Malingering: when will you put your foot down?

[whopper]

(I accidently put this in the wrong thread, I had intended to put it in its own thread).

I am very frustrated with the lack of orthodox and conventional guidelines written for this subject.

And the lack of orthrodoxy leads several docs to disagree on what to do, and that lack of agreement makes it difficult to take appropriate action.

What do you do with a patient where there is strong suspicion of malingering? E.g. a homeless patient who goes to an expensive hotel, gets the most expensive services, then when told to pay pulls the suicide threat and actually cuts themself. That patient is then brought to the ER, gets out of paying the bill (all the while has a smile on his face), goes to the hospital, is observed for several days, is discharged, the hospital psychiatrist slaps the patient with a depression label for billing purposes (the hospital makes no money with a malingering diagnosis), even though that psychiatrist doesn't believe the patient is depressed, then the patient simply repeats the behavior.

So now, you're the ER psychiatrist and being that your colleague now slapped a depression diagnosis. and being that this patient is actually willing cut themself to continue this lifestyle, are you going to confront the patient, being that the patient will cut themself, and refuse to continue the erroneous depression diagnosis on the patient's record?--> and under such circumstances, managed care will not pay for inpatient treatment for malingering. Or are you going to refuse this patient from gaining admission to the hospital, write in the record that this is malingering--risking the patient cutting himself, which in turn will get the hospital upset at you, then force the patient back to the ER, where you'll have a very upset ER attending, or do you just continue the faulty diagnosis because then it'll get the patient into the inpatient unit of the hospital, then it's now someone else's problem?

When should psychiatrists put their foot down? Why will no one openly discuss this issue?

Why for example isn't there an established standard of care to address this issue (at least as far as I know), especially for patients who are openly practicing malingering in a fraudulent manner.

I asked several of my attending doctors what should I do in this situation. Unfortunately all gave me a different answer, making me believe there is no established standard of care on this risky diagnosis. Further, Kaplan & Saddock doesn't provide any definitive guidelines either.

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[fiatslug]

the more time I spend in the ER, the more confident I get, and the more likely I am to call BS on an obvious malingerer. We have one who comes in nearly weekly--he is legendary--says "I'm going to kill the mayor," but can't identify the mayor (hello, it's Gavin Newsom--the hottest most famous mayor ever! 😛 ), or states he's suicidal, and has absolutely no history of ANY kind of self harm--I call him "the crack addict who cried wolf." He comes in when he can't get EtOH or crack, is happy to get a little Seroquel or anything else, and gets d/c'd the next day. After doing this with this pt twice, and confirming his utter lack of credulity with his case manager, I refused to see him--twice--when paged by the ED (all the ED docs with huevos would d/c him without calling psych, but a few well-known "dispo dumpers" always try to get psych to see these guys). He is truly notorious in this city. It's always easier to d/c a malingerer when you have history--when they're new to you, it's harder to do (but I still do it if I think they're full of crap!). Once they know you're on to them, it gets easier to talk them out of their DTO/DTS claims. Document, document, document!

 

[Poety]

Hi Whopper,

I think that a lot of malingering is definitely on the axis 2 spectrum - and unfortunately, although they may not have any intention to harm themselves, with just the threat we have to take it seriously. God forbid, that one time we call them out and d/c they go ahead and hurt themselves. Guess who is liable? UGG. I think a lot of the frustration arises from knowing these people are playing the system - and they're everywhere.

I agree that it would be nice to have a guideline to follow, the problem would be using that guideline for the right patient. I know in certain urban areas, people would be instituting it non-stop (or in rural communities as well where there's a high incidence of addiction)

I've spoken with some attendings about this as well, and one made a good point when he explained that although they may be malingering, they DO have an addiction issue which may be something to consider when you really don't want to admit them, but you know you have to. Personally (and everyone here knows it) I'm not fond of addictions, I'm all about tough love, but professionally, this illness has to be treated just as seriously as our Bipolar or schizophrenics.

I probably didn't add much to this thread, but I wanted you to know, I feel your pain 😉

 

[whopper]

Replies to above

"happy to get a little Seroquel or anything else"

I don't know if you knew this but Seroquel has a strong abuse potential. I don't know about California, but on the east coast, there is a strong street value for it. I get several patients requesting it, and I won't give it to them because I can tell they want it for the wrong reasons.

While Seroquel in and of itself isn't addictive, when mixed with opiates, it heightens & prolongs the high. People on the street nicknamed it the "quel" or "sleeping with Sara". If you don't believe me, its well documented in Kaplan & Saddock that antihistamines when mixed with opioids cause this effect, and we all know that Seroquel's strongest effect is antihistaminic.

Strangely, the drug abusing population don't know its the antihistamine, or else they'd just get benadryl OTC. They believe its something with Seroquel, and it makes sense to them because Seroquel is a psychotropic.

