A fair question.
IMHO doctors should not be educating patients on how to beat malingering evaluations when they are trying to evaluate them for it. Obvious right? The problem here becomes should I tell the patient what does is considered therapeutic if I have strong reason to believe he is malingering?
IMHO I'm not giving him wrong information, just seeing if Seroquel at a subtherapeutic dosage stops the "psychotic" behavior. I'm not going to tell him "Oh by the way, you can't have psychosis if Seroquel at that dosage is effectively treating your psychosis."
I have already questioned the ethics to the point where I have reached my own conclusion on it. I'm not saying I'm 100% right. Others could disagree. My retort would then be then give me a way to figure out if this person is malingering.
Also bear in mind that the scenario I do this in is a forensic one where the Court already has it established that they want me to figure out of the person is malingering. I don't do such things outside of forensic psychiatry. This type of situation has already been put before various ethics committees, judges, and professional societies and no one has ever condemned this type of thing as far as I'm aware.
If I ever was put through an ethics board for this type of practice here's what my response would be. The entire field of malingering testing is based on evaluating people to see if they have symptoms that are out of the ordinary for someone who has a real disorder, and the person doesn't know how to fake it, and thus the test will show they are malingering. If one finds this practice unethical and feels that I must tell the patient, then along the same lines I must also explain how the symptom exaggeration scale also works in an MMPI, how it also works on a SIRS, a TOMM, and an M-FAST.
If the law wants to go that route, there will now be no method at all other than simple clinical evaluation to diagnose malingering, and even then, under the same guidelines, I'd have to inform patients on behaviors they are doing that suggest malingering. If an ethics board wants to condemn it, then they too must condemn the above tests because in essence I'm doing the same thing...seeing if something presented doesn't jive with how the real disorder works without educating the patient on the exact way to successfully fake it.
Doctors do this type of practice all the time in nonforensic medicine. The level of education we give is supposed to reasonably inform a patient but not cover every single exact detail. E.g. a patient who comes in with a bellyache and the doctor suspects it's psychosomatic, gives a starting dosage that's not yet supposed to be effective, then the upset stomach subsides, leading the doctor more reason to believe the effect was psychosomatic. In general psychiatry in residency, we simply talked to patients about their symptoms, looked at the signs, and went from there. There's a lot we don't tell patients and rightfully so---because to inform them on every single aspect of a disorder will make seeing one patient an 8 hour session.
But aside from the forces of justice, another reason to find out if the person is malingering is so you could better help a person. To do that you have to know what's going on for real. I've had patients with factitious disorder or malingering, and when it was revealed so, it turned out they had other disorders the treatment team could not detect because the fake presentation was covering them up. E.g. I had a patient with factitious disorder and malingering who faked psychosis for years. When it was established everything was fake that we were seeing, we were able to modify her psychotherapy to explore why she did that. I have a guy on my unit right now that was malingering, and when we figured it out and he knew we knew, he later opened up and told us he had symptoms of PTSD, and I actually believe he has the latter.
Anyone else?
