But Ferrari thinks only a “very small percentage [are] malingering. People aren’t smart enough to malinger.” If someone were to exaggerate their symptoms for the sake of an insurance claim and then continue living their normal life, he thinks they’d be caught pretty quickly.
These patients are “clearly suffering,” he says. “There’s no doubt that if you assess people who have chronic neck pain, you will have physical examination findings that are clearly abnormal. The genuineness of the symptoms should not be the controversy. What should be the controversy is the attribution. To what are you attributing those symptoms and why?”
Filing an insurance claim forces someone to pay close attention to their symptoms, so that they can report them to the insurer and their doctor (and maybe a lawyer)—and the more carefully you’re keeping track of your pain, the more likely you are to notice it. The symptoms could come from many sources, but, Ferrari says, if you were in a collision, “you’re attributing them all to one thing. We are very suggestible individuals when it comes to pain, because we have no way of measuring the causes of those pains. And therefore we can attribute them to whatever makes the most sense for us at the time. And a collision makes a lot of sense.”
At least, it does in the U.S. And the U.K., and Canada, and many European countries. But not everywhere. Studies done in Greece, Germany, and Lithuania have found that almost all the whiplash injury patients surveyed in those countries were healed after four to six weeks—about what you’d expect for a sprain.
The difference, Ferrari thinks, is whether the country in question has a “whiplash culture.”
“Whiplash cultures are those cultures in which there is the expectation that if you’ve been in a motor vehicle collision, you’ll probably have some significant problem as a result,” he says. For example, surveys by Ferrari have found that about half of people in Canada expected that chronic symptoms would follow a whiplash injury, an association that wasn’t found in Greece, Germany, or Lithuania. And another study by Ferrari and colleagues found that people who expected to recover after a whiplash injury in fact did recover more quickly. Pain and belief are deeply entangled.
“I feel like you could almost take a healthy person and do the right things to them, and make them into a chronic pain patient,” Ferrari says.
Though railway spine and whiplash are not the exact same thing, there are obvious echoes. Railway spine sufferers, too, were accused of milking it by insurance companies; there were vague but unproven theories about what might be happening in the body after a train crash; and at one point, Erichsen speculated that “terror” might play a role in what patients were experiencing—in other words, that there could be psychological factors involved, too.
“I think railway spine is an example of how we can easily repeat ourselves,” Ferrari says. “We’re a society that wants to attribute pain, fatigue and other symptoms to some disorder or disease. So we just have this natural tendency to try to make connections that don't make a lot of sense, rather than sitting back and saying, ‘Let's try to understand why there are some people in our society with chronic pain.’”