What do you tell a pt when "nothing" is wrong?

[chagall]

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I'm having some trouble with this one patient (on a medical floor), and I was wondering if anyone had tips. The gist of it is that she complains of severe back pain and inability to walk or stand up due to weakness and pain. She's very histrionic and seems to have every Cluster B trait and predisposing factor you could think of.

So we've been through pretty much all the neuro tests (only a few labs pending), and all we found is mild hypothyroidism (which I know can do some weird things, but not this weird). Especially since when we ask her to move her toes, for example, she does a Valsalva and flexes many other muscles BUT her toe flexors. So it seems like this is at least mostly a psych issue. I'd like to consult psych, but I don't know that they would be willing to see her as an inpatient.

My dilemma of the moment is what to tell the pt when she asks why she has so much pain or why she can't walk when all our tests have been normal. I've explained to her all of what she doesn't have, and this only upsets her (she seems to wish she had a stroke, etc). Today I went into how some people have increased sensitivity to pain, and how we don't always find a cause for pain...my resident suggested mentioning how there may be a physical cause that is just not "declaring" itself yet, but I've been worried to go there for fear that she will go back to her ways of claiming "I know I must be dying, and no one knows why."

So 😕. I feel especially conflicted about this because I myself had a lot of physical pain for a few years that did finally show up as a rheumatologic condition (but before that, I was told it was "all in my head.") None of the rest of the story is similar, though, just to be clear!

There are many other issues, including dispo...but I will leave it at that for now. Any ideas? Thanks!

 

[whopper]

Are you asking how to tell her that nothing is wrong?

She either is in real pain--in which case something is wrong (physical or mental) or she's faking it for some reason.

If you want psychiatry on board, you need to be very certain there is no physical cause for her pain. Reason why is by standard procedure, physical causes need to be ruled out first before psychiatric causes can be entertained. Another problem with pain is the causes can be very complex and a lot of it is subjective in how its perceived. A problem I've had here with consults is often times not every investigation was done, and the medical doctor treating the patient wanted psyche to take care of the issue prematurely.

There are also non-psychiatric (though some may debate this) causes of pain or at least sensitivity to it such as fibromyalgia.

Without knowing more of the details, I'd say this may get trapped into one of those issues where no one specialist is going to take on the responsibility until its clearly pointed that they take it Investigate the issue until you feel you've done all you can. Did you consider other consults such as neuro or pain management?

 

[chagall]

Are you asking how to tell her that nothing is wrong?

She either is in real pain--in which case something is wrong (physical or mental) or she's faking it for some reason.

If you want psychiatry on board, you need to be very certain there is no physical cause for her pain. Reason why is by standard procedure, physical causes need to be ruled out first before psychiatric causes can be entertained. Another problem with pain is the causes can be very complex and a lot of it is subjective in how its perceived. A problem I've had here with consults is often times not every investigation could've been done, and the medical doctor treating the patient wanted psyche to take care of the issue prematurely.

There are also non-psychiatric (though some may debate this) causes of pain or at least sensitivity to it such as fibromyalgia.

Without knowing more of the details, I'd say this may get trapped into one of those issues where no one specialist is going to take on the responsibility until its clearly pointed that they take it Investigate the issue until you feel you've done all you can. Did you consider other consults such as neuro or pain management?

Thanks. Yeah, sorry, we are neuro...I had just meant a non-psych floor. She's on multiple meds for chronic pain (tricyclic, Cymbalta, also Darvocet) and we have a few others to consider...but pain consult sounds good if they would see her.

Except for fibromyalgia (which I think could be a valid diagnosis in her case) or other increased sensitivity issues, I think we (or the OSH she came from) have run most of the tests we can think of...C- and L-spine CT and MRI, brain MRI, lumbar puncture, CSF studies for MS, even EMG and nerve conduction studies (all essentially normal). Still have some rheumatologic tests pending (ESR and rheumatoid factor are negative so far).

