Malingering

[sujalneuro]

I often see agitated patients (drug users)who are intubated due to extreme agitation. To avoid jail time they usually tell me that they are suicidal. They have some remote history of seeing psychiatrists being diagnosed bipolar etc but no inpatient treatments. Any suggestions how to document this malingering, and avoid involuntary commitment?

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[whopper]

hey have some remote history of seeing psychiatrists being diagnosed bipolar etc but no inpatient treatments. Any suggestions how to document this malingering, and avoid involuntary commitment?

If this is going on where you are being trained it's likely been going on for years and will go on after you leave. Point is that this is an issue that if not already well address at your training location it might not be well-addressed for quite some time. This will have to be attending-dependent. The people running the place will have to be open to the changes. You could try to make a change but it really is up to them.

First, a psychiatric diagnosis of Bipolar Disorder with someone on drugs is likely not going to be accurate unless you have very good history of how that person was while sober off of drugs for at least months. Someone coming in on meth or cocaine acting manic-you can't diagnose them with Bipolar Disorder given that these substances when used cause behaviors identical to mania, in fact there's a lot of data showing what they do to the brain mimics mania.

But nonetheless a lot of lesser quality doctors are fine with misdiagnosing. I certainly hope this is not the case where you're at but I'd be lying if I said this is rare in psychiatry. 40% of people diagnosed with Bipolar Disorder don't have it.

If someone is claiming to be suicidal, you observe them. If you can't rule it out during the 24 hour period in the ER they will likely have to be admitted and if so it's up to the inpatient unit to catch malingering. There's only so much you can do in 24 hours. If it's caught they can document so if the guy ever shows up again you already have good data on this guy.

While I was at U of Cincinnati their ER and inpatient units were set up well for this. Hardly anyone got away with something more than once. Once we got a guy we knew forever if he were to show up to the ER again he'd be under intense scrutiny.

But where I did my training in South NJ many of the doctors put up "Bipolar Disorder" without even believing they had it. So when they showed up in the ER, now you got a document written by your colleague or superior putting up a diagnosis that's going to fly against you. Several of the attendings were aware of this problem but just tolerated it cause they couldn't get the other attendings intentionally messing up to correct their behaviors. It just led to further problems with lots of these guys getting a dx of Bipolar Disorder from one doctor then 3 weeks later getting an Adjustment Disorder from another.

What should've happened is the inaccurate attendings should've been fired but the institution couldn't just replace bad doctors easily due to the shortage of psychiatrists. Further certain key people just didn't seem willing to put their foot down. It was a constant irritation to me while I was a resident cause as a resident I'd be committing professional suicide by calling up an attending as incompetent.

There are tools and screens to detect malingering such as the M-FAST but many non-forensic psychiatrists aren't familiar with it nor are willing to take the small amount of time needed to familiarize themselves with it.

A big disappointment to me was at a place where I worked where almost all of my colleagues were allowing malingerers to get away with inpatient stays, I offered to teach all the faculty use of the M-Fast and also invited people to have me consult them for a case if they suspected it despite that it would cost me several more hours a week of work without extra pay.

Guess how many of them took up my offer? ZERO. The residents and medstudents were very curious and very happy and took up my offer very often but the attendings were zero. (I mentioned this in another thread-I left that place).

In hindsight I think this irritation I suffered as a resident was the prime driving force to go into forensic fellowship. Had I had adequate training on the phenomenon in residency my curiosity and drive to deal with this issue would've been sated.

This was one of the reasons why I loved U of Cincinnati. When psychiatrists there saw doctors that knew more than themselves they sought their expertise and took it seriously, while lesser ones would ignore or shrug off an opportunity to learn. It goes to show you the motive the person had to become a doctor-to either be one in the true sense of the word or to just get a higher paying job with better job security.

 

[whopper]

Adding to the above what the department could do is contact the local police departments on improving the understanding of when police officers should drop off people who claim to be suicidal. Also the local jail might also have to be involved. E.g. where I used to work if the patient claimed to be suicidal they often times still sent the patient to jail where a jail psychiatrist checked them out keeping the hospital out of the equation. If the jail psychiatrist really thought the person was suicidal and likely to act then they were sent to the hospital. I can tell you from my experience in doing this about 95% of them were prevented from going to the hospital.

