‘Faking’ or ‘Malingering’ or ‘Exaggerated Pain Behaviour’


Hot words!!

It’s amazing how often health providers get asked directly or indirectly whether someone experiencing pain is ‘faking’ it. The short answer is the most accurate – we can’t tell. We’re not lie detectors, there is no ‘gold standard’ to work out whether someone is pretending or not, and the question is based on erroneous thinking about pain and pain behaviour.

I can almost feel the spluttering at my last sentence from some readers!

Let’s look at this more closely.

Remember the biopsychosocial model of pain states that the experience of pain and pain behaviour is influenced by three broad groups of factors: the biomedical/biophysical factors such as extent of tissue disruption at the periphery (or site of trauma), neurological changes of transmission and transduction (throughout the peripheral and central nervous system), and disturbance of the neuromatrix.

At the same time, there are psychological factors such as the level of alertness and arousal, attention, past learning, expectations, beliefs, attitudes, mood, contingencies and so on.

And there is also a range of social factors such as the presence or absence of social support, the systems in which the event occurs (such as compensation, availability of health care and technology), cultural expectations, religious beliefs at the same time as the other two factors.

Recall that pain is not the same as pain behaviour – pain behaviour is everything that we do in response to pain, including involuntary physiological responses (flushing, sweating), reflexes (withdrawal), verbal utterances (groans, gasps, requests for help), as well as complex behaviours such as reaching for medication, going to see a doctor, asking for time off work etc.

Pain behaviour is subject to all the usual influences on any behaviour – that is, operant conditioning can be involved, as well as classical conditioning. And pain behaviour has developed from the behaviour we displayed as a baby to the more complex and modulated behaviours we demonstrate now.

So, it’s easy to see that pain behaviours vary hugely between individuals even if the original trauma is exactly the same.

I can understand several things about the question ‘can you tell if he’s faking’. Pain behaviour elicits strong emotions in observers – it’s designed to do just that! It communicates, and something we like to do as humans is work out whether someone is lying or not. The problem is – we’re not very good at telling who is and is not lying (but we like to fool ourselves that we personally don’t fall for liars!).

In a litigation or compensation situation, it would be great to work out exactly ‘how much’ each pain is worth in order to give it a dollar value, and determine compensation. But – pain can’t be measured directly, we have to use pain behaviour as the next best thing – and pain behaviours are influenced by a whole lot of things. So it’s not a very reliable measure.

Another reason for wanting to know ‘is he faking’ is how far to ‘push’ the person into doing more. The underlying concern is ‘will I cause harm’. And again we really don’t have any useful measure if we try to have pain or pain behaviour as our guide. We need to use something else – radiological union perhaps, control of a load, heart rate and respiration.

BUT the question is based on the assumption that there ‘should’ be a certain amount of pain behaviour for a certain amount (or length of time since) tissue damage. And there simply isn’t.

Some allied questions….‘can’t you use functional capacity testing to work out whether someone’s faking?’ No – sorry. A functional assessment, just like any physical examination or test, tells you what the person will do, and perhaps how consistently they will do it – today. Few, if any, FCE’s have demonstrated predictive validity - that is, they don’t accurately predict how much someone will or won’t do in a day-to-day ‘real’ situation, in fact they won’t tell you what the person can and cannot do at all.

What does this ‘consistency of effort’ tell me? Just that – how consistent this person carried out this activity this time. It doesn’t predict anything, and certainly doesn’t tell whether someone is ‘faking’. People vary in their consistency of performance depending on: their initial expectation of the activity (it may have been harder or easier than they first thought); their prediction of the effect of doing that activity (they may predict they will have an increase in pain – and therefore reduce effort, or perhaps increase effort in order to convince the examiner that they are trying hard); their fear/anxiety may vary throughout an activity; their past experiences may influence what they are prepared to do. Even when given the same instructions ‘use maximal effort’ – if a person hasn’t done anything very physical for a while, ‘maximal effort’ may be hard for them to predict. Some may even be ‘saving themselves’ for activities later in the assessment battery.

But surely some people do fake! Yes – but it’s not a health or medical matter. It’s just not helpful to work out whether someone is or isn’t faking. What happens if you do somehow detect ‘faking’? Confront the person? Take their health care away? Tell them to pull themselves together?

It’s more helpful to think about what factors might be initiating and then maintaining this behaviour – then start to work on these variables to promote change.

But I’ve seen even eminent researchers use the term ‘exaggerated illness behaviour’. Yes, well, even eminent researchers can be mistaken! All that we can observe is that this person behaves in this way at this time in this setting, and the person attributes the behaviour to pain (or illness). We can only identify all the possible factors that are contributing to the maintenance of the behaviour, elicit from the person the not so good things about the situation they find themselves in (and acknowledge the good things about their situation), and help increase the importance they place on making changes, and support their confidence to start to make changes. This might mean leveraging off contingencies (reducing compensation, withdrawing spouse support) if these things are maintaining the behaviour – but it may also mean simply resolving ambivalence about the positives of moving forward.

Malingering? Faking? Exaggerating? When someone can tell me why yellow is better than blue, or find a measure of the ‘chocolateness’ of chocolate and the banana-ness of a banana, perhaps we may have found an objective pain measure. Until then, don’t ask me to work out whether someone is faking it, just ask me to help them move forward.

