AMA Guides® Newsletter - Issue Archive

Articles

1. Somatization

   Leon H Ensalada, Christopher R. Brigham

   Pages 1–3, 10

   DOI: 10.1001/amaguidesnewsletters.2000.JulAug01

   Abstract

   The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fourth Edition, notes that individuals may consciously exaggerate the symptoms of a disorder in the clinical or impairment evaluation setting, an activity that is associated with the process of somatization. This article reviews the phenomena of somatization, its magnitude, factors that contribute, and somatizing disorders themselves. Somatization is characterized by the propensity to experience and report somatic symptoms that have no pathophysiologic explanation, to misattribute them to disease, and to seek medical attention for them. Reported symptoms could result from organic disease—which is precisely the point because somatizing patients choose symptoms, consciously or not, that will be taken as evidence of real, physical disease. The prevalence of somatization reportedly ranges from 5% to 60% and varies with the medical specialty and the clinical setting. Studies have reported that in 25% to 50% of all primary care encounters, physicians found no significant objective cause to explain the presenting symptoms. The somatization process contributes to somatoform disorders, which are mental disorders and are not intentionally produced or feigned. A table compares three types of somatizing disorders: somatoform disorders, factitious disorders, and malingering. The presence of somatization distorts symptom presentation and can confound assessment methodologies, but the AMA Guides instructs that impairment is rated on the basis of objective findings, not solely on subjective complaints.
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2. Tools and Resources: Nonorganic Findings

   Christopher R. Brigham, Leon H. Ensalada

   Pages 4–8

   DOI: 10.1001/amaguidesnewsletters.2000.JulAug02

   Abstract

   Experienced medical examiners perform detailed physical examinations that document negative, positive, and nonorganic findings. The latter are observations or subjective reports that cannot be readily explained on an anatomical basis. Nonorganic findings have been described since the early part of the 20th century, and nonorganic physical signs in low back pain were defined in 1979. Cervical nonorganic signs also have been developed, standardized, and proven reliable. Nonorganic symptoms and signs may indicate symptom magnification behavior or malingering, particularly if multiple findings are noted and are closely correlated with psychological distress and abnormal illness behavior. The presence of these findings does not necessarily preclude organic pathology. Table 1 extensively lists some of the tests commonly used by independent medical examiners to determine whether findings are nonorganic. Columns in the table list the area for which the test is used (eg, back pain, muscle spasm, or muscle weakness), the name of the test or maneuver (eg, log rolling, pinch test, or others), and a description with notes and recommendations.
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3. Clinical Update: Causality in Workers'Compensation

   Kathryn Mueller, Charles N Brooks

   Pages 8–10, 12

   DOI: 10.1001/amaguidesnewsletters.2000.JulAug03

   Abstract

   Because of their education and training, treating physicians often address causality only in terms of differential diagnosis (ie, what is causing the individual's symptoms and signs). Etiology also can be considered from a prophylactic or therapeutic standpoint (ie, how to prevent recurrent injury or eliminate the cause of an illness). In workers’ compensation, causation analysis extends beyond diagnosis, prophylaxis, and treatment and must consider whether the condition is attributable to the workplace. The terms cause, effect, exacerbation, and aggravation have specific meanings in the AMA Guides to the Evaluation of Permanent Impairment and are defined, with discussion. Three criteria must be met before causation is established in workers’ compensation: the cause is medically probable; the effect is medically probable; and the cause and effect probably are etiologically related (ie, the occupational trauma likely caused the injury, or the exposure caused the illness). A table presents the steps in a causation analysis in workers’ compensation: 1) define the injury, activity, or exposure (cause); 2) establish the diagnosis; 3) determine generic causation; specifically, determine if the reported mechanism, activity, or exposure ever causes the patient injury or disease; 4) determine specific causation in this instance and determine if another (more probably) nonoccupational cause was involved.
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