In the psych emergency room, dow do you personally deal with the malingering patient.

[carlosc1dbz]

The psych ER has a wide variety of patients, making it a great place to get a lot of experience and also stay up to date on basic medical management. Patients walk in to triage, police bring in patients, ambulances bring patients from outside clinics, and overall it is a very interesting and unique work environment.

One thing that is not interesting is when a triage comes in saying that they are "very suicidal," that they have auditory hallucinations telling them to jump in front of traffic, and therefore they feel that they feel they should be admitted. Of course they say this as they eat their meal comfortably and have their suitcase right next to them. The affect and behavior does not match up with the complaint that they are reporting.

I am seeing this more and more as the winter shelters close, and of course malingering is high on my ddx. I feel that different hospitals have different cultures when it comes to this type of patient, but I was curious how you guys that have worked in a psych ER or have worked in a psych ER manage this type of patient.

---

Members don't see this ad.

 

[Ψ-117]

My residency program had a psych ER. Typically, if malingering was suspected, the patient might be observed in the ER overnight and discharged in the morning. Sometimes we would admit them just to be safe. For those patients who have established a history of malingering, the ER psychiatrist would usually know them well enough to not admit, and at most the patient might be observed overnight.

 

[Doctor Bagel]

I've never worked in a dedicated psych ER (my city doesn't have one yet) but have seen lots of psych patients in the ED. Observation is nice although sometimes it's hard to sell the ED attending on that (again, no dedicated psych ER). Other tools include collateral information and really getting to know patients, which means it's harder to figure out what to do with a patient who is new to your town. Also, in my opinion, it's better to make a weak admit than to discharge somehow who has a bad outcome. Ultimately it's not any one psychiatrists job to fix an already broken system by too aggressively sending people out the door. The other big thing is documenting so you're able to justify why you're sending someone out who is saying they're going to kill themselves -- this includes doing a risk assessment (which includes history, which again means things work better with patients known to the system) and your observations of them.

 

[birchswing]

What happens when a hospital doesn't have a psychiatrist? I went to the ED a couple of years ago for what turned out to be Hashimoto's (which they thought was heightened anxiety at the time) but the doctor I saw was clueless about psych meds and wanted to give me Abilify (even though I was already on Seroquel) and 12 mg of Ativan to take daily even though I already had a psychiatrist and had already been able to decrease my 4 mg of Ativan to 3.5 mg (which he called peanuts and said a big guy like me needed to max it out). I asked if there was a psychiatrist I could talk to and he said the hospital didn't have any. It makes me wonder what they would do if someone came in with more acute mental distress. Well, I guess I know. They'd give them Ativan and Abilify. I know that neither of the hospitals near me has psychiatric beds and that people who go inpatient are taken to a city about an hour and a half away, but I would think they should at least have a psychiatrist in the hospital to consult in the ED. Have always wondered about that. And now I hear there are psych EDs. That's a new one. I would guess you would need to live in a very metropolitan area to have that?

 

[clausewitz2]

I've never worked in a dedicated psych ER (my city doesn't have one yet) but have seen lots of psych patients in the ED. Observation is nice although sometimes it's hard to sell the ED attending on that (again, no dedicated psych ER). Other tools include collateral information and really getting to know patients, which means it's harder to figure out what to do with a patient who is new to your town. Also, in my opinion, it's better to make a weak admit than to discharge somehow who has a bad outcome. Ultimately it's not any one psychiatrists job to fix an already broken system by too aggressively sending people out the door. The other big thing is documenting so you're able to justify why you're sending someone out who is saying they're going to kill themselves -- this includes doing a risk assessment (which includes history, which again means things work better with patients known to the system) and your observations of them.

Yeah, one program I interviewed at this year has a dedicated psych ED but the residents bragged about how they only have a 30% admission rate. I did not take this is a super encouraging sign wrt the institutional culture.

 

[Leo Aquarius]

The psych ER has a wide variety of patients, making it a great place to get a lot of experience and also stay up to date on basic medical management. Patients walk in to triage, police bring in patients, ambulances bring patients from outside clinics, and overall it is a very interesting and unique work environment.

One thing that is not interesting is when a triage comes in saying that they are "very suicidal," that they have auditory hallucinations telling them to jump in front of traffic, and therefore they feel that they feel they should be admitted. Of course they say this as they eat their meal comfortably and have their suitcase right next to them. The affect and behavior does not match up with the complaint that they are reporting.

I am seeing this more and more as the winter shelters close, and of course malingering is high on my ddx. I feel that different hospitals have different cultures when it comes to this type of patient, but I was curious how you guys that have worked in a psych ER or have worked in a psych ER manage this type of patient.

I have a lot of experience treating patients in the Psych ER environment. First, always remember that even malingerers who threaten suicide, a percentage of them do complete suicide whether it was on accident or not. So while the temptation is to call their bluff and discharge them, you can't just jump to that. Second, many malingerers have morbidities such as alcohol withdrawal or opioid withdrawal and are looking for more than a meal, but won't tell you that. You gotta observe them and their vitals. Look for signs of autonomic instability. We are, after all, in an ER, and we need to treat co-morbid issues. Third, they may in fact not be malingering and your gut is wrong. The best approach I've found is to do a little give and take. You let them stay overnight, with a sack meal, not an elaborate 3 course dinner. If they demand narcotics, you ask about pain and offer NSAIDs. You watch their reaction. Fourth, people with thought disorders often have poor insight and think they are simply malingering when in fact they need psychiatric care. Don't let their bluff call your bluff. Ultimately, many of these malingering patients need placement somewhere. Get your team to help with discharge placement and they won't come back as much.