Oh, and just for fun – how many different words are used to suggest that someone is ‘faking’?

- functional overlay

- supratentorial factors

- a ‘genuine’ man (as opposed to a fake one, or one that is faking)

- adopting the ‘sick role’ (if someone believes they are sick/unwell, what can we expect? How many people do we see ‘adopting the well role’?)

- demonstration of non-organic signs (now that one’s actually interesting, as Gordon Waddell states very clearly in his book ‘The Back Pain Revolution’ (2nd Ed), he never intended the term to mean anything other than to suggest the person was experiencing increased psychological distress – and NEVER to be used as a means of detecting faking!)

This paper by Michael Sullivan is a little philosophical, but at the same time illustrates the points I’ve tried to make above.
This reference is from the 2001 version of the New Zealand ‘Yellow Flags’ document on acute low back pain management.

It’s actually quite hard to come up with good (quality, evidence-based) references on ‘malingering’. By far the majority of articles I located using Google, searching on the terms ‘malingering pain behaviour’ suggested that somehow ‘medical people’ or ‘psychologists’ or ‘psychiatrists’ using special tests can identify malingerers. Someone please show me the ‘special test’!! This section of the IASP Core Curriculum should put to rest this sad aspect of the management of people experiencing persistent pain. Detection of malingering is best left up to private investigators, leaving health care providers to the really difficult work of helping people recognise that change is possible, desireable and important.

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42 comments

  1. A little too “black and white” for my taste and experience –ironic, isn’t it? — but it really highlights the question in healtchare that few dare ask:

    WTF are we doing????!!!

    And how dare we attempt to measure quality when we don’t even know what we are doing or why? Except for the monetary and control issues, of course. For that we claim to measure process as a surrogate.

    I’ve been in “Healthcare” — truly neither health nor care — for multiple decades and multiple generations and I see us as a society drifting further and further off the beam, obviously to our own detriment. But who is really willing to listen? “Reform” is a masquerade for a masquerade: changing the colors of the cups and balls for the funding source. Bread and circuses for the masses.

    The more I know the more I know that I don’t know. Careful what you measure: you may later be measured!

    MAL
    North Miami
    Diagnostic and Therapeautic Minimalism since before 1983.

    1. The short answer is yes, we learn to cry as babies and because people around the baby respond to the cries, the baby learns that crying works. No-one really knows why crying is what we do, but babies everywhere cry, even babies with no hearing. All pain behaviour seems to start that way – we learn to do it when we’re babies, we find it gets a reaction, so we do it more. Of course what we learn to do we can learn not to do as well, and when pain behaviour isn’t helpful, or it’s the wrong place to do it (eg in Church or a really quiet place when you stub your toe!) then we don’t do it. Really interesting stuff!

  2. i rationalized pain in the patients I helped. Now I am permanently disabled and in chronic pain. There is no possible way I could have understood what they were going through and it was arrogant of me to think I did.
    Pain changes every thought, movement, action and eventually changed my base personality. Saving money in hopes of punishing a malingerer may only be punishing someone in chronic pain who wants to pretend to have a moderately normal life.
    No one would ever want to live in chronic pain. I suggest you strap on a tens unit put up to an uncomfortable level, put your belt on too tight and walk around like that for a month. Then you will get some idea how exhausting it is. Then imagine there is no way out but death.

    1. Thank you. Thank you so much for this. I had lumbar fusion and it has not gone well. I just had a top physical therapist tell me I would just have to push past the pain. I was shocked because I didn’t know what was causing so much pain and neither did he. Fortunately I had an appointment with the neurosurgeon who said “stop all exercise now”. When I asked why he said he needed at CT to see if the hardware in my back was ok. I believe this therapist thought I was faking or an old lady who didn’t want to help herself. I am very fortunate the pain is not hardware and I will not need surgery to correct anything but,…had it been a hardware issue and I “pushed past the pain” I don’t want to venture into the thoughts of the pain I would have had.

      If you see someone like me who has been struggling with pain for years (in your records) and tried every trick in to book to get better and finally succumb to spinal fusion, does this not tell you something? I have gone through every effort to eliminate pain from my life why would I stand before you now and fake pain? I have been dealing with pain for three years and have just now begun to realize the ripple effect it has had on my life. I seem to always be in pain so I do little now, stay away from people and situations because everyone around me gets uncomfortable because they see my pain,or I have to leave or move because I am in pain, I can’t do simple things like pick up a grandchild, rake the yard, wash my car, clean the litter box, lift the mattress to tuck the sheet in. How frustrating, I can’t even complete changing the sheets on my own bed. Tell me these types of things do not have an effect.

      I need to return to work. I only have 6 weeks left before I run out of short term disability and no income. I wake to pain every 3 hrs, I can’t sit, stand or walk for long due to pain. If anyone has an incentive to feel no pain it is I! Add the constant and often sharp pain, coping with the pain on a physical, social and emotional level I am quickly becoming someone I don’t know and that is angering and upsetting. I am being forced into someone I don’t want to be and don’t know how to be with a rather frightening future. I will be ill, alone and on the street!

