The Effect of Compensation Status - Springer Link

15 The Effect of Compensation Status KEITH NICHOLSON AND MICHAEL F. MARTELLI

As discussed in Chapter 14, there had been increased concern about the possibility of malingering or related behaviors following the advent of various compensation plans from the mid-late 1800s. The relationship between compensation status, that is, whether the person is receiving compensation benefits or has the prospects of receiving compensation, and various aspects of response to injury or disability, has subsequently been extensively investigated. Of note, there are many different possible methods for procuring compensation with different types of injuries or disabilities in different jurisdictions, for example, various worker’s compensation, Social Security, and disability schemes, automobile insurance involving either tort liability or no-fault compensation, various private insurance plans, the U.S. Veterans Administration, and others. Weintraub (1995) suggested that the notion of “compensation neurosis,” introduced in the mid-late 1800s, was meant to indicate some mix of outright malingering or fraud and a host of other factors that might influence presentation when compensation is involved. Kennedy (1946), in an early and influential study, reported that only 5% of Danes, for whom a lump sum payment was made with no further ongoing benefits, continued to have a “neurosis” following an accident, but that 95% of Germans, living 30 miles away and for whom a stipend was paid while disabled, remained ill. It was suggested that “a compensation neurosis is a state of mind, born out of fear, kept alive by avarice, stimulated by lawyers, and cured by a verdict” (p. 20). In another early and influential study, Miller (1961) suggested that accident or compensation neuroses were characterized by an inverse relationship between symptom severity and the provoking injury, a conviction by the persons affected that they were unable to work despite no overt disability, and a failure to respond to therapy until the compensation issue was settled, after which nearly all of the individuals described recovered completely without treatment. However, noting that exaggeration is a part of both accident neuroses and conscious symptom simulation, Miller did not think it was possible to distinguish between conscious and unconscious purpose. An increasing number of studies have subsequently examined the role of compensation and related factors in the presentation of persons following an accident 411

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or injury. In an early review of the literature, Weighill (1983) suggested that limited conclusions could be drawn from research findings to date. It was suggested that there was general agreement that problems associated with accident neurosis involve a variety of secondary gains, not just financial, as well as an array of interacting physical, employment, psychological, social, and cultural factors. The author noted that “blaming” others for an accident was of poor prognostic value, and that becoming involved with a lawyer may be iatrogenic. There was little support for the generally held view that problems resolve on settlement of a case, most studies indicating that problems then continued, at least to some extent. Mendelson (1995), in a more current review of the literature, concluded that the overwhelming majority of follow-up studies of personal injury litigants indicate that individuals continued to have problems subsequent to settlement of their case. A number of possible factors that may be associated with compensation status were reviewed, including adoption of a “victim” role, iatrogenic factors associated with diagnosis or treatment, regression, object loss, personality traits, workplace and economic variables, and changes in marital or other social relationships. Several studies have found a relationship between availability of compensation and the number or nature of claims. Robertson and Keeve (1983) found that changes in injury claim rates were largely explained by increases in worker’s compensation rates over the course of 8 years in three U.S. states. Further review of the literature has suggested that a 10% increase in worker’s compensation benefits results in a 1–11% increase in the number of claims, and a 2–11% increase in the duration of claims (Loeser, Henderlite, & Conrad, 1995; Loeser & Sullivan, 1995). Several researchers have noted that there have been dramatic increases or expansion in benefits for psychological or medical impairments or illness in the past few decades, despite improvement on most objective measures of health and reduced work-related risks (Halligan, Bass, & Oakley, 2003; Waddell, 2002). There have been extensive efforts made to delineate the role that compensation has on presentation of persons with traumatic brain injury (TBI), chronic pain, Posttraumatic Stress Disorder (PTSD) or various other psychoemotional problems. Greiffenstein, Baker, and Gola (1994) reviewed the available literature in which litigation status was evaluated as a possible factor associated with poor performance, concluding that results were mixed, several studies finding that mild TBI subjects presented with impairment independent of litigation status. Binder and Rohling (1996) conducted a meta-analytic review of the effects of financial incentives on recovery after closed-head injury. Briefly, meta-analysis is a technique that enables the pooling of results from many different studies and yields a measure of how strong a given variable is. Binder and Rohling’s meta-analysis included 18 studies, with 673 patients receiving compensation and 1,680 patients not receiving compensation. The weighted mean effect size (i.e., the overall difference between compensation and noncompensation groups on the measures assessed) was .47, suggesting that, if compensation status was causally related and all financial compensation was eliminated, the abnormal findings and complaints associated with closed-head injury would decrease by some 23%. Several of the studies reviewed were considered to shed light on the causal relationship between

