The Power Point reviews various methods used for fraud detection, and points out that many are erroneous or not cost effective. It offers information about an Internet test which has been admitted as evidence in many court cases in many states

1. Lecture 21 of 22
Fraud Detection in Chronic Pain
-what stands up in court and what
doesn’t
www.MarylandClinicalDiagnostics.com
Nelson Hendler, MD, MS
Former Assistant Professor of Neurosurgery
Johns Hopkins University School of Medicine
Past president- American Academy of Pain Management

2. Spotting Fraud
• National Council on Compensation Insurance
(NCCI) published a report Assessing Pain, Real
and Imagined(11/29/98).
• www.NCCI.com/painreal.html
• Hendler reports that 6% of non-litigant patients
are exaggerating pain patients, while 10% of
Long term disability and 13% of workers’
compensation are exaggerating their claims
• For $300, The Pain Validity Test can identify
exaggerating pain patients
• Average savings of $1,654/claim by eliminating
IMEs, FCE, surveillance, & nurse case reviewer
in the objective pain patient, and focusing the
resources on the exaggerating pain patient.

3. California Does a Poor Job of
Combating Worker’s Comp Fraud
(Workers Compensation Report, Vol 15, No. 11, p.206 May 17, 2004)
• State Auditor Elaine Howle says the $30,000,000 annual
assessment to combat fraud may be wasted.
• Insurance companies cannot measure the effectiveness of
their efforts using IMEs and surveillance.
• The companies are relying on anecdotal testimony from
stakeholders in the workers compensation community,
unscientific estimates, and description of local cases
involving fraud.
• The fraud division publishes statistics showing the number
of investigations, arrests, convictions, and restitution, but
cannot show if anti-fraud efforts are cost-effective
• How to detect fraud vs. a normal response to chronic pain

4. Types of Chronic Pain Patients
Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven Press, ‘81
• Objective Pain Patient: Good pre-morbid
adjustment, objective findings, and goes through
the 4 stages of pain (case study: Car Exec.)
(87%-94% of all chronic pain patients)
• Exaggerating Pain Patient: poor pre-morbid
adjustment, minimal findings, and absence of
depression (case study: hysterical scoliosis).
• (Between 6% to 13% of all chronic pain patients)
• Mixed Objective-Exaggerating Pain Patient:
poor pre-morbid adjustment, objective findings
and very difficult to manage by medical or psych
(case study: sexual abuse, histrionic, TOS, disc)

5. Research Methodology
• Physicians want to know if a patient has a valid
complaint of pain
• Earlier research is flawed, because it say if a patient
has pain and depression, the cause of the pain is the
depression- a depressive equivalent.
• Researchers never looked at the effect of pain over
time.
• Have to study a normal response to appreciate an
abnormal response-
• Study anatomy to recognize pathology-it’s different
• What is a normal response?
• You know what is abnormal, because it is different

6. Objective Pain Patient-A normal response
Case Study: A 56 year old executive for a Big Three auto maker was married
for 25 years, had three children, none on drugs, all of whom were in college,
and was earning over $1,000,000/year. He was working on his boat, when the
engine fell, and traumatically amputated his thumb. He went to work the next
day, and continued to work, and he expected the pain to subside. However,
after two months, the pain in his thumb became so severe, that he could not
concentrate, nor sleep. He was diagnosed with a neuroma in the stump of the
thumb. Any sensation to the stump would cause severe pain to shoot up his
arm. When he was seen at a hospital in Baltimore, he had been suffering for
two years. He scored 14 points on the Mensana Clinic Pain Validity Test,
putting him the Objective Pain Patient category. He was suicidal, sleeping only
two hours a night, and was on three types of narcotics, sleeping medication,
and diazepam. He wanted to divorce his wife because he felt like a burden to
her. He was severely depressed and had never been depressed before the
onset of pain. He was so desperate to get rid of his pain that he had a thalamic
stimulator put into his brain. Unfortunately, this gave him only partial relief.
Eight years after the onset of his pain, he was less depressed, was off
narcotics, and sleeping medication, and was getting four hours of sleep a
night. He still had pain, but had adjusted to the pain. He had retired from the
auto company. (Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven
Press, New York, 1981).

