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Introduction We aimed to investigate the incidence and severity of orthodontically induced inflammatory root resorption (OIIRR) on maxillary incisors with clear aligner therapy using cone-beam computed tomography and to identify possible risk factors. Methods The root lengths of maxillary incisors were measured on orthogonal images from pretreatment and posttreatment cone-beam computed tomography examinations of 160 patients who received comprehensive orthodontic treatment with clear aligners. Results Mean absolute reductions in root length varied between 0.47 ± 0.61 mm and 0.55 ± 0.70 mm and were not significantly different between maxillary central and lateral incisors. The prevalence of severe OIIRR, defined as both maxillary central incisors experiencing greater than a 25% reduction in root length, was found to be 1.25%. Potential risk factors included sex, malocclusion, crowding, and posttreatment approximation of apices to the cortical plates. Race, interproximal reduction, previous trauma to the teeth, elastics, age, treatment duration, and pretreatment approximation of apices to the cortical plates did not significantly affect the amount of OIIRR. Conclusions Comprehensive treatment with clear aligners resulted in minimal root resorption. Sex, malocclusion, crowding, and posttreatment approximation to the cortical plates significantly affected the percentage of change in root length. Posttreatment approximation of root apices to the palatal cortical plate showed the strongest association for increased OIIRR.

Nondermatomal somatosensory deficits (NDSDs) are large sensory deficits not conforming to dermatomal/root territories, and no structural pathology accounts for them. They can be very mild or very dense, highly variable, or extremely fixed over time and may be very disabling. It is now accepted by mainstream pain science that they are the product of a central neurophysiological phenomenon. We demonstrated in this paper through literature review and through multiple clinical cases that NDSDs (a) have a psychobiological substrate at the level of the central nervous system, (b) are very frequently associated with chronic pain and/or psychotraumatic experiences, (c) occur very frequently in the context of conversion disorder, but (d) can also occur in the absence of conversion disorders, (e) can be superimposed on structural neurological deficits, and (f) respond positively, or at least in part, to sodium amobarbital (commonly referred to as the “truth serum”).

These studies examined the effect of rapid surface cooling on the numbers of Campylobacter on chicken carcasses. In two trials, chicken skins were immersed in liquid nitrogen. Campylobacter numbers were reduced by 1 log10 cfu/g by immersion for 20s. Immersion would not be practical for whole carcasses in commercial slaughterhouses. Twenty two trials investigated the effects of spraying liquid nitrogen towards whole carcasses either in a chamber or in a tunnel. The final four trials, with carcasses passing through a spray tunnel for 40s, caused average reductions in the numbers of Campylobacter of between 0.9 and 1.5 log10 cfu/g when tested the day after treatment and between 0.9 and 1.3 log10 cfu/g when tested a further six days later. The temperature of the flesh remained above −2 °C thereby showing that the flesh was not frozen by the process which offers a viable approach to reducing Campylobacter on chicken carcasses.

Background The Opioid Risk Tool (ORT) is a screening instrument for assessing the risk of opioid-related aberrant behavior in chronic noncancer pain (CNCP) patients. Objective This study aims to compare patient characteristics documented in the original ORT study with those identified in CNCP patients assessed using a physician-administered ORT in a tertiary care pain clinic in Toronto, Canada. Methodology This was a descriptive cross-sectional study of 322 consecutive new patients referred over 12 months. Data extraction included ORT scores, demographics, pain ratings, opioid, and other medication use at point of entry, diagnosis, and other variables. Characteristics were compared with those described in the original ORT study. Results The total mean ORT scores of patients in this study were related to several demographic (gender, age, marital status, and country of birth) and nondemographic variables (employment status, cigarette smoking, and contribution of biomedical and/or psychological factors to presentation). Prevalence of characteristics noted in this patient sample differed substantially from that found in Webster and Webster as the basis for ORT scores. Conclusion Significant differences existed between this study population and the patient sample from which the ORT was derived. Limitations of this study are discussed. We concur with the authors of the original study that the ORT may not be applicable in different pain populations and settings. Based on our findings, we encourage caution in interpreting the ORT in general CNCP settings until further studies are performed.