15. The Effect of Compensation Status

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compensation status and variables of interest. Patients seeking compensation had greater disability or abnormal findings despite having less severe injuries. Those on compensation also performed more poorly on measures of “effort” or related measures (see below) even if head injury severity was more severe in the noncompensation groups. It was eventually suggested that consideration should be given to the possibility of secondary gain in every case of closed-head injury, particularly milder injuries. However, as will be discussed further below, there is a problem with the interpretation of such studies or findings because many factors other than head/brain injury severity or compensation status may contribute to presentation, for example, chronic pain, PTSD, or other psychoemotional distress, sleep disturbance, and so forth (Nicholson, 2000a; Nicholson & Martelli, 2006; Nicholson, Martelli, & Zasler, 2001). Many studies subsequent to Binder and Rohling’s (1996) study have examined the relationship between compensation or litigation status and some aspect of (especially mild) TBI. Carroll et al. (2004) reviewed 120 studies considered to be of acceptable scientific quality (out of a possible 428 studies), concluding that there was consistent and methodologically sound evidence that children’s prognosis after mild TBI is good, with quick resolution of symptoms and little evidence of residual cognitive, behavioral, or academic deficits. The majority of studies indicated recovery for most adults with mild TBI within 3–12 months. Compensation/ litigation status was found to be associated with persisting symptoms. It was noted that there was consistent evidence that adults experience various symptoms, especially headache, in the acute post–head injury stage. However, headache was not considered as a predictor variable for persisting effects. It was also noted that few studies had adequately assessed for psychological distress or depression after injury, medication side effects, or pain from associated injuries. In addition, it was noted that studies were of varying quality, and that causal inferences were often mistakenly drawn from cross-sectional studies. As such, the causal relationship between compensation and symptomatology was thought to be unclear, and that various other factors may account for persisting problems that lead an individual to seek compensation. Cassidy, Carroll, Cote, Holm, and Nygren (2004) studied cases of mild TBI resulting from motor vehicle accidents in the province of Saskatchewan, Canada, before and after the transition from a tort to a no-fault insurance system. There was a 25% decrease in claims following the change and the median time to claim closure also decreased with adoption of the no-fault system. A number of other factors were found to be associated with time to claim closure, for example, there was a longer time to claim closure for those who had more than 20% of their body in pain, although no-fault payments were not made for “pain and suffering”. The authors concluded that they could not be sure why there were fewer claims after no-fault was adopted, but suggested that this was unrelated to medical care given that this was not affected by the change in systems. There has been extensive study of the relationship between compensation status and chronic pain perhaps, in part, because there have been dramatic increases in compensation for chronic pain problems. Fordyce (1985) reported a