But the improvements that have to go on need to be done by the department and as I mentioned above some are not willing to rise to the occasion. I hope yours is. If not you could try to make it a project and may (just maybe) they will be willing to follow what you come up with. If you do so I recommend you talk to someone high up in your department about making better relations with the local jail and police.

 

[NickNaylor]

If there is clear evidence of secondary gain and their psychiatric history doesn't match their reported diagnosis, that would start to raise red flags for me. As a general rule I find patients' reported diagnoses to be almost entirely unreliable. I find that their medication regimens are more indicative of what their previous provider actually thought was going on than whatever their listed diagnosis is. It's difficult to make the diagnosis on an initial visit unless the patient openly admits what they're in the hospital for (e.g., "I need a place to live," "it's cold outside," "I need a case manager"), but once you have a recurrent pattern of behavior it's easier to feel more confident in applying the malingering label.

We also have the additional problem of our local CMHCs only being able to receive reimbursement for certain diagnoses; namely, MDD, schizophrenia/schizoaffective disorder, and bipolar disorder. This results in many people that have had contact with this system carrying diagnoses of "schizophrenia" or "bipolar disorder" - or my favorite, "bipolar schizophrenic" - that are clearly not accurate after spending 10 minutes with the patient. I particularly enjoy the people that are "bipolar" but on bupropion monotherapy.

 

[tr]

I often see agitated patients (drug users)who are intubated due to extreme agitation. To avoid jail time they usually tell me that they are suicidal. They have some remote history of seeing psychiatrists being diagnosed bipolar etc but no inpatient treatments. Any suggestions how to document this malingering, and avoid involuntary commitment?

Intubated for extreme agitation?? What kind of hospital do you work at??

 

[WisNeuro]

Intubated for extreme agitation?? What kind of hospital do you work at??

 

[whopper]

I particularly enjoy the people that are "bipolar" but on bupropion monotherapy.

Or more like (not) enjoy the idiot physician that put the patient on that treatment.

 

[nexus73]

Ever had a malingering patient with medicare protest their discharge through medicare, thus delaying the entire process several days?

 

[whopper]

Yes. From what I recall, cause I've been out of hospital work for about 3 years, you then are required to keep the person 3 days.

In which case I do very good care. I mean very good care. E.g. no benzos, not enabling anything a malingerer would want. Person is overweight? A low calorie diabetic, low-salt diet. (which by the way should be done anyway on someone with metabolic problems).

 

[thoffen]

To the OPs question, your job is to assess suicide risk and determine level of care. Prior psych history and current diagnosis are relevant here, but if you can't really affirm them, you don't have to. So to document you have to do a risk assessment, document their gain, document their speech, behavior, affect, etc. that are incongruent with suicide, gain collateral, and observe long enough to be confident in your assessment. Sometimes you hospitalize someone you think is malingering because you can't get enough info to feel safe with a discharge. Nothing wrong with that. If you carefully document your thinking and don't carelessly slap diagnoses on you think are incorrect, you'll be doing a service to the next person.

 

[Onions]

Intubated for extreme agitation?? What kind of hospital do you work at??

A particularly memorable conversation I once had:

Me: Psychiatry, returning a page?
PICU resident: Yes, we have a 17 year old male, brought in by police, apparently he did a bunch of acid or something. He was really agitated and needed 4 cops just to keep him under control. We were wondering if you can give recs for agitation?
Me: Where is the patient and how is he doing now?
PR: He's intubated, on vecuronium and midazolam.
Me: Why is he intubated?
PR: Because he's on vecuronium and midazolam.
Me: Why is he on vecuronium and midazolam?
PR: Because he was agitated.
Me: Recs for agitation...I mean it sounds like you guys have it pretty well under control...

When my attending found out about that next morning he was like "why didn't they just shoot him?"