Purpose of review To review the literature and our current understanding of nondermatomal somatosensory deficits (NDSDs) associated with chronic pain in regards to their prevalence, assessment and clinical presentation, cause and pathophysiology, relationship with conversion disorder and psychological factors, as well as their treatment and prognosis. Recent findings NDSDs are negative sensory deficits consisting of partial or total loss of sensation to pinprick, light touch or other cutaneous modalities. Although they had been noted more than a century ago and appear prevalent in chronic pain populations, they are poorly studied. They may be very mild or very dense, may occupy large body areas, are often highly dynamic and changeable or, to the contrary, very stable and long lasting. NDSDs may occur in the absence of biomedical pathology or coexist with structural musculoskeletal or nervous system abnormalities. They appear to be associated with psychological factors and a poor prognosis for response to treatment and return to work. Recent brain imaging studies provide a basis for understanding NDSD pathophysiology. Summary NDSDs represent prevalent phenomena associated with chronic pain. Further, research is needed to elucidate their origin, response to treatment, and prevalence in the general population, primary care settings, and nonpain patients.

BACKGROUND: The present study is the result of an internal audit and examines the profiles of complainants and the sources and nature of complaints toward the staff in a tertiary care pain clinic, the Comprehensive Pain Program of the Toronto Western Hospital in Toronto, Ontario.METHODS: All sources of complaints over a nine-year period were reviewed, which included the following: Toronto Western Hospital Patient Relations (PR) records, with a subset of the files qualitatively analyzed in depth regarding the nature of complaints and complainants; complaints that bypassed PR and were addressed directly to the program director against members of the staff; complaints to the College of Physicians and Surgeons of Ontario; and complaints recorded anonymously at rateMDs.com.RESULTS: Although the prevalence of PR complaints was very low (1.73 complaints per 1000 visits), several other sources of complaints were identified. The typical complainant was a Canadian-born woman acting on her behalf or on behalf of a family member. More than one-half of the complaints were directed against the physicians regarding their opinion of psychological factors augmenting the patient’s presentation and/or inappropriate use of opioids. Defensive techniques instituted by the Comprehensive Pain Program staff in reaction to the complaints are discussed, and pertinent literature is reviewed.CONCLUSION: The present study is the first to examine the nature of complaints and complainants from a Canadian pain clinic. Further studies are needed to explore the complex issues of patient and staff interactions, and complaints in the era of ‘patient-centred care’.

Let M be a left module over a ring R and I an ideal of R. We call ( P , f ) a projective I-cover of M if f is an epimorphism from P to M, P is projective, Ker f ⊆ I P , and whenever P = Ker f + X , then there exists a summand Y of P in Kerf such that P = Y + X . This definition generalizes projective covers and projective δ-covers. Similar to semiregular and semiperfect rings, we characterize I-semiregular and I-semiperfect rings which are defined by Yousif and Zhou using projective I-covers. In particular, we consider certain ideals such as Z ( R R ) , Soc ( R R ) , δ ( R R ) and Z 2 ( R R ) .

Persistent cognitive, emotional and behavioral dysfunction following brain injury present formidable challenges in the area of neurorehabilitation. This paper reviews a model and practical methodology for community based neurorehabilitation based upon: 1. Evidence from the "automatic learning" and "errorless learning" literature for skills relearning after brain injury; 2. A widely applicable task analytic approach to designing relevant skills retraining protocols; 3. Analysis of organic, reactive, developmental, and characterological obstacles to strategy utilization and relearning, and generation of effective therapeutic interventions; and 4. Procedures for (a) promoting rehabilitative strategy use adapted to acute and chronic neurologic losses, (b) an individual's inherent reinforcement preferences and coping style, (c) reliant on naturalistic reinforcers which highlight relationships to functional goals, utilize social networks, and (d) employ a simple and appealing cognitive attitudinal system and set of procedures. This Holistic Habit Retraining Model and methodology integrates core psychotherapeutic and learning principles as rehabilitation process ingredients necessary for optimal facilitation of skills retraining. It presents a model that generates practical, utilitarian strategies for retraining adaptive cognitive, emotional, behavioral and social skills, as well as strategies for overcoming common obstacles to utilizing methods that promote effective skills acquisition.