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2,680% increase in the rate of compensation for low back pain from 1960 to 1980 with no corresponding evidence of any change in the incidence of actual problems. This was the fastest growing rate of compensation for any disorder or disease during this period, lung disease being the second at 400%. Others have described the growth in compensation claims for chronic pain as an “epidemic” (Chapman & Brena, 1989), threatening to bankrupt national economies (Nachemson, 1994). As has previously been noted (Nicholson, 2000b), such increases may reflect a number of factors including societal response to pain problems, with more effective treatment programs and more liberal compensation policies leading to increased reporting of pain, such pain problems then coming “out of the closet.” Rohling, Binder, and Langhinrichsen-Rohling (1995) conducted a meta-analytic review of the association between financial compensation and the experience and treatment of chronic pain. Of the 157 relevant studies that were identified, only 32 were considered to be of acceptable scientific quality and containing quantifiable data that could be included in the meta-analysis. The majority of studies included were with low back pain patients. Liberal statistical procedures yielded a mean effect size of .60 and conservative procedures yielded an effect size of .48 indicating that compensation is related to increased reports of pain and decreased treatment efficacy. However, it was noted that the meaning of such findings was dependent upon the causal relationship between variables. If compensation in some way causes increased pain problems or complaints then, simply, the obtained effect size conservatively suggests that there would be a decrease of 24% in chronic pain problems if compensation were eliminated. Rohling et al. (1995) concluded that the results did suggest that compensation results in increased pain perception and a reduction in the ability to benefit from medical and psychological treatment rather than the converse, that is, that increased pain and related problems resulted in persons seeking or obtaining compensation, or that some other factor(s) were mediating the obtained association. In particular, it was noted that comparison of treatment effectiveness utilized matched group designs in which a compensated and a noncompensated sample of pain patients were matched for such variables as organic pathology or pain severity. If, therefore, persons on compensation had poorer outcomes, it could not be attributed to these variables. It was suggested that a behavioral model (e.g., Fordyce, 1985), in which various operant reinforcements may maintain or exacerbate a pain problem, best accounted for the association between compensation and increased pain problems. It was noted that this model does not require a person to be conscious of the relationship between pain and compensation for compensation to reinforce pain experience. Rohling et al. (1995) were unable to substantiate that other factors (e.g., employment status) accounted for differences between compensated and noncompensated groups, although it was acknowledged that there may not have been sufficient power to detect the effect of other such variables. It was also noted that there were too few studies to determine whether a number of other possible mediating factors (e.g., psychiatric history, depression, or anxiety) would better account for the observed relationships. Caution concerning their causal inference


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of compensation “causing” pain and disability was recommended, and it was acknowledged that patients who experience greater pain and have a more difficult time in treatment may be the same patients who are more likely to seek and obtain compensation. Hadjistavropoulos (1999) reviewed the literature concerning the influence of litigation and compensation on chronic pain syndromes and concluded that effects continued to be controversial, but that compensation factors may contribute to delay in recovery and reinforcement of the sick role. Teasell (2001) more systematically reviewed the literature relevant to chronic pain of varied etiology and worker’s compensation, concluding that there was no definitive evidence that compensation affects the incidence of injury or the development of chronic pain because there were insufficient good quality studies addressing this issue. Consistent with studies cited above, there was moderate evidence that, as the ratio of compensation to preinjury wages increases, the duration of claims also increases. There was moderate evidence that compensation influences chronic pain disability. There was limited evidence that worker compensation status, particularly when combined with higher pain intensities, is associated with a poorer prognosis for treatment of patients with chronic musculoskeletal pain; that retaining a lawyer is associated with a longer claim duration; that filing a compensation claim is not by itself associated with either length of time out of work or regaining of physical function; that compensation had the least impact on the lower and higher income groups; and that the middle income group was the least likely to go back to work if replacement wages through compensation were available. Whereas it had early on been suggested that recovery rates dramatically improve following the settlement of claims, and some studies have supported this proposition (e.g., Burke, 1978; Kay & Morris-Jones, 1998; Miller, 1961; Miller & Cartlidge, 1972), many studies have found that this does not happen (e.g., Greenough & Fraser, 1989; Kelly & Smith, 1981; Kolbinson, Epstein, & Burgess, 1996; Mendelson, 1992, 1995; Norris & Watt, 1983; Rainville, Sobel, Hartigan, & Wright, 1997; Tarsh & Royston, 1985). Thomas (2002) suggested that differences in the results or conclusions of various studies concerning outcome in compensation cases might be due to the orientation of referral sources or attitude of the researcher conducting the study. Subjects assessed by authors who concluded that high levels of exaggeration were involved, or that there was resolution of symptomatology on resolution of the legal case, were usually referred by the defendant’s solicitor (attorney) or insurance companies, whereas litigants in the studies who were reported to have persisting difficulties postlitigation, were seen on behalf of the claimants’ solicitors. Several other more recent studies have examined the relationship between compensation status and various aspects of chronic pain. Most of these have found that compensation or litigation are associated with increased problems or adverse outcomes. McNaughton, Sims, and Taylor (2000) conducted a retrospective review of 100 back pain patients and found that the variable most strongly associated with continued problems was whether the claimant was receiving earningsrelated compensation, although it was acknowledged that many variables of

