How to handle manipulative patients in the ED

[Seroquelled]

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So I recently heard about an ~18 year old who came to the emergency department, requesting admission to a psychiatric unit for "depression". Their only symptoms were depressed mood, poor sleep, reported self-injury via superficial cutting (though patient would not allow reported site to be examined), and initially vague, infrequent passive suicidal ideation that progressed in severity as the upper level resident tried to explain to the patient that they did not meet criteria for inpatient psychiatric care. The patient was obviously changing their answers to questions such that they would meet admission criteria. The patient was not homeless and had no obvious secondary gain from being admitted. The patient banned the resident from calling the patient's family, would not participate in safety planning, and insisted on admission. What does SDN think is the right way to handle this situation?

Thanks in advance for any thoughts.

 

[splik]

First, I don't think it is helpful to describe the patient as manipulative. It's interesting that it is usually interns who react most negatively to such patients, perhaps partly because they lack the skills to deal with these patients, and partly it disabuses them of their more idealistic notions.

My take homes are:
1. all illness has secondary gain.
2. if someone is trying to gain psychiatric admission there is something terribly wrong with them. Now their problem may not be medical or psychological, it may well be social, but there has got to be something seriously wrong with your life if psychiatric admission seems like the solution. Inpatient units are toxic places.
3. Don't try to "get the goods" on patients by rumbling them. We're physicians. Our job is to help people. In order to do that we need to find out what is wrong and the best approach to this. It is very easy for students and junior housestaff to fall in the role of law enforcement or abuser. It's not our role, and is a recipe for burn out. You need to figure out what the hell is going on.
4. It is rarely helpful to describe people as manipulative. If you feel you're being manipulated they are obviously not doing a very good job of it. And if they are doing so - what are you learning about this relational style? Is this how others react to them? How might that contribute to their difficulties? How do disabuse them of any notions that this is helping them, and find a more appropriate idiom of distress?
5. If someone is being "manipulative" - could it be that this is actually the only way they can get the help they need? The reality is our MH care is so terrible you basically have to say you're suicidal in order to get what you want.
6. Always consider a factitious disorder. Psychiatric factitious disorders are real (well they're factitious but you know what I mean!) and are often overlooked. They typically occur in severe borderline personalities.
7. It doesn't matter if the patient refuses you to contact the family. You don't need their consent in an emergency setting. Absolutely contact the family. Collateral is essential here for appropriate disposition and I would not consider discharging an 18 year old with escalating suicidal threats who had no prior form without at least some attempt to contact the family for collateral.
8. Also consider that the "patient" is a "pseudopatient" participating in a sociological study vis-a-vis Rosenhan's on being sane in insane places. It was not so long ago that UCLA medical students were charged with the take of faking physical symptoms to try and get admitted to hospital.

The way these patients are handled varies wildly depending on resource allocation. In county hospital, they will almost never be admitted. In private for-profit hospitals they will almost always be admitted for a few days and then thrown out onto the streets when insurance stops paying. In fact some private hospitals lie about patients being suicidal and admit them just to fill up the beds.

Personally, I think this patient sounds more more interested than the usual dross that fills the inpatient unit, so if there was a bed I would be inclined to observe them to gather a clearer picture. Maybe this is a factitious disorder, or a borderline cry of distress, or maybe the patient is frankly psychotic without any disorganization in thinking that would give it away. Maybe they are avoiding being killed by their family, or sent back to whatever country they are from, hiding from their drug dealer, maybe they really are desperately suicidal but did not wish to disclose this in the first instance...

Once you have the information then if they present later you will know whether you can discharge them or not.

But the key is going to be collateral and as stated above, in the emergency room setting you do not need consent to contact family etc. Being sued for confidentiality breaches are exceedingly rare (are usually egregious). Being sued for suicide malpractice on the other hand... much more common

 

[wolfvgang22]

I agree with splik. Bottom line is I would most likely just admit the patient so I have more time to evaluate him rather than bang my head against the wall trying to figure out a new patient like this and then worry about him actually killing himself if I let him go. I have seen it go either way. I have lots of patients to worry about, why add more stress to life?

If it makes you feel any better, just keep in mind the patient will likely incur the cost of copays and inconvenience of sitting in the hospital a few days if he is faking. Only the very ill will repeat such behavior. On the other hand, if he really needs to be there you have simultaneously covered your ass and provided an opportunity to observe and assist the patient in recovery. Don't burn yourself out trying to be the great steward of hospital beds all the time unless you are in administration.