I also don't like to give it to homeless people because when we discharge patients to the rescue mission on Seroquel, they either immediately sell it or other people at the mission steal it from people who want to legitimately use it.

There are several other choices, so why give it? Another thing is strangely, several of my attendings don't know this, which bugs the heck out of me--several give it out like its candy, and when I tell them about it they pull this "I know more than you" attitude.


"I think that a lot of malingering is definitely on the axis 2 spectrum - and unfortunately, although they may not have any intention to harm themselves, with just the threat we have to take it seriously"


If you read the Kaplan & Saddock Comprehensive text on this, malingering is often associated with borderline personality d/o & antisocial personality d/o. The section in the comprehensive text is phenomenally well done, although it doesn't provide a concise way on how to handle the problem, and it seems to me no one will touch the issue with a 10 foot pole for fear of liability.

Anyways, there's this one malingerer who often shows up at my own hospital-in Atlantic City. When he's worn out his welcome, he goes to the hospitals in Camden, then when he wears out his welcome there, he ends up in hospitals in Philadelphia. It took me about 1 year to figure it out, because there were times I visited buddies at other hospitals, and I'd see this guy over there. He spends about 4 days a week, 52 weeks a year in the hospital, and when he wears out his welcome, he just goes to the next one, and the next one is willing to take him because they hadn't seen him for several months and they don't keep tabs with the other hospitals.

When hospital costs are about $1500 a day, well you do the math.

Consdering all the hurrumph going on with waste in the system, litigation, etc, I'm surprised no one will take a more open and vocal approach to malingering, especially since this problem is prevalent in urban areas. I can tell you, just at the hospital I work at, its probably costing the system at least a few million a year.

 

[Psyclops]

I'm quite familiar with the malingering patient, in fact I may even knw some of your malingering patients whopper, but I agree it poses an interesting problem. Even instituting guidelines or SOC for when to deny treatment is easier said then done. I think this is because, there will always be that doubt about the judgement call. Until we become more reliable at giving out valid diagnoses this will continue to be an issue. But even then we would need to be more reliable at predicting specific future behavior, something that we in the mental health field aren't that good at, surprising or not.

I will say that nothing will turn you into a republican faster tahn working psych intake. Be it ER or crisis line, you will run into some of the most demanding and entitled people around, refusing to take responsibility for anything, or even give an inch to help themselves.

In the end it is easy to deny a malingerer who is not suicidal. But the suicidal aspect is what makes it difficult (or homicidal). You know the legal system has dealt with this problem. They are willing to have experts come in and debate the issue, and allow a panel of 12 uninformed people make the decision.

Also, psych testing is manytimes set up by the insurance companies to detrmine if someone is malingering or not.

 

[fiatslug]

Yeah, they love their Seroquel on the West Coast too--I'm sure they'd rather take it intranasally if they could!

 

[Anasazi23]

Yeah, they love their Seroquel on the West Coast too--I'm sure they'd rather take it intranasally if they could!

They already do. They crush it and sniff it off a spoon.

 

[Poety]

They already do. They crush it and sniff it off a spoon.

What will they think of next ? 😕 🙄

They could always shoot I guess 😱 🙄

I wonder wy its off a spoon they sniff it, why not just make a line like they do with that cocaine.

 

[Anasazi23]

What will they think of next ? 😕 🙄

They could always shoot I guess 😱 🙄

I wonder wy its off a spoon they sniff it, why not just make a line like they do with that cocaine.

I think they heat it and it gets liquifies to some degree, and the spoon hold the residual for their little noses.

 

[Poety]

I think they heat it and it gets liquifies to some degree, and the spoon hold the residual for their little noses.

They snort a liquid? GROSS. I'm sure there'll be some other odd medical side effect of doing that. I've seen cocaine addicts come in with their septums deteriorated, not a pretty sight. And the constant sniffling and drizzling of the nose - oy!

 

[Psyclops]

I'm familiar with crushing it and snorting it (unliquified). This process is genearally refered to as "bumping" it. At least around my area.

 

[Poety]

I'm familiar with crushing it and snorting it (unliquified). This process is genearally refered to as "bumping" it. At least around my area.

I've heard of the kids 'bumping K' which is ketamine - I thought ketamine was a liquid - so go figure, maybe they make it a powder or something? Its a big "rave" thing to do - I always loved seeing the kids OD on it right in front of me, talk about killing the entire night. One girl even vomited on me, and that was it for me. Luckily I got to see Paul Oakenfold that one last time <sigh> before calling it quits, but Poety doesn't DO getting vomited on 😡

 

[Doc Samson]

I've heard of the kids 'bumping K' which is ketamine - I thought ketamine was a liquid - so go figure, maybe they make it a powder or something? Its a big "rave" thing to do - I always loved seeing the kids OD on it right in front of me, talk about killing the entire night. One girl even vomited on me, and that was it for me. Luckily I got to see Paul Oakenfold that one last time <sigh> before calling it quits, but Poety doesn't DO getting vomited on 😡

Pharmaceutical ketamine is a liquid. They gently heat it so that the solvent evaporates, concentrating the drug in crystalline form, which is subsequently ground up and snorted.