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possible interest were not able to be measured given the nature of the study. Blyth, March, Nicholas, and Cousins (2003), utilizing a community sample, found that past or present litigation for chronic pain was the strongest of several predictors of pain-related disability. This relationship remained even after taking into account certain other factors associated with poor functional outcomes. Osti et al. (2005) compared factors related to early (within 9 months) or late (more than 24 months) settlement of a compensation claim for whiplash following motor vehicle accidents. Consulting a solicitor was associated with a highly significant, fourfold increase of late settlement of the claim, whereas having a concurrent workers’ compensation claim, prior neck disability, and undergoing physiotherapy or chiropractic treatment were weakly associated with late settlement. The degree of damage to the vehicle was not a significant predictor of late settlement. Tait (2004) reviewed the literature examining the relationship of compensation and chronic pain, concluding that “the data generally show that compensation patients present with more severe and disabling symptoms and respond more poorly to treatment (unless the treatment explicitly targets functional and psychosocial factors)” (p. 560). However, it was also concluded that the incidence of malingering was generally thought to be low, and that various psychosocial factors interact with compensation status to influence symptom presentation and treatment response, for example, employment status, depression, and fear or pain avoidance behaviors. Rodriguez et al. (2004) reviewed the literature relevant to the pathophysiology, diagnosis, treatment, and prognosis of whiplash-associated disorder, concluding that there was great variability in outcome which, in part, depended upon the receipt of financial compensation for injury. Pobereskin (2005), in a large sample of persons involved in rear-end collisions, found that the most important predictors of neck or other pain at one year postaccident were the initial neck pain severity ratings and the presence of a compensation claim. There was only weak evidence that measures of the severity of the impact were associated with outcomes. Importantly, several studies have found that initial pain severity is predictive of development of many chronic pain problems, suggesting that sensitization effects at onset may account for ongoing problems (Nicholson, 2000b). Busse, Dufton, Kilian, and Bhandari (2004) reviewed a total of 1,101 consecutive files of patients presenting to a single chiropractor’s practice with whiplash-associated disorder and found that, among the many variables studied, higher self-reported disability on initial assessment was associated with being female and, in particular, with retaining a lawyer. Of note, female gender is associated with a greater incidence or severity of most chronic pain problems (Nicholson, 2000b). Balk, Hagberg, Buterbaugh, and Imbriglia (2005) found very little difference in the outcome of surgical intervention for tennis elbow between those receiving worker’s compensation and those who did not. However, although a majority of patients in both groups returned to work, a significantly higher percentage of patients in the worker compensation group changed jobs because of persistent symptoms. Several other studies have also found that compensation or litigation is associated with increased problems or adverse outcomes in chronic back pain


