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a synthetic opioid similar in potency to codeine. Tramadol has serotonergic and noradrenergic potentiating effects. It is theoretically possible that the combination of tramadol and sertraline enhanced the risk of experiencing a convulsion. However, this would be a much less common occurrence or explanation than the likelihood of faint leading to fall with seizure-like activity. An additional confounding factor in the case was that at the time of the incident, the patient fell back from a standing position, striking her head on the floor, and sustaining a 6-cm
in the patient for action on aggressive impulses. Dersh (2002) has shown a fivefold higher incidence of personality disorder in the Workers Compensation population when compared to the general population. Patients with characterologic traits or disorders may use physical complaints for secondary gain–monetary rewards, avoidance of arrest, solicitation of opioids or benzodiazepines. The concept of secondary gain is difficult, and perhaps at times misused, but certainly it is an important factor in certain cases seen by the disability evaluating physician