 

[FatherPsychiatry]

A particularly memorable conversation I once had:

Me: Psychiatry, returning a page?
PICU resident: Yes, we have a 17 year old male, brought in by police, apparently he did a bunch of acid or something. He was really agitated and needed 4 cops just to keep him under control. We were wondering if you can give recs for agitation?
Me: Where is the patient and how is he doing now?
PR: He's intubated, on vecuronium and midazolam.
Me: Why is he intubated?
PR: Because he's on vecuronium and midazolam.
Me: Why is he on vecuronium and midazolam?
PR: Because he was agitated.
Me: Recs for agitation...I mean it sounds like you guys have it pretty well under control...

When my attending found out about that next morning he was like "why didn't they just shoot him?"

I like your attending

 

[NickNaylor]

A particularly memorable conversation I once had:

Me: Psychiatry, returning a page?
PICU resident: Yes, we have a 17 year old male, brought in by police, apparently he did a bunch of acid or something. He was really agitated and needed 4 cops just to keep him under control. We were wondering if you can give recs for agitation?
Me: Where is the patient and how is he doing now?
PR: He's intubated, on vecuronium and midazolam.
Me: Why is he intubated?
PR: Because he's on vecuronium and midazolam.
Me: Why is he on vecuronium and midazolam?
PR: Because he was agitated.
Me: Recs for agitation...I mean it sounds like you guys have it pretty well under control...

When my attending found out about that next morning he was like "why didn't they just shoot him?"

I once saw a young adolescent in our medical ED get 30+ mg of lorazepam over a 24-hour period (!!!) for “agitation.”

Sometimes I appreciate the approach of our medical colleagues to behavioral issues.

 

[thoffen]

I once saw a young adolescent in our medical ED get 30+ mg of lorazepam over a 24-hour period (!!!) for “agitation.”

Sometimes I appreciate the approach of our medical colleagues to behavioral issues.

It's a strategy to reduce liability. Can't sue for malpractice if you don't remember being in the hospital...

 

[EBKTayK]

I offered to teach all the faculty use of the M-Fast and also invited people to have me consult them for a case if they suspected it despite that it would cost me several more hours a week of work without extra pay.

Guess how many of them took up my offer? ZERO. The residents and medstudents were very curious and very happy and took up my offer very often but the attendings were zero. (I mentioned this in another thread-I left that place).

That's disappointing, I honestly wish I had an attending willing to teach me the M-fast and other tools to detect malingering, only one's I've ever been taught are the tuning fork on the head with midline loss of sensation, dropping the arm on the head for pseudoseizures, Hoover test and any of the other "google-able" ones. Some people don't realize a good opportunity

Intubated for extreme agitation?? What kind of hospital do you work at??

I believe the theory behind it is that the amount of benzos/haldol you would need to adequately sedate them would likely make them at risk for airway compromise, so it is essentially a "prophylactic" intubation because they "know" that the amount of benzos needed will prevent the patient from protecting their airway.

I am neither a psychiatrist nor an intensivist though, (I just find malingering to be interesting,) so take what I say with a healthy dose of skepticism.

 

[splik]

That's disappointing, I honestly wish I had an attending willing to teach me the M-fast and other tools to detect malingering, only one's I've ever been taught are the tuning fork on the head with midline loss of sensation, dropping the arm on the head for pseudoseizures, Hoover test and any of the other "google-able" ones. Some people don't realize a good opportunity
.

you appear to be confusing FND with malingering.

 

[EBKTayK]

you appear to be confusing FND with malingering.

Fair enough

 

[NontradCA]

At my spot half of the patients come in c/o AH after smoking meth, leave with USSOPD diagnosis and some zyprexa, go out smoke meth til they’re too high and return. Serious question. What do you do with these patients?

 

[NickNaylor]

At my spot half of the patients come in c/o AH after smoking meth, leave with USSOPD diagnosis and some zyprexa, go out smoke meth til they’re too high and return. Serious question. What do you do with these patients?

This describes about 50% of the patients I see in my moonlighting position in our ED. My approach is to keep addressing substance use, give resources for substance treatment, and attempt to minimize positive reinforcement related to repeatedly coming back to the ED: i.e., no bus pass when you leave, no transfers to the psychiatric ED (which usually lengthens the LOS), and discharge as soon as the patient is sufficiently with it.