 

[Shikima]

Doesn't meet criteria for admission and needs to have the SW arrange in being sent to an IOP/PHP program. SW can also provide crisis management.

 

[hamstergang]

7. It doesn't matter if the patient refuses you to contact the family. You don't need their consent in an emergency setting. Absolutely contact the family.

It was my understanding from the last time I looked this up (years ago) that, as you say, consent is not needed to gather collateral in an emergency setting, but if the patient explicitly told you not to contact someone then you had to honor that. Am I remembering the law incorrectly?

 

[singasongofjoy]

When I was training on CL, the social workers were pretty skilled at handling similar situations. These are the types of situations that would be referred to the CL team (which consisted of a psychiatrist, 2 psychologists, 2 social workers, and various trainees).

 

[nexus73]

Doesn't meet criteria for admission and needs to have the SW arrange in being sent to an IOP/PHP program. SW can also provide crisis management.

Plot twist. The patient doesn't have insurance.

 

[Armadillos]

If this patient is unknown to the psych hospital (i.e. not a frequent flyer) and they are saying they can't stay safe outside the hospital, I would definitely admit him to figure out what is going on and how we can help.

Also from a more selfish self preservation standpoint as an intern, you get no tangible benefit from "successfully" discharging 100 malingerers, but are in for a lot of pain for denying 1 patient admission who ends up killing self .

 

[Merovinge]

My general rule is that if someone is coming in requesting admission and it's their first time in your system, find a way to get them admitted. It's dealing with frequent fliers who are clearly ASPD coming in for detox or BPD that requires much more experience/subtlety. These kind of cases just be as empathic as possible, make them trust the system so the inpatient doc can actually figure out what is going on. It's fine for your assessment to read that their story has been twisted but that they have endorses worsening SI and leave a broad differential in the assessment to pique the interest of the next doc caring for them.

 

[675015]

It was my understanding from the last time I looked this up (years ago) that, as you say, consent is not needed to gather collateral in an emergency setting, but if the patient explicitly told you not to contact someone then you had to honor that. Am I remembering the law incorrectly?

Not sure about the law, but I've found that whenever a patient in the emergency room tells us specifically not to call someone, its that person who is most helpful for figuring out what is actually going on.

 

[675015]

Its fine for your assessment to read that their story has been twisted but that they have endorses worsening SI and leave a broad differential in the assessment to pique the interest of the next doc caring for them.

And who knows, maybe once you told this person genuinely seeking help, that the emergency room was turning them away and refusing assistance, maybe that's when they started to have these vague thoughts of suicide? Their previously perceived last resort (the hospital) is gone.

 

[MacDonaldTriad]

It is sad that the number one risk factor for being admitted to a psychiatric hospital is having insurance. Clinical indications are much more likely to be applied to the uninsured.

 

[F0nzie]

The admission criteria for hospitalization is influenced by insurers. No SI? No admission. No payment. This criteria excludes high risk individuals that are not explicit with their SI and intent who are otherwise agreeable with admission. Someone who is depressed and on a downhill spiral should be granted admission even if they do not have SI. My stance is admit for additional monitoring, information gathering and make a case for early discharge. Rarely possible or safe to make complex decisions like these with ER driveby.


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[PistolPete]

If they tell me they are suicidal, then this is an emergency, especially if they are already physically located in the ER. At this point I contact collateral, if there's a number in the chart, even if it's against the patient's wishes, since I need to do what is necessary to save their life, and I can't do this without collateral. More often than not, there's no number in the chart, and the patient usually just gets admitted anyway.

 

[HarryMTieboutMD]

To the original poster, in the ED the patient is almost always unreliable, and if there is no chart, most of the family members are equally worthless historians (either they are too frenzied to recall accurately or they can't provide coherent answers despite numerous ways of asking questions clearly). So, your biggest tools diagnostically are going to be your mental status examination and clinical experience. Our PGY2 year was Q7ish overnight call in the ED (high volume) with no required staffing, so I developed pretty reliable heuristics for ED patients (maybe like 10-12 types) and now can generally have a good idea of what's going on by looking at them from across the room and figuring out an ideal dispo in the first 30 seconds.

As such, I can think about 5 different scenarios explaining the above presentation (from FOS and trying to get out of something to legitimately high risk requiring admission) but I would need to see the patient first.

HOWEVER, you need to be careful in your assessments and always make sure that you are doing what is best for the patient. The forensic literature suggests that your risk assessment is NOT a utilitarian measuring stick and that you need to be sound in your clinical reasoning (eg, demonstrate that you have thought about the case).

