Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss

Appendix 2: Inconsistent findings and pain behaviour are not the same thing as malingering

Pain behaviours are a normal part of the experience of pain and serve the important purpose of communicating to others - it is normal for people suffering pain to exhibit these behaviours.

The expression of pain behaviour is influenced by our upbringing, our culture, and the circumstances at the time. The behaviour observed in patients is usually a result of fear of being hurt and injured.

Pain behaviour, like any other behaviour, is subject to the effects of learning and reinforcement - the longer a pain problem goes on, the more opportunity there is for learning to occur from a wide range of influences. This is the main reason that some individuals with chronic back pain present with what appear to be unusual behaviours.

Learning often occurs by association. It is very significant that many people with back pain learn to associate irrelevant or less important factors with their subjective experience of pain. That is, an individual may associate a particular activity or movement with pain despite the lack of a real causal connection. This learning is unintentional, usually due to inadvertent reinforcement, and is often referred to as ‘learned irrelevance’. For example, a person with back pain may inadvertently associate going for a walk with a natural variation in their subjective pain severity and subsequently feel fearful about this activity.

It may be thought of as the development of a type of ‘superstitious’ behaviour. Those people who have developed ‘learned irrelevance’ will present with behaviours that are inconsistent with other aspects of the clinical assessment. For this reason they may appear unusual to clinicians with behaviours that are not easily explained. This should not to be misinterpreted as a sign of psychological disorder.

To summarise, pain behaviour is a normal part of being human, and is subject to wide individual differences and the effects of learning.

In contrast, malingering involves the intentional production of false or grossly exaggerated symptoms, motivated by obvious external incentives. Malingering is not the product of unintentional learning or emotions, such as fear of pain.

Interpreting the presence of pain behaviours and inconsistencies as malingering has not been demonstrated to help the patient or the clinician. The inevitable consequence of making that interpretation is an adversarial ‘them against us’ situation. Inconsistent behaviours may exist because the person with back pain perceives that they have little or no control over managing the problem. Many risk factors are, or are perceived to be, beyond the control of the person with back pain.

The goal of identifying Yellow Flags is to find factors that can be influenced positively to facilitate recovery and prevent or reduce long-term disability and work loss. This includes identifying both the frequent unintentional barriers, and the less common intentional barriers to improvement.