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Pain Assessment Tools for Malingering in Patients with Chronic Pain

Plus: Differentiating between this exaggeration and factitious disorder, somatization, and pain catastrophizing.

With Natalie Tuck, PhD, David Cosio, PhD, ABPP, and Debbie J. Bean, PhD

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.1

Malingering is characterized as “the intentional production of false or grossly exaggerated physical or psychological problems, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs” according to theAmerican Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).Among patients with chronic pain who have a financial incentive to malinger, prevalence is estimated to be between 20% and 50%.3 Nonetheless, the authors, based in New Zealand’s Auckland Regional Pain Service (TARPS), declared in their study that, “malingering is of little relevance in the treatment and management of chronic pain conditions.”

Differentiating between this exaggeration and factitious disorder, somatization, and pain catastrophizing. (Source: 123RF)

Problems in Theory & Practice

The traditional biomedical model of pain links pain and disability to tissue damage caused by wear and tear, injuries, or disease. Today, pain is understood as subjective, and a chronic pain diagnosis often relies on a patient’s report of their “symptoms and distress,” according to the researchers. Thus, “continued efforts to identify malingered pain are incompatible with the current biopsychosocial model of chronic pain and advances in pain science.”

Researchers examined dozens of studies on malingered pain assessment tools, including Waddell and behavioral signs; effort bias and functional capacity evaluations; self-report questionnaires; and tiered diagnostic criteria. Each method had significant limitations, as described in the researchers’ paper:1

  • Waddell signs and behavioral signs: Pain behaviors, which may include everything from complaints to facial expressions to the use of assistive devices such as canes, are considered observable responses to pain. This assessment tries to identify patients who exhibit different pain behaviors when distracted, report skin tenderness, or display behavior patterns that are “considered exaggerated or inconsistent with known pathology.”

Objections to this approach: Since pain fluctuates, variations in pain behaviors are to be expected. Skin tenderness is now recognized as a symptom of central sensitization, a condition in which the nervous system detects pain at lower thresholds.4

  • Effort bias/functional capacity evaluations:Patients’ strength is tested via various tests, and results, when analyzed, are supposed to indicate whether a patient has used less than full strength (known as effort bias). Such patients may be making an insincere effort, and might be malingering.

Objections to this approach: Patients might not use maximum effort because they’re afraid of sustaining more pain or another injury.

  • Self-report questionnaires/symptom validity tests: Patients use checklists to report their symptoms. High scores could indicate that patients are exaggerating.

Objections to this approach: Such tests are either poorly designed or not validated in chronic pain patients. They are often prone to a high rate of false positives.

  • Tiered diagnostic criteria: Clinicians use multiple methods, including physical exams, symptom validity tests, evidence of external motivations, and other measures to identify possible malingerers.

Objections to this approach:Tiered diagnostics have not been sufficiently validated in patients with chronic pain and may be at odds with current models of chronic pain.

These assessment methods may also be problematic because, “We have no group of definite pain malingerers that can be used to test the accuracy of any proposed test/assessment of malingered pain,” lead study author Natalie Tuck, PhD, of the University of Auckland's Department of Psychological Medicine and TARPS, told PPM. “There is no consensus on how common or rare malingering is.”

Thus, the actual number of people who malinger in clinical samples is unknown, as is thelikelihood that an assessment will incorrectly identify a patient as malingering, or fail to detect true malingering,she explained.

Is it Really Malingering?

“I am not surprised that the researchers found that neither subjective clinical opinions nor clinical detection methods can reliably identify malingering in patients with chronic pain,” said David Cosio, PhD, ABPP, psychologist at the Jesse Brown Veterans Administration Medical Center in Chicago, IL, and member of the PPM Editorial Advisory Board.

He continued, “It is common for providers to use the terms malingering, factitious disorder, and somatization interchangeably. This is a group of illnesses where patient-reported symptoms have no medical explanation. These diagnoses differ in whether the patient is deliberately misleading the physician and agreeing to unnecessary treatments and diagnostics tests.”

