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Cultural aspects of pain: when is a patient genuine? CULTURAL ASPECTS OF PAIN: WHEN IS A PATIENT GENUINE?
Brian's case summarises the often considerable assessment problems. When is a patient genuine, with a hard to diagnose problem or overlapping problems, and when is he or she merely one of the players in the 'pain game'?
Brian, 27, was an unemployed sports equipment salesman whose car had rolled over in gravel on a country road several years before. Essentially, all his spinal movement had been restricted since:
'I had all sorts of hateful thoughts about myself. About my helplessness. About being suddenly scared of the future. I had awful feelings of hopelessness knowing there was nothing I could do.
I was lying there this night. My head was throbbing. I was exhausted but I just couldn't get to sleep. Just lying there listening to every sound magnified in the room. Lying there with black despair. I was in constant internal pain no matter what position I was in. It just wouldn't go away. It was sheer hell on earth.'
His severe anxiety, and unwillingness to give his full co-operation, in the end proved an insuperable stumbling block to his rehabilitation. There had been very little improvement since the accident. He had been assessed by an orthopaedic surgeon who could not offer much help. A few infrequent visits for physiotherapy had also not helped significantly. He was then referred to our pain clinic for assessment regarding relaxation therapy, acupuncture and anything else that might help alleviate his constant distress.
On his first visit, Brian appeared to be almost entirely rigid during the interview. He looked profoundly unhappy and would not say very much. He was accompanied by his brother who helped him stand, sit, dress and even move. Pressed for details, Brian became a little more communicative about the accident. The accident had caused no obvious severe physical injury. He had received cuts to the head, abrasions to the arms and head and had not lost consciousness. He had been taken to hospital and then later seen by a local doctor who suggested that he commence physiotherapy.
Brian claimed that, before the accident, he had been working in the sports equipment business. He was unemployed prior to the accident for about 12 months. He described himself as having no psychiatric problems of any kind. Before the accident, he was an independent and active person who played soccer and squash, was keen on running and had no physical problems.
He had been involved with a woman before but the accident had ended the relationship.
When asked to move from his rigid sitting position, there seemed almost total rigidity of the neck. He appeared to be extremely tender over the entire back area alongside the spinal area. He was even unable to lift his leg off the couch a few millimetres without grimacing and loudly moaning. Every movement was helped by his brother who acted almost like a servant.
The medical team felt his demeanour was incompatible with any known organic problem. He demonstrated abnormal illness behaviour which appeared to have developed either as a hysterical reaction to his original injuries, or to outright malingering. He was advised that the only way he could be effectively treated was to be admitted to an in-patient program at the pain clinic. He was asked to consider this proposed admission and to complete the usual questionnaires. It was also suggested to him that he take some antidepressant medication and a mild sedative.
Over the ensuing months, several efforts were made to admit Brian to the pain clinic for further evaluation but to no avail. Eventually, after twelve months, he allowed himself to be admitted to the in-patient program. But, unlike his fellow patients, he made no real effort to change his behaviour. He did not appear to be capable of responding to the program's psychological content and seemed to have no insight into the non-physical aspects of his pain problem.
He appeared to be obsessed with his pain which had become the ruling force in his life. Further inconsistencies in his observed behaviour confirmed the belief that he may have been deliberately exaggerating his symptoms to gain increased financial compensation and sympathy from his family and friends. (At one time he was observed to have 'forgotten' which side he was 'paralysed' on!)
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