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Questions to ask potential malingerers

Discussion in 'Psychiatry' started by kugel, Jun 23, 2010.

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  1. kugel

    kugel

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    Looking for a list of questions to ask people who are potentially malingering or exaggerating psychiatric complaints.
    I'll start, but I need help.

    Do you ever sneeze backwards?
    Does it hurt behind your eyes when you urinate? (Retrobulbar micturitis)
    Do you often think of mermaids?
  2. whopper

    whopper Former jolly good fellow

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    Use the M-FAST if the person is malingering psychosis, use the TOMM if the person is malingering memory problems.

    Reason why I bring up the M-FAST instead of just telling you the questions on it is using that test will allow you to document that you used an accepted screening tool with data to support it's use.

    The M-FAST is a screening tool. If one wants to be very conclusive that a person is malingering, I'd recommend the SIRS.

    A question Resnick often asks if the person is having memory problems is "can you tell me of the event that led to your memory loss?" He mentioned that in studies, if someone suffers head trauma to the point where it causes memory loss, the person usually doesn't even remember the event. If they are able to describe it in detail, that's reason to believe they may be malingering.'

    In court cases, I often use the Atypical Presentation Scale, but that test is only focused on people malingering to try to get out of a court case. It has questions such as...

    "I asked you about the criminal charge against you. Do you often confuse these with charges on a credit card or electrical charges?"

    "Do you confuse the judge's black robes with black magic?"

    Some common questions I've seen people ask---"Do you hear the voices more on the right side of the ear? The left side? Or equal on both sides?

    "Have you ever noticed cars talking to each other?"
    (If yes), "Do cars have their own organized religion?"
  3. Chrismander

    Chrismander Junior Member

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    So again with the mysterious M-FAST. How do I get training on it, and more importantly how do I get to look at the damn thing?
  4. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    Yeah...what (whopper) said. :D
  5. loveoforganic

    loveoforganic -Account Deactivated-

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  6. whopper

    whopper Former jolly good fellow

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    I know they cost a pretty penny, but IMHO any program should have at least a few screening tools and a SIRS for malingering.

    Ask your program to pay for it. What program isn't going to have an issue with potential malingerers?!?!?!

    If your program really wants to go cheap, then buy the test, but don't write on the test booklets when you administer it. Write on a scrap piece of paper.

    If your program has a psychologist, they can shed light on the M-FAST and the SIRS and teach you the math behind it.

    In short, if a SIRS registers someone as malingering, if you know the math behind it, the person is very very likely malingering. If the test is negative, the person may still be malingering. The reason for this is the author set up the test so that those pointed as positive, he wanted people to be very darned sure they were malingering, at the cost of a few false negatives getting away.

    http://www4.parinc.com/products/product.aspx?Productid=SIRS-2

    Your program may not be able to shed light on the test. If so, I wouldn't be surprised, and that's not meant as a criticism. Most programs I know don't know about administering this test. It's a problem IMHO of psychiatrists not being trained in administering psychological tests, even when we're in a situation where psychologists are not readily available, and we clearly need to be able to administer these tests. I've mentioned this before, but even most forensic psychiatry programs don't even seem to know how to administer these tests, which I think is ridiculous because according to Rogers, the percentage of people malingering mental health issues in court cases is very high. Not over 50%, but much higher than zero. (A hallmark of a good forensic psychiatry program is that they will teach you these tests, along with having at least a strong forensic psychologist on the faculty.)

    As Resnick pointed out, the ability of a psychiatrist to detect someone as lying is no higher than a college student with no training in mental health. For that reason, IMHO, a psychiatrist should have some darned good documentation if you're going to take the stand of pointing to someone as malingering.

    If your program can't help you on this, I suggest you bring up this test with the PD, and ask them to buy a copy, and tell them that you would like to work on reading it either on your own or with an attending in the program. Heck, this could be your grand rounds presentation, and it wouldn't be a very hard area since it's already been thoroughly researched. You could steal the thunder by presenting a subject that may be very unfamiliar and needed to a department that may be in the dark about it.

    Another thing you could do is ask whoever coordinates a grand rounds in your program to get a psychiatrist and/or psychologist that is familiar with these tests to do a grand rounds on it if you don't want this as your topic.