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patients (Pearce, 2000; Suter, 2002), spinal disorder patients (Hee, Whitecloud, Myers, Roesch, & Ricciardi, 2002), patients receiving acromioplasty (i.e., shoulder surgery; Lopez, Ernst, & Wright, 2000), patients receiving physiotherapeutic McKenzie treatment for cervical nerve root compression (Rasmussen, Rechter, Schmidt, Hansen, & Therkelsen, 2000), and subjective complaints but not objective findings following anterior cruciate ligament reconstruction for knee problems (Barrett, Rook, Nash, & Coggin, 2001). There have been several studies examining outcomes and prognostic factors for several pain problems before and after the transition from a tort to a no-fault system in Saskatchewan, Canada, in which compensation for pain and suffering was eliminated. Cassidy et al. (2000) found that there was a 28% reduction in the incidence of whiplash claims following introduction of the no-fault system, and median time to claim closure was reduced 54%. Those individuals who were involved in an accident before the change in systems reported more intense and widespread pain than did those injured after. Under the tort insurance system, those who were not at fault for the collision had slower recovery than those who were at fault. Regardless of the insurance system, strong and independent associations were found between the retention of a lawyer shortly after the collision and delayed recovery. Cassidy et al. noted that several studies in the United States have shown that claims in which a lawyer is involved take longer to close and cost more than those that do not involve a lawyer, for both workers’ compensation and litigation for motor vehicle accident injuries (Butterfield, Spencer, Redmond, Feldstein, & Perrin, 1998; Insurance Research Council, 1994). However, again, effects may be bidirectional, that is, those with more significant problems may seek and obtain legal counsel, or, the presentation of those who may be malingering or who are more vulnerable to the effects of operant reinforcement for prolonged pain and disability may be adversely influenced by involvement in litigation or compensation factors. In another study of the transition from a tort to a no-fault system in Saskatchewan, Cassidy, Carroll, Cote, Berglund, and Nygren (2003) examined the incidence and prognosis for collision-related low back pain. Although this was a common problem in both systems, the incidence decreased by 31% after the introduction of no-fault insurance and the median time to claim closure dropped by 58%. However, measures of bodily pain, physical functioning, and depressive symptoms showed a strong and consistent temporal relation to the rate of claim closure for both tort and no-fault claimants. Prognosis was found to be worse for females, those with intense pain, and those represented by lawyers. In yet another study of the transition from the tort to no-fault systems in Saskatchewan, Cote, Hogg-Johnson, Cassidy, Carroll, and Frank (2001) found that lower pain, better function, and the absence of depressive symptoms were strongly associated with faster time to claim closure and recovery after whiplash, independent of the insurance system, indicating that these factors, rather than compensation or litigation, were relevant. Similarly, Scholten-Peeters et al. (2003), in a more recent systematic review of prospective cohort studies to assess prognostic factors associated with functional recovery of patients with whiplash

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injuries, concluded that there was strong evidence for high initial pain intensity being an adverse prognostic factor but that other factors that have often been found to be associated with poor outcome, for example, age, gender, and compensation, did not seem to be of prognostic value. Of note, there have been several critiques of the studies examining changes after the transition from the tort to no-fault system in Saskatchewan, perhaps the most important being that, as compensation for pain and suffering was eliminated, persons with pain and suffering would not apply for benefits, were denied benefits, or claims were closed prematurely on the basis of this legislative change. With regard to the Cassidy et al. (2000) study, we also note that the authors’ conclusions minimized or neglected the combination of two important considerations. Data presented on anxiety levels prior to injury demonstrated that higher preinjury anxiety was associated with delayed claims closure only in the tort system. Further, under the no-fault system, in addition to eliminating most court actions and associated delays and obstacles to treatment, income replacement and medical benefits were increased. These observations suggest that removal of medicolegal associated treatment barriers, especially in persons with higher than average levels of anxiety that may be heightened by difficulties inherent in the tort system, is an important ingredient for preventing delayed postinjury recovery. This conclusion is consistent with the findings of Evans (1994) who conducted a longitudinal study of personal injury litigants in automobile accidents. Evans found that the strongest predictors of successful outcome were the inclusion of psychological services in the treatment plan and receipt of immediate intervention with treatment focused toward return to work, including return at reduced status or modified duties. In contrast, by 6 months and every point thereafter, uncooperativeness and delayed bill paying of medical insurance carriers (vs. medical symptoms) were the most frequently reported stressors. Of patients whose insurance carriers paid bills promptly (i.e., 30 days), 97% had returned to work. In contrast, for patients whose insurance carriers delayed payments (i.e., 90 days), only 4% had returned to work. In commenting on the Cassidy et al. (2000) study, Deyo (2000) suggested that, whereas the vast majority of whiplash claimants may initially present with “real” symptoms, further medicalization prolongs problems. It was noted that merely assigning a diagnostic label may increase illness-related behavior (Haynes, Sackett, Taylor, Gibson, & Johnson, 1978) and that excessive testing or medical investigation may lead to the conviction that one has a disease, as well as to anxiety and overreaction (Colledge, 1993). Again, it was noted that adversarial systems, in which any improvement threatens the patient’s credibility and financial well-being, may impede the patient’s recovery (Hadler, 1996). Finally, Deyo suggested that the “myths” of either (1) that malingering with no actual symptoms accounts for most litigation and compensation claims, versus (2) that illness-related behavior after injuries such as whiplash is a consequence of purely biologic processes, are diametrically opposed and needed to be dispelled. Rather, it was suggested that disability and compensation claims are the result of complex interactions among biologic factors, psychosocial factors, legal influences, and economic incentives.


