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Compensation Neurosis: a Too Quickly Forgotten Concept?

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Compensation Neurosis: a Too Quickly Forgotten Concept? ANALYSIS AND COMMENTARY Compensation Neurosis: A Too Quickly Forgotten Concept? Ryan C. W. Hall, MD, and Richard C. W. Hall, MD There has been great debate concerning the existence and meaning of compensation neurosis. It is included in the International Classification of Diseases (ICD)-9 and -10 but not listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). On the eve of publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), we re-examine the history and concept of compensation neurosis and conceptually update the condition to reflect current psychiatric thought. We consider its utility as a diagnostic entity for forensic evaluations and its components as they relate to exaggeration in injury claims. We also discuss how compensation neurosis differs from malingering and factitious disorder. J Am Acad Psychiatry Law 40:390–8, 2012 The use of the term compensation neurosis was more which are based more on operationally or function- prevalent in the late 1800s to the mid-1900s than it is ally defined symptom criteria than on the interpreta- today, on the verge of the release of the Diagnostic tion of the patient’s underlying conscious or uncon- and Statistical Manual of Mental Disorders, Fifth scious mental motivations.13,14 Other criticisms are Edition (DSM-5).1–3 Highly revered historical med- that the diagnosis does not have a predictive value, ical figures such as Charcot have commented on as- since many people who receive the diagnosis do not pects of the condition, claiming it was caused by seem to improve or return to work after completion “hysteria and neurasthenia”4–6 (Table 1). The more of litigation.14 These criticisms highlight the prob- modern definition of the condition is seen in the lems encountered when researching this condition, 1946 quote from Foster Kennedy that “[C]ompen- which include identifying the proper population for sation neurosis is a state of mind, born out of fear, study; defining markers of improvement; evaluating kept alive by avarice, stimulated by lawyers, and for and controlling the vast number of confounding cured by a verdict” (Ref. 7, p 19). The concept was variables involved, such as the specific injury that further defined in 1961 when Henry Miller, a neu- occurred and the specific symptoms that developed; rologist, proposed a set of diagnostic criteria for ac- and subpopulations reporting different exacerbating cident neurosis that were initially accepted but were factors.6,13,15 As noted by the anxiety researcher later challenged by the medical community1,2,8–12 Mayou, “Few studies have been specifically designed (Table 2). to answer questions about the role of compensation, The Miller criteria are frequently criticized as be- but there is consistent evidence that the processes of ing unworkable by today’s diagnostic standards, compensation and insurance benefits should be seen as among the many social influences on course and Dr. Ryan Hall is Assistant Professor, Department of Medical Educa- outcome” (Ref. 13, p 400). tion, University of Central Florida College of Medicine, Orlando FL; Affiliate Assistant Professor, Department of Psychiatry, University of The popularity of the diagnosis was also affected South Florida, Tampa FL; and Adjunct Faculty Member, Dwayne O. by new disease categories and diagnoses that have Andreas School of Law, Barry University, Orlando, FL. Dr. Richard Hall is Professor, University of Central Florida College of Medicine been introduced in the Diagnostic and Statistical Department of Medical Education, Orlando FL, and Affiliate Profes- Manual of Mental Disorders, Third Edition (DSM- sor, Department of Psychiatry, University of South Florida, Tampa 16 17 FL. Parts of the current paper were discussed in presentations at Tulane III) and Fourth Edition (DSM-IV). Individuals University, New Orleans, LA, April 17, 2011, and at a meeting of the who might have received a diagnosis of compensa- Florida Psychiatric Society, Orlando, FL, April 14, 2012. Address correspondence to: Ryan C. W. Hall, MD, 2500 West Lake Mary tion neurosis in the past, in some cases now are erro- Boulevard, Suite 219, Lake Mary, FL 32746. [email protected]. neously subsumed into the categories of posttrau- Disclosures of financial or other potential conflicts of interest: None. matic stress disorder (PTSD), postconcussive 390 The Journal of the American Academy of Psychiatry and the Law Hall and Hall Table 1 Various Names for the Concept of Compensation Neurosis remains unclear whether ‘compensation neurosis’ That Have Been Used Over Time means a genuine psychiatric disorder or whether it Accident neurosis merely stands for a person who claims