Getting Rid of Malingerers

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MrChance2

MrChance2

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Any tips for inpt psych?

We have patients being admitted 4x a month. Exactly the same every time addicted+alcoholic-suicidal with some kinda plan. A lot of time they make the rounds at all the local psych hospitals and probably stay in the psych ward more often than not, generally at the end of the month with plans to leave on the first of the month when checks come out. They are laughing and having a good time on the unit, saying things like "I am having command auditory hallucinations telling me to hurt myself and other people" during exam without having any other signs of psychosis or schizophrenia then when they get DC'd they appeal the discharge to medicare to get a few more days while its reviewed.
 
Yes, don't admit them. Document why you think they're FOS.

During residency I saw a really old attending call the bluff of such a patient. He literally said to him, "I don't believe you. If you really wanted to kill yourself, you would have done it by now", and sent him out of the ER without an admission.
 
Do you have any input on whether they can be admitted in the first place? Otherwise, if they know the deal about appealing to Medicare I think you're SOL for a quickie discharge.
 
HooahDOc said:
Yes, don't admit them. Document why you think they're FOS.
Click to expand...

This is correct. To expand on this, you say they are in the inpatient unit 4x a month laughing, reporting psychotic symptoms in a rote fashion using psychiatric jargon, leaving when their check comes out (and presumably denying that they are a safety risk), and showing no objective signs of mental illness? Make sure your inpatient team DOCUMENTS THIS!! Don't have a series of daily progress notes like "Reports ongoing AH, VH, +SI, mood despondent, affect flat, r/o bipolar, r/o schizophrenia. Remains high risk appropriate for inpatient." All too often I see inpatient providers doing this, writing notes that make the person look legitimately ill. When the past ten admissions' notes make it look like the person is seriously mentally ill, it becomes harder to deal appropriately with the situation. So start by documenting accurately, and making sure others do the same.

Next, enact an appropriate plan when they show up again. Personally I think saying "I don't believe you. If you really wanted to kill yourself, you would have done it by now" is rather callous. It sounds almost taunting, and I would avoid emotionally charged "call-outs" even if it may feel satisfying. Presuming that there is at least some doubt about the malingering (which typically there is), I often use something more along the lines of: "Mr. X, you have been admitted eight times over the past two months, and looking over the records it doesn't seem like you benefit from these admissions. I also see that you haven't been to see the outpatient psychiatrist we referred you to. At this point, I think continuing to admit you to the hospital may actually be making things worse." Follow up with a pep talk about how being connected with outpatient management offers the best long-term prospect for improvement, and counsel them about drug use and other factors that may be worsening their mental state. Give them contact information for substance abuse programs if indicated. You then need to hold firm to the discharge plan, informing them that you are discharging them from the ER with a plan for outpatient followup. Document this very carefully, making sure that you explain the risks and benefits of your chosen management plan and showing that you exercised medical judgment in doing so. If there is a bad outcome, you want it on the record that you exercised medical judgment and chose the most appropriate treatment plan for the patient.

If they are straight malingering, and you are very confident, you can also document that and say that psychiatric followup is not indicated. I would avoid taking this lightly, though, and make a compelling case in your note.

Having had these interactions with many patients, in my experience when they see that they are not getting what they want they often want to just wrap things up so that they can go to another emergency room and get admitted there. Once in a while, things get uglier and they need to be escorted out by security. If that is the case, so be it. Odds are they will end up admitted somewhere if they really want to be, but you can still do what your medical judgment tells you is the right thing.
 
Bartelby said:
This is correct. To expand on this, you say they are in the inpatient unit 4x a month laughing, reporting psychotic symptoms in a rote fashion using psychiatric jargon, leaving when their check comes out (and presumably denying that they are a safety risk), and showing no objective signs of mental illness? Make sure your inpatient team DOCUMENTS THIS!! Don't have a series of daily progress notes like "Reports ongoing AH, VH, +SI, mood despondent, affect flat, r/o bipolar, r/o schizophrenia. Remains high risk appropriate for inpatient." All too often I see inpatient providers doing this, writing notes that make the person look legitimately ill. When the past ten admissions' notes make it look like the person is seriously mentally ill, it becomes harder to deal appropriately with the situation. So start by documenting accurately, and making sure others do the same.

