Weaving a tangled web: The psychology of deception and self deception in psychogenic pain

Soc. Sci. Med. Vol. 20, No. 5, pp. 517 527, 1985

0277-9536/8553.00+0.00 Copyright ~ 1985 Pergamon Press Lid

Printed in Great Britain. All rights reserved

W E A V I N G A T A N G L E D WEB: THE P S Y C H O L O G Y OF D E C E P T I O N A N D SELF D E C E P T I O N IN PSYCHOGENIC PAIN TIMOTHY L. BAYER Department of Psychiatry, Baylor College of Medicine, Houston, TX 77030, U.S.A. Accounting for the unusual economy of secondary gain or reinforcement, understanding abnormal illness behavior and evaluating for the role of the unconscious and primary gain are three important problems which complicate the understanding of psychogenic pain. These problems might be addressed in part by an examination of the experimental studies of the social psychology of deception of self and others. The forced compliance situation, in which subjects who lie for a certain level of compensation persist in telling the lie in other settings, is one of the best studied of these experimental situations. Ways in which this experimental work might apply to problems in understanding pain patients are explored. Possible applications of this research to treatment are discussed along with areas for further research. Abstract

Most physicians accept the idea that psychological factors can influence and alter symptom reports and particularly reports of pain. However, finding a useful and reliable model to explain this phenomenon has been difficult. Complaints of pain involve the subjective reporting of an internal state to an observer who can only make partial inferences about the accuracy of the complaint. These inferences are based on the patient's observed behavior and on the medical evaluation of the body changes which are suggested by the complaint. Both of these types of information have been shown to fail to reliably relate to pain complaints. Patients are seen who report pain in excess of what would be expected on the basis of their medical examination. Patients are also seen who behave in ways which are different from normal illness behavior. In evaluating and attempting to understand such patients several problems arise. This paper is an attempt to describe three of the problems which occur when pain patients are considered under existing models. An area of psychological investigation which examines an experimentally induced form of deception referred to as the forced compliance situation will be described in order to determine whether this experimental work can suggest solutions to these three problems. Possible contributions of this research literature to the treatment of pain patients will be described. Suggestions will then be offered for areas of further investigation which might lead to further development of a model, derived from experimental investigation, for the psychology of pain. Most of this discussion will apply specifically to what are called psychogenic pain disorders as defined in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III) [1]. As will be seen in the discussion, the defining criteria for this syndrome are sometimes hard to apply and patients are often seen who fail to exhibit the evidence required in the criteria for psychological etiology but who have persisting unexplained pain complaints. Numerous other terms have been used to describe this broader class of patients who present with persisting un-

explained pain. One general term often used is the chronic pain syndrome. Chronic pain patients are thought to have overdetermined pain which results from multiple psychological and physiological factors. Frequently no attempt is made to define the chronic pain syndrome by the use of evidence for psychological factors as is done in the DSM-III's psychogenic pain disorder although abnormal illness behaviors are often described in chronic pain syndromes. The chronic pain concept makes less effort to exclude patients without evidence of psychological causation and groups together a patient population with diverse characteristics. This group of patients may resemble each other physiologically only in what happens neurologically between their language cortex and their muscles of vocalization. On the other hand the diagnostic criteria for the psychogenic pain disorder lead to mistakes of both over and underinclusion. The problems which will be described occur in evaluating patients from both diagnostic groups. They also may occur in evaluating patients with other somatoform disorders. P R O B L E M S IN UNDERSTANDING AND EVALUATING PAIN

The first problem which occurs in discussions of pain involves secondary gain. Issues of secondary gain are often discussed in pain patients and evidence of secondary gain is often taken to suggest that the pain is psychogenic. In approaches to pain involving learning concepts the somewhat similar concept of reinforcement is thought to be important. However, if all patients in a medical facility are evaluated for evidence of secondary gain most patients could be expected to receive some gain from their symptoms [2]. In addition, if the gains that the patient receives are examined and particularly if these gains are balanced against the many losses involved in being ill, it is often difficult to understand how on balance the gains would reinforce the continuation of the complaints. Patients may receive some monetary compensation for their illness, but the amount that they

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receive is usually considerably less than their salary would be if they return to work. They may also receive some additional attention from family and doctors, but this attention is often given grudgingly and with some negative sanctions. They may communicate some psychosocial distress through the symptom but this communication also proves to be inadequate in that it conveys the distress but is not sufficiently clear to allow others to respond appropriately to the communication. Patients are excused from the requirements for normal social functioning but their new social role does not generally appear to be that much more comfortable than previous roles. The economy of secondary gain does not seem to adequately explain why some people would be induced to misrepresent or misperceive their level of pain. Differences in the relative values that patients attach to these gains may in part account for the behavior, although they seem to account less for the persistence of the behavior. The concept of secondary gain seems to present problems both when it is used diagnostically for evaluating patients for the role of psychosocial factors in the generation of pain and when it is used theoretically for understanding the role of reinforcement in understanding the etiology of chronic pain. The second problem in evaluating and understanding pain patients involves the illness behavior commonly observed in some patients. The diagnosis of psychogenic pain is sometimes suggested by unusual illness behavior which the doctor observes in his or her interaction with the patient. A popular system for evaluating patients for the presence of psychogenic pain components is the MADISON scale described by Hackett [3]. This scale describes a number of frequently observed characteristics of patients whose pain seems to be largely influenced by psychological factors. These characteristics include a tendency toward marked denial, heavy investment in convincing the doctor of the authenticity of the pain, and an insistence that psychosocial factors in no way alter the pain or the ability to tolerate it. Patients with less psychologically determined pain are thought to be more open to the suggestion that psychological factors influence their response to pain and are less invested in convincing others. A more systematic attempt to describe this difference is the abnormal illness behavior noted on the illness behavior questionnaire used by Pilowsky and others [4, 5]. They examined a number of patients with chronic pain complaints without clear physiological explanations and compared their behavior to patients with other chronic illness such as rheumatoid arthritis. They noted a number of characteristics of these chronically ill patients which they labeled abnormal illness behavior. On the illness behavior questionnaire patients with chronic intractable pain differed from patients with other types of pain on three scales. Elevation on the disease conviction scale suggested that they were more convinced of the presence of disease. Low scores on the psychologic vs somatic perception scale suggested a tendency to be somatically preoccupied. Persons with low scores on this scale often show difficulty accepting reassurance from their doctors. Elevated denial scores suggested a tendency to ignore current life problems [4]. In

