What would you do? Factitious DO patient willing to up the ante

[whopper]

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Got a patient that comes to the place I work for the past several years.

He has Factitious DO, and he's willing to "up the ante". Over the years, when doctors told him he wasn't appropriate for inpatient treatment, he found out he could fake suicidal ideation...

So he did it, and it got him in a few more times, but then the hospital got wise to what he was doing.

So then the hospital despite his claims of being suicidal wouldn't allow him as an inpatient--so then he superficially cuts his wrists....

Which will then get him in, for at least a day or 2, then he's discharged. The guy wants to be in for several days.
Now its to the point where he's actually seriously overdosed a few times to get in--he actually had to go to the ICU.

Now here's the problem.

Pretty much everyone I know who's treated him long term is convinced this guy has factitious disorder. However several doctors will put down he has a differing Axis I DO (Major Depressive DO, Bipolar, Schizophrenia, etc) for billing purposes.

This is a double bind-1-if you write he has factitious DO, the insurance company (and he has very good insurance which I never figured how he gets it becuase he's unemployed for years) won't want to pay for his stay, but this is what he has, but if you discharge him, he'll do a very real suicide attempt, and should this ever go to court, there's several doctors who have documented he has an Axis I DO that's not factitious DO.

or
2-continue to fake the diagnosi that have been going on for years by other doctors, pleasing the institution (he's got good insurance), keeping him safe (he won't attempt suicide). This is the all attractive option but its not honest.

Before anyone wants to get mad at my hospital--the department had discussed his case and decided he will for now on be dx'd with factitious DO & will not enable his condition any longer. The dept actually tried to steer him to do the right thing-get psychotherapy for factitious DO. However he still shows up to the crisis center with a very real suicide attempt which necessitates inpatient admission, & ends up going to a differing institution where they are all too happy to accept this guy with good insurance--he gets another med tacked on--(he was on 10 psyche meds last time I checked, 3 antipsychotics, 3 antidepressants, 3 mood stabilizers & klonopin), and the cycle continues.

 

[TheWowEffect]

Any substance abuse? How old is he?

Any social support? What about involving family or friends?

 

[whopper]

No substance abuse. In his early 50s. Caucasian male. This may be an inappropriate description but the guy gives me the "Tommy Flanagan" "Leo Getz" vibe. He's very nice, but you get this type of insincere-wimp impression from the guy & the way he conducts himself.

"Please put me in the hospital--if you don't, I'll be suicidal again" "I'm suicidal because I need the hospital, it makes me happy to be there". "why won't you put me there? That's what a hospital is there for, to make people feel better"

Social support? He will not discuss how he gets his insurance despite that he has been unemployed for years. Lives alone. Single, no children.
Will not provide any other information. He's been asked how he pays for his insurance & he never answers this question.

We've theorized he might have inherited some money that allows for his insurance. He's quite intelligent. He has a college degree, and I theorize he's smart enough to not blow his money & to keep his insurance paid. He's done it so far for several years.

He enjoys groups. I also theorized that perhaps he's got nothing to do, he's lonely and being on the inpatient unit satisfies all his needs--people to watch him, other people to socialize with. This is perhaps factitious DO in the worst extreme I've seen, and unfortunately the system's allowed this to go on for years.

I've considered doing an Intellius background check on the guy, but since it'd come out of my own pocket and I question the ethics behind digging this far into my patient's history, I haven't done so.

This is actually IMHO a very good case to publish, but I don't think I'll take it this far because I'll basically have to point out the other institution as being willing to take his insurance money & enable his problem. While that institution would've been kept anonymous--I could just imagine the repercussions.

 

[Faebinder]

I reread your post a couple of times. I think your department has done all it can and is doing the right thing. I personally would fully agree with their style of management. They gave him multiple chances, which is fair, but you have to draw the line when the problem continues.

 

[whopper]

I agree with you. However now he ends up going to the other institution and the cycle goes on.

Its not like they don't believe this is factitious DO. I've talked to several people on their staff & some of our own residents do electives there. Yet the cycle continues there.

Also, at our own institution, this guy ended up cycling here for some time and one of the attendings got fed up with the bull and pushed this issue to the dept. Pretty much all the attendings agree this guy has factitious DO. It went through a few phases..

1-first few times he got admitted-no one could tell and the dept had to go through the usual process of ruling out the possibilities he had another Axis I DO.

2-now we're realizing its factitious DO but some attendings kept putting a "real" axis I DO (yes I know factitious is real but you get my point), because they didn't want to take the risk or the guy was holding them hostage with the suicidal threat. Since there's multiple attendings in the dept, some nights the guy got in was the first night some attendings saw the guy & they weren't willing to discharge the guy when he's threatening suicide. Plus on top of that, when you got about 1 year's worth of diagnoses on paper that aren't factitious DO, should the case gone to court, its not going to look perfect.

