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In their admirable review, Ferrari and Schrader1 re-introduce2 the biopsychosocial model which recognises that the late whiplash syndrome is not the result of a chronic injury. They note the influence of compensation incentives such as that seen in Switzerland and other western countries. It is the high percentage of patients with chronic pain attributed to accidents that provide the greatest health care and economic burden,
The biopsychosocial model considers an effect of cultural expectation, cultural factors that generate symptom amplification and attribution. I agree with their conclusion that it negates the concept of “chronic injury”,3 but at the same time takes away the stigmata of the psychiatric label, while explaining that people's behaviour in response to their injury may generate much of the illness. The authors surprisingly neglect the final mechanism of the symptoms so often claimed in medicolegal practice, but so seldom encountered in the hospital clinic. They seem to blame cultural expectations and society at large, but they fail to consider the “victim”, who stands to gain sums of money, often larger than he or she has ever handled before the accident. The social and cultural factors they so well describe are real; but the production of symptoms4 ultimately depends on the conscious will of the claimant in providing a description of their severity, duration, and the consequent disabilities and loss of earnings. In litigation practice, deliberate exaggeration is common.5 6 It is misleading to inculpate society alone, and insulting to the patients or claimants to deny their exercise of free choice.
Pearce1-1 completes the biopsychosocial model(s) of whiplash by recognising factors that we could not, for lack of space, include, although they have been discussed in detail elsewhere.1-2 Illness behaviour is the end result of many factors, including pathophysiological processes, experience biased interpretations of abnormal versus normal bodily sensations, and environmentally influenced attributions affecting further expressions of illness behaviour. In most cases, the sum effects of these factors is often considered to be normal illness behaviour, as it is the norm in most illnesses that these factors come into play in most people.
Less normal, or frankly abnormal, illness behaviour is relevant in some illnesses,1-3 although there is a paucity of research in this area concerning collision victims. It is clear that there are at least three subgroups of patients with whiplash: (1) those who recover in days to weeks; (2) those who recover in weeks to months as they choose to resume their normal existence once more and free themselves of the environment that disables them; and (3) those who report a chronic, disabling illness that lasts years. Our article dealt primarily with the first two groups, but there are formulations and constructs that have evolved to understand subjects whose illnesses are characterised by grossly abnormal and extreme illness behaviour, the economy of secondary gain, adoption of the sick role through conscious and preconscious motivations, and so forth.1-4 1-5 Whereas this group may be the smallest group of patients in number, they consume disproportionately greater health care costs.
Collision victims make choices, but they need cultural support to enact those choices. Perhaps what makes us tend to underestimate the conscious choices of the patients is that they are blameless in the way lawyers, therapists, the media, and others, knowingly or not, encourage an illness behaviour that is at best maladaptive, and at the worst, greed driven. It is unfortunately all too easy, within the whiplash megaindustry, for those engaged in the pursuit of tertiary gain (gain from the illness of others) to act as permissive agents for those in society willing to succumb to the their characteriologic flaws of misguided righteousness, deservedness, and greed.1-6
Thus, we gather most whiplash patients are victims, not so much of the collision, but of a system that endangers their health. It is further clear that the day has come to view the whole beast that is whiplash. Researchers that assert that psychosocial factors do not primarily determine the outcome of illness behaviour in patients with whiplash, or that the primary determinants are to be found in the microscopic nature of the cervical spine are simply too wrong to be given any further credence or consideration.1-7-1-10 There are so many “facets” to whiplash, that the whiplash injury itself becomes of less importance when we desire to understand the larger range of illness behaviour, and why it evolves.1-11
British Neuropsychiatry Association 2002 Annual Meeting 21/22 February 2002
The British Neuropsychiatry Association 2002 Annual Meeting will be held at the Institute of Child Health, central London on 21/22 February 2002.
The meeting will cover four topics:
“Clinical and Neurobiological aspects of new variant CJD”
“The Mind's Ear”
“Pervasive Developmental Disorders”
“New Drugs for Neuropsychiatry”
The meeting includes keynote addresses from prominent international and United Kingdom speakers, along with a session for members' contributions.
For further information please contact: Gwen Cutmore, BNPA Conference Secretary, Landbreach Boatyard, Chelmer Terrace, Maldon, Essex. CM9 5HT, (tel/fax: 01621 843334; email:www.bnpa.fsnet.co.uk)., website:
For details of membership to the BNPA, open to medical practitioners in psychiatry, neurology, and related clinical neurosciences, please contact: The Secretary, Professor A S David, Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF.
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