Everybody lies

[northernpsy]

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Do you think psychiatrists tend to become more skeptical about patients' trustworthiness than docs in other specialties do? As an inpatient and CL psychiatrist, I feel like I probably see so many patients who are trying to deceive me (the occasional Munchausen patient on CL, plus more normal situations such as lying to get controlled drugs, to get discharged when they shouldn't be, to get admitted when they shouldn't be, to build their case for disability benefits, etc) that my knee jerk reaction is to be skeptical much of the time. I don't necessarily think this is a bad thing. In a way it is sometimes kind of fun to try to uncover the truth.

This thread was inspired by an incident in which I had an IM doc trying to persuade me to drop the psychiatric hold on someone who made a serious enough suicide attempt to get admitted to IM and I was like "Yeeeeahhhhno".

 

[wolfvgang22]

I don't feel the need to be any more jaded or cynical then any other specialty. Of course, that's not saying much.

 

[Shikima]

Just had a guy ask for SA Tx after showing up asking for Adderall to treat his "ADHD".

 

[smalltownpsych]

Dr. House never wasted much time with psych patients, but he still held firmly to the belief that "everybody lies". Of course, since he was popping pills and lying his a$$ off all day long, he might have been projecting a wee bit. 😎

More seriously though, being skeptical when there is potential for secondary gain is just smart practice. How we address it is what makes all the difference. I find that my being honest with my patients and taking them at face value while commenting on any obvious contradictions is what is most effective. "I want to give you the benefit of the doubt and believe you when you say that you are clean and sober, but I'm confused 'cause you smell like ETOH and your tox screen is positive for all kinds of stuff."

 

[Jules A]

Likely because this is my tendency I prefer those in psychiatry who approach every single thing the patient reports with healthy skepticism. This is especially valuable in my opinion if you can find a therapy team who operates in this manner. Showing blanket support for maladaptive behaviors or perceptions without attempting to challenge and encourage growth is a waste of everyone's time. There are many reasons patients either out right lie, minimize, deflect or aren't able view the situation accurately. I believe it is our responsibility to connect the dots in an effort to get a clear picture so we can treat the actual problems. The bleeding hearts, naive or cowardly providers are counterproductive in my opinion.

 

[WisNeuro]

Likely because this is my tendency I prefer those in psychiatry who approach every single thing the patient reports with healthy skepticism. .

I wish this thinking were more ubiquitous. I'm starting to grow weary of seeing patients for neuro evals presenting with "catastrophic disability" following one uncomplicated mTBI, CFS, fibromyalgia, etc; who other mental health professionals feel are legitimately cognitively disabled, despite all evidence to the contrary.

 

[calvnandhobbs68]

Psych might see a higher frequency (number of patients lying/number of patients seen). ED probably sees as many or more than you guys do (addicts trying to get drugs, the "nah doc my meth lab didn't blow up in my face I was just cooking and the pan caught on fire!"). Gen IM and gen peds floors (with the parents) are probably the next highest just due to the generality of admissions but probably don't have as high of a frequency. I'm sure all specialities get used to someone straight up blatantly lying to you at least once a week. My favorites are the ones who swear up and down that they don't do any drugs but UDS is positive for MJ or benzos or cocaine or opiates, etc etc.

 

[thoffen]

Anna Freud did say we should take a position equidistant from the id, ego, and superego. Many have included reality in there. Whether the "false report" is conscious or unconscious, gain primary or secondary, it's helpful to try to understand all of the operations at play for whatever is reported to you.

 

[MiddleRoad]

Anna Freud did say we should take a position equidistant from the id, ego, and superego. Many have included reality in there. Whether the "false report" is conscious or unconscious, gain primary or secondary, it's helpful to try to understand all of the operations at play for whatever is reported to you.

Agree with this.

"Healthy skepticism" without an equal amount of compassion can lead you to places just as counterproductive as the "naive bleeding heart" who reflexively reinforces maladaptive behavior.

 

[DD214_DOC]

Maybe it's just me and my own jadedness, but after having worked with a fair number of non-psychiatry mental health disciplines, particularly the LCSWs, it seems a rather significant percentage of them are overly touchy-feely naive fools. They are so conflict-avoidant or, "everyone must feel good all the time" they routinely end up aligning themselves with the patient's pathology and completely miss what is actually going on with a patient.

Yes, our patients do lie for various reasons, but probably not any more than other fields of medicine. They also omit or withhold important information, or try really hard to focus on other things, unintentionally in order to distract both themselves and you from uncovering and addressing what may REALLY be going on.

 

[clausewitz2]

Maybe it's just me and my own jadedness, but after having worked with a fair number of non-psychiatry mental health disciplines, particularly the LCSWs, it seems a rather significant percentage of them are overly touchy-feely naive fools. They are so conflict-avoidant or, "everyone must feel good all the time" they routinely end up aligning themselves with the patient's pathology and completely miss what is actually going on with a patient.

Yes, our patients do lie for various reasons, but probably not any more than other fields of medicine. They also omit or withhold important information, or try really hard to focus on other things, unintentionally in order to distract both themselves and you from uncovering and addressing what may REALLY be going on.

I think you find this attitude is less prevalent in people who cut their teeth in substance abuse, because you have to be truly thick to not recognize that you can't take your client/patient's statements at face value all the time.

 

[OldPsychDoc]

I think you find this attitude is less prevalent in people who cut their teeth in substance abuse, because you have to be truly thick to not recognize that you can't take your client/patient's statements at face value all the time.

What? Are you saying that my patient's Klonopin didn't accidentally spill into the toilet twice last month?

