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What to do when a patient is “inconsistent”

Posted Dec 08 2011 2:30pm

I’m a practical person, despite occasional flights of fancy dreaming of a health service that really integrates a biopsychosocial approach for pain management, sigh… Anyway, my intention with this short series of posts about “faking” and “inconsistency” is to:

  • point out that pain is personal and subjective and because of this, we can’t know what it’s like to have another’s pain
  • make it clear that pain and impairment and nociception and disability are not equivalent, so we shouldn’t be surprised when inconsistencies are present across various measures
  • move detection of fraud (malingering or faking for financial gain) out of the health arena
  • help clinicians know what to do when a patient is “inconsistent” – in a way that might help guide treatment

And it’s this last point that is the focus of today’s post – and might even be featured in more than one post.

Pain is a biopsychosocial phenomenon. Disability is also a biopsychosocial phenomenon – and it’s the disability that makes the difference between living well with pain or living as an invalid.  We could replace the word “disability” with the term “interference” because pain can interfere with anything a person wants to, or needs to do in life.  It doesn’t need to interfere completely, though, and that’s why I’m so passionate about working in pain management.  A life with chronic pain can be a very good life, but this seems to be a secret that so many health professionals don’t know, thus don’t share with the people they treat.

What should a clinician do if the person they’re seeing behaves “inconsistently”?

The first thing I’d advise is to be curious rather than suspicious – wondering rather than assuming.

I wonder why Alex is moving more comfortably when pruning the roses than when she’s hanging out the washing?”

I wonder why she says her pain is really bad today but seems relaxed and happy while chatting to the receptionist?”;

I wonder why Chris’s questionnaires show low pain anxiety and catastrophising, but he’s having such trouble returning to work?”

This opens up opportunities for exploring the sense a person is making of his or her situation.

  • Maybe it’s the effect of distraction
  • Maybe it’s about “faking good” with the receptionist
  • Maybe it’s “other factors” that are influencing return to work such as bullying or being socially excluded from the rest of the team

I think people generally do things for reasons that make sense at the time, also as a reflection of the information he or she has about their situation.  For this reason, it seems sensible to explore what the person thinks is going on, and in doing so, begin to generate some hypotheses about why the person is presenting in the way he or she is.  These hypotheses can be tested or verified, and resolution can be progressed.

It’s disability, or interference from pain, that is most profoundly influenced by psychological and social factors. 

By psychological, I’m referring not just to emotions as a response to experiencing pain, but the whole gamut from the attention the brain pays to the sensations that are eventually interpreted as “ouch, that hurt!”, through to the meaning of that “ouch!” as it influences future goals on the basis of what the person thinks the pain might mean – and so on.

And by social, I’m referring to responses from family (or lack of response because there are no family close by), from health professionals and their efforts to “find the cause” or believe/disbelieve the person, and ultimately to the societal attitudes towards people who have that kind of pain, and the legislative systems in which the person finds him or herself embroiled (not to mention the health systems).

For a health professional who notices that a person is not quite responding the way other people with the same impairment (ie injury, diagnosis, tissue damage, disease) responds, it’s only by working through all the above influences and generating a plausible and useful (ie testable) set of hypotheses that might explain why this person is presenting in this way at this time, that it’s possible to understand and address the next steps to help the person return to some of their important goals in life. Remember, as an observer, even the most astute clinician is filtering what they see through their own experiences, attitudes, beliefs and training.  And unfortunately, most of these influences occur without our knowledge (see here for some of the cognitive errors we all fall prey to).

For more on developing a case formulation, or set of working hypotheses, I’ve written several posts here , here , here and here – and yes, there are more, just follow the links.

My “take home” message today? Suspend judgement (it doesn’t help and usually hinders), be open to understanding the person’s reasoning for their so-called ‘inconsistency’, and work with the person to identify the hypotheses that can be tested to verify what is going on.


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