Also, you can obtain collateral without consent due to the emergency of the situation but odds are (as stated above) there is not going to be a reliable number in the chart

 

[Shikima]

The admission criteria for hospitalization is influenced by insurers. No SI? No admission. No payment. This criteria excludes high risk individuals that are not explicit with their SI and intent who are otherwise agreeable with admission. Someone who is depressed and on a downhill spiral should be granted admission even if they do not have SI. My stance is admit for additional monitoring, information gathering and make a case for early discharge. Rarely possible or safe to make complex decisions like these with ER driveby.


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If someone refuses to disclose their plan for SI, this is covered under the SI rule as if they were to have SI with a plan.

 

[Shikima]

Plot twist. The patient doesn't have insurance.

Then the hospital has a duty to create appropriate levels of treatment. Most places it is admit or outpt. There is no in-between. When you start working outside of academics, there are multiple levels of treatment which can be more effective than just inpatient treatment. I'm not saying don't admit or turn a blind eye, but the system, if it is going to spend money needs to have multiple layers in place to utilize that money more effectively. Besides, this is a good education than turfing you to the street to figure it all out (as I had to).

 

[AD04]

Would it be a HIPAA violation to get collateral when a patient with capacity did not want you to contact collateral?

According to HIPAA ( https://www.hhs.gov/hipaa/for-profe...t-the-patient-is-at-their-facility/index.html ), it says, "Even when the patient is not present or it is impracticable because of emergency or incapacity to ask the patient about notifying someone, a covered entity can still notify family and these other persons when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient."

The "impracticable because of emergency" is very vague so does that mean you are not violating HIPAA in this situation? Or is there a way to get collateral without letting family members know why you are calling and where their loved ones are at?

 

[HarryMTieboutMD]

Since I'm still in the academic bubble (and the first I've heard about insurance based criteria) can someone give me a brief rundown or links, please?

 

[FlowRate]

I don't have a huge amount of ED experience, but it's the clearly homeless looking for a bed who give me pause. I agree that life is awful and giving them shelter feels like the right thing to do, but the system needs to find a way to turn the $$$ of an ED/Inpatient Admission into $ for housing... An inpatient stay is like a month's rent in cheaper parts of the country...

Would it be a HIPAA violation to get collateral when a patient with capacity did not want you to contact collateral?

According to HIPAA ( https://www.hhs.gov/hipaa/for-profe...t-the-patient-is-at-their-facility/index.html ), it says, "Even when the patient is not present or it is impracticable because of emergency or incapacity to ask the patient about notifying someone, a covered entity can still notify family and these other persons when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient."

The "impracticable because of emergency" is very vague so does that mean you are not violating HIPAA in this situation? Or is there a way to get collateral without letting family members know why you are calling and where their loved ones are at?

Here's a reformatted version...
In these cases: "Even when the patient is not present or it is impracticable because of emergency or incapacity to ask the patient about notifying someone"
You can still call family, if: "doing so would be in the best interest of the patient."

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@HarryMTieboutMD Unfortunately I don't have great links, but I know the case managers on our inpatient units are always concerned with certain items in documentation and covered days, etc. I found it somewhat instructive to look at their admission flowsheets.

You could start with this, I guess: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c02.pdf

Or google other versions of "medicare inpatient criteria."

Edit: This one is pretty good: https://www.magellanprovider.com/media/1771/mnc.pdf

 

[Dharma]

Would it be a HIPAA violation to get collateral when a patient with capacity did not want you to contact collateral?

According to HIPAA ( https://www.hhs.gov/hipaa/for-profe...t-the-patient-is-at-their-facility/index.html ), it says, "Even when the patient is not present or it is impracticable because of emergency or incapacity to ask the patient about notifying someone, a covered entity can still notify family and these other persons when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient."

The "impracticable because of emergency" is very vague so does that mean you are not violating HIPAA in this situation? Or is there a way to get collateral without letting family members know why you are calling and where their loved ones are at?

Anytime I've had a patient refuse to provide contact information I usually say something along the lines that I need to speak with someone before they go home. Some may dance around a bit before I stand up and say "ok, well it may be a while before we have safe plan for discharge then. Think about it." Those refusing to provide such info are usually the ones who want to go home (or whom I think should go home) and when I tell them it's necessary for discharge then they usually buck up and allow me to call. I have also reassured patients that I will not provide any details to the collateral contact and will simply inquire of what family has perceived and if there are safety concerns. That said, I think it's ok to call either way (assuming you have the contact info) when a patient is displaying lack of insight (so lack of relative capacity) in the context of potential risk.

