James C. Hamilton, PhD

Patients who exaggerate, feign, or induce physical illness are a great challenge to their physicians. Trained to trust their patients’ self-reports, even competent and conscientious physicians can fall victim to these deceptions. In doing so, the treating physician may unwittingly provide support for specious claims of illness or injury by conferring official diagnoses, or by delivering treatments that transform the patient from a pretender into a person with a genuine, although iatrogenic, medical problem (eg, via adrenalectomy, pancreatectomy, serial amputation).

Forensic psychiatrists may be called on during civil or criminal litigation to help determine the authenticity of a patient’s apparent medical illnesses or injuries. Even when a patient’s medical deceptions are proved beyond any doubt, the forensic psychiatrist may be asked to help determine the underlying psychological processes that led to the deception. In other cases, the patient may pursue civil damages from the treating physician for performing unnecessary interventions, and the forensic psychiatrist is asked to weigh in on the culpability of a colleague for failing to detect the deception.

The forensic psychiatrist faces 2 synergistically related obstacles. First, in contrast to malingering, there is little empirical research on the nature of factitious disorder, its underlying psychological processes, or ways to assess it. Second, despite the aforementioned lack of scientific evidence, 

 provides an artificially definitive classification system for patients with inauthentic illness behavior, to which the examiner’s conclusions are expected to correspond.

Consciousness, intentionality, and insanity in 

Many decisions in legal proceedings boil down to the question of consciousness and intention. Was the defendant aware of what he or she was doing, did he intend to do it, and was the motive for doing it reasonable? Conveniently, 

 categories dealing with inauthentic illness behavior (ie, behaving as if one is sick when one really is not) neatly address these questions.

 somatoform disorders category specifies 5 disorders for which inauthentic illness behavior presumably is neither conscious nor intentional. These are somatization disorder, hypochondriasis, conversion disorder, pain disorder, and undifferentiated somatoform disorder. It specifies another category-factitious disorder-in which inauthentic illness behavior is consciously and intentionally produced. This category is reserved for people whose motives appear to reflect severe psycho-pathology (eg, a person who would agree to prophylactic double mastectomy just to get attention from medical personnel, friends, and coworkers).

 also recognizes cases of malingering (as a “V” code, not a true psychiatric diagnosis) in which the inauthentic medical behavior is conscious, intentional, and reflects more comprehensible motives (eg, faking a fall in a retail store to get millions of dollars in compensation for medical and emotional damages).

 diagnostic criteria sets for these disorders and their relations, the following is a summary of how 

 instructs psychiatrists to diagnose cases of inauthentic illness behavior:

 In the absence of overwhelming affirmative evidence of intentional medical deception (eg, caught on video, evidence from a room search), diagnose a somatoform disorder.

If there is traditional forensic evidence of overt medical deception, diagnose malingering or factitious disorder.

 If there is any significant material or instrumental benefit from the intentional medical deception (eg, financial settlement, disability determination, access to narcotic medicine), diagnose malingering.

These 3 categories are mutually exclusive, and there is no hedging.

Anyone with even minimal experience in dealing with patients with complex and suspicious medical histories recognizes how inadequate and oversimplified 

 directives are. The criteria make it virtually impossible to diagnose a case as anything other than a somatoform disorder when intentionality cannot be proved with traditional forensic evidence. There are no psychological tests of consciousness, and even strong evidence of a relationship between the occurrence of inauthentic illness behavior and tangible benefits would not suffice to overrule a somatoform diagnosis. Thus, in cases dominated by subjective complaints like pain, fatigue, and weakness, it is virtually impossible to definitively diagnose factitious disorder or malingering.

 bias toward somatoform disorder over factitious disorder and malingering, there is a similar bias toward malingering over factitious disorder. Malingering is to be diagnosed when tangible or instrumental benefits accrue from intentional inauthentic illness behavior. In almost every case of genuine illness, benefits are bestowed on the patient. The patient receives extra care and concern, may be placed on paid work leave, is allowed to pass on dinner with the in-laws, and so on. These things happen to virtually everyone who becomes ill or injured, but none of this informs the question of whether inauthentic illness behavior was designed to secure those benefits. There is a difference between a motive and a consequence.

