No longer applicable.

[Ceke2002]

No longer applicable.

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[ObsequiousAplomb]

I try to avoid thinking of it as all of these patients are trying to deceive me and instead I'm going to lump in the people who seem to genuinely think they have ADHD when they actually have a comorbid medical disorder. These are the most common details that come out during an interview that might not be initially offered:

- Recent onset instead of chronic
- High grades, persistently, without any history of disruptive or clearly distracted behavior in school or work
- Symptoms are closely tied to substance use, particularly alcohol or cannabis
- insistence that ADHD and school/work performance improves with cannabis
- a lack of hesitation when the addictive potential of stimulants is mentioned during the informed consent process
- neck circumference > 15 inches and/or a positive STOP-BANG
- symptoms started / became worse after onset/treatment for hypertension, diabetes, or another chronic medical illness that might impact cognition
- patient has Medicaid but hides that fact and tries to pay cash for the appointment
- refusal to entertain causes for symptoms other than ADHD

 

[Stagg737]

For what the OP is trying to accomplish (ie, standardized patient acting), I think the biggest things that are clinical red flags for me are:

1. No signs of hyperactivity or inattention on clinical interview. Some patients you can tell in the first 5 minutes that they clearly have ADHD. Ie, hyperverbal, somewhat tangential speech and thoughts which are redirectable but often ask "what was the question again?", easily distractible, difficulties sitting still, etc.

2. Showing signs of an untreated/uncontrolled anxiety (or to lesser extent depressive) disorder with primary ADHD symptoms being difficulties with concentration and "focus". Extra points towards the red flag if these problems are relatively new (a couple of years) and started in congruence with a social stressor like a certain job or relationship. Sometimes the anxiety is due to ADHD and this can be difficult to tease out, but if my patients aren't willing to treat/address their obvious anxiety first, that's a red flag.

3. Refusal to try non-stimulant treatments for ADHD or insistence that they need stimulants without already having failed other options (bupropion AND atomoxetine).

 

[Bartelby]

If these are medical students, keep it simple. Things like subtle MSE findings that might suggest feigning are too advanced for the combination of skill and time you are likely targeting (for example, the whole encounter might last only 15 minutes making an extensive malingering assessment unrealistic).

For this theme I would recommend coming in saying that you are pretty sure you have ADHD and then from that point describing a crystal clear major depressive episode and seeing if the student appropriately rejects the ADHD diagnosis.

 

[Sushirolls]

^That

Or come in saying you think have ADHD, but also started cannabis, and its been escalating both started at the same time, 1.5 years ago.

 

[comp1]

I hope this is not for med students. ADHD is too subtle a thing for med students in a standardized interview. However, for me, collateral is much, much more important than anything the patient says (adult or child). If there's pushback on calling the parents or some other family member, that's a red flag.

 

[Roxas]

If these med students are anything like my medical school, at least half of them have already been in that interaction for real by going to the school's student clinic with no prior diagnosis of ADHD and successfully getting stimulants to stay on top of the work load.

 

[calvnandhobbs68]

If these med students are anything like my medical school, at least half of them have already been in that interaction for real by going to the school's student clinic with no prior diagnosis of ADHD and successfully getting stimulants to stay on top of the work load.

idk what was up with your med school but none of that flew for the college clinic I worked in. If someone didn't come in with a well established prior history of ADHD treatment, we wouldn't even bother, they'd get a pamphlet with the school's requirements for establishing a diagnosis of a learning disability/ADHD and can come back when that's all done.

 

[annoyedpsychiatrist]

1. Hyperactive subtype usually i can see symptoms of clinical exam. Inattentive I think is easier to miss tbh. Sometimes thats harder to spot on exam
2. Insistence upon stimulants. Random, but a lot of people who have ADHD ive noticed dont necessarily enjoy being on stimulants and many would prefer not to use them. When people are more adamant about it, i start to question more.
3. Recent diagnosis from a sketchy clinic.
4. Not open to treating comorbid disorders first then further assessing residual attention issues after
5. People who are "overly friendly". Not everyone, but sometimes i get suspicious when they're overly friendly.
6. Requesting high doses of immediate release stimulant. Not willing to entertain the idea of alternatives
7. Generally inflexible patients
7. Unable to elaborate what their deficits are besides "i cant focus" on "everything"

 

[littlefred]

Y'all fell into OP's ploy, let's be real... what standarized patient or OSCE is hiring to only have this exact "ADHD" scenario?