 

[FlowRate]

If we imagine inpatient resources are limited and useful to genuine psychopathology, then I feel like it's inappropriate to admit clear-cut malingering. I have a hard time watching clear malingering be admitted, while on the other hand I understand the argument that life is tough and shelters have limited capacity. But does a 3-day respite really encourage independence?

 

[Doctor Bagel]

I have a lot of experience treating patients in the Psych ER environment. First, always remember that even malingerers who threaten suicide, a percentage of them do complete suicide whether it was on accident or not. So while the temptation is to call their bluff and discharge them, you can't just jump to that. Second, many malingerers have morbidities such as alcohol withdrawal or opioid withdrawal and are looking for more than a meal, but won't tell you that. You gotta observe them and their vitals. Look for signs of autonomic instability. We are, after all, in an ER, and we need to treat co-morbid issues. Third, they may in fact not be malingering and your gut is wrong. The best approach I've found is to do a little give and take. You let them stay overnight, with a sack meal, not an elaborate 3 course dinner. If they demand narcotics, you ask about pain and offer NSAIDs. You watch their reaction. Fourth, people with thought disorders often have poor insight and think they are simply malingering when in fact they need psychiatric care. Don't let their bluff call your bluff.

These are good points. Again, in a city with no dedicated psych EDs, but I'm amazed by how much ED docs overlook etoh withdrawal (super common, super risky) in psych patients.

Another frustrating thing as a psychiatrist dealing with possible malingerers either in the ED or in the inpatient setting is how much affect gets generated by other staff. You get a lot of push to get rid of patients who are deemed to be difficult or shelter seeking, but you've got to remember that you're the one shouldering almost all the burden with these decisions. If something goes wrong, it's all on you. So I guess what I'm saying again is to protect yourself and be cautious and don't take on too much risk trying to weed out a malingerer.

 

[Doctor Bagel]

Yeah, one program I interviewed at this year has a dedicated psych ED but the residents bragged about how they only have a 30% admission rate. I did not take this is a super encouraging sign wrt the institutional culture.

My city is going to launch a dedicated psych ED. It'll be curious to see how it goes. I'm not sure what normal admit rates would be for a dedicated psych ED? Actually I have no clue what the admit rate is for my hospital's ED without a dedicated psych ED. My understanding is that dedicated psych ED might give more people the ability to receive care in the ED longer to the extent where the ED stay might mirror short hospital admissions. If that's the case, a low admission rate wouldn't be too bad. Some people really only need one night to hang out in a safe place for whatever reason. But yeah, putting forth an idea that they're super aggressive about getting people out (kind of in a kicking people out sort of way) doesn't sound pleasant.

 

[notdeadyet]

Another thing to consider with PES malingering is that it looks more difficult as a rotating medical student or even resident than when you spend a significant amount of time there.

Most folks who abuse the system are known to the PES docs. This doesn't eliminate risk in managing malingering, but it reduces it. When you have someone that you think is malingering but is unknown to PES, you definitely hedge your bets and are more likely to admit.

 

[notdeadyet]

Doctor Bagel- Are you familiar with Dr. Scott Zeller's work and the Alameda Model? You might find it interesting reading.

 

[carlosc1dbz]

In the psychiatric emergency room that I have worked at, people brought in by police or the psychiatric community response team are usually already on a psychiatric hold. The triages are usually the ones that we put on a psychiatric hold if needed. We don't do medication management in the psych ER, as there is a walk in mental clinic that patient can go to during the day.

I remember one time, a patient came in to triage, had a cast on one leg, a crutch and a suitcase. The patient was seen by nursing. He reported feeling depressed and suicidal. The patient was waiting to be seen by me, and I was working on maybe a consult and a police case. When I got to him, he was on the floor sleeping, and was refusing to talk much. I was trying to do a risk assessment and understand how he ended up so far from home. Turns out a friend had brought him to the hospital and the patient would not give me his friends contact or anyone else's contact info so I could get some collateral . He was comfortable, maybe had eaten already, and I decided to tell him that based on the presenting complaint, he would better be served by establishing outpatient care and treating his depression there. It was then he decided to now wake up and engage with me. He attacked me with his crutch. He was very upset that he was not going to get admitted. Nursing was asking if I was going to put him on a psychiatric hold for danger to the community. I told them to simply call law enforcement to have him taken away. He didn't harm me luckily.

I do like the idea of overnight observation, but I don't like the idea of admitting someone just because they claim to be suicidal. I find it difficult to document that I suspect malingering, but I do try to document as many key words that would let other providers know what I think is going on. If I document malingering, disposition becomes a problem as the psychiatric inpatient units that we dispo to will likely not accept a patient suspected of malingering. Now that the emergency rooms around town have the same medical record system, we can see when they were at another hospital and read their notes. That has helped get a better sense of the patients as well.