BACKGROUND: Pain clinics tend to see more complex chronic pain patients than primary care settings, but the types of patients seen may differ among practices.OBJECTIVE: The aim of the present observational study was to describe the pain and demographic characteristics of patients attending a university-affiliated tertiary care pain clinic in Toronto, Ontario.METHODS: Data were collected on 1242 consecutive new patients seen over a three-year period at the Comprehensive Pain Program in central Toronto.RESULTS: Musculoskeletal problems affecting large joints and the spine were the predominant cause of pain (more prevalent in women), followed by neuropathic disorders (more prevalent in men) in patients with recognizable physical pathology. The most affected age group was in the 35- to 49-year age range, with a mean pain duration of 7.8 years before the consultation. While 77% of the Comprehensive Pain Program patients had relevant and detectable physical pathology for pain complaints, three-quarters of the overall study population also had significant associated psychological or psychiatric comorbidity. Women, in general, attended the pain clinic in greater numbers and had less apparent physical pathology than men. Finally, less than one in five patients was employed at the time of referral.CONCLUSIONS: The relevance of the data in relation to other pain clinics is discussed, as well as waiting lists and other barriers faced by chronic pain patients, pain practitioners and pain facilities in Ontario and Canada.

The rings in the title are studied and related to right principally injective rings. Many properties of these rings (called left pseudo-morphic by Yang) are derived, and conditions are given that an endomorphism ring is left pseudo-morphic. Some particular results: (1) Commutative pseudo-morphic rings are morphic; (2) Semiprime left pseudo-morphic rings are semisimple; and (3) A left and right pseudo-morphic ring satisfying (equivalent) mild finiteness conditions is a morphic, quasi-Frobenius ring in which every onesided ideal is principal. Call a left ideal L a left principal annihilator if L = l(a) = {r ∈ R | ra = 0} for some a ∈ R. It is shown that if R is left pseudo-morphic, left mininjective ring with the ACC on left principal annihilators then R is a quasi-Frobenius ring in which every right ideal is principal and every left ideal is a left principal annihilator.

Pain is a common yet challenging problem, particularly following traumatic injuries to the head or neck. It is a complex, multidimensional subjective experience with no clear or objective measures; yet it can have a significantly disabling effect across a wide range of functions. Persisting misconceptions owing to mind-body dualism have hampered advances in its understanding and treatment. In this article, a conceptualization of pain informed by recent research and derived from a more useful biopsychosocial model guides discussion of relevant medical, psychological, and neuropsychological considerations. This pain process model explains chronicity in terms of hyperresponsiveness and dysregulation of inhibitory or excitatory pain modulation mechanisms. Related neurocognitive effects of chronic pain are examined and recommendations for minimizing its confounding effects in neuropsychological evaluations are offered. A biopsychosocial assessment model is presented to guide understanding of the myriad of factors that contribute to chronicity. A brief survey of general classes and samples of the more useful pain assessment instruments is included. Finally, this model offers a rational means of organizing and planning individually tailored pain interventions, and some of the most useful pharmacologic, physical, and behavioral strategies are reviewed.

