Factitious disorder in outpatient psychiatry

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Styrene

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Wondering if anyone has had an outpatient in psychiatry clinic with suspected factitious disorder consisting of feigned psychological symptoms.

I have a case that has been very challenging, and there are several elements of the overall presentation and histories that raise my concern for factitious disorder. However, it is impossible to prove concretely considering the possible feigned symptoms are almost purely psychological.

On the other hand, I wonder if my concern for factitious disorder is based on countertransference. Or the contrary--that still seeing the patient to no avail is rooted in countertransference. Or if it might seem like factitious disorder on the face of it but is outside of the patient's awareness and something else dynamically.

Has anyone else here suspected a psychiatry clinic patient of consciously feigning psychological symptoms for attention and treatment in the clinic setting?

I've put tremendous thought and effort into this case, which may have been a mistake.

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In a patient who you worry is being incentivized (regardless of whether it's intentional or unintentional on either direction), the route to stability lies in de-emphasizing individual symptoms. So consider steps like de-coupling symptoms from being seen (ie, I will see you once a month whether you are doing well or getting worse). Particularly if the patient is constantly calling with emergencies to provoke a reaction, you want to cut off that reactivity and instead be consistent and reliable but not reactive. You also can move the focus from symptoms to function as much as you can. No more "let's try this to get rid of your hallucinations". Instead "tell me about your hallucinations and how they effect your life. Let's figure out what steps we want to take to get you living the life you want regardless of whether they go away".
 
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In a patient who you worry is being incentivized (regardless of whether it's intentional or unintentional on either direction), the route to stability lies in de-emphasizing individual symptoms. So consider steps like de-coupling symptoms from being seen (ie, I will see you once a month whether you are doing well or getting worse). Particularly if the patient is constantly calling with emergencies to provoke a reaction, you want to cut off that reactivity and instead be consistent and reliable but not reactive. You also can move the focus from symptoms to function as much as you can. No more "let's try this to get rid of your hallucinations". Instead "tell me about your hallucinations and how they effect your life. Let's figure out what steps we want to take to get you living the life you want regardless of whether they go away".
Thank you very much. That's quite helpful.
 
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I had a patient who was malingering and had factitious disorder. She malingered mental illness for legal reasons, but also liked to play it up for attention that she loved. I was stuck with this patient because she was on a forensic unit as a long-term patient.

If a patient is not honest with you about the important stuff (all things being equal, minor stuff is not a big deal), in outpatient, there's pretty much no point in continuing the treatment relationship unless you can somehow move the patient into being more honest. Add to the problem if you're not sure they're fabricating data, then kicking them out could be harmful because false accusations are extremely damaging.

I would terminate a patient if they're not being honest (to a degree where it's damaging to the treatment relationship), but you need good evidence before you would to move forward on that path. Otherwise ask them "what's going on?" Bring up your concerns. Also do not feed into attention-seeking behaviors.

It's a balancing act. Some people aren't being honest or at least revealing the whole truth because their ego can't handle it in the moment, but with time might be able to open up.
 
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Which psychological symptoms do you suspect are feigned?

This happens often in my patient population. The continuum between primary and secondary gain can be nebulous. Outside of clear primary gain, you'd have to wonder how the symptoms are meaningful to the person or the therapy. I, personally, consider these dissociative symptoms similar in kind to conversion. There are a few tricks to differentiate using symptom validity testing and hypnosis.

Practically, I have never had any luck confronting people with these types of symptoms (physical, neurological, or psychological). However, what has helped is putting them in a therapeutic bind. For instance, I think this worked in a patient where I said, "We'll give this medication 4-6 weeks; if it doesn't remit, we'll refer you to ECT." A therapeutic analogy would be, I'll work with you as long as you improve; if not, I'll refer you to a different modality. I want what works for you :)

Happy to discuss more, if you want to PM me!
 