What are left over for the factitious-disorder category are cases in which patients subject themselves to painful, embarrassing, or debilitating self-harm and medical interventions for no good reason. A malingerer takes a mild fall in a restaurant and gets a half million dollars; a factitious-disorder patient allows both her breasts to be removed so that she can play the role of medical patient for a couple of months.

There are countless scenarios in which malingering might be the product of financial desperation, a desire to escape physical or emotional abuse, or other causes.

The behavior of any patient who meets the stringent 

 criteria for factitious disorder strikes the average lay person as truly insane. In fact, clinical experience with dozens of prototypical cases suggests that few patients with factitious disorder-even the extreme Munchausen variant-have any overt signs of thought disorder, disorganized behavior, or psychotic symptoms. Nevertheless, experienced forensic experts who specialize in these types of cases remark that judges and jurors find it hard to believe that such a sane-looking person could have purposefully poisoned himself, or caused his own sepsis, as examples.

 criteria sets for forensic psychiatrists in cases that involve alleged inauthentic illness behavior. First, because of the flaws and biases in 

 diagnosis may not get the examiner or his or her client any closer to the truth of what has transpired in the case at hand. Second, despite its flaws, 

 can and will be used by opposition experts to support the opposition’s theory of the case. Rejoining that there are no data to support the 

 framework is a double-edged sword: there is also no body of evidence to support one’s alterative interpretations.

The differences between factitious disorder and malingering

When confronted with a patient with a factitious disorder, many people find it difficult to fathom someone’s inducing symptoms without the principal objective of external gain. However, for individuals who engage in this behavior, the motivation to play the sick role provides covetous interpersonal benefits. Diagnostic criteria specify that the individual intentionally produces or feigns psychological or physical symptoms without evident external motivations. In assigning this diagnosis, one can specify whether the behavior manifests with predominantly psychological signs and symptoms, predominantly physical signs and symptoms, or a combination of both.

Factitious disorder is always indicative of psychopathology and may be accompanied by pseudologia fantastica (the telling of tales that are a mlange of fact and fiction).

 Patients who exhibit pseudologia fantastica are usually florid; when questioned, however, these individuals give vague and inconsistent answers regarding the symptoms per se.

 suggests that malingering should strongly be considered if one or more of the following contextual factors are present:

• The patient is currently involved in litigation (most often disability claims are in dispute)

• There are noticeable differences between the individual’s claims and objective findings by a health care professional

• The patient is uncooperative in assessment or treatment attempts

The presence of an antisocial personality disorder should also be considered a possible comorbid diagnosis. However, while reasonably sensitive, the findings showing possible comorbidity with antisocial personality disorder have a low specificity.

, experience proves that factitious disorder and malingering often co-occur. For instance, a patient starting out with factitious disorder may find it necessary to malinger to “save face” in front of others who question why the patient is not pursuing legal remedies for the apparent medical malpractice that has actually resulted from self-harm.

 Generally, however, the malingerer will attempt to minimize contact with med-ical professionals and testing because each visit or test provides an opportunity for detection; in contrast, the person with factitious disorder welcomes the opportunity to play the role of patient and finds it intrinsically gratifying. 

 lists some of the similarities and differences between prototypical presentations of factitious disorder and malingering.

Formal assessments range from clinical guidelines for detecting signs and symptoms that are common to factitious disorder and malingering to formal personality and neuropsychological test batteries.

 Although measures built into some tests assist in detecting feigning, these are generally limited to detecting false neurocognitive impairment; such measures do not assess the motivations behind the deceptions. The assessment of internal versus external motivations is often more of an art skill than an objective undertaking. 

 presents indicators from patient charts that may point to possible medical deception.

As suggested, persons with factitious disorder may take their falsification of illnesses and injuries further than is seen in cases of malingering, where the goal is more discrete. The patient’s presentation may not match the diagnostic criteria for the disorder but rather the patient’s conceptualization of how the disorder should manifest.

 Symptom complaints may be unduly numerous or emphatic, or improbable in their combination or severity.

 A survey of neuropsychologists by Slick and colleagues19 found that clinicians often do not use the explicit labels of malingering or factitious disorder but merely indicate that their assessment of the patient’s symptoms was inconsistent with the proposed illness or injury.

There is an inherent uncertainty in differentiating malingering from factitious disorder. Drob and colleagues

 articulated several concerns that psychiatrists may face when evaluating these cases for forensic purposes. They note that there is a specific disadvantage in diagnosing malingering because it depends on the context rather than on the presence or absence of diagnostic criteria. In addition, other pathology comorbid with either malingering or factitious disorder can cloud the diagnostic picture.

