Predicting Positive and Negative Symptom Exaggeration in Chronic Pain Patients

Sometimes, chronic pain patients intentionally magnify or downplay their physical and mental symptoms during office visits. Despite that fact, little attention in the clinical setting is paid to underlying motives for positively or negatively biased self-reports.

For their pair of scientific posters presented at the American Academy of Pain Medicine (AAPM) Annual Meeting, held March 6-9, 2014, in Phoenix, AZ, a team of 4 psychologists from Colorado reviewed the existing medical literature on patients who consciously fake good or bad, as well as collected their own data to discern potential predictors for both positive and negative symptom exaggeration among chronic pain patients.

In terms of previous research findings on faking good in chronic pain, the authors said one study publish in The Clinical Journal of Pain showed that “patients who were trying to portray themselves in a more socially desirable manner reported less depression and anxiety, but higher levels of pain severity and disability, (so it) concluded that social desirability response biases should be considered in both research and clinical assessments of chronic pain patients.” Consistent with the belief that internal motivators for social gain cause patients to deceitfully portray themselves in a positive light, additional studies have found “patients may underreport alcohol consumption, substance abuse … color blindness, and depression.”

“Although little research has been conducted on this phenomenon, there would seem to be a number of scenarios where patients would be incentivized to fake good. For example, as many opioid treatment guidelines conclude that patients with histories of substance abuse or psychopathology may be at poor risk for chronic opioid therapy, this may incentivize patients to conceal that,” the researchers pointed out. “Overall, there would appear to be multiple scenarios where the patient may fear that disclosure of important but socially undesirable information may lead to being stigmatized or denied the type of care that the patient desires.”

On the other side of the symptom exaggeration coin, the investigators noted “a retrospective review of 508 patients diagnosed with chronic pain conditions over a 10-year period … found malingering was present in 20-50% of patients seen for potentially compensable injuries” — a recognized incentive for faking bad, along with gaining access to opioids or other medications. A second study of 73 patients diagnosed with complex regional pain syndrome (CRPS) discovered three-quarters of the subjects failed one of the administered performance validity tests, which “suggests that their motivation was suspect,” while a third study of disability applicants “estimated that 19% of the claimants were malingering.”

For their own research on positive and negative biasing, the authors conducted 2 separate studies of data collected from 346 patients who were being treated for chronic pain across 108 sites in 36 states. In the positive malingering study, 50 of those chronic pain patients were chosen at random, while another 50 were instructed to subtly fake good to “appear better than they really are, without faking in so extreme a manner that others might detect it.” The negative malingering study used the same methods, except the additional 50 chronic pain patients were asked to subtly fake bad in the same manner.

In both studies, 10 Battery for Health Improvement 2 (BHI 2) variables were tested as potential predictors for faking good or bad status, which consisted of depression, anxiety, hostility, borderline personality disorder (BPD), somatization disorder, pain level, functional complaints, muscular bracing, symptom dependency, and defensiveness.

The researchers’ faking good regression analysis identified defensiveness and pain scale scores as independent BHI 2 variables that were significant in predicting malingering. According to the authors, “these variables produced a regression equation that accounted for 65% of the variance between the (chronic pain patients and faking good) groups (and) led to the correct prediction of faking good status 83% of the time” — a finding they said “may have clinical utility.”

“Faking good status is often overlooked in the clinical setting, but by identifying patients who are positively biasing the information that they are presenting, symptoms that the patient is concealing or minimizing are more likely to be detected and receive appropriate treatment consideration,” the investigators concluded.

On the negative malingering side, the authors found symptom dependency, BPD, functional complaints, and muscular bracing scale scores were significant predictors of faking bad, as a combination of the 4 “produced a regression equation that accounted for 56% of the variance between the groups (and) led to correct prediction of faking bad status 82% of the time” —another finding with potential use in clinical practice.

“Faking bad status increases the risk of overtreatment or compensation for medical conditions that are not objectively present; (thus) the determination of faking bad status can help to provide for appropriate care in those with objective conditions and reduce the risk of iatrogenic complications,” they concluded.