      A year ago I could sit for hours doing kitchen designs or running heavy equipment moving refrigerators and today I can’t even carry a 10 lb bag of bird seed from my car to the house. Please look at the entire picture before you tell me “push past the pain”. I push past the pain every hour of every day now. I didn’t choose this, it chose me. I am not a name in a file, I am a person just like you and I am asking for help to improve my life. If you can not see me as an individual and alter your therapy to fit my current physical needs then you don’t belong in the physical therapy trade – your doing more harm than good.

      1. I’m so sorry to hear that your surgery didn’t go well, that in itself is a real challenge to cope with. And I’m sorry to hear that there have been suggestions that ‘all you need to do is push through the pain’ – that’s unhelpful if you haven’t been reassured that you’re not harming yourself, if you haven’t learned the coping skills to help you get through, and if it has been suggested to you in the context of ‘maybe you really haven’t got (much) pain at all’.
        Pain is a personal experience and despite all our technology, we can’t tell whether someone is ‘really’ having pain or not (with the possible exception of fMRI, but the technology isn’t widely available and isn’t really developed to the point that it can be used in this way).
        The most important thing to remember is that pain is directly influenced by your neurology, your psychology and what you’ve learned about pain in your setting. If you need help to manage your pain, then the best thing you can do is see a good interdisciplinary pain management centre where you can learn about what works best for you. I wish you all the best in learning how to have a good life despite pain.
        regards
        Bronnie

      2. By the way – I just had my reconstructive lumbar spinal fusion 6 months and one week after the original fusion! I was in so much pain because a nerve was wrapped in ever growing scar tissue and there was an infection. I doubt this was pain I “could work past”!
        Within hours of the surgery muscle spasms took over all across the area of the surgery site. They were so strong they tore up the site. I was kept in the hospital for 8 days and one month later I am still having issues with the incision site! I have lost the feeling in my left foot and calf. The doc admits that he doubts that will ever get better because of all the scar tissue he had to remove. I am on mega doses of muscle relaxers but fall into tears and grit my teeth when the spasms hit with pain that brings me to my knees. Now that the swelling is going down the pain at the base of my spine is increasing making it so painful to stand or walk. But the really good news is my spine feels stable for the first time in 6 months. And that is a fantastic feeling.

        I feel like I am hacking myself apart in an insane attempt to be void of pain. It is early yet and I have many months to go since I am just about 4 weeks out from surgery. Wish me luck and the strength to live with the pain.

  3. Hi again,
    I got todays column and saw the link to this and had to comment. I have to agree with Rebecca, there is no possible way you can understand or decide by behavior, who is faking. I have had chronic pain for over 20 years and in the beginning, it was very obvious I was in pain because I was like a caged animal trying to find my way back to freedom. But once I stopped “chasing a cure” for my fibromyalgia, constant, undiagnosed hip and neck pain, IBS, etc, and just realized that this was as good as it was going to get and I had to get back to living as best as possible, my Dr’s thought I didn’t “act” like I was in pain.
    If you cry and you’re franticly searching for pain reduction, you’re a drug “seeker”, if you come in well dressed and pulled together, trying to laugh instead of crying, it can’t be that bad and you don’t need meds/surgery/injections, even when your MRI clearly indicates the disc is shot and you have extensive facet problems.
    And when you finally beg for surgery because you can’t take the sever sciatica anymore, you’re supposed to figure out how to recover and get off the meds as soon as possible, with the help of a generic booklet.
    I have asked all the right questions, done everything asked of me but the Dr’s fail to see you as more than a sum of your parts, you’re just a list of symptoms to the GP and a body of parts to the surgeon.
    In the US, at least in the HMO that I belong to, my husband works for, and prior to my spinal fusion, I loved, there is no integrated medicine. And I have to come in looking like hell and be a malcontent for them to “see” my pain.
    I wished they’d understand that I try to make the best of it and if I look “normal” it may be because it’s the 1st time I’ve been out of the house in a week and I am trying to “be calm and carry on”.
    I wish they would put someone like you in touch with all of the surgery patients, at the very least. But no…

    1. Hi there!
      Sounds like you’ve had a real journey with your pain! It’s so difficult to know how to ‘act’ with pain. Like you’ve pointed out – if you’re looking for some help, it seems not be a good idea to ‘look good’. At the same time you don’t want to ‘look bad’ in case people think you’re only after something like drugs or surgery or time off work.
      That’s why I emphasise being real, authentic and honest – and learning as much as you can to manage your pain yourself.
      There is NO, I repeat, NO way to tell who has ‘real’ pain and who is acting. And even if you have pain, there is no way to tell how much pain behaviour you ‘should’ do. I’ve decided, and there’s a good amount of research to support this, that it’s best to be as normal as possible so I think of myself as a person rather than a patient, and live as normally as I can while at the same time not ignoring or pretending that I don’t have limitations.
      If you’re trying to get health providers to take you seriously, suggest they take a look at this site, or go to the International Association for the Study of Pain website. There they can see that the evidence is there in peer-reviewed journals, it’s seriously researched and very clear that the biopsychosocial model is the best way to view pain – and effective management is not only possible, it’s a human right.
      All the very best, and thank you for taking the time to comment.
      kind regards
      Bronnie

