‘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’!!
This is so important! Thanks for posting.
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When many people attempt to get healthcare, the first assumption the healthcare provider makes is that they are “malingering” or “get a payoff” from being hurt. Of course this always applies to women, people of color, and low income blue collar types. The mass media amplified this story over the years, to protect insurance and medical industry profiteers. The found lots of “researchers” willing to study this as long as there was plenty of funding available. No research was ever done on how many people with cancer or other serious medical conditions had care postponed or delayed, while their motivations were examined or their pain was dismissed as a lack of motivation, or “not enough” exercise.
“Researchers” who repeat this industry funded lie, in medical journals or well paid corporate speaking functions, get lots of industry funding. The NIH under the control of corporate insiders is a perfect example. Industry interfered with OSHA regulations, regarding workplace musculo skeletal injuries, 20 years ago. No federal agency is even allowed to count them. As more and more Americans were experiencing chronic pain form workplace injuries, they had to find a way to protect the industries profits. The for profit healthcare industry saw an opportunity here too, as more an more Americans died because they could not afford healthcare. All they had to do was create doubt and smear the sick. There are plenty of paid researchers who are very willing to take millions in industry funding to “study” the motivations of sick people.
quickly googles tests for malingering 3 I found on first page all for psych malingeirng porimarily however interesting stat form one link: Rogers and Shuman (6) found that the use of DSM criteria results in the accurate identification of only 13.6–20.1% of actual malingerers (true positives). However, 79.9–86.4% of individuals are misclassified as malingerers (false positives) using the same criteria. The accurate detection of malingering is thus a pressing societal issue.https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00700/full
changed google terms to include physical pain: Malingering may concern physicians (and insurers), but neither malingered pain nor malingered pain-related disability can be reliably identified using current assessment methods, a study has found.1https://www.practicalpainmanagement.com/treatments/psychological/cognitive-behavioral-therapy/pain-assessment-tools-malingering-patients
(tgis is the source) 1. Tuck NL, Johnson MH, Bean DJ. You’d better believe it: The conceptual and practical challenges of assessing malingering in patients with chronic pain. J Pain. 2018; 20(2):133-145.
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Wow, thanks for your research! It’s frightening to think that we could be accused of malingering when there are 4 times as many false positives as true positives.
I would hope a doctor wouldn’t use some standard method to declare me a malingerer, but these days it provides an easy dodge for docs who don’t want to treat our pain with opioids. But classifying us as malingerers would go into our medical record and then no other doc would dare prescribe us opioids either.
Pain patients are certainly a very vulnerable group these days. In the past we only worried about our pain, but now we have to worry about getting it treated too. It’s hard not to slide into depression in these dark days of winter when the future looks pretty dark too. (My doc retires at the end of the year, but since I’m staying with the same medical group I’m hoping my prescriptions won’t be changed.)