Did?

[Pedonc]

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I'm curious as to how many of you believe in true DID (formerly known as MPD)? What kind of patient experiences have you had with this?

 

[kugel]

I'll be blunt. I don't believe it.

I've never seen a supposed DID who didn't have more "switching" when rewarded for it and less "switching" when rewards (attn, desired meds, special treatment, etc) were withheld. I've watched the amount of "switching" reduced in a matter of minutes when salient rewards were withheld and others provided for behavior that is less dramatic. But that's only my experience in Psych Emergency Service, Inpt wards, and Crisis Outreach. I have to admit I've never attempted long-term outpt treatment for such a disorder. I'm a PES guy - so my view is pretty narrowed to that end.

IMHO, it's always an extreme example of Cluster B Personality Disorders.

 

[ClinPsycMasters]

I'll be blunt. I don't believe it.

I've never seen a supposed DID who didn't have more "switching" when rewarded for it and less "switching" when rewards (attn, desired meds, special treatment, etc) were withheld. I've watched the amount of "switching" reduced in a matter of minutes when salient rewards were withheld and others provided for behavior that is less dramatic. But that's only my experience in Psych Emergency Service, Inpt wards, and Crisis Outreach. I have to admit I've never attempted long-term outpt treatment for such a disorder. I'm a PES guy - so my view is pretty narrowed to that end.

IMHO, it's always an extreme example of Cluster B Personality Disorders.

Are you saying that reward responsiveness is reason enough to consider DID invalid?

As for your comment linking DID with personality disorders, I have expressed a similar opinion in another thread. There is considerable overlap between DID, PTSD, and BPD. At the same time, I have read quite convincing case studies of patients with DID. My issue with DID has to do with the "identity" part. Some of the so-called identities are more like fragments, not fully formed identities. They are more like dissociative experiences associated with severe BPD and PTSD.

 

[whopper]

I'm leaning on the side of believing it exists, but if it does, it's likely going to be something you're rarely going to ever see. Probably never or once every few years.


I've only had one solid case where the person believed she had it, and my former PD who was one of the best doctors I ever worked with was convinced she didn't have it, but merely convinced herself she had it because her therapist told her she had it.

My PD's reasoning was that her memories that were allegedly resurfaced through therapy were so characteristically unlikely and stereotypical, that he had a problem believing it. She claimed that through hypnosis, she was able to remember that her uncle, who was a Satanist" had her raped by goats, while he performed rituals.

My PD also intentionally caused a stressor to bring out one of her alters, and the presentation he felt was such as simplistic personality "I'm her protector, stop bothering her" with a voice that was on the order of cookie monster, that he had a problem accepting it.

IMHO, I didn't know what to believe. I thought that perhaps it was possible that she actually was abused, but the hypnotic therapy to bring forth submerged memories (which has been researched and found to be highly unreliable) may have brought out fake memories, or real memories that were exaggerated.

I suggested interviewing her while she was hooked to a lie detector machine, but I couldn't get the department to back it up because it was not something done before. (And I was willing to publish my findings). My PD argued against it because the acceptance of a polygraph lie detector among the scientific community was already questionable.

I have had, however, several patients with identify disturbances to the degree where I felt if this were a spectrum, if there was an extreme, it could possibly be DID.

 

[kugel]

Are you saying that reward responsiveness is reason enough to consider DID invalid?

Yea, I guess I am, sort of.
If a fully-formed separate personality can be sent packing by such simple behaviorist techniques, it seem very improbable to me that the "personality" really exists in any separate way.
Is there dissociation? Yes.
Is there DID/MPD? I don't believe it.

 

[Pedonc]

Thanks for all the input. I can't bring myself to fully buy into it either, at least not in the patients that I've seen labeled with it. I agree with kugel; dissociation, yes; DID, no. That's even after meeting a guy who seems to be mostly trying to compose his career out of DID.

 

[jettavr6]

Are you saying that reward responsiveness is reason enough to consider DID invalid?

I'll answer: Nope... It's even more simple than that -- DID=MPD= BS; pure and simple BS.

I'm with ya Kugel!

 

[whopper]

That's even after meeting a guy who seems to be mostly trying to compose his career out of DID.

That in and of itself points to the degree that the DID (even if it did exist) should not be validated.

Even if DID does exist, and is going on with this person, several argue that DID really are manifestations of different aspects of one true personality. If the person is trying to gain from his DID, aside from the fact that this strongly points to it as complete bull, studies show that not letting a person get away with the benefits of a diagnosis out of manipulation reduces expression of those alters (assuming DID does exist).

