they do no one gets too excited; truth claims are
usually over-ridden by pragmatic considerations. Claims are assessed, and,
by an obscure process, reports get translated into money.
To assess the validity of a claim, the following information
is needed:
Has the claimant been physically injured?
Is he still impaired?
Where is the lesion? _ or _ is this emotional in origin?
What is the psychopathology? and
What is its origin?
A psychiatrist working as a medical assessor is skilled
in the art of making a diagnosis, where the term "to "diagnose"
is taken to mean "to see through." Circumstantial evidence should
not detract from identifying the pathology or psychopathology which afflicts
the claimant.
By working backwards from the diagnosis to aetiology, the
psychiatrist may be able to enlighten the lawyer as to what the latter calls
"causation." Neither behaviour nor experience are subject to the
laws of causation but they are vulnerable to influence. Illness behaviour
is under the influence of the mind and will and a person cannot be caused
another person to act against his or her free will. Circumstances where one
form of behaviour carries more advantage than another can be created by doctors.
Traumas and injuries in themselves do not "cause"
neurosis, but this hardly deters lawyers from trying to establish that a symptom
which followed a trauma must have been caused by it. The trauma or injury
and what it symbolizes is converted to an idea which has a meaning, and that
meaning influences the mind and will, which in turn shapes individual behaviour.
In nineteenth century textbooks of neurology, the "neuroses"
appear as all the undiagnosable diseases Towards the end of that century,
their psychogenic origin was well accepted. Diagnosis must have been a rigorous
intellectual exercise in the days before CT scanners and x-rays and when it
was as well for a doctor not to get involved in expensive treatment which
would not succeed. The patient's relentless pursuit of medical and surgical
therapies leave the doctor with little alternative but to indulge in treatment
behaviour and there might be little incentive for a surgeon not to operate,
or for an occupational health specialist to refer. Epidemics of new "diseases"
appear - RSI[10],[11],[12],
fibrositis syndrome, benign myalgic encephalomyelitis.[13],[14] dental galvanism[15] They
share in common the fact that their names ALL contain a causal hypothesis
( ...itis, injury, galvanism,) which then provide a "theoretical basis"
for empirical therapies, which, in thirty years, will be as poorly regarded
as the packing of the nasal mucosa, bleeding by leeches, arsenicals, deep
sleep with electro-convulsive therapy and cocktails of psychotropic drugs.
Fields of interest in assessment
There are four areas of interest: first, the symptoms; second,
the background; third, the psychological profile and fourth, the state of
inter-personal relationships.
Disease must not be diagnosed on the single criterion of
"symptoms." Corroborating evidence is needed: in physical medicine,
a clinical sign; in psychiatry, further evidence in the experience and behaviour
of a claimant.
The symptoms of the claimant
If there is a physical condition, it is the psychiatrist's
task to diagnose it, to his or her own satisfaction.
Some psychiatrists regard diagnosis of a medical or surgical
condition as outside their speciality. Such reticence or modesty, if carried
too far would only serve to encourage those who would replace psychiatrists
with psychologists or appropriately programmed computers.
In an ideal world this responsibility would not fall to
them: medical examiners of different specialities would already have determined
that the symptoms were or were not those of any entity they could recognize
and they would have bowed out. However, in the real world there is a fight
for therapeutic jurisdiction and there are a number of diagnoses on any file
with therapeutic interventions to match.
Pain can be an experience caused by a disease or by a recognizable
lesion. On the other hand, sometimes pain is a feeling, an emotion on the
same level as anxiety and depression but experienced in the body. Pain can
be a manifestation of a distressed mental state, but more likely it will coexist
with it. Somatization is a feeling or emotion of pain, felt in the body rather
than in the mind. The undiagnosable physical symptom complex is inevitably
part of an emotional disturbance. Emotions can and do generate physical symptoms
both more durable and extensive than those of an original supposed trauma.
No claimant would disagree that emotional states can generate pain in the
chest or the stomach but some become quite adamant that back pain and arm
pain could not have such an origin. Common language refers to "a pain
in the neck" when referring to a certain category of nuisance, or "a
pain in the arse" for the more intractable variety.
The natural history of most injuries and traumatic neuroses
is towards recovery. An intelligent ten year old will tell you how long a
bruise hurts, how long bad dreams continue after a minor trauma.
