May 1, 2005 A new review of studies suggests that long-lasting symptoms of concussion -- subjective at best -- may increase when the outcome of a lawsuit is at stake.
The condition known as "postconcussional syndrome" is difficult to define medically but is generally defined as a string of cognitive, physical or behavioral losses that occur after a head injury.
Forensic psychiatrist Dr. Richard C.W. Hall of the University of Florida says a proliferation of lawsuits driven by claims of postconcussional syndrome means more physicians are being asked to make high-stakes diagnoses -- often for patients who are tangled financially and psychologically in litigation.
In the new review -- which appears in the May-June edition of the journal Psychosomatics -- Hall and coauthors try to strip litigation out of the picture to uncover a clearer idea of the recovery times and pathology of postconcussional syndrome.
The vast majority of postconcussional syndrome symptoms -- like headache, dizziness and memory loss -- are subjective, which makes it hard for doctors to distinguish feigned or dramatized complaints from legitimate injuries.
So, Hall says, "it becomes very important to understand the nature of those symptoms that are likely to be real and who is likely to be producing fictitious symptoms."
The review finds that well-motivated, younger patients, who experience no loss of consciousness, are less likely to suffer from postconcussional syndrome. By contrast, some predictors of persistent postconcussional syndrome include female gender, pre-existing psychiatric illness -- and being involved in a lawsuit.
Hall and colleagues examined 71 studies. "Many of the researchers found that the extent and duration of injuries in the United States, where compensation is obtainable, are greater than in countries -- where financial compensation is less likely to occur," they write.
The majority of postconcussional syndrome patients recover completely within three to six months, the review showed. After one year, just 7 percent to 15 percent of all people diagnosed with the condition are still experiencing symptoms.
Hall says the review provides an "overall pattern of the condition" that physicians can use as a guide when a patient has "persistent, prolonged or dramatic complaints."
Hall, who often serves as an expert witness, says postconcussional syndrome has become the cornerstone of litigation.
"It's a tool for lawyers basically," he says. "Patients think they will get a pot of gold at the end of rainbow," which can lead to "malingering for money" or overt lying.
In one study, the researchers reviewed 33,531 court cases and determined that 30 percent of disability cases and 29 percent of injury cases involved probable malingering and or extensive symptom exaggeration.
Carlton Carl, spokesperson for the Association of Trial Lawyers of America, disputes the conclusion. "Only the most serious injuries caused by the negligence of others tend to be litigated, and there are -- and should be -- serious consequences to those bringing false or inflated legal claims," he says.
"The review's less than one-page mention of long-lasting symptoms of concussion and their relation to legal claims is misleading at best. It compares the extent and duration of symptoms in the United States to those in Lithuania. No offense to Lithuania, but is the quality of medical diagnosis and care in Lithuania comparable to that in America? How many MRI machines does Lithuania have? How sophisticated are its diagnostic techniques and hardware?"
Beyond the ethical issue of feigning postconcussional syndrome, Hall says there are serious health risks.
Standard treatment can include narcotics, sometimes with spinal injections, which come with risks to the central nervous system, Hall says.
"What starts out as a litigation case can end up being a serious medical case," Hall adds.
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