suspended splits

“Faking” pain – and inconsistency in presentation


ResearchBlogging.org

There is a common belief amongst some people involved in pain and pain management that a person with chronic pain should be consistent in their presentation. That is, be consistent in various settings, and consistent across various measures.  This assumes that if inconsistencies are present there must be something going on to cause suspicion about the validity of the person’s presentation.

Returning to yesterday’s post, I discussed the distinction between nociception (activation of receptors in the nervous system), pain (the experience produced by the brain once it has interpreted the nociceptive action), disability (the changes in functional performance attributed to the experience of pain), and impairment (tissue changes).  These are not the same! Today’s post refers mostly to pain and disability.

Pain is, as I keep spouting, a personal, subjective experience – you and I can’t share our pain except through our behaviour.  And even when we describe it, we can’t actually experience what it feels like to have each other’s pain. What this means is that our behaviours, or what we do, are what conveys our experience to others but only to a certain extent.

While our experience of pain remains individual, our behaviour is shaped by all the influences around us.  And just to make things more complex,  the meaning of our pain experience is shaped by what we learn and believe about pain from interactions between ourselves and all those influences that shape our behaviour. Complicated? Oh yes.

So if I grow up in a family that is generally stoic, where my complaints of pain are ignored and I see that others in my family don’t generally cry or stop doing things when they are hurt, it’s likely I’ll also be less demonstrative about my pain than another person in a family where this is not the norm.

We also learn to behave differently in different contexts. It’s common to say a few choice words when we hit our thumb with a hammer in the garage on a Saturday afternoon, but we usually wince and gasp quietly if we thump that same thumb in Church the next day!

What this means in terms of consistency is that people often do different things in different settings when they have pain – maybe when they drive from home to a clinic they’re a bit anxious about what the consultation might mean. They get out of the car and walk quite carefully into the clinic and sit down rather gingerly. They’re not sure whether they’re going to hear good news, or not. They go through the examination and consultation, and get told they’re going to try a new medication that might help. Oddly enough, as they walk back out to the car someone looking out the window might see them moving fluidly and getting into the car quite smoothly.  Suspicious minds might start to wonder if they really had “that much pain”.

Turning to assessment of pain now, it’s been said that pain assessment should incorporate a number of different dimensions. At the very least, assessment needs to consider the location of pain, the intensity and quality of pain, and some sort of measure of the interference pain has with everyday activities.  Some commentators consider pain assessment should also make a diagnosis of the type of pain disorder present (or the cause of the pain), while others also think that psychological aspects of pain need also to be included (such as pain catastrophising, measures of avoidance and measures of mood and anxiety). And of course, assessments of range of movement, strength and reflexes are also often part of a pain assessment.

Should these measures all present a “consistent” picture?

Where we hurt and what it feels like (the quality of pain) don’t directly correlate with the amount of interference a person experiences from their pain.  If I’m a pianist I might be really bothered by tingling and burning fingers, while less bothered about the same pain qualities in my feet.  If I’m really anxious about my future as a nurse, I might be really concerned about my low back pain. If I’ve developed some effective coping strategies for managing my overall body aching, I might not be particularly anxious or have low mood despite having quite intense pain.

Inconsistency between various aspects of a person’s presentation doesn’t mean they’re faking, or that their pain is not real. It does mean we need to generate some hypotheses about the relationship between the various factors that could be influencing the person’s behaviour. To decide, on the basis of our own experience (which is always limited!) that another person’s pain is not real just because we don’t understand why they are doing what they’re doing, is a judgement call we can’t make, in all honesty.  More than that, it doesn’t help work out what to do next to move the person from being disabled (or getting a benefit they don’t “deserve”) to returning to function.

Personally, determining the validity of a person’s claim to have pain is not the province of a health professional – it’s a task for administrators of a compensation scheme.  We can describe what we see, we might even make a diagnosis, but we can’t tell whether someone’s cheating the system. Bring out the investigators and be honest that health professionals can’t do what some insurers want us to.

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

15 comments

  1. Very well written and shoul be read by anyone with pain or any medical professional who treats or refuses to treat pain sufferers. Pan sufferers are at a real disadvantage because we cannot (YET) measure pain or suffering. If a pain sufferer displays what we commonly interpret as pain (pain behavior) he/she is presumed to be faking itr. However if the same person sucks it up and appears “normal” they are then greeted with the statement: “You don’t look like you are in pain”. I have seen the same comp carrier attorney use each argument when it suits his companies pocketbook!

    There are measurable consequences of pain such as injuries from sudden falls, decreased functional participation with family, school, friends, and sometimes work. Someday we will be able to measure some neuro-electro-physiologic brain or other nervous system activity that are markers for the presence of pain!

