Why can he go surfing but can’t do the vacuuming?

Social contract theory is a theory drawn from evolutionary psychology – a ‘cheater detection’ system if you like. Following on from yesterdays post about detecting faking in pain, this study examines the judgements observers (in this case, friends and relatives of people with pain) in a study where four vignettes were presented. Each vignette varied in terms of four cues: the person continuing or stopping liked tasks, continuing or stopping disliked tasks, the availability of medical evidence, and the pain intensity as rated by the person.

Many variables have been studied with respect to how accurately observers judge another person’s pain – attractiveness, gender, ethnicity, social class, as well as the context (return to work or post-surgical), and the characteristics of the observer (parent, caregiver, spouse, clinician).

Results from past studies have included: unattractive patients were judged to suffer from more pain than physically attractive patients (Hadjistavropoulos et al.1990, 1996, 2000). Generally, higher reported pain intensity appeared to invite higher estimated pain intensity. When comparing sufferers’ self-reports and observers’ estimates, however, low reported pain intensities were overestimated and high reported pain intensities were underestimated (Chibnall and Tait 1995; Chibnall et al. 1997; Krokosky and Reardon 1989; Tait and Chibnall 1997; Zalon 1993).

For health professionals, some studies found no associations (Dudley and Holm 1984; Everett et al. 1994; Hamers et al. 1997; Oberst 1978; van der Does 1989), others found that less experienced observers gave higher pain estimates than did more experienced observers (Mason 1981; Perry and Heidrich 1982; Lenburg et al. 1970).

In terms of contextual cues, the absence of medical evidence to support the person’s report of pain has been associated with lower estimates of pain.

Yesterday I briefly discussed the idea of malingering being the purposeful faking of health problems in order to gain financial benefit: in this study, the evolutionary value of the ‘social contract’ is used as the theoretical model for evaluating our sensitivity to these responses. Social contracting is a situation where the ‘‘individual is required to pay a cost, or meet a requirement, to an individual (or group) in order to be eligible to receive a benefit from that individual’’ (Cosmides 1989, p.197).

It makes sense that as humans we have some systems developed to determine whether we are being exploited and that the normal ‘contract’ between people is being disturbed. There is empirical support for humans being sensitive to cues for cheating from both human and animal studies (Cosmides 1989; Gigerenzer and Hug 1992;Wilkinson 1990) – but as we saw yesterday, we can be deceived reasonably readily, so it makes sense for us to be particularly sceptical about situations where we may be manipulated.

In a situation where one person is likely to receive benefits (caring or free food, for example) because of their reported pain, it makes sense for the observer to be more aware of cues suggesting that the individual receiving the ‘benefits’ is not actually in pain (Williams 2002). This has been studied before, and it has been found that suspicion of cheating or faking leads to conservatism and underestimation of pain. This can explain why such weight is given to medical evidence by health care professionals even when the relationship between ‘evidence’ from radiology and pain, for example, is fairly weak. This is especially true in cases where time off work, or other ‘special’ treatment is given as a result of confirmation of a ‘real’ problem.

The hypotheses in this paper were:
– the combination of two behaviours (continuing liked and
stopping disliked activities) would be judged as unfair
and lead to lower pain estimates, whatever the level of
– there would be no effect on pain estimates of the
presence or absence of medical evidence, and
– pain as reported by the patient would affect pain
estimates by relatives

Although the results were from a very small group of respondents in the end (only 23% of the initial group recruited actually responded with complete questionnaires), some interesting findings were obtained.
– people who stopped doing things they liked were interpreted as ‘having to stop’, and this was perceived as fair
– people who stopped things they didn’t like but continued with things they did like, were perceived as being unfair
– behaviour of characters reporting high pain was estimated to be fairer

The authors suggest that perhaps greater pain meant greater recognition of the cost in pain incurred by doing any tasks, or that more leeway was exercised in judgements of behaviour as fair or unfair.

– more pain was attributed to patients who stopped liked tasks
– highest pain levels were assigned to patients having stopped both liked and disliked activities
– lowest pain estimates were assigned to patients who had stopped disliked but continued liked chores, the combination which also received the lowest fairness ratings

The authors comment that these findings ‘support our hypothesis concerning lowering of pain estimates by individuals close to someone with persistent pain if they judge patients to be behaving ‘‘unfairly’’, that is, ‘‘accepting the benefits’’ of having pain—of being permitted not to do some tasks—‘‘while not meeting the requirement’’—of being unable to do other preferred activities.’

– participants’ estimates were not significantly affected by presence or absence of medical findings in this sample

– higher given pain intensities led to higher estimated pain intensities
– there were systematic discrepancies in estimates since low given pain intensities were estimated as higher and high given pain intensities as lower.

Some food for thought – this is a first cut study using social contract theory as a framework for determining a priori predictions as to which cues are salient, and in which direction. I look forward to finding out more on this – it may help us help our patients reflect on their behaviour, as well as the ways in which family members interpret and respond to patient’s behaviour.

There are some limitations to this study – in particular the small sample size, and the use of written vignettes rather than video-recorded scenarios. But for making us think? I think it’s great.

If you’ve enjoyed this post, there will be more tomorrow – and don’t forget you can use the RSS feed above to subscribe, or you can simply bookmark this page and come on back! I love comments and always respond, so don’t forget to let me know what you think of the topics I cover (***pssst! I don’t bite!***)

Kappesser, J., C. Williams, A.C. (2008). Pain judgements of patients’ relatives: examining the use of social contract theory as theoretical framework. Journal of Behavioral Medicine DOI: 10.1007/s10865-008-9157-4

Faking and malingering (again!)

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