Fake News! Faking or Malingering Pain.

There’s been a lot of talk around the term fake news in the media. Mr Trump (I can’t believe he got a mention in my blog!) is a master of calling out fake news and it was so popular it was named word of the year in 2017 (reference).

Fake News is the term given to deliberate misinformation spread via the likes of glossy magazines and social media.  The behaviour behind fake news has many aspersions, it almost certainly is designed to attract attention.

Faking or Malingering is a term often thrown around in healthcare when someone is accused of behaving in a way for personal gain be that financial or to get out of work. In persistent pain because there is no objective way to tell how much pain someone is in pain behavior is the only means the individual has to express the distress they experience. Pain is unpredictable, invisible, variable, contextual, and can make the individual feel like they are treading on eggshells a lot of their time.

Whether you feel someone is ‘faking It’ or not there is always a reason for the individual to behave in the way they do. You might just not know those reasons.

A person’s behavior is contextual. What do I mean by this? Well let’s take spiders as an example. My partner hates them! It doesn’t matter what size they are, whether she sees a picture of them even to talk about them or describe them she reacts in a very different way to me.  I’m her knight in shining armour when I remove a spider from the house. Now, I might think that she is over-reacting but when it comes to wasps, there is a reversal in behavior. Ewww, I can feel my hairs on my neck standing up as I write this.

If I take a biopsychosocial approach to the above example and break it into 3 parts.

Biophysical factors would be sighting of the spider or hearing the description of the spider and the bodily reactions that occur, such as being twitchy or running away

Psychological factors would be my partner’s opinions of the spider and the fact that she believes that spiders move towards her.

Social factors would be that my partner doesn’t want the thing crawling around her home and that I’m her knight when it comes to getting rid of spiders (which I do in a humane way).

So, based upon our past experiences, beliefs, development, the environment, feelings, your level of arousal, your interactions all have an impact on how we appraise a situation.

What’s this got to do with faking you ask? Well, this means we can’t actually tell if someone is faking or malingering. Pain behavior is the thing that we do in response to pain be it avoidance or pushing through pain, sweating, grimacing, tensing, shallow breathing, breath holding etc.

To truly determine whether someone is ‘faking it’ this is the realm for the courts or a private investigator and is not down to the clinician to make those assumptions. In fact, if a clinician is deciding to label someone as faker then I would question that the clinician is at fault and unable to determine why the individual living with pain behaves in the way they do at that moment in time (Sullivan, 2004).

So, how do I identify this?

Well, first of all in the case of persistent pain there may not be an ongoing physical cause (i.e. tissue damage) despite there almost always being an inciting evident that did. So, sending people of for scans when you are scratching your head will unlikely give you the answers. Asking broader questions (from a yellow flag perspective) about the persons situation from a biopsychosocial perspective may help to determine why the person is presenting in the way they do. It’s best to stay open – minded and don’t judge the person. Don’t use psychosocial screening as means to confirm your suspicions that the person is faking it or malingering (Kendall, N. A, Linton, S.J, Main, 2004).

You could also use consider contextual factors to determine how the individual behaves. Graded Exposure is a good way to address how people behave in certain situations.  The use of variability in a rehabilitation setting may help to determine why a person behaves in the way that they do. Pain is closely tied to context and so placing the individual in an environment or performing a task that they associate with their pain (classical conditioning) could provide some clarity.

You may also want to monitor biological factors and one way is via heart rate. Anxiety and stress can be recorded via heart rate. The way to do this is to record an individual’s baseline heart rate and then ask the individual to perform the activity that they display pain behaviours towards and then identify if heart rate increases significantly. Remember if you are asking someone to exercise then heart rate will naturally increase. However, performing a task or movement that they are avoidant of should not see a significant increase in heart rate. Using objective measures like this can allay concerns that we may be doing more harm.

Finally, if we are not physically exerting people to an extreme (although this may be want some people want) that we are causing harm, we can place positive affirmations on how their bodies are changing in response to load, such as the body adapts, tissue becomes resilient to load and activity and that we are dealing with sensitivity rather than tissue damage. This can help to reinforce the message that hurt does not equal harm.

Thanks for having a read

TNP

References:

Kendall, N. A, Linton, S.J, Main, C. J. (2004). New Zealand Acute Low Back Pain Guide. New Zealand Guidelines Group.

Sullivan, M. (2004). Exaggerated pain behavior: By what standard? Clinical Journal of Pain, 20(6), 433–439. https://doi.org/10.1097/00002508-200411000-00008