The development of abnormal posturing of the neck or shoulder after local injury has been termed posttraumatic cervical dystonia (PTCD). Certain features seem to distinguish a unique subgroup of patients with this disorder from those with features more akin to typical idiopathic cervical dystonia, such as onset and maximum disability that occurs very quickly after injury, severe pain and a fixed abnormal posture. In an attempt to clarify the nature of this syndrome further, we evaluated 16 such patients (8 men, 8 women). Motor vehicle accident and work-related injuries were common precipitants, with posturing usually developing shortly after trauma, and little progression occurring after the first week. A characteristic, painful, fixed head tilt and shoulder elevation were present in all but one patient, who had a painless elevated shoulder and painful contralateral shoulder depression, as well as nondermatomal sensory loss in 14 patients. Additional abnormalities included dystonic posturing in a limb (2 patients) or jaw (1 patient), limb tremor (3 patients) and "give-way" limb weakness (8 patients). The tremor and the jaw dystonia demonstrated features suggestive of a psychogenic movement disorder, most commonly distractibility. Litigation or compensation was present in all 16 patients. Intravenous sodium amytal improved the posture, pain or both in 13 of 13 patients; in 7 of 13 the sensory deficit either markedly improved or normalized. General anesthesia demonstrated full range of motion in all 5 patients assessed. Psychological evaluations suggested that psychological conflict, stress, or both were being expressed via somatic channels in 11 of 12 tested patients. Our results suggest an important role of psychological factors in the etiology or maintenance of abnormal posture, pain and associated disability of these patients. The role of central factors triggered in psychologically vulnerable individuals after physical trauma is discussed. We propose that the disorder be referred to as "posttraumatic painful torticollis" rather than characterize it as a form of dystonia until further information on its pathogenesis is forthcoming.

There is increasing evidence that pain and related problems (e.g., affective distress, sleep disturbance, medication use) can interfere with cognitive performance and confound the interpretation of neuropsychological test results. This may be of particular concern in cases of the persistent post-concussive syndrome where headache is the primary problem. Such effects can be pronounced, obscuring the effects associated with mild or even much more significant brain injury. However, it remains unclear what specific chronic or acute pain experiences, in what individuals, with or without which associated problems, will actually result in particular performance deficits. Whereas pain may disrupt brain function, this is likely to be temporary and not indicative of permanent impairment of neuropsychological function. Further study of this important topic is warranted.

Medical College of Virginia, Richmond, VA, USA'University of Toronto, CanadaThe expanding Internet has become an increasingly valu-able tool for world wide sharing of information. Healthcare professionals, patients, lay persons, family membersand others are afforded instant access to masses of informa-tion and almost unlimited resources on virtually any topic,as well as an almost seamless vehicle for communication.This new medium offers tremendous implications for healthcare. However, the absence of a single clearinghouse, a sin-gle search procedure or guarantee of accuracy often make in-formation access efforts challenging, confusing and frustrat-ing. The present paper provides a brief introduction aimedat increasing appreciation of the Internet and enhancing itsutility with regard to chronic pain and its management andoffers rudimentary guidelines for efficient accessing of infor-mation. Finally, it presents the results of a comprehensivesearch including nearly 200 useful Internet web links for pro-fessionals, patients, family members and other interested per-sons who assess, treat or cope with chronic pain. Identifiedresources include numerous organizations, medical, psycho-logical assessment and practical treatment strategies, assess-ment and treatment reviews, support groups, list serve groupsfor patients and professionals, advocacy resources, news andassistive technology resources. Special emphasis is givento useful resources to assist professionals treating personswith chronic pain, as well as resources that can assist personschallenged by chronic pain.Keywords: Chronic pain, Internet, chronic pain management,world wide web

There has been considerable controversy concerning the problem of the persisting post-concussive syndrome and whether cognitive or other sequelae might be attributed to the effects of brain injury or other causes. Headache is the predominant problem in virtually all surveys of the post-concussive syndrome. It is suggested that pain and related problems may account for most of the difficulties in those presenting with the persisting post-concussive syndrome or other cases in which mild to moderate brain injury is suspected. A survey of the literature concerning the relationship of pain, cognition and traumatic brain injury indicates that cognitive difficulties are common in acute or chronic pain, with or without any indication of brain injury. However, numerous methodological problems are apparent and there is clearly need for further study. Consideration is given both to psychosocial and neurobiological effects underlying any such relationships.