    The TOMM is another good test to use. People just don't malinger psychosis. They also malinger memory.
    http://www.pearsonassessments.com/H...oductdetail.htm?Pid=015-8070-836&Mode=summary
    Last edited: Jun 24, 2010
  7. kugel

    kugel

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    New possibilities from friends at work
    (won't hold up in court, but they're fun):

    Are you unable to see the color Blue?
    Do you sometimes think to yourself, "I wonder if maybe I'm lying?"
    Do other people hallucinate your voice?
    Are you annoyed when nobody on the TV/Radio is talking about you?
    Do your ears twitch?
    Do you smell only normal things?
    Are you sometimes sure that both your feet don't belong to you?
  8. Do you have days when you're so stressed out than you can't remember your full name?
  9. whopper

    whopper Former jolly good fellow

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    Just double checked my Rogers book.

    32% of Forensic cases involve malingering.

    1% of nonforensic evaluations involve malingering.

    In my anectdotal experience, malingering was higher than that, but much much more depending on where. In the ER, it was much higher. In inpatient it was lower than the ER because the ER acted as a filter and the doctor (at least part of the time) tried to keep the malingerers out. In outpatient, it was very low.
  10. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    The question is gold and I use it during every neuro eval that involves suspected/reported memory loss. I'll give them more rope by throwing in a Rey 15, and if they bomb that I'll give them a TOMM. By this point it is usually quite obvious if they are malingering or not, but I'll still do a few more things just to make sure.
  11. whopper

    whopper Former jolly good fellow

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    More rope!!!?!?!?

    Ouch....I'd hate to be a malingerer if you were testing me.

    A clinical evaluation that suggests malingering, a Rey 15, and a TOMM---ouch. TKO, plus kicking the person while they're down with steel-tipped combat boots (and I mean that in a good way) if the person gets results on all of them suggesting they are malingering!

    I mentioned this before.

    Phil Resnick has a booklet he gives out if you pay for his specialized presentation on malingering at the annual AAPL conference. It's called The Detection of Malingered Mental Illness. As far as I know, you can't buy it online. You have to go to the AAPL lecture.

    It's a great source of information for detecting malingering on a clinical level. I previously recommended Richard Rogers book, Clinical Assessment of Malingering and Deception. While that book is superior to Resnick's, Resnick's booklet is far more user-friendly, fun to read and more practical.

    I paid for Resnick's lecture. It was worth every penny.

    I googled Resnick and the title of his booklet and got several hits. I haven't compared this article to the actual booklet. I will try to do so in the near future.
    http://www3.interscience.wiley.com/journal/112416967/abstract?CRETRY=1&SRETRY=0
    Last edited: Jun 25, 2010
  12. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    :laugh:

    Most everyone who walks through my door has already been told that the testing will take awhile, so it isn't really a hard sell to mix in some relative brief malingering assessments. If the consult mentions possible malingering, I'll do those assessments after the first part of my semi-structured interview. If I find they are malingering, I'll mix in a few psychiatric screeners and some other things to kill time before finishing up the second part of my interview. Typically by this time I am just filling in the gaps so I can formulate my report.

    I (obviously) prefer to use a flexible battery, as giving a full neuro battery to someone malingering is a waste of time. My batteries typically take anywhere from 1.0-2.5 hours to complete....suprisingly brief compared to the more formal neuro assessments that can last all day. The write-ups are pretty straight forward because I have plenty of objective data to support my clinical interview. It isn't 100% foolproof, but I have yet to get anything kicked back for re-evaluation.
  13. Scorcher31

    Scorcher31 Member

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    Probably nothing new here, but I figured I'd just some extra tidbits I got from a forensic psychiatrist I rotated with.

    1. It's pretty hard to constantly fake a thought process disorder. I.e. it's hard to fake being consistently loose, Flight of ideas, etc.

    2. Malingerers tend to favor command hallucinations and visual hallucinations

    3. They tend to be easily suggestible to add bizarre elements to their story if they think that's what you want to hear. The following are some questions he asked:

    Do you hear the voices even while your sleeping?
    Do the voices speak to you constantly or do they ever stop?
    Do you hear the voices outside your head our inside your head?
    Do you see the voices as they enter your right ear and twist around your brain?
    Why do helicopters eat their young?

