It’s amazing how often health providers get asked directly or indirectly whether someone experiencing pain is ‘faking’ it. The short answer is the most accurate – we can’t tell.
Remember the biopsychosocial model of pain states that the experience of pain and pain behaviour is influenced by three broad groups of factors:
- the biomedical/biophysical factors such as extent of tissue disruption at the periphery (or site of trauma),
- neurological changes of transmission and transduction (throughout the peripheral and central nervous system), and
- disturbance of the neuromatrix.
At the same time, there are psychological factors such as the level of alertness and arousal, attention, past learning, expectations, beliefs, attitudes, mood, contingencies and so on.
And there is also a range of social factors such as the presence or absence of social support, the systems in which the event occurs (such as compensation, availability of health care and technology), cultural expectations, religious beliefs at the same time as the other two factors.
Recall that pain is not the same as pain behaviour – pain behaviour is everything that we do in response to pain, including involuntary physiological responses (flushing, sweating), reflexes (withdrawal), verbal utterances (groans, gasps, requests for help), as well as complex behaviours such as reaching for medication, going to see a doctor, asking for time off work etc.
So, it’s easy to see that pain behaviours vary hugely between individuals even if the original trauma is exactly the same.
The problem is – we’re not very good at telling who is and is not lying
Another reason for wanting to know ‘is he faking’ is how far to ‘push’ the person into doing more. The underlying concern is ‘will I cause harm’.
BUT the question is based on the assumption that there ‘should’ be a certain amount of pain behaviour for a certain amount (or length of time since) tissue damage. And there simply isn’t.
Some allied questions….‘can’t you use functional capacity testing to work out whether someone’s faking?’ No – sorry. A functional assessment, just like any physical examination or test, tells you what the person will do, and perhaps how consistently they will do it – today. Few, if any, FCE’s have demonstrated predictive validity – that is, they don’t accurately predict how much someone will or won’t do in a day-to-day ‘real’ situation, in fact they won’t tell you what the person can and cannot do at all.
Patients are in same dilemma. We can force ourselves to do something that causes us even extreme pain, yet this is only an exception and not maintainable.
But surely some people do fake! Yes – but it’s not a health or medical matter. It’s just not helpful to work out whether someone is or isn’t faking. What happens if you do somehow detect ‘faking’? Confront the person? Take their health care away? Tell them to pull themselves together?
It’s more helpful to think about what factors might be initiating and then maintaining this behaviour – then start to work on these variables to promote change.
But I’ve seen even eminent researchers use the term ‘exaggerated illness behaviour’. Yes, well, even eminent researchers can be mistaken! All that we can observe is that this person behaves in this way at this time in this setting, and the person attributes the behaviour to pain (or illness).
Malingering? Faking? Exaggerating?
don’t ask me to work out whether someone is faking it, just ask me to help them move forward.
This is the crux of the situation. We are trying to get well, and even if the doctors think we are lying, they should at least examine why we feel the way we do and how we might best treat it.
This paper by Michael Sullivan is a little philosophical, but at the same time illustrates the points I’ve tried to make above. This reference is from the 2001 version of the New Zealand ‘Yellow Flags’ document on acute low back pain management.