Focus Article| Volume 20, ISSUE 2, P133-145, February 2019

You'd Better Believe It: The Conceptual and Practical Challenges of Assessing Malingering in Patients With Chronic Pain

  • Natalie L. Tuck
    Auckland Regional Pain Service (TARPS), Auckland, New Zealand.

    Department of Psychological Medicine, University of Auckland, Auckland, New Zealand.
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  • Malcolm H. Johnson
    Department of Psychological Medicine, University of Auckland, Auckland, New Zealand.
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  • Debbie J. Bean
    Address reprint requests to Debbie Bean, PhD, Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, FMHS, 12th Fl., Park Rd. Grafton, Auckland, New Zealand.
    Auckland Regional Pain Service (TARPS), Auckland, New Zealand.

    Department of Psychological Medicine, University of Auckland, Auckland, New Zealand.
    Search for articles by this author


      Chronic pain is a prevalent and costly condition, with many patients receiving income support and funded treatment. Given that pain cannot be assessed objectively, patients may be suspected of exaggerating their pain and disability to receive additional funding. Although numerous methods of detecting malingering have been suggested, it is unclear whether clinicians can reliably identify malingering in patients with chronic pain. The present focus article was developed to assess the theoretical basis and empirical support for proposed methods of detecting malingering in patients with chronic pain. Five approaches were identified: the evaluation of behavioral signs, effort testing, pen and paper measures, symptom validity tests, and combined methods. An examination of the literature revealed that proposed assessment tools have little theoretical basis or empirical support in patients with chronic pain. Additionally, assessment tools are inconsistent with advances in pain science and scores or observations are likely to be influenced by the typical features of chronic pain, including fear-avoidance and central sensitization. Clinicians should be aware that as yet neither subjective clinical opinions nor clinical detection methods can reliably identify malingering in patients with chronic pain.
      Perspective: There is interest in the development of assessment tools to detect malingering in patients with chronic pain. An evaluation of methods reveals theoretical and empirical limitations that undermine the usefulness of these approaches. As yet, there is no reliable way for clinicians to identify malingering in patients with chronic pain.

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