  4. Thanks Bronnie,
    I agree totally but I have watched my Dr just look at me like I am crazy when I try to be myself, laugh through the tears and do the best I can to have a life, while suffering with pain. If I make a joke, it’s frowned upon and I honestly think the only reason they take me seriously is because the MRI doesn’t lie.
    I was told I needed a single level fusion 9 years ago when I had the first lesioning but I wanted to avoid surgery. When severe sciatica set in and I begged for the surgery consult, I still got the “is she in as much pain as she says?” look and the how can you look good, act “normal” and be in pain.
    You have to learn to, or every day you die just a little. I died a little for about 7 years, then I decided to live within my limitations and enjoy what I could do.
    Dr’s have issues with that because it doesn’t fit their idea of what a person in pain should look like.
    I hope that through these types of exchanges, they will learn to listen with their ears, not their eyes and ask questions, like: how often do you leave the house? dine with friends? go on vacations? Then maybe they’d get it. I actually told my primary care/GP at our last visit that it was the 1st time I left the house in 10 days because the sciatica was so bad. He knows I try so hard to manage my pain with a little meds as possible and that during the summer I was doing so well I took a 2 week med break and was walking 15 miles a week, and he was well aware of this.
    Maybe now that I have a 7″ scar on my back, he will believe me because no one would go through spinal fusion if they weren’t desperate for relief!
    Thank you for your work, asking questions and being out there, fighting to bridge that gap in care. I only wish you were in California!
    Warmest regards,
    Yvonne

    1. It’s my pleasure to be here Yvonne! In case you haven’t realised, I’m a little mad about learning and teaching pain management! There are some really good clinicians experienced in chronic pain management in California, but often it depends on your insurance company as to whether they’ll include non-medical management for chronic pain. The best approach is to have an interdisciplinary team, but that’s often considered very expensive by insurers – if only they looked at the long-term cost effectiveness of this approach!
      Take care and be well
      Bronnie

  5. It’s impossible to know look at soccer players that fall on the ground screaming like badly injured animals and then recover as soon as the game goes on

  6. There is a difference between pain and function and that is what is often overlooked. It is possible to be quite functional despite pain and function (or lack there of) can be measured objectively, although not by most FCE systems. FCEs don’t attempt to measure pain or if a person is “faking” pain (at least they shouldn’t). They measure effort in order to get a true understanding of whether or not a person’s abilities and limitations identified during testing are valid. Even if a person is not consciously self limiting it is still important that this be identified and addressed in order to maximize their potential for improvement.
    The sad truth of the matter is that when there are secondary gain issues to be had some bad seeds will attempt to make their symptoms appear worse than they really are for personal gain. Unfortunately, it is these people who ruin it for the rest.

    1. Hi there
      I don’t know whether FCE’s attempt to measure ‘faking’ (although I have certainly seen some that intimate this very strongly!), but even if they don’t directly do so, the users of them (ie the purchasers or readers of the reports) can, without good knowledge, use them inappropriately – and it’s certainly happening here in NZ at times.
      I don’t know whether using an FCE is the most appropriate or effective way to identify whether someone has fears or anxieties about movement – to my mind it doesn’t need a rather intimidating array of physical performance measures to find this out, it takes sensitive and skillful interviewing as well as a very good interdisciplinary team to help the person who does have these sort of concerns.
      As I think I tried to point out, physical performance measures are only a snap-shot of what a person will do in a given set of circumstances. We don’t have any way to establish whether their performance represents ‘real’ life performance, ‘best’ performance, or even ‘adequate’ or ‘consistent’ performance – it’s simply a measure of what a person will do, on this day, in this setting. Validity of FCE’s haven’t been established – in fact I recently reviewed the literature on FCE’s and still haven’t found any that have adequate predictive validity, and the status of FCE hasn’t changed in the years since 2000 when I first started looking at them. Until some very good studies are made of the predictive validity (and reliability and other forms of validity also) I wouldn’t use an FCE except for the person who has pain to learn more about what he or she is able/willing to do. Certainly not a way to establish ‘faking good’ or ‘faking bad’. Malingering is not a health problem, it’s about attempting to obtain money through deceit – that’s an investigative problem rather than an FCE tool.
      cheers
      Bronnie

  7. HI Bronne
    Music to my ears regarding thoughts on usefulness of FCE”s. Coming from a pain amanagement background I have always wondered why there is not more emphasis put on asking people what they thought they can and cannot do, helping them to set baselnies to verify this, and use this as a useful starting point for return to work prgrams. There seems to be an assumption that using cleint driven baselines will be too “soft”, and that most people just wont try hard enough ( i.e. the underlying assumption is they could/should do more, the therapist knows better). It seems to me that FCE’s will almost always get it wrong, ( being a breif snap shot of someone’s expereince, and driven by the therapist, not the client), usually in my experience over-reporting the capacity of the person. I read the FCE reports written about my clients, and am often amazed at how little they resemble the planned and sustainable picture that I have worked with my client in establishing a reasonable level of activity tolerance. Unfortuately the FCE picture is often used in planning a return to work program ( with no say from the injured worker), ane then everyone gets frustrated and angry when it doesnt work, in particular the inured worker, who has yet again aggravated their symptoms and expereinced failure. My only hope is that I am gradually seeing a change of perception of the very limited usefulness of a FCE in rehab.
    Keep up the good work, Bronnie.
    Regards
    Edwina

    1. Hi Edwina, recently I wrote a paper about FCE for our NZ Pain Society journal in which I carried out a review of the literature – hardly surprising that they haven’t gained any more validity, or even for that matter reliability, over the 20 years I’ve been working in pain management! I used to carry them out, but only as a way to work out with the client what might be a reasonable starting point for RTW. I’ll see if I can get permission to repost the FCE paper on here, it might be interesting to see what others think!