Methylation experiments of the metals Sn, Pb and Hg were carried out using representative terrestrial and marine sediment samples from the Axios river and Thermaikos Gulf in northern Greece. GC-FID, GC-TCD and GC-MS were used. The experiments were carried out on sterilised and bioactive samples by adding pure metals and metal salts (chloride, nitrate, oxalate, acetic, penicillaminic, methioninic and cysteinic). Except for sterilised HgCl2, methylated derivatives of Sn, Pb and Hg were produced only from bioactive sediments, and therefore higher yields were measured when nutrients were added to the sediments. Volatile products (CH4 ,C O 2 ,H 2S) of biological activity range between 35 and 250 mg l ˇ1 . The correlation of methylation yield with organic sediment index (OSI), determined as the wt% product of [organic carbon] [organic nitrogen], is positive for all the metals and metal salts added in the sediments. Methylation yields for Hg are found to be four orders of magnitude higher than those of Pb and Sn. In low OSI (terrestrial) sediments, the rate of Hg-methylation is higher than those of Pb and Sn. In high OSI (marine) sediments, where methylation of most of the contained Hg has taken place, methylation of Pb is slightly faster than Sn.

The fluoroborate electrode shows a linear Nernstian response down to 0.35 mg/L of boron (B) and can be reproducibly calibrated to 0.001 mg/L B. Reproducibility at 0.1 and 1.0 mg/L of B is better than 0.5%. Electrode sensitivity declines significantly below 0.035 mg/L B, and this is the practical detection limit. Minimum equilibrium times increase with decreasing concentration, from 1 min at 5.0 mg/L to 10 min at

Introduction: The effect of opioids on driving performance has been much debated. Driving is a complex task requiring integration of psychomotor, cognitive, motor and decision-making skills, visualspatial abilities, divided attention, and behavioral and emotional control. The objective of this systematic review was to assess the quality of studies and to revisit the concept that patients on stable opioids are safe to drive as it applies to everyday practice. Methods: We searched MEDLINE, EMBASE, PSYCinfo, CENTRAL, TRANSPORT, CINAHL, reference lists of retrieved articles and narrative reviews, for studies on chronic cancer and noncancer pain patients on opioids, tested by driving, driving simulator, or cognitive/ psychomotor tests. Methodological quality was assessed with Methodological Index for Nonrandomized Studies, cognitive/psychomotor tests were appraised regarding their sensitivity and validation, and whether confounding variables potentially affecting the study conclusions were recorded. The results were analyzed both quantitatively and qualitatively. Results: We included 35 studies (2044 patients, 1994 controls), 9% of the studies were of poor, 54% of fair, and 37% of high quality; 3 quarters of the studies used high sensitivity cognitive tests. Amount and dose of opioids varied largely in many studies. Mean number of possible but unreported confounders was 2.2 (range, 0 to 4), relating to failure of the studies to mention coprescriptions with psychotropic effects, pain severity, sleep disorder or daytime somnolence, and/or significant depressive or anxiety-related problems. Interpretation: The commonly held concept that “chronic pain patients on stable opioids are safe to drive” cannot be generalized to all such patients in everyday practice, but may be applicable only to a subset who meet certain criteria.

Nondermatomal somatosensory deficits (NDSDs) not conforming to the distribution of peripheral nerves or dermatomes, and often present after a minor injury or with no known inciting event, have long been associated with "hysteria." This article reviews the modern literature concerning NDSDs associated with chronic pain with regard to their prevalence, phenomenology and clinical presentation, clinical assessment, etiology and pathophysiology, relationship with Conversion Disorder and psychological factors, and their treatment and prognosis.Past research and relevant literature concerning NDSDs are reviewed and summarized. Clinical case reports are presented to illustrate the salient features of NDSDs.The prevalence of NDSDs varies between 25% and 50% in samples of chronic pain populations. We describe the temporal, spatial, qualitative, motor, sensory, and behavioral characteristics of NDSDs. Illustrative case reports show the remarkable NDSD phenomenology, variability, and reversibility. NDSDs represent intensely dynamic phenomena that are likely associated with supraspinal mechanisms. Recent functional imaging findings show significant alterations in brain activation patterns in these patients. Similar but spatially and temporally restricted phenomena have been shown in experimental studies with healthy controls and pain patients. NDSDs are associated with certain demographic variables, and possibly psychological factors seem to constitute a poor prognostic sign for response to treatment and return to work and can coexist with structural musculoskeletal or nervous system abnormalities.NDSDs are important and prevalent clinical phenomena associated with chronic pain. Their prevalence in the general population, primary care settings, and non pain patients is unknown. Research needs to be carried out to elucidate these important phenomena.