Part of my reasoning in that this is more of a psych issue is that her neuro exam really isn't consistent from minute to minute or examiner to examiner, and neither are her complaints...and there's nothing objective (non-fake-able) on exam. Also, she uses the muscles that she claims are paralyzed without realizing it. I can't deny that she may have true pain, though...I have told her that we believe she does have pain and we want to treat it...but her persistent question is why she is unable to walk or move her legs if nothing is wrong?

 

[whopper]

These cases can be frustrating.

There could be a psychiatric component. Did you consider perhaps chronic pain syndrome?

 

[chagall]

These cases can be frustrating.

There could be a psychiatric component. Did you consider perhaps chronic pain syndrome?

Yes, that has been my thought. She has had major depression (with suicidal ideation in the past) and anxiety...seen by a psychiatrist on consult at the OSH, who diagnosed her with anxiety disorder NOS and mentioned a lot of depressive and PTSD-type symptoms as well...but this was all "pending further neuro work-up."

Some of her symptoms aren't pain-related, though...the "paraplegia," etc made me think more of conversion disorder. But yes, I was thinking along those lines. I have talked with the pt about the idea that it would probably be very helpful to f/u with psych as an outpt regularly.

She of course "knows" it's not in her mind because she fell when she tried to walk...and then tells me it's not possible for her to leave her house to see a psychiatrist because she can't get in a regular car (can't sit up without pain), but also doesn't want to go to an extended care facility. Hopefully we could figure something out, though...it's just a mess!

I was thinking about going into psych myself until recently...and I can see how she might have some benefit from outpatient psych. But from a neuro standpoint, it's frustrating and almost guilt-inducing (for me at least) when the patient is sobbing and says, "you're just going to send me home like this?"

(By the way, her last attempt at PT at an OSH ended in allegations that the staff "beat me up" by doing such things as raising her legs more than a few inches off the bed and trying to help her stand on her own). 🙄 So we haven't gotten PT involved yet here...

 

[OldPsychDoc]

Sometimes you can sit down with the patient and explain what conversion disorder is. Read the criteria, see what she identifies with, explain that it is a "real disease--we're not saying it's 'just in your head'--we don't know why this happens, but in many people who have severe stress..." etc. Explain that the treatment involves therapy to understand her coping with stressors, treatment of depression and anxiety with medications, and continuing your thorough medical workup to make sure nothing else is being missed. The key to this approach is to present it as a) something real, b) something treatable, and c) something that will take time and effort to manage--no quick fix. You've got to be able to assess her external supports, and provide them for her (e.g. therapist, groups, case management) if they don't exist. It's not easy for them or for you, and the system isn't going to make it happen unless someone (usually a primary psychiatrist) carries the ball. The counter-transference these patients inspire makes it supremely hard for a physician or therapist to want to commit to this long term course, but it can work. Unfortunately, most of us just want to get these folks off our service as fast as possible...🙁

 

[chagall]

Sometimes you can sit down with the patient and explain what conversion disorder is. Read the criteria, see what she identifies with, explain that it is a "real disease--we're not saying it's 'just in your head'--we don't know why this happens, but in many people who have severe stress..." etc. Explain that the treatment involves therapy to understand her coping with stressors, treatment of depression and anxiety with medications, and continuing your thorough medical workup to make sure nothing else is being missed. The key to this approach is to present it as a) something real, b) something treatable, and c) something that will take time and effort to manage--no quick fix. You've got to be able to assess her external supports, and provide them for her (e.g. therapist, groups, case management) if they don't exist. It's not easy for them or for you, and the system isn't going to make it happen unless someone (usually a primary psychiatrist) carries the ball. The counter-transference these patients inspire makes it supremely hard for a physician or therapist to want to commit to this long term course, but it can work. Unfortunately, most of us just want to get these folks off our service as fast as possible...🙁

Thank you...sounds like great advice. I will see what I can do (with the team's OK...for one thing, I don't know if neuro is "allowed" to diagnose conversion disorder (though I'm sure we could at least suggest it as a possibility). I'm thinking the psych consult team would be very unhappy if I were to call them down for this...but maybe I could curbside them to ask about what they suggest in cases like this. Thanks!

