"There must be some way out of here," said the joker to the thief."There's too much confusion, I can't get no relief. . . .""No reason to get excited," the thief, he kindly spoke,"There are many here among us who feel that life is but a joke.But you and I, we've been through that, and this is not our fate,So let us not talk falsely now, the hour is getting late."From "All Along the Watchtower," Bob Dylan
Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms that is motivated by external incentives.1 It is distinguished from factitious disorder by its easily identifiable secondary gain, such as evading criminal prosecution, and its absence of indications that the person has an intrapsychic need to maintain the sick role and a relationship with a treatment provider.
Commonly, a person presents to the emergency department (ED) or psychiatric emergency service (PES) with a chief complaint of suicidal ideation or auditory hallucinations and a contradicting clinical picture of relative ease and comfort. In addition, the patient may have a documented mental illness, but that aspect of his or her medical history is clearly not in need of urgent or emergent clinical attention.
An example of such a scenario follows: The police voluntarily transport a 45-year-old man with a documented schizoaffective disorder to the PES. The patient tells the triage nurse that he is suicidal and needs to be hospitalized. Moments later, however, the physician sees him smiling, talking pleasantly with a nurse's aide, and enjoying a bologna sandwich. In the psychiatric interview, the man is unable to explain how his life is in crisis in any way. His voices are at baseline, and there is a marked discrepancy between his complaint and his observable clinical condition. Medical records show that he has had numerous similar presentations in recent months. His case manager is contacted; she indicates he was fine that morning when she made her daily medication delivery. Eventually, he discloses that he was very upset with the staff at his group home for reprimanding him over his returning from a shopping trip after dinner, and he agreed to return there that night.
To a large extent, existing psychiatric literature on malingering focuses primarily on detection of the condition.2-17 This is entirely appropriate when, as is often the case, the malingering person is wrongfully seeking benefits or advantages from the military, criminal justice system, insurance industry, or Social Security Administration. When clinical management of the condition is described in the literature, its usual focus is on how to inform the person of one's impression of malingering safely, respectfully, and without undue damage to the physician-patient relationship.
Practitioners in EDs and PESs clearly face these challenges. One study reports the number of patients suspected of malingering to be as high as 13%.10 A recent report by Coristine and colleagues18 describes an interesting approach to triaging such patients more effectively.
Emergency clinicians face an even greater challenge, one which severely tests their equanimity and clinical acumen: seeing persons who have made a bad habit of malingering, who believably report not feeling welcome anywhere, who repeatedly come to clinicians seeking services, and who repeatedly fabricate psychological or physical symptoms. This, as the saying goes, is a different kettle of fish, and there appears to be little to no published data about them.
Typically, when a malingering visitor to an emergency service has a serious mental illness or chemical dependency and the malingering behavior is a comorbidity rather than a sole condition, the usual approach to care is to determine whether malingering is the uppermost problem. If the person is genuinely ill, he receives appropriate psychiatric and medical interventions. If his complaints, such as suicidality or psychosis, are manufactured, he is removed from consideration of the clinical pathways for high acuity and, sooner or later, shown the door.
The problem with this approach is that it does not always work. Persons who intentionally exaggerate or fabricate their symptoms may be successfully deflected, but a certain hard-core group of them, even after being offered a variety of social services for housing and other problems, keep coming back over and over. These patients become well known to ED or PES staff. As members of an unyielding and intransigent segment of the mental health population whose condition seems to be without hope of remedy or change, malingering patients are often in the process of failing or dropping out of treatment programs elsewhere.
Emergency clinicians--keepers of the health care safety net federally mandated to see all comers--are often by default the ones who end up seeing malingering patients on a regular basis.19 Even if there is a period when they have stopped frequenting a certain ED or PES, anecdotal reports suggest that it is often because they have temporarily taken that department or service out of rotation and have been frequenting others. It is only a question of when they will come back. If emergency providers do not take the initiative to help them, chances are that no one else will.