effect patients with chronic pain process information in a manner which excludes certain types of information and holds tenaciously to other information. Pilowsky and Spence [5] argue that the usual ways of describing and classifying pain disorders are fraught with many difficulties and suggest the term abnormal illness behavior would more usefully describe the phenomenology of these patients. It would seem that any model regarding the development of psychogenic pain should attempt to take into consideration these commonly described behaviors. Any model should explain the tendency for such patients to exclude information which questions the reality of their disease or suggests psychological distress. A third problem in evaluating and understanding pain patients involves issues of primary gain and the role of the unconscious. Part of the DSM-III classification system requires a judgement on the part of the clinician regarding whether conscious or unconscious processes lead to the complaint of pain. Thus patients are divided into malingerers, persons exhibiting factitious disorders, and persons suffering from a conversion disorder or psychogenic pain disorder on the basis of whether the evaluator feels that the complaint is under conscious and/or voluntary control [1]. This is difficult judgement to make and no clear guidelines for making this distinction exist. The initial field trials for the DSM-III showed relative poor reliability for the diagnoses of somatoform and conversion disorders [1, 6]. Furthermore several unusual things occur when this judgement is made. The diagnosis of a somatoform disorder tends to be made most frequently in women, while men are more often thought to be malingering or exhibiting a factitious disorder [1, 7]. There may be a number of reasons why this might occur including actual differences between men and women and differences in the way social roles allow for the expression of psychologically determined variables. However, it also may represent differences in the social determinants of diagnostic behavior. Evaluating patients for primary gain, or internal conflict which is settled by the symptom, is also inconsistently successful. Studies examining how frequently primary gain can be identified in patients thought to have conversion disorders demonstrate that the frequency varies markedly from clinician to clinician [2, 8]. The concept of the unconscious has proven to be valuable in explaining certain mental phenomena but also causes some conceptual difficulties. Miller [9], in his discussion of what he calls the accident neurosis concludes that "differentiation between conscious and unconscious purpose is quite insusceptible to any form of scientific inquiry". Even when the concept of the unconscious is not directly used in discussing chronic pain, similar concepts are implied. Patients with chronic pain are thought to actually experience pain in the absence of a peripheral lesion. For example the definition of pain developed by the International Association for the Study of Pain [10] includes sensory and emotional experience "described in terms of' tissue damage. Thus some pain patients are thought to experience pain in the absence of a peripheral organic source and these patients' experiences are included in the definition of pain. These patients may be deceiving

Deception and psychogenic pain themselves through a combination of physical and psychological mechanisms. Such patients are thought to be distinct from patients who intentionally misrepresent their pain. Although separating patients who misrepresent their pain experience from those who experience pain in this way is conceptually important, there are few explicit clinical criteria for making this separation. Moreover, although we now know more about the central neural mechanisms of pain perception, this knowledge has not made it possible to make the separation. Because visiting a physician and complaining of a symptom involves a social interaction, several authors have emphasized the interpersonal meaning of pain and other complaints. For instance, Szasz [11] has described the communication aspects of hysteria. He argues that although hysteria can occur in isolation, it more commonly occurs in a social situation. Thus the interpersonal and social aspects of somatoform communications are of particularly great importance and their complexity accounts for much of the complexity of psychogenic pain disorders. He describes the rhetoric of pain and sees complaining of pain in the presence of internal psychological distress as a powerful way of communicating the distress and of getting a response from a helping person through the symbolic use of pain complaints. His discussion most clearly describes the deceptive nature of the complaint. He also describes tendencies among physicians to fail to understand the fact that a deception has occurred and to make the metaphor concrete by considering the lie an illness. Although Szasz's discussion has generated a great deal of controversy it does seem to be a useful reminder that some patients do lie to their physicians and perhaps also lie to themselves. Unfortunately, detecting lies and understanding the nature of lies are both difficult tasks. Unraveling the social nature of deception both of others and of oneself could possibly be important in understanding some of the complexity of psychogenic pain. I N V E S T I G A T I O N S O F L Y I N G IN T H E FORCED COMPLIANCE SITUATION

In fact hundreds of college psychology students have been induced to tell lies in experimental situations in order to examine the effects of deception. One of the more famous studies of deception is the forced compliance study of Festinger and Carlsmith [12]. The subjects in this study behaved in a somewhat unexpected manner after telling a lie and it might be useful to examine the behavior of one of these subjects. When this subject arrives he is reminded that a representative from the Psychology Department will want to talk to him after the experiment in order to evaluate the types of experiments being done in the department. He is then asked to do two very boring tasks for an hour while the experimenter times his performance with a stopwatch. At the end of the hour the experimenter tells him the experiment is over. He debriefs him by telling him that he was part of the control group for an experiment studying the effects of pretask information on performance. He is told that the subjects in the experimental group are told by a confederate posing as a previous subject SS.M 20,'5 F