Bottom line, even if DID exists, you still hold a person responsible for their actions.

 

[Faebinder]

DID is BS so far for me.... it's just another borderline personality in action.

 

[whopper]

If DID does exist IMHO it's on a related, if not same spectrum of borderline.

Both are associated with extreme abuse in a primitive developmental stage, both have disturbances of identify and borderlines in studies tend to score higher than the general population on the DES.

I'm questioning as to what's going on at Columbia regarding any debate about DID in the DSM-5. Several psychiatrists have stated they do not believe in this diagnosis, yet I do not see much debate about it, and it is, as of at least as of now, seemingly going to be in DSM-5.

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=57#

This was brought up in the article below...(You need to be registered with Current Psychiatry to read it).
http://www.currentpsychiatry.com/article_pages.asp?AID=7830&UID=13981

When 301 board-certified U.S. psychiatrists were surveyed in 1999 about their attitudes toward DSM-IV dissociative disorders diagnoses:

35% had no reservations about DID

43% were skeptical

15% indicated the diagnosis should not be included in the DSM.1

Only 21% believed there was strong evidence for DID's scientific validity. On balance, published papers appear skeptical about DID's core components: dissociative amnesia and recovered-memory therapy.2

Pope HG Jr, Oliva PS, Hudson JI, et al. Attitudes toward DSMIV dissociative disorders diagnoses among board-certified American psychiatrists. Am J Psychiatry. 1999;156(2):321–323.

In court cases, there are two standards to accept expert testimony, depending on the location and what type of court you are in (federal, state, etc). The Frye standard (it has to have general acceptance in your profession's scientific community), and the Daubert standard (it includes the Frye standard, but it also must have empirical data supporting it's use that has gone through several standards such as peer reviewed journals, a statistical analysis, etc. The standards it must go through are somewhat subjective because there are some scientific aspects that may for one reason or another not have yet crossed these thresholds).

Based on the above, it suggests that one could make an argument that DID does not even meet the Frye standard, despite it being published in the DSM.

If DID is being debated, I'd love to hear what what's going on with that debate in the APA.

If the purpose of the DSM-5 is to improve upon the 4, and with so many people not believing in DID, it stands to reason that this should be an important topic of debate, yet I'm not hearing much if anything on it.

 

[sunlioness]

I think I may have misunderstood about the guy who was trying base his career on it? This is someone who thinks he has DID and wants to be a "professional multiple" somehow or this is a provider who wants to build a career on being a known DID expert? I initially read it as the latter, but it seems Whopper read it as the former, so I just wanted to clarify.

Regardless, Whopper is 100% correct when he says:

Bottom line, even if DID exists, you still hold a person responsible for their actions.

I think there is some misunderstanding about whether or not DID exists based on a misunderstanding on what DID actually is. I don't think anyone is really saying that people truly have different personalities or are really more than one person. It's really just ego-fragmentation and identity disturbance on crack.

 

[ClinPsycMasters]

Regardless, Whopper is 100% correct when he says: "Bottom line, even if DID exists, you still hold a person responsible for their actions."

*must...resist...philosophical argument...about...free will...*

 

[kugel]

*must...resist...philosophical argument...about...free will...*

Whether you will or won't resist has already been determined.
"Resistance is futile."

 

[OldPsychDoc]

Whether you will or won't resist has already been determined.
"Resistance is futile."

I knew you were going to say that.

 

[sunlioness]

You will be assimilated! 😍

 

[Pedonc]

The guy trying to base his career on DID is a psychiatrist with a large trauma practice who diagnoses as many of those patients as possible with DID. After spending time with those patients, I'm not convinced. Interestingly enough, several of those patients deny the diagnosis while acknowledging that they continue to see him b/c they think he is a good psychiatrist, even though neither they nor their families think they have DID.

 

[Regnvejr]

I have had one true DID patient. Solid dissociations with flashback, no memories of it, changes in voice etc to a younger version of herself.

She refused to believe it and asked me to audiotape it. I was worried about it, and we talked about risks etc., but finally did it. It completely freaked her out and actually set her back quite a bit. Ended up with several parts of her, several just being young versions who took and remembered the abuse (seemed to be their only purpose, no real intellect there), and then went away so the "original" could live more normal (or less abnormal. Terrible PTSD anyway). Eventually a kind of caretaker emerged and basically got rid of the original personality. Rather freakish, almost as if the original had been killed off, not just a change. She didn't get to be a whole lot better after that, not functioning very well outside of very strictly defined work scenarios.

I have had several others with severe dissociations and huge memory gaps and blocks, but nothing as dramatic.