Next, enact an appropriate plan when they show up again. Personally I think saying "I don't believe you. If you really wanted to kill yourself, you would have done it by now" is rather callous. It sounds almost taunting, and I would avoid emotionally charged "call-outs" even if it may feel satisfying. Presuming that there is at least some doubt about the malingering (which typically there is), I often use something more along the lines of: "Mr. X, you have been admitted eight times over the past two months, and looking over the records it doesn't seem like you benefit from these admissions. I also see that you haven't been to see the outpatient psychiatrist we referred you to. At this point, I think continuing to admit you to the hospital may actually be making things worse." Follow up with a pep talk about how being connected with outpatient management offers the best long-term prospect for improvement, and counsel them about drug use and other factors that may be worsening their mental state. Give them contact information for substance abuse programs if indicated. You then need to hold firm to the discharge plan, informing them that you are discharging them from the ER with a plan for outpatient followup. Document this very carefully, making sure that you explain the risks and benefits of your chosen management plan and showing that you exercised medical judgment in doing so. If there is a bad outcome, you want it on the record that you exercised medical judgment and chose the most appropriate treatment plan for the patient.

If they are straight malingering, and you are very confident, you can also document that and say that psychiatric followup is not indicated. I would avoid taking this lightly, though, and make a compelling case in your note.

Having had these interactions with many patients, in my experience when they see that they are not getting what they want they often want to just wrap things up so that they can go to another emergency room and get admitted there. Once in a while, things get uglier and they need to be escorted out by security. If that is the case, so be it. Odds are they will end up admitted somewhere if they really want to be, but you can still do what your medical judgment tells you is the right thing.
Click to expand...
This thread reminds me of a great quote from an angry lady whom I discharged from the ED as a resident. She was just looking for a bed, but wasn't being nice about it. I was a softy and would usually ask the ED attending to let such homeless patients stay until morning, and they'd usually appease me. This lady, however, ultimately needed to be escorted out by security.

On her way out, she saw me at a distance and yelled across the ED:

"Hey, just because I'm homeless doesn't mean I don't have a lawyer!!"

Good times.
 
Agree with above posters. It comes down to this: do you have the balls to call their bluff?

In residency, often times the attendings knew the patients were just FOS, but just admitted them anyway because the resident would do it and it's the safer route. So you may not have any control over this. But if you feel confident, you can push your attending to just discharge.

Otherwise discharge ASAP.
 
psyxh said:
This thread reminds me of a great quote from an angry lady whom I discharged from the ED as a resident. She was just looking for a bed, but wasn't being nice about it. I was a softy and would usually ask the ED attending to let such homeless patients stay until morning, and they'd usually appease me. This lady, however, ultimately needed to be escorted out by security.

On her way out, she saw me at a distance and yelled across the ED:

"Hey, just because I'm homeless doesn't mean I don't have a lawyer!!"

Good times.
Click to expand...

So... did you ever find out if she had a lawyer?! 😉
 
Make sure that you take very good care of all of their medical illnesses. BP a little on the high side?...better make sure that the low sodium cardiac diet is ordered. Active SI?...well we wouldn't want them to harm themselves with a dangerous implement so gowns and finger foods are appropriate. A smoker...hmmm better make sure to quickly get taper down nicotine replacement and offer bupropion and counseling. I would also remind them that people who get admitted for chest pain get a few days for cardiac enzymes and can leave the unit to go smoke.


Sent from my iPhone using SDN mobile app
 
You don't need to call their bluff. Document that you're going to refer to a PHP program instead due to the number of hospitalizations and demonstrating biomedical stability, the patient would likely not benefit from hospitalization.
 
ryerica22 said:
Can you guys do Neuropsych testing?
Click to expand...

Malingering is not a test bound conclusion.

There are some instruments out there such as the SIMS, MFAST, etc that can add a bit of confidence to suspicious presentations but this would generally not be necessary or even helpful for these type or acute inpatient issues.

Documenting behaviors that are inconsistent with the reported pathology and symptoms and establishing the presence of secondary gain is all you really need. You don't need a test for that.
 
Last edited:
ryerica22 said:
Can you guys do Neuropsych testing?
Click to expand...

In addition to what erg said, Neuropsych testing in this instance would also be not be good for the individuals who actually are floridly psychotic and/or suicidal, as they will likely trip validity indicators, not because they are malingering, but because that actually cannot adequately engage with the testing. Validity testing has its place, but the psych ER admitting area is not it. If I got this consult, I'd probably cancel it 99% of the time and say re-refer when patient is medically and psychiatrically at baseline, if possible.
 
I'm assuming this is in the ED/consult setting that the OP is referring to.