I can't say that this approach has been particularly effective.

 

[NontradCA]

This describes about 50% of the patients I see in my moonlighting position in our ED. My approach is to keep addressing substance use, give resources for substance treatment, and attempt to minimize positive reinforcement related to repeatedly coming back to the ED: i.e., no bus pass when you leave, no transfers to the psychiatric ED (which usually lengthens the LOS), and discharge as soon as the patient is sufficiently with it.

I can't say that this approach has been particularly effective.

My issue is that we’re admitting all these patients. I really have no say in the matter.

 

[NickNaylor]

My issue is that we’re admitting all these patients. I really have no say in the matter.

That's a slightly more complicated topic. The ED is likely under pressure to keep dwell time as low as possible, thus their motivation is to dispo the patient as quickly as possible. If your hospital doesn't have an alternative placement other than an inpatient unit, they may not agree to allow the patient to hang out until they MTF. I've also had this issue with attendings. Some seem to take a similar position as the ED docs, i.e., just admit them if they're acutely psychotic, even though they will likely improve with a relatively short amount of time of hanging out in the ED. Others are more resistant to doing that and would rather save inpatient beds for patients with non-substance-related presentations.

I should add that there are certainly some cases where inpatient admission for a substance-induced presentation is indicated and appropriate. But in many cases, relatively brief observation can prevent an admission and facilitate direct discharge from the ED.

 

[whopper]

o out smoke meth til they’re too high and return. Serious question. What do you do with these patients?

Not admit them. Discharge them and all the while in the ER they get no food other than pretzels and water.

You could also have them arrested...if that's possible and without violating HIPAA. E.g. if they're getting high on hospital grounds you can get them arrested for loitering.

But tread carefully. There's a very fine line between this and being intentionally rude/mean to someone who you might have unintentionally misdiagnosed.

Just reminded me of a true story.

Patients didn't get hot food in the psych ER. They only got pretzels and water or if they were lucky a sandwich and a really bad one at that. E.g. a slice of ham in between a slice of bread that was machine made and sitting in the fridge for about 10 days. Many of them after being in there hours gave up if they knew they couldn't get better food. One patient I knew was malingering (she came to every ER in town about once a week), demanded BBQ chicken. I handed her a bag of pretzels and she angrily demanded chicken. I told her "these pretzels are soooo goood. Common George Bush eats pretzels. He almost choked on one." She again demanded chicken. "Well ma'am there's a restaurant outside the hospital that could serve you chicken." She then angrily stated she had no money to buy any. I gave her a paper cup and told her she could put it on the ground, dance, and maybe in a few hours there'll be enough money in the cup for chicken. Each time I responded to her I was mindful to not express any anger. She said "a cup that's it?" I told her I'm not allowed to give her any money so that was the best she could come up with, "but maybe someone outside the hospital could come up with some better alternatives."

 

[hamstergang]

I gave her a paper cup and told her she could put it on the ground, dance, and maybe in a few hours there'll be enough money in the cup for chicken.

That seems unnecessarily disrespectful. You could have just told her to leave.

 

[whopper]

Already did.

She refused to leave.

Of course I'm against physicians being disrespectful to patients.

So at that point you either have security violently remove the patient (and I already knew her and knew she would escalate it to this level if we had security simply do their thing), while she's being violent there's a realistic chance she'll need to get injected thus prompting her to stay over 24 hours and then requiring an admission....

Or try to convince her to leave.

I chose this option. The above is written after all the niceties were done. E.g. discharge papers already handed to her and she's refusing to leave. Was the "nice speech" given? Yes it was by more than 3 people.

You could interpret this as sarcasm. It wasn't meant in that way. Seriously, it's down to the level of try to get her out using mental manipulation or violence cause she's not leaving otherwise.

You could of course say, "well you should've been nice."

Oh jeez, I already was...as was her nurse, a security guard, and other staff members for over an hour.

I know you already know this type of thing happens in ERs all the time and when you are nice and do the "nice thing" it doesn't often times work.