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Is this a therapy or a just med management patient in your resident clinic? If it's a dedicated therapy patient, this is all just grist for the mill as they say. There are an unlimited number of reasons a patient would want to appear sicker than they are in therapy, assuming that is the case. It's certainly not rare. The trick will be in determining if there is secondary gain and if this is actually conscious. If this is a med management patient, the patient needs to be in therapy and you need to be in contact with the therapist to discuss this. You're not going to get a firm grasp on this during 15 minute med management visits.
 
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Really helpful answers here. Thank you!

The other part of the story is that the patient sees many other doctors: rheumatology, cardiology, etc, all undifferentiated.
 
I also want to point out that DSM-IV Somatization Disorder (or earlier Briquet) has a general pop prevalence of around 2%, and can present with many psychiatric symptoms in addition to the physical complaints. Think of it as the somatic borderline - they are not lying to you, they really do experience those symptoms despite it not being physically grounded. They get more unnecessary surgeries, are on more medications, and have overall worse (and costlier) outcomes.

Additionally, DSM-5 Somatic Symptom Disorder which is a bit different really hangs on psychological components and time course of symptoms.

What I'm saying is, you may be dealing with true suffering in ways that feeds the uncomfortable transference, and will not get them better overall until you approach it with the somatization lens. Not saying it is for sure somatization disorder, however how sure are you that you've ruled it out compared to a feigned disorder - especially in light of the multiple medical specialists on board and likely long history of dramatic, unexplained medical problems.

A typical briq shows up with the disorder prior to the third decade of life. I would just review the history you have and make sure you aren't treating a briq like a liar.
 
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Just wanted to add that I've heard of cases of doctors accusing patients of lying, being sued and then losing the case. While some will say "well you heard," and who cares about rumors? The sources of these cases were top people in the field such as Phil Resnick, other top forensic psychiatrists, and professors in medicine who also were highly respected in their fields.

Resnick recommended to never document the word "malingering" or since we're talking about factitious disorder, I would add that too, unless you got extremely strong evidence to back it up. What I used to do in inpatient was write "the patient's reported symptoms do not match their signs of the disorder." E.g. "the patient claims to be depressed, lack energy, and not experience pleasure, but was seen throughout the day often times smiling, show no signs of fatigue, and was seen making sexual advances on other patients."

I've seen some doctors recommend to not even use the word malingering even if there is damning evidence, but to call it something else (personally I find this ridiculous. Yes I agree to make a false accusation is damaging to the patient, but if the doctor met a good standard of proof what else are they supposed to do? Enable a lying patient, or at least a patient where you have strong reason to believe they are lying? This is problematic if you never address it).

A problem I've seen in psychiatry is the lack of information on these topics. E.g. while in residency double digits of the patients coming into the ER for psych problems were malingering, and despite there was almost no serious discussion on this issue. It was a real problem, and no one wanted attack it. The only time I saw anyone really handle the topic well was in forensic fellowship, but I felt this should've been handled in PGY-1 and not just in psychiatry, but also in ER training.
 
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Just wanted to add that I've heard of cases of doctors accusing patients of lying, being sued and then losing the case. While some will say "well you heard," and who cares about rumors? The sources of these cases were top people in the field such as Phil Resnick, other top forensic psychiatrists, and professors in medicine who also were highly respected in their fields.

Resnick recommended to never document the word "malingering" or since we're talking about factitious disorder, I would add that too, unless you got extremely strong evidence to back it up. What I used to do in inpatient was write "the patient's reported symptoms do not match their signs of the disorder." E.g. "the patient claims to be depressed, lack energy, and not experience pleasure, but was seen throughout the day often times smiling, show no signs of fatigue, and was seen making sexual advances on other patients."

I've seen some doctors recommend to not even use the word malingering even if there is damning evidence, but to call it something else (personally I find this ridiculous. Yes I agree to make a false accusation is damaging to the patient, but if the doctor met a good standard of proof what else are they supposed to do? Enable a lying patient, or at least a patient where you have strong reason to believe they are lying? This is problematic if you never address it).