Several case decisions have intensified the standards that forensic psychiatrists must use to detect malingering).

These decisions have made it necessary for psychiatrists to use measures with accepted reliability in the scientific community more often than their personal expertise and clinical knowledge.

In the legal realm, the distinction between factitious disorder and malingering may have important implications. In a forensic evaluation, the recognition of either phenomenon has implications for the patient’s future, both legally and medically. In the legal context, not only are symptom presentations being called into question, but individuals who feign a medical disorder can also face criminal charges. These individuals may be prosecuted for false disability claims or charged with inappropriate use of health care resources by hospitals or their insurance companies.

 Furthermore, they themselves may bring charges against medical professionals for claims of malpractice that include explicit recognition of deception.

In interacting with these patients in medical practice, there are concerns about ethical obligations for treatment. Hamilton and Feldman

question whether the doctor-patient relationship persists after the patient enacts medical deception, and question what responsibility the physician has once feigning is discovered. If the relationship is broken, does the physician have a responsibility to notify other professionals whom the patient may see so that they are not misled into providing unwarranted treatment? When individuals are “exposed,” an additional complication includes medical professionals’ bringing legal action for the misdirected, and often unreimbursed, medical services.

One side or the other may use the existence of factitious disorder to advance the claim that the accused patient was legally insane and therefore not legally responsible for his actions. Each case must be considered individually. However, patients with factitious disorder rarely meet the criteria for legal insanity. In this respect, there is little practical significance to distinguishing between factitious disorder and malingering. However, it is reasonable to argue that the illness deceptions in factitious disorder bear a close relationship to compulsions and may represent a legitimate mitigating condition that is generally not present in malingering.

It is a mistake to assume that all malingerers are driven by shameless greed. There are countless scenarios in which malingering might be the product of financial desperation, a desire to escape physical or emotional abuse, or other causes. A fair and thorough evaluation of medical deception should include sufficient psychosocial history gathering to understand the context of medical deception.

Psychiatric reports of medical deception, particularly of cases involving factitious disorder, often make the curious assumption that a patient’s self-reported history about past abuse or another significant psychiatric event is somehow more trustworthy than all the lies, simulations, and obfuscations that are used to deceive doctors.

Professionals sometimes mistakenly assume that uncovering medical deception is sufficient proof that the patient is not really physically ill or injured. Medical deception does not ameliorate the risk of authentic disease or injury, however. In some cases, intentional exaggeration of symptoms might reflect a desperate attempt to get attention for a medi-cal problem that the patient actually has.

Andrea, a 32-year-old part-time athletic coach, was a passenger in a van operated by the Police Athletic League of a major city. During an outing, the van and a car sideswiped each other. No injuries were evident among the riders in either vehicle, and no one requested or required medical intervention. Six months later, Andrea filed a lawsuit alleging that the incident had in fact caused a head injury that resulted in progressive paresis. By the time a psychiatric expert was retained by the defense, Andrea was ostensibly quadriplegic.

After completing a review of the extensive medical records, the expert found it incontrovertible that the patient was feigning her paralysis. Among other factors, he noted that it was unusual that a motor vehicle accident for which on-site medical evaluation and treatment were refused-one in which no head injury was initially reported-had culminated in ostensibly permanent disability.

Although the patient had seen an extraordinary number of medical providers, she reported that no intervention had ever helped her. However, her symptoms were disconfirmed by objective testing. Andrea’s statements were deemed inconsistent and misleading, and she was found to have lied floridly and gratuitously about her education and career. The medical records showed that she had had more than 60 hospitalizations after the accident for ailments that typically eluded formal diagnosis. In addition, she had generally signed out against medical advice after the recommendation of a psychiatric consultation or the opposition of the staff to her escalating demands for potentially abusable drugs.

Before the accident, Andrea was living in poverty. Following the accident, she received full-time home health care, maid services, workers’ compensation payments, and Medicaid. Weighing the potential motivations for Andrea’s behavior, the psychiatric expert opined that malingering was primary, with factitious disorder secondary. Noting that the patient had obtained at least 30 prescriptions for diazepam and meperidine during an 18-month period, he indicated that the goals of the malingering included acquisition of abusable drugs, the disability entitlements and, most important, the potential financial windfall from the litigation. Factitious disorder was indicated by the severe and chronic nature of her falsified signs and symptoms, her pseudologia fantastica, and her itinerancy (ie, the triad for the diagnosis of Munchausen syndrome).

