Download malingering - Karen Tipton Murder

MALINGERING
Malingering is the conscious, purposeful “faking” of a medical or
psychiatric illness for “secondary gain.”
Malingering is similar in some ways to somatoform disorders, and to
factitious disorders. However, there are also distinct differences. A patient
with a factitious disorder, like Munchausen’s, does not pretend to be sick in
order to get drugs, money, or disability. No--they lie, exaggerate, and
actually make themselves genuinely ill in order to simply be a patient. The
symptoms—like fever—are quite real, and they are purposely created, e.g.
by injecting themselves with feces. It is quite rare.
On the other hand, somatoform (psychosomatic) disorders are
everywhere. In these disorders, medical symptoms may be grossly
exaggerated, as in hypochondriasis and somatization disorder. Perhaps the
most extreme form of somatization is conversion disorder. In conversion,
the symptoms (with no medical basis) are very real, e.g. paralysis or sensory
loss, and the reason for it is unconscious, as well. I dare say there is no
psychiatric disorder more intriguing than conversion, where the unconscious
mind creates genuine loss of function.
Family practice physicians routinely report ¼ to ¾ of their patients in
a given day having psychosocial problems presenting with a somatic
complaint. I’m not implying these are all malingerers, because they clearly
are not. Most of them, however, have some form of somatoform disorder,
and likely very active Axis II’s and IV’s.
It is a population that consumes an inordinate amount of limited
healthcare resources, about six times that of the general population. I point
this out to make sure you understand the backdrop of malingering. Do not
picture it as malingerers vs. “normal patients” when half of “normal
patients” aren’t really medically sick. I should also point out the uncertainty
of medical and psychiatric diagnosis. It is not a perfect science. There is
always another test that could be run to rule out a rare cause of an atypical
set of symptoms. Sometimes it can be difficult or impossible to tell what is
real from what is imagined or faked. And sometimes it’s so easy as to be
laughable.
In simple terms, patients can have symptoms for “psychological”
reasons. When the symptoms are real and the motivation is unconscious, it
is conversion. When the symptoms are not “real,” or are exaggerated, and
the motivation is unconscious, it is hypochondriasis or somatization
disorder. I should mention somatic symptoms can also be fully delusional,
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in the case of “delusional disorder, somatic type.” It is important to
emphasize these “psychosomatic” patients are not “faking.” They are in real
distress, and may want treatment they don’t need, and may not want
treatment they do need. They can be the most difficult of patients.
Malingerers are unique in that they purposely fake symptoms in order
to get something, and they know exactly what they want and why.
Malingering is not even a psychiatric disorder. It is a “V-code,” like a
marital problem or failing grades. To be entirely accurate, malingering is
not diagnosed—it is detected. It is grossly under-reported, because there is
often no incentive to do so. Many physicians are reluctant to make the
diagnosis; indeed, many physicians have never actually formally diagnosed
it, although they might see malingerers on a daily basis, and know it. Why?
You don’t get paid for V codes like malingering. As a matter of fact,
the entire process of assessment necessary to detect malingering will not be
paid for, either. There are financial, legal, and personal-safety incentives
to not diagnose it. I’ll address each of these incentives in the course of the
talk.
How large a problem is faking and lying for secondary gain? No one really
knows.
If you look at the larger picture, about 100 billion dollars a year are
lost to insurance fraud in general—about 10% of all claims. Your insurance
premium is 1-2 thousand dollars greater per year to pay for it. Counterfeit
products, like Rolex watches and designer clothes, are another 100 billion
dollar-per-year business. Almost a million people lied to FEMA to get the
$2000 Katrina payment—almost a third of all those getting the money.
But again, nobody knows how many people are malingering and lying
and what it’s costing. After all, in the end, it’s lawyers that decide when a
person is malingering and when they are genuinely injured or disabled. And
lawyers enjoy the second-worst reputation for trustworthiness of all
occupations, considered slightly more trustworthy than used car salesmen. It
is safe to conclude that a large number of people lie, cheat, and steal, and are
rewarded for it—at all levels of our society. In other words, crime pays. If
you don’t believe it, you’ve probably never heard of Pablo Escobar.
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Practical Observations
If you need a place to sleep tonight, all you have to do is go to an
emergency room and mention the word suicide and you will likely be
hospitalized, whether you want it or not, and whether you need it or not. It
is the ticket in. It’s helpful if you say you’re depressed, and you get extra
points if you’re hearing voices, especially if they’re telling you to kill
yourself.
Needless to say, malingering suicidal ideation, depression, and
psychosis are the most common pathway for malingerers to arrive on a
psychiatric inpatient unit. In a general hospital setting, including emergency
rooms, it is most commonly pain that is being malingered in order to obtain
opiates. In a physician’s office, it is all of the above, but whatever the
practice, you are likely to find LOTS of patients wanting opiates,
benzodiazepines, disability forms, and doctor’s excuses. I’ve joked many
times that if I ever wanted to get rich, all I’d have to do is set up a drive-thru
psychiatric practice, selling diet pills, pain pills, benzos, and doctor’s
excuses. I think I’d set it up on Ocrakoke. If I did, I betcha’ they’d have to
run another ferry to handle the traffic. My other old joke is that the two best
drugs ever invented are opiates and benzodiazpines. They’re so good,
patients actually WANT to take them, whether they need them or not.
Malingerers admitted to general hospitals are relatively young,
averaging in the mid-30’s. There are as many women as men malingering.
They usually stay in the hospital a few days, and some stay much longer.