I think spending a little more time than you otherwise might in your assessment spelling out why you think the patient is malingering - incongruences in their MSE and their reported complaints, extensive chart review of their previous presentations (if present), a more explicit risk assessment focusing on protective factors and the patient's the ability to seek out help, and clearly spelling out potential secondary gain - can be helpful. If I'm reviewing someone's chart and malingering is high in the differential, I will typically take a different approach in the interview and focus on what exactly happened that resulted in the patient presenting today and acute on social issues rather than doing a primarily diagnostic interview as the secondary gain will typically become more evident with that kind of approach.

Ultimately I think if you're unsure the "correct" thing to do is to admit, but if you've seen a patient multiple times, it's clear from their history that they're malingering, they haven't benefitted in the past from inpatient admission, and your diagnosis is malingering, the correct thing to do is discharge and do what you can - within reason - to address whatever issues that aren't psychiatric but are bringing the patient to the hospital. Sometimes the malingering is obvious. At my moonlighting gig I saw a patient in the PED who presented for alcohol detox and ultimately had no other complaints but then told me that "I'm suicidal and homicidal" after being told that she wasn't going to be admitted as she didn't make inpatient admission criteria. Other times the case is less clear and admission might be warranted if you're unable to fully convince yourself of the diagnosis. If a patient is being really problematic - for example, being discharged and immediately turning back around and coming to the ED with the same complaints (there are a few patients at our institutions that do this) - then escalating the issue and coming up with a generalized approach to the patient that is documented can be helpful to minimize the amount of time wasted on working up their malingering.
 
When I was training malingering was not considered to be a medical diagnosis, and as such did not require treatment. People don’t usually end up in psychiatric wards by choice, and some would argue that those who have the desire to do so at the very least have some kind of personality issue. The medicare check/challenge system is a foreign concept to me – we don’t have such things in place where I practice and there’s no financial incentive for going into hospital (aside from having meals and somewhere to stay), so if someone does come up with command AH and refused treatment, then they’d risk ending up on an involuntary treatment order, IM antipsychotics +/- ECT. Then there’s the issue of spending time around actual patients with real symptoms who may be agitated/aggressive etc, all of which is a negative incentive to “fake.” I think most of the malingerers I've seen have usually been accompanied by police and have threatened suicide or had a sudden onset of psychiatric symptoms to try and get out of incarceration.

My experiences with the revolving door/multiple ED presentation patients described by the OP tend to be more along the lines of borderlines-in-crisis, and while a brief admission for containment can be justified, some of the same difficulties can arise in terms of trying to get someone out of hospital who wishes to stay.

On a day to day level, I think the easiest way to cover this is to document your observations and note any inconsistencies. Eg. patient states they are having active AH, but on MSE does not appear to be responding to external stimuli or distressed by voices.

I often find the non-leading open ended question to be very useful – “What do you actually mean when you say “Auditory hallucinations?” or “Can you describe <reported symptom> in more detail?”

Verbatim DSM description are an obvious red flag, and if you feel a patient is trying to tell you what you want to hear, the other technique is to suggest things that aren’t in keeping with the expected phenomenology. Eg. "Does the voice occur in only one ear, or a specific quadrant of that ear?"

Observations in non-interview settings or by other staff members are useful to note, as patients often behave differently when they think they are not being observed. When you bring it to their attention, you can use it to highlight that they have improved. Eg, “We saw you in the smoking courtyard smiling and laughing with other patients. That seems to suggest that your condition has improved since being admitted” etc. If they disagree that they have actually improved, you can pull out the, “It doesn’t seem like being in hospital has actually been beneficial for you,” line. The same goes for patients who feel like self harming in hospital or use it as a threat to stay longer.

One of my old bosses had a great response to a borderline patient who threatened to OD and self harm to get re-admitted if she was discharged.

“It doesn’t bother me. I’ll go home tonight, and tomorrow morning I’ll be here, the junior doctors will be here and the nurses will be here just like every other day. If you end up back again we’ll look after you and send you home again – and if you return again, we’ll be here and do it all over again. We work in hospitals and this is our job. But what kind of life is that for you?”

She didn’t have an answer, and she didn’t come back (at least not when I was there).

When you have patients re-presenting multiple times, then sometimes the decision can only be made by higher ups. I remember my old service doing an audit which found that 5 patients (all BPD) were responsible for 75% of the readmissions, and a management plan was put in place to limit their total re-admissions and requiring all their admissions to be approved by one of the senior director/head of department psychiatrists.
 