Because of the breadth and duration of the symptoms, the associated litigation, and the inappropriate procurement of resources that had already taken place, the psychiatric expert predicted that resolution of the malingering was all but impossible. Although the defendant denied culpability, they were induced to settle the case for $500,000. Their reasons included the complexity of the case, the likelihood of a prolonged trial, and the difficulty a jury might have in believing that an ostensibly ill, wheelchair-bound woman would fake her own ailments and, in the process, successfully mislead so many physicians.

The primary difference between malingering and factitious disorder is the question of motivation. Is the patient seeking to take the sick role and receive interpersonal benefits from this illness behavior or are there external incentives for his behavior? Although evaluations of these patients are complicated, several protocols have been developed for assessment, and supplemental guidelines written by professionals in the field can aid in evaluation.

 Forensic psychologists are presented with a challenge when asked to evaluate these individuals in medical or legal settings. Specific concerns for the professional include ethical obligations for treatment of the individual, and financial and legal concerns related to factitious disorder and malingering.

 Cook DM, Meikle AW. Factitious Cushing’s syndrome. 

 Jordan RM, Kammer H, Riddle MR. Sulfonylurea-induced factitious hypoglycemia. A growing problem. 

 Feldman MD. Factitious disorders and fraud. 

 Eisendrath SJ, Telischak KS. Factitious disorders: potential litigation risks for plastic surgeons. 

 Janofsky JS. The Munchausen syndrome in civil forensic psychiatry. 

 Lipsitt DR. The factitious patient who sues. 

 Feldman MD. Prophylactic bilateral radical mastectomy resulting from factitious disorder. 

 Eisendrath SJ. When Munchausen becomes malingering: factitious disorders that penetrate the legal system. 

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision

). Arlington, VA: American Psychiatric Publishing Inc; 2000:514-515.


Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder.

 Rogers R. Development of a new classificatory model of malingering. 

 Hamilton JC, Feldman MD. Munchausen Syndrome.

eMedicine from WebMD. Updated September 16, 2009. 

http://emedicine.medscape.com/article/295127-overview

 McDermott BE, Feldman MD. Malingering in the medical setting. 

 Meyer RG, Deitsch SM. The assessment of malingering in psychodiagnostic evaluations: research-based concepts and methods for consultants. 

Clinical Assessment of Malingering and Deception. 

 Samuel RZ, Mittenberg W. Determination of malingering in disability evaluations. 

 Vittaco MJ, Rogers R, Gabel J, Munizza J. An evaluation of malingering screens with competency to stand trial patients: a known-groups comparison. 

 Parker PE. Factitious psychological disorders. In: Feldman MD, Eisendrath SJ, eds. 

 Washington, DC: American Psychiatric Press; 1996:37-99.


 Slick DJ, Tan JE, Strauss EH, Hultsch DF. Detecting malingering: a survey of experts’ practices. 

 Drob S, Meehan KB, Waxman SE. Clinical and conceptual problems in the attribution of malingering in forensic evaluations. 

 Reynolds C. Understanding and surviving the Daubert challenge in your testimony. Presented at: the 23rd Annual Conference of the National Academy of Neuropsychology; October 15-18, 2003; Dallas.


 Aronoff GM, Mandel S, Genovese E, et al. Evaluating malingering in contested injury or illness. 

 Ford CV. Ethical and legal issues in factitious disorders: an overview. In: Feldman MD, Eisendrath SJ, eds. 

 Washington, DC: American Psychiatric Press; 1996.


 Nadelson T. Historical perspectives on the spectrum of sickness: from “crock” to “crook.” In: Feldman MD, Eisendrath SJ, eds. 

 Washington, DC: American Psychiatric Press; 1996.

Articles

Patients who exaggerate, feign, or induce physical illness are a great challenge to their physicians. Trained to trust their patients’ self-reports, even competent and conscientious physicians can fall victim to these deceptions.

