Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression


dilemmaThe Dilemma: “When a patient reports difficulty returning to work, malingering need not be the first concern. A more central issue is to determine what the patient knows about his physical problem, why the pain is enduring, and how he assesses treatment to date.

A dilemma example: Take the example of a 42 year old male with a long, consistent work history. He has had previous injuries at work, but time lost has been brief. On this occasion, he fell from a platform, was treated by occupational medicine for neck and back pain, and when his pain continued, he was referred to an orthopedist.

The orthopedist tells the patient that the MRI indicates not only age-related degenerative disc disease but also that “there appear to be several bulges and what looks like a frank herniation.” The orthopedist does not recommend surgery or explain why surgery is not indicated, but refers the patient to a neurosurgeon.

The patient never sees the orthopedist again, and the neurosurgeon refers him to physiatry for conservative management. He remains in the care of the physiatrist for 18 months, is sent to physical therapy several times and undergoes ESIs of little benefit. The physiatrist then recommends a pain management center.

Another dilemma: The pain management recommendation is never authorized.

The patient returns repeatedly to the physiatrist for (non-narcotic) medication but continues to complain of neck pain radiating to both arms and low back pain radiating down the right leg.

The patient never mentions to the physiatrist what he believes he was told by the orthopedist, and he is never certain that the neurosurgeon personally reviewed his MRI.

Since pain management was recommended but not authorized, the physiatrist eventually has “nothing further to offer” and recommends a functional capacity exam (FCE) which is authorized.

The report of the FCE describes the patient’s performance as being suspect and questionable because of suboptimal effort. The patient reports that the examiner was scattered in her approach to the exam and that the exercises were beyond him, and he wonders if the examiner was being thorough and objective. The patient only knows for certain that after the FCE that he was in appreciable pain and bedridden for 72 hours.

Having “failed” the FCE, the physiatrist then releases the patient as maximally improved (MMI). Now that is a dilemma.

The employer and insurer draw the line that if the patient does not return to work, his symptoms are likely feigned and that he is malingering and benefits should be suspended. If he is offered light duty work and cannot sit or stand for prolonged periods in this sedentary position, he is again suspected of malingering even is his benefits are reinstated.

Among the many issues, here are several:

1. The patient fears that after two years, his spinal condition may have worsened beyond the point where early surgery would have been effective
2. The patient fears that pain is a sign of imminent spinal damage, and has developed a behavioral pattern that (unsuccessfully) attempts to avoid movements where pain is triggered, which in turn makes it appear that his complaints are feigned
3. The patient expresses the desire to return to his employer as well as the fear that he is no longer wanted
4. The patient believes that his experience of pain is poorly understood
5. The patient has become reactively depressed, feeling helpless and hopeless and has begun to live a life of withdrawn despair

What the patient requires but may never receive is an audience, someone who explains all findings, explains all options, and either reassures the patient that he is not in danger or that there is treatment definitively indicated for his complaints, or that there is no definitive treatment and “this is it”.

Will the patient be provided such an audience with a clinician, or merely be discharged MMI with a PPD (if any) rating?

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