They often have diagnoses of antisocial personality disorder and/or
borderline personality disorder. They are unstable and self-destructive
people who are not subject to change. They tend to receive larger than
average amounts of opiates and benzodiazepines.
THE DETECTION OF MALINGERING
The patient can only fake as well as they know the disease they are
faking.
Their perception of the disease is often based solely on what they see
on television. And what they see on television is absolute hogwash.
They receive better training while in psychiatric hospitals, and will often
take on the symptoms of other patients on the unit. They might learn enough
to realize EPS occurs with antipsychotics, but not know that Seroquel
doesn’t cause EPS. In other words, they might be able to feign a side effect
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in a very dramatic fashion, but might miss a fundamental detail—like it
takes more than 2 minutes for a pill of Cogentin to work.
They are the patients that complain of a full-blown panic attack with
normal vital signs and no apparent distress. They complain of excruciating
pain, far out of proportion to any injury present. It all just depends on what
they want, and a lot of them just want money, in the form of disability. In
the short term, they’d like opiates and benzodiazepines.
Malingering psychosis is extremely common. Hallucinations are the
most-reported symptom, so it’s important to understand genuine
hallucinations and the disorders that cause them. Schizophrenics
overwhelmingly report auditory hallucinations, but only four percent of
schizophrenics report visual hallucinations. Almost half of malingerers
report visual hallucinations. This is an example of “actuarial” psychiatry—
basing diagnosis on statistics. The character and description of the
hallucinations may be atypical for psychosis, also. A typical malingered
visual hallucination is “I think I see something and then I get a better look
and it’s gone.” This isn’t even an hallucination, it is an illusion. The
malingerer will often report their hallucinations while going off to sleep or
waking up (hypnogogic or hypnopompic), which are also not true
hallucinations. Another common theme is to complain of vaguely sensing
the presence of a dead loved one, which is entirely normal and not indicative
of psychosis. Some patients even report their hallucinations as occurring
while they sleep, which is almost comical.
It’s common for malingerers to report thinking they hear their name
called, or to claim to hear voices telling them to hurt somebody just before
they hurt somebody and go to jail. Malingerers may have difficulty giving
details of their hallucinations. Note, of course, that psychotic people may
have difficulty giving details, too, but it is more often that they DENY their
symptoms. The psychotic patient is likely to be guarded, even paranoid. It is
common for a psychotic patient to be responding to hallucinations while
denying their existence. The malingerer will be eager to report his
hallucinations—he just might not be able to give a believable performance.
It is vital to understand the concept of thought disorder. “Thought
disorder” literally means a disorder of thought, as manifested in specific
speech patterns. Loose associations are very difficult to fake. If a patient
displays a normal range of affect, appropriate to content, and a normal form,
rate, and progression to their speech, then you should be suspicious of the
patient claiming to be depressed, suicidal, and hearing voices. The content
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and the presentation need to match. When it doesn’t, it’s called a
dissimulative disorder.
Visual hallucinations, incidentally, are more common in drug
withdrawal and drug intoxication states. They are also more common in
“organic” causes of hallucinations, such as delirium. A patient in DT’s will
often hear voices, often of a voice in the next room saying bad things about
them, and they will see visual hallucinations, too, including Lilliputian
hallucinations. They’ll have tactile hallucinations, such as formication—
their skin is literally crawling. It is important to note that actuarial
psychiatry requires the understanding that “real” disorders can have atypical
symptoms—like a schizophrenic who reports seeing and feeling himself
being stabbed repeatedly in the abdomen. What makes him different is that
he spends most of his time utterly preoccupied with it, and shows the
genuine suffering one would expect. Great misery is not hard to discern, and
it is difficult to fake for any length of time.
NENC has its own standard script for malingering: Suicidal,
depressed, and hearing voices. It is one thing to say “I’m depressed” and
another altogether to appear and act depressed. A patient who says they are
depressed and does not look or act depressed is probably not depressed. If
you ask open-ended questions on assessment, they will often be unable to
describe any collaborative symptoms. On the other hand, they will endorse
any symptom offered. They’ll offer symptoms like “stress” and not wanting
to be around people—not collaborated by their party hearty lifestyle. There
is a caveat here: depressed people often feel worst in the morning, when
most “treatment” is occurring. They feel better in the evening, and might
stay up playing games on the unit. It is easy to misinterpret this as resistance
to treatment and having a party all night. Sometimes that’s exactly what it
is, and sometimes it’s just the normal diurnal variation of major depression.
Having said that, I am profoundly skeptical of the number of patients I
see with the diagnosis of major depression with psychotic features. Much of
it is a function of malingering and sloppy diagnoses. The psychotic
symptoms associated with mood disorders occur at the extremes of mood.
In other words, there is no such thing as major depression, recurrent, mild
with psychotic features. My point is that I see patients all the time, often on
disability already, with chronic mild depression—probably dysthymic
disorder—personality disorders, and substance abuse. They’ll carry
diagnoses of major depression with psychotic features or bipolar disorder or
schizophrenia—and they will have zero evidence of severe depression, or
mania, or bipolar disorder, or schizophrenia. Zero. Not in their current
presentation, or in any history available. Their reported symptoms, when
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adequately assessed, are not consistent with known psychiatric disorders (or
are at least very atypical). They aren’t depressed, they aren’t psychotic, and
they aren’t suicidal. But they’re in my hospital saying they are.
In the end, detecting malingering requires you to know more about the
illness than the patient. And even then, the diagnosis might not be obvious,
and it might not be certain.