7. 4 Stages of Chronic Pain in an Objective
Pain Patient- A Normal Response to Pain
(Hendler, in Diagnosis and Treatment of Chronic Pain, Edited by Hendler, Long
and Weiss, Wright-PSG, ’82)
• Chronic pain patients go through 4 stages remarkable
similar to the 5 stages a patient experiences when dying
(Kubler-Ross-’69)- this is a normal response to pain.
• Acute Stage 0-2 months –Pt. expects to get well, so no
psychological changes (MMPI is normal).
• Sub-acute stage-2-6 months- Pt. had anxiety and somatic
concerns develop (MMPI scales 1 & 3 are elevated)
• Chronic stage 6 months-8 years- Pt. is depressed (MMPI
has elevated scale 2, called a pain neurosis by Blumer,
pain prone patient by Pilling, low back loser by Sternbach)
• Sub-chronic stage-3-12 years Pt. resets goals-adaptation
(MMPI scales 1 & 3 elevated, hypochondriasis and
hysteria)

8. Exaggerating Pain Patient-The
Abnormal Response to Pain
A 43 year old woman was hospitalized in Baltimore, complaining of marked
scoliosis, that had just developed, in the past year. Further evaluation did not
verify the typical radiological findings seen with a constant scoliosis. She scored
24 points on the Mensana Clinic Pain Validity Test, putting her in the
Exaggerating Pain Patient category. A trial with an Amytal (truth serum) interview
failed to resolved the scoliosis, but when the patient was anesthetized, the
scoliosis resolved temporarily. Further Amytal interviews revealed the patient
had a stormy marital relationship, and she avoided sex with her husband,
because he was abusive. The patient was reassured she need not have sex with
her husband if he was abusive. The next day, she walked upright, and continued
in this posture, until her husband visited. The day of the visit, the scoliosis
returned. Additional Amytal interviews revealed she had been abused as a child.
She had a she had been afraid to seek divorce from her husband, but with social
worker intervention, she found the support to do so. The scoliosis resolved. On
five year follow-up, she was divorced, and remained free of scoliosis. (Hendler, N,
Filtzer, D, Talo, S, Panzetta, M, and Long, D, Hysterical Scoliosis Treated with Amobarbital
Narcosynthesis, The Clinical Journal of Pain, 2:179-182, 1987).

9. Mixed Objective-Exaggerating
Pain Patient
The patient was a 33 year old white female, married for the third time. She had a
gradual onset of lower neck and right arm pain. She complained of “excruciating
pain,” “devastating pain,” and “unbearable pain.” She arrived for her first interview
wearing heavy blue eye-shadow, bright red-lipstick, three rings on each hand,
reeking of perfume, wearing a low cut revealing blouse, and very short skirt. She
used superlatives for everything. Despite her clear histrionic personality disorder,
she scored 20 on the Mensana Clinic Pain Validity Test, placing her in the Mixed
Exaggerating-Objective pain patient category. Her MMPI scores showed elevated
scales 1 and 3: “a conversion V.” Her husband was 20 years older than she was,
and was a very successful business man, who provided her every creature
comfort, from the finest cars, to a maid. She clearly was overusing her narcotic
medication. Her pain was made worse with extension of her neck, and she
subsequently had C4-7 facet blocks which gave her 80% relief of her neck pain.
Facet denervations gave her 50% relief of her neck pain. After this treatment, she
was able to improve her level of functioning, and eliminate the use of narcotics.
(Hendler, Diagnosis and Non-Surgical Management of Chronic Pain, Raven Press, New York, 1981).

10. Functional Capacity Evaluation
• Functional Capacity Evaluations (FCE) uses isometric (static) strength
to predict dynamic lifting capacity
• In one study, 107,755 male and 23,078 female were tested for strength
using three standard static lifts and four dynamic lifts.
• The data confirms that standard errors of estimate for all isometric-to-
dynamic predictions make such predictions meaningless for the
purpose for which they are most commonly used.
• Conclusions: The Static Leg Lift, Static Arm Lift and Static Back (Torso)
Lift are not appropriate for making predictions relative to dynamic lifting
capacity.
• Given the degree of error in such predictions employers, clinicians and
risk managers now have substantial objective evidence to call FCE
testing into question.
Larry Feeler, James D. St. James, & Darrell W. Schapmire, Isometric strength assessment,
Part I: Static testing does not accurately predict dynamic lifting capacity Work 37 (2010)
301–308 301