  8. While in school I learned that pain is a “private and personal” thing. Meaning it’s almost impossible for me to appreciate your pain because it is personal to you. Pain doesn’t fit a template as much as we’d like it to. Which makes the following quote even more meaningful.

    “Detection of malingering is best left up to private investigators, leaving health care providers to the really difficult work of helping people recognise that change is possible, desireable and important. “

  9. This discussion reminds me of discussions we used to have within the New York Academy of Traumatic Brain Injury. It certainly seemed “obvious” that there were certain people who, when tested, didn’t seem to be “making an effort” to perform on a functional test – i.e., they were malingerers.

    On the other hand, some colleagues pointed out that a test for “malingering” has never been validated. In other words, if you tell a group of well volunteers to take a test and fake that they have disabilities, their test profile is far different from those who are labeled as “malingerers.”

    So there are at least three groups of people: people with so-called “real” problems”, “malingerers” whose test responses are somehow anomalous in a way we don’t understand, and people who are deliberately trying to fake a disability. And there are very few people in the last group.

    It’s interesting.

    1. …and we can’t tell who ‘belongs’ in which group!! Because we don’t have any externally validated measure for the presence/absence of pain nor for the effect of pain on performance. So, in the end it’s probably unhelpful to think of anyone as being a ‘malingerer’ or faking, because we need to help them all manage life more effectively.

  10. “You can’t fake to weakness, you can only fake to strength,” says a character in *Sometimes a Great Notion.* (Or something like that.) Someone may be representing one kind or grade of pain as another, with some kind of intent to deceive — though as you say, there is no way on God’s green earth to prove this — but you can be absolutely sure that people who say they are in pain, are in pain.

    Behind the desire to distinguish people who are “really in pain” from “malingerers” is the conviction that some kinds of pain, or some kind of sufferers, don’t deserve help. It’s a conviction I don’t share.

  11. Since there has been a huge increase in desire for chronic pain medications in the past 25 years, a component of malingering or addiction is surely rampant.. Lyndon Johnson said “If there is something you don’t understand, just follow the money.” There is BIG money in satisfying the cravings of an addict under the guise of relieving pain and suffering while proclaiming that there is no way to distinguish a chronic pain patient from a malingerer. Globalization of opium sales to China, leading to ornate Opium Dens, was quite profitable for the British.. Opium Dens are only historical remnants in China because the users and merchants/prescribers were summarily executed. Keeping that historical fact in mind plus the fact that the USA now uses 86% of the world production of opiates, I have decided to leave Chronic Pain Management to the “experts”.

    1. That’s an interesting comment. I have no doubt that the profit motive is behind many of the chronic health trends in our country. But in this case I see it a different way too. What about the rampant pro-inflammatory, pro-pain diet that Americans now consume, chock full of sugars, simple carbohydrates, grain-fed meat, safflower, corn, and sunflower oils?

      There’s plenty of profit to go around with these products. And they leave people more prone to pain and inflammation.

      1. Hi Ron, I haven’t seen any literature supporting this view with respect to chronic pain problems. From what I’ve seen the prevalence of having chronic pain hasn’t really changed, but the disability and the treatment seeking has increased over time – maybe because of societal beliefs (it’s not OK to have pain, if you have pain you ‘should’ seek treatment, pain means ‘something is wrong’ so be careful and don’t move much etc). If it were simply dietary changes I’d expect there to be a lower incidence of chronic pain in places like Japan with their quite different diet – but this is not the case.cheers
        Bronnie

    2. Dr Ellis, I have worked in pain management for over 20 years. While undoubtedly there are people who have been started on opiates and now have increased doses (in part because of the pharmacokinetics of opiates – tolerance and dependence), people are rarely started on them in the Centre in which I work. This is because opiates are not the best medication for so many pain problems that simply don’t respond – eg fibromyalgia. Human beings are not lie detectors, and neither should health professionals be such. Rather, we are called firstly to do no harm – this means giving people appropriate treatment, in as far as we have the knowledge and information to do so. At least in New Zealand, we don’t have quite the free market approach in the US, so I think it would be a rarity for opioids to be prescribed simply because of manufacturers are trying to generate income.

  12. That’s very interesting…I guess I’d better know more about what I’m talking about before I offer it! But how do we know about the incidence of chronic pain in the past?

    On a side note, I sometimes envy you working in a system that’s at least a little bit more sane. Healthcare in the US is nuts, to say the least. I’m not above being motivated by financial reward – but there’s little or no financial reward for doing a good job!

  13. Based on your feedback I tried to quickly search for research on chronic pain and the “anti-inflammatory diet” and sadly it’s hard to track down much that’s specific.

    It seems that in order to conduct a meaningful research study you have to limit your field of view – study the use of fish oil supplements for RA, for instance – rather than the overall idea of an anti-inflammatory diet for those with chronic pain.

    Though it would be nice to study this issue in more depth, in the meantime you have to read between the lines. Does the link seem plausible? Can you sketch out some underlying pathways in brain chemistry that make the relationship seem reasonable? And the all-time favorite – what’s your anecdotal experience?