 

[whopper]

The guy trying to base his career on DID is a psychiatrist with a large trauma practice who diagnoses as many of those patients as possible with DID. After spending time with those patients, I'm not convinced. Interestingly enough, several of those patients deny the diagnosis while acknowledging that they continue to see him b/c they think he is a good psychiatrist, even though neither they nor their families think they have DID.

A research idea I had is if someone is able to accumulate a decent number of DID patients, to put them under an f-MRI to see if they are telling the truth in their questions. That way, it'd allow us to determine if the person truly has DID.

Problem here is the technology on using f-MRIs for lie detection is still an emerging and unaccepted technology. It will, however, possibly have enough research to back it up a few years from now.

 

[sunlioness]

The guy trying to base his career on DID is a psychiatrist with a large trauma practice who diagnoses as many of those patients as possible with DID. After spending time with those patients, I'm not convinced. Interestingly enough, several of those patients deny the diagnosis while acknowledging that they continue to see him b/c they think he is a good psychiatrist, even though neither they nor their families think they have DID.

That just really creeps me out. I've met people like that and I think they do more harm than good. It's not a benign diagnosis (though I do believe it exists) and traumatized folks are often times more than willing, often unconsciously, to behave in ways (including producing sx) that are expected of them. And in the case of a misdiagnosed DID, this could actually be very fragmenting and destabilizing all on its own. I mean such therapists will often ask very leading questions like, "I want to talk to the part who does X" and insist that there is such a part. It's easy enough for an obliging people pleasing patient to find a "part" when asked, even if that part didn't necessarily exist up until that point. It's also why I am glad that the reputable folks don't do sodium amytal interviews or hypnosis anymore.

It's unfortunate, but I've come to believe that if you ever meet someone who refers to themselves as a "trauma therapist" or "trauma psychiatrist", you need to turn around and run very fast in the opposite direction. "Trauma expert" or "trauma competent" are better, but still keep an eye on them.

 

[kugel]

I knew you were going to say that.

Maybe that's because you're just the fragmented curmudgeonly part of my original personality that resulted from abuse I suffered someday in the future when I'm older.

Or not.

 

[toby jones]

> A research idea I had is if someone is able to accumulate a decent number of DID patients, to put them under an f-MRI to see if they are telling the truth in their questions. That way, it'd allow us to determine if the person truly has DID...

So you think the issue of the 'reality' of DID comes down to whether the patients are telling the truth or lying? Do you think that the existence of attention deficit, gender identity disorder, female sexual dysfunction, homosexuality etc etc etc is to be settled the same way?

If we are clear on what a self or personality is (according to current theories everybody is fragmented to a greater or lesser degree with different aspects coming to the fore in different contexts) then the notion that some people can be more fragmented than others really isn't terribly surprising, fascinating, or mystical.

How many souls per body get to go to heaven I wonder???

 

[ClinPsycMasters]

I have had one true DID patient. Solid dissociations with flashback, no memories of it, changes in voice etc to a younger version of herself.

She refused to believe it and asked me to audiotape it. I was worried about it, and we talked about risks etc., but finally did it. It completely freaked her out and actually set her back quite a bit. Ended up with several parts of her, several just being young versions who took and remembered the abuse (seemed to be their only purpose, no real intellect there), and then went away so the "original" could live more normal (or less abnormal. Terrible PTSD anyway). Eventually a kind of caretaker emerged and basically got rid of the original personality. Rather freakish, almost as if the original had been killed off, not just a change. She didn't get to be a whole lot better after that, not functioning very well outside of very strictly defined work scenarios.

I have had several others with severe dissociations and huge memory gaps and blocks, but nothing as dramatic.

That's nightmarish. You should publish that as a case study.

 

[ClinPsycMasters]

> A research idea I had is if someone is able to accumulate a decent number of DID patients, to put them under an f-MRI to see if they are telling the truth in their questions. That way, it'd allow us to determine if the person truly has DID...

So you think the issue of the 'reality' of DID comes down to whether the patients are telling the truth or lying? Do you think that the existence of attention deficit, gender identity disorder, female sexual dysfunction, homosexuality etc etc etc is to be settled the same way?

If we are clear on what a self or personality is (according to current theories everybody is fragmented to a greater or lesser degree with different aspects coming to the fore in different contexts) then the notion that some people can be more fragmented than others really isn't terribly surprising, fascinating, or mystical.

How many souls per body get to go to heaven I wonder???

I'm not sure what the disorders you mentioned have in common. Female sexual dysfunction is not primarily about identity nor is ADHD. Homosexuality is about one's identity as it relates to sexual orientation...but a gay person's identity is not necessarily composed of fragments that keep severe abuse/trauma away from conscious awareness.