3-finally the dept got sick of it and as a group mutually decided they must put their foot down.

Reason why I bring this up and ask "what would you do" is because for some time--the dept wouldn't put their foot down and as a clinician, the people here who wanted to do the right thing were in the double bind. It was a very difficult situation to be in for about 1-2 years.

And at the other place--they're not putting their foot down. The guy's good insurance coverage I'm sure is biasing this quite a bit because he's cycled through that place for about 3 years.

The institution needs to make money--but the patient clearly has factitious DO. It ended up working out on my end, but if you were a doc at the other place what would you do?

 

[nitemagi]

I think that one way or another you can specifically state that this patient does not benefit from hospitalizations. I know many hospitals basically have a blacklist for such individuals, for which extraordinary circumstances would be the only reason to admit someone. For this guy a full-blown SA might get him in the hospital, but I'd keep the stay absolutely minimal. Otherwise, refer the guy for therapy-- especially if he has such good insurance, and maybe they can help break the cycle. I wouldn't admit him. Just keep thorough records repeatedly stating that prior admissions have led to multiple axis I diagnoses but that these are all questionable even doubtful. Then just use a depressive d/o NOS for billing. Because that's what it is in some ways-- he doesn't meet criteria for the normal stuff (i.e. traditional axis diagnoses).

As for the other institution, that's a toughee. I'd say talk with someone covering him there, get him to consent to release of records from your institution to theirs, and really get the necessary documentation going overthere.

I swear I've seen like a dozen guys like this this year. They're incredibly high utilizers of the system, don't benefit from it, and end up preventing those that really would benefit from using it. In my eyes that lessens my sympathy, as sad of a case as it is.

 

[whopper]

We get a lot of malingerers & Axis II Cluster B patients pulling the same thing.

However most of them don't have good insurance--and because of that, the management eventually (for monetary reasons) put pressure for the cycle to end.

This is a case where its in the management's interest & those of lazy care givers to just let the guy get his way.

 

[Faebinder]

Lets go back to basics.

Should the insurance or payment status of a patient affect your medical decision? No... Take it from there. Do the right thing as if he was on medicaid. If he is going to jump institutions and the insurance system lets him, well shame on them and good for him.

 

[Wednesday]

We have a high utilizers program at one of our hospitals. It's for patients with borderline personality disorder to discourage parasuicidal behavior in an attempt to get into the hospital. They have a contract that says they can't come into the ED for a certain amount of time prior to a scheduled admission and that they can be admitted every 2-6 weeks and stay for a set number of days (usually 5) etc. They attend groups, have a special level (they can go off the unit as long as certain criteria are met), etc. Each patient has an individualized plan. Takes the reward out of being admitted because it's routine. Appears to work quite well and has a component of risk reduction because they stop doing things to convince you they are really in need of hospitalization. Might work with a guy like you're describing. Sounds like what he really needs is to find people on the outside who give him what the hospital does.

 

[Solideliquid]

We have a high utilizers program at one of our hospitals. It's for patients with borderline personality disorder to discourage parasuicidal behavior in an attempt to get into the hospital. They have a contract that says they can't come into the ED for a certain amount of time prior to a scheduled admission and that they can be admitted every 2-6 weeks and stay for a set number of days (usually 5) etc. They attend groups, have a special level (they can go off the unit as long as certain criteria are met), etc. Each patient has an individualized plan. Takes the reward out of being admitted because it's routine. Appears to work quite well and has a component of risk reduction because they stop doing things to convince you they are really in need of hospitalization. Might work with a guy like you're describing. Sounds like what he really needs is to find people on the outside who give him what the hospital does.

Very interesting. We have had one or two patients that had this plan applied to them. It's sort of like a reverse drug taper. Both patients in the end refused their second to last admission. We spaced the admissions out further and further until the patient just didn't want to come in, of course we sort of pushed them to come in the first few scheduled times.

Back to the OP, I see what you are saying about court. Since this guy has multiple attempts, some of which have landed him in the ICU, it is probable that one of these times he will accidentally kill himself. You may want to get a release from him, and speak to his other psychiatrists (other hospitals he has been an inpatient) and request they enter a lengthy addendum about his factitious d/o so that at least it is documented along with the other axis I.

Tread carefully, I can see lawyers point out (in a bad outcome event) that you may have been too focused on factitious d/o and avoided depression which is what they will say led to his suicide.

EDIT: I just want to add that I've been working in the VA for the last few months, jeebus we have like ten of these guys on the unit and there's NO WAY TO GET RID OF THEM. /end rant

 

[nitemagi]

Very interesting. We have had one or two patients that had this plan applied to them. It's sort of like a reverse drug taper. Both patients in the end refused their second to last admission. We spaced the admissions out further and further until the patient just didn't want to come in, of course we sort of pushed them to come in the first few scheduled times.

