You'd better believe it: The conceptual and practical challenges of assessing malingering in patients with chronic pain.

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.