I might point out that many, if not most malingerers have other
psychiatric disorders. They often have substance abuse or dependence, may
be genuinely depressed (for a host of obvious reasons), may have a
personality disorder (especially antisocial or borderline), and may have
significant medical problems, too. In the end, you have to consider “how
sick is it to pretend to be sick?”
The answer is: You have to be pretty desperate.
How do you treat it?
In a sense, you DON’T treat it, because it’s not an illness. There’s
nothing to “treat.” That’s the whole point, isn’t it? But that doesn’t make the
problem go away, does it? They’re still in the emergency room, feigning
symptoms to get admitted somewhere. If you don’t admit them, then if they
want in badly enough, they’ll up the ante with a scratch on the wrist or a
token overdose, or any level of drama and legal threat they can muster.
If they are persistent, the malingerer will always win, no matter how blatant
the malingering. They will be admitted somewhere, because nobody wants
to actually document they believe the patient is malingering, and should be
discharged home. The reason?
Because the ED doctor, if not the psychiatric screener, will insist on
admission “because he might go out and do something stupid and I’ll be
accountable.” I’m not picking on ED doctors. Psychiatrists are rarely any
better at this, and if a psychiatrist won’t “put his money where his mouth is,”
then why should anybody else? It is simply too easy to take the path of least
resistance. And, incidentally, there is a very good reason for this type of
defensive medicine—the legal system in our country is utterly out of control.
You WILL be punished for being truthful and ethical.
A lot of these patients get admitted to acute care psychiatric units, and
are frequently discharged within a few days (if not the same day). Those
who malingered to avoid going to jail the day before will be ready for
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discharge when they arrive. Those who malingered to have a place to stay
will leave only when made to leave, often with great protest and threat of
suicide or homicide. These patients are not generally welcomed back. Once
such a “frequent flyer” has exhausted the generosity of local facilities, the
ED is left with the patient going to the state hospital, where they will often
be discharged within a few days (if not the same day). And might well be
back in your ED the very night they’re thrown out of Cherry, doing it all
over again. And again. I’ve thrown malingering sociopaths out of hospitals,
with them screaming threats of suicide (and even homicide). They never
killed themselves, or anybody else (yet). Instead, they go immediately to the
closest emergency room and claim to be suicidal. I have told many patients
like this that if they kill someone, they will be held accountable and will go
to prison. They won’t be able to fake a doctor’s excuse. It was a serious
mistake for them to get a psychiatric evaluation just before killing somebody
that shows they are competent and not mentally ill. And I document very
clearly my reasons that the patient is dangerous, but not on the basis of a
treatable Axis I disorder, and should be held accountable for his actions.
It seems everyone’s solution is to send this type of non-patient down
the line to someone else. At some point, somebody has to (or at least needs
to) actually evaluate the patient and document the findings and justify the
discharge in terms of risk vs. benefit, knowing it is high-risk in medico-legal
exposure. And tell the truth: the patient is at increased risk of suicide,
homicide, and assault. After all, a typical malingerer is actively addicted to
crack cocaine and is funding his addiction through exclusively illegal means.
He or she is living a highly lethal lifestyle, and are on an unremitting course
of self-destruction, and none of it has anything to do with an Axis I treatable
disorder. They will be no less dangerous if kept for a month in a facility.
They are just dangerous INSIDE a facility. They are not seeking treatment.
They are lying. They are not participating in their treatment. They are
entitled. They are disruptive of a psychiatric inpatient milieu, and pose a
genuine danger to the “real” psychiatric patients there--patients who are
particularly vulnerable due to their illnesses. They deserve better than to
have to deal with dangerous sociopaths masquerading as psychiatric
patients.
You must clearly make a distinction between dangerousness and
mental illness. Folks in ED’s are often dangerous and not mentally ill. It
doesn’t mean you admit them to a psychiatric hospital. But that is exactly
what is done, and they are often promptly discharged, after given time to
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write the small novel required to satisfy the lawyers in case he “goes out and
does something stupid.”
Speaking of which, there is a well-documented incident of a
dissatisfied malingerer who showed his lack of customer satisfaction by
killing three orthopedists. This is the best example I can give you of the
personal safety reasons for what you should NOT do with malingerers.
Don’t put yourself or others in unnecessary danger. It is not in your job
description—I don’t care who you are—to directly confront a dangerous
person on their faked illness, any more than it would be helpful to tell the 99
percent on death row who claim to be innocent that you know for a fact
they’re lying. It’s rare that you have to, it seems to me.
In the end, you just do your job. Do a good assessment, and
document your findings. Most of these people (those sick enough to pretend
to be sick) have genuine, treatable mental health problems. Many of them
have utterly miserable lives. If they are actively addicted, it is unlikely any
intervention will be helpful without primary (or at least concurrent)
substance abuse treatment. A lot of them will actually be depressed, or have
anxiety disorders, or personality disorders, or have a history of emotional
trauma, and perhaps PTSD. Sometimes you can get past the person claiming
to be sick and find the person sick enough to try it.
Case presentations:
Sometimes malingering is an adaptive behavior.
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I was working in the emergency room as an intern. A 20-something
year-old female came in by ambulance, appearing to have some kind of
seizure, and then appeared dazed and unable to speak. A large medical
workup revealed nothing, and I was left not knowing what to do with her.
My thinking was she’d had a pseudo-seizure and was electively mute—
hardly reasons for admitting her to a hospital. About two hours later, her
husband had stepped out, and the young lady told me hurriedly that she was
being abused and this was the only way she knew to get safely away from
him. He came back in, and she fell back into her feigned stupor. She was
genuinely terrified, and for good reason, it turned out.
