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.