These patients become well known to ED or PES staff. 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. The problem with this approach is that it does not always work. 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. If the person is genuinely ill, he receives appropriate psychiatric and medical interventions. 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. This, as the saying goes, is a different kettle of fish, and there appears to be little to no published data about them. 10 A recent report by Coristine and colleagues 18 describes an interesting approach to triaging such patients more effectively.Įmergency 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. One study reports the number of patients suspected of malingering to be as high as 13%. Practitioners in EDs and PESs clearly face these challenges.
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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. 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.
To a large extent, existing psychiatric literature on malingering focuses primarily on detection of the condition. 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. His case manager is contacted she indicates he was fine that morning when she made her daily medication delivery. Medical records show that he has had numerous similar presentations in recent months. His voices are at baseline, and there is a marked discrepancy between his complaint and his observable clinical condition. In the psychiatric interview, the man is unable to explain how his life is in crisis in any way.
Moments later, however, the physician sees him smiling, talking pleasantly with a nurse's aide, and enjoying a bologna sandwich. The patient tells the triage nurse that he is suicidal and needs to be hospitalized.
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.Īn example of such a scenario follows: The police voluntarily transport a 45-year-old man with a documented schizoaffective disorder to the PES. 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.Ĭommonly, 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. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms that is motivated by external incentives.