11. 6 Things to know about Surveillance
http://morris.patch.com/blog_posts/6-things-you-need-to-know-about-surveillance-in-workers-comp-cases-e7d5dc5d
• As an injured worker, there are 6 things you should know about surveillance:
• Many private investigators take advantage of the times that you are at doctor
appointments. They’ll make sure they can properly identify you, your vehicle, where
you live, and how active you are.
• The investigator might not find anything suspicious, but that doesn’t mean that he or
she won’t try again. The surveillance may happen again in a few weeks or even
months.
• Investigators don’t just work from 9-5 on weekdays. They’ll also work on nights and
weekends, when you may not expect them to be watching.
• Try not to talk about your daily activities with people. After filing a claim, your
employer may try to get information from your co-workers about where you like to go
in your spare time. Investigators may go to these places to check up on you.
• Make sure you follow your doctor’s instructions. If you are caught doing something
that you were told not to, your case may become less valuable. You should avoid
activities like carrying heavy groceries, playing sports, making car repairs, or working
on the exterior of your home.
• The only income you receive should be from your weekly benefit checks. If you earn
additional income, even from odd jobs like babysitting or cutting grass, it is
considered to be fraud.

12. Surveillance
http://www.washingtontimes.com/news/2011/dec/7/feds-use-video-
surveillance-to-catch-fraud-for-wor/?page=all
• The Postal Service inspector general uses of video surveillance to target disability fraud
• The Government Accountability Office (GAO), the investigative arm of Congress, disclosed
the surveillance practices as part of a broader review of workers’ compensation fraud
controls at a half-dozen agencies across government.
• The Transportation Security Administration (TSA) has an internal affairs unit to review
potential fraud and make referrals to investigators, who in turn conduct video surveillance,
according to the GAO.
• The GAO also said the Air Force plans to hire staff early in fiscal 2012 to perform
background checks & conduct surveillance to make sure recipients are entitled to benefits.
• Still, the GAO also found that agencies face challenges investigating and prosecuting such
cases. For one thing, so-called “targeted investigations” can be costly and resource-
intensive, the GAO said. What’s more, the “limited resources” of some federal prosecutors
make it hard to bring fraud cases involving less than $100,000, the Postal Service inspector
general’s office told the GAO.
• Successful cases “can help deter future fraud and ultimately save money,” the GAO found.
• Overall, from April 1, 2010, to Sept. 30, 2011, the Postal Service inspector general told
Congress in a recent report that its workers’ compensation fraud investigations resulted in
$65 million in savings, with 19 arrests and 60 personnel actions.
• However, the report doesn’t mention how much it cost to save $60,000,000.

13. Independent Medical Evaluations
http://www.chr.com/independent-medical-evaluations-imes/
• Independent Medical Evaluations (IMEs) are occupational health
evaluations performed by a licensed medical examiner who is not
involved in the regular care of the employee.
• They are used by the workers’ compensation system, and are also
used to clarify other occupational health, disability and liability case
issues.
• These are physicians who see a majority of their patients at the request of
an insurance company, and have either no medical practice of their own,
or small one.
• They provide Second opinions, Peer evaluations. Chart reviews. Legal
testimony, Physical capacity exams, Pre-employment physicals. Fitness
for duty exams, Permanent impairment rating
• The vast majority of their cases require writing an opinion letter for an
insurance company.
• Very often, these physicians are use to determine if the injury was work
related, and do more detective work than medical work

14. Waddell signs as part of an IME
• The original article lists five Waddell's signs. (Waddell G, McCulloch
HA, Kummel E, Venner RM. Non-organic physical signs in low-back pain. Spine 1980; Mar-
April (5)-2: 117-25 )
• 1. Superficial and Widespread tenderness or non-anatomic
tenderness –subjective (seen in CRPS I)
• 2. Stimulation tests: Axial loading (actually a Spurling test
which really is pathological) and Pain on simulated rotation,
i. e. bending and turning.
• 3. Negative distracted straight leg raise (seated straight leg
raising, rather than supine-not valuable for facet syndrome)
• 4. Non-anatomic sensory changes: stocking or glove
anesthesia. (Peripheral neuropathy, carpel tunnel or Lymes
disease may manifest as this)
• 5. Overreaction-totally subjective. (Seen with fear of pain)
• According to “common wisdom”, if there are more than 3 of 5
present then there is high probability that patient has non-
organic pain. In reality, many Waddell signs really are found in
other diseases as indications of pathology.