At the other end of the spectrum, malingering can actually be a
felony. I had a patient once that I was giving methadone, in an attempt to
treat what I thought was severe chronic pain and trying to get him off other
pain meds.
He malingered his chronic pain with great expertise. What made this
one different was that he actively recruited friends of his to do the same,
providing them with the necessary symptoms in exchange for half of all the
methadone they could get out of me. Incidentally, I called the police on that
one, but they never returned the call.
I could give you more “greatest hits” from 18 years, but I decided to
limit the rest of the cases to those I have seen in NENC over a 15-month
period of time. To put it bluntly, and in layman’s terms, the typical
malingerer in NENC is a homeless crackhead sociopath.
Like the one referred to us from Pitt, reporting severe depression,
“voices,” and suicidal ideation. There was absolutely nothing in his
presentation to suggest significant depression or psychosis
==NOTHING!!== and there were multiple obvious inconsistencies in his
claims. I documented from the beginning that malingering seemed obvious,
although I was unaware of any secondary gain. About a week later, as I was
preparing to discharge him (over his protests—he began complaining he’d
had constipation for the past 7 years), I got a call from the Greenville Police.
Turns out he had an appointment with the police the day he went to the ED
instead. He was suspected in the beating murder of his girlfriend’s son.
He’s since been charged with the crime. Rather than show up for his
appointment at the police station, he went to Pitt’s ED instead, and
malingered his way to Ahoskie—hiding out from the police. With the
assistance of the Pitt ED, I might add.
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I’ve had the same demographic—homeless, crack addict, sociopath—
with the secondary gain being a place to stay, a place to get drugs, a place to
hide from police, a place to hide from somebody they owe money to that’s
going to kill them…I’ve seen it scores of times in my first year here. I’ve
seen multiple young women, crack-addicted, who had run up a large debt in
sexual favors for her crack cocaine, and needed a place to escape her
creditors.
In NENC, the greatest predictor of malingering in a psychiatric setting
is cocaine dependence. It’s also probably your greatest predictor of overall
dangerousness to “self and others.” They meet criteria for an involuntary
commitment on the basis of substance abuse. NOT for psychiatric. But the
psychiatric facilities get all of them in emergency cases, because to need
inpatient care, you need to say you’re suicidal, and if you’re suicidal they
won’t take you into a drug treatment facility. So all the crack addict
malingerers—the most dangerous men and women in the state—get filtered
through psychiatric hospitals, where they don’t belong, because their
primary, overwhelming problem is cocaine dependence and we are not a
drug treatment facility. We quickly verify they are not suicidal and have no
justification for psychiatric hospitalization, and are left with the task of
referring the patient to appropriate substance abuse treatment, which doesn’t
exist, at least not without a waiting list and a circus tent full of hoops to
jump through to get them there. In brief, if they are responsible and
motivated, then they don’t need inpatient. If they are irresponsible and
unmotivated, then they won’t benefit from inpatient.
The ones that typically come to us—about 90 percent of all those
positive for cocaine on a UDS--are actively cocaine-addicted, in need of
primary substance abuse treatment that the patient does not want and is not
available if he does. They are suffering the expected, natural consequences
of end-stage cocaine dependence. They are homeless. They are
unemployed. They have burned their bridges, and are breaking the law
every day. They are also severely personality-disordered. Most of the males
are antisocial; many of the females are borderline. They might well be
depressed, given that it is a guaranteed effect of chronic cocaine use, and
they might even be “bush people.” Yes, I can use drugs to treat their druginduced mental problems, but the only real treatment for drug-induced
psychiatric disorders is to stop inducing them with drugs. Anything else is a
joke—a very sad joke that is played out constantly.
Lexapro and Seroquel are not adequate alternatives to AA/NA,
recovery-informed medical care and halfway houses.
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But if crackhead sociopaths are the most blatant of malingerers, the
most common are those seeking disability. Of course, some of those are
sociopaths, too, and drug addicts. I admitted a guy in his twenties that had
been on disability for several years for schizophrenia—who had absolutely
zero signs of schizophrenia. He’d gone several years (living a life of petty
crime and self-indulgence) without any psychiatric care at all, and came into
the hospital for no apparent reason, obviously trying to fake psychosis (in a
dramatic, irritating, disruptive, and antisocial way) and threatening to kill his
mother. We learned his disability was up for review. During one of his
feigned episodes of utter incapacity, I looked through his wallet. In it, I
found a “to do” list. It included things like: go to the doctor, go to mental
health, go to the lawyer, and “kill mama haha.” Yes, it was the only time
I’ve actually seen the “to do” list of a malingerer. He needed to get his
lawyer on board, see a doctor, see mental health, get admitted by threatening
to kill his mother. It’s a very simple formula for disability. It worked the
first time.
Two patients in one week came to our hospital with the chief
complaint of “my lawyer told me to come.” Their lawyer was assisting them
with disability. They’d been trying for years on the basis of back pain, etc.,
and the lawyers (two different ones) told them a psychiatric diagnosis would
help. There is a general consensus that two or three psychiatric
hospitalizations are enough for disability. It’s blatant; lawyers coach their
clients on malingering. If you’re not sociopathic enough to make your own
“to do” list, then hire a lawyer to write you one.
I had a middle-aged lady literally smiling and giggling while
describing how horribly depressed she was. Seeking disability, of course.