What Whopper is saying, I think, is that doing a fMRI study may help us distinguish malingerers from the rest.

You seem to suggest that since the current theories assume we're all fragmented more or less, existence of DID is very well expected. Though I essentially agree, DID is at the extreme end of a continuum and there is indeed something quite mysterious about it and its clinical presentation. I think it's reasonable to be skeptical about DID, specially given that theories on fragmentation and identity are almost philosophical in nature, not to mention the difficulties in diagnosing someone with DID, someone with a history of severe trauma most likely, someone who is very suggestible.

 

[whopper]

What Whopper is saying, I think, is that doing a fMRI study may help us distinguish malingerers from the rest.

I should've clarified on this. There has been some recent data showing that f-MRIs may be the real lie detectors people have always wanted. Though it's needing more work, some are speculating that this may be a 100% accurate lie detection device.

So if you have a person claiming to have DID, after a structured interview while conducting an f-MRI, one could test to see if the person has it for real.

Such a test may be the only way to settle the debate once and for all, and it may also be a way to test other phenomenon such as pseudoseizures. One side believes it may be completely intentional, the other believes it may be a form of conversion disorder, where the person's seizure-like jerking movements are done unconsciously.

So you think the issue of the 'reality' of DID comes down to whether the patients are telling the truth or lying? Do you think that the existence of attention deficit, gender identity disorder, female sexual dysfunction, homosexuality etc etc etc is to be settled the same way?

Yes and no. It's a complicated issue. Simply because one believes one has a disorder does not mean they have it or not. Several people believe they have ADHD because a doctor told them they have it, but do not have enough DSM criteria for it.

An fMRI test with a structure interview would have to contain several questions that could a model of study. For example, if the person was interviewed while presenting as an alter, assuming the fMRI truly is extremely accurate (which it may not be, more work needs to be done on this), then the researcher could at least propose that there's now evidence that this alter is not an act, it could be a real and genuine thing. The problem with DID is several who do not believe it exists think so because they think the alters are an act for whatever reason--attention, malingering, factitious disorder, etc.

 

[nitemagi]

I went an interesting debate at an AAPL conference on this previously. The evidence is pretty scarce. Even the most famous case studies of MPD/DID patients have been largely disputed when studied longitudinally (re-examined pt. 20 years later).

 

[whopper]

Even if DID truly exists, within a forensic setting, there's plenty of arguments that it does not merit a legal defense.

One theory proposes that the alters are not a different personality, but rather an aspect of a fragmented personality of the same person. Based on this theory, alter or not, the same person committed the crime.

 

[ClinPsycMasters]

Man, DID in forensic setting, and now we're getting into the whole intentionality and free will stuff and agency of identity fragments...as if the DID discussion was not complicated enough already.

 

[whopper]

It's very complicated.

It may not even truly exist. We psychiatrists don't agree on that. If it does exist, we don't even agree on what it is.

 

[Regnvejr]

...So if you have a person claiming to have DID, after a structured interview while conducting an f-MRI, one could test to see if the person has it for real.

Most people who have DID don't accept or believe it to begin with. It is typically something you as behavioral health specialist pick out of the patient's function and symptoms.

Such a test may be the only way to settle the debate once and for all, and it may also be a way to test other phenomenon such as pseudoseizures. One side believes it may be completely intentional, the other believes it may be a form of conversion disorder, where the person's seizure-like jerking movements are done unconsciously.

You mean non-epileptic seizures? "pseudo" indicates willful deception, and these patients get blamed and vilified. I encourage all to avoid the term "pseudo seizures." Certainly, adrenaline surges and stress can cause movement problems.

To approach patients as liars rather than people who need help with controlling their own life is counter-productive.

...An fMRI test with a structure interview would have to contain several questions that could a model of study. For example, if the person was interviewed while presenting as an alter, assuming the fMRI truly is extremely accurate (which it may not be, more work needs to be done on this), then the researcher could at least propose that there's now evidence that this alter is not an act, it could be a real and genuine thing. The problem with DID is several who do not believe it exists think so because they think the alters are an act for whatever reason--attention, malingering, factitious disorder, etc.

And these providers probably won't be able to provide effective treatment.

If you think your patient is lying, you spend to much time trying to catch them in a lie. And so, if you do, then what? You challenge them, they get upset and leave, and then you got nothing, and they got no treatment.