This will be a guide on what not to do when going on a hunt for ADHD diagnosis/stimulants.

Patient's will get smarter and a lot of psychiatrists out there will be fooled.

 

[clausewitz2]

Y'all fell into OP's ploy, let's be real... what standarized patient or OSCE is hiring to only have this exact "ADHD" scenario?

This will be a guide on what not to do when going on a hunt for ADHD diagnosis/stimulants.

Patient's will get smarter and a lot of psychiatrists out there will be fooled.

@Ceke2002 has been a poster on this forum for over a decade and has always been on the up and up and quite transparent about the fact they are a patient rather than a healthcare provider. Let's hold off on the accusations of bad faith.

 

[Stagg737]

@Ceke2002 has been a poster on this forum for over a decade and has always been on the up and up and quite transparent about the fact they are a patient rather than a healthcare provider. Let's hold off on the accusations of bad faith.

Was going to echo this. Ceke's been around this forum longer than I have and has always been very open. I very much doubt they would be coming here to try and get this info given how active they generally are. If they are, it's one hell of a long con....

Y'all fell into OP's ploy, let's be real... what standarized patient or OSCE is hiring to only have this exact "ADHD" scenario?

This will be a guide on what not to do when going on a hunt for ADHD diagnosis/stimulants.

Patient's will get smarter and a lot of psychiatrists out there will be fooled.

I actually had this as one of my standardized patient in med school. Ie, patient drug seeking by pretending to have ADHD. I remember because I was a tutor for Level 2 PE and it was the most commonly failed standardized patient we had. I was pretty surprised by how many people weren't taking a drug history in someone asking for stimulants.

 

[calvnandhobbs68]

I don't doubt this may be an actual OSCE and OP certainly may be trying to get some help with this role but I do share the concern about the lists of ways to try to filter out patients who fit ADHD criteria vs not in a thread titled "what gives away the better ADHD fakers" in a publicly searchable/indexed forum. Idk wish there was some way to make these types of threads private at least to only forum members or something.

It's the same problem I have with people using the ASRS to screen or diagnose ADHD when anyone in the world can just google "ADHD rating scale" and know exactly what questions they're going to be asked ahead of time.

 

[littlefred]

@Ceke2002 has been a poster on this forum for over a decade and has always been on the up and up and quite transparent about the fact they are a patient rather than a healthcare provider. Let's hold off on the accusations of bad faith.

I thought this was a forum for physicians, residents or medical students interested in Psychiatry.

Nothing against OP, this kind of posts are just bad in general for our field.

 

[littlefred]

For what the OP is trying to accomplish (ie, standardized patient acting), I think the biggest things that are clinical red flags for me are:

1. No signs of hyperactivity or inattention on clinical interview. Some patients you can tell in the first 5 minutes that they clearly have ADHD. Ie, hyperverbal, somewhat tangential speech and thoughts which are redirectable but often ask "what was the question again?", easily distractible, difficulties sitting still, etc.

2. Showing signs of an untreated/uncontrolled anxiety (or to lesser extent depressive) disorder with primary ADHD symptoms being difficulties with concentration and "focus". Extra points towards the red flag if these problems are relatively new (a couple of years) and started in congruence with a social stressor like a certain job or relationship. Sometimes the anxiety is due to ADHD and this can be difficult to tease out, but if my patients aren't willing to treat/address their obvious anxiety first, that's a red flag.

3. Refusal to try non-stimulant treatments for ADHD or insistence that they need stimulants without already having failed other options (bupropion AND atomoxetine).

This actor also had to portray other roles.

This potential job is only asking for portraying 1 particular role, which made me suspicious immediately. Followed by an explanation in parenthesis which... I'll just stop.