Back to the OP, I see what you are saying about court. Since this guy has multiple attempts, some of which have landed him in the ICU, it is probable that one of these times he will accidentally kill himself. You may want to get a release from him, and speak to his other psychiatrists (other hospitals he has been an inpatient) and request they enter a lengthy addendum about his factitious d/o so that at least it is documented along with the other axis I.

Tread carefully, I can see lawyers point out (in a bad outcome event) that you may have been too focused on factitious d/o and avoided depression which is what they will say led to his suicide.

EDIT: I just want to add that I've been working in the VA for the last few months, jeebus we have like ten of these guys on the unit and there's NO WAY TO GET RID OF THEM. /end rant

I'll bet. And with the VA new focus on suicide prevention I'd bet it's even harder. Our VA (SD) also has a similar preventive admission program for frequent flyer axis I disorders that for one reason or another decompensate and need many admissions. Easier to admit on a regular basis and tune them up is the logic, rather than let them reach the anticipated point of decompensation. Starts to lead towards what should be our future -- preventive psychiatry.

 

[whopper]

EDIT: I just want to add that I've been working in the VA for the last few months, jeebus we have like ten of these guys on the unit and there's NO WAY TO GET RID OF THEM. /end rant

Yep...what do you do in this situation?

In the example I brought up above---should this ever go to court, there's going to be years worth of documentation claiming this guy has bipolar, MDD, schizophrenia, schizoaffective, panic disorder, GAD, etc.

So if you're the doc that stuck to your guns & put factitious DO, how will the judge & jury interpret this should this guy kill himself & it ends up going to court?

We have a high utilizers program at one of our hospitals.

I think all hospitals should adopt one of these since there clearly are a portion of patients that fall into this category. I'm wondering how many hospitals have done this.
This is the type of case to me that is one of the most challenging in our field. Very few texts give advice on dealing with this type of situation.

I got a few more patients like this one--but they're not factitious DO. They're Borderline-with extreme parasuicidal behavior. The thing though with these that have made it easier for me is that these patients either 1-have pressure for discharge because of lack of insurance 2-they don't want to be in the hospital or 3-they're so dangerous--truly dangerous to themselves that they needed to be in the hospital. In any of these cases I never felt an ethical conflict because whether they were in the hospital or they were discharged, I felt I was doing my job right. I didn't feel the guy I mentioned fit in #3 because he was only dangerous if we didn't admit him. He used it as a type of terroristic threat. If I discharge or admit the guy--there's strong problems with either.

 

[Solideliquid]

Yep...what do you do in this situation?

Since it is the VA system (and this is the SATP) these most of these guys aren't even from the state I work in. The problem is they are kind of traveling to a new VA across the country every few months for shelter.

We have a 21 day and a 90 day inpatient program, guess which one these guys want? If you tell them you are going to discharge them, they claim they are suicidal. If their bed is open, they feel great! We had one guy who was at day 90 in our inpatient unit, on day 91 he was found on the street by the cops, drunk in a puddle of his own urine. On to the next VA!

 

[toby jones]

Interesting... I was going to ask why you don't dx him with borderline personality disorder and try and get him into an outpatient DBT program - espcially since he seems to enjoy a group setting environment and DBT has been shown to be effective for reducing self harm / suicide attempts and also for reducing inpatient days. Sure, it has been largely tried on females, but perhaps there would be a program in the region who would be willing to accept a male???

What makes you (and others) think that he has factitious disorder as opposed to borderline personality disorder? I'm wondering whether gender bias might come into it (e.g., if he was female whether he would likely have received dx of BPD). It seems to me that people are dxing him with factitious disorder on the basis of ASSUMING that he has a certain intent behind his behaviour (e.g., to gain attention). Marsha Linehan has this whole speel on ASSESSING rather than ASSUMING intent. Though... This is odd as often people with BPD similarly wish to be hospitalised as having some good social supports (e.g., in hospital) can result in their temporarily feeling better whereas refusal to hospitalise can often induce a self harm attempt in order to show others that YES things really do feel THAT BAD.

Is there a DBT program in the region? If so.. I'd say you are doing him a disservice in not at least referring him on to take the MMPI or what-the-****-ever entry requirements there are for the program.

Could help for the issues that are worrying him (you?) the most...

 

[whopper]

We believed he had factitious DO because he had all the criteria of that disorder.

He verbally stated he loved being in the hospital several times, never showed any objective signs of a psychotic illness other than his verbal declarations that he heard voices (no responding to internal stimuli, no negative sx of psychosis, no cognitive sx), he'd show inconsistent sx depending on the day (one day he's claiming he's depressed, the other day he's claiming to to have had a panic attack, another day he's claiming he's hearing voices).

Borderline? No. Of the criteria for BPD...

