Experience of pain varies considerably in terms of intensity and variability. Individuals, sensitivity and tolerance also varies with gender, ethnicity, personality and culture, all of which interact, and need to be taken into account by the expert assessing causation, diagnosis and prognosis on behalf of the court.
Over 7 million people in the UK are affected by chronic pain, which is the 2ndmost common complaint cited by claimants on/for incapacity benefits. It is also associated with illness such as arthritis and cancer as well as traumatic events such as road traffic accidents, work and medical accidents.
Psychological factors not only contribute to how pain is initially perceived but is also predictive of how individuals will cope long term with ongoing pain.
Medico-Legal issues with Chronic Pain
When carefully distilling through the self-report and medical evidence associated with a claimant ‘in pain’, the medico-legal issues, which arise, include:
- The ‘egg shell skull’ principle – a claimant must be taken ‘as they find him/her’, even if index-event complaints are aggravated by previous health problems.
- The alternative ‘ predisposition’ model in which a claimant’s vulnerability to ill health or pain could be considered causative of a post index-event condition and that it would have been triggered by another further occurrence in any event.
These two issues have been considered in a number of earlier cases, Page v. Smith (1996); Giblett v. Murrays (1999). The key test of causation, arising out of these deliberations and case law is whether the index-event, on the balance of probability, caused or materially contributed to or increased the risk of the development or prolongation of the symptoms of a pre-existing disorder, physical or psychological/psychiatric (Gassoub, 2010).
Diagnosis of pain-related disorders
Clearly much of pain experience will have an organic/medical cause, which will be assessed, and diagnosed by a ‘medical’ expert. In some cases, despite an initial medical diagnosis, the continuation of the pain experience will be difficult to explain in organic terms or becomes a chronic condition which is so complex and confounded by social and psychological factors that the original cause has less, if any, meaning. It is at this stage in any of the above circumstances that a psychological/psychiatric opinion should be sought and typically is. Referring to DSM IV (TR), one of the two main classification systems of mental disorders (APA, 2000), disorders involving pain fall into at least seven categories: –
- General medical condition – Fully accounts for the physical complaints.
- Somatoform Disorder – A history of many physical complaints over several years in different body sites, plus gastrointestinal and sexual/reproductive areas and not fully explained by a known general medical condition.
- Pain disorder, sexual dysfunction, conversion disorder, dissociative disorder -Does not have multiple somatic complaints affecting a variety or organ systems and sites. Typically pain is adversely affected by psychological factors such as anxiety and depression.
- Generalised anxiety disorder – Is characterized by worry not limited, but including physical symptoms.
5. Panic disorder – Has somatic complaints occurring only during panic attacks.
6. Depressive disorders – May have somatic complaints that are limited to episodes of depressed mood.
- Schizophrenia or other Psychotic disorders – May have somatic concerns that are of a delusional nature.
Key Psychological Assessment Issues
When interviewing a claimant whose presentation has been described as one of chronic pain, the following area require investigation: –
1. Clear history of site-specific self-report or generalised pain onset.
This is obtained from claimant self-report plus GP (and other medical) attendance.
2. Evidence of unrelated prior attendance to, typically, medical practitioners for one or more somatic complaints and associated frequency of such attendance.
3. Evidence of social factors including partner and family response to the pain and associated difficulties.
4. Interview data on how the claimant presents and verbalises his/her pain.
5. Claimants awareness of how psychological factors (ways of thinking, self-confidence, optimism, behaviour and social activity) impacts positively or negatively on the claimants coping strategies and perception /tolerance of pain.
6. Reliability of claimants history giving – many people have difficulty recalling or giving accurate history, due to memory and lack of specificity issues, rather than a wish to mislead.
7. Truthfulness of claimant’s history giving – this is differentiated from ‘Reliability’, although it is clearly at the end of the reliability continuum. This is typically for secondary gain such as financial gain and is ‘conscious’ ie, intended to mislead.
Joint Orthopaedic/psychological Assessments
To address comprehensively the several medical and psychological aspects of chronic pain, some orthopaedic/psychologist teams are currently offering ‘joint appointments’ to lawyers, which have the advantage of:
· Same day appointment with orthopaedic specialist and clinical psychologist.
· Separate reports with agreed conclusions following case discussion between experts.
· Appointment within 6-8 weeks.
These assessments cover:
· Location of pain (anatomical; organ system).
· Temporal characteristics of pain and pattern of occurrence .
· Psychological experience of pain.
· Impairment in social and occupational functioning.
· Psychological factors in onset, severity, exacerbation and maintenance of pain.
· Exclusion of factitious disorder or malingering.
· Use of pain coping strategies.
Treatment and prognosis of chronic pain
Psychologists and pain management specialists are activity engaged in providing psychological (and medical) interventions in cases of chronic pain, addressing the several psychological (cognitive, emotional, behavioural) and social aspects of disability. This can be offered either as an individual (one-to-one) basis or as part of a multi-disciplining hospital –based pain management prognosis.
APA ( 2000) DSM IV (TR)
Gassoub.S (2010) A medico-legal guide to somatoform disorders.
Kaufman A (2011 ) Medico-Legal reporting, warts and all. Apil PI Focus. 21, 2, 23-24.
Koch HCH & Kevan T (2005) Psychological injuries XPL. St Albans.
Trimble M (2010) Somatoform Disorder: a medico legal guide. Cambridge University Press.
Koch HCH & Mackinnon J (2009). Understandign ongoing pain. Legal & Medical, 13.