Careful diagnosticians can identify psychogenic illness
and differentiate it from traumatic lesions. Somatization follows no anatomical
boundaries suggesting, simultaneously, both motor and sensory neurological
impairment. Symptoms cannot be explained by anatomy nor any other patho-physiological
mechanism, that is to say that symptoms do not follow the known natural history
for injury or illness and fail to respond to physical treatment.
The background of the claimant
I was much influenced by some research in the early sixties
into an epidemic of brucellosis in twenty four laboratory workers.[16] Extensive
medical work-ups, including both psychological and psychiatric consultations,
revealed evidence "of disturbed or troubled life situations existing
at the time of the acute infection or within a year before," in most
of the objectively well but otherwise malaised group. The same researchers
examined six hundred individuals before an epidemic of influenza broke out.
Their conclusion was that
"It was of particular interest that those test results
which we regarded as indices of depressive tendencies served to differentiate
the recovered from the symptomatic groups."
Thus those who had a prior problem became chronic victims
of Asian "flu. There have been further confirmatory studies of this phenomenon,
which is described as "changing an unacceptable disability for an acceptable
one." [17] The
problem has been shown to exist outside of the compensation field, but when
one adds an element of being paid for being sick, the tendency to attribute
symptoms to one cause rather than another stretches towards the irresistible.
My own observations confirm repeatedly that concurrent stress
changes illness experience and illness behaviour, with an unknown effect on
pathological data.
Generally, it may be said that a the claimant's state of
mind reveals his or her world view and self image, and the stresses, conflicts
and needs of the individual are often being expressed and met met by the adoption
of the sick role. If stressors of psychosocial origin are not found in the
examination of the claimant's background, the operant stress might be an unrelated
personal illness, the aging process, or, if it has been severe, the compensable
injury itself and its consequences.
The psychological profile of the claimant
The third reference is to the psychological symptom profile
which must be consistent with the experiencing of such discomfort as the claimant
describes. A change in temperament is evidenced by irritability, an increase
in querulousness, impatience, displays of annoyance, raising the voice, or
worse. This change is the most sensitive indicator that a person is under
stress. Without these corroborating features in the claimant, we are on shaky
ground attributing reported symptoms to illness of either a physical or mental
nature. Few, if any, such saints exist who could be suffering from a symptom
severe enough to impair their working capacity that would not bring about
a change in temperament.
With the temperament and libido in order, it is unlikely
that there is psychogenic pain or, indeed, severe pain from any cause.
Questions can be asked about the claimant's emotional state
on a "then" and "now" basis, and through such comparative
questioning, one can determine whether or not a stress-induced disorder did
exist at an earlier time, and whether or not recovery had been achieved. Indeed
the diagnosis may refer to a number of time frames in the claimant's life,
rather than suggest a continuing episode of pathology.
Interpersonal relationships reported by the claimant
Exaggeration of physical symptoms can be picked up by reference
to the state of relationships with close relatives and friends. Severe pain
of any origin changes one's life. Families do change if a member becomes disabled
as do social and recreational pursuits. If there is no change in these domains,
this suggests that there is no change in health status.
Five extreme examples demonstrate helpful but not infallible
characteristics. Most claimants cluster around these groupings and the assessment
of those who fall between is a matter for judgement.
1. Neurosis following injury, functional overlay
The most common presentation is of a person who has had
an accident but presents with pain which is unphysiological in distribution
or prolonged beyond expectations. The history will reveal psychological symptoms
which came on weeks or even months after the original trauma, difficulties
with close family members, and withdrawal from friendships and loss of capacity
for recreational pursuits. Irritability is reported with shame and guilt as
well as disturbances of sleep, anxiety, nervousness, dizziness, headaches,
depression, feelings of worthlessness, and loss of libido. There is evidence
of pre-occupation with health and with the future rather than with litigation.
Weight has been gained through inactivity.
With an emotional state so disturbed, it is easy to see
the somatic symptoms as manifestations of emotional distress and a malingerer
is unlikely to turn up in this group.
2 The physically injured claimant, without emotional complications
This person rarely reaches the psychiatrist's office unless
his symptoms have not been explained or he has not recovered. No immediate
stressor is found, although personal background is generously revealed. There
is some irritability, reportedly associated with pain but not perceived as
caused by it, as in the hysteric and the somatizer. Disability evaluation
reveals that specific movements are painful and avoided, but the claimant
makes successful compensatory adjustments. The hysteric cannot make the act
of will to do a thing; the person with a broken arm will use the other.