No frantic efforts to avoid real or imagined abandonment
No pattern of unstable relationships--he pretty much has none outside the hospital
No unstable sense of self image
No affective instability
No problems controlling anger
No transient, stress related paranoia or dissociation
No impulsivity that is self damaging other than the parasuicidal behavior (and the criteria for BPD does not put parasuicidal behavior in this specific criteria point)

He does have parasuicidal behavior. Yes that's a possible sx of Borderline, but he does it in direct correlation with not being admitted to the hospital. He does not show this behavior otherwise.

Chronic feelings of emptiness? I believe he has that, but he doesn't admit to it or show it, and he seems to fill it up with being in the hospital.

So he's only got 2 of the criteria-if you're willing to stretch it. IMHO he may only have 1-the feeling of emptiness. The parasuicidal behavior I think is too much of a stretch because he only showed it when we started referring him to outpatient instead of inpatient.

Actually as a first year resident I thought he had BPD because my understanding of that DO was limited. Several of the staff label any patient that ticks them off that does not have a clear Axis I a borderline--whether or not they have it. E.g. the patient has a differing Cluster B DO such as narcisism or histrionic PD and the staff label the person a borderline.

I remember as a first year, when this guy was discharged, right as he was leaving the door, he turned around, waved his arms goodbye and said "Thank you everyone, I'll see you in a few days!!" and he wasn't being sarcastic or crass. He had a lot of gratitude & happiness in his face as he said those words.


Well just a few days later, he was in the crisis center, and he was pulling his same old act. He was back on the unit a few hours later with a big smile on his face.

The MMPI idea is a good one and I suggested it. However I guess the dept wasn't willing to go down that road. The attendings I talked to about the MMPI on this patient told me they were confident the test wouldn't change their opinion of what was going on. The dept also has showed an unwillingness to do an MMPI on chronic malingerers, choosing instead to just discharge them.

 

[toby jones]

> We believed he had factitious DO because he had all the criteria of that disorder.

Well, yeah. I guess I'm just thinking that most people who meet criteria for one meet criteria for more than one. What is the treatment of choice for factitious disorder? I guess I'm wondering about how ethical it is to dx someone with something when there isn't a treatment for that. Especially when... DBT has been shown to be effective for 1) reducing inpatient days and 2) reduction in self harm which both seem to be what is most problematic about his behaviour. So... If there is anyway that a dx of BPD could be swung, and if there is anyway that he could get into a DBT program then that could save the health system... Er... How much? Also save clinicians the anguish of having a possible suicide on their hands after discharging him. Also save him from his institutionalisation and teach him to do some behavioural analyses of what his behaviour is doing for him and perhaps get him getting his needs met via more adaptive means...

> No transient, stress related paranoia or dissociation

Does he maintain that the voices are coming from inside or outside of his head? Does he hear them only when he claims he wants to be hospitalised or at other times as well? Voice hearing can be a manifestation of dissociation (hearing ones thoughts as 'other')

> he'd show inconsistent sx depending on the day (one day he's claiming he's depressed, the other day he's claiming to to have had a panic attack, another day he's claiming he's hearing voices

> No affective instability

That could (possible) be construed as labile affect / emotional instability??

> No frantic efforts to avoid real or imagined abandonment

Self harm gestures when the hospital system discharges / 'abandons' him could count.

> No pattern of unstable relationships--he pretty much has none outside the hospital

Avoidant personality frequently co-occurs with BPD... Some borderlines do avoid relationships - sometimes because they have had unstable relationships in the past and they appreciate that they are unable to foster stable caring relationships with others so they socially withdraw.

> He does have parasuicidal behavior. Yes that's a possible sx of Borderline, but he does it in direct correlation with not being admitted to the hospital. He does not show this behavior otherwise.

A fair number of borderlines only self harm when they fear abandonment. Not being admitted could be construed as an abandonment. This makes him typical of BPD not a-typical.

> Chronic feelings of emptiness? I believe he has that, but he doesn't admit to it or show it, and he seems to fill it up with being in the hospital.

Some borderlines deteriorate on admission and others do quite well on admission because of the increase in care / social supports in an inpatient environment. He could be in the latter camp.

> So he's only got 2 of the criteria-if you're willing to stretch it.

I think you could try looking again...

> Several of the staff label any patient that ticks them off that does not have a clear Axis I a borderline--whether or not they have it.

Yeah, and that is wrong. That isn't what I'm suggesting here, however. I think it sounds like he DOES meet criteria (and more importantly could really benefit from DBT if it was available to him).

> The MMPI idea is a good one and I suggested it. However I guess the dept wasn't willing to go down that road. The attendings I talked to about the MMPI on this patient told me they were confident the test wouldn't change their opinion of what was going on. The dept also has showed an unwillingness to do an MMPI on chronic malingerers, choosing instead to just discharge them.