'calling it something else' would be weird. What else would you call it? But describing in plain language and sidestepping stigmatizing jargon as in the examples you provided here isn't that and is certainly something I also do.

Factitious and most malingering patients are still suffering. It's not a black and white rule, IF speaking 100% truth THEN is suffering AND deserves help IF misrepresentation THEN not suffering. I return to this teaching point again and again with my residents--the point is not to deny care. The point is to figure out what care they actually need. After all, how bad do things need to be for trying to be admitted to a psychiatric unit to seem like a good alternative?
 
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I had a case where it was pretty damning the guy was malingering, but the psychologist and I were also convinced he might've had a real problem he was exaggerating. IT was a young guy that while in jail was hit in the head by several correctional officers with a baton. The injuries were so severe he was brought to a hospital, and required holes in his skull to relieve the pressure in his brain. So it was very believable he had suffered some type of neurological damage.

The guy was suing the state for millions alleging he had serious brain injuries. He alleged his memory was so terribly affected, he alleged he couldn't perform ADLs, couldn't remember things from moments before, and he was seeking compensation for damages.

After literally days of observation where he showed no signs of memory problems (unless the psychologist or I was within his presence), a TOMM test showing he was most definitely exaggerating his memory problems, and when told he may need a guardian who would have to control his finances if he won the lawsuit because he alleged he couldn't remember anything from minutes before, then flipping his argument to that "okay I'm not that bad," and then arguing he should be in control of the money, the judge threw the case out.

Getting to the point, and what you wrote...
factitious and most malingering patients are still suffering. It's not a black and white rule
The psychologist and I were convinced this person may have some cognitive deficits on some level that likely could've warranted some real compensation. The problem being, as the psychologist wrote in his report, it's next to impossible to determine the true extent of this person's real loss of cognition because he's not volunteering to do the tests accurately. The testing was enough for him to determine that the plaintiff was exaggerating, and no test would truly be good enough to determine the true extent of the problems unless the plaintiff dropped the act which he refused to do.

We delivered that opinion to the judge, but the judge told us his responsibility to the plaintiff was pretty much nothing if the plaintiff's evidence didn't exceed the threshold required. IT did not because he was exaggerating thus the case was then over. It wasn't his job to try to dig at a deeper truth especially since there was no way we could deliver to the judge the real extent of the plaintiff's cognitive damage.

The point is to figure out what care they actually need. After all, how bad do things need to be for trying to be admitted to a psychiatric unit to seem like a good alternative?

Oh I agree, but the problem then becomes this...So the person is lying. I'm not saying that in a pejorative sense. I'm saying it in a neutral sense. The further you try to help when you don't know the facts of the case, the much more likely you are to cause damage by acting on erroneous data. It's one thing to come to a conclusion of D when criteria A, B and C are met, but to know A, B, and C are not true then decide to conclude D can be even worse.

When I encountered malingers in the ER I wouldn't deride them. I'd politely refer them to services that I felt they may have really needed such as a referral to a homeless shelter, outpatient referrals, and not make any judgmental comments.
 
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'calling it something else' would be weird. What else would you call it? But describing in plain language and sidestepping stigmatizing jargon as in the examples you provided here isn't that and is certainly something I also do.

Factitious and most malingering patients are still suffering. It's not a black and white rule, IF speaking 100% truth THEN is suffering AND deserves help IF misrepresentation THEN not suffering. I return to this teaching point again and again with my residents--the point is not to deny care. The point is to figure out what care they actually need. After all, how bad do things need to be for trying to be admitted to a psychiatric unit to seem like a good alternative?

"Feigning" is a term that is often used. You avoid speculating on the fundamental motivation of the behavior and focus more on the face that you have concerns that the verbal report and ostensible behaviors of the patient are not strongly veridicial representations of their internal experience.
 
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"Feigning" is a term that is often used. You avoid speculating on the fundamental motivation of the behavior and focus more on the face that you have concerns that the verbal report and ostensible behaviors of the patient are not strongly veridicial representations of their internal experience.