Liquid8 said:
When I was training malingering was not considered to be a medical diagnosis, and as such did not require treatment. People don’t usually end up in psychiatric wards by choice, and some would argue that those who have the desire to do so at the very least have some kind of personality issue. The medicare check/challenge system is a foreign concept to me – we don’t have such things in place where I practice and there’s no financial incentive for going into hospital (aside from having meals and somewhere to stay), so if someone does come up with command AH and refused treatment, then they’d risk ending up on an involuntary treatment order, IM antipsychotics +/- ECT. Then there’s the issue of spending time around actual patients with real symptoms who may be agitated/aggressive etc, all of which is a negative incentive to “fake.” I think most of the malingerers I've seen have usually been accompanied by police and have threatened suicide or had a sudden onset of psychiatric symptoms to try and get out of incarceration.

My experiences with the revolving door/multiple ED presentation patients described by the OP tend to be more along the lines of borderlines-in-crisis, and while a brief admission for containment can be justified, some of the same difficulties can arise in terms of trying to get someone out of hospital who wishes to stay.

On a day to day level, I think the easiest way to cover this is to document your observations and note any inconsistencies. Eg. patient states they are having active AH, but on MSE does not appear to be responding to external stimuli or distressed by voices.

I often find the non-leading open ended question to be very useful – “What do you actually mean when you say “Auditory hallucinations?” or “Can you describe <reported symptom> in more detail?”

Verbatim DSM description are an obvious red flag, and if you feel a patient is trying to tell you what you want to hear, the other technique is to suggest things that aren’t in keeping with the expected phenomenology. Eg. "Does the voice occur in only one ear, or a specific quadrant of that ear?"

Observations in non-interview settings or by other staff members are useful to note, as patients often behave differently when they think they are not being observed. When you bring it to their attention, you can use it to highlight that they have improved. Eg, “We saw you in the smoking courtyard smiling and laughing with other patients. That seems to suggest that your condition has improved since being admitted” etc. If they disagree that they have actually improved, you can pull out the, “It doesn’t seem like being in hospital has actually been beneficial for you,” line. The same goes for patients who feel like self harming in hospital or use it as a threat to stay longer.

One of my old bosses had a great response to a borderline patient who threatened to OD and self harm to get re-admitted if she was discharged.

“It doesn’t bother me. I’ll go home tonight, and tomorrow morning I’ll be here, the junior doctors will be here and the nurses will be here just like every other day. If you end up back again we’ll look after you and send you home again – and if you return again, we’ll be here and do it all over again. We work in hospitals and this is our job. But what kind of life is that for you?”

She didn’t have an answer, and she didn’t come back (at least not when I was there).

When you have patients re-presenting multiple times, then sometimes the decision can only be made by higher ups. I remember my old service doing an audit which found that 5 patients (all BPD) were responsible for 75% of the readmissions, and a management plan was put in place to limit their total re-admissions and requiring all their admissions to be approved by one of the senior director/head of department psychiatrists.
Click to expand...

Malingering is often partial, and another illness to consider is factitious disorder. I've seen people who were labeled as malingerers by staff for housing, etc. yet seem to come in and out of the hospital and never obtain or stick with the housing, or even claim they want help with it and ultimately request shelter discharge. While it's possible their motivation is a different secondary gain (evading legal trouble, waiting on a check to come in, etc.), primary gain should be considered too.

Regardless, I think the better argument here is documenting why another inpatient hospitalization isn't going to help the patient with their symptoms, be they malingered, factitious, legit, or any combination, and then trying to get them to the setting that will.
 
NickNaylor said:
I'm assuming this is in the ED/consult setting that the OP is referring to.
Click to expand...
OP's first line states that we're discussing inpatient psych, so I think that's the better assumption.
 
hamstergang said:
OP's first line states that we're discussing inpatient psych, so I think that's the better assumption.
Click to expand...

Ah, well that's a little more difficult then. Theoretically they shouldn't have made it there in the first place, but...

I still think most of post still applies.
 
MacDonaldTriad said:
"I am here because I am a danger to myself and others and yes that is my suitcase over there"
Click to expand...
I love the positive suitcase sign! "I hate myself and don't care what happens to me! I just want to die! But I did make sure to bring my five favorite t-shirts with me..."
 
chicagochildpsych said:
Make sure that you take very good care of all of their medical illnesses. BP a little on the high side?...better make sure that the low sodium cardiac diet is ordered. Active SI?...well we wouldn't want them to harm themselves with a dangerous implement so gowns and finger foods are appropriate. A smoker...hmmm better make sure to quickly get taper down nicotine replacement and offer bupropion and counseling. I would also remind them that people who get admitted for chest pain get a few days for cardiac enzymes and can leave the unit to go smoke.