So lets get this straight... They think he meets dx criteria for having factitious disorder and then they... Think that he isn't entitled to any treatment for his condition whatsoever? I don't understand why they aren't super dooper keen to pass this guy off on psychology. There is a difference between malingering (no psychological benefit) and factitious disorder (psychological benefit) and the latter should surely be treated. I would say... Discharge without follow-up treatment at your peril. I wouldn't want to play chicken with this guy and hear that he had killed himself on discharge...

 

[whopper]

Several good questions
I don't think its unethical to dx him with factitious, especially since this was what about 6 attendings, all the residents in the program and pretty much the entire staff thought he had.

DBT as far as I know (and I could be wrong) doesn't have any applications to factitious DO. As I mentioned above, we tried to get him to see a therapist for psychotherapy as an outpatient and he didn't follow that reccomendation. We were going to let that psychotherapist decide which type of psychotherapy would be used.

Does he maintain that the voices are coming from inside or outside of his head? Does he hear them only when he claims he wants to be hospitalised or at other times as well? Voice hearing can be a manifestation of dissociation (hearing ones thoughts as 'other')

Well his presentation was inconsistent. He'd change it pretty much everytime he saw us. Whether it was inside or outside. He showed no objective sx of psychosis or for that matter dissociation. (though good to see you're considering all the alternatives)

> he'd show inconsistent sx depending on the day (one day he's claiming he's depressed, the other day he's claiming to to have had a panic attack, another day he's claiming he's hearing voices

> No affective instability

That could (possible) be construed as labile affect / emotional instability??

I should clarify this and I apologize for any misrepresentation. The guy's presentation was pretty much consistent in terms of affect & behavior. Its his story that would change. E.g. he'd claim he was depressed but had a euthymic affect. Next time he's in the crisis center, he again has euthymic affect but is claiming to be hearing voices and that if we don't admit him he'll commit suicide.

> No frantic efforts to avoid real or imagined abandonment

Self harm gestures when the hospital system discharges / 'abandons' him could count.

IMHO that is a stretch. People with borderline show efforts to avoid abandonment in several aspects of their lives. Its the malingerers or people with factitious DO for example that start getting upset when confronted with their duplicity. This guy only got suicidal if you told him you were going to refer him to outpatient. Since he showed no parasuicidal behavior in any other regard-I didn't consider this an effort to avoid abandonment. Though if you did consider it, it still doesn't satisfy enough BPD criteria.

Avoidant personality frequently co-occurs with BPD... Some borderlines do avoid relationships - sometimes because they have had unstable relationships in the past and they appreciate that they are unable to foster stable caring relationships with others so they socially withdraw.

He didn't show any criteria of Avoidant PD. Actually he was quite comfortable in the inpatient unit and was very friendly with staff & other patients. He didn't show any sx of BPD or any other personality DO in the unit. (another reason why we were all confident he didn't have BPD-if he did, he would've showed sx of it on the unit. Remember we had him coming in for years).

In the unit--he was well, very happy & stable.

A fair number of borderlines only self harm when they fear abandonment. Not being admitted could be construed as an abandonment. This makes him typical of BPD not a-typical.

Well pretty much touched on this one above.

I think you could try looking again...

I have for years--so have several others--at several institutions. Seems like the more you know him, the more convinced you are of factitious DO. The guy as I mentioned above admitted he loves being in the hospital.

So lets get this straight... They think he meets dx criteria for having factitious disorder and then they... Think that he isn't entitled to any treatment for his condition whatsoever?

I don't think I ever stated the dept didn't want to treat him. The dept did want him treated by outpatient.

I don't understand why they aren't super dooper keen to pass this guy off on psychology.

Agree with you completely. I don't know what it is--tribal grouping, politics, what have you. The only time I've seen psychiatrists try to get an MMPI done for Malingering or Factitious DO was in a forensic setting. I suggested an MMPI be given but was told that wasn't going to be done. Heck-if K&S says its one of the tools, and considering the severity of this situation--why not use it? Seems to be happening at a lot of hospitals. I haven't seen many psychiatry depts do an MMPI on a malingerer or a factitious DO patient.

 

[whopper]

double post

 

[toby jones]

My thought about the diagnosis was that often the appropriate dx is far from clear and sometimes it might be better to give a dx that will facilitate the patients getting some treatment.

Perhaps this depends on your theory... But I guess I kinda think of certain conditions (factitious disorder, hysteria, borderline personality disorder etc) as being fairly inter-related. With respect to the underlying motivations for the pathological behaviour and hence... I guess I think it is likely that a treatment that is effective for one manifestation might well be expected to be effective for other manifestations as well. Not sure whether the EBM studies have been done, but I suppose I'd be more surprised if he didn't find some benefit to DBT.

For example, DBT would get him doing some behavioural analyses. Why does he want to go to hospital? What does that do for him? Would he prefer something different in life (e.g., to have those needs met outside the hospital environment). DBT has been shown to be effective for reducing inpatient days. People with borderline personality disorder sometimes want to be hospitalised and threaten to hurt / kill themselves if they are not admitted. DBT tries to teach people some coping skills such that they can cope outside of a hospital environment. Reduction in self harm, reduction in inpatient days. Bingo.