Idk, feigning still sounds too much like a synonym of malingering to the layperson, and probably lawyers. I just write things like "significant concern for secondary gain as patient... *insert reason here* (is homeless, has court date tomorrow, is demanding benzodiazepines, etc.)". Even better when you can quote the patient saying what the secondary gain is ("I don't really want to kill myself. It's just so cold outside.").

In the outpatient setting I think malingering less of an issue as patients will usually eventually tell you exactly what they're after. The factitious side is trickier, and idk if feigning is really the right word in that setting for most of these people as I've found they often aren't consciously aware that they're exaggerating their symptoms.
 
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I’ll often say “medically unexplained symptoms “ despite xyz work up. I’ll note relevant factors like patient is homeless, has an upcoming court date, worried about losing ssi payments, housing etc.

Some of these patients do wind up having real medical problems and I also don’t want to be dismissive or overly bias other caregivers into ignoring symptoms.
 
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I remember someone showing their template for discharging chronically suicidal and parasuicidal patients from the ER. Something to the effect of, "my responsibility for this patient is not just their short-term safety, but also to see that they improve in general for the long-term. Constantly admitting this patient that hasn't shown improvement in inpatient, who hasn't made any attempts, and whose treatment is likely better off with outpatient treatment is why I'm discharging this patient."

One could write a template of "the patient shows signs not consistent with the problem they claim to have. I have done an evaluation, and for this reason I believe they would be better treated with the following..." in situations with factitious disorder or malingering. One could also add, "if the patient has what I believe is going on with them, then continued treatment along the lines they requested I fear may cause further harm."
 
I remember someone showing their template for discharging chronically suicidal and parasuicidal patients from the ER. Something to the effect of, "my responsibility for this patient is not just their short-term safety, but also to see that they improve in general for the long-term. Constantly admitting this patient that hasn't shown improvement in inpatient, who hasn't made any attempts, and whose treatment is likely better off with outpatient treatment is why I'm discharging this patient."

One could write a template of "the patient shows signs not consistent with the problem they claim to have. I have done an evaluation, and for this reason I believe they would be better treated with the following..." in situations with factitious disorder or malingering. One could also add, "if the patient has what I believe is going on with them, then continued treatment along the lines they requested I fear may cause further harm."
Where I'm at we've got a template along those lines. Basically says patient has had multiple inpatient admissions without benefit and further admissions would only serve to further reinforce maladaptive coping skills. Recommend outpatient follow-up, following resources have been provided, etc.

Occasionally when a patient is really insistent on their SI we'll send out their chart to all the local units and let them get denied (we have several patients who are well-known throughout the city) and then we'll say "Have sent patient's information to all local facilities and patient has been denied by all facilities due exhausting therapeutic benefit and/or behaviors while previously admitted. Patient has been offered...insert crisis/other resources here... and has refused all of these options." We have a couple of patients who regularly come in (one had 19 ER visits in 30 days), say they'll kill themselves if discharged, but also repeatedly report they've never attempted. ER psych really is a different world sometimes...
 
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Idk, feigning still sounds too much like a synonym of malingering to the layperson, and probably lawyers. I just write things like "significant concern for secondary gain as patient... *insert reason here* (is homeless, has court date tomorrow, is demanding benzodiazepines, etc.)". Even better when you can quote the patient saying what the secondary gain is ("I don't really want to kill myself. It's just so cold outside.").

In the outpatient setting I think malingering less of an issue as patients will usually eventually tell you exactly what they're after. The factitious side is trickier, and idk if feigning is really the right word in that setting for most of these people as I've found they often aren't consciously aware that they're exaggerating their symptoms.

It's the term that seems to be suggested consistently by the people who do research on this stuff. The trouble with documenting potential for secondary gain as the reason for doing something (unless they straight up tell you as in your example) is that you are guessing. You do not know why they are doing something, even if there are very plausible guesses. assume it is not the case that there is a blanket policy of refusing to admit all homeless people regardless of circumstances, so the potential of secondary gain alone is not what is dispositive in your decision. You are basing your decision on your clinical judgement that the reports of symptoms are being manufactured or modified in a purposeful way.

