Monthly Archives: October 2016

Faking it: How to detect malingered psychosis

This was an amusing and interesting article shown to me by one of our consulting psychiatry faculty — in it, the authors Drs. Resnick and Knoll lay out their approach to determining whether someone might be feigning madness for secondary gain. This is, sadly, something we see very frequently in the emergency department — not so much specifically the faking of psychosis, but more often things like suicidality, which some patients (whose unfortunate lives are such that they would prefer being stuck in the emergency department on an “involuntary” hold to being out in the streets, or often those who were just arrested and are now on their way to jail) will endorse knowing that it results in a cascade of CYA consultations that result in a longer LOS and often a sandwich / sometimes psychotropic medications, or alcohol withdrawal. In the case of arrested patients, sometimes they can avoid a trip to jail by diverting to the hospital which will lead the officer to write them a ticket instead of arrest them. Sometimes this population also endorses psychotic symptoms such as command hallucinations, and the subjective nature of these complaints makes them very difficult to determine as being organic or not.

Malingering, defined by the authors as “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives” is obviously a diagnosis of exclusion, particularly in our most vulnerable populations such as the homeless or incarcerated. However, one must also consider the patients whose care is being delayed by beds occupied by those without true illness, and the resources allocated to sussing out those actually at risk from those who are angling for secondary gain. There is also a very strong “Peter and the Wolf” phenomenon that can result from dealing with the same patients every day who come in claiming suicidality, only to recant after they sober up, or who are found to have conditional suicidality that hinges on things like being fed, housed, or given controlled substances such as pain medications or benzodiazepines — meaning, there is a risk that it could both degrade one’s index of concern for true suicidal ideation, and one’s empathy for other patients presenting with concern that they are a danger to self.

So what do they recommend? Some highlights:

Asking about improbable symptoms, which are rarely seen even in the most severely disabled patients, e.g. “When people talk to you, do you see the words they speak spelled out?” or (my personal favorite) “Have you ever believed that automobiles are members of an organized religion?”

Focusing on incongruities between the way they are presenting or endorsing symptoms and the circumstances they were in before arrival, or the way they behave when the examiner is not present, e.g. endorsing having active auditory and visual hallucinations yet showing no evidence of being distracted or attending to internal stimuli.

Critically evaluate reported hallucinations, particularly visual ones which are less often seen in true psychosis than reported in malingering. True visual hallucinations also are usually of “normalized people” and seen in color, rather than dramatic or atypical things such as giant monsters or devils, or flashes of light/color, which is more associated with neurologic disease or drug intoxication than psychosis.

They close by advising clinicians to “avoid direct accusations of lying, and give the suspected malingerer every opportunity to save face. For example, it is preferable to say, ‘You haven’t told me the whole truth'”, rather than directly confront them as malingering or lying.

All in all, this was an interesting diversion regarding a very difficult population and a sad phenomenon seen in the ED. Worth the 10 minutes it takes you to read, even if it doesn’t ultimately stop you from consulting psychiatry.


Transient Hypotension in the Emergency Department

An interesting technicality in the use of the PERC rule to rule out pulmonary embolism is the tachycardia component — it asks not whether the patient is tachycardic at the time of the application of the rule, or whether tachycardia was sustained throughout the emergency department stay, but instead whether the patient had (as described by Jeff Kline in his great review article on PE diagnosis and risk stratification): “3. Pulse <100 beats/min during entire stay in ED”.  Meaning, even transient tachycardia may suggest a life-threatening diagnosis, even if it resolves while the patient is in the emergency department, and we’re probably PERCing out a whole bunch of patients inappropriately, at least according to Kline (who, notably, testifies a whole bunch as an expert witness in cases of missed pulmonary emboli).

I recently had a handful of patients in whom concerning blood pressures were measured and documented, which then resolved when vital signs were re-checked or after a small quantity of fluid or repositioning. I was wondering whether anyone had looked at the prognostic significance of ED hypotension, and whether these momentary dips in blood pressure should be something that concerns me. I did a quick search and found two studies that addressed this question in two different populations:

First we have, from the Rick Bukata school of title writing: “Emergency department hypotension predicts sudden unexpected in-hospital mortality: A prospective cohort study.”  This study, by Alan Jones and Jeff Kline out of (and formerly out of) Carolinas, prospectively enrolled 4,790 adult ED patients admitted to the hospital for reasons other than trauma. Patients were divided into those with and without systolic BPs below 100 mmHg at any time during their ED visit and followed through their hospitalization for the primary outcome of in-hospital mortality. Secondary outcomes included “sudden and unexpected death”, the relationship between the degree and the duration of hypotension measured and mortality, and the test characteristics of hypotension as a test for predicting in-hospital mortality.

Their conclusions are illustrated well in this graph:


As they concisely summarize in the article’s conclusion:

Patients exposed to hypotension had a threefold increased risk of in-hospital death and a 10-fold increased risk of sudden, unexpected in-hospital death. Patients with any one SBP < 80 mm Hg had a sixfold-increased incidence of in-hospital death, and patients with a SBP < 100 mm Hg for > 60 min had almost a threefold-increased incidence of in-hospital death.

The second article from the same group echoes this conclusion in a different population of patients. This article, “The significance of non-sustained hypotension in emergency department patients with sepsis” is a secondary analysis of the above data set which looks specifically at the prognostic value of non-sustained hypotension defined as one or more occurrence of SBP < 100 mmHg in patients with sepsis as defined by the receipt of antibiotics in the ED + at least two SIRS criteria.

774 patients met their inclusion criteria for sepsis, and after 74 were excluded for “overt shock” (sustained hypotension or use of pressors). They examined the remaining patients for a primary outcome of in-hospital death.  They found, as one might expect, that hypotension predicts worse outcomes in this sub-population of patients — including when patients had non-sustained hypotension. Again, there seemed to be a “dose-dependent” relationship, with an inverse relationship between the nadir of the ED SBP and the frequency of in-hospital death, as shown here:


Another important finding (though taken in context of a fairly small sample) was the statistically similar incidence of the primary outcome in both the groups with transient and sustained hypotension. Both groups of patients had a 2.5-3x higher risk of in-hospital mortality when compared to patients without any hypotension.

Without belaboring the point, these two studies underscore the prognostic significance of even transient hypotension in the undifferentiated emergency department patient, and (as is better known to have implications in terms of severity) in patients diagnosed with sepsis. Like the previous post regarding lactate, or the well-known pearl about tachycardia at discharge, this is a number that should get your attention and which demands evaluation and possible intervention / escalation of care.


Marchick MR1, Kline JA, Jones AE. The significance of non-sustained hypotension in emergency department patients with sepsis. Intensive Care Med. 2009 Jul;35(7):1261-4. PMID: 19238354. [PubMed] [Read by QxMD]
Holler JG1, Bech CN1, Henriksen DP2, Mikkelsen S3, Pedersen C4, Lassen AT1. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: a systematic review. PLoS One. 2015 Mar 19;10(3):e0119331. PMID: 25789927. [PubMed] [Read by QxMD]