In a separate thread I criticized the doctor that refused to give the patient Clonazepam and said some disrespectful things towards him. Reason why I criticize that doctor is 1-she just met that guy for the first time, this particular patient I'm talking about was a well-known malingerer 2-The doctor in the other case started with the confrontation early on, we spent several minutes being nice with our patient and telling her why she needed to leave in a respectful manner, but she refused then gave a threat of giving her chicken or else, 3-she made it clear (and I didn't mention it but it goes without saying given the other data) that she wasn't there for treatment. She was there for free room and board and demanded hot food. This wasn't a hunch. We already had her there for hours, did the due diligence (social worker checked out, she was already well-known to us, did not show any signs of mental illness for several hours in the ER). Of course all the referrals were given to the local homeless shelter in the discharge papers and she was well-aware of them. In fact some of the local shelters kicked her out cause she was a regular trouble-maker there too.

What did eventually happen was I told her that if she didn't leave she could either get security to kick her out, or she could leave with the bag of pretzels.

She chose the latter.

About an hour later we got called by a different ER in town and she was seeking admission over there.

 

[clausewitz2]

That seems unnecessarily disrespectful. You could have just told her to leave.

Also I really hope this patient wasn't black because if she was you dodged being featured on the evening news because of protests being organized demanding your firing.

 

[clausewitz2]

Already did.

She refused to leave.

Of course I'm against physicians being disrespectful to patients.

So at that point you either have security violently remove the patient (and I already knew her and knew she would escalate it to this level if we had security simply do their thing), while she's being violent there's a realistic chance she'll need to get injected thus prompting her to stay over 24 hours and then requiring an admission....

Or try to convince her to leave.

I chose this option. The above is written after all the niceties were done. E.g. discharge papers already handed to her and she's refusing to leave. Was the "nice speech" given? Yes it was by more than 3 people.

You could interpret this as sarcasm. It wasn't meant in that way. Seriously, it's down to the level of try to get her out using mental manipulation or violence cause she's not leaving otherwise.

You could of course say, "well you should've been nice."

Oh jeez, I already was...as was her nurse, a security guard, and other staff members for over an hour.

I know you already know this type of thing happens in ERs all the time and when you are nice and do the "nice thing" it doesn't often times work.

In a separate thread I criticized the doctor that refused to give the patient Clonazepam and said some disrespectful things towards him. Reason why I criticize that doctor is 1-she just met that guy for the first time, this particular patient I'm talking about was a well-known malingerer 2-The doctor in the other case started with the confrontation early on, we spent several minutes being nice with our patient and telling her why she needed to leave in a respectful manner, but she refused then gave a threat of giving her chicken or else, 3-she made it clear (and I didn't mention it but it goes without saying given the other data) that she wasn't there for treatment. She was there for free room and board and demanded hot food. This wasn't a hunch. We already had her there for hours, did the due diligence (social worker checked out, she was already well-known to us, did not show any signs of mental illness for several hours in the ER). Of course all the referrals were given to the local homeless shelter in the discharge papers and she was well-aware of them. In fact some of the local shelters kicked her out cause she was a regular trouble-maker there too.

What did eventually happen was I told her that if she didn't leave she could either get security to kick her out, or she could leave with the bag of pretzels.

She chose the latter.

About an hour later we got called by a different ER in town and she was seeking admission over there.

So what did the chicken comment add that would not have been accomplished by (much earlier) saying "we do not plan to admit you to the hospital tonight, here are crisis phone numbers, now you can leave by yourself or these large gentlemen will escort you to the door" ?

 

[NickNaylor]

I actually saw a patient yesterday that I feel a little conflicted about with respect to how I handled the situation.

The patient has chart diagnoses of bipolar I and IDD (likely mild - able to live independently but has very poor functioning: homeless, no social support, no stable income, etc) along with an extensive, extensive trauma history as a child. They had a multi-month stay on our inpatient unit earlier in the year with relatively little benefit as far as I can tell. They come into the ED yesterday electively mute, only speaking with staff by writing down responses to questions. I know this patient from about a month ago and at that time they were fully verbal, so I know they are capable of speaking. Had no medical complaints and walked into the ED voluntarily to see psych because they were feeling “mentally unwell.”