15. Waddell Signs as part of a physical exam
• Fishbain, et. al., (Pain Medicine, vol. 4, ’03).
• Meta analysis of 61 studies (a review of 61
published articles)
• Positive Waddell signs do not correlate with
malingering, secondary gain, hysteria,
psychological distress, abnormal illness
behavior, nor somatic amplification
• They do not discriminate organic vs. non-
organic problems
• They do predict poor treatment outcome.
• There may be a real organic basis for + signs.

16. No scale on the MMPI can
invalidate the complaint of pain
• MMPI: a 566 true-false question personality
test
• MMPI can not consistently predict the presence
or absence of organic pathology. Four articles
report not one single scale ever correlates,
consistently, with the presence or absence of
organic pathology.
• The MMPI cannot be used to diagnose faking
or malingering. It only measures personality
problems or psychiatric disease.
( Pain, ’85, J. Occ. Medicine,’88, J. Neurolog & Ortho. Med. & Surgery, ’85, Clinical

17. Comparison
• Pain Validity Test • MMPI -Fake Bad Scale
• Predicts objective • Cannot predict objective
organic test pathology organic test using any
with 95% accuracy scale of the MMPI
• Proves that 87%-94% • Says 85% of all people
of all people have valid are fakers, even if they
pain complaints are not
• Tested on 794 people • Tested on many more
• Available on Internet • Available on Internet
• Measure impact of pain • Measures psychological
on a person problems
• Always admitted in • Thrown out of court as
court -8 states “junk science”

18. Comparison of Fraud Tests Used
Test Cost Physical or Accuracy Accuracy
Verbal Predicting medical
test abnormality Proving fraud
MCD Pain $300 Verbal 95% 85%
Validity Test
Functional $1,400+ physical No No
Capacity
Evaluation correlation correlation
Detectives $2,000+ visual poor variable
Independent $1,500+ both poor Medical
Medical certainty >51%
Examination
Waddell signs Part of physical poor poor
physical
MMPI $3,500 verbal Articles report Articles report
none none

19. PVT compared to other tests
• The Pain Validity Test is the most accurate &
least expensive way of documenting fraud
• The Pain Validity Test is based on published
articles by top physicians, in medical journals
• The Pain Validity Test as been admitted in
court in 8 different states as part of testimony
• The Pain Validity Test offers an objective
method for determining fraud
• Go to www.MarlyandClinicalDiagnostics.com
for more information.

20. This is a small representative sample of the court cases
and depositions where the Pain Validity Test was used as
part of physician testimony and always admitted as
evidence. Go to www.MarylandClinicalDiagnostics.com to
see a sample of the actual test results.

21. More Cases where PVT was used

22. More Cases where PVT was used

23. Daubert Criteria-Rule 702-A
• If you want to know if your expert’s use of the PVT would be
admissible in a federal district court, you should review Rule
702 of the Federal Rules of Evidence.
• That Rule provides:
• If scientific, technical, or other specialized knowledge will
assist the trier of fact to understand the evidence or to
determine a fact in issue, a witness qualified as an expert by
knowledge, skill, experience, training, or education, may
testify thereto in the form of an opinion or otherwise, if (l) the
testimony is based upon sufficient facts or data, (2) the
testimony is the product of reliable principles and methods,
and (3) the witness has applied the principles and methods
reliably to the facts of the case.

24. Daubert Criteria-Rule 702-B
• Rule 702 was amended in 2002 in
response to the Supreme Court’s decision
in Daubert v. Merrell Dow
Pharmaceuticals, Inc., 509 U.S. 579
(1993), and many cases applying Daubert,
including the Supreme Court’s decision in
Kumho Tire Co. v. Carmichael, 526 U.S.
137 (1999).

25. Daubert Criteria-Rule 702-C
• In Daubert, the Supreme Court held that the district court
undertakes a “gate-keeping” function, and determines
“whether the reasoning or methodology underlying the
testimony is scientifically valid. and whether that
reasoning or methodology properly can be applied to the
facts in issue.” - 509 U.S. at 592-593. (This gate-
keeping role has been described as a mechanism to
guard the jury from considering “. . . as proof pure
speculation presented in the guise of legitimate
scientifically-based expert opinion. It is not intended to
turn judges into jurors or surrogate scientists.” Joiner v.
Gen. Elec.. Co.. 78 F.3d 524,530(11th Cir. 1996), 4, 522
U.S. 136 (1997). Anthony Z. Roisman, The Courts,
Daubert and Environmental Torts: Gatekeepers or
Auditors, 14 Pace Envtl. L. Rev. 545 (1997).