Manganese oxides have a strong sorption capacity for cationic species in the depositional fluid. This sorption capacity is reflected in the chemistry of the oxides, which is different from that for the oxides precipitated from fresh water, seawater, and hydrothermal fluids. Characteristic mineralogical-geochemical enrichment and geochemical association (defined statistically) signatures, in conjunction with several diagnostic plots, can be employed to distinguish between the following different genetic types of manganese deposits: supergene hydrothermal; supergene marine terrestrial; supergene dubhite; and supergene marine hydrothermal sedimentary exhalative (sedex). "Dubhites" are manganese oxides derived from the weathering of a mineralized sequence (i.e., base and precious ore minerals and gangue). Hydrothermal deposits characteristically show geochemical enrichments in the assemblage As-Ba-Cu-Li-Mo-Pb-Sb-Sr-V-Zn and an Mn-As geochemical association. Supergene marine deposits show Na-K-Ca-Mg-Sr and Co-Cu-Ni geochemical enrichments, whereas supergene terrestrial deposits tend to have very high Ba contents and an Mn-Ba association. Dubhites contain high levels of Pb and Zn, show an Mn-Pb-base metal association, and are composed of significant quantities of base metal-bearing manganese oxides. Bixbyite, braunite, hausmannite, huebnerite, jacobsite, and pyrochroite occur predominantly only in hydrothermal deposits, whereas chalcophanite, coronadite, crednerite, delta -MnO 2 , groutite, hollandite, lithiophorite, manganite, nsutite, quenselite, ramsdellite, romanechite, todorokite, and woodruffite are generally of supergene origin. In addition to established plots presently used to identify marine sedimentary exhalative deposits, the following diagnostic graphs were devised: Na vs. Mg distinguishes deposits of marine and fresh water origin, Co + Ni vs. As + Cu + Mo + Pb + V + Zn discriminates between hydrothermal and supergene oxides, and Pb vs. Zn can be used to recognize dubhites and therefore prospective sequences.

There are over 70 occurrences of manganese oxides throughout Scotland; of these, only 13 are sufficiently well developed to be worthy of description. The deposits are categorized on the basis of the formation processes; eight are supergene ground-water or soil deposits, three formed by weathering, and two are hydrothermal in origin. The chemistry of marine sedimentary exhalative deposits can be related to the paleospreading rate of the once-active ridge and, under favorable conditions of stratigraphic preservation, be used to estimate the halfwidth of the ancient ocean. This approach yields estimates of 5 cm yr (super -1) and about 1,000 km for the spreading rate and maximum half-width of the Ordovician Iapetus ocean, respectively: figures which compare favorably with earlier estimates from faunal migration studies.Several of the Scottish manganese outcrops are associated with Old Red Sandstone (Devonian) sediments--a continental fluvial-lacustrine facies in northern Scotland. Diagenetic remobilization, with subsequent oxidation and deposition, of the manganese within the lacustrine sediments led to the formation of a manganese-rich horizon in the uppermost sections of the Old Red Sandstone sedimentary pile. Previously immobile in the pre-Devonian inorganic reaction-dominant regime, manganese mobility increased dramatically with the introduction of large quantities of organic acids following terrestrial colonization by plants. Climate change from arid to tropical with increased vegetation development promoted the formation of thick, organic-rich soils with the concomitant increase in available manganese-chelating ligands. Organomanganese reactions fundamentally changed the pattern of manganese mobility in the postcolonization surficial environment, making the Devonian a stratigraphic geochemical boundary. These changes in weathering processes would also affect the dispersal patterns of other metals which form organo complexes, gold being an obvious example.

