Faking and malingering (again!)


ResearchBlogging.org

One of the most popular posts I’ve written on this blog concerns ‘faking’ or ‘malingering’. I’m curious about this, because even though I have been asked many times whether I have had patients that are ‘faking’, I don’t think about it very often myself. I suppose it is a subject that is dear to the heart of anyone who is concerned about ‘motivation’ – especially where entitlements to payment or other benefits are dependent on the authenticity of the person’s claim to be unable to function.

So, time to unpack the whole topic again I think.

Last time I posted I had trouble finding relevant literature – the main problem being that in academic publications where pain is being discussed, the concept of faking has been superceded by research into areas we can work with clinically. The role of determining whether malingering or faking is not one for clinicians: it properly lives within the realm of private investigators – and even then, findings are up for challenge when a person is observed behaving in one way in one setting and another in a different setting. There are so many things that influence behaviour that it’s simplistic to decide that motivation to intentionally deceive is the primary reason.

If we start with the idea that pain itself is an experience – something we can’t share with each other, in the same way we can’t share whether we see the colour blue in the same way as each other, or the taste of banana! So you and I can’t tell just how much pain any person is in.

What we depend on is behaviour – what the person actually does behaviourally when they experience pain. And you and I know that we do different things in different places even when we experience the same pain! Take the example of stubbing your toe – in your garage you’ll probably swear loudly and jump up and down. In a very quiet church? Well, we probably won’t be able to hear your swearing and your jumping might be replaced with a wince…

In another example: if someone asked you to run 200m, you might take off at a bit of a gallop, but I’ll bet that if you knew there was a large and very angry bull coming after you, you might just move a little faster!

So we know that the social environment influences pain behaviour, and we also know that beliefs about the consequences of action also influence behaviour. We know too that what people understand about the significance of their pain is also a factor that changes behaviour. If you are unaware that the tickling feeling down your leg is actually a large and venomous spider biting you, you may well ignore it, if you think the vaguely tender lump under your armpit is cancer you’ll probably pay good attention to it and ask for a medical opinion. And your reaction to this lump might be even greater if you’ve had a history of cancer in your family.

In the compensation situation, there is no doubt that the security of receiving a weekly payment can be very helpful in the initial stages of recovery from an injury. That security can become problematic when the person is being asked to undertake the relatively risky business of returning to work – What if returning to work fails? What if my pain gets so bad that I can’t keep going? What if I let my employer down?

Some of these very realistic fears can interfere with the readiness for someone to return to work – and yes, compensation means it can easier to remain in status quo than to attempt to return to work. Does this equal malingering? Is the person faking? Or would you and I feel very much the same, and be quite hesitant to risk our health and livelihood too?

Can we as health professionals ‘tell’ whether someone is intentionally faking?

The short answer is no – humans are very poor at telling whether someone is lying. That’s why movies are so successful – even though we know the people are ‘actors’!

Take a look at this clip from You Tube:

And this one:

and the truth?

For another good article on deception – if a bit cognitive – this newly published article review the latest and greatest on the art of detecting deception. It’s just too early to apply this to pain and malingering.

SIP, K., ROEPSTORFF, A., MCGREGOR, W., FRITH, C. (2008). Detecting deception: the scope and limits. Trends in Cognitive Sciences, 12(2), 48-53. DOI: 10.1016/j.tics.2007.11.008

6 comments

  1. I once asked my brother-in-law, who claimed to be unable to work because he had back problems and who was one of the “night” people who extract sellable rummage from other people’s trash, how he could make that claim and still do all the lifting and carrying involved in working flea markets and rummage sales and rummaging through people’s trash. He said something I thought was quite astute:”When I do it, I work at my own speed and level of pain. When I work for someone else, I have to work at their speed and they ignore my pain.” I had no real good argument against that.

  2. Thanks for your comment! I think that’s a very astute observation – there are real differences between the demands within a paid work environment and other environments – and the ability to choose the pace and approach used for tasks is certainly one of them. Once again it makes it difficult for anyone to actually define who is ‘faking’ and who is not. Perhaps we’re better off trying to understand how and why the person is behaving in different ways in various contexts.

  3. I think you raise some excellent points here. I tend to see that many of us with pain just want to be believed. Pain is one of those things where it seems like society has some weird factors around pain and behavior. I can’t think of any other condition where people are so worried about someone faking their problems. I may try to develop these thoughts a little further in a post of my own, but wanted to just sto by and thank you for your excellent reporting on studies. I always learn a lot from your posts!

  4. Having read both your posts on malingering and found them thought provoking, and overall very well written, I wanted to comment. I would have thought it quite obvious why people are so concerned about others ‘faking it’, certainly in countries where people are given government benefits when they are unable to work due to ‘pain’, which in turn are paid for by the tax payer.
    Few hard working people (who may be working with their own ‘pain’ but who have the social conscience and moral fibre that mean that they want to and do return to work) are happy to sit back and fund others (through their taxes) who exagerate the effect that their pain has on their function, and sit at home watching day-time television, or worse still earn money illegally while claiming benefits.
    I also disagree with it being left to private detectives to assess these people. I think health professionals should be concerned about diagnosing these people (however difficult) as their recurrent visits to pain clinics and physiotherapists is a drain on health service resources. Not to mention the possible damage to the patients themselves by the prescribing of strong opiates and benzodiazepines leading to drug dependance, which they’re often given by their general practitioners, in the mistaken belief that the patients are in crippling agony…
    However, I do agree that it is extremely difficult to diagnose this problem, and we must remember that there may be underlying reasons for them to behave in this way (that’s not to say we should let the behaviour continue because of the reasons). Doctors have become afraid of what patients will say and do (litigation), when it may be in the patient’s best interests to be confronted.

  5. Hi Chris
    Thanks for your very considered response to these two posts. I agree with you on almost every point – I am one of those hard-working people who is working despite experiencing chronic pain, and I don’t want to fund others who are receiving payment for being excellent actors!
    However, and this is where you and I do diverge in our opinions, I don’t believe there is any way for any health professional to diagnose whether someone is faking or not. That’s the problem with pain generally, and not only with pain but other disorders with no observable physical signs (eg depression, chronic fatigue, even post-concussion syndrome).
    Until we have a consistently accurate way to determine the truth of someone’s self-report, as health professionals we cannot determine whether someone is faking ‘bad’ or not.
    I agree that when there is evidence (and I’ve suggested private investigators because their job is to observe and record) that someone is receiving financial recompense while at the same time is receiving compensation or a benefit, that they should be confronted with this. The problem is that as a health provider it is not my area of expertise to collect that information – and neither should it be. My role is to help identify areas of behaviour amenable to change, and to elicit motivation for change and then to support that change.
    I don’t want private investigators assessing these people – but I do think they provide the surveillance that then a team of health professionals and compensation agents can use to confront the individual to find out what is happening.
    There are almost always IMHO reasons for people to behave in this way – that is, to be receiving money for being able to deceive a health professional by ‘faking bad’. One is that the financial assistance received is motivating itself – and reinforces this behaviour. Another is lack of confidence about obtaining money through work.
    I’ll post some more about this shortly – and thanks for visiting and commenting.

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