    Obviously the best way to go is with the actual testing, but this might be useful to send up a red flag for a student, or a new intern like me to closely observe the patient over the next few days.
  14. Voc Doc

    Voc Doc

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    Anyone know a publisher or distributor where I can purchase the Rey 15 item memory test? Thanks.
  15. nitemagi

    nitemagi Senior Member

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    I second the Rogers book (Clinical Assessment of Malingering and Deception). One of my faves. :D

    And some these days prefer the Rey-II, rather than the original.
  16. whopper

    whopper Former jolly good fellow

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    I'll ask around. Usually, with most tests, you can find them on sale. I didn't see the Rey 15 on sale on a google search.

    I do know that some of the tests I've employed that are actually common such as the Atypical Presentation Scale, I couldn't find available on an online search. My PD gave me a copy.

    An online search only yielded articles about the test but not the test itself or someone selling it.

    Yes because we don't think in that manner. Also to act in a manner where one does not have an organized thought process expends a lot of effort. IF someone is faking it, you can usually tell so long as staff members are monitoring the person 24/7. That will be happening if it's an inpatient unit and staff members are doing their jobs. Usually during the shift report, I tell staff members that I want all eyes on the suspected malingerer. Almost always, a malingerer trying to present with a nonorganized thought process will at some point drop the act because it takes too much effort to be that way all the time.

    The problem here is that it can take at least a day or two before that happens. Then you have the billing issue. How can you bill if the person is not mentally ill? Some places will, from what I understand, give a problem with this, even though the treatment team spent time and resources to detect the malingering. I'm not advocating that malingerers be falsely diagnosed for billing purposes. I'm simply stating this is a problem and it does lead to false diagnosis plenty of times.

    At least for me, I don't have the above problem because when patients are ordered to a forensic unit by the court, the state ends up paying for everything and they are expecting me to find out if the person is malingering or not. About 1/3 of patients in a forensic setting are expected to malinger so, on average, I should be carrying about 7 malingerers at a time. Remember, malingering is not merely the fabrication but also the exaggeration of a mental illness. I've seen plenty of patients clear up with treatment but pretend to remain ill to avoid facing the music in court.

    Malingerers want to be noticed, and usually do things that are in your face. After all, they want to make sure they've convinced you. E.g. there's a guy on my unit, he got a marker and drew various symbols on his face. Malingerers tend to fake symptoms seen in the media and do not know how to correctly portray mental illness. The in-your-face stuff tends to be positive symptoms because (+) symptoms are in-your-face. They hardly show negative symptoms.

    A few studies have catalogued the type of symptoms exhibited by psychotic patients. Some of those studies have utilized thousands of participants. Resnick, in his manual, mentioned "atypical" symptoms. The more atypical symptoms, the more likely the person is malingering.

    E.g. we all know that paranoia, thought broadcasting, thought blocking, etc are symptoms we'd expect to see. Drawing on one's face is not one, nor is claiming there is a "robot religion" only in the presence of staff members, but when the person is on the unit there is no behavior that can be connected with it. Little green men is another atypical symptom (though it can be seen in delirium).

    Some "fun" with malingerers: don't give them anything they want so long as you can justify it. E.g. so long as the person is overweight---AT ALL, put them on a weight loss diet. They can't smoke (if your state allows it), after all, they're supposed to be in a hospital to get better right? Never given Ativan or any other benzo. You're only going to stimulate their nucleus accumbens and reinforce the desire to be in the hospital. If they get out of line and medication is warranted, give out Vistaril or Benadryl for anxiety among other things that may be needed. Be wary of giving out Seroquel because it has a street value and I've noticed several malinger for it. In fact the phenomenon has now been published several times and meets the peer-reviewed status. Always have things the malingerer could do such as play cards or other games. Coherent playing gives enough evidence to suggest an organized thought process, memory and concentration.

    You could offer medications not geared toward improving the mental illness (e.g. PRN Ambien), and see if the person starts mentioning how the voices are going away with it.