The Case of Factitious Disorder Versus Malingering

The first of these trends is the medicalization of misery, in which an ever-expanding list of human discontents, such as inattentiveness, wrinkled skin, and inconsistent erections, are being recategorized as medical diseases. At the same time, there has been a trend toward reductions in social entitlement programs. As more and more avenues for securing basic human needs have been closed off, the needy have increasingly turned to the ED as a place to get those needs met. For some members of our society, the hospital may be their only refuge from the pressures, deprivations, and even dangers of modern life.

Looked at in this light, malingering can be understood as a perfectly predictable by-product of a society that not only promotes the view that sickness is the underlying cause of most human distress but also attaches so many entitlements uniquely to the sick role. It is left up to Dr Berlin and physicians such as him to face the waves of patients who come to the ED seeking the stamp of medical legitimacy on their claims to the benefits of the sick role.

Dr Berlin's reflections about his work with malingerers feature 2 important and inter-related themes: the enmity that develops in the doctor-patient relationship and the importance of an honest and earnest individual assessment of each case. We share Dr Berlin's view that these are the major impasses that characterize encounters with suspected malingerers. Our discussion here is intended to elaborate on Dr Berlin's excellent analysis.

Malingering is not a genuine illness, at least as far as the 

 Even referring to a malingerer as a "patient" is controversial. However, malingering may become a principal focus of clinical attention much more frequently than ED clinicians and staff would like.

The malingerer often presents with a subacute or chronic problem for which the ED appears particularly unsuitable. This population is easily among the least gratifying that professional caregivers face, and it is understandable that some clinicians view the malingerer, along with other patients who present very repeatedly, as a "hateful patient."

 The malingerer mobilizes intense countertransference, ranging from perplexity to anger, aversion, and a feeling of being exploited. These negative reactions toward the malingerer may be reinforced by a staff that clearly views offering assistance--such as an opioid or benzodiazepine prescription--as betraying personal and professional weakness.

At the heart of these scornful feelings is the assumption that the malingerer is trying to get something to which he or she is not entitled. The common view of malingering is that it is defined by 2 criteria: (1) lies or misrepresentations (2) intended to secure some benefit to which the malingerer is not otherwise entitled.

 Even this simplistic view of malingering may be replaced in clinical practice by an even simpler heuristic; if a patient is being dishonest, the patient 

 trying to secure a benefit to which he is not entitled. Accordingly, the management of malingering is often reduced to uncovering the patients' lies or deceptions and sending them packing. Apart from the probable incorrectness of the underlying assumptions of this approach, Dr Berlin also notes astutely that handling malingerers this way may do little more than relocate a difficult patient from one ED to another.

Dr Berlin points out incisively that a patient's dishonesty about his presenting complaint does not necessarily mean that the patient does not have a legitimate need that he is trying to meet through enactment of the sick role. Understandably, Dr Berlin focuses on patients whose manifest psychiatric problem is somehow covering up another, different type of psychiatric issue (eg, in Case 2 [page 23], in which bipolar disorder served as a pretext for securing help in a homicidally distressed patient). For our part, we would like to extend Dr Berlin's analysis by highlighting the wide diversity of malingering presentations and of underlying motivations that may lead persons to enact the sick role in the ED.

One can envision 5 patients who come to the ED at 1 am seeking a medical admission to the hospital. In a manner of speaking, they are all seeking the same thing; in another way, they may all be looking for something different. One might be seeking refuge from domestic violence, another might be looking for a warm bed on a cold winter's night, another may be executing the first part of a complex plan to extract a medical liability settlement from the hospital, another may be seeking to avoid the unbearable social anxiety of a job interview scheduled for later that morning, and yet another may simply be looking for basic human caring and kindness.

Arguably, all of these persons are malingering, and they all want the same thing: to be admitted to the hospital. However, if ED staff focuses only on the malingering and concludes that these patients' complaints are not legitimate, or at least not treatable, the staff has missed an important opportunity to help these patients and, ultimately, themselves.

A psychiatrist may have nothing to offer the sociopath bent on bilking the hospital and might rightfully conclude that the patient does not have a legitimate claim to aid or assistance. In addition, there may be little that clinicians can offer a homeless person who is seeking physical comfort, although they acknowledge that he has a legitimate need. On the other hand, abusive relationships, debilitating anxiety, and loneliness are the sorts of problems for which psychiatry confidently claims to provide solutions. In many cases, accurately assessing the patients' needs and channeling patients to appropriate social service agencies or nonemergent medical or psychiatric care might reduce their excessive and inappropriate use of the ED, thereby helping both the patient and the hospital.