I think that you said that he likes group therapy. DBT has a group therapy component. In fact... Sometimes people start DBT in an inpatient setting and then stick with it through the transition to outpatient. The idea is that instead of simply refusing to admit crisis services etc have a management plan of 'practice your skills' and talking them through that until the next DBT group meeting or individual therapist meeting.

Some people aren't sure whether the voices sound internal or external or they vaccilate between regarding them as internal and regarding them as external. Might be that in times of stress thoughts are experienced as internal but 'other' and that in times of great stress thoughts are experienced as external and other. It has often been said that people with BPD can present in an inconsistent fashion, too. That they can seem happy on the ward but when you ask them how they are doing they will go on about how terrible everything is while objectively seeming euthymic. Hence the 'manipulative', 'attention seeking', and 'liar' adjectives being applied to people with borderline personality disorder.

I guess I'm concerned that people are assuming that he is lying when he talks about hearing voices. If you believed that he was telling the truth about his experience then that would constitute a dissociative symptom. If it occurred in times of stress (e.g., when it didn't look like he was going to gain admission / when it looked like he was going to be discharged) then that would constitute the 'transient psychosis' aspect of the criterion for BPD.

> People with borderline show efforts to avoid abandonment in several aspects of their lives.

Not necessarily. As I said, avoidant personality disorder is the most frequent second personality disorder dx for people with borderline personality disorder. He didn't seem avoidant on the ward - but that was where he seemed to exhibit the intense fears of abandonment...

Matter of interpretation, I guess. I guess I'm mostly thinking that DBT might be able to help him (reduce inpatient days, reduce threats of / attempts to self harm). It might also be something that he would consent to doing since he likes a group setting.

I wonder if the thing with not getting an MMPI done for malingering / factitious is that these are the disorders with the most stigma from mental health professionals. Similarly to how people had trouble with the BPD dx being applied to 'difficult' patients before the development of DBT as an effective treatment I have trouble with the factitious disorder dx being applied to 'difficult' patients as there isn't really a treatment for that... Is there? Or if there is... It is to treat the underlying personality disorder...

 

[whopper]

Thoughtful post Toby.

I too agree its wrong to label someone as "factitious" if they are "difficult". Actually one of the most difficult things about this case is the easy thing to do would've been to just write him off as MDD or Psychosis NOS and let him continue his cycle. The difficult thing was to put the foot down. The market forces, the severity of his suicide attempts & him being a "nice guy" make it easy to just keep the cycle of false but billable treatments going on.

The guy is nice on the unit, he likes group tx (on inpatient--doesn't want to attend any outpatient services we referred him to, even group tx @ acute partial), he's very nice to staff & attendings.

I think an MMPI should've been used. IMHO the reason why it wasn't is that psychiatrists aren't using it much these days, and there seemed to be a resistance to using a psychologist. I'm not sure what it is. I've been given several answers by my attendings. I think some of it was that some attendings have no experience with using an MMPI. Some of it was that they felt the outpatient therapist should've been the one going that road because its impractical to use in a crisis & inpatient STCF setting.

I agree the guy could've benefited from psychotherapy--but he wasn't going to outpatient.

My own analytic perspective is this guy is unemployed & has nothing to do to occupy his time. Instead of getting a job, or a hobby, he's chosen to be a "professional patient". He enjoys being taken care of by staff & tries to take center stage in groups.

 

[OldPsychDoc]

...My own analytic perspective is this guy is unemployed & has nothing to do to occupy his time. Instead of getting a job, or a hobby, he's chosen to be a "professional patient". He enjoys being taken care of by staff & tries to take center stage in groups.

Perhaps he could be offered a job teaching rectal and inguinal hernia exams to medical students...

 

[TheWowEffect]

Perhaps he could be offered a job teaching rectal and inguinal hernia exams to medical students...

.....or he can be hired as an inpatient group/occupational therapist. I am sure he'll be pretty good at it by now😀

 

[Anasazi23]

Some claim that so-called hospital addiction is the same entity as factitious disorder. I feel I tend to see a difference in the manifestation of the pathology, however. With the former presenting with less distinct or poorly defined symptoms that are garner less rage when confronted. High comorbidity with dependent PD, it seems. Many of these patients, however, have no outside social structure, and others can't tolerate their presence. Their dependency, therefore, falls on helpless medical professionals who by definition, cannot simply turn him away or ignore him completely.

 

[toby jones]

> The difficult thing was to put the foot down. The market forces, the severity of his suicide attempts & him being a "nice guy" make it easy to just keep the cycle of false but billable treatments going on.