 

[LasVagus]

The important questions in the ED really are: "what level of care does the patient need for their severity of symptoms and do they need any medication immediately to treat these symptoms?" As striking as the behavior is that you describe above, OP, I would probably just document the behavior in my evaluation, admit the patient, and move on. That being said, I find that this style of evasiveness and answer modification usually means one of a few things: 1) they are in pain and they don't think that they can get help unless they say they are suicidal (unfortunately, there's a lot of truth to this), 2) they want to demonstrate to other people that they are in a lot of pain and saying they're suicidal is always an attention-grabber, 3) they are homeless (not the case with your guy), 4) they want drugs ("yeah, one thing that helped for my mood in the past was something called... Banax, Sanax... oh wait, Xanax... is that the name of a medication?"), 5) they are avoiding court, 6) they are avoiding an abusive partner.

 

[clausewitz2]

Occasionally, especially with adolescents, you get 7) someone important to me is currently inpatient and I want to be near them, be it boyfriend/girlfriend/twin sibling (!).

 

[MLT2MT2DO]

Plot twist. The patient doesn't have insurance.

A plot twist would have been if the patient did have insurance

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[smalltownpsych]

Admit. A key point to this case is that males with Borderline pathology cause some of the strongest negative countertransference reactions and it is almost universal with staff. Female patient with BPD is more likely to have half of the people hate her and half want to save her. Don't get caught up in the enactment of the transference, just align with the patient the way that you would with any other and they will open up. Easier said than done when our emotional reaction is the complete opposite. We'll see how I do with it this afternoon with a new patient who played out a very similar dynamic to what you are describing with their last psychologist. I had a strong negative emotional reaction just from reviewing the chart. 😱

 

[PistolPete]

Admit. A key point to this case is that males with Borderline pathology cause some of the strongest negative countertransference reactions and it is almost universal with staff. Female patient with BPD is more likely to have half of the people hate her and half want to save her. Don't get caught up in the enactment of the transference, just align with the patient the way that you would with any other and they will open up. Easier said than done when our emotional reaction is the complete opposite. We'll see how I do with it this afternoon with a new patient who played out a very similar dynamic to what you are describing with their last psychologist. I had a strong negative emotional reaction just from reviewing the chart. 😱

Let us know how it goes? I find it so tough with BPD pateints. Easier with adolescents now that I've completed training in DBT. But still tough.

 

[PistolPete]

Occasionally, especially with adolescents, you get 7) someone important to me is currently inpatient and I want to be near them, be it boyfriend/girlfriend/twin sibling (!).

And they magically get better when their friend is discharged!

 

[Shikima]

I have a BPD borderline on my case load, hard to work with as she's got Asperger's too. She is manipulative without knowing it - insight is poor. Before I got her, her old psychiatrist discharged her because he didn't know what else to do with her. I adjusted medications, she was hospitalized twice more before I got things stable and had the insurance company pay for a DBT program. She's also seeing her psychologist. Seen her yesterday, she is "suicidal" again with scratching until bleeding because of her fighting with a family member. Doesn't cope well. And then stated that she's wanting not to go to DBT any longer and hadn't seen her therapist this week because she wanted a break.

She's still in an outpt program, I won't admit her because she uses admissions as a form of running away.

 

[smalltownpsych]

I have a BPD borderline on my case load, hard to work with as she's got Asperger's too. She is manipulative without knowing it - insight is poor. Before I got her, her old psychiatrist discharged her because he didn't know what else to do with her. I adjusted medications, she was hospitalized twice more before I got things stable and had the insurance company pay for a DBT program. She's also seeing her psychologist. Seen her yesterday, she is "suicidal" again with scratching until bleeding because of her fighting with a family member. Doesn't cope well. And then stated that she's wanting not to go to DBT any longer and hadn't seen her therapist this week because she wanted a break.

She's still in an outpt program, I won't admit her because she uses admissions as a form of running away.

Somebody on the spectrum will not do well in a typical group treatment setting without people who specifically understand this population and how to help them. When I was a director of a residential program, it was one of our disqualifying dx'es and when someone would slip through the cracks, no matter what we would do they would decompensate until we had to hospitalize and transition them out of our program. This was the case until I hired a postdoc with some interest and experience with this population and we learned and brought in a couple of people with some expertise how to modify the program itself to meet the needs of those clients. It worked and we went from a zero success rate to about an 80% or so success rate as measured by being able to complete our rigorous therapeutic and academic program. Thus, I was able to shift from having that dx be a disqualifier to a more balanced approach where I would weigh the relationship between academic abilities with social and emotional abilities when evaluating prospective patients.