    If I suspect someone of malingering, I often times do not give any medications to see the person in their baseline state. If you medicate, it can muddle the picture if the person is malingering or not because any organized behavior seen by the person could possibly be attributed to medication treatment.
    Last edited: Jan 30, 2011
  17. nitemagi

    nitemagi Senior Member

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    While I usually agree with whopper on all forensic issues, I'll depart a little.

    I think that presence of atypical symptoms is more specific to malingerers, but the evidence shows that the more exposure/knowledge someone has to the actual illness, the better they are at malingering. While a first time malingerer may not be very good, if they get admitted 4 or 5 times they're gonna have better training at it just through observing and talking with other patients. In a way we run the risk of iatrogenically creating better malingerers by admitting them. Medicolegally I don't see an easy way around this though, as sometimes you're in a bind and have to admit to CYA.

    Here in SD there's actually a xeroxed instruction manual floating around in the homeless community on not only how to malinger to get hospitalized, but how to do it to build a case for disability. A few examples include stating your psychiatrist is out of state (reduces likelihood of trying to find/contact them), and that you don't remember any of your former medications except cogentin (an obvious trigger to indicate they must have been on older antipsychotics and have a legitimate thought disorder).
  18. whopper

    whopper Former jolly good fellow

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    You may have disagreed "a little" with my post but I don't find anything wrong with it.

    If someone does fake mental illness convincingly, and they're not dangerous, and they don't want meds, well guess what? They don't need to be in inpatient. I discharge them.

    If someone is faking mental illness and trying to show they are dangerous, well now they're going to get meds. If they refuse the meds, I then request the court for forced medication. A malingering patient doesn't want to be in that situation.

    In a forensic unit, (at least mine), you malinger, you don't get away with it, or you get forced medication, and I'm not talking benzos. They also get a healthy diet and psychological testing. It usually doesn't pay to malinger though I do know of about 2 patients in the hospital that fall in the perfect storm area where the hospital can't get rid of them but they can get away with what they do.

    Now I totally understand that in a non-forensic unit, most of you don't have the resources I have. Where I did training, no one knew what a SIRS was. There are still plenty of things that can be done.

    I nickname it the bullspit artist intranet. Patients in the hospital I work at, in the cafeteria area, all talk to each other on how to beat the system. E.g. if someone's malingering, they ask the patients "which unit should I go to?" For all intents and purposes, and this is even in non-forensic psych wards, you are viewed by many not as a caring healer but as Colonel Klink or the Kommandant from the Great Escape. Where I did residency, the homeless patients all coached each other on how to maligner for benzos, opioids, and 3 hots and a cot. If a doctor isn't aware and modulating his treatment strategy without knowledge of this, then they are the equivalent of the clueless teacher whose students are manipulating him all the time and getting away with it.

    Several patients I've seen had it down to a science. They even know the hours and days of duty of the doctors that gave out the benzos and admitted everyone so long as they mentioned the word "suicide."

    In this respect, you should not enable these malingerers while also balancing your approach with being therapeutic. It can be done.
    Last edited: Jan 31, 2011
  19. nitemagi

    nitemagi Senior Member

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    Agreed.

    From my moonlighting in a county hospital, I've been impressed with the staff psychiatrists' ability to ID malingerers from just an interview. Though again we're not dealing with the most sophisticated malingerers in that population.
  20. whopper

    whopper Former jolly good fellow

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    I've noticed that if a hospital has enough competent doctors to figure out the person is malingering, some just go to the next hospital in town. Then when that hospital figures it out, they just go to the next hospital.

    Then, after a year or two, you see them again, and then some doctors and staff figure since they haven't been seen for several months, maybe even years, maybe they're different and perhaps really mentally ill this time.

    A problem I noticed in residency is that it was only the cynical doctors that figured this out and they often kicked out a patient in a very confrontational and judgmental manner. The compassionate doctors let everyone in. Tell them you had anxiety, you got as much Ativan as you wanted, with no consideration that the person had an extensive history of susbtance abuse or dependence and with no mention to the patient that the medication was potentially addictive. Then the "compassionate" doctor didn't know why the person kept on showing up again and again and again and again and again. Each time that patient was given a medication that just reinforced his desire to be hospitalized again. Ativan as much as you want and a warm place to stay at night. I only knew of one attending that IMHO was in the sweet spot (and he left the program my 4th year).