    Each practitioner will doubtless find himself or herself on a different point of this spectrum.

    Personally, though I stubbornly cling to my biases as much as anyone else, I certainly appreciate having my slumber aroused now and again by these interesting blogposts and discussions.

  14. I have had a pretty challenging day at work today, so I am going to try not to sound too angry. I think many patients have unreasonable expectations. It is completely unreasonable to have a BMI of 43, do no exercise, eat junk food and smoke and expect to feel “good” or be pain free. You SHOULD be in pain. It hurts to be fat and out of shape. ( I know cuz that is me sometimes and it hurts my knees if I am overweight). Hydrocodone won’t fix your pain for very long. I am ready to scream at that stupid SSRI commercial that says..” you have to wind yourself up in the mornings”…Yeah, you need a drug that can increase your risk of suicide. Or you could have a cup of coffee like the rest of the world. Yes, there are people in pain, but I don’t see the patients in the clinics I work ( I am a locums) who I find on duragesic patches, AND oxycodone AND Ativan AND Celexa AND Ambien AND medical marijuana living active, happy lives. People with fibromyalgia on methadone. Yes, methadone and most of the above drugs. This is common and it is crazy. There has got to be a better way. I don’t know if we can measure it.

  15. Idiocy to say “we can’t tell when people are faking”. If a patient jumps off the table at the slightest touch, reports pain to superficial pressure all over, if they proclaim that they can barely move due to pain — but are moving without restriction when they think they’re not being observed… You really think that isn’t some “non-organic” pain behaviours?

    1. Curious, I was sure I made a clear distinction between pain behaviour and “faking” or “malingering”. We cannot determine whether a person is demonstrating reasonable (to them, given their unique history, learning, family, biology and reinforcement – not to mention future expectations, beliefs, and predictions) behaviour, or is deliberately pretending to have pain when they don’t. If a person “jumps off the table at the slightest touch” it undoubtedly does mean something is going on – whether it’s pain, anxiety, distress – or something else – we cannot determine without spending some time learning about what he or she is thinking, expects or has been reinforced to do. It is “idiocy” to suggest we can do otherwise, unless of course, we hold with the out-dated view that doctors know best, pain is a unitary and single-dimensional experience that is only the sum of inputs laid upon a “tabula rasa” or blank slate of a nervous system. I hope that people reading this blog take a rather more sophisticated and informed approach, and work with the person to understand and then help them develop a more helpful way of living with their experience.

  16. Please excuse me, i need to rant a bit as i am in the middle of some really bad s)(*.

    I am not in pain, my mother is. She has metastatic lung cancer and for no apparent reason at her back started hurting.

    One day, two weeks after it started, she almost faints, we go to er. OTW there she takes 2 ibuprofen. We get into a room where i cannot get any attention from anyone, its an er so this happens, so i fetch her purse out and she takes two more ibu.

    When it is finally time to see the dr, he says that she likely almost fainted from pain. He speaks of constipation but does not ask about it nor really let us speak. My mother was constipated, not from pain pills unless ibuprofen does it, because she cannot comfortably sit on a toilet to evacuate her bowels. The dr does not ask about the bottle of ibu sitting conspicuously on the tray, left it there for them to see. He asked her pain level when she almost passed out, she says 8, this is one tough lady tht is a ten to most. He asks her pain now, she says 4, this is with 800 mg of ibu but he does not ask about that.

    The doctor says to my mother, do u need pain pills. My mother is over seventy and has been told all of her life taking pain pills is a bad thing, she hasnt taken one since the 1960s, she has suffered thru broken bones with just an asprine, crazy if u ask me. This time, i pipe up, yes she does need pain pill, man she really does, cant u see she just almost passed out from pain? I tell the doctor that she thinks taking pain pills is a bad thing. The doctor does not correct this misconception in her, he agrees she does not need pain pills but gives a prescription for 12 tramadol.

    My mother agrees with me to take the tramadol, still not enough relief to sit on the toilet comfortably but she can now cough without yelling out.

    I get her to the ocologist two days later and i explain to them she cannot sit on a toilet and she cant seem to shit standing up, u need to help her understand pain pills are fine when u need them. He did. He gave her some vicodin and i was finally able to help my mother with that other little problem while we wait to see her regular dr. Now the ct scan and the bone scan apparently didnt show what was wrong with her back, this is falling into the realm of the regular dr…not a particularly good one.

    The regular doctor when we see her immediately starts harping about the vicodin like we need to run, not walk, my mother straight to detox. She states at my mother age, she should be going to a Pain clinic, i thought these were for chronic pain! I was alarmed more than a bit, i asked her if we should not worry more about the source of the pain. She does do a fair evaluation but never once asks about the pain….my mother is sitting in her evaluation room dizzy from pain and she is insisting it is the vicodin despite my mother not having taken any that day until just b4 the dr came. this dr has some major issues about narcotics for sure. She states that she heard all about our er visit from dr miller, who also failed to ask enough questions…. i am guessing we are pegged as drug seekers. My mom has been going to this hack for 16 years, she was aware that dr was not much good but was not sick enough to care, of course the dr never did catch her cancer that was another er visit. This dr only prescribes lidocain patches…

    I called reg dr back…patches are 300 dollars, she says then wait for the pain clinic, a week from now. I pay the 300, they bring her pain from omg i am sick to my stomach to omg this hurt a lot and they can only be worn 12 hr a day. 300 for that? I call her back again, i explain that she is in a ton of pain and the patches are only for part of the day…her response is pretty much so sad get used to it.

