Symptom Magnification Syndrome

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Symptom Magnification Syndrome

• PHED 3806
• Functional Assessment

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Symptom Magnification Syndrome (SMS)

• History
• Identification of SMS
• Types
• Treatment

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HISTORY (brief)

• L.N. Matheson combined some existing key concepts
  to form a model that is clear and useful in
  viewing injured workers eg. from cognitive/social
  learning theories, chronic pain theories, social
  support systems.
• Talcott Parsons-sick role (escape other
  responsibilities)
• David Mechanic-illness behaviour (part of a
  coping repertoire which makes a challenging
  situation more manageable)
• Pilowsky-Abnormal Illness Behaviour-physical
  complaints but no organic cause

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IDENTIFICATION

• The individual appears to not be "responsible"
  for their symptoms and relates to him/herself as
  the victim. This is a vicious cycle in that
  he/she feels the environment is uncontrollable
  but in essence the symptoms he/she exhibits ends
  up controlling the environment.

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IDENTIFICATION

• The symptoms are non-negotiable. Vagueness and/or
  lack of awareness may indicate the person is not
  taking responsibility for developing activities
  to control the symptoms, or cannot answer what
  makes it worse since he/she has been avoiding
  engaging in activities to find out. For SMS,
  symptoms can't be made worse or better . . .
  nothing makes it better. Self-descriptive
  statements such as "the pain won't let me . . . "

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IDENTIFICATION

• It is a self-destructive pattern of behaviour
  learned and maintained through social
  reinforcement.

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IDENTIFICATION

• SMS is composed of reports and/or displays of
  symptoms and the symptoms magnify his/her
  functional limitations. Look for . . . less than
  a full effort, over-reaction to loading, work
  themes that are not based on recent experiences
  or not consistent with recent experiences eg. I
  have problems with my back when doing . . .
  (perhaps his/her back has not been an issue for 7
  years!)

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IDENTIFICATION

• SMS may be conscious or unconscious . . . the
  person may not even know that they are exhibiting
  certain patterns of behaviour or he/she may be
  aware but not have insight re why this is
  happening.

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IDENTIFICATION

• An infant learns that symptoms (eg crying) will
  control the environment (eg. Parents respond by
  changing diaper), and as the person ages, he/she
  internalizes the responsibility for alleviating
  symptoms (eg. stomach growls - person eats). For
  SMS, the situation appears unmanageable and
  he/she develops "helplessness" and relinquishes
  responsibility.

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IDENTIFICATION

• Helplessness in turn causes a decrease in
  motivation to initiate voluntary responses to
  control the environment. The perception of
  control is distorted (perceived
  uncontrollability) and therefore attempts in the
  future are futile. Furthermore, a disability
  induced depression can result as normal
  anxiety/fear of adjustment to disability does not
  subside.

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IDENTIFICATION

• SMS is to be identified and treated, not
  caught. SMS is not to be confused with
  Malingering since this involves the VOLUNTARY
  production of symptoms for which the person has
  total control, and he/she has a recognizable goal
  in mind. Malingering is not treatable since
  he/she knows fully well what is "going on and
  why" and can discontinue the pattern at will.

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TYPES

• Three types of symptom magnifiers have been
  established. A person does not necessarily belong
  exclusively to one type and may have
  characteristics of other types or be
  predominantly in one type at one point in time,
  then change to fit more into another type. In
  fact, it has been proposed by a critic that the
  types may be different stages.
• The Refugee
• The Gameplayer
• The Identified Patient

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TYPES

• The Refugee
• Provides an escape from a perceived unresolvable
  conflict or life situation (looking back over
  shoulder while "escaping" a difficult life
  situation). For example, a person abused in
  his/her childhood may be experiencing "flash
  back" as an adult thereby decreasing
  concentration and resulting in an accident while
  working. The injured person now has something
  else to focus attention on and avoid dealing with
  the root of the problem.

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TYPES

• The Refugee
• He/she is willing to grit teeth and endure a
  conflict that appears unresolvable . . . Presents
  as a MARTYR in relation to symptoms, the pain is
  terrible but I'll make it through somehow. For
  example . . . George may be off work and his wife
  Mildred suggests he might try going back. George
  perceives she means going back in full capacity .
  . . he does not feel capable but braves the
  elements and goes forth. While at work his boss
  Marvin reprimands him on an apparently trivial
  issue but George goes home stating that's it . .
  . I can't do it . . . I'm disabled. He/she has
  little future orientation . . . goals are very
  difficult to derive . . . there is an absence
  of goals. The motivation to follow through with
  treatment is limited.

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TYPES

• The Refugee
• He/she often provides "yes . . . but"
  interchanges. For example, the health care
  professional suggests a goal in treatment and
  he/she provides a yes . . . but. Thus it would
  be very important to encourage that person to
  assist in developing his/her goals so it is more
  difficult to provide yes . . . buts.

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TYPES

• The Gameplaver
• Symptoms provide an opportunity for positive
  gain.
• This person is in a "day dreaming" stage of
  career development (opportunist) and has a
  history of extravagant goal setting with poor
  goal attainment. Eg. to be a drug counsellor ...
  (but has a grade 8 education, cannot sit more
  than 1 minute, and has a severe volatile temper!)