I think it's better to say the actual reason you are doing what you are doing instead of obscuring it; if it's a reason you don't want to commit to paper that might be a sign that it is not a good reason for making the decision, modulo concerns about sensitive issues involving third parties that might come up in court and/or get subpoena'd.
 
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I've ranted about pseudoseizures getting renamed to Psychogenic non-epileptic seizures. Same problem here. The problem isn't the language, it was that a doctor may have inappropriately presented this as a "you're lying" situation without doing the due-dilligence, making an inappropriate character judgment, and pretty much calling the patient a liar.

If you ask any patient that you suspected a pseudoseizure, most patients will not know WTF that is, and then as the doctor you should explain, non-judgmentally what it is. Further even if it wasn't a real seizure this could be a form of conversion disorder further suggesting the patient is suffering and needs help. Last thing they need is a judgmental person inappropriately condemning them.

But given that idiots (well IMHO idiots) thought this was a language problem, despite that seriously no patient would've known WTF a pseudoseizure was to begin with, the term was changed to PNES, despite that there was no seizure to begin with and they're now calling it a type of seizure with a phallic sounding nomenclature. Further then the real problem wasn't addressed. Name changing won't fix the situation. Addressing conversion disorder would've been a better approach.

Anyone here an expert and have a lot of experience with PNES? Doctor to female patient. "You've had a lot of big PNES's." ;);););)
 
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I've ranted about pseudoseizures getting renamed to Psychogenic non-epileptic seizures. ;);););)
I think I mentioned this before - the new name is functional seizures (though the term dissociative seizures is used in Europe). "psychogenic" has fallen out of fashion and "functional" is back in (although the term dates back to the 19th century at least to Hughlings Jackson if not before). That said it takes years for these things to catch on and many older neurologists or physicians in more rural parts of the country (I consult fairly widely) still use the term pseudoseizures. It wasn't that long ago one of my supervisors described a patient as having an "hysterical conversion." I still have a soft spot for the term hysteria, but of course I never use it with patients.
 
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It's the term that seems to be suggested consistently by the people who do research on this stuff. The trouble with documenting potential for secondary gain as the reason for doing something (unless they straight up tell you as in your example) is that you are guessing. You do not know why they are doing something, even if there are very plausible guesses. assume it is not the case that there is a blanket policy of refusing to admit all homeless people regardless of circumstances, so the potential of secondary gain alone is not what is dispositive in your decision. You are basing your decision on your clinical judgement that the reports of symptoms are being manufactured or modified in a purposeful way.

I think it's better to say the actual reason you are doing what you are doing instead of obscuring it; if it's a reason you don't want to commit to paper that might be a sign that it is not a good reason for making the decision, modulo concerns about sensitive issues involving third parties that might come up in court and/or get subpoena'd.
You can say the same thing about using the terms feigning or malingering though. Unless they outright admit it you're just using clinical judgment to guess. I was taught that more specific reasoning in documentation, as long as in line with the standard of care and reasonable decision making, is more protective. If there's evidence that the term "feigning" offers more legal protection in these cases I'd love to see it and would do that. I can just see a lawyer easily twisting the phrase "feigning" into calling the patient a liar whereas "secondary gain" does not directly do that.
 
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'calling it something else' would be weird. What else would you call it? But describing in plain language and sidestepping stigmatizing jargon as in the examples you provided here isn't that and is certainly something I also do.

Factitious and most malingering patients are still suffering. It's not a black and white rule, IF speaking 100% truth THEN is suffering AND deserves help IF misrepresentation THEN not suffering. I return to this teaching point again and again with my residents--the point is not to deny care. The point is to figure out what care they actually need. After all, how bad do things need to be for trying to be admitted to a psychiatric unit to seem like a good alternative?
I wholeheartedly agree with these points you've made. Great.
 