 

[notdeadyet]

i find it difficult to document that I suspect malingering, but I do try to document as many key words that would let other providers know what I think is going on. If I document malingering, disposition becomes a problem as the psychiatric inpatient units that we dispo to will likely not accept a patient suspected of malingering.

Why are you admitting someone from a PES to a inpatient unit if they are thought to be malingering? Our hands may be tied in PES, but we certainly shouldn't be admitting/transfering patients to an inpatient unit of we think they are malingering. That's bad juju.

 

[carlosc1dbz]

Why are you admitting someone from a PES to a inpatient unit if they are thought to be malingering? Our hands may be tied in PES, but we certainly shouldn't be admitting/transfering patients to an inpatient unit of we think they are malingering. That's bad juju.

You are right, that would be very bad. I personally wouldn't. All patients in the psych ER I worked at have an active dispo plan of getting the patient a bed somewhere in the city. If malingering is in the documentation, then the case workers usually come talk to you and tell you that no one is accepting the patient. The culture at this PER is to take a very conservative when it comes to discharging patients from the psych ER. That is why I am wondering what approach other psych ERs take when it comes to dealing with this kind of patients. Even with overnight monitoring, we have patient's still endorse SI as they like the food and the warmth of the psych ER.

 

[Doctor Bagel]

Doctor Bagel- Are you familiar with Dr. Scott Zeller's work and the Alameda Model? You might find it interesting reading.

Thanks, I'll check it out.

 

[thoffen]

A couple of call shifts ago, I had a patient start his song and dance. When ferreting out supposed suicide attempts, etc. I got the you aren't listening speech followed by the how old are you anyway speech.

I dunno exactly why, but I absorbed a little bit and said "sir, I'm your doctor and you're being very rude to me", and it magically fixed things.

Other times you just gotta have security escort them out and document, document, document.

 

[birchswing]

A couple of call shifts ago, I had a patient start his song and dance. When ferreting out supposed suicide attempts, etc. I got the you aren't listening speech followed by the how old are you anyway speech.

I dunno exactly why, but I absorbed a little bit and said "sir, I'm your doctor and you're being very rude to me", and it magically fixed things.

Other times you just gotta have security escort them out and document, document, document.

Depressed resignation or gained agreement?

 

[Shikima]

A couple of call shifts ago, I had a patient start his song and dance. When ferreting out supposed suicide attempts, etc. I got the you aren't listening speech followed by the how old are you anyway speech.

I dunno exactly why, but I absorbed a little bit and said "sir, I'm your doctor and you're being very rude to me", and it magically fixed things.

Other times you just gotta have security escort them out and document, document, document.

 

[nancysinatra]

You are right, that would be very bad. I personally wouldn't. All patients in the psych ER I worked at have an active dispo plan of getting the patient a bed somewhere in the city. If malingering is in the documentation, then the case workers usually come talk to you and tell you that no one is accepting the patient. The culture at this PER is to take a very conservative when it comes to discharging patients from the psych ER. That is why I am wondering what approach other psych ERs take when it comes to dealing with this kind of patients. Even with overnight monitoring, we have patient's still endorse SI as they like the food and the warmth of the psych ER.

Are you saying that at the psych ER you worked at, ALL patients were dispo'd to inpatient hospital beds? And the problem was that known malingerers were hard to admit?

What? You're saying that every person that walks through the door of this psych EC gets slated for inpatient admission? No way. I don't believe it. For a lot of reasons. But first can you clarify if that's what you actually mean?

 

[nancysinatra]

Yeah, one program I interviewed at this year has a dedicated psych ED but the residents bragged about how they only have a 30% admission rate. I did not take this is a super encouraging sign wrt the institutional culture.

I think there could be a reason they are bragging. A 30% admission rate means the residents there get experience in d/c'ing patients from the ER. This is really valuable experience. You will find it hard to gain after residency. You're right about institutional culture - each ER, and each psych ER, is more or less conservative when it comes to d/c'ing patients back to home, the street, or elsewhere. You have the rest of your career to admit patients, but for your training, you want to do as much discharging as possible.

 

[notdeadyet]

I think there could be a reason they are bragging. A 30% admission rate means the residents there get experience in d/c'ing patients from the ER.

Also, if a place only has a 30% admission rate, it means that they are treating and stabilizing patients sufficiently to discharge them instead of just being a transit center that takes down information and admitting.


Sent from my iPhone using Tapatalk

 

[nancysinatra]

Also, if a place only has a 30% admission rate, it means that they are treating and stabilizing patients sufficiently to discharge them instead of just being a transit center that takes down information and admitting.


Sent from my iPhone using Tapatalk

Exactly. It also means that residents, and not social workers, are doing most of the work.