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that the tasks were in fact very interesting. The experimenter then says somewhat uneasily that the confederate who was to have told this to the next subject just called and said that he could not come in. He wonders whether the subject would be willing to act as the confederate and offers him a dollar to do so. He agrees to do this and is shown into a room where a woman is waiting. He is introduced to her as the previous subject and the experimenter leaves the room. They converse for a while and the subject tells her that the experimental task was very interesting. She says that she is surprised to hear that because a friend of hers had taken the experiment the week before and had told her that it was boring and that she ought to try to get out of it. He replies that it is really very interesting and he is sure that she will enjoy it. The experimenter returns and asks if they could check to see if the guy from the department wants to interview the subject. They go down the hall to an office where an interviewer says that he does indeed want to talk with him about the experiment. The experimenter leaves and the interviewer asks the subject several questions about the experiment including how interesting it was, how scientifically important it seemed and would he participate in another experiment like it. When asked how interesting the experiment was, the subject rates it as moderately interesting. The subject was misled about the nature of the experiment. The subject was not actually a confederate but the woman to whom he lied was. In fact the experimenter was interested in how subjects would describe the boring task after they had lied about it. Subjects in one group were paid a dollar to lie. Subjects in another group were paid $20 to lie. Subjects in this study who were paid one dollar to deceive the person they thought was the next subject were likely to report later that the experiment was in fact interesting. Subjects who were not induced to lie described the task as boring. However, subjects who were paid $20 to lie also were more likely to describe the task as boring. The experiment thus suggests that people who are induced to tell a lie but are given small inducements to do so may come to believe their own lies. The results of this study were originally explained in terms of cognitive dissonance theory [13]. Cognitive dissonance theory suggests that subjects will wish to avoid inconsistencies in cognition. Dissonance is thought to occur when one cognitive element in our thoughts implies the opposite of another cognitive element. In the experiment the thought that "I said the task was interesting" implies the opposite of the thought that the task was boring. The fact that an individual has said one thing and believes another as in the experimental condition will lead to an internal state of cognitive dissonance. Cognitive dissonance is thought to be an uncomfortable state with motivational properties. This discomfort can be resolved in a number of ways which include a tendency for the individual to change the cognitive elements in order to eliminate the dissonance. Because the actual behavior such as reporting the task as interesting is often harder to deny, the attitude toward the task is more likely to be changed. The theory further suggests that the larger the press-

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ure to induce the behavior the weaker the tendency to change the cognition because less dissonance has been produced. In other words, subjects who engage in the deceptive behavior for obvious reasons such as receiving $20 will experience less dissonance because they are aware of their reasons for the deceptive behavior. Subjects who engage in the behavior with minimal inducement will experience greater dissonance because they are less aware of their reasons for engaging in the behavior. The theory as originally outlined by Festinger has been modified in several ways, primarily to take into account the findings of various studies which have more clearly defined the situations in which the attitude change effect will occur. Brehm and Cohen [14] suggested that the effect will occur only when there is some sort of behavioral commitment to one of the cognitive elements. The effect has also been noted to occur only when the subjects believe that they have voluntarily chosen to engage in the attitude discrepant behavior. When subjects feel they were forced to engage in the behavior, dissonance is not aroused [15]. The experimental situation is often referred to as a forced compliance situation although a more accurate description would really be induced compliance. Aronson [16] further modified the theory by describing the issues of self esteem involved. In addition to the dissonance between the behavior of reporting the task as interesting and the thought that the task is boring Aronson emphasized the dissonance between the knowledge that the subject has told a lie and his or her self concept as an honest person. In this discussion, people are seen as also resisting information which would threaten self esteem and thus dissonance reduction is referred to as ego-defensive behavior. Wicklund and Brehm [17] expanded further on these defensive elements by taking into account experiments that also showed two other conditions which are necessary for dissonance mechanisms to occur. First of all, the individual must feel that his behavior has some consequences. For example if subjects write something that is attitude discrepant but believe that no one will be influenced by what they have written, then dissonance will not be aroused [18]. Secondly, subjects have been shown to experience dissonance arousal only when they feel responsible for the consequences of their behaviors [19]. In summary then, the modified theory of cognitive dissonance suggests that voluntary behavior which has consequences for another person, for which the individual feels responsible, and which threatens self esteem, will lead to a state of cognitive dissonance which may be resolved through defensive distortion of information. C O G N I T I V E D I S S O N A N C E AND T H E P R O B L E M OF SECONDARY GAIN

How might this occur in patients with complaints of pain or other symptoms? It seems likely that there would be many times when patients would experience inducements to inaccurately report their pain. Patients may respond to social pressures to stoically bear their pain and may report less pain than they actually experience. On the other hand there may also be multiple inducements to exaggerate the level of