Sent from my iPhone using SDN mobile app
Click to expand...

Low sodium, low fat food for everyone!
 
LasVagus said:
I love the positive suitcase sign! "I hate myself and don't care what happens to me! I just want to die! But I did make sure to bring my five favorite t-shirts with me..."
Click to expand...

+ Suitcase sign

Brilliant! I will start utilizing this most precise indicator in future notes, thank you, lol.
 
thoffen said:
Malingering is often partial, and another illness to consider is factitious disorder. I've seen people who were labeled as malingerers by staff for housing, etc. yet seem to come in and out of the hospital and never obtain or stick with the housing, or even claim they want help with it and ultimately request shelter discharge. While it's possible their motivation is a different secondary gain (evading legal trouble, waiting on a check to come in, etc.), primary gain should be considered too.

Regardless, I think the better argument here is documenting why another inpatient hospitalization isn't going to help the patient with their symptoms, be they malingered, factitious, legit, or any combination, and then trying to get them to the setting that will.
Click to expand...

By definition, symptom magnification is malingering.
 
PSYDR said:
By definition, symptom magnification is malingering.
Click to expand...

Disagree. Symptom magnification for secondary gain is malingering as is symptom fabrication for secondary gain. Partial malingering refers to magnification instead of fabrication, but it is still malingering.
 
thoffen said:
Disagree. Symptom magnification for secondary gain is malingering as is symptom fabrication for secondary gain. Partial malingering refers to magnification instead of fabrication, but it is still malingering.
Click to expand...

Meh, splitting hairs, and partial malingering isn't really codeable. Most definitions of malingering in a clinical sense include full malingering of symptoms as well as exaggerated, or grossly exaggerated symptoms. Bottom line is, though, that whether or not it's full or partial, spending the time to try and discern how much is malingered vs how much is real, in certain contexts, at least, is just not very feasible.
 
WisNeuro said:
Meh, splitting hairs, and partial malingering isn't really codeable. Most definitions of malingering in a clinical sense include full malingering of symptoms as well as exaggerated, or grossly exaggerated symptoms. Bottom line is, though, that whether or not it's full or partial, spending the time to try and discern how much is malingered vs how much is real, in certain contexts, at least, is just not very feasible.
Click to expand...

No. I don't think so either. I was merely stating that even malingerers often are in distress and are appropriate for some different level of care. It is not practical and probably not helpful to try to tease all that out. Just enough to make a treatment decision that is more than just covering your ass is all I advocate.
 
thoffen said:
No. I don't think so either. I was merely stating that even malingerers often are in distress and are appropriate for some different level of care. It is not practical and probably not helpful to try to tease all that out. Just enough to make a treatment decision that is more than just covering your ass is all I advocate.
Click to expand...

Not all psychological distress needs to be treated by psychiatry/mental health professionals.
 
My two cents: it's ineffective and risky to be the lone voice of reason in the psychiatric system. For these patients it's much better to have a care plan developed that can be shared and followed by all parties from outpatient to ED to inpatient. Each frequent hospitalization is another opportunity to fine-tune the plan.
Of course, the system does not do a good job of incentivizing or paying for such case management.
 
erg923 said:
Not all psychological distress needs to be treated by psychiatry/mental health professionals.
Click to expand...

Of course not. "Different level of care" doesn't necessarily mean mental health professional.
 
thoffen said:
No. I don't think so either. I was merely stating that even malingerers often are in distress and are appropriate for some different level of care. It is not practical and probably not helpful to try to tease all that out. Just enough to make a treatment decision that is more than just covering your ass is all I advocate.
Click to expand...

Good catch on the secondary gain aspect. My error.

It seems that our differences are in conceptualizing things as categories or degrees. Probably very different practices.

I would argue if sufficient data is present to determine that the patient is lying about their internal state for secondary gain, one could posit that:

1) The pt has demonstrated that they are in control of their own behavior.
2) The pt has demonstrated they can modify their own behavior to their own benefit.
3) Any diagnosis and treatment would be based on inaccurate information, and therefore it would be impossible to conform to the community standard of care.
 
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