 

[JamesPhilly]

I work in our psych ED every week, either being on call or moonlighting, and I get a couple of these pts every shift. The key part is figuring out what they actually want, which tends to be housing, drug tx (maybe they left AMA from detox so they know they won't get approved again), helpimg their app for SSI, or to get away from people they owe money to. I ask for collateral phone #s which of course they deny, "everyone I know is dead!", but then I see them on the free phone in the waiting room for hours. Hmm. I will call the medicaid provider for philadelphia (CBH) who keep meticulous records, and get a sense of their hx. They very rarely are completely new to the system. Then their MSE does not match their complaints at all. Armed with my evidence, I will sit them down and say straight up that they are not going inpt psych, that is out of the question. But if they tell me what's really going on maybe I can try to help them, ie drug tx, set them up with a recovery home, etc but either way they're not going into the hospital. I'll offer them to sit in the waiting room as long as they like, and it's helpful that our psych ED is not a place where you could sleep comfortably, so it discourages people from coming just for sleep. It also shows that although you don't buy their story, you still care for them and want to help in some way. So many just say fine, I want tokens for the bus, I can stay with a friend, etc. This happens so often that I have some well rehearsed lines that help steer the conversation to something productive. "How do you think the cocaine effects your mood?"

As you said, if the MSE, interview and treatment hx all point to malingering, then I have no problem discharging. The key is you document everything to backup your diagnosis: the phone calls and then not giving collateral, asking for more food, being "really suicidal" for the last year, the visit today coinciding with relapsing on pcp/heroin/coke and getting kicked out of their recovery home, wanting 3 tokens instead of one, etc. When they scream that they're going to sue me, or go another ED to talk to a doctor who is caring ,etc, that's very helpful, "pt is goal directed & future oriented, focused on getting inpt, suing this writer." As with all of medicine you could always be wrong, so you support your decision in as much as you can.

The difficult part is explaining to an ED attendings that the CC of wanting to to kill themselves is not enough to go inpt. That's another type of conversation I have often. They'll call back upset when the pt presents a second time to their ED. I will use the analogy of chest pain. Do all pts with CP get inpt? They figure out the etiology, and if it's serious, in they go, or if it's not something life threatening (like costochondritis) and then d/c. In this case the SI is a means to an end, so off you go.

Hands-down the toughest pts are prisoners. Our psych ED is also responsible for a local prison during off hours. These people will do crazy stuff to get a doctor's note. Many times the things they do are the stuff that mentally ill people would attempt in a movie. Like write 666 on the walls, VH of 'dead people' talking to them constantly, and no objective findings on the MSE. These people will also hurt themselves, I had a case of self-immolation (he wasn't hurt that bad). That one i waited till the AM for the attending to d/c, even though I knew he was malingering I did not feel comfortable having my name on that sheet

 

[swisschard]

where I did residency the culture was to keep nearly everyone who came in on a hold... 30% admission rate--is that letting them stay overnight or 2 nights for observation, or an actual IP admit? If it's the former, that's pretty ballsy for the docs to turn away so many folks.

also consider that burnout may be feuling this. I certainly got a lot nicer to potential malingerers when I went from working 70 hours a week to 30 hours a week.

 

[smalltownpsych]

At our ED malingering is actually pretty low which is probably a function of being in such a small rural community. When we do have questionable cases, I usually recommend admit. If they want to stay in a locked room, why not? I see how it could be different if there were limited beds and people filled them up, but we usually have space so in they go. Then again it is not an actual inpatient unit, and so it is more like solitary confinement which acts as a deterrent. We actually have more problem getting people to stay there who need to while they are waiting for a real bed across the state somewhere.

 

[thoffen]

At our ED malingering is actually pretty low which is probably a function of being in such a small rural community. When we do have questionable cases, I usually recommend admit. If they want to stay in a locked room, why not? I see how it could be different if there were limited beds and people filled them up, but we usually have space so in they go. Then again it is not an actual inpatient unit, and so it is more like solitary confinement which acts as a deterrent. We actually have more problem getting people to stay there who need to while they are waiting for a real bed across the state somewhere.

Yeah. There's a lot of value in thinking, "well I think you're FOS, but even still that means there's something seriously wrong going in your life that you'd rather be in a psych ED/hospital. Let's try to explore that". If you can build an alliance to figuring out someone's dysfunction and reason for pursuing gain, you might be able to help them.

 

[thoffen]

Depressed resignation or gained agreement?

Not sure of the word for word response, but it wasn't depressed resignation. He might have apologized or otherwise said OK and talked about something real going on. I brought him a sandwich, then we chatted on what we had identified the real needs were (homelessness, getting back to a different city where he had support, interpersonal conflicts with family), and I offered for him to speak to the SW before d/c. There wasn't any hostility.

 

[MacDonaldTriad]

One out of three doesn’t seem too far-fetched to me. It depends upon how involuntary hold happy the providers are in your community. The more separation there is between the inpatient and the outpatient providers, the lower the admission rate should be. If you have no motivation to manage your risk, you let someone else make the difficult choices. If you admit more than half the people who show up asking for meals a shower and a clean bed to sleep in, you are discharging a lot of people who didn’t benefit from your intervention. A year, a month, a week, or even a day later, it would be hard to tell if someone was treated as an inpatient or not in many of these cases.

“Out of the thousands of homeless people who need to shower and wash their clothes, you are bringing this gentleman to us today and not yesterday or tomorrow exactly why?”

