The malingering patient is motivated by a conscious secondary gain that may be tangible or intangible. It is important to remember that a malingerer may be uninterested in financial rewards and may instead be seeking other forms of reinforcement from employers, coworkers, or family. In contrast, the compensatory patient is interested only in monetary gain. The patient may have been injured at work or may be involved in litigation related to an automobile accident. The possibility of large financial settlements motivates many victims, some with quite minor injuries, to file lawsuits claiming extensive and even ridiculous disabilities. These patients usually give a vague story and try to confuse the examiner by avoiding specific details of their problem or their pain distribution. A bizarre gait, inconsistent with physical findings, is typical (Figure I-59). After bending forward, the patient returns to the erect position in a cogwheel fashion, groaning and complaining of increased pain. These complaints usually indicate that the patient is exaggerating or feigning complaints to impress the examiner. A well-trained examiner should find it relatively easy to identify malingerers and patients with compensatory low back pain. However, it is not advisable to inform the patient of this diagnosis. This can lead to legal action against the physician for defamation of character. The best course is simply to state, "no organic basis can be found for the patient's symptoms."
Therefore when pain is being felt, it can be differentiated between its localization, the feeling of being hurt and the experience of displeasure. And because pain has a strong emotional component, painful sensations are always an individual experience that should be treated individually. The following features significantly affect pain sensations:
1. The current environmental situation when pain is being experienced,
2. the individual genetic make-up
3. the underlying education,
4. the sociocultural environment,
5. the religious environment,
6. the ethnic origin,
7. the level of civilization.
The pain threshold on the other hand can be raised or lowered by the following attributes:
8. fear and/or grief,
12. brooding, and
On the other hand, the following elements increase pain threshold, resulting in a lesser feeling of pain:
6. career, especially when
8. antidepressants, and/or
Because pain can always be influenced by a number of different features, it can be considered as an extremely subjective experience. Pain gets its individual color in the limbic system, an old phylogenetical system, characterized by a dense accumulation of opioid receptor sites . It is a system, with which the cortex intensively communicates. At the same time, it is a system where all incoming afferent impulses are being assessed and evaluated, receiving an individual attribute.
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