 

[nitemagi]

Most people who have DID don't accept or believe it to begin with. It is typically something you as behavioral health specialist pick out of the patient's function and symptoms.
You mean non-epileptic seizures? "pseudo" indicates willful deception, and these patients get blamed and vilified. I encourage all to avoid the term "pseudo seizures." Certainly, adrenaline surges and stress can cause movement problems.

To approach patients as liars rather than people who need help with controlling their own life is counter-productive.
And these providers probably won't be able to provide effective treatment.

If you think your patient is lying, you spend to much time trying to catch them in a lie. And so, if you do, then what? You challenge them, they get upset and leave, and then you got nothing, and they got no treatment.

I would agree that the word pseudo has bad connotations, but it also indicates a separation from what could be considered normal or legitimate. Pseudoseizures or pseudohallucinations have different causes and thus different treatments, and should indicate as such. The name I do not believe confers blame, but the blame comes from the bias inherent towards much of mental illness, with the inaccurate myth that will power alone could change the situation.

 

[ClinPsycMasters]

I do realize this was addressed at Whopper but I'll just share my opinion merely for keeping the discussion going, as you raised some interesting points.

Most people who have DID don't accept or believe it to begin with. It is typically something you as behavioral health specialist pick out of the patient's function and symptoms.

Yet some patients do think they have it, but don't have it (based on expert opinion and data). Some believe they have it, and specialist agrees. Some do not believe they have it, but specialist thinks otherwise. Some don't think they have it, and nor does the specialist. Wouldn't it be wise to tell them apart?

You mean non-epileptic seizures? "pseudo" indicates willful deception, and these patients get blamed and vilified. I encourage all to avoid the term "pseudo seizures." Certainly, adrenaline surges and stress can cause movement problems.

I do not believe that's what "pseudo" means. It is not "willful deception" as it is not deliberate feigning but beyond patient's conscious awareness. And blaming and vilifying patients for that is uncalled for. There is not justification for it.

To approach patients as liars rather than people who need help with controlling their own life is counter-productive.
And these providers probably won't be able to provide effective treatment.

I agree but some healthy skepticism is in order. Often enough patients are either actively lying (specially when it comes to sensitive issues) or are simply unaware of why they acted in a particular way. So questioning their data/story is reasonable. Again, the intention is not to blame but to understand them better.

If you think your patient is lying, you spend to much time trying to catch them in a lie. And so, if you do, then what? You challenge them, they get upset and leave, and then you got nothing, and they got no treatment.

I certainly concur. To have this idea that we're out there to get confessions, to have this FBI-like state of mind when dealing with patient is certainly counterproductive, disrespectful, and potentially harmful.

 

[whopper]

Regarding the bad connotations of pseudoseizures, fair enough. There is debate as to whether these are willful deception or a form of conversion disorder. The term some are trying to replace it with is a Nonepileptic psychogenic seizure.

That, however, too could be unfair. Why? Well first, it's not a seizure. There are several who are convinced that it is not a form of conversion disorder, and therefore may be completely fabricated on the part of the patient. Of course, it might not be, but the point is this has not been proved either way.

To approach patients as liars rather than people who need help with controlling their own life is counter-productive.

Which is another problem. Some patients are lying. To brand them as liars I believe is counterproductive. Everyone's a liar. It's like using the racism label. (That's not directed at you for using the term, I'm just trying to steer the debate out of that that area). It adds an unproductive level of emotionalism. The problem here is with those who malinger or have factitious disorder, it's a very difficult situation on dealing with it. Several do not agree with the level of confrontation, if any (some recommend against it) we doctors should take.

A significant portion of psychiatrists do not even believe DID exists. Another significant portion are not convinced it exists. Altogether, those portions outnumber the number of psychiatrists who believe it does exist.

If you believe DID exists, wouldn't you want proof that this is indeed a real disorder? Wouldn't you then want a test to prove it? Isn't that a case in all of medicine? If a patient came into a IM doctor's office convinced he had a disease, would us wanting to verify he had it be us calling him a liar? I think not. If tests could prove this disorder was real beyond a shadow of a doubt, it'd help those who truly have it, and take away a stigma with this disorder that exists even with mental health professionals.

And these providers probably won't be able to provide effective treatment.

If you think your patient is lying, you spend to much time trying to catch them in a lie. And so, if you do, then what? You challenge them, they get upset and leave, and then you got nothing, and they got no treatment.

Ouch. I don't think I'm in a rare position when I tell you I've had several several patients malinger for medications of abuse, disability, what have you. While I've stated before that malingering per studies is going on in 30%+ of forensic cases, in several specific types of clinical scenarios, this also is more common than I'd like it to be. In fact, pretty much everyone I know has malingered at some point in their life (Mom, I'm feeling sick, I dont' want to go to school.)

