Biomedical subjects
Publications and source records attributed to David A Fishbain.
A factitious disorder is one that has been fabricated or simulated by the patient. Münchausen syndrome is a subtype of factitious disorder. This syndrome has not previously been described in relationship to chronic pain/chronic pain treatment units. Such a patient is presented, and the clues to the identification of this syndrome within chronic pain patients are presented.
Two hundred and eighty-three chronic pain patients, consecutive admissions to the Comprehensive Pain Center of the University of Miami School of Medicine, received an extensive psychiatric evaluation based upon the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria and flowsheets. All patients received the following type of diagnoses: DSM-III axis I; DSM-III axis II, and personality type. The distribution of assigned diagnoses for the entire patient sample was reviewed and a statistical comparison between male and female patients was performed with regards to the prevalence of each diagnosis. Anxiety syndromes and depression of various diagnostic types were the most frequently assigned axis I diagnoses with over half the patient sample receiving each of these diagnoses. Males were significantly overrepresented in the axis I diagnoses of intermittent explosive disorders, adjustment disorders with work inhibitions, and alcohol abuse and other drug dependence, while females were significantly overrepresented in disorders of current depression of various diagnostic types and somatization disorders. 58.4% of the patients fulfilled criteria for axis II personality disorder diagnoses. The most frequently personality disorders found in the patient group were dependent (17.4%), passive aggressive (14.9%), and histrionic (11.7%). Males were significantly overrepresented in paranoid and narcissistic disorders while females were overrepresented in histrionic disorder. The most frequent personality types found in the patient group were compulsive (24.5%) and dependent (10.6%). All personality types were similarly distributed between the sexes. The results of the present study were compared to a previous study of DSM-III diagnoses in chronic pain patients and are discussed in terms of the prevalence of DSM-III diagnoses in the general population. Questions are raised as to the applicability of certain DSM-III diagnoses in the chronic pain population.
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.
OBJECTIVES: Fatigue is frequently found in chronic pain patients (CPPs) and may be etiologically related to the presence of pain. Fishbain et al. have recently demonstrated that chronic low back pain (LBP) and chronic neck pain patients are more fatigued than controls. The purpose of this study was to determine whether chronic LBP- and chronic neck pain-associated fatigue responded to multidisciplinary multimodal treatment not specifically targeted to the treatment of fatigue. DESIGN: A total of 85 chronic LBP and 33 chronic neck pain patients completed the Multidimensional Fatigue Inventory (MFI), Neuropathic Pain Scale (NPS), and Beck Depression Inventory on admission. In addition, an information tool was completed on each CPP by the senior author. This tool listed demographic information, primary and secondary pain diagnoses, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) psychiatric diagnoses assigned, pain location, pain precipitating event, type of injury, years in pain, number of surgeries, type of surgery, type of pain pattern, opioids consumed per day in morphine equivalents, worker compensation status, and whether, according to the clinical examination, the CPP had a neuropathic pain component. At completion of the multidisciplinary multimodal treatment, each CPP again completed the MFI. Student's t-test was utilized to test for statistical changes on the MFI five scales from pre- to post-treatment. Pearson and point-biserial correlations were utilized to determine which variables significantly correlated with MFI change scores. Variables found significant at less than or equal to 0.01 were utilized in a stepwise aggression analysis to find variables predictive of change in MFI scores. SETTING: Multidisciplinary pain facility. PATIENTS: Chronic LBP and chronic neck pain patients. RESULTS: Multidisciplinary multimodal treatment significantly improved CPP fatigue as measured by the MFI. The available variables utilized to predict fatigue best explained only a small percentage (28.9%) of the variance. Improvement in fatigue was related to NPS-10 scale scores (neuropathic pain) and a previous diagnosis of fibromyalgia. CONCLUSIONS: Multidisciplinary multimodal pain facility treatment improves chronic LBP- and neck pain-associated fatigue. At the present time we cannot predict this improvement with significant accuracy.