A further point about the complexity of malingering presentations is raised by Dr Berlin's third case presentation (page 25). In this case, there was a complex blend of apparent exaggeration of distress in the context of strong and pressing motives to malinger but with a history of unambiguous suicidal behavior. Despite its complexity, this case may represent the rule rather than the exception--namely that most cases of medical or psychiatric deception reflect a combination of internal and external motivations, of which the patient may be more or less aware. Experiences with genuine illness can introduce patients to the adventitious reinforcement associated with the sick role, which might lead to other strategic sick-role enactments. The existence of such cases reinforces the need for a thorough assessment of suspected cases of malingering.

Most patients who are suspected of malingering probably do not fit the stereotype of the malingerer as a con artist or drug seeker but rather are simply desperate people who are doing their best to cope with difficult life situations and have nowhere left to turn for help. As we have alluded, both patients and hospital staff are victims of a social system that has made the hospital ED the de facto provider of a wide range of social welfare services. Realizing this may go a long way toward redirecting angry and hostile feelings away from the patient. Recognizing that the patient probably has legitimate basic human needs, perhaps emergent ones, should help mobilize an empathic response to patients who are often perceived simply as cheats.

The obvious complication that arises in suspected cases of malingering is that the malingerer gives the impression that he is not being honest with the evaluator about the exact nature of his problem, making it impossible to evaluate the patient's real needs. Why are they not being honest with the evaluator? Dr Berlin focuses his attention on psychological barriers, such as a "defensive need to dehumanize the image of the clinician" and a lack of trust that limits self-disclosure. We suggest that there is another psychological obstacle to honesty, one that may be present in all but the most nefarious cases: the need to save face.

Sociologist Erving Goffman observed that most social interactions have a bit of dishonesty built into them.

 According to this dramaturgic analysis, the rules of social engagement specify that we each are entitled to small lies, boasts, and excuses and, in return, we are obligated to honor the lies, boasts, and excuses of others. For example, a physician arrives late for an important social engagement, telling her husband she had to answer a page; the husband accepts the excuse, knowing that in all likelihood it is not true; the physician knows that her husband doubts the excuse; and domestic tranquility is maintained--at least for the time being. Goffman's genius was in seeing this type of subterfuge as a normative and necessary part of human interaction and not as a form of psychopathology.

We believe that in many cases in which malingering is suspected, the patients' specific needs are accompanied by a second, universal need to maintain a sense of basic human dignity. In these cases, it is the desire to save face, not the desire to cheat the system, that explains why the malingering patient is not honest with the evaluator.

The patient who is seeking refuge from an abusive spouse is lying about being ill for 2 reasons: one is to gain access to the safety of the hospital; the other is to avoid admitting to a total stranger that she has been too weak, afraid, or emotionally needy to break away from a man who treats her worse than he treats his dog. The economically disadvantaged African American mother brings her child to the ED with exaggerated reports of respiratory distress because she cannot afford primary pediatric care and because she wishes to avoid the indignity of being judged by yet another white social security administrator from whom she must beg for charity. Even in Dr Berlin's second case presentation, the patient was seeking relief from the pressures of his home life without having to suffer the humiliation of admitting to the physician that he has been abused by his girlfriend's children and is so angry over this fact that he is afraid he will hurt someone.

Dr Berlin suggests a number of approaches for breaking out of the dishonest communication patterns in which clinicians and suspected malingering patients often find themselves. Many of his suggestions involve direct confrontation of the dishonesty. Although there may be some cases in which confrontation is necessary and advisable, we suspect that less direct strategies that are attentive to the issue of saving face may ultimately produce a better result in most cases.

CASE MANAGEMENT OF THE SUSPECTED MALINGERER

Effective management of suspected malingering should begin with the working assumptions that the patient has a legitimate need and that the ED visit is probably the patient's last best hope for getting that need met. The evaluator should communicate to the patient that people turn to the ED for help with a variety of legitimate problems, some of which can be dealt with at the hospital and some of which cannot, and that the evaluator is committed to doing everything possible to ensure that the patient's needs are met.