pain or to persist in reporting it after it has resolved. The patient on a p.r.n, narcotic schedule who fears that the nurse will not respond quickly enough if his or her pain returns might be induced to report pain before it actually returns. The patient who is anxious about returning home, returning to work or returning to other areas of social functioning might also be induced to misrepresent the pain. What is likely to happen to those patients who do dissemble regarding their pain? When the nurse brings the patient the medication or when the family or employer excuses the patient from his or her usual social role, these things are generally done somewhat grudgingly and with some negative consequences. Thus the inducements are likely to be small and mechanisms similar to those operating in the forced compliance situation of the Festinger and Carlsmith study are likely to apply. These mechanisms could then lead to a persistence of the pain complaints as patients perhaps actually change their beliefs or perceptions about the presence of the pain. They in fact come to believe that they have pain when they no longer have a physiological reason to experience pain. Dissonance theory then predicts what in fact may be seen in patients with chronic pain or somatoform disorders. Secondary gain which is just sufficient to produce the continued reporting of pain is more likely to lead to persistence of the complaints than is secondary gain of much greater magnitude. For instance, the patient whose family grudgingly and with a great deal of hardship allows the patient to continue missing work is more likely to have persisting pain than either the patient whose family warmly accepts and adapts to the change in the patient's functioning or the patient whose family gives absolutely no support. C O G N I T I V E D I S S O N A N C E AND T H E P R O B L E M OF ABNORMAL ILLNESS BEHAVIOR

Because cognitive dissonance theory suggests that dissonance arousal is an uncomfortable state that will be avoided, the theory also predicts that after an individual has decided on a behavior he will wish to avoid information and situations that will suggest that choosing the behavior was incorrect [18]. Thus positive aspects of the chosen behavior and negative aspects of the rejected behavior will be consonant with the choice. On the other hand negative aspects of the chosen behavior and positive aspects of the rejected behavior will be dissonant with the decision. Dissonance theory predicts that subjects will concentrate and attend to consonant information and ignore dissonant information. Numerous studies have been done to attempt to demonstrate this effect. Both children and adults who are induced to choose a less attractive toy or other object may come to find the chosen object more attractive and the previously more attractive object less so [23, 24]. People who place bets are more convinced that they will win after putting down their money than they are before making the bet [23]. The prediction of dissonance theory regarding information seeking has been less consistently validated by research studies and several reviewers have suggested that there is little evidence to support the contention that subjects will avoid

Deception and psychogenic pain information which is dissonant with their choice [17, 24]. The studies which have examined the prediction have been criticised for several methodologic errors [25]. However, a recent study which attempted to avoid these errors did show that subjects would seek consonant information and avoid dissonant information after making a choice in which they had high perceived fredom and in which there was evidence for dissonance arousal [26]. The post decision effects predicted by cognitive dissonance theory are consistent with the abnormal illness behavior described by Pilowsky. Dissonance theory would predict that patients who choose to actively report their symptoms in the presence of ambiguous internal signals are more likely to reject dissonant information. In particular, they would be expected to deny the possibility that psychological issues play a role in their complaints and to even deny the presence of any life problems. They are likely to be more invested in convincing others of the reality of their complaints, and they would be predicted to be less likely to accept reassurance from their doctors when this reassurance also is dissonant with their complaints. One explanation for the difficulty in consistently demonstrating the information seeking component of cognitive dissonance theory is the possibility of an individual difference effect which might dilute the expected results. One frequently mentioned individual difference which might also have some relevance to considerations of pain behavior is the psychological variable of repression-sensitization. Repression-sensitization refers to the usual defensive strategies used by individuals to deal with anxietyprovoking situations [27]. Repressors use avoidant defenses such as regression and attend to positive or reassuring information. In contrast, sensitizers use approach defenses such as intellectualization and rumination and do not attend selectively to positive information. A study comparing repressors and sensitizers in a forced compliance situation found that only repressors showed dissonance reduction through attitude change [28]. In this study subjects were induced to perform a task at which they were led to expect that they would fail. In conditions of high expectation of failure and low inducements to participate in the task, only repressors showed attitude change on a question regarding their desire to succeed. Sensitizers then are less likely to use attitude change as a means of dissonance reduction. It would seem that they are more likely to use other means of managing the dissonance situation. A later study, looking at attitudes toward record albums after subjects have made a choice among several albums, has shown evidence for increased use of intellectualization in sensitizers in this situation which is thought to induce cognitive dissonance [29]. Both repressors and sensitizers showed attitude change in this study despite the differences in measured use of intellectualization. Neither of these studies examine attitude change in situations involving deception. However, their findings are interesting because repressionsensitization has also been related to the way that people report medical and psychological symptoms [27]. Sensitizers have been shown to be more likely to

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report medical symptoms and male sensitizers were shown to visit physicians more often. In a study of patients at the Mayo clinic [30] sensitizers were also more likely to have diagnoses which included psychiatric disorders. Neither of these patterns clearly relate to the typically described pattern of abnormal illness behavior. Unlike sensitizers who are more likely to report both physical and psychological symptoms, individuals with abnormal illness behavior report physical symptoms but actively deny psychological symptoms. Nevertheless it seems possible that further study of the role of defensive style in both forced compliance situations involving deception and in illness behavior could lead to better understanding of psychogenic pain. Experimental study of pain behavior should address the interaction of personality variables and situational variables. C O G N I T I V E D I S S O N A N C E AND THE P R O B L E M OF T H E U N C O N S C I O U S