BACKGROUND: Reports indicate that characteristics of older adults with chronic pain may be different than those of younger persons.OBJECTIVE: To study the pain characteristics of older patients presenting to a tertiary pain clinic for the first time.METHODS: Age, sex and relative contributions of biomedical versus psychosocial variables contributing to chronic pain were investigated in patients 65 years of age and older, in comparison with younger patients, from a sample of 1242 consecutive new patients attending a tertiary care pain clinic. The presence ofDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revisionsomatoform pain disorders were defined, using an explicated method of ascertaining the biomedical and psychological variables underlying the pain complaints.RESULTS: The older patients (14.7% of the total sample) had relatively more physical problems (concordant with their complaints) but fewer psychological factors contributing to disability than the younger pain patients. Musculoskeletal and neuropathic disorders affected 40.7% and 35.2% of the older patients, respectively, while several patients had more than one painful disorder. Musculoskeletal problems were more prevalent in the women, and neuropathic problems were more prevalent in the men.CONCLUSIONS: The older pain patients are a distinct group. Factors affecting the delayed presentation of older pain patients to the pain clinic and limitations of the present study are discussed.

Although there have been a few case reports in the literature of self-inflicted symptoms presenting as complex regional pain syndrome (CRPS), there has been no systematic study. This report investigates the period prevalence and characteristics of self-induced disorders in patients referred to a comprehensive pain clinic with a diagnosis of CRPS.Retrospective chart review was conducted for all cases referred as "neuropathic pain" to a comprehensive pain clinic over a period of 2 years.Out of 175 consecutive neuropathic pain referrals over a 2-year period, 41 were specifically referred as CRPS. Application of (modified) 1994 IASP CRPS criteria confirmed the diagnosis of CRPS in 11/15 men and in 15/26 women. Four of the 15 women had evidence of active self-induced signs and symptoms (eg, ligation of the limb, ulcerations, bizarre migrating wounds), which abated with casting, strict observation, discussion with the patient, or other intervention. The characteristics of these cases are presented and compared with other similar cases seen in previous years.This is the first report of a case series of patients diagnosed as CRPS with self-induced symptoms. We discuss in detail limitations of the study, factors that contribute to the index of suspicion, and the complex nature of the behavior including the overlap between factitious disorder, somatoform disorders, and malingering, whereas we stress the legitimacy of CRPS as a diagnosis.

Heaton, Smith, Lehman, and Vogt (1978), using a simulation design, provided the first evidence that it was possible to purposefully do poorly on neuropsychological measures derived from the Halstead-Reitan Neuropsychological Battery and the Minnesota Multiphasic Personality Inventory (MMPI). It was also early on documented that neuropsychologists, even if highly experienced, were very poor at detecting malingering if relying solely upon subjective impression or clinical experience and not specific, empirically-validated techniques (Faust, Hart, & Guilmette, 1988a; Faust, Hart, Guilmette, & Arkes, 1988b; Frederick, Sarfaty, Johnson, & Powell, 1994; Heaton et al., 1978). This is consistent with the more general finding that empirically based, systematic, formally validated, statistical and objective decision making procedures are superior to subjective or impressionistic clinical decision-making, reflecting the longstanding clinical vs. actuarial debate (Grove & Meehl, 1996). This distinction holds for most other domains of human experience and scientific investigation, for example, use of a ruler with a formal rating system will result in more accurate assessment of the length of a room than would “eyeballing” it or other less objective procedure. However, the superior predictive capacity of formal empirical and statistical techniques rests upon those techniques being valid.

Having a degree and a license to practice does not demonstrate that the expert is competent to fulfill [her or his] responsibilities. For example, a review of the scientific literature demonstrates that at any given point in time some questions are unanswerable. In addition, an expert’s response to answerable questions may be inaccurate unless the expert keeps abreast of the relevant scholarly literature on the topic. (Sales & Shuman, 2005, pp. 134–135)

Mendelson and Mendelson (2004) suggest that medical examiners most often suspect malingering in the context of assessing chronic pain. There has long been concern about whether pain may be “real” or feigned. Thomas (1923) thought headache was the most frequent clinical pain problem and the most difficult to detect if feigned. A number of techniques to identify malingerers were suggested, extended observation being considered to be the most reliable. Collie (1932), in an influential work entitled “Fraud in Medico-Legal Practice,” thought that back pain was the most common complaint in cases where compensation was being claimed. However, such pain was thought to be usually mental rather than physical, reflecting the problem of mind-body dualism (Nicholson, Martelli, & Zasler, 2002).