    I have been a slave to my mothers pain for over a week, she cant even stand without help. If i go to an er or even back to the oncologist then i am dr shopping for pain pills. It has been most painful to me to give up totally my life because doctors seem to be too reluctant to admit that some people really do need pain pills. I am really looking forward to the pain clinic where i expect my mother to be put on some proper pain medications while we wait for a proper diagnosis of whatever this is. I have an appointment with a new doctor two days after the pain clinic, her current dr isnt to be tolerated, cant be dr shopping after the pain clinic…i just want someone interested in how she feels. Maybe the first words in the exam room wont be u dont need pain pills but how are u…..what a wonderful difference that would make.

    Please listen when someone says they are in pain. i am sorry u get all kinds of jerks who want to get high but ask the right questions dont assume. I feel the dr in the emergency room has a bit of an excuse but not a particularly good one.

    1. Sounds like you’ve been having such a difficult time! I’m not a doctor, and I don’t prescribe, so it’s my job to really listen. At the same time it’s even more important for doctors to listen because that’s the only way to find out about a person’s pain. I hope you are able to find a way to get support for both your mother and yourself.

  17. I’m happy to see that this blog has continued to be monitored by the author and responses are still forthcoming.

    I began my research on extreme pain and pain rebound a few days ago in response to MRI findings of a knee injury I received a few weeks prior. I just knew in my heart that I’d torn something very badly when the injury occurred but as of the MRI findings, that wasn’t the case at all. At the time of injury, I was merely squatting and shifted a bit of weight to my right side. Suddenly, a very loud pop followed by a ripping, burning feeling shot up and down the lateral side of my leg from the center of the knee. The pain was so extreme that as I was trying to stand and straighten, I began to feel faint and my spouse had to grab me to keep me from chewing grass. I did the usual thing I do when I’ve injured myself and immediately applied ice, got it elevated and waited for the pain to subside. I experienced immediate swelling over and around the patella, I was unable to bend my knee more than approximately 10 degrees and unable to bare weight at all. My spouse took me to the ER where they did the usual X-ray, placed me in a knee immobilizer and on crutches and told me to follow up with ortho within 3 days.

    Sorry it’s a bit long of a history but pertinent to my question.

    Ok so I did the follow up with ortho PA, MRI, different knee brace etc. MRI findings within acceptable limits minus age related arthritis. So I asked the doc, what caused the extreme pain though I hadn’t actually torn anything and he gave me a generic answer. These by the way do not satisfy me as I have a personal need to keep track of what’s happening with my body. His response was, these things happen and they take time to heal. So then I asked him to check my MRI that I’d had done on my cervical spine the same day as a post op follow up and again the findings are normal. The spinal stenosis has reverted and the hardware from my c5-c7 fusion are intact and doing what they were designed to do. Now I know something is not right in the land of health where my body is concerned.

    I’d had my surgery for the fusion (accident related) in December the previous year and still experience extreme pain and numbness of the shoulder, neck, and upper left arm. I’m on 10 mg of oxycodone every 4-6 hours and have been since the original date of injury just a bit over a year ago. Yes, I know these medications are highly addictive and I have asked several times to be sent to the pain clinic so that I could come off these meds. I had to ask to go to physical therapy, it took them 2 months to get me in and then they supplied me with a list of passive exercises, a tens unit and a heating pad and that was that. I do use all of the items given on a regular basis but the relief has been minimal and doesn’t last long.

    Pain is increased with activity and inactivity so I have to find a balance daily and let my body determine what it can and can’t do with every project I take on.

    So my question to the ortho PA was, why, if my MRI results are within normal and acceptable ranges am I experiencing extreme pain. We discussed pain rebound to narcotics. It he really didn’t want to take the time to explain it or didn’t know enough about it to share with me. Being the dutiful student I am, I took the time to do some basic research on my own. I understand that given the amount of time I’ve been taking these meds, I certainly could be falling into this category. However, with all things involving health, nothing is cut and dry and my behaviors don’t seem to fit the “classic” pain med rebound symptoms. However, it could be said that I generally tend not to follow the “rule of thumb” as even after my appendix burst over 20 years ago, my white cell blood count remained normal before and after the surgery.

    So my question is, how do I determine for myself if it is indeed pain med rebound that I’m experiencing and that my body is ” over reacting” to what wouldn’t normally be so extreme. Also, just need to add that until this injury to my cervical spine, I had an exceptionally high pain tolerance.

  18. I wanted to add something but was pulled away to other responsibilities at the time.

    There are I’m sure many patients who are placed on pain meds immediately and left on them for long periods of time because of either time constraints within the examiners office or just plain ease of access and pain control. Under these circumstances, is it any wonder we are conditioned to seek immediate relief from pain without putting in the effort required to get there on our own.

    I agree with you in that there is no way to measure pain in another, even taking into account all the variables that might effect that persons perception of the pain, as the examiner will always bring with them their own perceptions and biases. As for the FCE, well, in my honest opinion that’s just a joke. It doesn’t take into account the many different ways a person can compensate for lack of any particular ability and they can ruin a person’s life goals just as fast as they can inaccurately award a malingerer for false injuries.