You can say the same thing about using the terms feigning or malingering though. Unless they outright admit it you're just using clinical judgment to guess. I was taught that more specific reasoning in documentation, as long as in line with the standard of care and reasonable decision making, is more protective. If there's evidence that the term "feigning" offers more legal protection in these cases I'd love to see it and would do that. I can just see a lawyer easily twisting the phrase "feigning" into calling the patient a liar whereas "secondary gain" does not directly do that.
Feigning doesn't ascribe any motivation whatsoever, it describes a behavior. I would also argue that you are being far more specific if you discuss the behavior you observe and why it makes you suspicious than simply saying 'well this person could be doing this for x and x reasons'.
 
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A patient of mine is highly eminent in a specific field of medicine, but not neurology. She's been suffering from a serious neurological disorder that will eventually take her life, unless something else happens to do it first like a car accident, will likely die in several years, and not immediately.

She was recently diagnosed with Conversion Disorder, by a neurologist who only superficially examined her, didn't read up her history, didn't read up the years of her treatment and evaluations by literally one of the top neurologists in the field (who's in a different state, she moved back to the area where she lived most of her life).

She's pissed. Add to that when she talked to me, I reviewed his records and it seems he, the neurologist, only spent a few minutes seeing her, didn't see an easy option, saw her history of psych issues, and just wrote down she has "conversion disorder" despite her protests, despite that she's an eminent physician herself, never bothered to see her neurology history, and that he didn't do the required due diligence such as extensive tests to rule out the physical causes, nor address the psych component of it even if he really believed it was conversion disorder.
 
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Feigning doesn't ascribe any motivation whatsoever, it describes a behavior. I would also argue that you are being far more specific if you discuss the behavior you observe and why it makes you suspicious than simply saying 'well this person could be doing this for x and x reasons'.
To feign literally means to pretend/fake a state of being and it's almost literally calling someone a liar. It may not imply motivation, but I'd imagine calling someone a liar is something lawyers would jump all over regardless of what term you're using. Of course you document specific behaviors and why you suspect malingering if you're going to suggest anything along those lines, I just don't see how the term feigning really any better than malingering other than maybe sounding slightly less harsh.

When I discharge someone from the ER for potential malingering or "feigning" symptoms, I believe (and have been told by forensic psychiatrists in my state) that it offers more protection to provide the reasoning I believe they are malingering (with motivation and evidence for that if reasonable), why that doesn't warrant psych admission, and what other resources were offered. We've had a few recent events where risk and legal got involved after patients followed through with their threats to harm themselves, one being a serious event on campus immediately after discharge. I've been fortunate to not be involved in these cases, but I've worked with risk and legal on documentation and they've suggested against using any terms along the lines of malingering or feigning at all unless a patient straight up admits to it.

Again, if you (or anyone) has data or papers suggesting we should be using the term "feigning", I'd be interested in reading it. I've heard forensics/legal people say it's better than saying "malingering", but never really seen anything to suggest it's a "correct" term to use.
 
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To feign literally means to pretend/fake a state of being and it's almost literally calling someone a liar. It may not imply motivation, but I'd imagine calling someone a liar is something lawyers would jump all over regardless of what term you're using. Of course you document specific behaviors and why you suspect malingering if you're going to suggest anything along those lines, I just don't see how the term feigning really any better than malingering other than maybe sounding slightly less harsh.

When I discharge someone from the ER for potential malingering or "feigning" symptoms, I believe (and have been told by forensic psychiatrists in my state) that it offers more protection to provide the reasoning I believe they are malingering (with motivation and evidence for that if reasonable), why that doesn't warrant psych admission, and what other resources were offered. We've had a few recent events where risk and legal got involved after patients followed through with their threats to harm themselves, one being a serious event on campus immediately after discharge. I've been fortunate to not be involved in these cases, but I've worked with risk and legal on documentation and they've suggested against using any terms along the lines of malingering or feigning at all unless a patient straight up admits to it.