 

[Bartelby]

I have encountered plenty of these patients, and except in the case of intellectual disability most of them learn how to put on an effective show (crying, appearing distressed, saying the right things to raise red flags, etc.). I think it is also likely that some are both malingering and experiencing significant mental distress. My approach has been roughly as follows:

-If they are new to the emergency room I have a high threshold for "calling their bluff." I don't know them, and while there might be red flags you have to ask yourself whether you have enough time to collect outside records, contact multiple sources of collateral, observe the patient's behavior over time and in response to different things (discussions of discharge, denial of abusable medications, behavior in the inpatient milieu) sufficiently to be sure about malingering. Often the answer is no. Admitting them to the inpatient unit for further evaluation while noting that malingering remains on the differential is, in my opinion, appropriate. The inpatient doctor then needs to continue the evaluation: gather collateral, observe behavior on the unit, etc. The patient may may brighten up right after admission, or admit/boast that they were lying to the doctor in the ER, or manipulate in an antisocial way, try to trade their meds with other patients, or have friends sneak drugs onto the unit, etc (all of which I've seen). The inpatient doctor can then make a more firm determination of malingering and discharge the patient after doing due diligence. When the inpatient physician instead simply applies a diagnosis, starts a medication, and fails to document any of the suspect behaviors exhibited on the inpatient unit that is their failing, and worth taking up with them because it really muddies the waters.

But in short, I don't try to run an inpatient unit in the ER. If collecting adequate data would take hours I admit. That's a legitimate use of admission in my book.

-If they are well known (which is often the case) I look at what collateral we already have, how the patient has responded to past admissions and interventions, what their claims usually are, whether those claims fit the pattern of known mental illness, etc. I also contact treaters or people who know them well if available. In short a risk assessment. Depending on the case if I have some doubt I might refer to a partial hospital program or other non-inpatient level of care, documenting all of the harms (which often go unmentioned) of continuing a cycle of repetitive hospitalizations. A PHP removes a lot of the secondary gain of hospitalization, especially if it is just for a bed and meals, but allows for those who genuinely seek help to obtain it. If it is clear after careful evaluation that the patient is simply malingering I will discharge them from the emergency room, assisted by security if necessary. As has been mentioned above stewarding the scant resources available is extremely important.

That said, I think these patients (and the legal concerns surrounding them) are some of the toughest evals to come through the emergency room. Unfortunately all of the incentives for the ER psychiatrist line up behind just admitting them and making them someone else's problem. It is good to put yourself out there a bit, though, to do what is right clinically.

 

[Merovinge]

If they are new to the emergency room I have a high threshold for "calling their bluff."

I agree with this. I had a pretty high rate of calling out malingers at our VA ED, but my rule was basically if it's anyones first go at psychiatric admission (which is easy to know at a VA with the national record), they get an admission automatically.

 

[MacDonaldTriad]

Automatic admission ER = automatic uselessness. Just my opinion, we need to practice psychiatry out there people. Jesus Christos.

 

[NickNaylor]

We have quite a few malingerers at our county PED. Most of the time they are allowed to stay overnight for observation (I've only worked nights) and are quickly discharged in the morning. A couple of patients well-known to the PED have earned a reputation of being too difficult to discharge until "they're ready" (requiring police escorts/security to drag them out, immediately returning back to the ED as soon as they leave the hospital, etc.) and so they end up staying a few days. One woman who has been coming to the PED for years stayed for 3-4 days even though she is a known malingerer, gets next to no actual medical care while in the PES, and does almost nothing but eat sack lunches and sleep.

I do wish the attendings were a bit more aggressive in dealing with malingerers in some cases. There are many patients who are well-known to the PED, don't have a MSE that is congruent with their complaints, and have clear secondary gain yet aren't discharged and are allowed to linger on the unit. I understand the liability issue, but sometimes the cases are so clear cut that I can't tell if I'm just missing something or if the attendings don't have the cajones to discharge someone with a malingering diagnosis.

A couple of the attendings do have minimal tolerance for malingering, and when the case is clear they will be assessed, collateral called, and assuming everything lines up immediately discharged. However that doesn't seem to be the rule but rather the exception.

 

[Bartelby]

... couple of patients well-known to the PED have earned a reputation of being too difficult to discharge until "they're ready" (requiring police escorts/security to drag them out, immediately returning back to the ED as soon as they leave the hospital, etc.) and so they end up staying a few days. One woman who has been coming to the PED for years stayed for 3-4 days even though she is a known malingerer, gets next to no actual medical care while in the PES, and does almost nothing but eat sack lunches and sleep.

I do wish the attendings were a bit more aggressive in dealing with malingerers in some cases. There are many patients who are well-known to the PED, don't have a MSE that is congruent with their complaints, and have clear secondary gain yet aren't discharged and are allowed to linger on the unit. I understand the liability issue, but sometimes the cases are so clear cut that I can't tell if I'm just missing something or if the attendings don't have the cajones to discharge someone with a malingering diagnosis.

And the liability issue here is more complicated than administrative discharge = risky and keep them for a while = risk free. If the patients are known malingerers then are they kept and "cared for" under a diagnosis of malingering? I presume not, which means they are probably there under "r/o bipolar" or "r/o depression versus SIMD" or something similar. That allows for them to stay, but it's hard to have it both ways. You can't describe the patient as bipolar when you want to avoid confrontation and then suddenly say they're not as soon as they agree to leave the ER.