The third problem with pain to be considered is the problem of distinguishing between conscious and unconscious processes, or between pain that is misrepresented and pain that is experienced in the absence of a peripheral organic lesion. These distinctions are difficult to make clinically. The forced compliance experiments suggest that the two states may be somewhat fluid. What was once misrepresented pain may become actually experienced pain through mechanisms similar to those operating in the experimental setting. Thus attempts to separate the two types of pain complaints may make little operational sense. However several questions remain unsettled regarding the congitive dissonance explanation for the experiments. Some of these questions involve problems similar to the problem of the unconscious in explanations of psychogenic pain. The work toward solving these problems may provide some basis for also resolving similar problems with pain. There are a number of theories which provide alternative accounts for the experimental phenomenon in forced compliance studies in addition to cognitive dissonance theory. They differ in part in whether deception of self or deception of others is involved. The two most prominent alternative theories are self perception theory and impression management theory. Self perception theory also suggests that a real change of attitudes occurs. It suggests particularly that when subjects' original attitudes are unclear, they will infer their attitudes from their own behavior in a manner similar to the way that an outside observer would make the same inferences. Thus in the forced compliance situation if they report the task as interesting they will observe themselves doing so and this observation will lead to the belief that the task was in fact interesting [31]. Although several attempts have been made to experimentally compare self perception theory to cognitive dissonance theory, Bem and McConnell [32] conclude that it is unlikely that an experiment to separate the two theories could ever be executed. Nevertheless, self perception is likely to also have relevance to pain perception. The theory suggests that the ability to identify some internal

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states, especially affective states, is imperfectly learned during childhood because of the failure of parents and others to be able to accurately perceive and label such states. The other alternative theory, impression management theory, predicts that people will want to present themselves in the best possible light and will use self presentation strategies to do so. Impression management theory suggests that a real change of attitudes does not occur in the forced compliance situation. It suggests instead that people want to appear consistent and will report attitudes that foster that impression. Subjects in the experiment will be concerned that the evaluator will attribute blame for their acts and will disapprove of them for choosing to harm or mislead others [33]. Thus in impression management theory moral behavior is seen as largely a response to external concerns whereas cognitive dissonance theory sees moral behavior as a response to internal standards and concerns. Cognitive dissonance theory and self perception theory involve deception of the self while impression management theory involves deception of others. This is a distinction similar to the distinction between intentionally misrepresented pain and pain that is experienced in the absence of peripheral lesions. A unique way of testing for the role of self versus other deception components in the experimental situation has been used. This technique is referred to as the bogus pipeline. In bogus pipeline studies subjects are connected to complicated machinery which they are told is a newly developed lie detector that can discern their true feelings. By means of trickery they are convinced that the machine works. When the bogus pipeline is used it is assumed that the belief that the experimenter can tap their attitudes through the use of a lie detector will make subjects less likely to state attitudes that they do not privately hold. Several studies have demonstrated that this does in fact occur [34]. The bogus pipeline has been used to assess the reality of attitude change in the forced compliance situation. Gaes et al. [35] had subjects write essays arguing against toothbrushing. They were told that these essays would be shown to high school students with the expectation that those who read the essays would get more cavities. Subjects whose names were on their essays and therefore thought that their behavior was clearly identifiable to the experimenter showed an attitude change toward being less in favor of toothbrushing when their attitudes after writing the essay were assessed with a paper and pencil form. Subjects who thought that the experimenter could not identify them because their names were not on the essays did not show this attitude change on the paper and pencil measure. Subjects both with and without their names on the essays who were assessed with the bogus pipeline procedure also did not show any attitude change. Thus both anonymity and the bogus pipeline could eliminate the forced compliance effect in this situation. In a second study using the same essay writing procedure, subjects were evaluated with both a paper and pencil measure and with the bogus pipeline procedure. Subjects who received the bogus pipeline procedure first did not show significant attitude change. Subjects who received the pencil and

paper measure first showed significant attitude change on the pencil and paper measure and continued to have attitude change on the bogus pipeline. The authors intepreted these results as most consistent with impression management theory since the fear of being found out as a liar seemed to outweigh the discomfort of being seen by the experimenter as someone who would advocate that high school students not brush their teeth. In the situation in which subjects have already lied on the pencil and paper measure, their choices are whether to reveal the lie on the bogus pipeline or to maintain consistency in the hope of avoiding detection. The authors also believe that continuing to lie, the choice seen in the study, is best explained by an impression management theory. Several subsequent bogus pipeline studies have also shown that the bogus pipeline can eliminate or reduce the forced compliance effect [36, 37]. In one study the bogus pipeline was not actually used but subjects were only told that it would be used and this manipulation alone could eliminate the attitude change [37]. In sum, the bogus pipeline studies seem to support the impression management theory. Some authors have argued with the assumption that the bogus pipeline eliminates self presentation effects and have also sugested that it plays a role in arousing dissonance and focusing the dissonance itself [38, 39]. In addition, although the attitude change would be expected to be permanent according to cognitive dissonance theory, this is in fact not an essential component of the theory. However, the burden of proof does seem to rest more with the proponents of cognitive dissonance theory at this time. SELF DECEPTION AND OTHER DECEPTION

Tesser and Paulhus [40] have argued that in fact most deception has components of both self and other deception and that subjects will respond both to internal pressures from the self and to social pressures to conform. Paulhus [41] examined the possibility that both impression management and cognitive dissonance might be responsible for the forced compliance effect. In this study subjects were again asked to lie to another person about a boring task. A paper and pencil evaluation was used in the form of an apparently anonymous form labeled 'Human Subjects Committee'. The bogus pipeline measure was labeled as another experiment by another experimenter who asked them about various events during their day including the boring task. One control group was also asked to lie to the confederate but was evaluated with two paper and pencil measures. A second control group was not asked to [ie but was evaluated with a paper and pencil measure and then with the bogus pipeline. The bogus pipeline was able to significantly alter the reports of interest so that a large amount of the attitude change as seen on the pencil and paper measure seems to have been due to the self presentation strategies suggested by impression management theory. However, a significant difference still remained between the experimental group and the control group which did not lie but were evaluated with the bogus pipeline. The author suggests that some of this residual difference could be accounted for by cognitive dis-