Do I sometimes think a patient is lying? Yes. Do I spend time trying to catch them in a lie? Yes. Why? Well I've had patients falsely accuse other patients of raping them, start throwing furniture just so they could get ativan, and say they're suicidal when they clearly were not. Was I wrong? I don't think so. Many of these patients, after some time, even admitted they were exaggerating or fabricating the problem.

I do, however, not boldly state to the person, "I think you're lying." I will try to be more discreet and diplomatic and make a comment such as, "The evidence does not back up your statements. You could be telling me the truth, and sometimes the evidence can support something that is not likely to have happened. I need to know what's going on so I can best help you."

If I can't tell at that point, but I have a suspicion, I'll continue to do what I can, while not enabling any potential manipulation, while at the same time investigate the case further until I get enough information that points either way. I've mentioned this before. I do not confront someone who I believe is willfully deceiving me and tell them that's my opinion unless it's to the degree where it's beyond a shadow of a doubt. (e.g. I walk out of the office, and then the guy calls up someone on a cell phone and when I'm walking back, I can hear him tell the person how he thinks he's going to score some Ativan off of me and he's preparing to sell it to the person on the other end of the line. That has happened. Another incident that happened is a guy told me he had panic disorder, and I actually considered he was telling me the truth. I prescribed him 2 weeks worth of Ativan and he tried to sell it less than 5 minutes after he walked out of the office. The person he tried to sell it to actually went to the office and reported it to us saying he was going to call the police.)

If you haven't had to work in clinical scenarios where this is actually quite common, then good for you. I do or have--> the emergency room in a city hospital with large crime rate and homeless population, a forensic psychiatric unit, a community psychiatry office servicing those of a low SES (several patients had criminal records), an involuntary unit servicing a city with a large homeless population. About once a month, in residency, we had a patient that the entire treatment team thought was malingering, and after some investigation, it turned out the person was, and then all their symptoms disappeared when we talked about it with the patient. (e.g. Person is acting bizarre, gave us a fake name, claiming he sees little green men-which is an atypical symptom. Then he grabs a nurse's butt. We investigate the state criminal data bank and it turns out he has no history of mental illness and he's 50 years old, and wanted by the police. When we tell him we have reason to believe he's actually John X, in fact even show him a picture with his photo on it and real name beside it, and ask him who that person is.....Well all of a sudden this guy's psychotic presentation stopped.)

Even if a patient is caught in a lie, I do not boldly point the finger at them as the bad guy. In the case I mentioned, where the guy was caught red-handed trying to sell Ativan right after he left my office, I still think that guy was doing it out of desperation. I knew his case, and he was doing the best he could in several areas of his life. IMHO, he tried to sell the Ativan because he really did need the money to put food on his table. The person could be deceptive, but may not have bad intentions, and his deception may indicate a need for psychiatric help, but not in the manner it seemed on the surface. Finding out the person is "lying" could add more insight into our knowledge of the case. In the case I mentioned, it made me realize how desperate the guy's situation was, and he was too proud to tell me. After we talked about the incident, he opened up to me more and we both felt his treatment sessions were more effective.

A question for you. Would you write a letter recommending disability to a judge in 100% of patients that requested it of you given the knowledge that in a forensic setting 30%+ of patients by studies are malingering (disability would be included in that setting)? If you actually investigated the issue with something such as a physical and mental status exam to see if the person truly meets a definition of disability, or are you spending too much time on that issue?

 

[Regnvejr]

I would agree that the word pseudo has bad connotations, but it also indicates a separation from what could be considered normal or legitimate. Pseudoseizures or pseudohallucinations have different causes and thus different treatments, and should indicate as such. The name I do not believe confers blame, but the blame comes from the bias inherent towards much of mental illness, with the inaccurate myth that will power alone could change the situation.

Reality is that when patients get that diagnosis, esp. in inpatient settings, all "less-informed," from nurses on down starts accusing the patient of faking. That WE know what it means doesn't help the patient.

....I do not believe that's what "pseudo" means. It is not "willful deception" as it is not deliberate feigning but beyond patient's conscious awareness. And blaming and vilifying patients for that is uncalled for. There is not justification for it.

And yet, that is exactly what happens.

Regarding the bad connotations of pseudoseizures, fair enough. There is debate as to whether these are willful deception or a form of conversion disorder. The term some are trying to replace it with is a Nonepileptic psychogenic seizure.

That, however, too could be unfair. Why? Well first, it's not a seizure. There are several who are convinced that it is not a form of conversion disorder, and therefore may be completely fabricated on the part of the patient. Of course, it might not be, but the point is this has not been proved either way.