I walk in, ask how I can be helpful, and the patient begins gesturing using one hand as a piece of “paper” and the other hand as a “pencil” to indicate that they want to write down responses and need paper and a pen to do so. I tell the patient that I know they are capable of speaking and that I would like them to use their words to speak with me - mostly because I don’t want to do a complete psychiatric assessment by having them write their responses to me when I know they are capable of speech. They continue to do this gesture with me, refusing to answer any questions verbally, and become inreasingly more agitated: punching the guard rails on the bed, crying, screaming, etc.. They tell me (verbally by the way) that they cannot speak because “my throat hurts.” At one point they throw all of their belongings at me (including a delicious “ham” sandwich described in a previous post). I tell the patient that I will give them a couple of minutes to calm down and then I’ll come back and we’ll try again. They follow me out of the ED room and to the nurse’s station and begin gesturing to other staff that they want a pen and paper; I tell the staff that I know they are capable of verbal speech and to not acquiesce as I don’t want to encourage this behavior in the future. They punch the nurse’s station counter, obviously upset, and sit in a chair outside of the nurse’s station. I walk away for a few minutes to go talk to the ED doc to discuss what is happening and that I will plan to discharge them if they are unwilling to participate in an interview, which he is fine with.

I return and find the patient in their ED room and that they have found some paper and a pen to communicate with me. They want refills on medications and again says that they are “mentally unwell.” When I ask what that means, they say they are having “racing thoughts” but explicitly denies SI/HI and AH/VH, writing “hell no” when I ask about these. I discuss with them that I will give them refills for their medications but that I do not think they require inpatient admission, which they are also requesting. I finish up the interview and there are no significant issues going on that can’t be addressed in the outpatient setting. I discuss with the ED doc that I would recommend discharge and to call police officers when discharged as they might get quite agitated given how fixated they were on being admitted. I never heard about the patient again so I assume they were discharged without incident.

My impression was that this was all behavioral as, beyond their irritability (which appears to be consistent with their long-time baseline), there was no evidence of an acute mood disturbance or psychosis. I did not want to encourage this kind of behavior as this is the kind of patient that is at “high risk” of using the ED for respite and support. I wonder if I should have just given in as she got quite agitated when I refused to accommodate her in this way and I was worried that she may require emergent medications. I wonder if it just would’ve been easier/more appropriate to communicate with her as she requested and not risk the agitation.

 

[SilverHawk]

You can only treat what you see. Based on the scenario you described, if they didn't have an acute issue prompting admission, then no reason to admit them. Also agree with trying to get the patient to actually speak with you, not acquiesce to demands. These types of patients for me are incredibly challenging. She may have borderline/lowish IQ, but knows enough to manipulate the system to attempt to get what she wants. You may have been the one of the few attendings (soon to be) that attempted to set communication boundaries with her.

That being said, still incredibly important to keep professional demeanor plus keep things statements simple and to the point. Don't respond/retort to nasty behavior, that is exactly what the patient desires. If a patient doesn't (and really won't) engage in conversation, dis-engage. Don't linger.

It may be tempting to be sarcastic with these patients but you have to be so careful. This reminds me of the ER doc that got national news for mocking a patient. Unfortunately, you never know who else may be watching your encounters.

 

[whopper]

So what did the chicken comment add

She got a laugh. Actually she also got a laugh with the pretzel and George Bush comment.

Like I said, we knew her, she knew us. She knew when she walks into our ER our BS-meter is already up and running.

The complaints to what I said, I get it, but I also knew this patient, and the typical responses were already done.

 

[thoffen]

I think we are starting to enter the territory where factitious disorder, somatiform & conversion illnesses, hysterical psychosis, etc. need to be considered. Malingering is conscious behavior for obvious external reward. There are many people who are motivated to utilize resources without clear understanding of what they are getting from it. And yet there are many who have no conscious control whatsoever of their symptoms. Just because someone's behavior doesn't line up with physiology doesn't mean they are intentionally producing it. In the "I can't talk" case, the fact that she verbalized after being provoked does not prove that she could do so volitionally. It does prove that the problem is not biologic.

