EXPERT ANALYSIS FROM APA INSTITUTE ON PSYCHIATRIC SERVICES

WASHINGTON (FRONTLINE MEDICAL NEWS) – Imagine desperately wanting addiction treatment while living in a homeless shelter with many people who were using drugs. Could you remain sober for 6 weeks until treatment was available at an outpatient clinic – or would you bluff your way into treatment in an emergency department, where you would receive follow-up care within a week?

This is the kind of challenge that Margaret Balfour, MD, PhD, said she puts to her staff – and to anyone who treats patients they suspect are lying about this medical conditions. “Could [you], as a well-adjusted professional with reasonably good coping skills tolerate the things we ask our patients to do in order to help ‘appropriately’ ” asked Dr. Balfour , chief clinical officer at the Crisis Response Center in Tucson, Ariz., and a vice president for clinical innovation and quality at ConnectionsAZ in Tucson and Phoenix.

As one of several panelists in a session dedicated to detection and deterrence of malingering – defined in the DSM-5 as the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives” Dr. Balfour made her comments at the annual American Psychiatric Association’s Institute on Psychiatric Services.

Signs of malingering

On average, 13% of the people presenting in the ED malinger, according to panelist Scott A. Simpson, MD, MPH , of the department of psychiatry at the University of Colorado at Denver, Aurora, and the medical director of psychiatric emergency services at Denver Health. So, how can a clinician differentiate whether a patient’s story is fact or fiction, and what can be done to get the real story?

Classic signs of malingering include a notable discrepancy between observed and reported symptoms, reports of atypical psychosis, and inexplicable cognitive symptoms. “Watch for things that seem odd, such as late-in-life onset of psychosis, Dr. Simpson said.

One of the main ways to identify malingering is to use mental status and other exam; however, laboratory and neuropsychological tests have more limited roles. Lie detection tests specifically are very difficult to administer in the clinical setting, making them impractical.

Patients who grow increasingly irritated during the patient interview, even to the point of threatening suicide if their treatment demands aren’t met, also can be patients who malinger However, some data do not necessarily support this as cause for alarm, according to Dr. Simpson, who cited a studyshowing that among 137 patients who endorsed suicidality, the 7-year suicide rate among those who did so conditionally was 0.0%, compared with 11% in those who did not have conditional suicidality ( Psychiatr Serv. 2002 Jan;53[1]:92-4 ). The overall 7-year mortality in the first cohort was 4%, compared with 20% in the latter.

Rather than panic in such a situation, go deeper, said panelist John S. Rozel, MD , of the department of psychiatry at the University of Pittsburgh, where he also completed a master of studies in law program and serves as an adjunct professor of law. Dr. Rozel also is the medical director of the university’s re:solve Crisis Network .

“Maybe the person is worried they won’t be taken seriously,” said Dr. Rozel, explaining why some patients will escalate their claims and often are oblivious to their deceit. He shared an anecdote of having been called to treat a 14-year-old trauma patient with suicidality but who didn’t endorse any thoughts of self-harm during the patient interview. Instead, she told him that being suicidal is“what you say when you need more support, and the staff aren’t paying enough attention to you.”

Documenting the behavior

Even when clinicians are sure their patient is malingering, they often are reluctant to document it, according to Rachel Rodriguez, MD , an inpatient/emergency attending psychiatrist at Bellevue Hospital Center in New York.

“Malingering is lying, and lying is distasteful. It’s difficult to talk about,” Dr. Rodriguez said. “It’s also making a judgment about someone’s intentions, which is outside the bounds of what we are trained to do.”

Clinicians are reluctant to formally identify malingering for many reasons, Dr. Rodriguez said in an interview. Those reasons include:

• Future denial of necessary care.

• Fear of retaliation.

• Concerns about making a judgment about motives/intentions.

• Risk of misidentification.

• Fear of liability.

• Feeling sorry for the patient and helpless to address the patient’s actual needs.

Dr. Rodriguez said the underidentification and overidentification of malingering also include unique sets of risks.

At the session, Dr. Rozel agreed that an unwillingness to address malingering head-on does have its risks.

“Documentation is very important in medical malpractice. If we [record] our thinking in our notes, it’s kind of like high school math; you at least get partial credit if you show the work.” Thorough note taking includes recording the observations of all the personnel involved in the patient’s case, according to Dr. Rozel. As an example, he shared an anecdote of a patient endorsing suicidal symptoms in the interview with the clinician, but flirting with others in the waiting area, as witnessed by the admitting nurse.

Based on your observation and on a review of your patient’s prior history, Dr. Rozel suggested this partial list of notes and phrasing can be effective at establishing a “clear paper trail” should there need to be one:

• “Records show an established pattern of seeking inpatient services for … and delaying discharge during admissions of [include dates].”

• “Review of prior records indicates no evidence of clinical improvement for brief or extended admissions similar to her current presentation.”

• “A second opinion obtained from … concurs with …”

• “This case has been reviewed in detail with …”

• “Formulation and plan have been discussed with patient and other [relevant] providers, including …”

Dr. Rozel offered this caveat: “I am not a lawyer. The only thing I promise that your lawyer and I will agree on is that they would rather you get your legal advice from them and not from me.”

Reframing the situation

Understanding yourself first will help you understand the patient better, according to Dr. Balfour: “What underlies all this is how you are feeling. Being aware of this is important.”

The range of emotional experiences when dealing with a patient who malingers can run from anger at being lied to, frustration with wasted time and resources, helplessness that nothing seems to make a difference, fear of making the wrong decision, and even hatred borne of constantly experiencing all the other emotions, she said.

Being honest about your own emotions helps keep them out of the way of delivering better care, as does being mindful of the language you use to describe patients. Describing a patient to other staff in words that connote negativity, such as “manipulative,” “attention seeking,” or “high maintenance,” might influence others to see the patient as problematic rather than someone to be helped, said Dr. Balfour, who is with the department of psychiatry at the University of Arizona, Tucson.

Instead of labeling patients, “I find using the techniques of dialectical behavioral training very effective in dealing with [this population],” Dr. Balfour said. A more effective approach includes reframing your view of patients not as liars, but as people who are doing the best they can with what they have in a system that is often set up in ways that prevent, more than augment, care.

In that case, a person who lives in a homeless shelter and who wants help with a drug addiction, for example, will “understandably come to the emergency department to try and get admitted to the inpatient unit where they can get into rehab,” Dr. Balfour said. “Sometimes, our system makes people do things we find annoying in order to get the help they need.”

Instead of making the prevention of unnecessary admissions the goal, find a way to create a rapport with patients to determine their actual problem and see what can be done to solve it. This might take several engagements with the patient, often with more than one staff member. Using the statement, “I don’t feel like I’m getting the whole story” in the patient interview is an effective way to engage patients without accusing them of lying, Dr. Balfour said. “It’s like a magic phrase. Its effectiveness is predicated on the idea that all people, even those who dissemble or embellish, have a wish on some level to reveal sensitive, personal material.”

Remembering not to take malingering personally and that your role is “to be a detective not a bouncer” will help de-escalate untruths, and can lead to a partnership with the patient rather than enmity, Dr. Balfour said.

Dr. Balfour disclosed that she is a consultant for Connections Health Solutions and Otsuka. Dr. Simpson, Dr. Rozel, and Dr. Rodriguez had no relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

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