Is There a Relationship Between Nonorganic Physical Findings (Waddell Signs) and Secondary Gain/Malingering?

Abstract

This is a structured evidence based review of all available studies addressing the concept of nonorganic findings (Waddell signs) and their potential relationship to secondary gain and malingering. The objective of this review is to determine what evidence, if any, exists for a relationship between Waddell signs and secondary gain and malingering. Waddell signs are a group of 8 physical findings divided into 5 categories, the presence of which has been alleged at times to indicate the presence of secondary gain and malingering. A computer and manual literature search produced 16 studies relating to Waddell signs and secondary gain or malingering. These references were reviewed in detail, sorted, and placed into tabular form according to topic areas, which historically have been linked with the alleged possibility of secondary gain and malingering: 1) Waddell sign correlation with worker compensation and medicolegal status; 2) Waddell sign improvement with treatment; 3) Waddell sign correlation with Minnesota Multiphasic Personality Inventory validity scores; and 4) Waddell sign correlation with physician dishonesty perception. Each report in each topic area was categorized for scientific quality according to guidelines developed by the Agency for Health Care Policy and Research. The strength and consistency of this evidence in each subject area was then also categorized according to Agency for Health Care Policy and Research guidelines. Conclusions of this review were based on these results. There was inconsistent evidence that Waddell signs were not associated with worker's compensation and medicolegal status; there was consistent evidence that Waddell signs improved with treatment; there was consistent evidence that Waddell signs were not associated with invalid paper-pencil test; and there was inconsistent evidence that Waddell signs were not associated with physician perception of effort exaggeration. Overall, 75% of these reports reported no association between Waddell signs and the 4 possible methods of identifying patients with secondary gain and/or malingering. Based on the above results, it was concluded that there was little evidence for the claims of an association between Waddell signs and secondary gain and malingering. The preponderance of the evidence points to the opposite: no association.

The Relationship Between Self-Rated Disability, Fear-Avoidance Beliefs, and Nonorganic Signs in Patients with Chronic Whiplash-Associated Disorder

“…Fishbein et al 49,50 have critiqued the notion that the correlation between nonorganic pain behavior and the NOS tests with psychological states has strong empirical support. In fact, it is their contention that there is almost no support for the correlation between NOS and malingering.…”

Malingering? No Evidence in a Predominantly Hispanic Workers' Compensation Population with Chronic Pain

“…Some researchers such as Fishbain et al (2004), who conducted a systematic review of the literature, conclude that there is inconsistent evidence for malingering and psychological etiology in chronic pain sufferers. Sullivan (2004) argues that the determination of exaggerated pain behavior is moral not scientific in nature.…”

“…Diagnostic criteria for malingering often recognized in worker's compensation population include marked discrepancy between complaint of pain and objective findings in individuals who are in the process of litigating for compensation (p. 739). Yet, the validity of this diagnosis is questionable in light of equivocal research findings and inconsistent evidence for malingering and psychological etiology in chronic pain sufferers (Fishbain, Cutler, Rosomoff, & Rosomoff, 2004). Thus, while the likelihood of clinicians and third party payers to suspect patients of malingering is high, there is little, if any, objective evidence to support such suspicions.…”

“…Malingering is the “intentional … [exaggeration of] physical or psychological symptoms motivated by external incentives such as …avoiding work, obtaining financial compensation, or obtaining drugs” (American Psychiatric Association [APA] 2000, p 739). Despite evidence that malingering in chronic pain sufferers is rare (Social Security Administration, 1987), insurance companies, third-party payers, and others attribute chronic pain complaints to malingering when they lack a definitive cause or physical evidence to explain symptoms (Bianchini, Greve, & Glynn, 2005; Fishbain, Cutler, Rosomoff, & Rosomoff, 2004; Flor & Turk, 2006, p. 241; Geisser, Robinson, Miller, & Bade, 2003). Likewise, clinical journals apprise physicians and other providers to suspect malingering when patients seek compensation for injury or when pain is not or cannot be objectively confirmed, is judged disproportionate to the cause, or is recalcitrant to treatment (Aronoff et al, 2007; Bienenfeld, 2008; Kiester & Duke, 1999; McDermott & Feldman, 2007; Mendelson & Mendelson, 2004).…”

History and Physical Examination of the Pain Patient

“…In fact, recent data suggest that Waddell's signs cannot accurately distinguish between organic and nonorganic causes of pain. 12 The physical examination may be helpful in elucidating the cause of a patient's pain complaints; however, when used alone it has limitations, and the results of physical examination need to be considered in the context of the patient's history, as well as in the context of the results of diagnostic studies.…”