 

[Anasazi23]

OldPsychDoc's advice is the proper, standard fare for these types of conditions, assuming you've ruled out all causes. Dismissing the patient's concerns will often make the condition worse...not saying that you did this.

Good luck.

 

[Chimed]

Sometimes you can sit down with the patient and explain what conversion disorder is. Read the criteria, see what she identifies with, explain that it is a "real disease--we're not saying it's 'just in your head'--we don't know why this happens, but in many people who have severe stress..." etc. Explain that the treatment involves therapy to understand her coping with stressors, treatment of depression and anxiety with medications, and continuing your thorough medical workup to make sure nothing else is being missed. The key to this approach is to present it as a) something real, b) something treatable, and c) something that will take time and effort to manage--no quick fix.

I completely agree with OPD's recommendations here (assuming, of course, other causes have been ruled out). This was one of the most useful psych interview/counseling skills I've learned as a psych intern this year--to educate patients that their psych illness is not "just in their heads" and that emotions and stress can manifest themselves as real symptoms. I've used this with patients with pain syndromes and pseudo-seizures (hate the word pseudo....). I've been amazed at how well patients who where otherwise weary of psych treatments respond when you simply change the wording as OPD suggested.

Hey, OPD, you must have gone to an awesome residency! 😉

 

[OldPsychDoc]

Hey, OPD, you must have gone to an awesome residency! 😉

I just had awesome C/L attendings. 😀

 

[billypilgrim37]

I don't know if neuro is "allowed" to diagnose conversion disorder (though I'm sure we could at least suggest it as a possibility)

I'd imagine neuro "diagnoses" it more often than anybody, given the vagaries and characteristics of the initial complaints.

Come on, doesn't your institution have a combined neuro-rheum-psych service? 🙄

 

[MBK2003]

Another additional thought, beyond the pearls of wisdom from OPD, is to call the psych consult service and see if they have any staff with an interest/specialty in conversion or somatization disorders. I had a C/L attending whose bread and butter was somatization disorders, taking private patients from all the GI and neuro attendings. He really had a gift for the work with these patients and was more than happy to consult or supervise a consult on this kind of patient.

Just a thought.

 

[chagall]

Thanks for all the advice...a quick update...

So it's a miracle! The patient got up with PT today and walked across the room and back with a walker. She told me my "tough love" (of telling her that all our tests so far show that there is no damage to her brain, muscles, or nerves, etc) motivated her, after crying for several hours, to work to force her feet to move. 😱 🙄

Before all this happened, I talked with my team this morning, and even with my pushing and questioning, the attending emphatically did not want me to tell the patient she had conversion disorder or any type of psychiatric disorder causing her symptoms. I argued that it would be important to get her therapy as an outpatient and not string her along, thinking she had some exotic medical disease...but the attending said he has had only bad experiences with telling patients things like that in the past.

Anyway, it was a little too late since I had already mentioned to her that it would be helpful to get psych follow-up for depression and anxiety since those can make pain worse and can cause a variety of other symptoms. And she's going home today, hopefully with home health, since PT cleared her as able to walk...so I guess it all turned out OK...but I don't think that diagnosing these things just as "gait disorder" or "pain and weakness" as my attending says he does is the best or most honest policy in general...but I'm just a lowly med student...

 

[whopper]

Hmm, the above does point out to a possible psyche disorder, but then it brings up various ones such as factitious, malingering, conversion, etc.

Unfortunately, most of us just want to get these folks off our service as fast as possible..

Unfortunately seems true in my neck of the woods as well. These are cases where there's plenty of reasons for headache. The psyche doc might not be confident in the other doctor's efforts to rule out physical causes. Even when they truly are psychiatric, they are difficult to diagnose, may take months (if at all) to make progress and not very compatible with the way managed care compensates doctors.