 

[WisNeuro]

I think we are starting to enter the territory where factitious disorder, somatiform & conversion illnesses, hysterical psychosis, etc. need to be considered. Malingering is conscious behavior for obvious external reward. There are many people who are motivated to utilize resources without clear understanding of what they are getting from it. And yet there are many who have no conscious control whatsoever of their symptoms. Just because someone's behavior doesn't line up with physiology doesn't mean they are intentionally producing it. In the "I can't talk" case, the fact that she verbalized after being provoked does not prove that she could do so volitionally. It does prove that the problem is not biologic.

While this is true, I see plenty of both types of non-credible presentations, the obviously intentional vs. the somatoform flavor, it wouldn't change the plan much in this specific instance. If it was somatoform, admitting the patient would just lead to reinforcement of the underlying psychiatric pathology, and likely lead to more frequent admissions in the future, and possibly an escalation of functional symptoms. I imagine you could try to find this person treatment for a somatoform presentation, but you run into two Sisyphean tasks. 1.) Getting the person to acknowledge a psychiatric etiology for their symptoms and enter into psychological treatment, and 2) finding a provider who can actually competently treat somatoform issues. I hate to be the cold utilitarian, but these patients tend to require gobs of time, with relatively small chances of successful treatment. And, with my waiting list where it's at, not a great use of my time.

 

[thoffen]

While this is true, I see plenty of both types of non-credible presentations, the obviously intentional vs. the somatoform flavor, it wouldn't change the plan much in this specific instance. If it was somatoform, admitting the patient would just lead to reinforcement of the underlying psychiatric pathology, and likely lead to more frequent admissions in the future, and possibly an escalation of functional symptoms. I imagine you could try to find this person treatment for a somatoform presentation, but you run into two Sisyphean tasks. 1.) Getting the person to acknowledge a psychiatric etiology for their symptoms and enter into psychological treatment, and 2) finding a provider who can actually competently treat somatoform issues. I hate to be the cold utilitarian, but these patients tend to require gobs of time, with relatively small chances of successful treatment. And, with my waiting list where it's at, not a great use of my time.

Oh it wasn't criticism of a choice not to hospitalize. Although, treating a patient unempathetically when they are not consciously enacting their behavior is counter-therapeutic. Really, you can even make progress with some malingerers if you are in alliance with their problem but not their plan.

 

[WisNeuro]

Oh it wasn't criticism of a choice not to hospitalize. Although, treating a patient unempathetically when they are not consciously enacting their behavior is counter-therapeutic. Really, you can even make progress with some malingerers if you are in alliance with their problem but not their plan.

In my experience in the VA, the problem was merely getting their SC increased. Not exactly something I care to be in alliance with

 

[thoffen]

In my experience in the VA, the problem was merely getting their SC increased. Not exactly something I care to be in alliance with

You could care about what life is like on their current income or about respect for their service to the country.

 

[WisNeuro]

You could care about what life is like on their current income or about respect for their service to the country.

I feel like I can respect their service to their country and get an idea of what life is like on their current income without reinforcing waste of healthcare services and depriving other people of said services, or making people who need those services wait that much longer.

 

[thoffen]

I feel like I can respect their service to their country and get an idea of what life is like on their current income without reinforcing waste of healthcare services and depriving other people of said services, or making people who need those services wait that much longer.

Exactly what I'm advocating. I'm just saying that while their seeking disability income may be unwarranted, it can be related to real conflicts that you should care about. Without collaborating on that, they may feel you are rejecting these conflicts themselves instead of their inappropriate solution.

 

[WisNeuro]

Exactly what I'm advocating. I'm just saying that while their seeking disability income may be unwarranted, it can be related to real conflicts that you should care about. Without collaborating on that, they may feel you are rejecting these conflicts themselves instead of their inappropriate solution.

In some clinics, it is merely not worth my time or effort. In my last VA clinic, my validity failure rate on testing was 45-50%, in my current clinic (with sicker, high comorbidity patients), it's <5%. There's a reason for high levels of provider burnout/attrition in certain clinics, looking at you polytrauma. I'd rather work in a system where my patients actually need my services. The significant pay raise was just icing on the cake.