26. Daubert Criteria-Rule 702-D
• The specific factors set forth in Daubert are as follows:
• 1. Whether the expert’s technique or theory can be or has been tested, i.e.,
whether the theory can be challenged in some objective manner, whether it is
instead simply a subjective, conclusory approach that cannot reasonably be
assessed for reliability. (509 U.S. at 593) and Advisory Committee Notes to Rule
702;
• 2. Whether the theory or technique has been subject to peer review and
publication.
(509 U.S. at 593). According to the Court, peer review is important in that the
likelihood is increased that substantive flaws in methodology will be detected. ~.
Accordingly, publication, or the lack thereof, in a peer review journal is a
relevant, although not dispositive, consideration in determining the scientific
validity of a particular technique or methodology on which an opinion is based.
(509 U.S. at 594);
• 3. The known or potential rate of error of the technique or theory when applied,
as well as the existence and maintenance of standards controlling the
technique’s operation. 509 U.S. at 594;
• 4. Whether the technique or theory has been generally accepted in the scientific
community. According to the Court, a technique which has only been able to
attract minimal support within the community may properly be viewed by the
district court with skepticism. Id.

27. “Fake Bad” Scale of MMPI
http://forensicpsychologist.blogspot.com/2008/03/new-mmpi-scale-invalid-as-forensic-lie
New MMPI scale invalid as forensic lie detector, courts rule March 5, 2008
Psychology's most widely used personality test, the MMPI evoked controversy, by
pitting corporate interests such as Halliburton against the proverbial little guy.
At issue is the "Fake Bad Scale" that was incorporated into the Minnesota
Multiphasic Personality Inventory last year for use in personal injury litigation
Although a majority of forensic neuropsychologists said in a recent survey that they
use the scale, critics say it brands too many people - especially women - as liars.
Research finding an unacceptably large false-positive rate includes a large-scale
study by MMPI expert James Butcher, who found that the scale classified high
percentages of bonafide psychiatric inpatients as fakers.
The controversy came to a head last year in two Florida courtrooms, where
judges barred use of the scale after special hearings on its scientific validity. In a
case being brought against a petroleum company, a judge ruled that there was "no
hard medical science to support the use of this scale to predict truthfulness.”

28. The “”Fake Bad” Scale of the MMPI
Butcher JN, Arbisi PA, Atlis MM, McNulty JL
The construct validity of the Lees-Haley Fake Bad Scale (FBS). Does this scale measure somatic
malingering and feigned emotional distress? Arch Clin Neuropsychol. 2004 Apr;19(3):337-9;
author reply 341-5.
The Fake Bad Scale (FBS [Psychol. Rep. 68 (1991) 203]) was created from
MMPI-2 items to assess faking of physical complaints among personal
injury claimants.
Little psychometric information is available on the FBS measure.
This study was conducted to investigate the psychometric characteristics
of the FBS in over 20,000 patients, in 6 different settings.
The FBS classified 2.4%-30.6% of individuals as malingerers.
Compared to men, in most samples, almost twice as many women were
classified as malingerers.
The results indicate that the FBS is more likely to measure general
maladjustment and somatic complaints rather than malingering.
The rate of false positives produced by the scale is unacceptably high,
especially in psychiatric settings.
The scale is likely to classify an unacceptably large number of individuals
who are experiencing genuine psychological distress as malingerers.
It is recommended that the FBS not be used in clinical settings nor should
it be used during disability evaluations to determine malingering.

29. Minnesota Multiphasic Personality
Inventory (MMPI):
lack of predictive capabilities
• Hagedorn et al (Pain, ’84) followed 50,000
patients for 25 years. This is the only
prospective study on MMPI ever done.
• They all received the MMPI when they first
entered the Mayo Clinic system.
• 68 of them had back surgery.
• No difference in pre-surgery MMPI
between those who did do well or didn’t do
well with surgery.