Emergency clinicians may ask themselves whether there is anything more that can be done for persistent malingering. Is there some approach that could break the cycle of misguided visits, unrewarding clinical interactions, and unsuccessful dispositions and referrals--a cycle that is both expensive and wearing on patients and practitioners?
One might expect to see a keen scholarly interest in a group of patients who are treatment-resistant, for they are part of the scientific frontier. In actual practice, the opposite is true. Residents and attendings and other staff usually spend as little time with this clientele as possible. Often, clinicians hasten to make the big decision--to admit or not to admit--and quickly move on.
The negative gut reaction that these patients generate in physicians and other emergency staff cannot be ascribed simply to discomfort with treatment failures. Most practitioners come to accept that their knowledge has limits. Whether their professional efforts are primarily clinical, didactic, or research-based, the boundaries of their understanding are what they press against. Nor can the negative reaction be ascribed to frustration with the lack of available medical and social resources.
When a patient exaggerates his symptoms to receive care from an unresponsive system, most clinicians are able to put this behavior into perspective and take it with the proverbial grain of salt. However, there are patients who have gone for too long without the necessary definitive treatment and for whom clinicians lack the methods to manage a syndrome after it has seemingly become chronic. Victims of both inadequate resources and knowledge are doubly unfortunate.
The real challenge is to work more effectively with malingering persons, who frequent emergency services and arouse no positive feelings among the staff. Experienced nurses--professional clinicians--will tell the physicians on duty that so-and-so is at the door again and ask what they should do. Do they have to see him? It is as if they have never heard of the Emergency Medical Treatment and Active Labor Act. A common scenario is that when psychiatry or medical residents see the person's name on the census board, they offer to take the next 2 cases if they can skip this one. The more experienced physician agrees, thinking "I can handle this joker in 5 minutes."
How are we to understand such questions from caring nurses who know full well their legal, clinical, and ethical obligations? How are we to understand this behavior by humane physicians who normally welcome the chance to practice their craft?
A TRANSFERENCE/ COUNTERTRANSFERENCE STALEMATE
One conceptual perspective that may be usefully adapted for managing malingering is described in the psychoanalytic literature on therapeutic impasses.20-25 The basic premise is that a psychological and interpersonal "script" originating in the patient has unconsciously drawn in the clinician to play one of the roles, and that both "players" are locked into these roles.
In order to break out of a pathological stalemate, clinicians need to be alert to the underlying feelings and attitudes that a patient may have about them, as well as the feelings and attitudes they have about the patient. In particular, clinicians need to examine those feelings that seem driven and egodystonic or foreign.
From personal experience and the reports of colleagues and trainees, the type of malingering that is unique to EDs and PESs is approached with a particularly intense form of dread. Malingering is commonly found in association with antisocial personality disorder.1 Thus, I suggest that this dread stems in part from clinicians' reactions to a very antisocial, interpersonal dimension of the patient's personality that very quickly seems personal.
Rarely a pure condition by DSM-IV-TR criteria, the repetitious malingering that emergency clinicians have the privilege to see is, among other things, a noxious form of lying that attempts to dupe and exploit the evaluator. The impetus for the behavior is the presumption that the evaluator will not of his own accord give anything of value to the patient.21,22 Also present is the presumption that only a predetermined thing--often hospitalization or addictive drugs--will be useful to the patient; nothing of unexpected worth will spontaneously come out of the evaluator.
The evaluator naturally reacts viscerally to the patient's presumption. The implicit characterization is devaluing and dehumanizing. It is easier for the evaluator to take a history of antisocial behavior than to be subjected to this type of psychological sociopathy. The evaluator is on guard from the outset and often views the patient as an adversary, not as a collaborating partner in treatment or recovery.21,22
Persistent malingering can thus be characterized as a script of shackled interaction between patient and clinician with little to no chance of a therapeutic outcome. The malingering patient either manipulates the clinician to obtain an unhelpful hospitalization that does nothing to change the patient's limited--and limiting--perception of people or is denied his demand and feels he has been cheated out of anything of worth. He sees the evaluator as a thief.