 

[djo208]

My two cents here (maybe more like 5 cents with inflation?) which doesn't precisely answer your question, but is related to the task in a more clinical rather than acted format. I'm not an actor, so I find it hard to give advice around that, but I can give my thoughts on the topic from a clinical perspective, for forum readers who might click into the post for advice around how to doctor rather than how to act.
* Document your findings well and how you came to your conclusion, whether it's the ADHD diagnosis or malingering that you're diagnosing.
* There's a tightrope that's challenging to walk: Trust individuals unless you have reason not to on an individual level, but it is true that somewhere out there people are looking to obtain prescriptions for purposes for which they are not indicated. Be prepared to find and open to finding inconsistencies that might suggest malingering.
* If you suspect malingering, build your case in the chart. I will often compile over time a list of contradictions if the clinical picture isn't adding up in some way. Sometimes, it's only after my list of contradictions reaches a critical mass that I feel I have enough evidence to make a conclusive decision around diagnosis. There may be evidence in either direction and not every inconsistency is due to a lie. You don't have to know everything immediately and you can still take a lower risk course of action (e.g., non-stimulant treatments, behavioral skills around approaches to attentional deficits) while you continue to collect data.
* Ask specifics around the patient's efforts with respect to completing specific tasks. Implementing and trouble-shooting behavioral approaches to attentional deficits in almost a Linehan-like behavioral analysis format should give you a LOT of data around the patient's actual attentional deficits and executive function.
* Have an informed consent discussion, informing of the risks of whatever you're prescribing.
* Monitor controlled prescription databases on some frequency and stick to your policies around controlled substance prescribing.
* Monitor your own countertansference. Discuss tricky cases with colleagues and supervisors. If we are distrustful of a patient, it could stem from the patient or from somewhere else and if we're too close to it, it's hard to dissect this on our own. Maintain empathy as possible. Even if someone is lying or attempting to manipulate you, they're still human. Conceding this is not an apology for their behavior, it does not mean it is alright, nor that you should condone it or relax boundaries, but it can lead to more productive interactions to maintain empathy. If you are having trouble with this, it is definitely time to call a colleague or a supervisor and talk it through.

We're not perfect. We can't know everything. We can only do our best. We can't read minds.

 

[ObsequiousAplomb]

Was going to echo this. Ceke's been around this forum longer than I have and has always been very open. I very much doubt they would be coming here to try and get this info given how active they generally are. If they are, it's one hell of a long con....


I actually had this as one of my standardized patient in med school. Ie, patient drug seeking by pretending to have ADHD. I remember because I was a tutor for Level 2 PE and it was the most commonly failed standardized patient we had. I was pretty surprised by how many people weren't taking a drug history in someone asking for stimulants.

One of the standardized patients I'm still bitter about was someone who had their buttons mis-matched (they had skipped a button on their shirt). Their hair was gelled in a disheveled way, which was supposed to impart that they were disheveled, not that they intentionally chose that disheveled gel style that was popular in the late 90s. I did not ask them if they had showered recently, but if we did then the answer was supposed to be several days ago. Obviously I would ask someone who stinks when they showered, but this actor didn't commit to the smells.

Apparently we were supposed to upgrade their depression from moderate to severe. I definitely made note of both of those things mentally, but assumed that they were too detailed for a standardized patient (especially because physical exam findings were generally written down for these encounters, psych was unique in that we only had what we saw).

 

[comp1]

Yeah, I've never been in to the standardized patient concept at all. There are plenty of actual patients out there already for students to talk to. Trust and believe that people do not need SDN to fake ADHD. Honestly, ADHD is not an emergency. You do not need to make any decision on the first visit and this is a particularly good situation to not. Get a good history and GET COLLATERAL.

 

[Roxas]

idk what was up with your med school but none of that flew for the college clinic I worked in. If someone didn't come in with a well established prior history of ADHD treatment, we wouldn't even bother, they'd get a pamphlet with the school's requirements for establishing a diagnosis of a learning disability/ADHD and can come back when that's all done.

Good to see that somewhere had a legitimate approach to ADHD then. I've extrapolated my experience and some friends from other schools with similar experiences and just figured that ~50% of med students were taking stimulants.