Deception and psychogenic pain sonance mechanisms. Part of the reason for suggesting this is an additional measure done in the study. All subjects also completed the OtherDeception Questionnaire which is a measure of tendency to engage in self presentation. This measure is thought to tap individual differences in self presentation independent of self deception effects. When subjects were divided into those high and low on the Other-Deception Questionnaire, only those subjects high on this measure showed the marked change with the bogus pipeline. The author argues that this suggests that the bogus pipeline served to eliminate the majority of the impression management effect. How might the differing explanations be important in understanding patients with chronic pain? It seems likely that deception both of self and others could occur. Issues both of self esteem and of altered social role are likely to lead to the need to make justification to both the self and others. In fact there seems to have been some merging of the two theories as they have developed. Impression management theory originally denied the importance of discomfort as a motivating force. It now proposes a form of social motivation which involves discomfort about being discovered while violating a social norm [42]. Cognitive dissonance originally proposed an uncomfortable state as the motivating force. However the proposed source of this discomfort has now shifted to assume a more social role. Instead of wanting to maintain logical consistency, individuals are now seen as wanting to maintain self esteem. These changes seem to have brought the two theories fairly close together. Impression management attributes behavior to internalized prohibitions driven by fear of external sanctions. Cognitive dissonance attributes the same behavior to internalized prohibitions driven by fear of internal sanctions. However, these internal sanctions are derived from the same external sanctions. It is difficult to tell the difference between these two types of motivations in much the same way that it is difficult to distinguish between unconscious and conscious processes. Pain patients who at some time misrepresent their pain will need to justify this behavior both to themselves and to others. Separating out the two may be less important than realizing what the results of this need for justification are likely to be. Either process will lead to alterations in the symptom report so that the pain complaints will no longer correspond to the physiological pain input. The need for justification will also lead to the relatively fixed nature of the complaint and may result in forms of abnormal illness behavior. Although the dependent variable in the forced compliance studies are most frequently referred to as attitudes, in fact they represent a variety of mental elements. Festinger and Carlsmith's original study looked at reports of how interesting an actually experienced task was. A very large number of college students have written essays on toothbrushing and other issues and then had their attitudes toward those issues examined. Attitudes and reports of internal states probably represent different types of internal information. It could be argued that impression management theory would apply more to attitudes, which are determined more by social interaction.

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Attitudes toward toothbrushing are largely internalized through the general wisdom of society. Lying about them represents a violation of a social norm and requires a social explanation. Interest, as in the boring task studies, represents knowledge gained by examining a more specific brain state. Lying about it represents more of a violation of an internal cognitive norm in addition to violating the social norm which prohibits lying. COGNITIVE DISSONANCE AND THE REPORTING

OF PHYSIOLOGICALSTATES Several studies have looked at dissonance effects on reports of other internal states. These studies did not require the subjects to lie to a confederate. Instead the subjects were induced to voluntarily tolerate uncomfortable states with variable justification and their level of reported discomfort was examined. With both food and water deprivation, subjects given minimal justification report less hunger or thirst than subjects given strong reasons for undergoing the deprivation [43, 44]. In addition the water deprived subjects drink less water when given an opportunity to do so [43]. The food deprived subjects show smaller increases in free fatty acid levels [44]. Cognitive dissonance theory would suggest that the subjects given less justification would experience dissonance because they would be uncertain why they chose to undergo the deprivation and come to believe that in fact the deprivation makes them less thirsty or hungry. In both studies the subjects seem to be deceiving not only the experimenters but also that part of themselves which regulates water intake and free fatty acid levels. In one of the few studies to actually look at pain and cognitive dissonance, Zimbardo et al. [45] studied subjects who received a series of painful electrical shocks. They were then asked to take part in a second experiment which would also involve being shocked in the same manner. Subjects in one group were given high justification for taking part in the second procedure. They were told the experiment was important for science, the experimenter, and especially for the space program. Subjects in a second group were given little justification for proceeding with the second study but were simply asked to do so. Thus it would be assumed that the subjects in the high justification group would experience low dissonance levels while subjects given little justification would experience high dissonance. Several control groups also received a second set of shocks but were not given any choice about continuing. When the second set of shocks was administered, the high dissonance group which received little justification reported less pain than either the low dissonance group or the control group which continued to receive the same level of shock. Two additional measures were done on these subjects. They were asked to perform a learning task during the shock. The control groups showed a clear relationship between the level of shock and impairment on the learning task. The low dissonance group showed a persistence of impairment with the second set of shocks. However, the high dissonance group showed a significant reduction in the way that the shock interfered with their performance on the learn-

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ing task after the dissonance manipulation. Galvanic skin resistance was also measured in response to the shocks. Again the subjects in the high dissonance groups showed a significant reduction in their physiological response to the shock. These experiments suggest that, at least in the situations involving the evaluation of perceptions of pain, hunger or thirst, something more than deception of the experimenter occurs. The subjects seem to deceive themselves enough to alter their mental and physiological responses. The Zimbardo experiment in particular provides evidence that alterations in the social setting of pain which are likely to lead to cognitive dissonance can alter the subjects' reported experience of pain as well as their physiological experience. Nevertheless, the means for understanding deception and for separating self from other deception in experimental as well as clinical situations have not been fully discovered. Because the distinction is important both conceptually and clinically, the work of the social psychologists in attempting to make similar distinctions may be important for pain researchers. In addition to the forced compliance studies several other avenues of investigation in social psychology may also prove to be useful in understanding the nature of deception. Gur and Sackeim [46] have recently developed a way of experimentally studying what they feel is a laboratory example of self deception. When asked to distinguish between their own and other voices some subjects will misidentify their own voice even though their galvanic skin resistance suggests that they were aware that the voice was their own. The tendency to make these misidentifications has been correlated to various personality variables. In addition several scales for separating the tendency to self deception from other deception are now being developed and tested [47]. TREATMENT CONSIDERATIONS