The evaluator can either give in to the demand and feel as though he has been a victim of highway robbery or stand up to the patient and feel robbed of some peace of mind. Although the evaluator may take some comfort in the fact that studies on contingent suicide show that persons who blatantly and manipulatively threaten suicide do not usually attempt it,26 he cannot disregard the feeling that he may be risking an adverse outcome after discharge. Thus, the clinician views the patient as a thief.
Both scenarios are repetitive and compulsive in nature. With experience, a practitioner can avoid costly hospitalizations. However, the basic problem of the patient repeatedly and expensively visiting the PES or ED is unresolved.
Given the unpleasant feelings that these encounters may activate in clinicians, there is a high likelihood that clinicians will react either with sarcasm and callousness or with guilt, overindulgence, and overly defensive medicine. In general, the standard of care is not set too high. Emergency clinicians may consider it a successful intervention if there is good documentation, appropriate risk management, conferencing with outpatient providers, not acting out too much on their own negative feelings, and limiting the ED or PES visit to a minihospitalization in the waiting room or observation area.
A casualty of the encounter is an honest conversation. With so many subtexts and affective undercurrents, it is difficult to be direct with the patient. For example, instead of explaining why hospitalization is not a good idea, clinicians might fall back on the explanation that there are no beds. Instead of clinicians saying that they are concerned that the patient will develop dependency on the benzodiazepine he is requesting, they find themselves saying that policy does not allow for such prescriptions. Clinicians become a kind of joker in their own right in that they do not say what they are really thinking. They forget that in certain situations, it is entirely possible to put their speculation about the patient's basic distrust of their altruism and competence into words. For example, a clinician might say to the patient, "You know, as we talk, I get the distinct feeling that you're working me, as if I would never take an interest in helping you or as if I don't have anything to offer you other than what you can get out of me. Is that it?"
A more subtle source of the patient's dishonesty that has a less discouraging prognosis is his defensive need to dehumanize the image of the clinician and to have the clinician in his mind dehumanize the image of the patient.22 Here, the interpersonal agenda is more one of avoidance than paranoia and exploitation. The patient feels there might be something of worth in himself and the clinician, but given his history of disappoint- ing people or being disappointed by them, he finds it too dangerous to contemplate or experience this worth. Dishonesty then becomes a quick way to set up an alienated relationship between the patient and an entire clinical service and to avoid any chance of a genuine and meaningful interaction.
INVENTION AND INTERVENTION
"Let us not talk falsely now, the hour is getting late."
Is it just one's imagination, or do many of these deeply troubled malingering patients usually come in after midnight, when our defenses are down and when "the wind began to howl"? It may be the most trying time to go head-to-head with persistent malingering in combination with mental illness, drug addiction, and personality disorders. Sometimes, however, suffering breeds creativity. What might this look like? Following are 6 suggestions that may help clinicians better manage a suspected case of persistent malingering.
Awareness. Emergency clinicians must be aware of the feelings and assumptions about the other person that are generated on both sides of a divide. These become key pieces of data that are incorporated into the formulation. It is also not possible to refrain from acting out on feelings for very long if one is unaware of them.
Inevitability. Clinicians must realize that the interaction is unavoidably traversing a path with deep grooves and that the grooves will interfere with the spirit of free inquiry into the patient's current life situation. These are inevitable "enactments" that clinicians must accept and understand.
Acute precipitant. Clinicians must always attempt to ask the patient the crucial questions about the circumstances that have led up to the ED or PES visit. Determining what, if any, stressors the patient is dealing with and why he has presented for treatment at this moment is useful.