    In the meantime, please keep up this extremely usel=ful and TRUTHFUL information!! Thanks

    1. Thank you so much for your kind words. I’ll be writing about how clinicians can work with people who have pain and don’t appear “sick” or appear “too unwell” again soon – it’s so important to help people with pain return to as normal a life as possible.

  2. In the US there are constant news stories of people who are “milking the system,” and just by virtue of receiving disability I worry what people might be thinking when they see me appearing somewhat functional out in the real world. Do they immediately believe that I lied?

    I am blessed to have had a well-established working relationship with my primary care physician when I got sick. I know others with my illness whose pain is under-treated or even completely ignored by their healthcare providers.

    There is a lot of shame in being a chronically ill pain patient, much of it placed there by the media, in my opinion. News articles that minimize the suffering of chronic pain patients and insinuate that no one needs pain medication except in cases of end-stage cancer or severe acute injury do a great disservice to the many people who do not abuse pain medications, choose a multi-modal approach and have improved functionality from the treatment. Then there are pundits and politicos who make examples of the rare person who manipulates the system and could be functional but chooses to be paid a government stipend. All of those stories tend to reinforce a belief set that suggests that anyone can work for a living and provide for themselves and anyone who chooses not to must be a liar.

    I was glad to read this. The days when I feel guilty because I can make it to the store and back and wonder what it must look like don’t seem so condemning anymore.

    1. Thank you so much for your kind words. I agree so much with your observation that it’s only a tiny number who do try to milk “the system” yet these examples are used to slate anyone with chronic health problems. So many people I’ve worked with say how guilty they feel, and often doubt themselves and wonder whether they’re exaggerating – but then the reality of living with pain rises up and reminds them they’re just doing the best they can in a difficult situation. I hope it helps people with chronic pain remember that there is no pain thermometer to let others know how it is today, and no-one looking from the outside can know what it’s really like. At the same time, I hope people with pain also know that there is hope and help to step (one step at a time!) closer to the life they want to live.

    1. Absolutely, feel free to translate it! Hopefully by discussing this issue more openly we can all think about our beliefs about people with pain and maybe help them feel less threatened – and then be able to move forward to wellbeing.

  3. Lovely blog. So well stated, and likely to even shift the contemplators some.
    Particulrly enjoyed the last statement about whose job it is not to validate pain existence or ‘authenticity of disability’
    neil

    1. Thanks Neil. It’s such a difficult topic for some and I hope that by bringing it into discussion it might help clinicians think about their own assumptions. And yes, it’s not a health professionals job to detect faking – I’m not a lie detector!

  4. I love your take on these subjects. I get stuck between frustration and amusement when it comes to experts telling patients how they should feel and behave. I think when healthcare in general refuses to tap into the patients cognitive abilities and help them re-conceive their relationship to their body and pain responses it will fail to fulfill its mission.
    Keep these great posts coming:)
    BJ Erkan
    http://www.bothellintegratedhealth.com

    1. Thanks! I feel the same when I see clinicians thinking they can tell whether a person is faking or not – apparently “years of experience” is equal to “developing intuition” is equal to “really knowing” how someone else experiences their pain! The science of lie detection and popular TV shows don’t quite line up…

      1. Yes the audacity to presume that I know and understand what someone else is going through is absurd. I can not walk in their shoes no matter how much therapeutic intuition I think I have at the ready:) Not to discount sympathy or empathy. How effective can the therapy be when a practitioner wants to blame the patient. I once told a physician that the well-being of the patient is a greater concern to me than the ego of the provider. He doesn’t refer to me anymore:) Go figger…I don’t make it a practice to insult my referral sources but the problem of blaming the patient because of insecurity or the inconvenience caused to the provider is a pet peave of mine.
        I love you blog. We are on the same journey on two different rivers:)
        BJ Erkan
        http://www.bothellintegratedhealth.com

  5. I could not agree more. I am one of millions of people with cronic back pain. I , like others have to go to a Pain Management doctor to get pain medication. The problem with me lies with that fine line in wich doctors “judge” patients when asking for other options for medication or alternative therapies, etc. I personally have been judged of being a ‘drug addict” and it s not fair. since i was 24 (currently 28), i have had to deal with this confusing world of PAIN. Not only has my quality of life been damaged but I my way of looking at life. It s easy for someone to tell you what medecine to take and what to do, but until you have experienced this PAIN, you dont know.

  6. Excellent post! Thanks for speaking out about this topics. Having loved ones in chronic pain and massage clients with chronic pain, I’ve learned not to judge other’s perception of their own pain. Two different people can have the same procedure and react completely different to the physical sensations. It doesn’t mean one person is tougher or stronger than another or that one person is taking and another has “real” pain. My perception of my client’s pain is not as important as their perception. Kudos for shedding light on this important topic!

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