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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, 1 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. 2 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 3 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 4 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 5 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 6 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 7 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. 8 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. 9 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. 10 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 11 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. 12 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 13 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. 14 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 15 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. 16 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 17 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. 18 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 19 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 20 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. 21