Key thing to keep in mind is that the social aspects of the DBT group itself will be an overwhelming social stressor for someone with an autistic disorder and they will likely experience a lot of invalidation from the socially adept clients and therapists.

 

[Shikima]

Somebody on the spectrum will not do well in a typical group treatment setting without people who specifically understand this population and how to help them. When I was a director of a residential program, it was one of our disqualifying dx'es and when someone would slip through the cracks, no matter what we would do they would decompensate until we had to hospitalize and transition them out of our program. This was the case until I hired a postdoc with some interest and experience with this population and we learned and brought in a couple of people with some expertise how to modify the program itself to meet the needs of those clients. It worked and we went from a zero success rate to about an 80% or so success rate as measured by being able to complete our rigorous therapeutic and academic program. Thus, I was able to shift from having that dx be a disqualifier to a more balanced approach where I would weigh the relationship between academic abilities with social and emotional abilities when evaluating prospective patients.

Key thing to keep in mind is that the social aspects of the DBT group itself will be an overwhelming social stressor for someone with an autistic disorder and they will likely experience a lot of invalidation from the socially adept clients and therapists.

Fortunately, she's in one on one therapy and does respond to therapeutic contacts in a meaningful way. Very bright, but harder for her to process due to limited insight.

 

[PistolPete]

Somebody on the spectrum will not do well in a typical group treatment setting without people who specifically understand this population and how to help them. When I was a director of a residential program, it was one of our disqualifying dx'es and when someone would slip through the cracks, no matter what we would do they would decompensate until we had to hospitalize and transition them out of our program. This was the case until I hired a postdoc with some interest and experience with this population and we learned and brought in a couple of people with some expertise how to modify the program itself to meet the needs of those clients. It worked and we went from a zero success rate to about an 80% or so success rate as measured by being able to complete our rigorous therapeutic and academic program. Thus, I was able to shift from having that dx be a disqualifier to a more balanced approach where I would weigh the relationship between academic abilities with social and emotional abilities when evaluating prospective patients.

Key thing to keep in mind is that the social aspects of the DBT group itself will be an overwhelming social stressor for someone with an autistic disorder and they will likely experience a lot of invalidation from the socially adept clients and therapists.

I'm curious, what were the modifications that you made to improve the success rate? Surely it can't just be smaller groups for group therapy with ASD patients, since I'd wager there aren't many ASD patients in residential units.

 

[PistolPete]

I have a BPD borderline on my case load, hard to work with as she's got Asperger's too. She is manipulative without knowing it - insight is poor. Before I got her, her old psychiatrist discharged her because he didn't know what else to do with her. I adjusted medications, she was hospitalized twice more before I got things stable and had the insurance company pay for a DBT program. She's also seeing her psychologist. Seen her yesterday, she is "suicidal" again with scratching until bleeding because of her fighting with a family member. Doesn't cope well. And then stated that she's wanting not to go to DBT any longer and hadn't seen her therapist this week because she wanted a break.

She's still in an outpt program, I won't admit her because she uses admissions as a form of running away.

Is PHP or IOP an option?

 

[smalltownpsych]

I'm curious, what were the modifications that you made to improve the success rate? Surely it can't just be smaller groups for group therapy with ASD patients, since I'd wager there aren't many ASD patients in residential units.

We were able to populate a group of about 8 "socially awkward" kids out of a population of about 50 and about 5 or 6 of those were diagnosed with an autism spectrum disorder. This meant that they spent only one group a week with more socially adept kids and two groups a week with each other. The therapist they were assigned to was the postdoc who was both experienced and motivated to help this population and was very focused on the balance between treating their anxiety about social situations with improving social skills. We would also allow them to isolate more and would actually schedule some of them alone/decompress time. We also allowed them to spend more time on laptops while in the milieu whereas more social types prone to depression or anxiety would be encouraged/pressured to interact more. I would tell our caring staff, "No, he is fine sitting over there in the corner with his head buried in a laptop or book. Go talk to another kid." Actually had to fire one staff because they would not modify their approach and it amounted to bullying. That was because of another modification which was lowering some of the athletic expectations and pressure because many of these kids struggled with team athletic activities.

 

[Shikima]

Is PHP or IOP an option?

I left it up to her therapist. I have reached out to her for case conference due to the new information and issues cropping up recently. This is a pattern of behavior for her and improving!