Transcript Symptom Magnification Syndrome (SMS)

Symptom Magnification
Syndrome
PHED 3806
Functional Assessment
Symptom Magnification Syndrome
(SMS)
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History
Identification of SMS
Types
Treatment
HISTORY (brief)
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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.
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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
IDENTIFICATION
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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.
IDENTIFICATION
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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 . .
."
IDENTIFICATION
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It is a self-destructive pattern of
behaviour learned and maintained
through social reinforcement.
IDENTIFICATION
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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!)
IDENTIFICATION
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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.
IDENTIFICATION
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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.
IDENTIFICATION
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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.
IDENTIFICATION
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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.
TYPES
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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.
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The Refugee
The Gameplayer
The Identified Patient
TYPES
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The Refugee
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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.
TYPES
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The Refugee
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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.
TYPES
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The Refugee
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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.”
TYPES
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The Gameplaver
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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!)
TYPES
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The Gameplaver
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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”
TYPES
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The Identified Patient
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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.
TYPES
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The Identified Patient
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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.
TREATMENT
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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”
TREATMENT
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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.
TREATMENT
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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.
TREATMENT
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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.
TREATMENT
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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.
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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.
TREATMENT
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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.
Red Flags
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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
Red Flags II
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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
Red Flags III
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I’ve 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)
Red Flags IV
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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
Red Flags V
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I keep my feelings inside - i don’t 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
Red Flags VI
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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