Still though, they are very interesting cases. I always wanted to work on a psychotherapy case for a patient with conversion but haven't had that oppurtunity.

 

[nancysinatra]

I'm thinking the psych consult team would be very unhappy if I were to call them down for this...but maybe I could curbside them to ask about what they suggest in cases like this. Thanks!

Why would the psych consult team be unhappy to be consulted on this kind of case? If it really is conversion disorder, isn't that one of the things they are precisely there to do consults for? I'm just a med student and I've had no exposure to C/L, so I apologize if this question is super naive--but I would have assumed it would be most proper to consult psych for a problem like conversion disorder, assuming all medical causes have truly been ruled out... Wouldn't the same be true for the other psych disorders mentioned--facticious, malingering, etc? I can see where not all patients would be receptive to such consults, but why would the psych team itself be opposed? Anyway, I'm just curious.

 

[whopper]

You are right in the sense that it should be psychiatry that should consult these cases.

The frustrating part is that sometimes the medical team hasn't ruled out the physical causes to the degree the psychiatrist would like. The medical team may have already done all the appropriate tests, but because several tests are not 100% accurate, even if done, the psychiatrist still may have some doubt that the etiology still has a physical cause. (Remember conversion DO is rare--way smaller than even 0.1% incidence according to several sources)

This clarifies my point...
http://www.emedicine.com/EMERG/topic112.htm

Recent studies have found a variety of organic diseases in patients who were initially diagnosed with conversion disorder. In one case report, a woman was seen with leg weakness and back pain who was subsequently diagnosed with sporadic Creutzfeldt-Jakob disease.

The standard of care dictates that physical causes must be ruled out before psychiatric causes are supposed to be investigated. In several cases of possible conversion disorder, dozens of non-psychiatric diseases could've been the culprit, but often times the doctor handling the physical end won't rule out every single possible cause. Creutzfeldt-Jakob disease too is rare and they may have felt like giving up on the physical causes. This can cause frustration on the end of that doctor and that doctor may be willing to "turf" the patient to psychiatry.

Then if the psychiatrist picks up the case, they may feel later on that a specific test testing for a physical etiology may have been missed or should be redone, but then the doctor handling the physical end may not be cooperative with working as a team. (& vice versa, the medical doctor may not be happy with the psychiatrist--both sides sometimes play "turfing").

Other problems: because of the rarity, its to the point where several doctors aren't very experienced with the treatment, even after residency.

another: diagnosis is tricky: an amytal or benzodiazapine interview even if done may yield a false negative.

And add to that, the entire time its frustrating not being able to nail the correct diagnosis and not being able to "fix" the patient, and while psychotherapy is often needed for these cases, managed care won't pay for it if a psychiatrist does it. Adding a therapist to handle the psychotherapy adds a layer of complexity, especially since this has already been spread between 2 or more doctors.

This particular diagnosis can mimic a House episode in several ways. The only time I can see this case being extremely easy to diagnose is if an amytal or benzodiazapine interview is done and it very quickly detects the disease (the patient, in an disinhibited, non-anxious state loses their symptoms). Otherwise I can see a lot of frustration.

While I wish that we all had the time & resources to pursue a diagnosis as doggedly as House, often times the reality of limited resources & managed care creeps in.

Actually IMHO, this is exactly the type of case I like handling. I like the HOUSE type cases where you really have to think hard & do research. I love the feeling of putting the feather in the cap when you solve the case and several other docs missed it. However I think my enjoyment with this type of case would diminish if I had managed care strangling me (which I figure would happen much more as an attending) and in a non-academic setting that is not as flexible with this type of thing.

 

[t33sg1rl]

The only reason that conversion disorder is rare is that the diagnostic criteria are so tight... you're asking the neuro service to test for EVERY condition known to science, and even then you really can't exclude a new or unknown disorder. If you diagnosed it as pseudoneurological symptoms that fluctuate with time, are inconsistent with real illnesses, and nothing abnormal on only routine screening tests, then the prevalence on the Neuro floor is about 10-15%.