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Several other studies suggest that cultural, ethnic, or political factors may be important in determining the presentation of various pain or other problems including response to injury and disability. Carron, DeGood, and Tait (1985) studied back pain sufferers with comparable initial levels of pain frequency and intensity in the United States and New Zealand, the latter having a no fault compensation system that automatically reimburses to the patient the costs of patient care and basic income losses for any accident, irrespective of fault or how the injury occurred. Participants were taking part in an outpatient treatment program and were surveyed at the start of the program and one year later. The U.S. patients consistently used more medication, experienced more dysphoric mood states, and were more hampered in social-sexual, recreational, and vocational functioning. It was suggested that the adversarial system in the United States, where claims are processed much more slowly and often require a claimant to “prove” their disability, may promote poor functioning. In contrast, there is more assured provision of income replacement and rehabilitation services in New Zealand. In addition, if an injured person in New Zealand who has not been able to return to his or her preinjury occupation is eventually found able to do some work after rehabilitation or reassessment, then the person must do so or have benefits decreased. It was concluded that, compared to the United States, the New Zealand compensation-disability system is used less, or for shorter durations of time. Volinn, Nishikitani, Volinn, Nakamura, and Yano (2005) found that, although back pain is common among workers in both the United States and Japan, there is a dramatic disparity in worker’s compensation claims, rates being some 60 times greater in the United States. Several studies have concluded that recovery from whiplash tends to be much faster in jurisdictions operating under a system that does not compensate for pain and suffering, or in countries where litigation is less common (Awerbuch, 1992; Borchgrevink, Lereim, Royneland, Bjorndal, & Haraldseth, 1996; Harder, Veilleux, & Suissa, 1998; Malleson, 2002; Partheni et al., 2000). Schrader et al. (1996), in a frequently cited study of 202 people involved in rear-end accidents in Lithuania, where few drivers have personal injury insurance and there is no legal system that encourages personal injury lawsuits or the expectation of financial gain, found that there was no significant difference between accident victims surveyed 1–3 years after the accident and uninjured matched controls with respect to headache, neck, or back pain problems. Approximately one-third of both groups reported neck pain, and half of both groups reported chronic headaches. About 12% of the accident victims had chronic back pain compared with 15% of the control group. Mickeviciene et al. (2002) studied 200 persons in Lithuania who had sustained a minor head injury and 200 matched control subjects who had not. Whereas all of the head injury subjects reported having headaches in the acute stage after trauma, headaches had fully resolved in 96% of cases within a month whereupon there was no significant difference in prevalence compared to the control subjects. Of note, this study suggests a much different incidence of headache in the general population than the study of Schrader et al. (1996), giving rise to some conflict of interpretation.