So the decision has been to play chicken with this guy. He might well up the ante on the suicide attempts either in order to gain admission or in order to manage the distress caused by a refusal to admit. He might well (intentionally or unintentionally) kill himself in the process... I guess the thought is that outpatient services has been offered to him and so if he declines to take them up on their offer then there is little more that can be done. I mean this guy isn't psychotic - he is perfectly able to make an informed treatment decision (or refuse treatment) all by himself...

I'm still concerned about this.

I didn't know that p-docs were qualified to administer and score the MMPI - I thought psychological testing was something that the clinical psychologists were trained to do...

> My own analytic perspective is this guy is unemployed & has nothing to do to occupy his time. Instead of getting a job, or a hobby, he's chosen to be a "professional patient". He enjoys being taken care of by staff & tries to take center stage in groups.

That reminds me of a very old take on hysteria in females. The verdict was that they presented with paralysis and other symptoms in order to elicit care from others (their intention could well be unconscious). The prescription? Marriage. It was thought that looking after children (not to mention a good ****ing) would be the perfect cure.

I was going to ask whether the guy was homeless (to try and get at whether there might be secondary gain).

I still think referral to psychological services (and potentially DBT) would be a good bet. Even if the DBT was started on an inpatient basis and then they could manage him in the transition to discharge and to an eventual 'no admit' policy. DBT is good at managing 'playing chicken' behaviour. Lives have been saved (whether the patients were manipulative, lying, attention seeking or whether more charitable interpretations are possible). Lives have been saved...

 

[Anasazi23]

Good luck finding an inpatient DBT program. There isn't enough time or money.

The MMPI is over 500 questions long, and is difficult to get inpatients to complete. If he were to complete it, it would likely have a high "fake bad" elevation. This probably isn't extraordinarily useful on an inpatient unit.

 

[whopper]

So the decision has been to play chicken with this guy

I wouldn't call it chicken.

If you claim to write on documentation that the guy had a disorder other than factitious, you are committing medical billing fraud. Reason being that pretty much everyone working on this guy believes that's what's going on & is confident in that dx. This is not a 1st time presentation. He's been seen for years by several different staff & attendings who have come up with the same conclusion.

Nor would it be ethical to put someone in the hospital under false pretenses.

I guess the thought is that outpatient services has been offered to him and so if he declines to take them up on their offer then there is little more that can be done.

Yep.

If a patient refuses to get treatment, you can't force it upon them.

You offer an alcoholic patient who's not commitable a referral to AA and they refuse, and refuse pretty much everything else you offered them for treatment--you can't do more.

He was offered outpatient psychotherapy--which could've provided DBT. He didn't take it. No STCF I know of provides DBT-since you wouldn't see any benefit from it for quite some time (months--STCF can only hold a pt for up to 1 month, they are usually only held for a few days). Maybe yours is different.

I was going to ask whether the guy was homeless (to try and get at whether there might be secondary gain).

He's not homeless.

This probably isn't extraordinarily useful on an inpatient unit.

Exactly.

I personally would've preferred an MMPI be done. However this was what some of the attendings gave as an answer. I got some differing answers, but that was the answer I got from the attendings I felt actually knew what they were talking about. They stated even if the MMPI didn't push in the direction of malingering or factitious DO, it still wouldn't have changed their minds on it because they had seen the guy for years. My own opinion was that it still should've been done simply for liability reasons.

In any case, analyze the ethics & morality. He's got private insurance--he ends up going to the other STCF (a private facility)-they take the insurance money, slap on another dx, and he gets 1 or 2 of his 6-14 psychiatric meds changed. So apparently-its not playing chicken. Its a revolving door where both he and the facility get what they want.

 

[whopper]

feel I tend to see a difference in the manifestation of the pathology, however. With the former presenting with less distinct or poorly defined symptoms that are garner less rage when confronted. High comorbidity with dependent PD, it seems. Many of these patients, however, have no outside social structure, and others can't tolerate their presence. Their dependency, therefore, falls on helpless medical professionals who by definition, cannot simply turn him away or ignore him completely.

Agree. This is the situation going on with this guy. He's a nice guy, but the type of guy no one would invite to a party, which is why I mentioned he gave the "Leo Getz/Tommy Flanagan" vibe.

http://www.youtube.com/watch?v=mOcoTnXHoDs

Seems to me the guy's lonely and this is the only thing he can come up with to occupy his time.

 

[toby jones]

> If you claim to write on documentation that the guy had a disorder other than factitious, you are committing medical billing fraud.

I think that often a patient who meets DSM criteria for one disorder meets DSM criteria for more than one DSM disorder. The rationale for the arbitrary exclusion criterion on certain diagnoses is partly provided in order to attempt to restrict co-morbid diagnoses. Even with present arbitrary exclusion criteria people who meet DSM criteria for one disorder are more likely to meet the criteria for one or two or three other disorders than to meet diagnostic criteria for just one, however. I'm not attempting to argue that the diagnosis of factitious disorder is wrong - I am attempting to argue that people should be willing to consider co-morbid (underlying) personality disorders, however. How come?

