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