Assessing Secondary Gain In Chronic Pain Patients
Readers may be familiar with the concept of secondary gain, which has received increasing attention as a perpetuating factor in illness and pain disability.1-4 health practitioners working with chronic pain patients are often confronted with individuals whose presentation of physical symptoms appear to be exaggerated in light of identified organic pathology, who exhibit abnormal or non-organic illness behaviors, who are persistently noncompliant, and/or who fail to make expected progress in treatment. Such individuals often prove frustrating, as health care providers typically seek to identify problems, develop treatment plans, and prescribe treatments that result in improved health. When organic pathology/symptom presentation discrepancies are identified, or expected treatment progress is not forthcoming, many health care practitioners invoke the concept of secondary gain as an explanation. Secondary gain may be a significant perpetuating factor in illness and disability. Unfortunately, it is often poorly understood and/or confused with malingering.
Freud first proposed the concept of secondary gain, which he described as both the intrapsychic and external advantages attained by the patient as a consequence of illness. He conceptualized it as a preconscious (i.e., just beneath awareness and able to be brought to awareness) holding on to the illness because of supposed or real advantage.5 In more recent years, secondary gain has taken on a life of its own outside the traditional psychoanalytic arena.1,4,5 As early as 1976, Finneson6 observed that the term secondary gain has developed increasing use and has generally referred to the financial rewards associated with disability. In turn, the presence of potential financial rewards is often equated with conscious malingering.1,4,7 The suspicion that arises in the clinician may interfere with treatment and development of empathy. As a result, secondary gain issues are then often used as an excuse for treatment failures.
Secondary Gain and Loss: Current Theoretical and Research Perspectives
Sophisticated observers are aware that secondary gain rarely equals malingering or factitious disorder.1,4,8 Furthermore, such observers understand that relatively few patients with medico-legal issues (including chronic pain patients) are malingerers or suffer from factitious disorder.9,10 Within this context, several groups of investigators have attempted to clarify the concept of secondary gain and associated concepts.1,2,4,7,8 However, this information does not appear to be widely disseminated among clinicians (or in forensic settings). This unfortunate set of circumstances may, in part, be due to unresolved theoretical issues. Whatever the reason, it is essential that the clinician consider secondary gain whenever symptom magnification, the chronic pain syndrome, abnormal illness behaviors, or deception are observed.
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