This section critically reviews issues associated with malingering, focusing on these in the context of traumatic brain injury (TBI), chronic pain, and Posttraumatic Stress Disorder (PTSD), or other psychoemotional problems such as depression that are often the subject of medicolegal proceedings. There will be very little discussion of malingering and related issues in the context of criminal or other forensic settings, although some such material will be presented given that many pertinent findings or contributions have been made in these other fields. The primary focus of this section will be on the differential diagnosis of malingering. There is an emphasis on TBI and chronic pain, reflecting the interests of the authors but, also, as there has been more research conducted in these areas than in PTSD, depression, or other psychoemotional problems. There is notably considerable overlap in the chapters of this section, which reflects both the commonality of issues, for example, the comorbidity between the disorders of interest or the use of multiscale self-report inventories to assess malingering, exaggeration, or other accentuation of symptomatology in all of the clinical conditions that are a focus of the chapter.

In this concluding chapter, we review the different sections of the book, as well as respond to the challenge launched by Daniel Shuman and Jennifer Hardy in Chapter 20—to demonstrate the efficacy of the science of psychology in the area of causality in psychological injury. We include practice recommendations, and indicate directions for future conceptualization and research. Finally, we anticipate future trends in the law and how, in the area of psychological injury and law, psychology must keep its focus if it is to adapt and increase its capacity to present reliable, valid, trustworthy, and relevant evidence in court.

It has long been known that it is possible to feign mental or other disorders and not be detected. Barrows (1971) showed that a wide range of psychiatric, neurologic, pain, fatigue, or other problems, in which there are usually few physical findings, could be readily simulated in the context of teaching or examining medical students. Psychiatric symptoms or syndromes that were readily simulated included depression, agitation, psychosis, neurotic reactions, and thought disorder. Neurologic symptoms that could easily be feigned included paralysis, sensory loss, reflex changes, extensor plantar responses, gait abnormalities, cranial nerve palsy, altered levels of consciousness, coma, seizures, and hyperkinesias. Even after being warned that there were simulators among the examinees, experienced clinicians found it difficult to detect them. Rosenhan (1973) reported that 12 people posing as “pseudopatients” and presenting with some psychiatric symptoms were able to gain admission to psychiatric hospitals in five different states. All but one of the 12 were diagnosed with Schizophrenia and none of the pseudopatients were detected despite hospital stays of from 7 to 52 days.

Malingering is often of concern within the context of personal injury litigation or other medicolegal situations in which compensation or disability benefits for traumatic brain injury (TBI), chronic pain, Posttraumatic Stress Disorder (PTSD), and other psychoemotional problems may be at issue. Although there has been extensive study, there is still very poor understanding of what the incidence or prevalence of malingering may be in such situations. Estimates of incidence or prevalence vary widely, mitigating against the use of base rates in determining the utility or most appropriate cutting scores of any diagnostic sign or test result. Overall, there is generally only moderate and often inconsistent evidence that litigation or compensation status (i.e., those involved in litigation, applying for compensation or receiving compensation) by itself is associated with increased symptomatology or disability and there are many possible explanations for such a relationship independent of malingering.

As discussed in Chapter 14, there had been increased concern about the possibility of malingering or related behaviors following the advent of various compensation plans from the mid-late 1800s. The relationship between compensation status, that is, whether the person is receiving compensation benefits or has the prospects of receiving compensation, and various aspects of response to injury or disability, has subsequently been extensively investigated. Of note, there are many different possible methods for procuring compensation with different types of injuries or disabilities in different jurisdictions, for example, various worker’s compensation, Social Security, and disability schemes, automobile insurance involving either tort liability or no-fault compensation, various private insurance plans, the U.S. Veterans Administration, and others.