How might these theoretical possibilities suggested by the forced compliance studies be important in the treatment of patients with pain or other complaints? Either cognitive dissonance theory or impression management theory make predictions about behavior that are different from learning theory and perhaps this is why the question of whether the theories have any relevance to pain behaviors is important. Learning theory suggests that pain behavior can be reduced by reducing the reinforcements which support the behavior. The forced compliance experiments suggest that this is true, but reducing the reinforcements also carries the risk of actually perpetuating the behavior. This would be predicted to occur if the reinforcing factors are not reduced to a sufficiently great degree to eliminate the behavior. If they are only reduced to a level that will just barely produce the behavior they will in fact activate cognitive dissonance or impression management mechanisms and enhance the behavior. The usefulness of learning theory in the treatment of chronic pain has gained wide acceptance. However, the popularity of learning concepts in considering pain may also lead to difficulties, particularly in attempts to prevent patients with acute pain from

developing chronic pain. Excessive concern about removing the reinforcers in patients experiencing acute pain may lead to treatment which will set the stage for the activation of cognitive dissonance if the patients at some point lie about their pain. Physicians may be excessively hesitant to prescribe narcotics in the fear that they will be reinforcing and thus will prescribe them in inadequate amounts and with negative sanctions. Hospital staff may be uncertain about how much support and concern to show to their patients' pain complaints and thus may be inconsistent in their response. These behaviors may induce patients to exaggerate their reports of pain and if they do so, the same behaviors are likely to lead to dissonance arousal. If this occurs, the pain complaints are likely to become relatively fixed. On the other hand, the patients with acute pain who get more than sufficient medication, support, and attention may still at some point lie about their symptoms, but if they do so are less likely to persist in doing so or to believe their own lies. In fact, learning theory approaches to pain have generally emphasized the importance of distinguishing between acute and chronic pain [48]. The assumption that acute pain becomes chronic pain because of reinforcement received from the sick role has not been clearly demonstrated. The only real evidence which supports this assumption is the fact that chronic pain complaints can sometimes be altered through attention to learning mechanisms. The problem seems to lie more in a misunderstanding many health care professionals have had about the proper application of learning theory. Both learning theory and cognitive dissonance theory suggest that attention to reinforcers will be useful in altering chronic pain behavior. Learning theory suggests that intermittent reinforcement will lead to more fixed behavior. Cognitive dissonance theory predicts that smaller reinforcement will lead to fixed behavior. Cognitive dissonance approaches suggest that internal attitudes may change so that altering the way that patients talk about their pain may alter the way that they feel. What they say becomes a part of themselves. This suggests that cognitive dissonance change may be less situation bound. The research on the forced compliance situation suggests several approaches both for preventing acute pain from becoming chronic and t\~r treating patients who develop chronic pain. Cognitive dissonance theory most clearly indicates interventions in preventing acute pain from becoming chronic through dissonance mechanisms. After dissonance has occurred, if it was reduced by a change in the pain perceptions or reports, less is known about what interventions will alter the pattern. The factors which have been shown to influence the dissonance situation suggest several interventions. The clearest area for intervention is in the inducements to misrepresent the pain that might occur in pain patients. Thus cognitive dissonance as well as other approaches suggests the value of using fixed doses of medication rather than an as needed schedule. Changes in the amount of inducement can be either in the direction of increases or decreases. Decreases in the inducements must be of sufficient magnitude to eliminate the tendency to inaccurately report the pain. Increases in the induce-

Deception and psychogenic pain ments must be sufficient to allow patients to be aware of why they are describing pain that they may not initially feel in order to prevent them from actually coming to feel greater pain through cognitive dissonance mechanisms. Cognitive dissonance theory suggests that payment for disability should be made in large lump sums rather than in small regular payments. In fact Ludwig's [49] review of the method of payment and its relationship to recovery rates suggests that large lump sum payments are more often associated with recovery than are protracted payments. After pain has become chronic, there may also be interventions regarding the issue of justification that can be made. Approaches that attempt to develop insight into the reasons for the behavior may reduce the need to justify the behavior through altering the perception or reports of pain. Insight oriented approaches may also be useful because they tend to involve deterministic assumptions. Thus patients come to see their behavior as less subject to voluntary control. This would be expected to reduce their need to use attitude changing mechanisms. This effect on the dissonance mechanisms can perhaps be increased when the therapist sees the patient as doing the best he or she can given difficult circumstances. Thus while discussing difficult life circumstances, the therapist suggests that the patient must have felt trapped with few effective solutions available. These interventions will act to reduce the patients' sense that the behavior is voluntary and will reduce the sense of responsibility. This in turn would be expected to reduce dissonance because of the reduced need to justify the behavior. Reiss and Schlenker [50] showed that if observers told subjects that they had little choice the subjects would not show attitude change. Because issues of self esteem are also important in the forced compliance situation, interventions aimed at addressing self esteem would also seem to be useful. In fact a recent study by Steele and Liu [51] demonstrated that if individuals are given an opportunity to affirm an important, self-relevant value, the forced compliance situation will not induce attitude change. This occurred even when the values affirmed had little to do with the attitudes being expressed in the forced compliance situation. Thus it seems that interventions that allow patients to examine and affirm their values will reduce the tendency to perpetuate any deceptions that occur in pain patients. Self esteem, concern about consequences, and concern about responsibility are all in part socially determined and the social role of the patient may be important in setting the stage for a forced compliance situation. Parsons [52] has defined the social role of the acutely ill as one in which patients are not considered responsible for their illness and are excused from their usual social expectations but are held responsible for wanting to get better and for cooperating with their doctors. This role serves to allow for the maintenance of self esteem and makes statements about responsibility. Patients are allowed some regression but are held responsible in part for their illness behavior. The sick role is somewhat inconsistently applied in different families or other social structures and it would seem that attention to inconsistencies and difficulties in a patient's social