 

[Poety]

Pharmaceutical ketamine is a liquid. They gently heat it so that the solvent evaporates, concentrating the drug in crystalline form, which is subsequently ground up and snorted.

Thanks DS, I've only seen it at my vets office. I couldn't believe these kids are snorting it. Craziness, absolute craziness.

 

[HiToday]

The hotel bill is not the doctors problem. It is up to the hotel to sue or file criminal charges against the person for larceny etc. The doctor does not know that this is not happening since it could happen several weeks or even years later. If the hotel gets ripped off like this it is their own fault for giving a key to a room without either a credit card or payment up front and not pursuing charges against the thief when this occurs. Most hotels routinely request a credit card before booking a room.

Suicide and self harm are not always the result of mental illness and are not psychiatric issues when not the result of mental illness. Suicide is a constitutional right. If a person is seeking to be in a place as harmful, dangerous, and unsafe as a hospital he is mentally ill. If he is suicidal or desires to harm himself a few days is not going to make any difference.

If you do not address his issues but put him in a hospital for a few days then discharge him to the street you are not helping him, the issues still remain and thus it is no wonder there is a repeat revolving door.

You dont say if how severe the cuts are. If they are serious he might need medical attention for the cuts. If this person has insurance and is a malingerer, sooner or later the insurance company will catch on when they see repeated bills of this nature.

Be sure to document, document, document everything which corroborates malingering. Malingering is fraud not a mental illness.

Do not engage in insurance fraud. If he is a malingerer put it in the record.

Any normal person would be depressed if they do not have a home. This person has a genuine problem with genuine pain, your job is to relieve the pain. This person must be very desperate if he is cutting himself for attention. If you ignore it he may try something more extreme. This person needs help, help finding a home. If he ends up in your emergency room provide him a safe place to sleep where he is free to leave and provide him social services to help him get a home.

(I accidently put this in the wrong thread, I had intended to put it in its own thread).

I am very frustrated with the lack of orthodox and conventional guidelines written for this subject.

And the lack of orthrodoxy leads several docs to disagree on what to do, and that lack of agreement makes it difficult to take appropriate action.

What do you do with a patient where there is strong suspicion of malingering? E.g. a homeless patient who goes to an expensive hotel, gets the most expensive services, then when told to pay pulls the suicide threat and actually cuts themself. That patient is then brought to the ER, gets out of paying the bill (all the while has a smile on his face), goes to the hospital, is observed for several days, is discharged, the hospital psychiatrist slaps the patient with a depression label for billing purposes (the hospital makes no money with a malingering diagnosis), even though that psychiatrist doesn't believe the patient is depressed, then the patient simply repeats the behavior.

So now, you're the ER psychiatrist and being that your colleague now slapped a depression diagnosis. and being that this patient is actually willing cut themself to continue this lifestyle, are you going to confront the patient, being that the patient will cut themself, and refuse to continue the erroneous depression diagnosis on the patient's record?--> and under such circumstances, managed care will not pay for inpatient treatment for malingering. Or are you going to refuse this patient from gaining admission to the hospital, write in the record that this is malingering--risking the patient cutting himself, which in turn will get the hospital upset at you, then force the patient back to the ER, where you'll have a very upset ER attending, or do you just continue the faulty diagnosis because then it'll get the patient into the inpatient unit of the hospital, then it's now someone else's problem?

When should psychiatrists put their foot down? Why will no one openly discuss this issue?

Why for example isn't there an established standard of care to address this issue (at least as far as I know), especially for patients who are openly practicing malingering in a fraudulent manner.

I asked several of my attending doctors what should I do in this situation. Unfortunately all gave me a different answer, making me believe there is no established standard of care on this risky diagnosis. Further, Kaplan & Saddock doesn't provide any definitive guidelines either.

 

[whopper]

Hitoday

Thanks for your remarks, and thanks to everyone else.

I'm frustrated over this issue, and I'm getting the impression that perhaps this is more of a departmental problem than something I can really tackle myself. Several of the attendings will not be on the same page on this issue and will not mutually agree on a manner to handle this problem. Several of them are willing to do the "dump" on the other.

Being that I work with all the attendings, and several of the attendings only see each other every few months during a departmental meeting, I am now kinda in the middle of the battle between differing philosophies on how to handle the malingerers.

Its frustrating. What makes it worse is IMHO several of the attendings are choosing their choices soley on avoiding liability and are dumping the problem on the next doctor. Heck if the attending actually believed they were doing right I'd be able to take it with no problem.

 

[Anasazi23]

I put the foot down this weekend.

See post in "On-Call Diaries"