This lady was so unsophisticated that she didn’t even realize she should try
to APPEAR depressed. She thought just saying it was enough. I found it
comical. I actually told the lady if she wanted to convince me she was
depressed, she was going to have to do better than that. Two weeks later,
when she was seeking her second admission for alleged depression, she told
the referral source that she wouldn’t mind going back to Ahoskie, although
she thought the psychiatrist there was crazy.
There are other variations on the theme. I had a young man on
disability for bipolar disorder, committed to me involuntarily because of
aggression and refusal to take medications. I saw no evidence whatsoever of
mental illness. He told us he was NOT mentally ill and that his grandmother
had him and most of his family on “crazy checks.” I kept him long enough
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to assess him carefully, 24/7. I got psychological testing, including MMPI,
which showed no evidence of any Axis I disorder. He was a case of
malingering by proxy.
Another variation: I saw a used car salesman with a disability claim
that I suspected of malingering. After a good assessment, I decided he was
genuinely severely depressed and was quite ill. He was also exaggerating
some of his symptoms—“selling” his illness. I didn’t diagnose him as
malingering.
I have seen scores of patients in the past year on disability for bipolar
disorder who do not have bipolar disorder. They’re not malingering bipolar,
really--they are misdiagnosed as bipolar. Most of them are probably best
described as persistent borderlines—persistent in creating enough problems
to get disability for their personality disorder.
I saw a guy recently that had gotten disability for 15 years for
schizophrenia—a diagnosis he received from Cherry Hospital after a 3-day
stay (and was likely in DT’s at the time). He’d never received any
psychiatric treatment in the ensuing 15 years, and could not describe one
symptom of schizophrenia ever happening to him. He was an active
alcoholic… I found him to be quite sane. I’ve seen a woman on disability
for 15 years for depression, and there was no evidence she was ever
depressed and never sought or received any treatment.
One of my other favorites was the gentleman claiming to have PTSD,
seeking disability from SS and the VA. He was extremely antisocial, and
was actively crack-addicted. His “traumatic event” that caused his PTSD
was his wife leaving him.
Again, these are only a few of the most blatant cases I’ve seen this
year. The diagnosis or “detection” of malingering is easy in cases like this,
especially when I have the luxury of watching the person for several days, or
even longer. If the patient’s chief complaints center on overwhelming
depression, disturbed sleep and appetite, and social withdrawal, then I am
not impressed if they immediately become the chairman of the socializing
committee, request double portions, complain about being awakened to
actually PARTICIPATE in their treatment, hit on the young females, and so
on. You might think I exaggerate, but I have seen this exact scenario at least
monthly, and would see it daily if I did not refuse them admission from the
beginning.
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Which brings to mind a young man from Maryland who had a fight
with his girlfriend, and got in his car and drove until he was out of gas and
out of money. It happened to be Elizabeth City, NC. He was a day away
from home and had absolutely no resources whatsoever. What would you
do?
This young man stopped at a gas station, and used the pay phone to
call 911. He told the operator he was suicidal. Within minutes, a swarm of
police and rescue personnel arrived, and transported him to the local
emergency room. Within a few hours, a pleasant social worker found him a
bed in Ahoskie, NC, by reporting him as severely depressed and actively
suicidal. She even arranged transportation for him by involuntarily
committing him, although he WANTED a place to stay. By doing so, she
got him transportation there, courtesy of the sheriff’s department. I saw him
the next morning. I immediately dropped the “IVC for transportation”
(because it is the lawful thing to do), discharged him (because he didn’t need
to be there), and bought him a bus ticket home (because it’s cheaper than
giving him room and board for even a few hours, much less a few days).
These are not isolated events.
It makes me consider the role physicians—and everybody else—plays
in the faking patient. The standard response is to take the path of least
resistance, and “fudge” what you must in order to get them out of your
emergency room or your office and into the realm of someone else’s
responsibility. What am I saying? I’m saying it’s often easier to give
malingerers what they want, especially if it’s somebody ELSE having to give
it to them. It’s just easier to dump. And call me cynical if you wish: I
believe the most-performed medical procedure today is the DUMP. In the
end, there are some natural dumping grounds: emergency rooms, hospitals,
psychiatric units, and the state mental hospitals, in particular. I can tell you,
when you are in a state hospital, you are in the ultimate dumping ground for
malingerers and sociopaths and all manner of “train wrecks.” There is no
place to dump them, except back out of the hospital. You are often left
providing social and financial services that have nothing to do with anything
psychiatric for proper “placement.” The ultimate dump from a state hospital
for a recalcitrant patient is into another state altogether. And that, if you are
not aware, happens ALL the time. It’s called Greyhound therapy. The whole
idea is to get them gone. If you can’t solve the problem, make it someone
else’s problem. Yes, it’s the House of God. But it’s real, not a fiction.
There is a problem with this widely accepted “standard of care” for
dealing with liars and criminals in the healthcare system (to dump them on
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somebody else). The problem is we are rewarding them for the lying and
faking, while taking precious resources away from people who genuinely
need them.
But I want to take this a step further. Consider this patient:
He’s presented to me as an 18 YO male with bipolar disorder and
Tourette’s Syndrome, who is depressed and after an altercation at home,
had come to the emergency room seeking “help.” I accepted the patient.
After talking with him (about an hour and a half), I got this story:
He was on probation for threatening to kill his principal. He had
violated his probation the day of admission by getting in a brawl with his
brother and step-dad over whether he had won or lost a game on his
PlayStation. The step-dad insisted the police be called to take him to jail; he
was not pleased that his perpetually violent step-son threatened to kill him.
