Just How Many Patients Have Real Psychiatric Illness? The Rise of Malingering in Emergency Psychiatry

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Inpatient psychiatry and emergency departments (EDs) are some of the most challenging environments in medicine. While some may disagree, the combination of clinical acuity, diagnostic uncertainty, and unpredictable patient behavior makes these settings uniquely stressful—for both clinicians and staff. The stakes are high, and the risk of harm, both to patients and staff, is real.

One of the most vexing problems we face in these settings is the intentional production or exaggeration of psychiatric symptoms for external gain—what we call malingering. It differs from factitious disorder in that the motivation is obvious: avoiding jail time, securing shelter, gaining access to food, or simply escaping an uncomfortable living situation. These are not rare occurrences. In fact, they seem more common than ever.

Let me give you a few familiar scenarios. A patient presents to the ED claiming suicidal ideation. Yet in the waiting room, they are on the phone laughing, joking with staff, and asking about the best shelter options nearby. Another patient reports hearing voices, but lacks the thought disorder, internal preoccupation, or functional decline we would expect in a genuine psychotic episode. Often, there is a prior psychiatric diagnosis—but the current presentation does not remotely reflect acute decompensation.

Some patients are blatantly open about their motives. Others try to mask them with superficial charm or vague distress. But for those of us who have worked in this field for years, the patterns are easy to spot. One patient reports suicidal thoughts but is more excited about the sandwich in the ED than the possibility of treatment. After a nap and a snack, their mood has “miraculously improved” just in time to attend an event on the boardwalk. Another insists on admission, only to demand discharge hours after arrival.

These encounters are more than just frustrating. They are emotionally draining. They wear down staff morale. They stretch limited resources. And over time, they cost hospital systems significant amounts of money. A patient may cycle through the ED multiple times in the same day or return for readmission 48 hours after discharge. Even when malingering is obvious, the system often bends toward admission—not because it is clinically indicated, but because there is no better option.

The literature is rich with strategies for recognizing malingering, but far less helpful when it comes to managing it. In practice, we are often left stuck in a tug-of-war: the patient pushing for a secondary gain, the clinician resisting manipulation. Both parties make assumptions about the other’s motives, and both feel misunderstood. It creates a therapeutic stalemate—the worst kind, where no progress can be made and no needs are genuinely met.

What is often missing from these interactions is honesty. I do not mean documentation or risk stratification—we have become skilled at those. I mean direct, human honesty. That means telling patients, clearly and compassionately, why we believe hospitalization will not help. If we think a controlled substance is inappropriate, we need to say so—not avoid, delay, or manipulate our way out of the conversation.

We also need to be aware of our own emotions. Frustration, resentment, cynicism—these feelings are valid, but they are also diagnostic data. They tell us when our objectivity is at risk, and when we are slipping into patterns of avoidance or disengagement.

Most importantly, we must recognize that even patients who malinger are often experiencing real suffering. Sometimes it is a humiliation, a loss, or a basic survival need that brings them to our door. That does not excuse manipulation, but it does demand empathy. A thorough medical and psychiatric evaluation is always warranted—no matter how rehearsed the presentation may seem. Malingering patients can, and do, develop serious medical or psychiatric illness. Dismissing them entirely is a risk we cannot afford.

When malingering is the likely diagnosis, the best intervention is often a direct, respectful conversation. Let the patient know you understand their motives—even if you do not condone the behavior. Explain your clinical reasoning. Be transparent. This kind of honest, nonjudgmental dialogue might not change the system, but it can preserve the dignity of the encounter—and sometimes, it can shift the trajectory of care.

These interactions are not going away. In fact, they are likely to become more common as the social safety net frays and access to basic needs becomes increasingly tied to psychiatric diagnoses. Rather than avoiding or resenting these encounters, we must understand them, accept them, and learn to navigate them with clarity, compassion, and courage.

Dr Rossi is an inpatient and consultation liaison psychiatrist who also performs electroconvulsive therapy services at AtlantiCare Regional Medical Center in Pomona, New Jersey. He currently serves on the board of the New Jersey Psychiatric Association, where he has worked on advocacy projects, including enhancing access to collaborative care in the state.