I think that when it's clear the best option is diagnosing malingering and forcing them out with security. A several day stay will likely just create documentation that undermines the clinician's assessment of the situation, not to mention encourage the behavior to continue (creating more headaches for everyone).

 

[NickNaylor]

And the liability issue here is more complicated than administrative discharge = risky and keep them for a while = risk free. If the patients are known malingerers then are they kept and "cared for" under a diagnosis of malingering? I presume not, which means they are probably there under "r/o bipolar" or "r/o depression versus SIMD" or something similar. That allows for them to stay, but it's hard to have it both ways. You can't describe the patient as bipolar when you want to avoid confrontation and then suddenly say they're not as soon as they agree to leave the ER.

I think that when it's clear the best option is diagnosing malingering and forcing them out with security. A several day stay will likely just create documentation that undermines the clinician's assessment of the situation, not to mention encourage the behavior to continue (creating more headaches for everyone).

In some cases there is a legitimate alternate diagnosis being considered, but in some cases there isn't and the diagnosis of malingering is well known. The plan ultimately amounts to "observe for respite."

 

[Merovinge]

Automatic admission ER = automatic uselessness. Just my opinion, we need to practice psychiatry out there people. Jesus Christos.

Automatic for anyone coming into the ED requesting one who has never done so before. Obviously they get a full assessment, but when you are seeing 5-10 folks for admission/shift, several of which are cocaine + and threatening your life, it became very helpful for me to mentally separate the (quite rare) newcomer and the guy who has over 200 admissions. Sometimes folks who are new to needing the help don't know what to say, and if you are doing poorly enough to want to be at a VA psych inpt unit, I have certainly found everyone deserves that chance.

 

[Guyton]

Perhaps the emergency department is not the most appropriate context in which to address malingering. Although malingering may affect the diagnosis, course, and treatment of a patient’s mental disorder, it is not in itself a mental disorder. It is a circumstance. As with any circumstance, the physician is obligated to understand its interplay with illness and maintain an index of suspicion regarding its presence. These suspicions should be aroused when there are clear external incentives in play, when there are marked discrepancies between claims and the objective findings, when there is blatant lack of cooperation, or in the presence of documented antisocial personality disorder. However, these are not subtle criteria. The treating psychiatrist should not take the demeanor of a district attorney on cross examination nor employ the techniques of a private investigator to reveal them. There is a specialty in psychiatry for that sort of thing- forensics. After all, someone needs to "bust" the lying malcontents out there angling for a ham sandwich and safe place to sleep. I proffer that is not the clinician's role, and certainly not the emergency department psychiatrist's role.

 

[smalltownpsych]

Perhaps the emergency department is not the most appropriate context in which to address malingering. Although malingering may affect the diagnosis, course, and treatment of a patient’s mental disorder, it is not in itself a mental disorder. It is a circumstance. As with any circumstance, the physician is obligated to understand its interplay with illness and maintain an index of suspicion regarding its presence. These suspicions should be aroused when there are clear external incentives in play, when there are marked discrepancies between claims and the objective findings, when there is blatant lack of cooperation, or in the presence of documented antisocial personality disorder. However, these are not subtle criteria. The treating psychiatrist should not take the demeanor of a district attorney on cross examination nor employ the techniques of a private investigator to reveal them. There is a specialty in psychiatry for that sort of thing- forensics. After all, someone needs to "bust" the lying malcontents out there angling for a ham sandwich and safe place to sleep. I proffer that is not the clinician's role, and certainly not the emergency department psychiatrist's role.

The main way it becomes our job to sort this out in the ED is when others place pressure on us to do that and then we cave to that pressure. I typically resolve it by communicating my doubts as to the patient's sincerity (mainly because I don't want the other staff to think everyone in psych is as foolish as they think we are) and then state the reasons that I will recommend admission anyway.

 

[Guyton]

The main way it becomes our job to sort this out in the ED is when others place pressure on us

Agreed! I find these consults to be real softballs though .... right up there with delirium secondary to UTI. One of my favorite chief complaints was, "The cop told me I had to come in to the hospital or go to jail." Well, off you go. I do not hesitate to discharge with a malingering diagnosis if I detect false or grossly exaggerated symptoms motivated by external incentives. However, I do not put my super sleuth hat on and start ordering CSI diagnostics to look for it. The patient, no matter the vicissitudes that brought them in, is not my adversary. Maybe I am the fool, but I feel I stand on good precedent.

"The fool will go take care of the madman." Shakespeare. Twelfth Night. Act I, Scene 5.

 

[splik]

there seem to be a number of misconceptions reinforced here - which I have discussed in a previous thread.