 

[TheWowEffect]

The only reason that conversion disorder is rare is that the diagnostic criteria are so tight... you're asking the neuro service to test for EVERY condition known to science, and even then you really can't exclude a new or unknown disorder. If you diagnosed it as pseudoneurological symptoms that fluctuate with time, are inconsistent with real illnesses, and nothing abnormal on only routine screening tests, then the prevalence on the Neuro floor is about 10-15%.

Are you suggesting that conversion disorder is not real😕.

 

[whopper]

If you diagnosed it as pseudoneurological symptoms that fluctuate with time, are inconsistent with real illnesses, and nothing abnormal on only routine screening tests, then the prevalence on the Neuro floor is about 10-15%.

Interesting. Any links?

Wish I had a link but I can't find one. The head of my department, Thomas Newmark, M.D. is quite skilled in Amytal interviews for detecting conversion DO. I have heard from more than 1 source that Camden actually has the highest incidence of conversion DO (he's in Camden) and I suspected it may have been to his ability to detect the disorder on an amytal interview. He is also very willing (unlike some other psychiatrsits I've seen) & open to the consideration of convesion DO on consults. Unfortunately I haven't been able to find any data on the net to back this up. I'm going to ask him directly next time I see him.

 

[cleareyedguy]

People who have worried about these cases include the ancient Egyptians (1600 BC in Ebers Papyrus), Hippocrates, & Galen. Sydenham, who I think is the first great modern physician, talked about such people (meaning people who fall into the somatoform cluster) in the 1600's--he thought they were psychological and attributible to "antecedent sorrows.". There are approaches to them, and I fully agree with Nancy Sinatra in her pleasantly-asked question: if you don't want to get involved with these patients, then what are you doing consults for?


Earning a full somatoform diagnosis is tough since it usually requires years of dysfunction, but it's not uncommon to see people whose behavior includes a somatoform dimension even if it doesn't reach full category status. For example, pseudoseizures are very common in neuro clinics.

If you really want to see how to interview such people, you might want to check out the pertinent chapter in MacKinnon, Michels, and Buckley's interviewing text that came out last year.

 

[nancysinatra]

Whopper--thanks so much for your very helpful answer to my question earlier about why these consults aren't just gleefully accepted by C/L folks. It really helped me to better understand what's involved in this.

Now, for anyone who's interested--do consults ever get requested where the problem turns out to be factitious disorder or malingering? Do patients ever get officially diagnosed with these disorders? Also, as far as malingering, who gets to define what this is? For example, what if you live in America and have a boss who wants you to work 60 hours a week, but your personal work ethic only extends so far as the European standard of about 37 hours a week? If you're calling in sick with pseudoflu all the time, or going to doctors with exaggerated headaches and getting notes a little too often, does that make you a malingerer? Whereas if you worked the same 37 hours a week but happened to live in Belgium, you would not be a malingerer, just a normal person? Or what if you were a person living in, say, the former USSR and your job was to copy meaningless forms in triplicate for a factory that makes only left shoes--then you might have a whole different attitude toward "work" altogether. In that situation, might it not make very good sense to fake illness more than is acceptable here? Would that still be malingering? I know this might sound silly, but I'm just wondering how you translate this disorder into settings that don't share American beliefs about work.

I saw a lot of patients in the psych ER who were clearly malingering, and it might say so in their HPI, but I never saw it in their Assessment and Plan as a dx or thing to be treated. Is there a treatment, honestly?

And if there is a treatment, what kind of psychotherapy would it involve? Would you encourage the patient to work harder and stop cheating the system? I can think of a lot of problems with trying to push a patient in those directions.

But anyway, I can't imagine an internal medicine doctor being so patient with their annoying malingerer that they called a consult rather than just d/c'ing them as quickly as possible. So probably this is all a bit hypothetical...

Oh and what about factitious disorder?