And how much are we willing to let patients suffer for what is "correct"? I do have significant concerns about this, as I have quite a few times seen stigma hurt patients.

 

[whopper]

And how much are we willing to let patients suffer for what is "correct"? I do have significant concerns about this, as I have quite a few times seen stigma hurt patients.

True. Willful deception should not be seen in a black and white manner. If someone, for example, has factitious disorder, there's likely a reason why that person feels the need to resort to a degree where they have to fake symptoms that could benefit from treatment.

A problem here IMHO is with our profit and medication driven environment, if a case occurred with such an event, a psychiatrist may immediately cut off the patient, label them a liar, and cut the treatment relationship off.

In several cases I've seen, malingering or factitious disorder, and the detection of it could be a signal to gain further insight into the patient's situation to help them, and that type of help will likely require more of a psychotherapeutic intervention than a medication one. Clinicians should be asking themselves why the person may be presenting in a manner where a psychogenic condition exists with the intent to help the person. That's one of the reasons why I don't have much faith in psychiatrists pursuing this in a therapeutic manner because IMHO psychiatrists (in general, not individuals) rely too much on medication. Once they realize the person has an issue that cannot be medicated, their oversimplistic mental treatment model shuts down.

But getting back to what you mentioned, if staff members are allowing labels to judge patients in a manner causing harm to patients, this ought to be brought up to the administration and there should be efforts to cut through this attitude through education.

But I will not skirt the issue of the sometimes needed event of detecting malingering in a not so compassionate manner. I often times have to do testing on someone trying to get out of a criminal charge by faking mental illness. In those cases, the person I evaluate is not my patient. It's my job simply to render an opinion to the court.

 

[Regnvejr]

All valid points. there are no easy answers to any of this.

....A question for you. Would you write a letter recommending disability to a judge in 100% of patients that requested it of you given the knowledge that in a forensic setting 30%+ of patients by studies are malingering (disability would be included in that setting)? If you actually investigated the issue with something such as a physical and mental status exam to see if the person truly meets a definition of disability, or are you spending too much time on that issue?

Fortunately, I am in an all-are-welcome outpatient sliding-scale clinic, but I know that I get people who exaggerate symptoms and whatnot. As for reports, I will present my findings and impressions as I see them, including incongruence of symptoms and symptoms of the patient being over-eager to report symptoms and so on.

I do have plenty of people on disability. Heck, Medicaid is our BEST payer. But typically, I don't get give-impression-based-on-one-visit stuff very often. I typically see my patients over months and years. With that, I get a good sense of their strengths and weaknesses. So if disability gets info from me, they typically get my observation of many visits.

 

[whopper]

One of the attendings that I felt best taught me in residency, well, ouch, I got to admit to this (and I know some residents from my old program frequent this board), I felt once he detected someone as malingering, bang--out of there in a very harsh manner.

While I did feel there was some merit to this in some cases, I did not agree with him on all cases. At the time, I was also in a situation where I felt he knew more than most of the other attendings. Those who are inexperienced tend to see things in more black and white terms (I'm referring to me, not him), so in my opinion, I mentally minimized the impact this attending was having.

It was an area where I had a lot of conflict with the issue of deception. Several doctors I felt side-skirted the issue because they didn't know what to do with it. The one doctor who was willing to confront the issue, I felt I overly relied on his direction because he was one of the few giving it. (By the way, if you're from my program, I still think that one attending was one of my best teachers, I just happen to disagree with him on this one area to a certain degree.)

I've come to a point where if I do suspect someone as malingering, my level of animus is nowhere to the degree where it was in residency. If I suspect it, my thinking mode is now to dig deeper to find out what's really going on, for the purpose of determing either the best way to help the person, or to find the truth as the Court wants me to do. If I'm the treating physician, it's the former, if I'm doing a forensic evaluation and I have no treatment relationship, then it's the latter. If I'm treating the person, and I believe the person is malingering, I then start to try to figure out why. The reason why may indicate the person needs some type of help I can provide. (Someone malingering for suboxone may be doing so because his brother actually needs it). Of course it could be the person's intentions aren't so selfless.
Malingering IMHO is not enough to jump the gun and label a person and then go on the offensive against them.

I think I only got to this point where my own internal conflict has met some form of resolution because working in a forensic institution, where almost all the faculty have great experience in dealing with this issue, gave me a lot of insight I didn't get in residency.