Again, if you (or anyone) has data or papers suggesting we should be using the term "feigning", I'd be interested in reading it. I've heard forensics/legal people say it's better than saying "malingering", but never really seen anything to suggest it's a "correct" term to use.
Feigning of course implies that there is an intentional or instrumental aspect to what they are saying trying to achieve some purpose. That's the whole point; presumably if you thought the pan-SI/HI type presentations of frequent fliers were entirely genuine reports of their intentions you would hospitalized them.

I am confused as to why you don't malingering also implies the same thing. In fact, as the word is typically understood it means doing just that but in service of avoiding responsibility. It actually goes beyond feigning - not just doing X but doing X for reason Y. You are not just describing a behavior, but you are making an assertion about what you believe the motivation for that behavior is. Why raise the standard of evidence for yourself?

here's an editorial from Richard Rogers that touches on the distinction:


he makes the same point I do but also notes that we have psychometric tools that are decent at detecting feigned symptoms but not so much malingering properly understood. The one you can develop by comparing responses by people who genuinely suffer from a condition to people told to pretend to have the condition. The other you would need a sample of people who you are 100% confident are pretending to have a condition due to external incentives. Do you see how the first is much easier to establish norms for than the second?
 
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Thanks for the article, will read it!

I am confused as to why you don't malingering also implies the same thing. In fact, as the word is typically understood it means doing just that but in service of avoiding responsibility. It actually goes beyond feigning - not just doing X but doing X for reason Y. You are not just describing a behavior, but you are making an assertion about what you believe the motivation for that behavior is. Why raise the standard of evidence for yourself?
I was saying that feigning and malingering have the same implications to the layperson and likely lawyers representing patients. But if you can provide some evidence of malingering then you can at least provide a reason why they would be lying as opposed to just calling them a liar. If a patient were to be discharged and harm themselves or make an attempt, I'd imagine the latter would look worse in court, but I'll defer to the forensic docs here if that's not correct.

I find factitious disorder harder to document well at discharge specifically for that reason, as patient is literally just asking for medical treatment and you're saying no. Without longer periods of monitoring behavior it's a lot harder to justify discharging potentially feigned symptoms than someone who has a clear reason for faking symptoms (it's so cold outside, I've got court tomorrow, etc) and the ER often does not want to monitor for 30+ hours before discharging these people.

he makes the same point I do but also notes that we have psychometric tools that are decent at detecting feigned symptoms but not so much malingering properly understood. The one you can develop by comparing responses by people who genuinely suffer from a condition to people told to pretend to have the condition. The other you would need a sample of people who you are 100% confident are pretending to have a condition due to external incentives. Do you see how the first is much easier to establish norms for than the second?
I don't disagree that establishing malingering over feigning requires extra criteria and understand Rogers' point in the synopsis that we're using the wrong term with "malingering scales" in terms of what we're actually measuring. Idk about the bolded though. I think any of us who have spent significant time in the ER or on inpatient units (which is hopefully all of us in residency) should know that people who feign symptoms irl are often much more skilled at doing this than people told to do so as standardized patients. Maybe it's just because the former is experiencing some level of distress while standardized patients aren't, but idk that I would trust results from studies done using people told to feign symptoms vs studies where people actually did this and then admitted to doing so later (which I realize would be very difficult to do).
 
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Wondering if anyone has had an outpatient in psychiatry clinic with suspected factitious disorder consisting of feigned psychological symptoms.

I have a case that has been very challenging, and there are several elements of the overall presentation and histories that raise my concern for factitious disorder. However, it is impossible to prove concretely considering the possible feigned symptoms are almost purely psychological.

On the other hand, I wonder if my concern for factitious disorder is based on countertransference. Or the contrary--that still seeing the patient to no avail is rooted in countertransference. Or if it might seem like factitious disorder on the face of it but is outside of the patient's awareness and something else dynamically.

Has anyone else here suspected a psychiatry clinic patient of consciously feigning psychological symptoms for attention and treatment in the clinic setting?