OBJECTIVE: There have been a few open-label nonplacebo reports on the successful use of lidocaine 5% patch (L5P) for other types of pain besides postherpetic neuralgia, such as chronic low back pain. With the these reports, we began to utilize L5P routinely for chronic pain patients (CPPs) with various pain diagnoses. The purpose of this report was to describe the results of a retrospective review of this open-label naturalistic L5P chronic pain treatment trial and to attempt to delineate predictors of perceived clinical response. DESIGN: Consecutive CPPs were selected for this clinical trial according to the following inclusion criteria: the CPPs with pain greater than 6-month duration and either a hyperalgesic pain area or trigger point, which could be covered by one L5P, were offered a 3-day L5P naturalistic treatment trial. The purpose of this trial was to determine which CPPs would perceive improvement and continue using L5P. CPPs entering the trial completed the neuropathic pain scale (NPS) at entrance and completion of the trial. The senior author also completed a baseline information tool on each CPP entering this naturalistic trial. At the completion of the 3-day trial, the CPPs were asked if they perceived pain improvement with the use of L5P. In the retrospective review, the CPPs were thus segregated into two groups, those with and without perceived clinical improvement, and were statistically compared for available clinical variables. Logistic regression was then utilized to determine which significant independent variables contributed to the correct prediction of perceived improvement. SETTING: Multidisciplinary pain facility. PATIENTS: Patients with chronic pain. RESULTS: Of 362 consecutive CPPs, 114 or 31.5% were deemed candidates for this naturalistic trial. None of the CPPs refused or fulfilled exclusion criteria eliminating them from the trial. The total sample (N = 114) showed statistical improvement on all 10 NPS scales (except scales 4 and 6) plus the NPS 4, NPS nonallodynic 8, and NPS 10. The perceived clinically improved group (N = 87, 76.3% of those entering the trial), also showed perceived improvement on all preceding scales except 4 and 6. The perceived clinically nonimproved group (N = 27, 23.7% of those entering the trial) showed statistical improvement on scales B and NPS 10. Perceived improvement was predicted by the following variables: pain wakes patient up, patch placement not low back, and not in litigation. These variables explained 9.8%, 20%, and 14% of the variance, respectively. Overall, 44.5% of the variance was explained. CONCLUSIONS: A significant percentage of CPPs exposed to an L5P 3-day naturalistic trial perceived clinical improvement. However, this can only be concluded as an initial effect, and whether or not this effect is attributable to L5P cannot be derived from our data as the effect could have been nonspecific. The apparent CPP perceived clinical improvement was not associated with any particular useful clinical indicator. As such, at present, no variable can be recommended for use in selecting CPPs for such a naturalistic L5P clinical treatment trial. However, this study indicates that such a trial can be useful in selecting CPPs who may perceive benefit from L5P.
STUDY DESIGN: This is a structured evidence-based review of all available studies on the effect of pain, (a state phenomenon) on the measurement of personality characteristics (a trait phenomenon). OBJECTIVES: To determine whether pain treatment changes trait scores. SUMMARY OF BACKGROUND DATA: Recent evidence from the psychiatric literature indicates that the measurement of personality characteristics (traits) can be affected or changed by the presence of state psychiatric disorders, for example, depression. At issue then is whether the measurement of chronic pain patients' (CPPs') trait characteristics is affected by the presence of pain, a state problem. METHODS: Computer and manual literature searches for pain studies that reported a prepain treatment and postpain treatment (test-retest) personality test or inventory score produced 35 such reports. These references were reviewed in detail and information relating to the above problem was abstracted and placed into tabular form. Each report was also categorized as to the type of study it represented according to the guidelines developed by the Agency of Health Care Policy and Research (AHCPR). In addition, a list of 15 quality criteria was utilized to measure the quality of each study. Each study was independently categorized for each criterion as positive (criterion filled), negative (criterion not filled), or not applicable, by two of the authors. Only studies having a quality score of 65% or greater were utilized to formulate the conclusions of this review. The strength and consistency of the evidence represented by the remaining studies were then categorized according to the AHCPR guidelines. Conclusions of this review were based on these results. RESULTS: Of the 35 reports, 32 had quality scores of 65% or greater. According to the AHCPR guidelines, there was a consistent finding that the Minnesota Multiphasic Personality Inventory (MMPI) scores changed (improved) with treatment. In reference to the Millon Behavioral Health Inventory, Locus of Control, the Symptom Checklist-90-Revised (SCL-90-R), trait anxiety, and personality disorders, there were not enough studies to draw conclusions about consistency. In reference to coping/self-efficacy inventories, somatization/illness behavior inventories, and personality questionnaire studies, there was a generally consistent finding that these tests changed (improved) with pain treatment. Overall, of the 32 reports, 92.3% demonstrated a change in trait scores (improvement) with pain treatment. This evidence was categorized as consistent. Finally, 100% of a subgroup of reports (N = 12) that had controlled for pain indicated that there was a relationship between a change in pain scores and a change in trait scores. CONCLUSIONS: Based on the above results, it was concluded that some trait tests and inventories may not be pain state independent. Therefore, caution is warranted in interpreting postpain development personality profiles as being indicative of the true prepain personality structure, if measured by these tests. Why trait scores may change with treatment, confounding test-retest issues, and whether trait tests actually measure what they allegedly measure are discussed.
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