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TYPES

• The Gameplaver
• There is great variability in his/her maximum
  performance level and will act impulsively
  heroic disregard. This must be watched in
  order to avoid injury?
• I lifted 200 lbs. When I was working for . . .
  Oh, ya that's nothin' . . . I've always been
  called THE BULL

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TYPES

• The Identified Patient
• symptoms ensure survival and maintenance of the
  patient role
• Life is to be survived not enjoyed . . . "if I
  can get through the week . . . if' I can make it
  to my next disability check . . . He/ she has
  few goals but at least there is something to work
  with even if it's to say "what needs to happen in
  order for you to make it through the week" etc.

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TYPES

• The Identified Patient
• This person may act impulsively in "accidental
  disregard" or his/her impairment so again watch
  for this to avoid injury. The purpose it to
  "sabotage" in order to maintain the patient role.

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TREATMENT

• Treatment of SMS usually occurs in a work
  hardening context and do not expect results over
  night. The idea is to work with the client so
  he/she can decrease the use of reports/display of
  symptoms as a means to cope with helplessness and
  in turn control the environment. Approach
  discussion of SMS behaviours in a constructive
  manner this is a normal response after an injury
  however the response you have is now
  self-destructive and harmful if continued . . . I
  can help you in making changes

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TREATMENT

• The goal is to assist the person in a cognitive
  revolution in his/her perception of him/herself
  in relation to the environment. Hopefully his/her
  awareness is increased, he/she will become more
  specific (goal setting fosters this), and the
  opportunity for exploring his/her abilities is
  provided. The approach falls in line with the
  Cognitive Behavioural frame of reference.

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TREATMENT

• Become familiar with the whole picture . . .
  what are his/her goals, the greatest perceived
  loss and is it amenable to change, what have been
  the adjustments made in lifestyle, what are the
  supports for the behaviours (who helps with what
  and what are their goals for/expectations of the
  person), what is the reinforcing structure (how
  will the person benefit or what is the perceived
  benefit of maintaining symptoms) ETC.

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TREATMENT

• Goal Setting allows the person to expand his/her
  sense of controlling the environment somehow, it
  is future oriented and realistic. Goal setting
  also helps in developing a shared reality base
  with the health professional which in turn will
  allow he/she to provide positive reinforcement
  for POSITIVE behaviours. This is social
  reinforcement, but not for negative behaviours
  that he/she is use to having reinforced. The use
  of contracting with the person may be of use.

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TREATMENT

• Graded Activities to develop the clients'
  ability to have control over symptoms while
  engaging in activities thus increasing his/her
  sense of being able to control the environment.
• The idea is to produce symptoms that can be
  mastered (the demand for quality and
  concentration is graded incrementally). A daily
  log of "pledges" can be useful. Break times are
  not based on discomfort but by an achieved amount
  of activity or by time limits.
• Watch for an increase in consistency in terms of
  his/her responses and function. It is vital
  measures be taken so the client does not injure
  him/herself eg medication, poor body mechanics
  and safety practices. Education re proper work
  pacing, body mechanics, and alternate coping
  methods is part of the process.

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TREATMENT

• With any treatment strategy used, it must be
  remembered dealing with SMS is dealing with a
  negative cognitive set! Distorted perceptions.
  Therefore, it must be the clients perception
  that his/her OWN action controlled the experience
  and our job is to help them identify his/her
  successes and how this was accomplished. You are
  facilitating the development of an Internal Locus
  of Control.

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Red Flags

• Vague or implausible injury history / vague pain
  description
• Discrepancies in injury history / inconsistent
  pain description
• Elaborate imagery to describe pain
• Emergency room visits by ambulance for pain
  medication
• Narcotic overuse or dependence
• Pain rated 9 or more on a scale of 10

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Red Flags II

• Symptom proliferation
• Total body pain
• History unable to move / legs collapsing /
  sudden numbness
• Blames current life problems on physical
  condition
• BLAMES MOOD (irritable, depressed) ON PHYSICAL
  CONDITION
• Insists illness is purely somatic / unrelated to
  stress

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Red Flags III

• Ive worked all my life / asserts former
  independence
• Pain has changed entire life / inappropriate
  activity curtailment
• I just want to get rid of the pain / get on with
  my life
• "Fears" will be unable ever to work again
• Has learned to accept invalid status, is a
  victim
• Has family member phone for medications (passive
  dependency)

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Red Flags IV

• Patient angry at employer / generally irritable
• Patient critical of previous doctors / doctor
  shopping
• Symptoms worsen / proliferate despite treatment
• Setback as return to work date approaches
• Multiple return to work date extensions
• Denial of psychosocial problems or blames them on
  pain

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Red Flags V

• I keep my feelings inside - i dont show my
  feelings
• Histrionic presentation / strange limp
• Patient doleful tearful or weeps
• Tattoos, especially macho tattoos
• Glove / stocking hypesthesia or pain
• Give-way weakness / variable grip in absence of
  atrophy

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Red Flags VI

• Discrepancy between observed vs tested motion
• Discrepancy between sitting vs recumbent SLR
• Low back pain on gentle cervical compression
• TENDERNESS ON GENTLE PALPATION (jumping jack
  syndrome)
• Patient grabs or pushes examiner's hand away
• Patient angers or frustrates doctor