I've put tremendous thought and effort into this case, which may have been a mistake.

So I'm mainly on here as a former patient who was looking to return to studies in the mental health field, but I was also doing voluntary peer support work a while back as well. One of my clients had a lengthy history of EDs and BPD, and a habit of creating false crises in order to get attention/validation. Anytime she contacted me with anything along the lines of, "Nobody cares, I'm so worthless and unloved, goodbye cruel world I'm headed to the nearest bridge to jump off it" she basically got the same response every time, which went something like, "I care about you as a person, and I care what happens to you; because I care I am now going to end our conversation and immediately contact the appropriate first responders to try and ensure your safety." Eventually she made enough progress to be able to contact me and actually express certain things (feelings, difficulties discussing certain issues in therapy, etc) without feeling like she needed to make some grand gesture like threatening to throw herself off a bridge. Unfortunately all of the good work both her therapist and myself had managed to do with her was then completely undone when she got 'adopted' by a group of 'surrogate mothers' who catered to her every whim and crisis, and treated her support team as if we were cruel and unfeeling for not sitting with her for several hours while she bathed in the attention of yet another false crisis she had created. I ended my work with her at that point.

Point is if a patient is creating crisis after crisis, sometimes the best thing to do is to still obviously make sure they are safe, but at the same time not get sucked in to their drama, and to be prepared to do that repeatedly even if they pitch a fit and demand you pay more attention to them.
 
Thanks for the article, will read it!


I was saying that feigning and malingering have the same implications to the layperson and likely lawyers representing patients. But if you can provide some evidence of malingering then you can at least provide a reason why they would be lying as opposed to just calling them a liar. If a patient were to be discharged and harm themselves or make an attempt, I'd imagine the latter would look worse in court, but I'll defer to the forensic docs here if that's not correct.

I find factitious disorder harder to document well at discharge specifically for that reason, as patient is literally just asking for medical treatment and you're saying no. Without longer periods of monitoring behavior it's a lot harder to justify discharging potentially feigned symptoms than someone who has a clear reason for faking symptoms (it's so cold outside, I've got court tomorrow, etc) and the ER often does not want to monitor for 30+ hours before discharging these people.


I don't disagree that establishing malingering over feigning requires extra criteria and understand Rogers' point in the synopsis that we're using the wrong term with "malingering scales" in terms of what we're actually measuring. Idk about the bolded though. I think any of us who have spent significant time in the ER or on inpatient units (which is hopefully all of us in residency) should know that people who feign symptoms irl are often much more skilled at doing this than people told to do so as standardized patients. Maybe it's just because the former is experiencing some level of distress while standardized patients aren't, but idk that I would trust results from studies done using people told to feign symptoms vs studies where people actually did this and then admitted to doing so later (which I realize would be very difficult to do).

Oh I agree they may be more skilled and it's the nature of the job that sometimes you will be taken for a ride. So even more damning if someone's behavior and answers to questions is in line with a college student who has had the DSM criteria reviewed with them and offered $10 to fake it, right?
 
You can be sued for anything at any time, medical or not. Treat the patient with their long term recovery being the focus and chart accurately what is going on. That's literally all you can do. If the presentation isn't consistent with depression or bipolar disorder or whatever, chart why it's not. Malingering and factitious disorder should be part of any differential, although usually relatively far down on the list.
 
Functional Neurological Disorder is a legitimate diagnosis and not malingering, and sometimes it responds to treatment (just not to AEDs).
 
Malingering is also a legitimate diagnosis that requires management within systems.
 
I just wanted to write and say i've run into a few really great cases lately where it comes down to a dysregulated somat (i.e. hysteria/borderline/conversion) vs a factitious disorder (aspd/malinger).

These cases are quite fun really, and quite a challenge. Luckily, either way, increased frequency of visits, in depth interviews - you can usually either catch the person slippin' (factitious/malingered cases) or see them improve (hysterics).

Really interesting pathology. Any updates OP?
 
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