If the visit seems to be the result of a spontaneous and gratuitous attack of sadism, clinicians should consider that assumption to be a prejudice in themselves that the patient is unconsciously trying to provoke. In the most treatment-resistant patients, clinicians may see a dynamic of self-destructive "terrorism" at work; in such cases, the only way the patients seem to be able to feel like a success in life is to make clinicians and their best efforts fail.22
Although the malingering behavior might seem gratuitous, it is useful to assume that the patient has just suffered some humiliation, disappointment, or loss--perhaps not great enough to correspond to his stated complaint, but not insignificant.
Assessment. Clinicians must always attempt to complete a thorough medical and diagnostic assessment. During this process, it is helpful to try to determine whether malingering is the primary condition or whether there is another clinical condition in ascendancy.
Despite the sparsity of literature on malingering in the emergency setting, 10 years of treating patients and consulting on cases in a PES have given me the distinct impression that PES patients who malinger also have 1 or more bona fide Axis I or Axis II disorder. It is also a well-known pitfall, as well as another potential form of unconscious acting out, to forget that persons who intentionally feign symptoms are as much at risk for development of a life-threatening physical illness as anyone else. In actuality, they probably are at much greater risk for an overlooked diagnosis because of the difficulty that caregivers and clinicians may have of taking their complaints seriously.
Confrontation. If the primary condition is one of persistent malingering, serious and thoughtful consideration should be given before confronting the patient about the suspected behavior. First, one must feel well-acquainted enough with the person. This is not something one does with a relative stranger. Second, one must be certain that he is not dealing with a case of factitious disorder. As mentioned at the outset, persons who crave a clinician-patient relationship from deep-seated psychological needs have a condition much different than malingering. Interventions are also much different, and confronting a patient with factitious disorder can precipitate a devastating crisis.
Different situations call for different approaches, and each clinician needs to develop his own style for managing malingering. Discussing this behavior with a patient may be awkward, but implementing the following guidances may make it easier to do so:
•Break out of the monotony.
•Maintain a mindset of respect and helpfulness.
•Stand up for oneself and be honest.
•Monitor the patient for hostile reactions and work in safe surroundings so that one may speak freely.
There are several approaches to confronting a patient about his malingering behavior. There is the diplomatic approach: "This isn't easy for me to say, and it might not be easy for you to hear, but as your doctor I have to be honest with you. I don't think you're feeling as hopeless as you say are." There is a more direct approach: "You know, what you're saying doesn't quite hang together. I don't think you're being totally straight with me."
Showing some emotion is not always wrong. With very manipulative patients, a strong and loud objection may be required: "Now just hold on a minute! Stop putting that guilt trip on me! That's not right. If this is how you treat other people, I can see why you have a hard time getting along with them!"
If there is a good rapport, sometimes a paradoxical approach may surprise the patient and produce positive results. For example, one might say, "Of course you're suicidal. A day doesn't go by that you don't think about suicide. That's not news. A day you didn't think about suicide, now that would be news."
When a suicide threat is clearly revenge-based but still under a person's control and if one is quite certain that the behavior stems from malingering in the context of a personality disorder and not a factitious disorder, very experienced practitioners have been known to say: "Before you kill yourself, be sure to pin a note to your clothes saying that this wouldn't have happened if my spouse and my parents and Dr So-and-So gave a good goddamn."
Treatment. Once malingering has been identified, clinicians can try to steer the conversation to the more general issue of treatment impasse and persistent malingering. One might say to the patient, "Looking at your history, your treatment doesn't seem to be going anywhere. Our contacts and the others I see written up in the chart show the same thing over and over. Can we work together to figure that out?" As appropriate, one might proceed to a deeper insight: "I wonder if maybe you feel that it's safer to have the same cat-and-mouse conversation each time we talk rather than risk showing me part of your real self or trusting that there's a part of me that is really interested and qualified to help you. What is your idea of a really good conversation between you and me?"
