Faking or Malingering or Exaggerated Pain Behavior

‘Faking’ or ‘Malingering’ or ‘Exaggerated Pain Behaviour’ | HealthSkills Blog – 2008

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. We’re not lie detectors, there is no ‘gold standard’ to work out whether someone is pretending or not, and the question is based on erroneous thinking about pain and pain behaviour.

pain is not the same as pain behaviour –

This is a truism because pain is something that happens to a person and pain behavior is the person’s reaction, some involuntary, some voluntary.

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.

it’s easy to see that pain behaviours vary hugely between individuals even if the original trauma is exactly the same

I can understand several things about the question ‘can you tell if he’s faking’.

Pain behaviour elicits strong emotions in observers – it’s designed to do just that! It communicates, and something we like to do as humans is work out whether someone is lying or not.

The problem is – we’re not very good at telling who is and is not lying (but we like to fool ourselves that we personally don’t fall for liars!).

pain can’t be measured directly, we have to use pain behaviour as the next best thing – and pain behaviours are influenced by a whole lot of things.

The assumption is that there “should” be a certain amount of pain behavior in response to a certain intensity and duration of pain arising from tissue damage. And there simply isn’t.

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.

even eminent researchers use the term ‘exaggerated illness behaviour’

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).

Here I wonder whether it’s correct to call “flinching” or sudden vocalizations like “ouch!” as a “behavior”. These strike me more as reflexes because they are difficult to suppress.

Malingering? Faking? Exaggerating?

When someone can tell me why yellow is better than blue, or find a measure of the ‘chocolateness’ of chocolate and the banana-ness of a banana, perhaps we may have found an objective pain measure. Until then, don’t ask me to work out whether someone is faking it, just ask me to help them move forward.

What a wonderful attitude!

just for fun – words used to suggest that someone is ‘faking’:

• functional overlay
• supratentorial factors
• a ‘genuine’ man (as opposed to a fake one, or one that is faking)
• adopting the ‘sick role’ (if someone believes they are sick/unwell, what can we expect? How many people do we see ‘adopting the well role’?)
• demonstration of non-organic signs

It’s actually quite hard to come up with good (quality, evidence-based) references on ‘malingering’.

By far the majority of articles I located using Google, searching on the terms ‘malingering pain behaviour’ suggested that somehow ‘medical people’ or ‘psychologists’ or ‘psychiatrists’ using special tests can identify malingerers. Someone please show me the ‘special test’!!