What to do when a patient is “inconsistent”

I’m a practical person, despite occasional flights of fancy dreaming of a health service that really integrates a biopsychosocial approach for pain management, sigh… Anyway, my intention with this short series of posts about “faking” and “inconsistency” is to:

  • point out that pain is personal and subjective and because of this, we can’t know what it’s like to have another’s pain
  • make it clear that pain and impairment and nociception and disability are not equivalent, so we shouldn’t be surprised when inconsistencies are present across various measures
  • move detection of fraud (malingering or faking for financial gain) out of the health arena
  • help clinicians know what to do when a patient is “inconsistent” – in a way that might help guide treatment

And it’s this last point that is the focus of today’s post – and might even be featured in more than one post.

Pain is a biopsychosocial phenomenon. Disability is also a biopsychosocial phenomenon – and it’s the disability that makes the difference between living well with pain or living as an invalid.  We could replace the word “disability” with the term “interference” because pain can interfere with anything a person wants to, or needs to do in life.  It doesn’t need to interfere completely, though, and that’s why I’m so passionate about working in pain management.  A life with chronic pain can be a very good life, but this seems to be a secret that so many health professionals don’t know, thus don’t share with the people they treat.

What should a clinician do if the person they’re seeing behaves “inconsistently”?

The first thing I’d advise is to be curious rather than suspicious – wondering rather than assuming.

I wonder why Alex is moving more comfortably when pruning the roses than when she’s hanging out the washing?”

I wonder why she says her pain is really bad today but seems relaxed and happy while chatting to the receptionist?”;

I wonder why Chris’s questionnaires show low pain anxiety and catastrophising, but he’s having such trouble returning to work?”

This opens up opportunities for exploring the sense a person is making of his or her situation.

  • Maybe it’s the effect of distraction
  • Maybe it’s about “faking good” with the receptionist
  • Maybe it’s “other factors” that are influencing return to work such as bullying or being socially excluded from the rest of the team

I think people generally do things for reasons that make sense at the time, also as a reflection of the information he or she has about their situation.  For this reason, it seems sensible to explore what the person thinks is going on, and in doing so, begin to generate some hypotheses about why the person is presenting in the way he or she is.  These hypotheses can be tested or verified, and resolution can be progressed.

It’s disability, or interference from pain, that is most profoundly influenced by psychological and social factors. 

By psychological, I’m referring not just to emotions as a response to experiencing pain, but the whole gamut from the attention the brain pays to the sensations that are eventually interpreted as “ouch, that hurt!”, through to the meaning of that “ouch!” as it influences future goals on the basis of what the person thinks the pain might mean – and so on.

And by social, I’m referring to responses from family (or lack of response because there are no family close by), from health professionals and their efforts to “find the cause” or believe/disbelieve the person, and ultimately to the societal attitudes towards people who have that kind of pain, and the legislative systems in which the person finds him or herself embroiled (not to mention the health systems).

For a health professional who notices that a person is not quite responding the way other people with the same impairment (ie injury, diagnosis, tissue damage, disease) responds, it’s only by working through all the above influences and generating a plausible and useful (ie testable) set of hypotheses that might explain why this person is presenting in this way at this time, that it’s possible to understand and address the next steps to help the person return to some of their important goals in life. Remember, as an observer, even the most astute clinician is filtering what they see through their own experiences, attitudes, beliefs and training.  And unfortunately, most of these influences occur without our knowledge (see here for some of the cognitive errors we all fall prey to).

For more on developing a case formulation, or set of working hypotheses, I’ve written several posts here, here , here and here – and yes, there are more, just follow the links.

My “take home” message today? Suspend judgement (it doesn’t help and usually hinders), be open to understanding the person’s reasoning for their so-called ‘inconsistency’, and work with the person to identify the hypotheses that can be tested to verify what is going on.



  1. Thank you for a thought provoking article. As a patient with chronic pain, I don’t always think about how problamatic it is for the doctor to understand the nature of my pain. I have been fortunate to have doctors believe I have pain, though I imagine it is more difficult to fully understand it.

    Chronic pain is inconsistent and this makes it confusing for everyone. I can see myself in all three of your examples above where it doesn’t often make sense. I can alter my pain level by my thinking and distraction, but can never take it away entirely. I find I feel less pain when I am engrossed in a conversation, or moving my body around than if I am laying around or doing something I dislike. Doing a puzzle keeps my mind focused and relieves pain more than watching television. Extreme temperatures, illness and stress increase my pain. I can generally push myself for a day or two, but may find myself inactive for a few days as a result. Psychological issues aren’t the whole reason for my pain, but conficts can take me down another level. On the other hand, being positive, breaking down steps, finding new activities I enjoy, and finding support can keep me stable.