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Davis et al. (2002) analyzed compensation claims for medical injury under the no-fault system in New Zealand, concluding that, although the New Zealand system is generally free of financial and legal barriers, a change in legal doctrine alone has not in itself been sufficient to remove completely the claims traditionally associated with patient compensation under tort. Aceves-Avila, Ferrari, and Ramos-Remus (2004) suggest that many illnesses that lack objective features of pathology (e.g., fibromyalgia, chronic fatigue syndrome, Gulf War syndrome, chronic whiplash, chronic low back pain) are culture-driven, with a number of underlying factors, including disability and compensation systems, serving to shape clinical presentation. There has also been considerable research into the association of compensation status and PTSD or other psychiatric or psychoemotional disorders. Rosen (1995) reported on an unusually high incidence (86%) of claimed PTSD among crew members following a boating accident. The extraordinary incidence rate appeared to be explained, at least in part, by crew members’ reports of attorney advice and symptom sharing. Citing the work of Burkett (e.g., Burkett & Whitley, 1998) and others, Pankratz (2003) argued that much of the PTSD research has been based upon veterans’ dubious self-reported experiences. In particular, Pankratz critiques the National Vietnam Veteran Readjustment Study (NVVRS; Kulka et al., 1988) in which it was concluded that 50% of Vietnam veterans had experienced PTSD, although only 15% were involved in combat. Data collection for the study involved having interviewers repeatedly ask the same question from different angles until they got the responses that they expected, persisting in their questioning in the belief that Vietnam veterans would be unwilling to talk about their experiences. It was suggested that both patients and clinicians may have wrongfully attributed various problems or experiences to either an actual or nonexistent traumatic event. Pankratz concluded that a large industry has erroneously been constructed, suggesting that, in many instances, Veterans Affairs (VA) programs do not cure PTSD but that they teach it. Frueh et al. (2003) reviewed evidence suggesting that the presentation of veterans seeking compensation through the Department of Veterans Affairs system in the United States for PTSD may be influenced by financial incentives. Note was made that studies consistently demonstrate that the combat veterans who are evaluated for PTSD in the VA system exhibit extreme and diffuse levels of psychopathology on several instruments, with elevations on validity scales suggesting an over-reporting of symptomatology. This issue will be discussed further below, but Frueh et al. noted that there may be a number of possible explanations for such findings, including the co-occurrence of other disorders and symptomatology, a “cry for help,” a sociological phenomenon known as “Vietnam syndrome,” the influence of systemic variables within the VA, as well as financial incentives. Kimbrell and Freeman (2003), expressing concern about the increase in claims and possible exaggeration of symptomatology, note that after a claim for a serviceconnected disability is filed, the Department of Veterans Affairs gives claimants a detailed list of the psychiatric symptoms that correspond to each level of monetary compensation. If a claimant is denied 100% disability with maximal benefits,


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they may report further symptoms on subsequent visits in an attempt to procure further benefits. Kimbrell and Freeman note that the problem of possible exaggerated symptomatology in an attempt to procure benefits is not limited to the VA system, citing studies that document a surge in claims for Social Security Disability Income for psychiatric disorders. Bryant and Harvey (2003) cite several studies that challenge the notion that compensation issues significantly influence PTSD status. For example, Blanchard et al. (1998), in a longitudinal study of 132 motor vehicle accident victims, found no difference in PTSD over time between those who did and did not settle their compensation claims. However, it was noted that compensation status is associated with symptom severity in both veterans and civilian trauma survivors seeking compensation. It was suggested that increased symptom reporting in people who are involved in compensation may happen because more severe trauma reactions lead to seeking compensation, although disentangling the factors associated with litigation from factors associated with trauma response is a difficult task that has often limited the inferences that can be drawn from studies of the relationship between litigation and PTSD. In summary, despite numerous studies over the course of several decades, many or most of which document at least some relationship between compensation status and aspects of presentation or disability in persons with TBI, chronic pain, PTSD, or other problems, the nature of the causal relationship remains poorly understood. It seems likely that this relationship, generally found to be quite moderate, is multifactorial. In particular, it remains unclear to what extent such findings reflect the greater difficulty (either associated with biomedical indices of impairment, various psychological injuries/disorder, or greater psychological difficulty coping with injury) persons who seek and obtain compensation may have vs. to what extent difficulties are presented as more serious or maintained due to the prospects of obtaining or remaining on compensation. Several studies have indicated that, as compensation increases proportional to preinjury wages, the incidence and/or duration of claims increase. Of course, this correlation may reflect economic realities that workers face when they are injured and have to decide whether to remain at or return to work despite ongoing problems in order to better support themselves or their families, vs. not working and having a lower standard of living. It may also be that some workers who have little, if any, injury-related problems decide that they would rather not be working and receiving a percentage of their regular take-home pay. Whereas some of the persons seeking or receiving compensation may be malingering (either outright fabrication or exaggeration, misattribution, etc., of actual symptoms), we suspect that this accounts for relatively little of the variance in the relationship between presentation and compensation status. Rather, there are a host of other possible factors that may mediate such relationship. These include operant reinforcement of illness behavior independent of any conscious dissimulation. Several studies have documented that more severe pain, psychoemotional distress, and related problems lead to compensation seeking. As has been discussed above and will be discussed further below, this may be of particular

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relevance for those studies of the relationship between compensation status and mild TBI. Numerous other studies involving differential prevalence designs will be presented below in the context of discussing malingering and TBI, chronic pain, PTSD, or other psychoemotional disorders that may be a focus of medicolegal proceedings.

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