Factitious disorder is a mental condition in which a person either lies about or creates medical symptoms for attention and sympathy. Many patients with factitious disorder do not recognize their behaviors as deceptive; some have other mental health problems as well.5

Somatization refers to various ongoing physical symptoms with no known cause;6 people with somatoform disorders (now known as somatic symptom disorder) struggle with disruptive or upsetting thoughts, feelings, or behaviors caused by their symptoms.7 The condition is common among patients with chronic pain conditions.8

Dr. Cosio provided the following chart to help clarify the difference between these three interchangeable terms:

“When they see these diagnoses, providers jump to the conclusion that a patient is ‘faking it,’ often times without gathering sufficient evidence to support that conclusion,” Dr. Cosio said.

Unfortunately, when a patient’s pain report is doubted, he or she may be more likely to have “poorer outcomes in terms of both reported pain and functional disability, potentially leading to misdiagnosis, improper treatment, increased litigation, and increased cost of care,” the study noted.

Where Does Pain Catastrophizing Fit In?

“Pain catastrophizing” is another term that may come up in discussions of malingering, though it is better described as “negative regulation of pain” or “negative pain appraisal” according to Dr. Beth Darnall’s team at Stanford University. It “refers to the tendency to think about pain in an anxiety-provoking manner, and it is common for people living with chronic pain to score high on pain catastrophizing [scales],” explained Dr. Tuck. “Unfortunately, some of the proposed tests of malingering are likely to be confounded with pain catastrophizing, and this means that people with chronic pain that are high in catastrophizing may be at greater risk of being mistakenly identified as malingering.”

“It is possible (though to our knowledge untested) that catastrophizing would be associated with symptom exaggeration,” study co-author Debbie J. Bean, PhD, of the Department of Psychological Medicine at the University of Auckland, told PPM. “For example, if a person fears that activity such as work would lead to worse pain or tissue damage (this may be considered catastrophizing), they may be more likely to exaggerate symptoms when sent for a medical assessment designed to determine work capacity, due to genuine concerns about their condition.”

Opioids and Malingering

Should malingering concern physicians who prescribe opioids for chronic pain? The DSM-5 includes “obtaining drugs” as a motivation for malingering, and a 2015 study found that opioid addiction rates average between 8% and 12% among chronic pain patients; misuse rates averaged 21% to 29%.9 On the other hand, “Opioids are only a small part of chronic pain treatment,” Dr. Tuck pointed out. Only 3 to 4% of US adults are prescribed long-term opioid treatment.10

Furthermore, current CDC guidelines11 advise clinicians to prescribe opioids only “in conjunction with building functional capacity and/or developing cognitive, emotional, and behavioral strategies for managing pain,” Dr. Tuck said. “So even if a patient were ‘faking’ their pain to acquire medications…it is reasonable to assume that with appropriate treatment, people will be less incentivized to acquire opioids” via malingering.

“The research shows that people tend to be honest when it comes to their substance use disorder (SUD),” including opioid use disorder (OUD), Dr. Cosio pointed out. “One study found that only about 9% of chronic pain patients provided incorrect self-report information about current drug use, and the incorrect information was mostly about illicit drugs (ie, cocaine and cannabis).”12

“I would prefer to focus less on whether a patient is ‘malingering’ and focus more on how to adequately assess for SUD,” he added.Chronic pain patients have high rates of SUD;13,14 in one study, nearly 65% of patients with OUD also had chronic pain, which preceded the OUD diagnoses in close to 62% of cases.15

Meanwhile, "there are likely to be instances in which it is helpful for a malingering patient to be identified as this stage, none of the proposed tests of malingering have been sufficiently validated to be used in the context of chronic pain," Dr. Tuck said. "This means that there is no way for a physician to know whether or not a person is malingering, beyond asking them."

Last updated on: May 17, 2019
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Pain Catastrophizing: What Practitioners Need to Know
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