Sorry for rambling on with so many questions, and I don't mean to divert the thread from its original purpose, but if anyone wants to discuss these things, please tell me what you know!

 

[manwhoisthursdy]

Nancy ... I don't have time to try to answer all of your questions ... but I do want to point out that factitious disorder is just that -- a disorder (Axis I).

Malingering, however, is *not* a disorder. It's not an Axis I condition (or even Axis II, though certainly Axis II traits can be involved in a patient choosing to malinger). In the different situations (US, Europe, USSR) that you describe, the fact still remains that to feign symptoms that one does not truly experience, for *secondary gain*, is malingering. (To exaggerate or add symptoms is also a form of malingering).

Secondary gain means to get something out of it other than that sickness itself, i.e. more than just to be in the sick role. The motive could be, in the judgment of the clinician, rotten (I want to avoid prosecution) or very reasonable (I want to avoid my abusive partner, or I need a place to sleep because I'm homeless and it's below zero outside). It's still malingering.

 

[nancysinatra]

Malingering, however, is *not* a disorder. It's not an Axis I condition (or even Axis II, though certainly Axis II traits can be involved in a patient choosing to malinger). In the different situations (US, Europe, USSR) that you describe, the fact still remains that to feign symptoms that one does not truly experience, for *secondary gain*, is malingering. (To exaggerate or add symptoms is also a form of malingering).

Secondary gain means to get something out of it other than that sickness itself, i.e. more than just to be in the sick role. The motive could be, in the judgment of the clinician, rotten (I want to avoid prosecution) or very reasonable (I want to avoid my abusive partner, or I need a place to sleep because I'm homeless and it's below zero outside). It's still malingering.

Ok, thanks for explaining that--I didn't know it was not a disorder. That must be why I was having such a hard time seeing how it could be applied. After all, "secondary gain" can be achieved by manipulating almost any realm of life, not just illness. You could pretend you're going to a funeral to get that same time off of work. You could commit homeowner's insurance fraud to gain money. I would say that most human beings fudge a bit on honesty in pursuit of secondary gain at one point or another. So I thought it was unfair to call some people "malingerers" just because of the arbitrary fact that the system they are exploiting is the hospital and the gain is money, time off, etc--things that everyone wants and seeks out. But it's not a disorder after all!

Now I am wondering why we learned about it along with factitious and conversion disorders. And--are my classmates and I malingering when we go to the hospital library to "study" when really we just want to avoid whatever is going on on the floor? Granted, it's not illness but our zeal to learn that we are exaggerating.

 

[manwhoisthursdy]

nancysinatra,

I think the reason malingering is included with factitious and conversion d/o's is simply because it's in the differential diagnosis of "I have no idea what is causing this, and the pieces of the puzzle don't fit together!"

Malingering explains symptoms not by finding a cause but by determining that those symptoms are not truly present. (Or, like I mentioned earlier, it partially explains a patient presentation by determining that symptoms are added or exaggerated).

 

[whopper]

I ranted about this in other threads in the past, but I sometimes find the consults I get frustrating. E.g. "we want to know if the patient is lying". As a psychiatrist I have yet to learn of any ability to read patient's minds. Or "depression"--when in reality the patient was upset for about an hour because the Eagles lost.

I've gotten a fair shair of consults that I suspected were malingerers or factitious disorder.

Be careful in these situations. Often times there is countertranference on the part of the doctor (the doc asking for the consult or even yourself). Malingering is in a sense telling the patient that they are a liar. You got to stand your ground and not enable the patient if they are indeed malingering, but you also got to give an objective analysis & not let your own countertransference affect your judgement.

I've noticed several junior residents are too scared to consider malingering because they spent years having a "customer is always right" philosophy. Psychiatry as you may know is one of the fields where we tend to not always give what the patient wants, but instead what they need. When the junior resident finally becomes confident enough to dx someone with malingering or factitious do, I've noticed a lot of countertransference & prejudgement-especially in the poor inner city programs.

