The stigmatization of patients with chronic pain due to assessed exaggeration of symptoms

Patients with chronic pain that cannot be explained by tissue abnormality may be accused of symptom amplification and at worst malingering. This is particularly relevant in the medicolegal setting where legal decisions are highly dependent on objective and validated information, conditions mostly lacking in the setting of chronic pain. When evaluations are conducted by assessors less familiar with current knowledge of pain mechanisms, subjective complaints of pain and associated symptoms such as fatigue and cognitive difficulties, are at risk of being misinterpreted leading to bias and stigmatization. In this commentary we will highlight some of the pitfalls that erroneously lead to a biased assessment of pain severity including failure to pay attention to psychological state and sociocultural influences, application of poorly reliable physical maneuvers, and use of neurocognitive testing of intentional cognitive dysfunction as a surrogate for dishonesty in pain and functional impairment report. Concerns about misinterpretation of exaggeration in persons with chronic pain are highlighted by recent report of symptom exaggeration in up to two thirds of those attending for an independent medical evaluation. Directives to help the medical assessor to provide pertinent information that will assist the courts in reaching a fair decision are discussed, with emphasis on need for a comprehensive assessment of biosocial factors, contextual variables and nonphysical evidence.