30. Validating the Complaint of Pain
• MMPI is not consistent in predicting the
presence or absence of organic
pathology. Not one single scale ever
correlates, consistently, with the presence
or absence of organic pathology (Hendler
et al, Pain, ’85, J. Occ. Medicine,’88, J.
Neurolog & Ortho. Med. & Surgery, ’85,
Clinical Neurosurgery, ‘89)

31. Longitudinal Studies on Depression
Patients admitted to Mensana Clinic:
77% of the chronic pain patients were
depressed, as confirmed by Beck scores.
However, 89% had never been depressed
before the onset of their pain ( Hendler,
Clinical Neurosurgery, ‘89)
After six months or more, chronic pain
produces depression (Hendler, J. Clinical
Psych, ’84)

32. How to use the PVT properly
• Medical research shows • 87%-94% of claimants have
that 6%-13% of claimants a valid complaint of pain
are fakers and malingerers • Use the MCD Pain Validity
• The PVT can detect these Test to identify clients who
cases instead of investing have valid pain complaints
time and money in • The MCD Pain Validity Test
detectives, FCE and IME predicts who will have
• The insurance company abnormal medical testing
can settle these cases for a with 95% accuracy.
small amount of money • 40%-67% of these cases
• Saves you time and money are misdiagnosed, and 50%
• The Pain Validity Test will need surgery to get well
identifies exaggerators with • Use Diagnostic Paradigm
85% accuracy for proper diagnosis

33. Overused Psychiatric Diagnoses in
Chronic Pain Patients
• Conversion reaction is defined as an
unconscious manifestation of a physical problem
(usually visible) without an organic basis
(300.11- DSM-IV).
• Malingering is defined as a conscious attempt
to deceive for personal gain (316.V65.2-DSM-
IV). Patients refuse to go for tests.
• Pain Disorder (307.80- DSM-IV) defined as a
pain for which is there is no medical explanation.
• Somatoform Disorder (300.81- DMM –IV)
defined as a cluster of 4 pain, 2 GI, 1 sexual and
1 pseudo-neurological symptoms without
medical diagnosis.

34. Overused Psychiatric Diagnoses
in Chronic Pain Patients
• Conversion reaction: What is the incidence?
Kemp, Am. J. of Insanity, 1913 less than 1%
of admission to Phipps were conversion.
• Stephens, J. of Nervous and Mental Disease,
’62, less than 2% of Phipps admits were
conversion
• Hendler. N. Neurosurgical Management of
Pain , ’97, Edited by Richard North, MD and
Robert Levy, MD, Chap. #2, reports only
3/6,000 chronic pain patients with conversion
reactions.

35. Overused Psychiatric Diagnoses in
Chronic Pain Patients
• Slater, E. Br. Med. J. ’65 did 9 year follow-up on 85
patients diagnosed as conversion hysteria at
Queens Square Neurological Hospital in London.
• Only 7/85 were confirmed as conversion
• The rest has atypical myopathy, trigeminal
neuralgia, disseminated sclerosis, dementia,
thoracic outlet syndrome, epilepsy, vestibular
lesions, Takayasu’s syndrome, neoplasms,
schizophrenia, somatizing disorders, cord
compression, and endogenous depression.

36. Overused Psychiatric Diagnoses in
Chronic Pain Patients
1) The incidence of hysterical conversion
reaction is small in a general psychiatric
population (1%-2% of admissions).
2)The incidence of hysterical conversion in a
chronic pain population that is properly
diagnosed, is even smaller (3/6000 or .05%).
3) Even after diagnosed with conversion
reaction, there is less than a 10% chance the
patient really has this, and most likely has
medical disease.

37. Overused Psychiatric Diagnoses
in Chronic Pain Patients
• Conversion reactions (300.11 DSM IV), such as
paralyzed limb, blindness, or falling -visible signs
• Not in DSM IV- The disorder does not produce
distress in the patient (“La belle indifference”).
• The symptoms will remit with amobarbital
narcosynthesis, at adequate doses (>450mg)
• Hendler et al Clinical J. of Pain, ‘87 described a
case of hysterical scoliosis diagnosed by the
orthopedic surgeon, which did not respond to
Amytal, but responded under general anesthesia.

38. Hysterical Conversion Reaction
Hendler, N., Filtzer, D., Talo, S., Panzetta, M., Long, D.: "Hysterical Scoliosis Treated with
Amobarbital Narcosynthesis." The Clinical Journal of Pain. Vol. 2, No. 3:179-182, 1987.
• Hysterical Scoliosis =walking with back
twisted to one side.
• Note-visible symptom – “I am sick.”
• Note-responded to narcosynthesis.
• Note – represented an unexpressed
psychological conflict
• Pain is a bad conversion symptom,
because it is not visible, and even people
with real pain have trouble convincing
people they have something wrong.