 

[clausewitz2]

What? Are you saying that my patient's Klonopin didn't accidentally spill into the toilet twice last month?

Naw, see, the toilet was just the one time, and then the second time it was stolen by Some Dude while they were having their midnight Bible study class on their porch minding their own business.

 

[Jules A]

Naw, see, the toilet was just the one time, and then the second time it was stolen by Some Dude while they were having their midnight Bible study class on their porch minding their own business.

And of course both incidents occurred right after the script was filled. That poor patient maybe only got #1 tab out of each bottle before the highjinx and tomfoolery began. The best recourse at this point is to refill at a significantly increased dose just in case.

 

[DD214_DOC]

I have had a couple parents call my office to request an early refill of a stimulant for their kid, citing that the bottle was accidentally spilled into the sink. One left the cap off of the bottle, the other was months ago and I can't remember details. At first I thought they were abusing the meds or diverting them. After working with the population for awhile now, I finally realized that many are just incredibly stupid.

 

[smalltownpsych]

I have had a couple parents call my office to request an early refill of a stimulant for their kid, citing that the bottle was accidentally spilled into the sink. One left the cap off of the bottle, the other was months ago and I can't remember details. At first I thought they were abusing the meds or diverting them. After working with the population for awhile now, I finally realized that many are just incredibly stupid.

Sometimes a spilled bottle of drugs is just a spilled bottle of drugs. 🙂

 

[Shikima]

Darn those pills being on the ground and covered in dust! Now it'll never work if I take it... worse yet, I may get an infection!!

 

[WisNeuro]

Yeah, people lie all the time. Although, sometimes I'm surprised at the honesty. Like when someone tells me they just want their SC increased so that bills are easier to pay.

 

[DD214_DOC]

Sometimes a spilled bottle of drugs is just a spilled bottle of drugs. 🙂

Exactly, same with cigars.

Us (or is it we?) shrinks tend to overanalyze everything. Sometimes things just happen, such as meds being stolen, lost, or falling down the kitchen sink. This is one of the many reasons why I tend to not make much of isolated incidents, both with regards to med refills and patient concerns. (yeah, your child threw a really bad tantrum in a store ONCE 3 weeks ago and not since, or before? WHO CARES). Patterns matter. Random life events, not so much.

 

[smalltownpsych]

Exactly, same with cigars.

Us (or is it we?) shrinks tend to overanalyze everything. Sometimes things just happen, such as meds being stolen, lost, or falling down the kitchen sink. This is one of the many reasons why I tend to not make much of isolated incidents, both with regards to med refills and patient concerns. (yeah, your child threw a really bad tantrum in a store ONCE 3 weeks ago and not since, or before? WHO CARES). Patterns matter. Random life events, not so much.

Were you listening into my meeting with a parent yesterday? 🙂 As I told the parent, "if it happens again, then we'll worry about it." I was thinking that pediatricians probably have a similar type of dynamic. "Call me in a few days if their _____ doesn't improve." Although, I do tell the anxious parents that I am glad that they are concerned about the welfare of their child. It typically helps to alleviate their anxiety when I tell them it's okay to worry about these things. That's an ACT principle at work.

 

[OldPsychDoc]

Sometimes a spilled bottle of drugs is just a spilled bottle of drugs. 🙂

Yet it never seems to happen to lisinopril or a statin...

 

[smalltownpsych]

Yet it never seems to happen to lisinopril or a statin...

True that 99% of the time when meds are dropped in toilet, they are abusable. Go figure. But actually, I have had patients who lost their antipsychotic meds, but then again they tend to be a bit disorganized anyway . Then again I do know a few people who have dropped cell phones in toilets and i have come close a few times myself. Gotta run. Have one more consult for a patient with some type of delirium that should be managed by the doc that consulted me.

 

[QofQuimica]

Do you think psychiatrists tend to become more skeptical about patients' trustworthiness than docs in other specialties do? As an inpatient and CL psychiatrist, I feel like I probably see so many patients who are trying to deceive me (the occasional Munchausen patient on CL, plus more normal situations such as lying to get controlled drugs, to get discharged when they shouldn't be, to get admitted when they shouldn't be, to build their case for disability benefits, etc) that my knee jerk reaction is to be skeptical much of the time. I don't necessarily think this is a bad thing. In a way it is sometimes kind of fun to try to uncover the truth.

This thread was inspired by an incident in which I had an IM doc trying to persuade me to drop the psychiatric hold on someone who made a serious enough suicide attempt to get admitted to IM and I was like "Yeeeeahhhhno".

Not a psychiatrist, but I assume any time a patient's mouth is moving that they may be lying, particularly if the subject is related to sex, drugs/EtOH, tx compliance, or psych. I think Reagan put it best: trust but verify. Which is why yes, I still test regularly for pregnancy, STDs, or drug levels even when the patient swears there's no way/they're 100% compliant. Amazingly, I've discovered more than one apparent "virgin birth," and yes, I can confirm that your seizure meds will not work unless you actually take them.

 

[ArcArsenal]

I like to take EVERYTHING with a fair amount of skepticism.

especially my own skepticism.


I take anything a patient tells me as schroedinger's HPI: it is both simultaneously true and untrue until there is sufficient evidence to "open" the box and lock the truth into one position from quantum superposition.

I joke, but it really is how I try to do it.

it seems a rather significant percentage of them are overly touchy-feely naive fools. They are so conflict-avoidant or, "everyone must feel good all the time" they routinely end up aligning themselves with the patient's pathology and completely miss what is actually going on with a patient.

you mean transference? we are all aware of it. The interesting conundrum is that being aware of it doesn't nullify its effect. This came up in discussion yesterday.