It is difficult for a person to tell a lie that does not have a kernel of truth to it. When a patient blandly says he is suicidal, even if he is exaggerating, it is usually a strong indicator that the patient is feeling hopeless about the conversation or the visit doing any good. This tends to generate in the evaluator an empathic feeling of desolation or emptiness that feeds the overall feeling of dread that often accompanies these cases. It is essential to discuss this with the patient if one can. One might do this by saying, "I really get the feeling that you've given up on yourself. I don't know if you're ready to kill yourself right now, but I do think you've given up on doing anything that leads to your recovery. I sense that in a way you already feel dead. You keep coming back here without any hope of getting real help. And maybe you're right. In some ways, we haven't helped you at all. But I'd like to change that. Tell me what's really going on with you."
Depending on the particulars of the case and how adventurous the clinician is feeling at the moment, the complaint of hearing voices can also be approached as having some metaphorical truth. One possible comment might be: "You say the problem is that you're hearing voices. Maybe part of the problem is that you keep hearing the same voices, like when you and I, or when you and all of us doctors and nurses and social workers, keep saying the same things to each other, over and over. Maybe you're sick of these voices, and maybe when you think you hear voices you're really craving to hear some new voices that are saying new things that you haven't heard before."
There is a place for telling a patient that there might come a time when he really is in need of hospitalization but that if we admit him now when he does not need to be hospitalized, it is going to be hard for ED or PES staff to take him seriously in the future when he is in need. Accusing a person of "crying wolf" is generally an unhelpful criticism. However, if the patient is given some explanation about what constitutes an emergency and what does not, his seeing the evaluator's willingness to make some distinctions and judgments increases the likelihood that he will become less distrustful and more discriminating in his use of emergency service resources.
When looking at the big picture, it can be extremely liberating to take a step back and ask the patient: "What do you really want out of life? What kind of person do you really hope to become?" Possible follow-up questions are: "If things were going well for you and you were having a good day today, what would you be doing?" or "Have you ever been in love? Have you ever had your heart broken?" By no means is this approach reliable. However, when it works, it is surprisingly effective,23 and asking these questions takes only a couple of minutes. However, clinicians rarely take this approach with a patient they have written off.
Clinicians must, of course, be realistic. Some of the most intractable conditions are seen in psychiatry, and EDs and PESs are where the buck stops. Clinicians will always see patients in the PES and ED who remain lifeless no matter what is said to them and will always have days when they are so busy that there is only time for the bare essentials.
Yet any clinician who has seen one of these "hopeless cases" cock his head with curiosity and start talking about something interesting or meaningful will never forget the experience. The experience is memorable for the patient as well. When 2 people are able to make contact, that tiny success injects a little bit of hope into both of them. At a minimum, things go better the next time they meet and, at best, they begin to create a healing context in which recovery can begin.
Cases of persistent malingering and multiple repeated visits in combination with mental illness are among the most frustrating in all of psychiatry. Because malingering patients often drop out of treatment or have needs that greatly exceed the care that they receive in their assigned therapy programs, it usually falls to emergency clinicians to treat them. Unfortunately, intensely negative transference and countertransference reactions foster therapeutic impasses that preclude effective intervention beyond detection and deflection.
On occasion, the emergency practitioner can break out of the deadening repetitiousness of this syndrome and spark some clinician- patient interactions that may hold some potential for better outcomes. Of course, this is only a preliminary discussion of malingering. There is much more study that needs to be done to determine the ultimate usefulness of the interventions described here. At least, though, they involve the cultivation of humaneness, empathy, realness, psychoanalytic insight, and invention with an extremely difficult patient population. Moreover, these are traits and technical skills that have demonstrated value with other types of deeply troubled patients who may be more receptive to this treatment approach.20-24 *
Although the malingering behavior might seem gratuitous, it is useful to assume that the patient has just suffered some humiliation, disappointment, or loss--perhaps not great enough to correspond to his stated complaint, but not insignificant.
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