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role would be useful in preventing the occurrence of the forced compliance effect. Although separating self deception from other deception in clinical situations is difficult it may be important in determining how actively the deception should be confronted. Cognitive dissonance theory suggests that confrontation is likely to rearouse the dissonance and will lead to avoidance of the information presented in the confrontation. Experiments which have examined this situation have also noted that subjects will devalue the person doing the confronting [53], a behavior that many doctors have also experienced even when they very gently suggest that stress may play a role in a patient's illness. Thus confrontation may not work and will cause the patient to devalue the doctor. However, the bogus pipeline studies suggest that a convincing confrontation can be very effective. In fact dissonance theory has also suggested that convincing information which makes it increasingly hard for the individual to distort reality will eventually lead to rearousal of the dissonance and that the dissonance will be reduced by another mechanism [13]. Although some studies have demonstrated that dissonance mechanisms are resistant to later intervention [54] other studies have demonstrated effective interventions [50]. Confrontation should be particularly effective in situations in which the other deception component is highest. However it may also be effective in self deception, particularly if it is coupled with other interventions aimed at providing other ways of reducing dissonance and at maintaining self esteem. RESEARCH CONSIDERATIONS

Current definitions of pain include experiences 'described in terms of' tissue damage [10]. Because this definition includes pain involving self deception, and perhaps even pain described in order to deceive others, it is important that research on pain address the role of the psychology of deception in some forms of pain. Greater diagnostic clarity could be achieved through an increased ability to identify persons more likely to engage in deceptive behavior. The mechanisms by which biological, psychological and social factors interact to generate pain complaints in the absence of peripheral lesions remain to be clearly defined, and models such as the learning model remain to be clearly tested as accounts for the etiology of pain. It would also be useful to test models based on experimental approaches which have already been used to account for self deceptive behavior. For example several investigators have shown that subjects will report pain in response to stimuli, sometimes referred to as nocebos, which normally would not be described as painful. These pain reports have been induced through the use of social modeling [55] or the suggestion of pain as a side effect of a normally unpainful but stressful procedure [56]. These studies could be extended to include other social settings, including settings which might lead to cognitive dissonance. The effects of compensation and other rewards could also be evaluated in these nocebo studies. In some ways this discussion has oversimplified fairly complicated theories of social psychology and

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m u c h further work needs to be done in defining the p a r a m e t e r s of the forced compliance effect and its range o f application. F o r example, studies looking at individual differences in self esteem a n d at m a n i p u lations in self esteem and their effects on the forced compliance effect have produced conflicting results d e p e n d i n g in part on h o w self esteem is defined a n d measured [57]. It would seem, however, t h a t refinements in u n d e r s t a n d i n g the psychology of deception could lead to better u n d e r s t a n d i n g and treatm e n t of the chronic pain a n d the s o m a t o f o r m disorders. Despite Z i m b a r d o ' s d e m o n s t r a t i o n of a cognitive dissonance effect on pain complaints, it remains to be d e m o n s t r a t e d whether cognitive dissonance m e c h a n i s m s can also increase pain particularly in situations involving deception. It would also seem that consideration of patients with s o m a t o f o r m disorders m i g h t suggest other areas for future research in the psychology of deception. C h r o n i c pain patients a n d other patients with s o m a t o f o r m disorders could be examined for their responses in a forced compliance situation. They could also be examined for the presence of characteristics k n o w n to predispose to distortions in the cognitive dissonance situation. As measures separating self from other deception are further developed, it would also seem useful to apply these measures to patients with som a t o f o r m disorders. This could be d o n e b o t h to define characteristics of these patients a n d also to examine whether dividing patients in this way will predict response to various interventions. Cognitive dissonance theory has generated a large a m o u n t of research. It is an attractive theory in that is makes predictions that seem to run counter to c o m m o n sense. It is also attractive because it provides interesting a n d perhaps useful interpretations of how attitude changes have occurred in o u r own lives. It seems to be an intermediate theory between learning theory a n d theories involving primary a n d secondary gain. It suggests internal mechanisms which the black box a p p r o a c h e s of learning theory avoid. On the other h a n d its p r o p o s e d internal m e c h a n i s m s are s o m e w h a t more definable t h a n are those used in our current diagnostic approaches. There is a great deal of research into the nature of these internal mechanisms and thus this research m a y suggest areas for t r e a t m e n t a n d for further research in pain mechanisms. The conceptualizations of cognitive dissonance theory regarding what will h a p p e n when people first 'practice to deceive' are still incomplete but seem to provide some beginning for understanding the processes involved. This in turn could provide a way of u n d e r s t a n d i n g a very difficult medical problem, the patient whose medical complaint does not seem to be due entirely to a medical illness. Acknowledgements--The author wishes to express appreciation to Drs R. Roessler, H. Kaplan and E. Silverman (Baylor College of Medicine) for comments on this manuscript.

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