 

[OldPsychDoc]

... I've come to a point where if I do suspect someone as malingering, my level of animus is nowhere to the degree where it was in residency. If I suspect it, my thinking mode is now to dig deeper to find out what's really going on, for the purpose of determing either the best way to help the person, or to find the truth as the Court wants me to do. If I'm the treating physician, it's the former, if I'm doing a forensic evaluation and I have no treatment relationship, then it's the latter. If I'm treating the person, and I believe the person is malingering, I then start to try to figure out why. The reason why may indicate the person needs some type of help I can provide. (Someone malingering for suboxone may be doing so because his brother actually needs it). Of course it could be the person's intentions aren't so selfless. Malingering IMHO is not enough to jump the gun and label a person and then go on the offensive against them.....

As I'd mentioned in another thread, there is a lot of what is technically malingering that goes on simply because the individual doesn't know any better way to cope with what's going on in their life. But really--is it really such a great gig to know how to get yourself admitted to a psych ward to get what you think you need? It actually indicates quite a desperate level of need on their part, IMHO.

 

[kugel]

As I'd mentioned in another thread, there is a lot of what is technically malingering that goes on simply because the individual doesn't know any better way to cope with what's going on in their life. But really--is it really such a great gig to know how to get yourself admitted to a psych ward to get what you think you need? It actually indicates quite a desperate level of need on their part, IMHO.

I firmly believe that letting exaggerating, lying, feigning, or malingering patients think we can help (in those cases where we can't), is just cementing a behavior pattern that is of no use to them. When we reward them (by pretending they have conditions a psych hosp will effectively treat), we hurt them more than help them. The trick is to be firm and point out the uselessness of continuing the same pattern, without being punishing, cruel, demeaning. It's a very fine line.

In the psych emergency setting, we often tell such patients something like, "I realize you didn't know where else to go. I'll keep you here overnight so that you can discuss it with the Social Worker (or the internist, or whatever) in the morning, and maybe get some ideas for resources. But even if the social worker has no new ideas for you, we need to plan for you to be on your way tomorrow morning. We'll keep you as comfortable as we can tonight, and you're welcome to use our showers and clothes washer/dryer. But I need you to be very clear on a couple things:
A) we don't put people in the psychiatric hospital for lack of social/medical resources. I'll keep you here in the psych ER overnight, but just overnight. You will need to leave tomorrow morning right after seeing the social worker.
B) This is a one-time offer. From now on, you need to see the staff at the clinic or at the shelter, and lack of planning to do that during their hours will make no difference.
You are always welcome to come back, but if you don't have a need for psychiatric hospitalization (and we both know you don't have a psychiatric illness of the types we treat here), then you will be discharged no matter what the hour and no matter what the weather."

Now what can I do to help you be more comfortable tonight. Would you like something to eat or drink? Do you need a blanket? How about slipper-socks to wear while you're here?"

And then in the morning, I arrange what I can, and then tell them, "Okay, it's time for you to leave. You can have an hour to use the shower, eat something more, use the phone, whatever you like, but you will be discharged in an hour - whether all that is done or not. I'm not mad at you, and I know you didn't choose to be in this mess - but this is simply not what we do here. I wish I had a real solution for you, but I don't and I need to focus our resources on those serious mental illnesses we're designed to treat."

If the pt demands to stay because things are still bad or he'll be conditionally suicidal "if I have to deal with that (homelessness, drug use, difficult family, etc.) again," then I tell them something to the effect of, "Look, I know you're in bad straits but you're at Burger King asking for Kentucky Fried Chicken. No matter how much you ask, we don't have what you need. We just don't. And begging or bullying won't make it happen. You've gotten all the we have to offer. There is nothing more we can do for your situation."

 

[ClinPsycMasters]

This is just so sad. Obviously the hospital can't do anything more for people in that situation but whenever I see someone who is so messed up I think to myself, this must be the failure of some part of system. This is not some outlier...there are countless others on the street just like him....

 

[whopper]

I've noticed that many of my patients with factitious disorder had a serious medical disorder or other condition as a child that caused their parents to give them serious amounts of attention and reinforcement for being sick.

There are some published reports of people with factitious disorder having had serious medical problems as children.

It's led me to a theory that the treatment for these people should be to have them recognize that they may have been inappropriately reinforced to believe that being sick is the answer to their needs and that they need to work on having a more constructive outlook. Perhaps insight guided psychotherapy.

There have been studies done showing that those that are conditionally suicidal are actually at lower risk of suicide. There was one, and then it was replicated by the same researcher. Unfortunately in both studies, the author clearly pointed out that he felt more work needed to be done and did not recommend anyone make conclusions based on his work. I know of no further work done in this area.