    A thing you'll notice in the later years of residency is there are things you need to know that are not taught. E.g. no one I know of has made an "official" and accepted way to handle malingerers. Some even argue to never write malingering on a chart because you are in effect calling your patient a liar, even if you have proof positive they are malingering.

    It's an issue that is often seen in city ERs and dealt with daily but no one officially addresses it. It's not PC.
    Last edited: Jan 31, 2011
  21. nitemagi

    nitemagi Senior Member

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    I once saw a guy that had literally gone VA hospital to hospital from the midwest westward to seattle, then to every one down the west coast finally ending in SD, always malingering SI. God bless CPRS.
  22. kugel

    kugel

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    I would Love to get a copy of that for our county hosp. Has anyone scanned it to a computer file, or can I pay you to send me a copy?

    From what I can tell, most of ours have no manual except the quote I've heard, "Just keep telling them you hear voices telling you to kill yourself and they have to give you disability."
  23. curious member

    curious member

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    you could ask them if they would like to partake in a study involving ect therapy followed by long courses of haloperidol
  24. Cinnameg

    Cinnameg "the psych machine"

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    I always wondered how people watching the movie "Memento" could suspend disbelief on this point. How could the guy possibly remember he had a memory problem?
  25. Cinnameg

    Cinnameg "the psych machine"

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    One that I saw work in a forensic setting:
    - Do you ever see the world tinted in green?

    One that didn't work:
    - Do you sometimes see people walking around with animal heads?
  26. PsyDGrrrl

    PsyDGrrrl Head Shrinker

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    You don't need to purchase anything for the Rey. You can make your own, in fact.
  27. st2205

    st2205

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    That was exactly the thought that came to my mind when I read that!
  28. tennreb

    tennreb

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    I wonder what percentage of the VA population is malingerers. It's amazing that they get paid to be sick. Both outpatients and inpatients. I've gotten in trouble for increasing a GAF. Some clues that a patient might be malingering:

    "If you discharge me, I'm going to walk into traffic."

    "I'm having audiovisual hallucinations."

    "I'm a danger to myself and others."

    Variation: "I'm having suicidal and homicidal ideations."

    "Is there a bed available on ___ unit?"

    "I need to come in for two weeks [until my check comes in]"
  29. Lauraaa

    Lauraaa

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    I don't know if you happen to know but...

    Is this the same course / lecture The Detection of Malingered Mental Illness that Dr Resnick is giving this year at APA on Tuesday morning for $155?

    I would think it was, given it's the same title... just at the APA rather than APPL. But in the course format it doesn't say the booklet is part of the materials.

    http://psych.org/Departments/OSP/Courses2011.aspx?FT=.pdf
  30. whopper

    whopper Former jolly good fellow

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    I'd wager it is though I can't say for certain since I'm not the good Dr. Resnick (as much as I'd like to be). I did Dr. Resnick's course at AAPL on malingering. I figure it's the same one.

    Got a story for you. I was at AAPL, Resnick's standing a few feet away from me getting his laptop ready, and as he was about to click on his presentation, I saw literally dozens if not over a 100 presentations he worked on all sitting there in one nice folder on his Windows. All these nice little power points just there in front of me and Dr. Resnick clicked a button to start the presentation. I felt like a kid in a candy store but I was only allowed to have one candy when I wanted them all.

    I had a sudden rush to steal his laptop so I could have all of his lectures. Of course I didn't.

    The other whacky thing in the story was a particular forensic fellow was assisting the good doctor in getting his computer ready. That fellow was given certain honors (I will not mention them because forensic psychiatry is a small world), and that guy, I know for a fact, was stalking someone to the point where that person lived in fear for her safety.