unjustified Aftermath neurosis demands after having suffered a traumatic situation” Cogniform disorder Compensation hysteria (Ref 19, p 219). Compensation neurosis Entitlement neurosis What Is Compensation Neurosis? (Ethnic or national group) neurosis/injury Fright neurosis We propose that compensation neurosis is an ex- Greenback neurosis aggeration of symptoms that occur as a result of the Injury neurosis unique stressor of seeking legally awarded compen- Justice neurosis sation. It is brought about primarily by internal mo- Litigation neurosis tivators coupled with a lesser degree of anticipation Postaccident syndrome of secondary gain. Financial reward can clearly be a Posttraumatic syndrome Profit neurosis component in the condition and may influence the Railway spine course, but the overall constellation of symptoms is Secondary gain neurosis due to more than just the pursuit of money. Social iatrogenesis for disease production by well-intended social Compensation neurosis is born out of many fac- programs tors, such as unwarranted suggestions of illness and Syndrome of disproportionate disability Traumatic hysteria long-term injury (e.g., by lawyers, friends, family, Traumatic neurasthenia and experts); the prolonged time and resultant stress Traumatic neurosis incurred when seeking to have the claim heard; ten- Triggered neurosis dencies for stress to exacerbate somatization and un- Unconscious malingering derlying personality dynamics (dependent, avoidant, Various work groups (usually manual labor) neurosis Whiplash neurosis borderline, histrionic, and narcissistic disorders); ra- Workman’s compensation neurosis tionalization; a need for justice, retaliation, or vindi- cation; advantages of embracing the role of victim; or a sense of entitlement.1,4,6,9–12,15 Just as many psychiatric conditions can have var- syndrome, adjustment disorders, pain disorder, and ious prognoses and rates of remission, so can com- somatoform disorder. For example, Blanchard et al., pensation neurosis. Very rigid interpretation of the looking for prognostic markers to identify individu- definition of compensation neurosis leads to the als who would later receive a diagnosis of PTSD after straw-man argument that the condition has no prog- a car accident, found the single greatest prognostic nostic value because not everyone who receives the indicator to be whether a lawyer was contacted. As diagnosis improves after settlement.14 It is unlikely they noted, “[I]t is possible that those who have de- that just because a claim has been settled, all of the cided to seek litigation are subsequently inclined to previously mentioned factors that influenced the de- portray themselves as more symptomatic. .and thus velopment of the compensation neurosis would re- more likely to meet the criteria for PTSD” (Ref. 18, solve (Table 3). As noted by Woodyard in his study p 8). of compensation neurosis: Thus, the field of psychiatry, particularly the field of forensic psychiatry, is left with the question of Table 2 Accident Neurosis (1961)10,11 whether one of the historical explanations for the Occurs in a situation in which someone else is at fault or is exaggeration of symptoms should be totally forgot- perceived to be at fault. ten or should be maintained in some form as a valid Occurs in a situation in which an award of damages is possible. diagnostic and real-world concept, even if unrecog- Has an inverse relationship with degree of injury if any physical injury at all. The more severe the injury, the less likelihood of nized in the DSM-5. Should this diagnosis be refor- accident neurosis. mulated and incorporated into a new diagnostic term Is more likely to occur in those with lower socioeconomic status. that does not contain the ambiguity and stigma that Is characterized by failure to improve until after compensation plague the term compensation neurosis? As noted by litigation is settled, with ensuing improvement from significant to Winckler, “Despite long-standing discussions, it still complete. Volume 40, Number 3, 2012 391 Compensation Neurosis It is, therefore, unfortunately not possible to estimate the with financial reward. Although there can be finan- total effect of settlement (since there are few unsettled con- trols), but clearly it does not guarantee loss of symptoms cial secondary gain as part of a compensation neuro- and return to work. However, review of general practitio- sis, the distinction is that the exaggeration occurs ner’s records very often shows heavy [office] attendance entirely, or at least primarily, for the external incen- that drops sharply soon after a final medicolegal report is given, presumably at the time of settlement, supporting the tives in malingering and as a combination of external traditional belief that symptoms will improve once the
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