1. malingering is NOT a diagnosis. you do not make a diagnosis of malingering.
2. more likely than not the patient will have a diagnosis of psychiatric disorder. It may be a personality disorder or substance use disorder, but patients with schizophrenia and bipolar disorder also malinger too
3. It is a mistake categorically document that a patient is simply malingering. You aren't doing symptom validity testing and the like in the emergency room so you are unlikely to be thoroughly assessment of malingering. Your job is to rule out psychiatric illness necessitating hospitalization, not rule in malingering (which are separate things - malingering is not a diagnosis of exclusion). It is best to document "Although the possibility of a bipolar disorder (or whatever dx) cannot be excluded, there is no evidence of symptoms of mania or depression at the time of evaluation" for example
4. it is unhelpful, unproductive, and a recipe for disaster to "try to get the goods" on patients by trying to play detective and catch them out. Instead, you should approach how you are going to help the patient. Malingerers in the ER are typically attempting avoid an aversive situation (i.e. being killed by a drug dealer, evading the police, avoid freezing in the cold) and are doing so out of desperation. Things will go much more smoothly and you will become less jaded if you try to work collaboratively with the patient and see how you can help them rather than focusing on how you can't. Some malingerers are deeply unpleasant people, but malingering is an adaptive behavior used to weather an intolerable situation. People don't malinger for the fun of it.Better (and more satisfying) to help how you can, and own up to what you can't help with.
5. you should consider the presence of malingered symptoms rather than malingered mental illness - is this symptom internally consistent with the rest of the patient's presentation? is this symptom consisted with what has been reported previously by the patient? is this symptom a known symptom of a psychiatric disturbance (for example visual hallucinations in black and white are not known to occur).
6. Rather than using "malingering" to justify why you are not admitting someone you should instead document a mental status examination and risk assessment that describes why hospitalization is not indicated and show that you have weighed the risks and benefits of hospitalization. If there are no benefits to hospitalization, well then you don't admit...
7. Patients who malinger in the ER settings are not usually the brightest sparks - they will usually tell you what the obvious external reward is quite early on.
8. run with your countertransference - a patient that makes you feel scared is at greater risk of violence than a patient who makes you want to laugh in response to their violent ideation. document your countertransference response (without using the word countertransference) as part of your risk assessment. Patients who are genuinely at risk of suicide will make you feel concerned or scared (even if they may be frustrating or hateful help-rejectors), patients who are at risk of violence to others will frighten you or creep you out. Patients who are malingering will make you feel annoyed, roll your eyes, smile, or laugh - basically a response that is incongruent with the complaints the patient has.

 

[nitemagi]

Great post, Splk, except that Malingering is billable, though I agree not clearly a diagnosis (and not a disorder). But at the end of al the basic codes is Z76.5 (ICD-10 code).

 

[Guyton]

1. malingering is NOT a diagnosis. you do not make a diagnosis of malingering.

At the risk of pedantry, I would say malingering is a diagnosis, albeit not a medical diagnosis. Such diagnosis of circumstance, i.e. history of fall (Z91.81), is used to describe conditions of clinical attention. Of course, if the person who fell presents with an injury, one would use the appropriate medical diagnosis. However, not all persons who fall and present to the emergency department are injured. Indeed, I might discharge such a person with both a Z91.81 and Z76.5 diagnosis, depending on how disproportionate there symptomatic complaints are related to objective findings. This is especially the case when my examination interrupts their phone call with a personal injury attorney... which has happened.

 

[Nasrudin]

I sometimes find it useful to meet feigned distress with feigned concern. Particularly with the creepy sort. It's harder for their brittle ego defense to spur them to violence when you are performing a serious intent to help.

I've seen the conflict/Gotcha! oriented encounter go badly with other clinicians and that puts everyone at risk.

Plus when you elicit a less guarded accounting of their complaints they tend to reveal their inconsistencies more readily. Like with Splik's black and white hallucination. In some cases I've suggested all sorts of nonsense phenomenon with serious furrowed brow and let them wildly endorse ridiculous and contradictory sx. Then you can ask them how they cope with these symptoms and such and sometimes they forget all about being suicidal.

The hold and wait move is always a good one if you have the space. It's miraculous how a couple hours of sleep and a meal cures most people.

 

[Doctor Bagel]

Automatic for anyone coming into the ED requesting one who has never done so before. Obviously they get a full assessment, but when you are seeing 5-10 folks for admission/shift, several of which are cocaine + and threatening your life, it became very helpful for me to mentally separate the (quite rare) newcomer and the guy who has over 200 admissions. Sometimes folks who are new to needing the help don't know what to say, and if you are doing poorly enough to want to be at a VA psych inpt unit, I have certainly found everyone deserves that chance.

If there's not enough time built into the system to do a multi hour assessment, there's not enough time. Admitting versus not admitting does less harm for the patient overall (although there are some situations where recurrent admissions are counter productive), and the main push not to admit is to protect beds and save money. Ultimately it's not one overworked psychiatrist in the EDs responsibility to solve those issues.

 

[HarryMTieboutMD]

Splik's post is right on. Of course these patients can be annoying, and I think to myself, "how am I going to kick this person out" but being confrontational does NOT work (from much personal experience). As Splik said many (if not most) of the patients have personality/substance use disorders (which are usually inextricably linked), so I try and focus on the substance component using MI/basic 12 Step facilitation, etc. Typically, however the patients are pre contemplative, and tend to externalize their problems to psychiatric diagnoses they have been given, while failing to take responsibility for addressing substance issues. I nevertheless give them a lot of resources and document "the patient's substance use disorders are best managed in alternative settings- residential tx center/12 Step program, which do not necessitate inpatient admission. Furthermore admission will reinforce maladaptive behavior". And yes, be aware of counter transference. Some ASPDs can be very charming and pleasant, whereas others will make your blood boil, but do not let this get in the way of your clinical judgment.

