Whiplash and Cognitive Complaints
Whiplash treatment is made difficult by the fact that organic lesions are seldom detectable. One area that has seen increased interest in the last few years is the issue of brain injury from whiplash-type accidents. Some studies have reported signs of brain tissue damage with sensitive PET and SPECT scans, while other researchers have found no signs of brain damage using various neuropsychological tests.
Two recent studies have been published discussing the relationship of cognitive complaints and whiplash—specifically regarding attention and memory.
In the first study, researchers performed a neuropsychological test (the PASAT) on a group of 24 whiplash patients and 21 healthy controls. The goal was to determine whether or not whiplash patients showed signs of brainstem damage.
The study found that the whiplash patients did indeed have lower scores on the neuropsychological test—indicating a decrease in attention—but that the results were not due to brainstem injury. The study found, not surprisingly, that whiplash patients encounter psychological problems in their everyday life, including anxiety, fatigue, tension, and depression. The researchers surmised that the patients' distress could:
"...be related to both emotional distress caused by the accident itself and to additional experienced stressing life events, either prior to the accident or during recovery. However, these high scores could also be the consequence of organical lesions, causing physical complaints (e.g. neck pain or headache) that lead to psychological stress."
Brain Injury...or Malingering
In the second study, Schmand et al gave a series of tests to 108 chronic whiplash patients. One of these tests was the Amsterdam short term memory (ASTM) test, a new test developed by the same authors that is used to detect malingering. This test is designed in such a way that it seems like a difficult memory test when it really is not. Previous tests have shown that patients with severe, documented head injury do quite well on it.
The researchers also gave the same series of tests to 20 patients with closed head injury and 46 normal controls. The study found the following:
- 43 of the 108 (40%) whiplash patients scored below the cutoff on the ASTM malingering test.
- 22 of 36 (61%) of litigating whiplash patients were scored as malingering.
- 21 of 72 (29%) of non-litigating whiplash patients were shown as malingering.
These numbers are disturbing to those who work with whiplash patients. 61% of litigating whiplash patients are malingerers? And why would 29% of non-litigating whiplash patients be motivated to fake their injury?
There are a number of factors that complicate the issue. First, the authors are extremely liberal with the use of the word "malingering." According to the Merriam-Webster dictionary, malingering is defined as "to pretend incapacity (as illness) so as to avoid duty or work." In the medical and legal communities, malingering is the intentional faking of injury. This is not how the authors of this study define it, however.
"We stress that the concept of malingering was used in this paper not only to mean deliberate fabrication of bad test results, but also in the sense of a possibly unconscious tendency to perform below the actual level of competency. Such a tendency might be induced by factors such as assumption of patient role, the need to get recognition for complaints in the face of medical skepticism, or perhaps by a strategy of self protection against exhaustion."
So, according to this study's definition of malingering, "unconscious tendencies" are included.
Another serious problem with this study is the way the authors chose the test subjects. "The post-whiplash patients were referred for neuropsychological evaluation because of memory or concentration problems, either as part of a litigation procedure, or as part of the neurological evaluation..." The authors do not make the meaning of this clear. Was this a referral by the plaintiff or the defense? If these tests were IMEs, then there is the potential for bias. Unfortunately, the study does not clear up this issue.
Another interesting finding was that in the whiplash patients who were not labeled as malingerers, there was a significant decrease in the scores on memory and concentration.
"This is a clinically significant finding which cannot be explained as the result of malingering. Its order of magnitude is similar to that of the mild cognitive disorders found in patients with other types of chronic pain, chronic fatigue, and non-psychotic depression. Thus it seems plausible that the reduced cognitive function in non-malingering post whiplash patients is a consequence of a combination of these factors."
The authors, who throughout the study refer to the "malingering" patients, conclude the following:
"We do not conclude that the problems of patients with late post-whiplash complaints are mere products of their imagination. On the contrary, we think that the complaints should be taken seriously...Our findings only indicate that the neuropsychological test results of groups of post-whiplash patients are strongly influenced by a subgroup of patients who perform way below their actual level. Explanations of the poor results of this subgroup in terms of brain damage are not warranted."
This study is an excellent example of why it is important to examine an entire medical study carefully, and not simply read the abstract. Compare this qualified conclusion above to the one in the abstract of the study: "The prevalence of malingering or cognitive underperformance in late post-whiplash patients is substantial, particularly in litigation contexts."
- Kessels RPC, Keyser A, Verhagen WIM, et al. The whiplash syndrome: a psychophysiological and neuropsychological study towards attention. Acta Neurologica Scandinavica 1998;97:188-193.
- Schmand B, Lindeboom J, Schagen S, et al. Cognitive complaints in patients after whiplash injury: the impact of malingering. Journal of Neurology, Neurosurgery and Psychiatry 1998;64:339-343