The mother, however, would have none of that. The step-dad indicates that
either the boy leaves, or he leaves, so the mother took the boy to the local
mental health center. The mother also called the boy’s probation officer,
who verified that, so long as he was admitted to a hospital, his behavior
would not be considered a violation of probation. So they show up at mental
health, and are seen immediately by a supervisory-level social worker, who
called in the referral to us as I described above—bipolar with Tourettes,
depressed, and genuinely seeking psychiatric help after a regrettable
altercation at home.
So I see the patient, and ask him the symptoms of his bipolar disorder.
He indicates he has mood swings. When asked to describe his mood swings,
he said sometimes he feels good, and then sometimes he’ll be snappy. When
he’s “snappy,” he has “anger problems” and he gets in trouble. He was
unable to describe anything remotely resembling a manic or a depressive
episode. He wasn’t even aware what they were.
I ask who diagnosed him as bipolar. He tells me his mom knew he
was bipolar from the time of birth, because she has it, too. He was
diagnosed at age 8 by somebody in Rocky Mount. He got the Tourette’s
diagnosis at the same time. He didn’t know what “tic” meant. He said he
has Tourettes because when he gets mad he says things he doesn’t mean—
like he’s going to kill somebody. This generally immediate presages his
physical attack on another person. While searching for any evidence of a
motor tic, he said he had the “shakes” that his doctor told him probably came
from his Depakote.
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So I ask him if he thinks he has ADD. He corrected me, saying
ADHD, and yes, he knew he had it. So I ask him if he has attention
problems, and he denies it, saying he did in the past but no more. So I ask
him what his symptoms actually ARE of his ADHD, he says he has a lot of
problems being in crowds of people, and he hears voices. Exasperated, I
asked him to describe the voices. He told me he hears voices sometimes
telling him to hurt somebody, just before he hurts somebody. He said it
hadn’t happened for two months.
He volunteered the information that at one point he was in a
residential treatment center and was on 18 different medications at one time.
He told me he was on some medication once that “had steroids in it” and it
“messed with my hormones” and it caused him to sexually assault a young
girl. He told me proudly how he’d convinced the prescribing psychiatrist to
stop the medication by attacking him and attempting to choke him.
He had been on Zyprexa for a long period of time, and had recently
been changed to Seroquel. He was on Depakote, Klonopin, and Cogentin.
He said the Cogentin was his treatment for his Tourettes and it made the
voices go away. He had elevated liver function tests from the Depakote. He
was subclinically hypothyroid. And he was five feet six and weighed three
hundred pounds, having gained most of his weight while on the Zyprexa,
Seroquel, and Depakote. He was spilling sugar in his urine, and had an
elevated fasting blood sugar; in short, he was, he was verging on being a
type-II diabetic, and if he kept it up, he might actually have a lawsuit against
his doctors.
This young man was hardly bipolar, and did not have Tourette’s. He
had a ten-year treatment history with every medication known to mankind,
and now had serious medical problems as a result of the medications. It’s
doubtful that any of the medications had ever helped him. He certainly
didn’t think so, and his record of unrelenting antisocial behavior suggests he
is right. When asked the last time he was involved in any kind of anger
management therapy, he responded, “When I was six.”
I diagnosed him as intermittent explosive disorder, probable residual
AD/HD, and antisocial personality traits vs disorder. Given an accurate
long-term description of his behavior, it is very likely the primary diagnosis
would be antisocial personality disorder, and that he was diagnosable as
conduct disorder, ODD, and perhaps ADHD, HI type when he was younger.
I stopped the Klonopin. I stopped the Seroquel. I continued the
Cogentin, because he wanted it (absolutely the only reason) and continued
the Depakote, since it has utility in intermittent explosive disorder, but I
warned him of the liver problems. I asked how long he thought he needed to
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stay in the hospital. He indicated his mother wanted him to stay for three
weeks. I had her called, and told he would be discharged the next day. She
was very pleased. Then we get a call from his case manager, whom we had
no idea existed. The case manager is furious at us for our plans to discharge
him. She is incredulous I would question the diagnoses. She is incredulous
I would discontinue any medication. She is incredulous I would discharge
him, and tells us he has spent the last nine months in a secure residential
facility of some sort and HAS to be SOMEWHERE. I note this was
information we’d not been given by the mental health center “screener.” If
we’d been properly informed of his actual history—regardless of the bogus
diagnoses—I would not have admitted him. If I’d been given accurate
diagnoses, I would not have admitted him, because I would have known he
was an inappropriate patient for our unit, and likely an inappropriate referral
anywhere, other than jail.
And that’s the whole point. Everybody knows that a hospital will not
admit a malingering sociopath if they are given a choice—and nor should
they. So the malingering sociopath is HELPED in his malingering by
virtually everyone in the system. You need the right diagnosis to get
admitted. You need the right diagnosis to get disability, or to get paid for
any of the services you’re having to provide. I note that most insurers,
government and private, will not pay hospitals such as ours for a less-than24-hour stay. The assumption is that if they didn’t even need to be there for
a day, then they should never have been admitted in the first place. But it is
the hospital, not the referral source that has to pay for providing the
services—the actual evaluation, lab work, and perhaps 10-12 man-hours of
work to admit and discharge a patient.
