1. Malingering. Is refusal to discuss the delusions / hallucinations any indication of this? Most psychotic pts I have treated have been a bit more forthcoming.
being excessively vague in describing symptoms could indicate malingering, but in general malingerers WANT to tell you all about how crazy they are. In contrast, psychotic patients tend to be guarded and not give much away, though of course some psychotic patients can't wait to tell you all about their delusions etc. It may depend on the nature of the psychosis, and level of insight. Patients with delusions of persecution may be unwilling to disclose too much if they think it will hurt them. Patients with some insight will not want to be labeled as crazy and thus not say much.
2. Psychosis in BPD. Is it really a different beast? This pt has complex delusions of persecution from what little she has said (bits and pieces here and there), well formed (non pseudo) auditory hallucinations and some decent paranoia. But is it the BPD type or the "true" psychotic type?
BPD and narcissistic personality disorder are associated with micropsychotic episodes typically lasting hours to days in the context of interpersonal crisis involving abandonment, rejection, narcissistic injury etc. It can also occur in the course of analytic therapy which is why traditional analytic approaches are contraindicated in such patients (they cannot handle lots of defense interpretations etc.) They may represent a kind of dissociative reaction. The main clues however is that the content of the hallucinations or pseudohallucinations tends to be related to abandonment/failure etc. For example a borderline patient on an inpatient unit heard the nurses talking about how they didn't love her. Another borderline patient who was cheating on her partner, became paranoid that her partner was cheating on her and began to hear a "voice" tell her as much. A patient with narcissistic personality disorder when severely narcissitically injured began to heard people talking about what a failure he was and laughing and pointing at him on the street. In patients with complex trauma the voices are typically related to the trauma (for example, a woman who was sexually abused by her father would hear her father's voice telling her never to let anyone touch her like this.) In contrast, patients with frank psychosis tend to have disorganization in thinking (which if you believe Bleuler is the sine qua non of psychosis), the form of the hallucinations etc is more typical (e.g. though echo, voices heard arguing, running commentary etc) and the content not as obviously related to trauma/abandoment etc though these themes and anxieties are absolutely related to the formation of the psychotic content, it just tends to be much more distorted and removed from reality.
You don't see complex systematized delusions in cluster B personality disorders because the "psychosis" is transient. More entrenched beliefs are either obsessions, overvalued ideas, or indicate a co-occuring primary psychotic disorder.
3. How do you really tell if a pt is malingering? We dont do the tests here. She has stable accommodation and is on disability so no known secondary gain but I just have questions.
We no longer use the term "secondary gain" and they took it out of the DSM because the notions of primary and secondary gain relate to more psychodynamic notions of motivation which are often unfalsifiable and unverifiable. Instead malingering is associated with "obvious external reward." If there is no "obvious external reward" (e.g. evading drug dealer, claiming disability, evading criminal responsibility, place to stay for the night etc.) then it is not malingering.
In clinical practice, most malingerers are not terribly bright so they usually tell you why they are malingering. In criminal litigation, most malingering is quite bad as well, but psychopathic individuals in more high stakes litigation (e.g. homicide cases) often more expertly malinger, and in some cases have even researched how to evade detection on the MMPI-2 or PCL-R. In civil litigation, malingering and feigning of symptoms is often more sophisticated especially with the more intelligent and educated individuals.
Clues to malingered psychosis in addition to there being the obvious external reward (which is an absolute must) - not everyone faking is malingering - include: symptoms not known to occur in psychosis, performance worse than severely demented people on basic tests, excessively vague symptoms, endorsing symptoms that only occur when paired with something that would make it unusual, endorsing delusions as delusions (it's not a delusion if you say you're delusional), using DSM verbatim language, presenting in a caricature way e.g. "I have suicidal and homicidal ideation and am a danger to myself and others" or "I'm hearing voices telling me to kill myself" (which of course could be genuine), lack of disorganization, presentation markedly different from previous presentations.
Remember most people malingering in clinical settings are mentally ill, which is how they learned to malinger in the first place. Which is why we talk about malingered symptoms, rather than malingered diagnoses - and that malingering is often partial (i.e. creating some symptoms)
In general, it is best to avoid making a firm "diagnosis" of malingering and instead explain why the current presentation is not consistent with major mental disorder.
4. Or am I just too new to all of this and it is usual for pts to be so non compliant and non responsive and evasive? How do I get her to discuss her symptoms so I can help her?
Psychotic patients aren't going to talk about "symptoms" by definition. Symptoms are things people complain of. If someone is complaining of being delusional - they are not delusional! Also never use the term "non-compliant" which you are incorrectly using anyway. In this case, you're asking about cooperativeness. Well that is a finding on your mental status exam - oh the irony of complaining that the patient is not giving you anything when they are telling you all you need to know!
You need to feel your way into the patient's experiences - I always see junior residents asking completely useless questions like "do you hear voices?" or "do you feel like anyone is out to get you etc." Instead pick up on behavioral clues - if the patient seems distracted, ask them about it. Ask them "can you hear other people talking to you right now?" "are those people over there talking about you?" "I notice you just when quiet, what's happening?" "I noticed you were looking at those people go by - do they know who you are? Is your life in danger? Is anyone monitoring you whereabouts? Has anyone bugged your phone?", "Can I know what you are thinking without you saying anything?" Always ask questions about delusions as if they are true, and then validate and exaggerate the patient's response. Sometimes patients dont say anything because they get invalidated or people think they're crazy. Another helpful technique in the ED setting is to remind the patient "the more you tell me, the best I can help you, otherwise I will just have to admit you/let you go (whichever one they dont want) based on the limited information I have"