3 The malingerer
Typically, this is a person who has had some injury and
reports vague physical symptoms and gross incapacity . The personal, marital
and family background reveal no stressors at all, an idyllic existence, and
there has scarcely ever been an illness in the claimant or his family. A supportive
spouse is said to "understand".
Irritability is usually denied, but demanding behaviour
is promoted as proof of sickness. The advice
of other doctors is cited to to support his case, mostly inaccurately. Anxiety
focuses on seeing the medical examiner and an impending court case. Libido
is unimpaired. The malingerer will admit that any symptom you care to offer
occurs "sometimes" or "a little bit" but is unable to
go into any detail when asked to describe how it feels to be, say, anxious
or depressed. You might hear him thinking out loud, rationalizing that, "of
course", one would be depressed if one had these problems. For some reason
the "of course" reply is ominous. Sometimes he might oblige by forgetting
his address and phone number and then pulling out his driving licence to orientate
himself.
A symptom might be put forward several times during the
interview and there might be reference to a prepared statement.
There is no history of invasive, or uncomfortable therapies.
He reports no change in his weight, leaving available the hypothesis that
he is not so inactive at all.
By his account, his condition is still forever deteriorating.
He claims to be taking regular medication, but prescription
dates on his bottles belie this.
A quick calculation of his family's rent, repayments, telephone,
car costs, cigarettes and alcohol might reveal an expenditure which cannot
be maintained on sickness benefits or compensation. I initially identified
this profile by calculating expenditure in social security recipients.
4 Attitudinal Pathosis
[18]
Ellard, writing in the Medical Journal of Australia, describes
this behaviour in the following terms:
"The essence of the matter is that the person concerned
takes the view that because he has been injured he cannot work. Careful interrogation
will make it clear that he is not incapacitated by symptoms, but rather that
he has decided that he is unfit because of what has befallen him. Whereas
the neurotic consciously rejects his symptoms and wishes to be rid of them,
the person classified in this way believes that his state is an inevitable
consequence of his accident, not to be striven against, but rather to be paraded
as a grievance.
The "sufferer" is confident and loquacious, and
often one has the feeling that long years of being a bush lawyer have distiled
his paranoid and aggressive traits to a remarkable degree. He cannot concede
that here is any way of assessing the situation other than his way. He is
not so much concerned with establishing that he is sick, as with proving the
correctness of his attitude. Indeed, his dogmatism, forcefulness and apparent
lack of dependence make him as unlike a sick person as anyone can be, for
he does not seek to be healed, but to be justified. One can be certain that
he will not change until the litigation has ended. I do not know what happens
after that."
In more formal terms, this person would attract only the
diagnosis of his personality disorder, most commonly, narcissistic. Neither
neurosis nor injury can be diagnosed; he spends his time avoiding examination
in favour of ventilating his, probably projected, fantasy that the medical
examiner will not acknowledge his problem. In spite of some judicial opinions
to the contrary, this problem should not be compensated if it manifests alone,
as its goal directed behaviour based on an attitude and not the consequence
of injury. This presentation will include that of the paranoid schizophrenic
with somatic delusions, so it can be dangerous to offend him. It can also
be the presentation of an injured but paranoid individual.
5 The conversion hysteric
Here, there is no history of accident, but simply of a variable
onset of symptoms which are attributed to the activity in which the claimant
has been engaged. The claimant has firm ideas about his or her symptoms and
is unable to change paterns of belief.
The psychological profile reveals either shallow anxiety
and unhappiness, said to be present "because of" the symptom and
its consequences. If there is a conflict about working that is caused by family
illness, or marital difficulties anxiety and depression will be evident on
closer examination. Even the most obvious stressor and its logical consequences
are suppressed in favour of a pre-occupation with the symptom.
A change in mood in the conversion hysteric occurs at the
same time as the physical symptoms, not weeks or months later as in the case
of the physically injured somatizer, whose neurosis develops after discrete
interval. Careful history taking will reveal that the stressor precedes the
both physical and psychological symptoms, or was concurrent with their onset.
Proffered treatments are assiduously pursued but laughingly
reported as "useless." There is an indifference to the loss of ability
to do useful things, a loss which would be catastrophic had it been the consequence
of nerve or muscle damage. Interpersonal relationships are characterized by
increasing dependence on family and friends, with predictable disruption.