39. Overused Psychiatric Diagnoses in
Chronic Pain Patients
• Malingering: No statistics about frequency (Hendler
and Talo, Current Therapy of Pain, edited by Kathy
Foley and Richard Payne, BC Decker, ’89).
• Pain Disorder is defined as a pain for which is there
is no medical explanation. However, if 40%-67% of
chronic pain patients are misdiagnosed medically,
then these patients receive a faulty psychiatric
diagnosis, because of a poor medical diagnosis.
• Depressive Equivalents: Depression causes pain.
• Circular logic in the diagnostic criteria in DSM-IV for
somatoform disorder, pain disorder, and depressive
equivalents. With a poor medical work-up, these
“diagnoses” becomes self fulfilling prophecies.

40. Malingering- V65.2-DSM IV
• This is a conscious attempt to deceive
people
• The malingerer picks highly visible
disabilities, like limping, or totally
subjective ones, like chronic pain which
can’t be measured.
• The hallmark of a malingerer is a refusal
to participate in objective medical testing,
which, of course, would detect an absence
of any pathology.
Hendler and Talo, Current Therapy of Pain, edited by Kathy Foley and Richard Payne,
BC Decker, ’89

41. Somatoform Disorder-300.81
• Diagnostic and Statistical Manual IV code for
Somatoform Disorder is 300.81 or Somatization
disorder. This is also known as Briquet's
syndrome. Patients with this type have a long
history of medical problems that starts before
the age of 30.The symptoms involve several
different organs and body systems. The patient
may report a combination of:
• Pain,neurologic problems,gastrointestinal
complaints.sexual symptoms
• Many people who have somatization disorder
will also have an anxiety disorder.

42. Pain Disorder Associated
With Both Psychological
307.89 Factors and a General
Medical Condition
Pain Disorder Associated
307.80
With Psychological Factors
The distinction between these disorders, as defined by the DSM IV, is
the severity of the psychiatric disorder. However, these definitions
totally overlook the cause effect relationship between pain and
psychological factors. There is no provision for the fact that pain
produces depression, and that this is a normal response to pain. Also,
in the later diagnosis, Pain Disorder Associated with Psychological
Factors, if a physician misdiagnoses a patient, or can’t find the cause of
the pain, the DSM-IV allows the physician to blame the patient, and say
the patient has psychological factors causing his complaint of pain.
This is faulty logic, and faulty medicine.

43. Suicide and Pain
Chronic pain patient commit suicide at a
higher rate than the general population
(Fishbain et al Clin. J. of Pain, ‘91).
White males with pain complete suicide at a
rate 2X higher than the general population.
White females with pain complete suicide at a
rate 3 X higher than the general population.
White males with pain, involved in workers
compensation litigation complete suicide at a
rate 3 X higher than the general population.

44. Rational Clinical Approach
• Patients can have both psychiatric disease
and organic pathology co-existing
• Schizophrenics get brain tumors, and
hysterics get disc disease. Psychiatric
disease does not confer an immunity
against getting a medical disease.
• Treat each patient as if they have organic
pathology.
• Give patient the benefit of the doubt.
• See www.MarylandClinicalDiagnostics.com
for the Pain Validity Test

45. What are the Questions?
• Does the patient have a valid complaint of pain?
• Variables: pre-existing psychopathology,
resultant psychopathology, negative tests,
positive tests that do not correlate with the
anatomical complaint of pain (i.e. L5-S1 disc on
MRI: pain in top of thigh = L2-L3)
• KEY Concept: Severe chronic pain produces
consistent psychological and sociological
responses in a patient, regardless of pre-existing
or co-existing psychiatric disease.
• If the response to pain is normal, believe the
patient, not the tests, and keep looking
• People with pre-pain psychiatric illness can also
get medical illness. This is not conversion.

46. From; Hendler and Talo, Current Therapy of Pain, edited by Kathy Foley and Richard Payne, BC Decker, ’89

47. Available Help
• Pain Validity Test is available on Internet to
validate pain, and improve diagnostic
accuracy, as a screening tool to help get
an accurate diagnosis, and supplement the
use of IMEs, and surveillance.
• Preliminary studies (next slide) show an
average cost savings of $1,654/case for
answering the question – “Is the pain
valid?” using Pain Validity Test for $300.
• Average $97,000/case cost containment
for “What is the diagnosis and treatment?”
(Appendix A) using Diagnostic Paradigm.

