The Unifying Concept of Illness Behavior

Abstract Spinal cord (dorsal column) stimulation (SCS) and intraspinal opioids (ISO) are treatments for patients in whom abnormal illness behavior is absent but who have an objective basis for severe, persistent pain that has not been adequately relieved by other interventions. Usually, physicians prescribe these treatments in cancer pain or noncancer-related neuropathic pain settings. A survey of academic centers showed that 87% of responding centers use SCS and 84% use ISO. These treatments are performed frequently in nonacademic settings, so evaluators likely will encounter patients who were treated with SCS and ISO. Does SCS or ISO change the impairment associated with the underlying conditions for which these treatments are performed? Although the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not specifically address this question, the answer follows directly from the principles on which the AMA Guides impairment rating methodology is based. Specifically, “the impairment percents shown in the chapters that consider the various organ systems make allowance for the pain that may accompany the impairing condition.” Thus, impairment is neither increased due to persistent pain nor is it decreased in the absence of pain. In summary, in the absence of complications, the evaluator should rate the underlying pathology or injury without making an adjustment in the impairment for SCS or ISO.

Download Full-text

Behavioral Factors Impact Impairment and Disability Evaluation

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2011.sepoct03 ◽

2011 ◽

Vol 16 (5) ◽

pp. 5-7

Author(s):

Lee Ensalada

Keyword(s):

Social History ◽

Standardized Test ◽

Somatoform Disorders ◽

Disability Evaluation ◽

Body Part ◽

Emotional Reactions ◽

Illness Behavior ◽

Validity Testing ◽

Symptom Validity Testing ◽

Disease Pattern

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 Tutorial: Functionally Limiting Upper Extremity Pain: Controversies in Impairment Rating

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2003.sepoct02 ◽

2003 ◽

Vol 8 (5) ◽

pp. 4-12

Author(s):

Lorne Direnfeld ◽

James Talmage ◽

Christopher Brigham

Keyword(s):

Upper Extremity ◽

Radicular Pain ◽

Illness Behavior ◽

Orthopedic Surgeon ◽

First Case ◽

Clinical Presentations ◽

Whole Person ◽

Physical Examinations ◽

Upper Extremity Impairment ◽

The Individual

Abstract This article was prompted by the submission of two challenging cases that exemplify the decision processes involved in using the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). In both cases, the physical examinations were normal with no evidence of illness behavior, but, based on their histories and clinical presentations, the patients reported credible symptoms attributable to specific significant injuries. The dilemma for evaluators was whether to adhere to the AMA Guides, as written, or to attempt to rate impairment in these rare cases. In the first case, the evaluating neurologist used alternative approaches to define impairment based on the presence of thoracic outlet syndrome and upper extremity pain, as if there were a nerve injury. An orthopedic surgeon who evaluated the case did not base impairment on pain and used the upper extremity chapters in the AMA Guides. The impairment ratings determined using either the nervous system or upper extremity chapters of the AMA Guides resulted in almost the same rating (9% vs 8% upper extremity impairment), and either value converted to 5% whole person permanent impairment. In the second case, the neurologist evaluated the individual for neuropathic pain (9% WPI), and the orthopedic surgeon rated the patient as Diagnosis-related estimates Cervical Category II for nonverifiable radicular pain (5% to 8% WPI).

Download Full-text