    When looking for diagnosis, it is often scary when nothing fits correctly into a box. Everyone has some level of psychologcal issues and trauma that effects what they do and their health. The advantage for some people with pain, is it is more difficult to ignore as it can manifest into phsycial symptoms, and can aid in healing. I continue to look at the psychological, and though it is extremely helpful, it still hasn’t cured me. I am highly positive and “look good” so that a common question I hear is “are you still having health problems”. I can still smile and be in pain, because my new level of “normal” has changed. I have learned to adapt most of the time, but can stil struggle with depression and anxiety, that isn’t noticed unless you dig deeper. My first doctor was very good at regularly asking about my mental health and how I was holding up. Perhaps because she was with me at the beginning of the changes.

    I can understand the complexities of trying to understand if someone is not being truthful about their pain. The reality of addictions to pain medications is real and can create desperate acts by people. I have known several people who fell back into addictions when on pain medications. I have also known many, including myself, who have a better quality of life bcause of them. Really listening to people and asking questions is crucial. Regular monitoring and support could also make the difference for some. Addiction and pain are both medical issues. Hopefully we can do a better job helping those in pain, those dealing with addiction, and those who struggle with both pain and addiction.

    Thank you for your willingness and desire to educate on such an important topic. Your patients are fortunate to have you.

    1. Thanks so much for taking the time to comment, and for your kind words. It means a great deal to me that people who have pain think my posts are helpful. Addiction is a different beast from dependence on a drug – dependence happens to anyone, addiction is the disorder that means a person will cheat, lie, steal and become devious in order to feed the craving.
      Without being conscious, we cannot experience pain. While maybe our body will respond to nociceptive stimuli, and we’ll have physiological responses, it’s that conscious emotional/psychological experience we call “pain” that only we can know – and yet I still find that some even quite eminent researchers don’t fully differentiate between the two phenomenon. The way our brain processes information is “psychological” too, so this includes what our brains decide we should pay attention to, and what sense we make of that experience. And all we have to communicate with in terms of our own experience are words and actions. So it’s hardly surprising that we don’t all do it the same way, is it!
      I’m glad you have found some good ways to cope with having ongoing pain, it seems like you’ve got some really helpful ways under your belt.

  2. Another excellent post! It reminds me of some research I read a while back that found subjects rated pain higher when they thought that someone was doing it to them. I think the opposite might also be true – that they would rate relief higher when they think that someone is doing it to them. You know how it feels better to have someone massage you than to massage yourself?
    SO, being judged falls into the “being done to” category. The psychosocial implications should be obvious to all but the biggest faker-hunting cynic.
    I really do enjoy your posts:)

    B.J. Erkan

  3. I understand your point in your articles. I do think though that the appeoach you are suggesting may be quite costly and time consuming. There is little enough time and money available within our NHS service already. People who are suffering real pain or who need urgent attention should take priority over those whose pain is deliberately exaggerated for personal gain or in order to avoid responsibilities. Yes, Those behaviours should not be medical issues so shouldnt be dealt with as such. One way of doing this would be making sure they ate identified at the earliest possible opportunity and dealt with by referrals to professionals other than those in the medical arena. This may also help the person understand their problems are not medical and help them focus on the cause rather than the symptoms, surely? There is also the cost of disability benefits and people not paying taxes through not working to consider. The priority for medical staff should not be non-medical conditions, even when the symptoms are. These will disappear with treatment in the correct field of expertiese.

    1. Hi Natasha, some interesting points – but my first question is: “How do you identify those people who don’t have medical conditions, deliberately exaggerated for personal gain, or avoid responsibilities?” Given there is no way of determining who has pain and who hasn’t, how would you suggest identifying this group of people? Or would you sideline people on the basis of a personal opinion that they’re feigning their pain? And what if some of the people you sideline turn up with “real” pathology (ie pathology than can be visualised?). How would you tell the difference between someone with migraine (no diagnostic tests to verify they are “real”), dysmennorhoea (no diagnostic tests to determine pain there), and someone with “real” pain? Would it be related to whether you believe them? or whether you think they “deserve” treatment? or only treat those people with blood pouring out or a bone poking through the skin?
      Would you be willing to tell that person that they don’t “deserve” treatment? And who do you think they should see? Just a few questions for you to ponder.

    2. I have a couple of questions for you to ponder: How do you want to identify those people you think don’t suffer “real” pain, are using their “pain” for gain or are “deliberately” exaggerating? Would you do this on the basis of your opinion? And would you apply the same yardstick to people with migraine (no diagnostic test available), dysmennorhoea (no diagnostic test available) – or only give treatment to those people with bloody wounds, bones pushed through the surface, or who fit with your beliefs about what people look like when they’re in pain? And would you be prepared to tell those people “I’m sorry, but I don’t believe you have real pain, go away”? Do people with pain and difficult pain behaviours deserve this kind of judgement? They need help and you’re quite correct, their problems don’t fit the biomedical model – but they need and deserve help from people who have taken the time to learn about chronic pain from a modern neuroscientific perspective, not those who confine their understanding to rather outdated notions of what pain is.

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