While I often think about malingering, I will almost never document it and instead use substance use disorder or personality disorder (given clear longitudinal history) if I can. I will write "strong suspicion for malingering given inconsistency of history and symptoms and clear, secondary gain," but unless the patient directly admits that he/she faked his or her symptoms for a clear secondary gain, or the patient has extensive documentation in our charts with the same behavior, I will hold off on giving him/her the official label.

 

[MacDonaldTriad]

If the culture of your ER is to be so risk avoidant as to admit almost everyone who says they will harm themselves, then no supply of beds will satiate the need. How many beds will meet the needs of such practice of psychiatry? 40, 80, 200? Some systems spend over half of their resources at acute inpatient care and then point to a perceived need for even more beds. Even if you then listened to this reasoning and put in the other half of the funding towards more beds, the ERs would be happy for about a week and a half before they filled all of these and then decided they need more. We face difficult admission vs. no admission decisions all the time because we know that maintaining a funded ambulatory system is better for the greater good and deserves some of our scarce funding. Withholding care to the least ill, yet ill person goes against our nature as helping physicians, but we also have a duty to use our beds judiciously so that the people most likely to benefit from such an intervention have beds when they are needed.

 

[thoffen]

I'll take a different approach from splik, although it's mostly functionally the same recommendation.

1. Malingering is a diagnosis (for the reasons stated above)
2. As splik says, it is likely a comorbid diagnosis rather than standalone (or even primary)
3. Agreed that simply documenting "malingering" as a diagnosis does not do anything for you (understanding patient or liability). Disagree on the focus of documenting with the purpose of excluding symptoms for alternative working diagnosis (e.g. claimed bipolar illness). While good (remarking on absence of pressured speech, flight of ideas, etc.), the emphasis is on decisions that pertain to safety of disposition (essentially, admit v. discharge), in which case specific diagnosis is likely less helpful and may lead you astray from the actual important things to assess
4. Agree that we are not doing interviews like detectives, but this doesn't mean we shouldn't explore things that don't make sense in a story. It's really helpful to get details on things that don't add up, but this is secondary to your alliance with the patient and identifying gain
5. Agree strongly to look for malingered symptoms rather than diagnosis. Actually, more generally, non-malingerers will lie to you plenty of times as well. Essentially, the error is to identify malingering as a unifying diagnosis that drives decision making in totality
6. As per #3, the emphasis is on risk/benefit documentation rather than diagnostic clarity, and this is where your liability lies (not to mention the majority of patient benefit and risk) so focus on that
7. Not sure if they'll tell you the reward up front, but if you focus initially on the alliance and needs rather than the symptoms, things will be more productive (for all patients)
8. Countertransference is good

 

[Doctor Bagel]

If the culture of your ER is to be so risk avoidant as to admit almost everyone who says they will harm themselves, then no supply of beds will satiate the need. How many beds will meet the needs of such practice of psychiatry? 40, 80, 200? Some systems spend over half of their resources at acute inpatient care and then point to a perceived need for even more beds. Even if you then listened to this reasoning and put in the other half of the funding towards more beds, the ERs would be happy for about a week and a half before they filled all of these and then decided they need more. We face difficult admission vs. no admission decisions all the time because we know that maintaining a funded ambulatory system is better for the greater good and deserves some of our scarce funding. Withholding care to the least ill, yet ill person goes against our nature as helping physicians, but we also have a duty to use our beds judiciously so that the people most likely to benefit from such an intervention have beds when they are needed.

Then the system would be best served by hiring enough psychiatrists to adequately do their job, including doing a potentially multi hour type of assessment if needed. If systems don't put that in place (and many don't, at least in my community where psychiatrists in the emergency department are not the norm and if present at night/weekends, they consist of residents covering the entire hospital), then you have to concede that weak admissions are going to be a cost of this. Making an individual psychiatrist feel guilty or inadequate for sometimes erring on the side of admission doesn't solve the problem. When you make posts like this, I start to wonder if you actually do clinical work or function entirely in an administrative role these days.

 

[MacDonaldTriad]

I do get administratively irritated when I see soft admits on wards and sick people in line in the ER. Ward psychiatrists tend not to criticize the decisions made in the ER as much as ER psychiatrists see differences in practice among themselves.

 

[thoffen]

I do get administratively irritated when I see soft admits on wards and sick people in line in the ER. Ward psychiatrists tend not to criticize the decisions made in the ER as much as ER psychiatrists see differences in practice among themselves.

There is truth to that, excepting unsafe patient or incomplete medical workup. I imagine people in the wards prefer cleaning up messes to risking making them, though.

 

[Giovanotto]

As an incoming medical student with an interest in both psych and EM, I found this thread very informative! Is an ER psychiatrist a thing? Is that a fellowship after psychiatry training?