Behavioral Factors Impact Impairment and Disability Evaluation

Abstract Illness behavior refers to the ways in which symptoms are perceived, understood, acted upon, and communicated and include facial grimacing, holding or supporting the affected body part, limping, using a cane, and stooping while walking. Illness behavior can be unconscious or conscious: In the former, the person is unaware of the mental processes and content that are significant in determining behavior; conscious illness behavior may be voluntary and conscious (the two are not necessarily associated). The first broad category of inappropriate illness behavior is defensiveness, which is characterized by denial or minimization of symptoms. The second category includes somatoform disorders, factitious disorders, and malingering and is characterized by exaggerating, fabricating, or denying symptoms; minimizing capabilities or positive traits; or misattributing actual deficits to a false cause. Evaluators can detect the presence of inappropriate illness behaviors based on evidence of consistency in the history or examination; the likelihood that the reported symptoms make medical sense and fit a reasonable disease pattern; understanding of the patient's current situation, personal and social history, and emotional predispositions; emotional reactions to symptoms; evaluation of nonphysiological findings; results obtained using standardized test instruments; and tests of dissimulation, such as symptom validity testing. Unsupported and insupportable conclusions regarding inappropriate illness behavior represent substandard practice in view of the importance of these conclusions for the assessment of impairment or disability.

Download Full-text

Impairment Update: Illness Behavior

Guides Newsletter ◽

10.1001/amaguidesnewsletters.1998.mayjun02 ◽

1998 ◽

Vol 3 (3) ◽

pp. 4-5 ◽

Cited By ~ 1

Author(s):

Leon H. Ensalada

Keyword(s):

Illness Behavior ◽

The Other ◽

Symptom Validity ◽

Validity Testing ◽

Symptom Validity Testing ◽

Sensory Deficits ◽

Effort Testing ◽

Symptom Exaggeration ◽

The One ◽

Self Presentations

Abstract The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes that many methods used to report medical impairments rely on the completeness, accuracy, and honesty of the patient's self-presentations. Symptom exaggeration is best understood in the context of clinical phenomena that lie along a continuum from unconscious and unintentional to conscious and intentional. Illness behavior refers to the ways in which given symptoms may be perceived, evaluated, and acted upon by different persons, and such behavior can be appropriate or inappropriate, depending on context, and can be learned and reinforced. Further, certain illness behaviors potentially confound the association between illness or injury, on the one hand, and impairment or disability, on the other hand. For example, any deficit can be exaggerated, including neuropsychological deficits, pain, and loss of sensation. Specialized assessments include symptom validity testing to assess memory or sensory deficits, and maximum voluntary effort testing assesses strength deficits. In their assessment of illness behavior, physicians should employ the same degree of thoroughness as they would with any condition. Written reports should include not only the conclusion that symptom exaggeration is present but also the basis for this determination. A table shows the characteristics of symptom magnification syndromes and other related conditions vs the presence of symptoms such as seeking gain or deception.

Download Full-text

Symptom Validity Testing

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2018.novdec03 ◽

2018 ◽

Vol 23 (6) ◽

pp. 14-15

Author(s):

Lee H. Ensalada

Keyword(s):

Memory Deficits ◽

Symptom Validity ◽

Sensory Cues ◽

Validity Testing ◽

Symptom Validity Testing ◽

Tunnel Vision ◽

Blurry Vision ◽

The Common ◽

Fatigue Evaluation ◽

Choice Testing

Abstract Symptom validity testing (SVT), also known as forced-choice testing, is a means of assessing the validity of sensory and memory deficits, including tactile anesthesias, paresthesias, blindness, color blindness, tunnel vision, blurry vision, and deafness. The common feature among these symptoms is a claimed inability to perceive or remember a sensory signal. SVT comprises two elements: a specific ability is assessed by presenting a large number of items in a multiple-choice format, and then the examinee's performance is compared to the statistical likelihood of success based on chance alone. These tests usually present two alternatives; thus the probability of simply guessing the correct response (equivalent to having no ability at all) is 50%. Thus, scores significantly below chance performance indicate that the sensory cues must have been perceived, but the examinee chose not to report the correct answer—alternative explanations are not apparent. SVT also has the capacity to demonstrate that the examinee performed below the probabilities of chance. Scoring below a norm can be explained by fatigue, evaluation anxiety, inattention, or limited intelligence. Scoring below the probabilities of chance alone most likely indicates deliberate deceptions and is evidence of malingering because it provides strong evidence that the examinee received the sensory cues and denied the perception. Even so, malingering must be evaluated from the total clinical context.