    1. Thanks for taking the time to comment, sorry it’s taken me a while to reply. I agree, people can be put on medication without being fully informed of the long-term problems with taking them, and without being made aware of alternative options. This could reflect the bias of the clinician, time constraints, lack of knowledge on the part of the clinician, and often the way insurance is structured. I think it’s important for anyone who has chronic pain to become their own pain expert – learning as much as possible about your diagnosis, chronic pain mechanisms, the treatment options and so on – so that you can inform those who might be treating you. In the end, living with chronic pain is a personal journey, others can only walk beside you.

  19. What might you suggest to a family member who has watched someone being treated for chronic pain, taking oxy, elavil and valium for pain and muscle relaxation and ambien to sleep due to the pain keeping them awake.

    What might you suggest to a family member who is aware the patient magnify’s the pain symptoms to the doctor to ensure the drugs keep coming and does not take the meds as prescribed? I’ve seen the patient use his chronic pain to elicit attention and I’ve seen the patient go from no pain to high level pain, reaching for a handful of meds then a short while later not remembering drugs were taken, and more is taken. Most days are spent in a drug induced haze as most events are not remembered.

    I have felt the entire package of chronic pain and narcotics has driven my family member into a terrible state of spinning into a terrible cycle, and he himself is no longer capable of knowing what he is doing cognitively due to the effects of the drugs and the effects of chronic pain and depression. He needs help but is not unaware anything is amiss. Attempts to bring attention to his decline in quality of life is met with his reply he has no choice but to take narcotics due to his chronic pain.

    It is a cycle that is spinning into a very sad ending.

    1. I’m so sorry to hear this has happened to your family member. I think it would be worth attending an appointment with the person, so you can provide an additional viewpoint – and support the doctor who is probably aware that this is happening but doesn’t have knowledge of how extensive the problem is.

  20. When I read here about PCPs passing the opportunity to care for a patient with a conscientiously chosen pharma where appropriate, onto a Pain Mgmt specialist, I start to see some reasons that we’re sitting here reading the pleas from what seems to be pretty average and normal persons for anyone to seem to care…
    I can pass that buck when I, for personal reasons, have made a judgement about the deserved-ness of my patient to access narcotic meds (in particular to the discussion here…) OR I have decided that a patient’s other underlying issues leading to conditions such as obesity PRECLUDE a completely independent cause for the pain symptom, OR I buy into the idea, despite years of training, that non-cancer pain is really more like a character flaw than a serious and life-altering state that no one should ever have to endure – let alone endure alone which I am hearing at alarmingly frequency.

    I wonder if these are the same PCPs who act as though they feel deep down, that their patient books that appointment, probably drags him/herself out of the house and into the waiting room for the express purpose of ‘bothering’ said PCP? I wonder what might happen if when that other odd patient out who IS found later to be drug-seeking was approached with the attitude that the provider GETS to help them through the real issue? Might that seem to appear more closely resembling HEALTH care?

    Sorry if this seemed like a touch of rant but it just so happened that I caught the end of one of the neverending exposes of OxyContin and I was actually shocked to hear a PCP on national TV, refer the interviewer to the office’s new sign that stated that NO patient in the office would be prescribed Narcos for NCP! Across the board and recorded for posterity no less. I’m not naive that the attitude and the medical NIMBY doesn’t exist in many practices, but I’m still shocked when I see a “care professional” profess to hand it over to the ‘experts’ without even having done any due diligence…I have no problems and in fact, am grateful for easy access to a local Pain Mgmt Clinic where there are complications or running into tolerance issues etc, but without even having done your best???

    Maybe for PCPs adopting or stuck in this archaic blood-letting; It’s time to move on to real estate or retire…sheeesh.

    ok rant over. Great site.
    Quentin

  21. Some researchers argue that the determination of exaggerated pain behavior is moral not scientific in nature. Also, the psychologist knows that any signs of symptom exaggeration by the individual could be interpreted as a cry for help rather than anything like conscious exaggeration for monetary gain or malingering.

  22. I know this is an old post, but I had to comment. I fell over a year ago and injured my right SI Joint to the point where I couldn’t sit, walk, or roll over in the bed. I couldn’t even lift my leg to get in the bed or a car. Worker’s comp was getting impatient with the Dr. so he said he couldn’t do anything else for me and found me at MMI. They sent me to have an FCE done while I was on crutches. The pain was so intense trying to do any of the tests that I had to just lie down on a bed in the middle of testing and cry my eyes out. I couldn’t perform 3/4 of the FCE, because I couldn’t do anything without the crutches. The PT wanted to stop the FCE because of my pain and my crutches so she called the dr. The dr told her that WC needed numbers so she needed to do what she could. When I returned to the dr a few days later he told me that I was “self limiting” and that I was 5/5 on the Waddell test. Funny thing is they didn’t perform anything from the Waddell test on me. I told him I thought the Waddell test was suppose to show psychological issues and not try and prove malingering. He disagreed. Well, now I’m still on crutches after 1 yr. No Long Term Disability, No Worker’s Comp, no Unemployment benefits and no job. Just because they think I was Malingering. Funny thing is the dr found me 7% impairment…How does that happen? Malingering and a 7% impairment rating? I hate worker’s comp…

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