SECONDARY GAIN
Secondary gain is usually present following personal injury, if no more than the attention, concern and indulgence of family, friends and caregivers, and the freedom from responsibilities. A recent meta-analysis[1] of the medical research literature concluded it can be viewed as a major determinant of illness behaviour.
Problems arise when the secondary gains become so desirable that they interfere with timely recovery from disability. Rogers distinguishes[2] Malingering and Defensiveness. His third category - "irrelevant and random responding" (Ganser Syndrome) - is seen in criminal cases, but rarely in civil litigation.
It is axiomatic that identification of Malingering [see Medical Litigation News Volume 1, Issue 5] is the court's prerogative. Nevertheless, psychiatrists and psychologists are well-placed to marshall the evidence according to generally accepted criteria[3].
Secondary gain is of medicolegal significance when there is conscious distortion of symptoms. It is self-evident that medical conclusions about causation are frequently based on the plaintiff's description of pre-accident functioning without the reality-check of previous medical records.
PRACTICE POINT
Objective assessment of the level of pre-accident functioning often requires laborious and meticulous analysis of previous medical records.
Such defensive misrepresentation may be conscious or unconscious - or more precisely on a malingering-hysteria-psychosis[4] continuum between the two. Unfortunately for medicolegal purposes, the unconscious is a metaphysical concept which is not susceptible to scientific or legal evaluation.
PRACTICE POINT
Psychologists and psychiatrists, rather than orthopedic surgeons and physiatrists, are the appropriate specialists to debate consciousness of secondary gain for legal purposes
A personal injury claimant with a conscious desire for compensation for physical trauma will commonly develop an unexplained functional disability which satisfactory legal resolution does not cure. Different schools of psychology will couch in different terminologies the unconscious, presumed-underlying motivations and feelings - dependency or masochistic needs, anger, avoidance of continuing interpersonal/marital difficulties and the like[5].
Copyright © 2008 Electronic Handbook of Legal Medicine