Once again:
The guys major problems seem to be
1) Number of inpatient days
2) Risk of self harm / suicide when he is not admitted to an inpatient unit.

DBT has been empirically shown to be the most effective treatment for reducing the above two symptoms. Because of that (pragmatically if for no other reason) I suggest your carefully looking again at whether his symptoms could be construed as meeting criterion for borderline personality disorder. How come? If you diagnose him with factitious personality disorder ONLY then while he is offered outpatient services clinicians will typically accept his refusal to take them up on that offer. If you diagnose him with borderline personality disorder IN ADDITION then he will likely be pressured to take clinicians up on that offer, however. That diagnosis offers hope that he can constuct a life worth living outside a hospital environment. THe only treatment reccomendations I've seen for factitious disorder involve TREATING THE UNDERLYING CHARACTER PATHOLOGY. So I ask you: What is his underlying character pathology? Sounds like Borderline personality with the (typically comorbid) avoidant personality to me.

You can construe his symptoms in that way. You don't HAVE to. But if you CHOOSE to then treatment options become available to him that never were before. I don't think it constitutes billing fraud anymore than construing people with borderline personality disorder as having 'rapid cycling bi-polar' constitutes billing fraud. Often diagnoses really are a matter of interpretation (within certain limits for sure). But these neurotic types... Oh, how many DSM diagnoses there are to pick from! How to choose between them (or how to choose how many different ones to give?) well it depends on what that buys the client - of course. In this case it could buy him: A certain variety of treatment that is likely to be effective for his main problems. Also: Hope that he can build a life worth living outside a hospital environment.

Truth 'by consensus' is the major driving force behind the DSM. Thats how come homosexuality was taken (read 'voted') out, thats how come this guy gets to count as having factitious personality disorder. Be pragmatic for a sec... What does dx of factitious disorder buy him in terms of treatment and in terms of likely prognosis? Nothing - that is what. What does dx of borderline personality buy him in terms of treatment and in terms of likely prognosis? Help with the issues that are of most concern, that is what. I'm not asking you to lie. I'm asking you to LOOK AT HIS SYMPTOMS AGAIN. With the pragmatic benefits in mind. You can't say that that isn't what psychiatrists do when it comes to dxing 'rapid cyclling bi-polar' instead of borderline personality disorder. Matter of interpretation... Look again...

> If a patient refuses to get treatment, you can't force it upon them.

There are involountary treatment orders that are sometimes given. I wouldn't be so sure that this guys pathology doesn't render him dissociative / psychotic when he is refused admission. Of course if 99% of psychiatrists agree he has factitious disorder and is simply attempting to 'manipulate', 'lye' and 'deceive' in order to gain admission then you buy yourselves a clear conscience (and a likely 'not responsible' verdict in a court of law). But really, DBT could be a terrific thing for such clients who do indeed seem to be playing chicken such that they might well kill themselves if you refuse to admit.

Even if the guy is simply 'lonely and looking for a way to occupy his time' trying to be an inpatient seems to be a particularly pathological way of attempting to occupy your time. Seems to suggest some sort of inability to occupy his time with alternative, socially acceptable, ways of doing that. So... Seems to suggest that he legitimately needs some assistance with sorting out socially appropriate ways of occupying his time.

DBT attempts to provide people with the skills such that they can attempt to get their needs met in an outpatient environment. Have you assessed whether he has those requisite skills in an outpatient environment? IF not... Then I'd suggest you don't know enough to make a differential diagnosis...

 

[whopper]

Whether or not DBT would be the best thing for him, he chooses not to pursue outpatient psychotherapy, where it could be explored.

The outpatient services we have referred him to is part of our own institution. The dept decided they would allow him to get psychotherapy as an outpatient. The outpatient office would not have turned him away. He chose not to get it.

Reconsider his diagnosis again?. Have for years--repeatedly. Each time he comes in.

The DSM-while a very useful tool does not diagnose everything. There are of course "NOS" disorders worthy of treatment.

 

[whopper]

double post

 

[MBK2003]

The DSM-while a very useful tool does not diagnose everything. There are of course "NOS" disorders worthy of treatment.

I once had an attending who when discussing a similar situation stated,
"The DSM just doesn't have a category for poor defenses and a miserable existence."

That summed up a couple of our ER frequent fliers who didn't have comorbid substance abuse.

 

[Faebinder]

I once had an attending who when discussing a similar situation stated,
"The DSM just doesn't have a category for poor defenses and a miserable existence."

That summed up a couple of our ER frequent fliers who didn't have comorbid substance abuse.

That's deep.

 

[whopper]

That summed up a couple of our ER frequent fliers who didn't have comorbid substance abuse.

Its unfortunate that this is the reality of practice in several areas, yet the texts only talk about the "obvious" things.