Is it clear? If I diagnose/detect malingering and axis II problems
accurately and “treat” it properly, then I am paid nothing for my work. If I
“fudge” it a little (or a LOT) on the diagnosis and provide unnecessary and
inappropriate care, I get paid. The same dynamic is in effect in outpatient
treatment. It’s simple: you will not get paid to treat personality disorders,
even if it’s entirely appropriate care. There is a strong financial incentive to
over-diagnose mood disorders, psychotic disorders, and especially bipolar
disorder, schizoaffective disorder, and major depression with psychotic
features. You’re going to be serving these clients, anyway, at a mental
health center with insufficient funding for essential services. If you give
them a serious mental disorder diagnosis, then they are more likely to get
Medicaid, disability payments, and Medicare. They are more likely to be
profitable for you and your facility. Or at least they will be less of a
liability.
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Is it scary to you that a doctor can make more money being a bad
doctor than a good one? That an unethical doctor could make more money
than an ethical one?
It should.
This 18-year-old “bipolar Tourettes” was admitted to a psychiatric
hospital purely for the reason of avoiding the consequences of his illegal,
willful behavior. He got a psychiatric excuse—a doctor’s excuse—for his
behavior. But he’s not faking. He’s not malingering. He’s not even trying.
He doesn’t have to, because his mother and the system are doing it for him.
He’s ten years and scores of medications into his career as a psychiatric
patient. He’s probably a million-dollar man, courtesy of the NC taxpayers.
And as a result of the million dollars’ worth of services, he is more
dangerous than ever. He is at very high risk to do a murder. If he does, he’ll
have a lifetime of doctors’ excuses for the crime. And by the way, two days
later, in the middle of the night, I got a call from an emergency room, saying
they had this unfortunate 18-year-old with PTSD that had been abused in
one of his placements and was really wanting help. His mom was with him.
Although I’ve taken some time to present this case, he’s not really
malingering. He’s malingering by proxy, and the proxy is the “system.”
I admitted two patients in one day that came to a hospital rather than
go to jail. The first was a young male who had been convicted of selling
narcotics, and part of his plea agreement to stay out of jail was to pay a fine.
He didn’t pay the fine (because he was too busy using drugs to work), and
had a court date, and it was a certainty he would be incarcerated at that time.
He went to mental health the day before his court date, was evaluated for
depression, and given an appointment the next day to see the psychiatrist.
“That wasn’t quick enough,” he said, so he got drunk and stoned and went to
the emergency room. It sounds comical, but that’s all it takes. He told them
he was nervous and depressed and suicidal.
His story was nicely packaged by the screener, who IVC’ed him and
got him a ride to Ahoskie. Upon arrival, he was not suicidal, he was not
depressed, and he had no axis I disorder, except for alcohol intoxication,
alcohol abuse, and cannabis abuse. He slept all day, and complained bitterly
anytime he was awakened by staff. About bedtime, he woke up and
demanded a sleeping pill. The next morning, he woke up long enough to
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have an argument with his pregnant girlfriend by phone, and actually left
orders at the nurses’ station he was going to bed and was not to be disturbed.
I invited him to go home, and he was pleased. His mother, on the
other hand, threw an absolute fit and made it clear he wasn’t welcome back
there. So the sheriff gave him a ride back to Nash County, not knowing
there was likely an arrest warrant to carry his passenger directly to jail. It’s
against the law for us to tell them, you know. Ironic? It’s against the law to
tell the truth about a convicted criminal that is hiding out, but it’s not against
the law to harbor a criminal, which is (actually) against the law. Are we
confused? We should be.
The second patient was an 18 year old girl with a history of
shoplifting and petty thefts going back to elementary school. She came by it
honest—her brother, her mother, and her grandmother were all thieves, too.
There was apparently one occasion where 5 family members were arrested at
one time for shoplifting. The mother had spent prison time for theft.
Anyway, the girl had been charged again with shoplifting. She had failed to
appear for her court date, and had another court date scheduled for her
failure to appear plus the initial charge. She was fully expecting thirty days
in jail just for the failure to appear. Her grandmother took her to the
courthouse on time to see the judge, but at the last minute took her across the
street, instead, to the mental health center for a “crisis” evaluation.
The grandmother told a social worker the girl was psychotic, was
having auditory, visual, and tactile hallucinations, and had been running
down the street naked. The social worker never saw the girl. She social
worker told us the girl was, well, psychotic, hallucinating, and had been
running down the street naked, and had Medicaid. When asked, social
worker told us the girl had a pending court date, but didn’t know when it
was. I accepted the patient.
Upon arrival, she was perfectly pleasant, with a normal mental status
exam. She had no idea what her grandmother was talking about, and was a
bit upset she’d been prevented from going to court. She asked to be put on
Zoloft, which she said had helped her before when it was being slipped into
her food by an aunt while in another state, having “run away from home” to
prevent incarceration. She can’t go to South Carolina, incidentally, because
she has charges there, too. The patient was no problem at all—quite a
pleasant young lady, actually. But her mother and her grandmother were on
the phone raging that we didn’t think the girl was crazy, and she was going
to be discharged and that I would not give the girl a “doctor’s excuse” to
prevent her from going to jail.
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The first patient, the young male in his twenties, an alcoholic and
addict, antisocial personality disorder with a court date the next day: he is
the prototype malingerer. The second patient, the young girl, is malingering
by proxy. And she’s got plenty of help, including her family and the social
worker. By the way, we didn’t get paid for her hospital stay, because it was
a lie (by grandmother passed along by the social worker) that she had
Medicaid. She turned out to have hyperthyroidism, and our hospital spent a
lot of money evaluating and treating her genuine medical problem that
became our responsibility.
