Exaggerated pain behavior: by what standard?

This paper provides a philosophical, historical, and clinical analysis of exaggerated pain behavior, focusing on the nature of the standards used to judge behavior as exaggerated. Malingering is understood as a special case of exaggerated pain behavior. Drawing upon the work of philosopher Ludwig Wittgenstein and psychiatrist-anthropologist Horacio Fabrega, I argue that these standards are primarily moral rather than scientific in nature. Pain behavior is not validated by matching public pain behavior with private pain experience. If this pain experience is truly private, it is not available to scientific investigation. Rather, pain behavior is judged as appropriate or exaggerated through complex assessments of the function of this behavior in its social context. As human social contexts have become more complex through history, so have the accommodations made for sick and disabled members of the group. Criteria for legitimate entry to the sick role have evolved with society, with only modern industrial society placing heavy emphasis on tissue damage demonstrated on medical tests. The highly variable relation between clinical pain and tissue damage, as well as the common problem of medically unexplained physical symptoms in primary care, pose serious challenges to this strategy of illness behavior validation. It will remain necessary to triage suffering presented to health care providers into that which should be addressed in the medical setting and that which is better addressed elsewhere. But we need to discard pseudoscientific reliance on medical tests and develop new standards that are openly acknowledged to be moral and social in nature.