Also, the evaluator should set a tone of acceptance and respect that will foster open and honest responses on the part of the patient. Patients who sense a positive and accepting attitude in the evaluator may feel comfortable in confiding their true need to the clinician. In larger urban settings, it might be advisable to have around-the-clock coverage by a clinical social worker who can help assess the patient's broader needs and make appropriate referrals to public and private social service agencies, such as shelters, safe houses for abused women, and free clinics.

For persistent malingerers, the sorts of assessments that would provide useful insights into the causes of their malingering are certainly not compatible with the limited time and resources of clinicians in the ED setting. In these especially difficult cases, we believe the clinician should support, whenever possible, a brief hospitalization. The chief objective of the admission would be to conduct a thorough functional analysis of the patient's health care use. Such an analysis functions to help clinicians understand the patient's health care use in the context of a broad range of ongoing and acute stressors, as well as the resources available to the patient to cope with these challenges.

Unlike an ED workup, the evaluation of inpatients can be more deliberate and wide-ranging. Whereas a focus on broad psychosocial concerns in the ED might strike the patient as invalidating their acute complaint, that sort of broad approach is expected in the inpatient context and may communicate to the patient that he is being taken seriously. Moreover, an inpatient evaluation would provide the opportunity for nonphysician health care professionals to evaluate the patient and perhaps match some of their nonemergent medical and psychosocial needs with available resources in the community. An inpatient evaluation also would provide an opportunity for a definitive evaluation of the patient's presenting complaint, helping protect the patient in cases of difficult-to-diagnose medical or psychiatric conditions and the hospital from future claims of negligence.

There are 3 possible outcomes of a brief inpatient evaluation of a suspected malingerer. First, the patient might fail to cooperate in an honest and forthcoming manner despite the best efforts of staff to treat him in a nonjudgmental and dignifying manner. If this occurs, the hospital has a medical record of the concerted efforts that have been made to help the patient and his unwillingness to accept that help. These data would be valuable to ED personnel should the patient return to the ED with suspicious complaints, providing evidence to support a denial of services.

Second, the patient may cooperate with the evaluation, revealing that he has legitimate needs that fall outside the purview of medicine or psychiatry. Hospital team members who are aware of programs through which the patient's needs could be met can help educate the patient, assist him with paperwork, and make appropriate referrals.

Third, the cooperative patient might reveal that the problem with which he has been using the sick role to cope may be amenable to psychiatric or psychological intervention. Each of these outcomes ultimately enhances the ability of hospital staff to gauge the fit between the patient's needs and the hospital's resources and, therefore, maximizes the likelihood that the patient will receive the help he needs.

Anyone who has been to a busy ED in the late hours of the night can attest that it is not a pleasant place to be. Long waits are punctuated by brief interactions with busy staff who simply have no time and energy for pleasantries with the patients. The idea that anyone would freely and willingly subject himself to the experience flies in the face of common sense. Most persons with genuine illness visit the ED as a last resort, and we believe that most suspected malingerers who visit the ED do so as well.

The challenge to ED psychiatrists and clinicians is to uncover the patient's need, to understand the nature of his inability to satisfy it in more adaptive ways, and to do all this in a manner that preserves the patient's basic human dignity. Achieving this will require that the clinician redirect hostile feelings away from needy patients and onto the systems that have forced both themselves and their patients to play this mutually humiliating game of cat and mouse. In the end, the system is destined to fail. The EDs of the world cannot provide food, clothes, protection, and kindness to all those in need.

The Perfect Storm: A True Story of Men Against the Sea

. New York: HarperTorch; 2000.2. Korry E. LA hospitals investigated on patient-dumping [transcript]. "All Things Considered." National Public Radio. March 28, 2007.3. American Psychiatric Association.

 Diagnostic and Statistical Manual of Mental Disorders.

 4th ed, text revision. Washington, DC: American Psychiatric Publishing; 2000.4. Groves JE. Taking care of the hateful patient.

The Presentation of Self in Everyday Life.

In The Perfect Storm, Sebastian Junger describes the desperate plight of sailors and fisherman who, in the fall of 1991, were caught out in the Atlantic Ocean as 2 powerful storms converged into 1.1 Like those mariners, emergency department (ED) clinicians find themselves at the confluence of 2 powerful trends in modern society.

Author | James C. Hamilton, PhD

Articles

The Case of Factitious Disorder Versus Malingering

Functional Analysis of Malingering in the Emergency Department