I have one final patient. We got a referral from an emergency room.
The screener tells us they have a grossly psychotic patient who has refused a
urine drug screen. They know almost nothing about him, because he won’t
tell them anything, except he’s from Virginia and has been in state hospitals
there. He doesn’t need placement; he has a house in Rocky Mount. When
asked if he is aggressive, the reply was that he was “loud.” So we asked
who filed the petition, and were told a friend of his without a telephone had
done it, and he was unavailable for comment.
I asked for copies of the petition and their first evaluation. It turned
out there was no friend without a phone. It was the police that brought him
in. From jail. He’d been arrested for trespassing, probably for sleeping in
an abandoned building because he’s a homeless, psychotic crack addict. The
reason he was taken to the emergency room: he’d threatened to kill the jail
nurse. Basically, he was too dangerous for the jail, and they were trying to
dump him into a psychiatric unit “guarded” by three women. I would
humbly submit that when the chief complaint is a violent man threatening to
kill a nurse, the treatment is not provide him with defenseless nurses.
I have the referral document, and I have the legal documents saying
something completely different. I want to make it very clear. People seem
to forget that EMTALA is more than just filling out the proper forms. It
actually means telling the TRUTH in them. If you blatantly lie in order to
get a patient transferred into an inappropriate setting, it is a dump. And
dumps are EMTALA violations. If you lie to get somebody inappropriate
into a psychiatric unit and they hurt somebody or kill somebody, you could
be held accountable. And should be.
I understand it, certainly: the polish, the spin, and the transfer. The
CYA, the creative misdiagnosis. It’s part of defensive medicine—a problem
even larger, and more expensive, than malingering. In very rough numbers,
each year in the US, 50 billion dollars is spent, paying for DEFENSIVE
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MEDICINE. But before you blame the doctors, consider the fact that the
state of the legal system requires physicians (and others) to practice
defensively.
In simple terms, the lawyers are costing us 50 billion dollars in
healthcare dollars each year. But doctors have little claim to moral
superiority. They’re the ones ordering the inappropriate care—tests and
treatments ordered without medical justification, and they are often paid for
doing so.
Where is the money going? Who’s getting this 50 billion? Who must
you fight against to change this waste, this status quo manner of conducting
healthcare? Here’s who:
The healthcare industry itself, the very ones wasting the money: hospitals,
doctors, nursing homes, home health, mental health providers…
At it’s most basic, doctors practicing defensive medicine are writing checks
to themselves—and they have little room to complain about the lawyers
taking their cut. More and more, doctors are writing checks to their
employers—always a gracious thing to do.
The pharmaceutical industry… unnecessary and inappropriate
prescribing, off-label fiascos from a medical standpoint can make billions of
dollars, e.g. Neurontin. I might mention I am amazed—flabbergasted—by
patients on greater than 25 medications. I’m skeptical when they’re on more
than 5 or 6. The record I’ve personally seen as 30. He was on about five
drugs per diagnosis, I figured. Most of this isn’t defensive medicine; I just
can’t resist bringing it up. It’s just really BAD medicine, and wasteful of
incredible sums of money on the part of doctors to the benefit of the
pharmaceutical industry.
Medical technology, especially laboratory and radiology… doesn’t
everyone need 1K of labs and an MRI of something? After all, you might
get sued if you DON’T do it…
The insurance industry… note doctors pay 9 billion a year for malpractice
insurance, which pays out 4 billion a year in claims. Seems like doctors are
surely giving a lot of money to lawyers just to keep them away.
Lawyers… Consider: there is no correlation between the severity of the
physician’s error, or whether there was an error at all, with being sued at all.
If malpractice is found by the court, there is no correlation between the
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actual damage done to the patient and the award. That’s not unique to
malpractice, of course. It is routine to get next to nothing for a severely
disabling on-the-job injury. But you might get 20 million dollars for spilling
your coffee. In healthcare, a famous case involved a multi-million dollar
award to a woman claiming the CT scan of her brain had taken away her
psychic powers. The award was shot down on appeal, but the message is
clear. Malpractice suits occur when people are angry or greedy or both,
whether their anger is justifiable or not, and whether the doctor has done
anything wrong. And once it gets into the world of lawyers, things like
simple reality take a back seat to lawyering, and absolutely anything can
happen. So doctors are overly-cautious. They practice defensive medicine,
and it’s costing you—those who pay taxes and buy insurance--50 billion
dollars a year.
So why is this Tipton fella talking about malpractice and laywers?
We asked him to talk about malingering. Well, it’s because you can’t talk
about faking and cheating and malingering very long without having to
consider the system that allows, perpetuates and even rewards the fakers,
cheaters, and malingerers.
And I guess, in the end, the message is that the treatment for
malingering is honesty, ethics, and professionalism. It takes the
recognition that in any given sensitive situation, you can get sued no matter
what you do, and the best defense is to do your job well and pass the
“reasonable person” test. I cannot reform the healthcare industry, the
pharmaceutical industry, the insurance industry, the lawyers, and the
politicians. But I can be honest, ethical, and professional. If I can stay
underneath the radar screen, I will. But if I’m made into a target, then I
strive to be a formidable target with strong defenses.
I tend to keep my mouth shut a lot when I’m dealing with malingerers
and severe personality disorders. I let them do the talking. I do the writing.
I maintain distance. I’m the casting director, and they want a part. If they
don’t pass the audition with me, they generally move on quickly seeking a
more receptive audience.
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