The vexed question of determining whether pain is “real”

Every now and then the old chestnut of whether it’s possible to determine if a person’s pain is “real” arises. Usually it’s in the form of an insurer, or maybe an employer, who wants to know if the pain this person is describing can possibly be as bad as the person says because

• “they don’t look like there is anything wrong”
• “there are these inconsistencies”
• “it’s taken too long for them to recover”
• “they’re not participating in their rehab”

For the avoidance of doubt, I have not been able to identify any readily available test or technology that can reliably determine what another person really experiences.

More than that, I’m not sure that it’s helpful in clinical practice to try to determine whether someone is “faking it”, and here’s why (sit back and get comfortable, this could take a while!).

Pain is not an actual or tangible thing.  We infer that someone has pain on the basis of their behaviour.  As Gatchel, Kishino and Minotti say “It is important to distinguish pain as a neurological event (nociception) from pain perception (which is subjective in nature).”  Nociception is about activation of receptors which pass through pathways to the central nervous system. Pain is the interpretation of this activation by the brain once it determines this information needs to be noticed and acted upon.  The same nociception activity in one person may not be perceived in the same way by another.

Having identified that pain is personal, we then turn to how a person responds to this event.  Gatchel, Kishino and Minotti remind us that pain, disability (the functional limitations, or behavioural expression of our individual experience of pain), and impairment (the physiological or physical findings) are not directly correlated.  While there is overlap, it’s not unusual to find someone with significant changes on x-rays and blood tests, who reports high levels of pain – but doesn’t let that stop them doing things.  At the same time, many painful conditions fail to show on x-rays or blood tests, but the person reports high levels of pain and finds it very difficult to carry out normal activities.

Why might someone’s disability from pain be greater than another persons?

That’s the million dollar question!And why it’s so important to obtain a biopsychosocial assessment of a person who is having trouble recovering because of pain.

We do need to understand the physiological processes involved in an individual’s presentation – knowing the diagnosis can be helpful, as can knowing the structural problems that underpin disability and pain.  At the same time, the science of diagnosis is not 100% reliable, and more importantly, unless there is a clear-cut treatment that can remediate the problem, searching for a diagnosis can play an important role in iatrogenic, or “resulting from the activity of physicians”, disability.

On to why identifying whether someone is faking it is unhelpful.

People with chronic pain have usually seen about 4 or 5 (or more) clinicians by the time they come to get a diagnosis of chronic pain.  Each time they see a new clinician, their history is repeated.  Clinicians are trained to find “what’s wrong” – and fix it. We get flummoxed when the person fails to “get better”. For some clinicians, it can mean repeating a treatment in the vague hope that what didn’t work the first time might work the fifth.  For others this failure can be turned on itself and (albeit inadvertently) the person with pain is seen as having “failed”. Maybe they weren’t motivated enough, maybe they didn’t really try hard enough, maybe they just don’t want to get better, maybe they don’t really have pain.

Patients can also be going through a process of feeling as though they’ve failed, maybe they’re not really motivated – maybe this pain is “all in my head”.

I don’t think many clinicians directly tell patients that they suspect they’re not really motivated, or don’t really have this much pain – but in a situation where the patient is already doubting, is anxious about recovery, and given our human tendency to jump to conclusions, it’s very easy for the person with pain to misinterpret what is going on.

In this situation – what do you think a person is likely to do if confronted by someone as to whether they might be “faking”? Hmmmm – I might just try to demonstrate how bad it is for me.  Chance of reducing disability has just dropped. And in the face of factors that reinforce disability such as family members who might be suggesting it’s risky to do anything “because the last time you did you were sore for ages!”, or coworkers who say “you look terrible, you need to go home”, or disability payments that are greater than unemployment benefits, or payment of a mortgage insurance that will make the house completely paid off – well, it’s probably quite hard to recover.

I’ve worked in pain management for 20 years or so, and I can’t tell whether someone is faking bad. I’ve met hundreds of people who say they have chronic pain, with an enormous range of factors that are working to hold the person in to their currently disabled situation. I have yet to find any medical, psychological or functional test (or combination of tests) that can determine the validity of the person’s pain and disability. And believe me, I’ve looked.

I’ll write more about this topic shortly – taking a look at psychological measures that have been suggested as ways to detect malingering or symptom magnification. I’ll also look at functional measures that supposedly show whether someone is giving “full effort”. In the meantime, I wonder whether it might be more useful to consider that a person’s self report of pain is what it is, and for clinicians to work at identifying the factors that could be responsible for maintaining disability.

Gatchel, R., Kishino, N., & Minotti, D. (2010). The Three Major Components of Behavior Used for Assessing Pain: Problems Faced When There Is Discordance Among the Three Psychological Injury and Law, 3 (3), 212-219 DOI: 10.1007/s12207-010-9081-0