Movie with Sean Penn-Colors clarifies this. Penn plays a rookie cop who gets disillusioned with the gang wars happening in LA in the 80s. By the time he feels he knows what's going on for real, he goes ballistic against the poor urban culture in LA. Finally by the end of the movie--he reaches a happy medium, but only after a lot of pain & suffering.

My advice--by the time you've dx'd a few patients with factitious or malingering, and you can discuss the dx with the patient in an honest manner where you find yourself not giving into their demands, but not getting upset (or at least keeping your cool), you're possibly getting to the "happy medium" point.

I also suspect that part of the anger felt by junior residents is they tend to get a lot of these "dumped" on them. Everyone has a breaking point. When you're a resident doing all the "hard" scutwork cases--it can make it worse.

Malingering & Factitious--remember these too are situations where the person can benefit from our profession. Laying the law down with a malingerer can be therapeutic & stop regressive tendencies to find the easy way out. Patients with Factitious DO often have issues that need to be dealt with psychotherapy.

 

[nancysinatra]

My advice--by the time you've dx'd a few patients with factitious or malingering, and you can discuss the dx with the patient in an honest manner where you find yourself not giving into their demands, but not getting upset (or at least keeping your cool), you're possibly getting to the "happy medium" point.

During my psych rotation I found myself trying to find some kind of happy medium with almost every patient I got to talk to. I loved that you could address annoying or uncomfortable issues in a very direct way without resorting to anger, unless the patient wanted to, and then that became just one more thing to TRY to discuss openly... (Now, how often do you get to do that in real life??) I was on an eating disorders unit for awhile where I had this one patient who was 39 and a half and abusing laxatives, and making a big fuss about how here she was on the eve of turning 40 and what a horrible tragedy she'd gotten enmeshed in. I got the impression that she was really just trying to get attention from the world, but of course she denied that entirely. Everyone in her life was all wrapped up in the drama, and I thought it was interesting to see how she reacted in the hospital--where there was some actual scepticism. I know that's not factitious disorder--she really did have a medical problem--but is there some similarity to the way you'd have to confront a malingerer or factitious patient? I didn't succeed in getting her to discuss her true motives, but I thought the process was a great challenge and I wanted to get better at it.

I'm doing my medicine rotation right now, and I keep wishing we'd get a patient who truly is malingering or factitious, so I could get some practice. Of course I don't wish for people to misuse the medical system, but if they're already in the act, at least send one or two of them to me! 🙂

Now if I were just being asked to find out if a patient was lying or if there were medical explanations that still needed ruling out, that would be annoying. But I'm only talking about the situation where a consult is requested for the most appropriate reasons.

Uh oh--I'm afraid I have totally usurped this thread! It was about something totally different at the start...

 

[whopper]

I don't think anyone minds being that the original poster seemed satisfied with the info.

Several people with an eating DO, but also malingerers & factitious DO patients have a cluster B personality DO. There are a lot of similarities with these disorders in this sense.

I worked in an Eating DO clinic and several of the patients had some strong cluster B type of pathology. You have to set limits with these patients, while at the same time not allowing yourself to get angry with them.

From my own anectdotal experience, malingering is seen much more in psychiatry than in the other fields. Its easier to fake because there's often times no specific tests. I have seen perhaps only a small handful of medical cases during my 4 months of medicine, but I'd estimate that I perhaps seen dozens in 4 months of psychiatry.

Don't worry--you'll see 'em during consult duty in psyche residency.

 

[Solideliquid]

My C/L attending was chatting with me today during treatment team and pointed out something. Don't be afraid to explain to a patient "there isn't much we can offer you".

You will have patients with primary Axis II disorders, which medications cannot help (cluster B mostly). These patients have a low level of insight, and as such are not good candidates for analysis psychotherapy. In other words, they can engage in supportive and other kinds of psychotherapy but they need the drive to try and get better.

Don't discount the possibility that you don't have much to offer certain people who may be trying to manipulate you in the first place.

Just a thought (or two 🙂