    Not the first or last time I've seen someone with a bunch of awards and honors who fits the category of scumbag. Not referring to Resnick. (Well heck, it's not like I know Resnick well at all for real, but I am referring to the other guy--the stalker). Wow, talk about someone who went into a field because he has the pathology himself.
  31. Manicsleep

    Manicsleep

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    Next time someone goes to see Resnick, just picture Mr. Burns from the Simpsons. I am convinced they are the same person.
  32. Lauraaa

    Lauraaa

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    So, I really would like to see his presentation at the APA in May, but there's also other sessions at the same time that his course is scheduled that I would like to go to see too. But, from your post Whopper it looks like he gives his presentation every year at the annual AAPL meeting? Maybe I could just wait and see it there if it's a yearly thing.
  33. whopper

    whopper Former jolly good fellow

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    Well he gave it at the AAPL I attended. I did not attend last year's AAPL only because I needed to save my lecture credit hours for the American Academy of Forensic Sciences because I gave a presentation there in February 2011.

    Resnick does a review course where much, though not all of his malingering lecture is contained in the course. His actual lecture that you pay to attend gives you a booklet and is more in depth than what he covers in the malingering section of the AAPL review course.
  34. Manicsleep

    Manicsleep

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    How many times have you seen him speak Whopper.
  35. whopper

    whopper Former jolly good fellow

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    Hmm...counting the entire AAPL review course that is over 20 hours as one time....

    About 10 times? My program director from fellowship is buddies with him. My fellowship also had a joint venture with his own fellowship where the two programs interacted on case presentations and mock trials. We sometimes would have a our program vs. their program mock trial.

    If you go to one of the smaller functions such as midwest AAPL, you could more than likely hang with the giant since it's a smaller event, and Resnick is very open and down to earth, and he spends time in the areas specified for social gatherings to greet people and talk to them. He likes to give people time and tries to avoid brushing people away unlike most people with his level of fandom.
  36. PsyDGrrrl

    PsyDGrrrl Head Shrinker

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    Hahahaha. I can see it.
  37. Manicsleep

    Manicsleep

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    Then how can you not see the Mr. Burns thing...unless...it can't be...you don't like the simpsons???
  38. whopper

    whopper Former jolly good fellow

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    I totally see the Mr. Burns thing though Resnick is not like Mr. Burns other than in physical appearance.

    [​IMG]

    [​IMG]
    Last edited: Apr 23, 2011
  39. Red Beard

    Red Beard

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    Ugh, I just FINALLY discharged a guy who was pulling all of these almost verbatim, plus a variety of somatic complaints that unfortunately couldn't be patently ignored given his CAD s/p 6 stents. "My check comes in on the 28th, but if I have to go to the street again even for one night I will kill myself!"


    One line for patients feigning psychotic symptoms that I saw work and that I have used myself 'successfully':

    "Often times folks with your condition hallucinate small animals, like squirrels and rabbits...are you seeing these things now?"
  40. whopper

    whopper Former jolly good fellow

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    Don't recommend you use the line exactly the way you mentioned it. It's not factually accurate. There are ways to fish out the malingerers while using factually accurate statements.

    E.g. Sometimes people with a mental disorder see little green men. Do you see them?

    Factually accurate, but this does not typically happen in psychosis but in delirium. Get it?

    E.g. There is a higher incidence of people having heart attacks on Mondays. Do you notice that you're only paranoid on Mondays?

    Again, factually accurate.

    Some other questions that may have been mentioned...
    When I talk to you, do you see the letters forming the words come out of my mouth?

    To a male patient: Female hormones are theorized to have some benefit with psychosis. What would be your opinion if a treating psychiatrist attempted to have a court order you to take female hormones?

    (right after they answer the above question...) Do you understand that it's within your rights to prevent a doctor from making you take court-order medications? (Explain to the person how the court process works, tell them things like they can fight using a lawyer, and the pros and cons with female hormone treatment including that it has poor research, risks of blood clots, gynecomastia etc. Then wait 5 minutes)

    So, if you don't want to take the female hormones, how would you stop this in court?

    Edit: upon reinspection, the hallucination remark about animals could still be considered accurate though I don't know of any studies where this type of hallucination was actually measured in terms of frequency among psychotic people. The studies done to estabish what are the atypical symptoms did establish several of the more common hallucinations and what pretty much never happens though I didn't review that data for some time.
    Last edited: Apr 27, 2011

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