48. Spotting Fraud
• National Council on Compensation Insurance
(NCCI) published a report Assessing Pain, Real
and Imagined(11/29/98).
• www.NCCI.com/painreal.html
• Hendler reports that 6% of non-litigant patients
are exaggerating pain patients, 10% of LTD, and
13% of workers compensation.
• For $300, The Pain Validity Test can identify
exaggerating pain patients
• Average savings of $1,654/claim by eliminating
IMEs, surveillance, and nurse case reviewer in
the objective pain patient, and focusing the
resources on the exaggerating pain patient.

49. California Does a Poor Job of
Combating Worker’s Comp Fraud
(Workers Compensation Report, Vol 15, No. 11, p.206 May 17, 2004)
• State Auditor Elaine Howle says the $30,000,000 annual
assessment to combat fraud may be wasted.
• Insurance companies cannot measure the effectiveness of
their efforts using IMEs and surveillance.
• The companies are relying on anecdotal testimony from
stakeholders in the workers compensation community,
unscientific estimates, and description of local cases
involving fraud.
• The fraud division publishes statistics showing the number
of investigations, arrests, convictions, and restitution, but
cannot show if anti-fraud efforts are cost-effective
• How to detect fraud vs. a normal response to chronic pain

50. Scattergram of Computer Scored Pain Validity Test.
On the left, 3* is a severe abnormality, 2 a moderate abnormality, 1 a mild abnormality,
and 0 is no abnormality on at least one objective medical test. At the bottom, 8-25
represent the score on the Pain Validity Test. 17 or less is an Objective Pain Patient, 21
point or higher is an Exaggerating Pain Patient
*3
65/69 = 95%
2 Exaggerating
Objective Pain Patient Pain Patient
1
11/13 = 85%
0
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

51. Explanation of the Scattergram
• 87%- to 94% of clients score as an objective pain
patient on the Pain Validity Test.
• Look at Scattergram- Objective Pain Patients have
a 95% chance of having moderate or severe
abnormalities on at least one objective measure of
organic pathology, such as EMG nerve conduction
studies, root blocks, facet block, provocative
discograms, MRI, CT, etc. Medical articles prove
that the MMPI has no predictive medical
capabilities. Insurance companies often claim that
the MMPI does, but can’t prove it.
• Pain Validity Test can identify patients who will not
have medical abnormalities with 85% accuracy.
Only 6%-13% of patients are exaggerating

52. Efficacy?
• Other than the PVT, no test was cost effective
• A literature search using Google, Jeeves,
National Library of Medicine, National Council
of Compensation Insurers, AOL, Yahoo, etc.
never revealed an article documenting the
cost effectiveness of IMEs, surveillance,
P.T., Functional Capacities Evaluations, and
Case Reviews. There were lots of case
reports.
• 54 cases reviewed for “XZY” insurance had an
average of 3.8 IMEs (1-7), and cases were still
active, out of work an average of 3.9 years
• Fraud detection cost were over $5,000/case

53. Richard Pimentel at National Council on
Compensation Insurance Symposium,May 6,’04
(Workers’ Compensation Report Vol. 15, No. 11, p. 206, May 17, 2004)
• Insurers hold the key to reducing claims duration
with effective Return to Work Strategies
• Currently: Worker goes to doctor, Worker files a
claim with insurer, Worker doesn’t want to return to
work, Insurance company contacts employer for a
job description, and send RTW form to doctor, who
fills out form and sends it to insurance carrier, who
contacts the employer to to to get worker to RTW.
• His plan: remove the insurer from the equation.
• Having a supervisor of the worker from the
company go to the doctor with the worker saved
$1,400/claim.

54. Conclusions
• The current methods of assessing fraud are not
cost effective, and not accurate.
• Misdiagnosed patients cost insurance
companies much more than fraudulent cases.
• The Pain Validity Test is a reliable method for
detecting fraud.
• Physical therapy has not been documented as
cost effective in chronic pain patient treatment.
• Insurance carriers should demand Evidence
Based Medicine proof of efficacy of treatment.
• See www.MarylandClinicalDiagnostics.com