Hysteria sufferers are walking tributes to textbook psychiatry.
If somatization is not apparent, and there are no malingering
indicators, look for gout and bow out. If the claimant is not somatizing or
malingering, psychiatrists add little to the assessment of a relevant specialist.
The mono-symptomatic malingerer and the mono-symptomatic neurosis cannot be
diagnosed.
The defence of hysteria claims
The most common form of invalid claim in my practice concerns
the mistaken identity of the cause of hysteria. If hysteria is the diagnosis,
and we subscribe to the psychogenic theory of neurosis, then we should not
attribute causal powers to a physical entity such as a keyboard or an injury.
Sloppy language generates sloppy thinking. It is the idea
of a keyboard or the idea of an injury and their respective meanings
for the claimant which have provided the basis, and the legitimating for the
hysterical symptoms.
Some psychiatrists call hysteria "unconscious malingering",
since the adoption of the sick role furnishes a solution to the claimant's
predicament, whatever that might be. I prefer to view such a claim in the
light of psychodynamic theory. However I find that there is little understanding
of psychodynamic theory in the legal world, considerably less than in the
community generally. In a number of cases, the evidence has been that there
is no injury, but psychogenesis of symptoms but barristers have not been willing
to follow through. Failing to differentiate the various categories of "being
in the mind," they prefer instead to impugn poor faith to the claimant.
They find it more often than I do and remind me that my older textbooks of
psychiatry suggested that hysterics were dishonest.14
In ascribing origins of hysteria (and indeed for any neurosis
or somatization), a profitable inquiry might be to find the origin of the
stress. The determinants of neurotic illness are stress, ideas (which affect
mind and will,) and personal vulnerability . A theory of social iatrogenesis15 might determine the source of ideas and
hysterical beliefs and implicate those who mis-diagnose and misinform, the
vested interests in the business of promoting such ideas for their own purposes.
Illich has called this phenomenon "social iatrogenesis"
How forensic psychiatrists diagnose can ultimately determine
how others treat. Claimants have a right to be informed, to have their conflicts
attended and they should not to be subjected to theoretically unsound treatment
behaviour. Doctors are not healers nor shamans but practitioners of the healing
arts based on theoretically sound medicine.
Neuroses are the product of belief and desire and there
is very little to be done about them in a culture which rewards this mode
of adjustment.
The claimant will report voluntarily only the information
which appears to serve his or her perceived interests and the rest has to
be elicited. Occasionally a cacophony of poorly correlated data is the only
clue that something unfamiliar to medicine is going on.
[1] Hinsie, LE, Campbell
RJ, psychiatric dictionary #rd edition, New York, Oxford University press.
[2] Katon from Bridges
[3] Kleinman
[4]
[5]
[6] Lipowski, Z.J. Somatization: The experience and communication of psychological
distress as somatic symptoms.
[7] Goldberg
[8] Kaplan and Saddock
[9] Ellard, J. Psychological reactions to compensable injury. Med. J.
Aust. 1970 2 349-355.
[10] Lucire, Y. Neurosis
in the workplace. Med. J. Aust. 1986; 145: 323-327
[11] Cleland, L.G. "RSI": A model of social iatrogenesis. Med
J Aust 1987; 147: 236-239.
[12] Lucire, Y, Social iatrogenesis of the Australian disease "RSI"
J . Health Stud. XII . 2, 1988 146-149.
[13] Medical Staff of the Royal Free Hospital. An outbreak of encephalomyelitis
in the Royal Free hospital group, London, in 1955. Br Med J 1957; ii: 895-904
[14] McEvedy, C.P., and Beard,A.W. 1970 Royal Free Epidemic, 1955: A reconsideration.
Br. Med. J., i, 7-15.
[15]
[16] Imboden, J.; Canter, A.; and Cluff, L.: Symptomatic recovery from
medical disorders; Influence of Psychological factors, JAMA 178 11822-1184
(Dec 30) 1961.
[17] Hirschfield, A.H. Behan, R. The accident process 111 Disability: Acceptable
and Unacceptable.
[18] Pokorney, A.D., and Moore, F.J. (1953) Neurosis and Compensation,
Arch Industr. Hyg., 8 : 547-563.
[19] Mayer- Gross,W.
Slater, Eliot and Roth, Martin. Clinical Psychiatry, 1954, 1955, 1960. Cassel
& Company Ltd.
[20]
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