Malingering in Acute Care Settings

The role of every emergency clinician is to determine whether the patient has a condition that threatens life or limb. Determining this in patients who malinger can be quite a challenge, because the malingering patient presents with false or exaggerated symptoms for secondary gain. The patient's motivation may be to obtain some type of compensation; acquire drugs; or avoid school, work, military duty, or even criminal confinement or prosecution.

It is interesting to note that malingering is not considered a form of mental illness or psychopathology; rather it is considered a deliberate behavior. Malingering is classified in the DSM-IV-TR as a "V" code (ie, other conditions that may be a focus of clinical attention).¹

The incidence of malingering in the emergency setting is unknown. Malingering should be considered when patients request certain evaluations or treatments that may or may not be recommended by their attorney or other legal counsel or when there is a marked discrepancy between patients' concerns and the physical findings. Clinicians may experience difficulty in evaluating these patients because of lack of cooperation or compliance. Often, persons who malinger are seen multiple times before the condition is diagnosed, if it ever is. These factors make it even more difficult to provide good care and treatment for malingering patients. This problem is confounded by the limited time, resources, and facilities that most emergency clinicians have.

The clinician is placed in a precarious situation when dealing with malingering patients. Should the physician confront patients about their behavior? Should the physician give patients whatever they ask for? Should the physician request or demand a psychiatric evaluation?

In the emergency setting, there is always a concern that a physician may miss a significant life- or limb-threatening condition. The burden of making the correct diagnosis can be onerous when dealing with patients who are not being candid about their symptoms. Physicians tend to err on the side of making a medical diagnosis. It takes much more energy and time to deal with malingering patients than it does to deal with patients who present with a typical medical or psychiatric condition.

The overall cost of dealing with malingering patients is magnified by their demands for testing, evaluations, and treatment that may not be appropriate in the emergency setting. Giving in to their demands may also expose patients to unnecessary radiation, blood draws, treatments, and medications. The costs related to malingering are part of the much larger cost of insurance fraud in the United States. Health care fraud from all sources amounts to 10% of all health care expenditures per year.²

In his article, Dr Berlin eloquently presents a treatise on malingering, a difficult but important subject. He delves extensively into how to evaluate and deal with malingering patients once the behavior is identified and how to treat them. There is an interesting discussion of transference and countertransference in reference to the malingering patient. Most intriguing is the discussion of invention and intervention, which includes awareness, inevitability, circumstances, assessment, confrontation, and treatment. Dr Berlin also presents 3 cases that explore some of the quagmires that physicians must deal with when taking care of these patients.

In their commentary, Drs Hamilton and Feldman elaborate on the difficulty of dealing with a malingering patient. They also discuss the value of a brief inpatient admission for evaluation of a suspected malingerer. Although there is value in determining what, if any, the patient's underlying condition is, there is also a concern that the inpatient evaluation might validate the malingerer's secondary gain.

Together, Drs Berlin, Hamilton, and Feldman offer emergency clinicians some practical tools and useful insight into the evaluation and management of malingering in the emergency setting.

Leslie S. Zun, MD, MBA
Professor and Chair
Department of Emergency Medicine
Chicago Medical School at Rosalind Franklin University of Medicine and Science
Chair
Department of Emergency Medicine
Mount Sinai Hospital
Chicago

References:

REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Publishing; 2000.2. Coalition Against Insurance Fraud. By the numbers: fraud stats. Available at: http://www.insurancefraud.org/stats_set.html. Accessed May 3, 2007.