Download Full-text

Clinical Update: Symptom Validity Testing

Guides Newsletter ◽

10.1001/amaguidesnewsletters.1999.julaug05 ◽

1999 ◽

Vol 4 (4) ◽

pp. 8-9

Author(s):

Leon H. Ensalada

Keyword(s):

Symptom Validity ◽

Validity Testing ◽

Symptom Validity Testing

Download Full-text

Impairment Questions and Answers

Guides Newsletter ◽

10.1001/amaguidesnewsletters.1999.julaug02 ◽

1999 ◽

Vol 4 (4) ◽

pp. 4-4

Keyword(s):

Symptom Validity ◽

Validity Testing ◽

Symptom Validity Testing ◽

Negative Results ◽

Tunnel Vision ◽

Questions And Answers ◽

Blurry Vision ◽

Fatigue Evaluation ◽

Choice Testing ◽

Rule Out

Abstract Symptom validity testing, also known as forced-choice testing, is a way to assess the validity of sensory and memory deficits, including tactile anesthesias, paresthesias, blindness, color blindness, tunnel vision, blurry vision, and deafness—the common feature of which is a claimed inability to perceive or remember a sensory signal. Symptom validity testing comprises two elements: A specific ability is assessed by presenting a large number of items in a multiple-choice format, and then the examinee's performance is compared with the statistical likelihood of success based on chance alone. Scoring below a norm can be explained in many different ways (eg, fatigue, evaluation anxiety, limited intelligence, and so on), but scoring below the probabilities of chance alone most likely indicates deliberate deception. The positive predictive value of the symptom validity technique likely is quite high because there is no alternative explanation to deliberate distortion when performance is below the probability of chance. The sensitivity of this technique is not likely to be good because, as with a thermometer, positive findings indicate that a problem is present, but negative results do not rule out a problem. Although a compelling conclusion is that the examinee who scores below probabilities is deliberately motivated to perform poorly, malingering must be concluded from the total clinical context.

Download Full-text

Letter to the Editor: The Continuing Challenge of Evaluating RSD Impairment and Disability

Guides Newsletter ◽

10.1001/amaguidesnewsletters.1998.sepoct05 ◽

1998 ◽

Vol 3 (5) ◽

pp. 8-10

Author(s):

Robert L. Knobler ◽

Charles N. Brooks ◽

Leon H. Ensalada ◽

James B. Talmage ◽

Christopher R. Brigham

Keyword(s):

Disability Evaluation ◽

Body Part ◽

Loss Of Function ◽

Regulatory Requirements ◽

Major Cardiac Event ◽

Clinical Scenarios ◽

Impairment Score ◽

Occupational Activities ◽

The Difference

Abstract The author of the two-part article about evaluating reflex sympathetic dystrophy (RSD) responds to criticisms that a percentage impairment score may not adequately reflect the disability of an individual with RSD. The author highlights the importance of recognizing the difference between impairment and disability in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): impairment is the loss, loss of use, or derangement of any body part, system, or function; disability is a decrease in or the loss or absence of the capacity to meet personal, social, or occupational demands or to meet statutory or regulatory requirements because of an impairment. The disparity between impairment and disability can be encountered in diverse clinical scenarios. For example, a person's ability to resume occupational activities following a major cardiac event depends on medical, social, and psychological factors, but nonmedical factors appear to present the greatest impediment and many persons do not resume work despite significant improvements in functional capacity. A key requirement according to the AMA Guides is objective documentation, and the author agrees that when physicians consider the disability evaluation of people, more issues than those relating to the percentage loss of function should be considered. More study of the relationships among impairment, disability, and quality of life in patients with RSD are required.

Download Full-text