 

[Stagg737]

I don't doubt this may be an actual OSCE and OP certainly may be trying to get some help with this role but I do share the concern about the lists of ways to try to filter out patients who fit ADHD criteria vs not in a thread titled "what gives away the better ADHD fakers" in a publicly searchable/indexed forum. Idk wish there was some way to make these types of threads private at least to only forum members or something.

It's the same problem I have with people using the ASRS to screen or diagnose ADHD when anyone in the world can just google "ADHD rating scale" and know exactly what questions they're going to be asked ahead of time.

This actor also had to portray other roles.

This potential job is only asking for portraying 1 particular role, which made me suspicious immediately. Followed by an explanation in parenthesis which... I'll just stop.

I definitely get those concerns, which is why I tried to keep my post about things the actor could do/say that would be red flags that med students or interns should be able to pick up on that aren't as obvious as "patient screams at you about stimulants". I wouldn't share specific pearls on a thread like this as they're things that I don't think an actor would be able to consistently work into interviews and are also things I don't expect residents to know until they're solidly in their outpatient year.

Timing of these threads are always funny to me because I actually staffed 3 patients where this was relevant in our resident clinic today. One of them I think probably does have legit ADHD, one came in for an eval for "ADHD" but likely isn't that, the other seemed highly likely to be seeking. I used to like treating ADHD, but it's been ruined for me lately.

 

[Ceke2002]

My apologies if this came across as problematic, and I feel it is only right I address some (very legitimate) concerns.

I was contacted by a friend on social media, who I have known for over 15 years, and who knows about my mental health history (including an ADHD diagnosis), and wondered if I would be interested in doing some work as a 'patient actor'. I asked what sort of scenarios they were talking about, and this was one of the potential scenarios they gave me (others included playing the role of a schizophrenic, roleplaying as an aggressive patient, clinical depression, anxiety, straight up drug seeker, etc). With this scenario in particular I straight up told them I didn't think I'd be a suitable candidate if they expected me to essentially fake something I would find very hard to actually fake. I then mentioned that I did know some medical professionals I could talk to to get gauge on how someone might perform a scenario such as (paraphrased) 'pretend you have ADHD when you don't.'

My contact details have supposedly been passed on to a company who hires such roles, although I have not heard back from them (and am beginning to wonder if there were positions available at all at this point).

For further context my Auntie does similar work for the SA Police, roleplaying both victims of crime, and perpetrators as part of Police training exercises. I assumed the job offer was something along the same lines, but for Medical students.

And just for full transparency:

I was diagnosed with the pre-cursor name for ADHD (Hyperkinetic Reaction of Childhood) in 1975.
I was diagnosed again with ADD (without hyperactivity) in 1999.
I had the diagnosis confirmed around 2010, but changed slightly to ADHD predominantly inattentive type.

Although I have never been able to find any actual record of proof, my case was included at an Australian symposium for ADHD in the late 90s.

I do have a rather extensive history of mental health issues in general, but I am also no longer in treatment, or on any medication, as my mental health has been almost completely stable for several years now thanks to previous long term therapy. When I first joined this forum it was because I was considering returning to University studies and trying to do Medicine post grad. That didn't work out for me in the end, but I made some friends on here and so I decided to stick around.

Anything else you wish to know, please feel free to ask me. I will answer any questions or concerns (within reason).

Again my apologies if this post came across in any way other than it was intended.

 

[Ceke2002]

Yeah, I've never been in to the standardized patient concept at all. There are plenty of actual patients out there already for students to talk to. Trust and believe that people do not need SDN to fake ADHD. Honestly, ADHD is not an emergency. You do not need to make any decision on the first visit and this is a particularly good situation to not. Get a good history and GET COLLATERAL.

I totally agree with this, and to be honest I would much rather have had an offer of 'Hey do you wanna come talk to some Psych trainees about your own mental health diagnoses and experiences, we'll pay you for your time' rather than 'Hey do you wanna come potentially act out some scenarios, some of which you're probably going to find almost impossible to do convincingly'. It's just the money right now would come in handy.

 

[Ceke2002]

Thank you to everyone who gave responses. This post is no longer applicable. I have removed the first post, if mods want to delete thread entirely please go ahead.