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2005: M E Jan Wise wrongly (Chairman of the BMA's Medico- Legal Committee) makes false claim

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13,774
[edit: the garbled title is because I couldn't fit what I wanted in!]

Minor thing, but I may as well post it up in case it's of interest.

Converts to conversion?
4 November 2005
Editor: Stone et al (1) have significantly added to the credibility of conversion disorders. The role of illness behaviour in symptom presentation is often overlooked, with professionals neglecting the influence of secondary gain. The role of advocate and healer has rightly been foremost in the minds of doctors. However recent research in the areas of disability and somatisation has highlighted the poor ability of doctors to detect symptom exageration (2).

Over 40% of patients with Chronic Fatigue making claims for disability fail tests of memory which are passed by those with pentrating brain injuries or dementia severe enough to require 24 hour care (3). Increased use of psychological testing helps detect such inconsistencies in performance. Perhaps with increased use of psychometric tests we will diagnose these psychosomatic disorders with greater skill, and possibly frequency, reducing unneccessary investigations, and improve health outcomes by providing the right treatments.

1 Stone, J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ 2005;331:989-91.

2 Green, P., Lees-Haley, P.R. & Allen, L.M. (2002) The Word Memory Test and the validity of neuropsychological test scores. Journal of Forensic Neuropsychology, 2, 3 / 4, 97-124.

3 Gervais, R.O., Russell, A.S., Green, P., Allen, L.M., Ferrari, R. and Pieschl, S D. (2001) Effort testing in patients with fibromyalgia and disability incentives. Journal of Rheumatology, 28, 1892-1899.

Competing interests: Chairman of the BMA's Medico- Legal Committee

Competing interests: None declared

http://www.bmj.com/rapid-response/2011/10/31/converts-conversion

The ' Effort testing in patients with fibromyalgia and disability incentives' is available here:

http://www.researchgate.net/publica...bility_incentives/file/60b7d518ff55d0216e.pdf

Nothing about Chronic Fatigue patients in there.

They tested those with FMS and arthritis using two techniques to identify symptom exaggeration, and found:

No patient in the FM No Disability and RA groups scored
below the effort cutoff on the CARB, in contrast to 11 (24%)
of the FM Disability group. Only 2 (4%) of the FM No
Disability group scored below the cutoff for any one of the
2 WMT effort measures (IR or DR) compared to 14 (30%)
of the FM Disability group. In total, 16 (35%) of the FM
Disability group scored below the cutoffs for one or both
tests (likelihood ratio = 22.5, df = 2, p < 0.0005).

They also found this, they made little of it:

Five of the 8 patients reporting a history of head
injury passed both the CARB and WMT effort measures.

I think that sentence was the only mention in the paper of them having tested those with head injury too.

So 37.5% of those reporting a history of head injury got results taken to indicate symptom exaggeration, even though the cut-offs for the test were based upon the mean-3sd for moderate-severe brain injury patients:

In a recent study of
298 consecutive patients with head injury, 64 with moderate to severe brain
injury scored a mean of more than 90% correct on all of the WMT effort
measures18. The cutoff for failure on the WMT effort measures in the
current study was defined by an IR or DR score nearly 3 standard deviations
below the mean IR and DR scores obtained by patients with moderate
to severe brain injuries and neurological patients assumed to be making a
satisfactory effort (IR: mean 95.5%, SD 5.1; DR: mean 96.1%, SD 3.9)21,22.
Failure on either the CARB or the WMT effort measure is usually interpreted
as evidence of response bias or incomplete effort and it raises questions
about the validity of the patient’s test results, self-reported symptoms,
and claimed disability.



It sounded like the testing could take a long time, and I wonder if problems with endurance could have led to some patients giving up, and just putting in random answers to get it over with - they did say:

Some of the more severely
symptomatic patients declined (e.g., because they could not
sit for an hour, computers made them feel worse, etc.).

Pain for the patients seeking disability and not:

The pain severity scores of
both FM groups were higher than the RA group mean score
of 1.1 (SD 1.0, p < 0.0005). On a similar 6 point scale rating
perceived memory problems, with zero representing no
memory problem and 5 indicating severe memory problem,
the FM Disability score of 3.0 (SD 0.7) and the FM No
Disability score of 2.6 (SD 0.8) did not differ.

Symptom exaggeration seems like a really difficult thing to study honestly, but this paper doesn't seem to do a great job. Jan Wise is also pimping himself out on websites for 'expert witnesses' as an expert in MUS/CFS. (eg: http://www.witnessdirectory.com/cfs.html )

I'm not going to really dig into this, but it seemed potentially dodgy, so I thought I'd post up my initial thoughts, in case it's of interest to anyone else in the future.

PS: That FMS paper has been cited 115 times.
 
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Messages
13,774
I suspect that researchers could have lot of input into their results for effort testing, and sympathetic/hostile researchers could probably get the results that they wanted.

That Gervais et al. ended up with more of their control group indicating symptom exaggeration than the disparaged FMS patients going through a disability claim indicated that something was odd.

re effort stuff: it wouldn't really surprise me if a desire to get symptoms taken seriously did lead to those with diagnoses that commonly lead to them being mistreated trying to exaggerate their difficulties, and going through a disability benefit system which classes people as 'fit to work' even when they are not certainly creates a reasonable justification for exaggeration too. At the same time though, I did a few tests which required me to work at something, and I've noticed that I still have a weird natural desire to want to do what the doctor tells me, even when it leaves me feeling knackered.
 
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15,786
re effort stuff: it wouldn't really surprise me if a desire to get symptoms taken seriously did lead to those with diagnoses that commonly lead to them being mistreated trying to exaggerate their difficulties, and going through a disability benefit system which classes people as 'fit to work' even when they are not certainly creates a reasonable justification for exaggeration too.
It could also be a natural effect of trying to communicate something, when they just don't get it. So the patients try to think of alternative ways to explain it until that light switches on.

Unfortunately, it's a rather low-wattage bulb, if it's even screwed in at all :p